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Heckert SL, Bergstra SA, Goekoop-Ruiterman YPM, Güler-Yüksel M, Lems WF, Matthijssen XME, van Oosterhout M, Huizinga TWJ, Allaart CF. Frequency of joint inflammation is associated with local joint damage progression in rheumatoid arthritis despite long-term targeted treatment. RMD Open 2023; 9:rmdopen-2022-002552. [PMID: 36609354 PMCID: PMC9827264 DOI: 10.1136/rmdopen-2022-002552] [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: 07/01/2022] [Accepted: 12/07/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To investigate whether in rheumatoid arthritis (RA) frequency of local joint inflammation is associated with radiographic joint damage progression in that joint. METHODS Data from 473 patients with RA and available radiographs from the BeSt study were used. Patients were treated to target (Disease Activity Score of ≤2.4) for a median of 10 years. At each study visit every 3 months, joints were assessed for swelling and tenderness. Radiographs of hands and feet were made yearly. A generalised linear mixed model was used to assess the association between the percentage of study visits at which clinical inflammation was observed in a joint (cumulative inflammation) and radiographic joint damage in that same joint. Clinical inflammation was primarily defined as joint swelling (with or without joint tenderness). For secondary analyses, we also investigated joint tenderness without joint swelling. Damage was measured as the percentage of the maximum possible Sharp-Van der Heijde score in a particular joint. RESULTS Cumulative local joint swelling was associated with local progression of radiographic damage in the same joint (β=0.14, 95% CI 0.13 to 0.15). This association was also found in a subset of joints that were swollen at least once. Cumulative local joint tenderness without concurrent local joint swelling was less strongly associated with local radiographic joint damage progression (β=0.04, 95% CI 0.03 to 0.05). CONCLUSIONS In RA, long-term cumulative local joint inflammation is associated with joint damage progression in the same joint.
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Affiliation(s)
- Sascha L Heckert
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Melek Güler-Yüksel
- Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Willem F Lems
- Rheumatology, Amsterdam UMC VUMC Site, Amsterdam, The Netherlands
| | | | | | - Tom W J Huizinga
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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2
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Chaiamnuay S, Jiemjit S, Songdechaphipat W, Narongroeknawin P, Pakchotanon R, Asavatanabodee P. Predictors of flare in rheumatoid arthritis patients with persistent clinical remission/low disease activity: Data from the TARAC cohort. Medicine (Baltimore) 2022; 101:e29974. [PMID: 35960097 PMCID: PMC9371488 DOI: 10.1097/md.0000000000029974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
To identify predictors of rheumatoid arthritis (RA) disease activity flare in RA patients who achieved low disease activity (LDA) or persistent remission from the observational Thai Army Rheumatoid Arthritis Cohort study. RA patients with persistent clinical remission, defined by disease activity score 28 (DAS28) < 2.6 and LDA defined by DAS28 ≤ 3.2 for 3 consecutive months, were recruited and followed-up for at least 2 years. The flare was defined by an escalation of DAS28 ≥ 1.2 plus their physicians' decision to enhance RA treatment. Differences between sustained remission/LDA and flare groups were analyzed, by Chi-square test and unpaired Student t test. Multivariate Cox proportional hazard regression analysis was conducted to determine flare predictors. From 199 RA patients, female were 82.9%. Anticitrullinated peptide antibodies (ACPA) or Rheumatoid factor (RF) were found in 69.8% of patients. Flares occurred in 69 patients (34.9%). Multivariate analysis found that the timescale from symptoms emergence to DMARD commencement, the timescale from DMARD commencement to when RA patients showed remission/LDA, the occurrence of RF or ACPA, LDA (in contrast to remission) and the increased DAS28 score when remission/LDA was achieved and tapering DMARDs promptly when persistent remission/LDA was achieved were predictors of RA flares with hazard ratios of (95% confidence interval [CI]) of 1.017 (1.003-1.030), 1.037 (1.015-1.059), 1.949 (1.035-3.676), 1.926 (0.811-4.566), 2.589 (1.355-4.947), and 2.497 (1.458-4.276), respectively. These data demonstrated that early and aggressive DMARDs treatment approach could maintain remission espcially in seropositive patients. Tapering should be applied minimally 6 months after reaching remission.
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Affiliation(s)
- Sumapa Chaiamnuay
- Rheumatic Disease Unit, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
- * Correspondence: Sumapa Chaiamnuay, MD, Rheumatic Disease Unit, Department of Internal Medicine, Phramongkutklao Hospital & Phramongkutklao College of Medicine, 315 Ratchawithi Road Ratchathewi district, Bangkok 10400, Thailand (e-mail: )
| | - Srisakul Jiemjit
- Rheumatic Disease Unit, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | | | | | - Rattapol Pakchotanon
- Rheumatic Disease Unit, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Paijit Asavatanabodee
- Rheumatic Disease Unit, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
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Hepworth EP, Lee A, Pardo Pardo J, Aydin SZ, Tugwell P. Short-term induction glucocorticoids and disease-modifying anti-rheumatic drugs (DMARD) therapy for rheumatoid arthritis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Alex Lee
- Faculty of Medicine; University of Ottawa; Ottawa Canada
| | - Jordi Pardo Pardo
- Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus; Ottawa Canada
| | - Sibel Zehra Aydin
- University of Ottawa, the Ottawa Hospital Research Institute; ON Canada
| | - Peter Tugwell
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Canada
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4
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Glennon V, Whittle SL, Hill CL, Johnston RV, Avery JC, Grobler L, McKenzie BJ, Cyril S, Pardo Pardo J, Buchbinder R. Short-term glucocorticoids for flares in people with rheumatoid arthritis receiving disease-modifying anti-rheumatic drugs (DMARDs). Hippokratia 2021. [DOI: 10.1002/14651858.cd014898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Vanessa Glennon
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Samuel L Whittle
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
- Rheumatology Unit; Queen Elizabeth Hospital; Woodville South Australia
| | - Catherine L Hill
- Rheumatology Unit; Queen Elizabeth Hospital; Woodville South Australia
- Discipline of Medicine; The University of Adelaide; Adelaide Australia
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Jodie C Avery
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
- Adelaide Medical School, Robinson Research Institute; The University of Adelaide; North Adelaide Australia
| | - Liesl Grobler
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences; Stellenbosch University; Cape Town South Africa
| | - Bayden J McKenzie
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Sheila Cyril
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Jordi Pardo Pardo
- Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus; Ottawa Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
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5
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Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
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Jung SY, Koh JH, Kim KJ, Park YW, Yang HI, Choi SJ, Lee J, Choi CB, Kim WU. Switching from TNFα inhibitor to tacrolimus as maintenance therapy in rheumatoid arthritis after achieving low disease activity with TNFα inhibitors and methotrexate: 24-week result from a non-randomized, prospective, active-controlled trial. Arthritis Res Ther 2021; 23:182. [PMID: 34233727 PMCID: PMC8265052 DOI: 10.1186/s13075-021-02566-z] [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: 02/08/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background Tapering or stopping biological disease-modifying anti-rheumatic drugs has been proposed for patients with rheumatoid arthritis (RA) in remission, but it frequently results in high rates of recurrence. This study evaluates the efficacy and safety of tacrolimus (TAC) as maintenance therapy in patients with established RA in remission after receiving combination therapy with tumor necrosis factor inhibitor (TNFi) and methotrexate (MTX). Methods This 24-week, prospective, open-label trial included patients who received TNFi and MTX at stable doses for ≥24 weeks and had low disease activity (LDA), measured by Disease Activity Score-28 for ≥12 weeks. Patients selected one of two arms: maintenance (TNFi plus MTX) or switched (TAC plus MTX). The primary outcome was the difference in the proportion of patients maintaining LDA at week 24, which was assessed using a logistic regression model. Adverse events were monitored throughout the study period. Results In efficacy analysis, 80 and 34 patients were included in the maintenance and switched arms, respectively. At week 24, LDA was maintained in 99% and 91% of patients in the maintenance and switched arms, respectively (odds ratio, 0.14; 95% confidence interval, 0.01–1.59). Drug-related adverse effects tended to be more common in the switched arm than in the maintenance arm (20.9% versus 7.1%, respectively) but were well-tolerated. Conclusion This controlled study tested a novel treatment strategy of switching from TNFi to TAC in RA patients with sustained LDA, and the findings suggested that TNFi can be replaced with TAC in most patients without the patients experiencing flare-ups for at least 24 weeks. Trial registration Korea CDC CRIS, KCT0005868. Registered 4 February 2021—retrospectively registered Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02566-z.
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Affiliation(s)
- Sang Youn Jung
- Division of Rheumatology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Jung Hee Koh
- Division of Rheumatology, Department of Internal Medicine, Bucheon St. Mary's Hospital, the Catholic University of Korea, Seoul, South Korea
| | - Ki-Jo Kim
- Division of Rheumatology, Department of Internal Medicine, St. Vincent Hospital, the Catholic University of Korea, Seoul, South Korea
| | - Yong-Wook Park
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Hyung-In Yang
- College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Sung Jae Choi
- Division of Rheumatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, South Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Chan-Bum Choi
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Wan-Uk Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, Center for Integrative Rheumatoid Transcriptomics and Dynamics, College of Medicine, the Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, South Korea.
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7
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Kelleher D, Barry L, McGowan B, Doherty E, Carey JJ, Kane D. Budget impact analysis of an early identification and referral model for diagnosing patients with suspected rheumatoid arthritis in Ireland. Rheumatol Adv Pract 2020; 4:rkaa059. [PMID: 33364546 PMCID: PMC7749785 DOI: 10.1093/rap/rkaa059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/24/2020] [Indexed: 12/02/2022] Open
Abstract
Objective To estimate the budget impact from the perspective of the Irish health-care system attributable to a reconfiguration in the diagnostic care pathway for patients with suspected RA by adopting an early identification and referral model (EIM). Methods The budget impact model evaluated the total health-care use and costs attributable to an EIM to diagnose patients with suspected RA relative to the reference scenario of current practice. The modelling also assessed a primary outcome of effect, which examined how many patients can be diagnosed by a rheumatologist within 3 months of symptom onset. The budget impact analysis model was estimated over a 5-year time frame. Results The EIM generated a cost saving for the Irish health-care system of €237 547 over the time frame relative to current practice. The cost savings were realized owing to a reduction in the number of general practitioner (GP) visits of 18 790 and a reduction in diagnostic tests carried out by GPs. The results showed that 1027 (510%) more patients were diagnosed within 3 months of symptom onset in the EIM compared with current practice. Conclusion This paper has presented an alternative rheumatologist-led service design that can be used in diagnosing patients with suspected RA. The rheumatologist-led service provision detailed in this study has the potential simultaneously to reduce demand for primary care services and to improve the health outcomes of patients. The use of an EIM sees rheumatologist activity incorporate patient demand.
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Affiliation(s)
- Dan Kelleher
- Health Economics and Policy Analysis Centre, National University of Ireland, Galway, Galway, Ireland
| | - Luke Barry
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland
| | - Bernie McGowan
- School of Medicine, National University of Ireland, Galway
| | - Edel Doherty
- Health Economics and Policy Analysis Centre, National University of Ireland, Galway, Galway, Ireland
| | - John J Carey
- School of Medicine, National University of Ireland, Galway
| | - David Kane
- Department of Medicine (Rheumatology), Trinity College Dublin, Dublin, Ireland
- National Clinical Programme for Rheumatology, HSE, Ireland
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8
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Drosos AA, Pelechas E, Kaltsonoudis E, Voulgari PV. Therapeutic Options and Cost-Effectiveness for Rheumatoid Arthritis Treatment. Curr Rheumatol Rep 2020; 22:44. [DOI: 10.1007/s11926-020-00921-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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9
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Treatment strategies are more important than drugs in the management of rheumatoid arthritis. Clin Rheumatol 2020; 39:1363-1368. [PMID: 32088801 DOI: 10.1007/s10067-020-05001-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023]
Abstract
The treatment of inflammatory arthritides has been changed dramatically in the past two decades with the introduction of the biological (b) disease-modifying anti-rheumatic drugs (DMARDs) as well as the targeting synthetic (ts) DMARDs that can be used as monotherapy or in combination with conventional synthetic (cs) DMARDs. The concept of treat to target (T2T) and tight control monitoring of disease activity represents a therapeutic paradigm of modern rheumatology. In rheumatoid arthritis (RA), this treatment approach has proven to be effective in many clinical trials and is now a well-established approach. The most common treatment strategies rely on the combination of csDMARDs (mainly methotrexate, sulfasalazine and hydroxychloroquine). This comes from different studies which compare the outcomes of combination therapies versus csDMARD monotherapy or versus methotrexate plus biologics in early RA patients. Here, we review the literature of the most important T2T studies for RA patients. The results showed that a tight control strategy appears to be more important than a specific drug to control RA. T2T approach aiming for remission or low disease activity can be achieved in early RA patients using less expensive drugs in comparison to newer drugs and this may need to be recognised in the future recommendations for the management of RA. KEY POINTS: • Tight-control and treat-to-target (T2T) strategies are the cornerstone in achieving remission or low disease activity in rheumatoid arthritis (RA) • A plethora of clinical trials has confirmed the efficacy of csDMARDs when the tight-control and T2T strategies are applied • T2T and tight-control strategies are a less expensive option in comparison to newer drugs and may be recognised in the future recommendations for the management of RA. • Treatment decisions and strategies are more important than just the drugs.
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10
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Response to: ‘Metering the METEOR in methotrexate failure: is propensity score a falling star?’ by Ahmed et al. Ann Rheum Dis 2019; 78:e132. [DOI: 10.1136/annrheumdis-2018-214652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 11/04/2018] [Indexed: 11/03/2022]
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11
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Blomjous BS, Boers M, Den Uyl D, Twisk JWR, Van Schaardenburg D, Voskuyl AE, Lems WF, Ter Wee MM. Predictors of sick leave and improved worker productivity after 52 weeks of intensive treatment in patients with early rheumatoid arthritis. Scand J Rheumatol 2019; 48:271-278. [DOI: 10.1080/03009742.2019.1570549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- BS Blomjous
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
| | - M Boers
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
| | - D Den Uyl
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
| | - JWR Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
| | - D Van Schaardenburg
- Amsterdam Rheumatology and immunology Center, Reade, Amsterdam, The Netherlands
| | - AE Voskuyl
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
| | - WF Lems
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
| | - MM Ter Wee
- Department of Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije University Amsterdam, Amsterdam, The Netherlands
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12
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van de Laar CJ, Oude Voshaar MAH, Vonkeman HE. Cost-effectiveness of different treat-to-target strategies in rheumatoid arthritis: results from the DREAM registry. BMC Rheumatol 2019; 3:16. [PMID: 31168521 PMCID: PMC6487515 DOI: 10.1186/s41927-019-0064-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/25/2019] [Indexed: 02/07/2023] Open
Abstract
Background Adjusting medication of patients with rheumatoid arthritis (RA) until predefined disease activity targets are met, i.e. Treat-to-Target (T2T), is the currently recommended treatment approach. However, not much is known about long-term cost-effectiveness of different T2T strategies. We model the 5-year costs and effects of a step-up approach (MTX mono - > MTX + csDMARD combination - > Adalimumab - > second anti-TNF) and an initial combination therapy approach (MTX + csDMARD - > MTX + csDMARD higher dose - > anti-TNFs) from the healthcare and societal perspectives, by adapting a previously validated Markov model. Methods We constructed a Markov model in which 3-monthly transitions between DAS28-defined health states of remission (≤2.6), low (2.6 < DAS28 ≤ 3.2), moderate (3.2 < DAS28 ≤ 5.1), and high disease activity (DAS28 > 5.1) were simulated. Modelled patients proceeded to subsequent treatments in case of non-remission at each (3-month) cycle start. In case of remission for two consecutive cycles medication was tapered, until medication-free remission was achieved. Transition probabilities for individual treatment steps were estimated using data of Dutch Rheumatology Monitoring registry Remission Induction Cohort I (step-up) and II (initial combination). Expected costs, utility, and ICER after 5 years were compared between the two strategies. To account for parameter uncertainty, probabilistic sensitivity analysis was employed through Gamma, Normal, and Dirichlet distributions. All utilities, costs, and transition probabilities were replaced by fitted distributions. Results Over a 5-year timespan, initial combination therapy was less costly and more effective than step-up therapy. Initial combination therapy accrued €16,226.3 and 3.552 QALY vs €20,183.3 and 3.517 QALYs for step-up therapy. This resulted in a negative ICER, indicating that initial combination therapy was both less costly and more effective in terms of utility gained. This can be explained by higher (±5%) remission percentages in initial combination strategy at all time points. More patients in remission generates less healthcare and productivity loss costs and higher utility. Additionally, higher remission percentages caused less bDMARD use in the initial combination strategy, lowering overall costs. Conclusion Initial combination therapy was found favourable over step-up therapy in the treatment of Rheumatoid Arthritis, when considering cost-effectiveness. Initial combination therapy resulted in more utility at a lower cost over 5 years. Electronic supplementary material The online version of this article (10.1186/s41927-019-0064-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Celine J van de Laar
- 1Arthritis Center Twente, Medisch Spectrum Twente, University of Twente, Enschede, The Netherlands.,Transparency in Healthcare b.v., Hengelo, The Netherlands
| | - Martijn A H Oude Voshaar
- 1Arthritis Center Twente, Medisch Spectrum Twente, University of Twente, Enschede, The Netherlands.,Transparency in Healthcare b.v., Hengelo, The Netherlands.,3Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Harald E Vonkeman
- 1Arthritis Center Twente, Medisch Spectrum Twente, University of Twente, Enschede, The Netherlands.,Transparency in Healthcare b.v., Hengelo, The Netherlands.,3Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.,4Department of Rheumatology and Clinical Immunology, Medisch Spectrum Twente, Enschede, The Netherlands
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13
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Papadopoulos CG, Gartzonikas IK, Pappa TK, Markatseli TE, Migkos MP, Voulgari PV, Drosos AA. Eight-year survival study of first-line tumour necrosis factor α inhibitors in rheumatoid arthritis: real-world data from a university centre registry. Rheumatol Adv Pract 2019; 3:rkz007. [PMID: 31431995 PMCID: PMC6649942 DOI: 10.1093/rap/rkz007] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 02/11/2019] [Indexed: 01/01/2023] Open
Abstract
Objective. This study aimed to investigate the efficacy, safety and survival of TNF-α inhibitors in patients with RA. Methods. A total of 178 patients >18 years of age were treated with TNF-α inhibitors. A total of 74 patients were treated with infliximab, 75 with adalimumab and 29 with etanercept. Each patient was followed-up for a period of 8 years. Results. Anti-TNF-α therapy resulted in rapid clinical improvement. The rate of good/moderate response according to EULAR response criteria for the index 28-joint DAS with CRP in the first 6 months was 82% for infliximab, 89.6% for adalimumab and 95.6% for etanercept. The rate of withdrawal in 8 years was 80% for patients on infliximab, 61.4% for patients on adalimumab and 47.6% for patients on etanercept. The main reasons for discontinuation were allergic reactions for infliximab (rate of discontinuation 25.7%) and inefficacy for adalimumab and etanercept (17.5% and 23.8%, respectively). Systemic allergic reactions and infections were significantly more frequent in the infliximab group (P < 0.05 and P < 0.001, respectively). However, there was no significant difference among the three drugs concerning serious infections. According to Kaplan–Meier survival analysis, a significantly faster withdrawal for infliximab patients was depicted compared with adalimumab (P = 0.003) and etanercept (P = 0.019), while adalimumab and etanercept were not statistically different (P = 0.089). Conclusions. TNF-α inhibitors establish an effective therapeutic option in RA showing an acceptable safety profile. Infections and allergic reactions appear more often with infliximab, while serious infections did not differ among them. RA patients treated with infliximab are more likely to discontinue treatment earlier compared with the other alternatives.
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Affiliation(s)
- Christos G Papadopoulos
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Ilias K Gartzonikas
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Tatiani K Pappa
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Theodora E Markatseli
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Michael P Migkos
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Department of Internal Medicine, Rheumatology Clinic, Medical School, University of Ioannina, Ioannina, Greece
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14
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van Mens LJJ, de Jong HM, Fluri I, Nurmohamed MT, van de Sande MGH, Kok M, van Kuijk AWR, Baeten D. Achieving remission in psoriatic arthritis by early initiation of TNF inhibition: a double-blind, randomised, placebo-controlled trial of golimumab plus methotrexate versus placebo plus methotrexate. Ann Rheum Dis 2019; 78:610-616. [PMID: 30808625 DOI: 10.1136/annrheumdis-2018-214746] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/26/2019] [Accepted: 02/04/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Early initiation of effective treatment favours remission in rheumatoid arthritis, but it remains unknown if the same concept applies to psoriatic arthritis (PsA). Therefore, this study investigated whether the combination of golimumab plus methotrexate (MTX) as a first-line treatment is superior to MTX alone in inducing remission in PsA. METHODS This investigator-initiated, multicentre, double-blind, randomised, placebo-controlled trial included 51 MTX and bDMARD-naive patients with PsA fulfilling the CASPAR criteria and with active disease at baseline (≥3 swollen joint count/tender joint count). Patients were randomised to golimumab (50 mg SC monthly)+MTX (n=26) (TNFi arm) or matched placebo+MTX (n=25) (MTX arm). MTX was started 15 mg/week and increased to 25 mg/week over 8 weeks. The primary endpoint was percentage of patients achieving Disease Activity Score (DAS) remission (<1.6) at week 22. Safety was assessed throughout the study. RESULTS The primary efficacy endpoint was achieved by 81% in the TNFi arm versus 42 % in the MTX arm (p=0.004). This difference in DAS remission was already observed at week 8. A significant difference in favour of the golimumab+MTX arm at week 22 was also observed for other response criteria such as MDA, ACR20/50/70, disease measures and patient-reported outcomes. The occurrence rates of adverse event and treatment-emergent adverse event were similar in both arms. CONCLUSIONS In patients with early PsA, DAS remission at week 22 was almost doubled with golimumab+MTX versus MTX alone. This double-blind, randomised, placebo-controlled study supports the concept that early initiation of TNFi in patients with PsA favours remission. TRIAL REGISTRATION NUMBER NCT01871649.
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Affiliation(s)
- Leonieke J J van Mens
- Clinical Immunology and Rheumatology, Amsterdam UMC, AMC/University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
| | - Henriëtte M de Jong
- Clinical Immunology and Rheumatology, Amsterdam UMC, AMC/University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
| | - Inka Fluri
- Clinical Immunology and Rheumatology, Amsterdam UMC, AMC/University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
| | - Michael T Nurmohamed
- Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands.,Clinical Immunology and Rheumatology, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Marleen G H van de Sande
- Clinical Immunology and Rheumatology, Amsterdam UMC, AMC/University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
| | - Marc Kok
- Rheumatology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Arno W R van Kuijk
- Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands.,Rheumatology, Jan van Breemen Research Institute
- Reade, Amsterdam, The Netherlands
| | - Dominique Baeten
- Clinical Immunology and Rheumatology, Amsterdam UMC, AMC/University of Amsterdam, Amsterdam, The Netherlands .,Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
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15
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Rantalaiho V, Sandström T, Koski J, Hannonen P, Möttönen T, Kaipiainen-Seppänen O, Yli-Kerttula T, Kauppi MJ, Uutela T, Malmi T, Julkunen H, Laasonen L, Kautiainen H, Leirisalo-Repo M. Early Targeted Combination Treatment With Conventional Synthetic Disease-Modifying Antirheumatic Drugs and Long-Term Outcomes in Rheumatoid Arthritis: Ten-Year Follow-Up Results of a Randomized Clinical Trial. Arthritis Care Res (Hoboken) 2018; 71:1450-1458. [PMID: 30295425 DOI: 10.1002/acr.23782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 10/02/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The short-term outcomes of remission-targeted treatments of rheumatoid arthritis (RA) are well-established, but the long-term success of such strategies is speculative, as is the role of early add-on biologics. We assessed the 10-year outcomes of patients with early RA treated with initial remission-targeted triple combination of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), 7.5-mg prednisolone, and additional infliximab (IFX) or placebo infusions. METHODS Ninety-nine patients with early, DMARD-naive RA were treated with a triple combination of csDMARDs and prednisolone and randomized to double-blind receipt of infusions of either IFX (the Finnish Rheumatoid Arthritis Combination Therapy Trial [FIN-RACo] + IFX) or placebo (FIN-RACo + placebo) during the first 6 months. After 2 years, the treatment strategies became unrestricted, but the treatment goal was strict remission in the TNF-Blocking Therapy in Combination With Disease-Modifying Antirheumatic Drugs in Early Rheumatoid Arthritis (NEO-RACo) study. At 10 years, the clinical and radiographic outcomes and the drug treatments used between 5 and 10 years were assessed. RESULTS Ninety patients (91%) were followed after 2 years, 43 in the FIN-RACo + IFX and 47 in the FIN-RACo + placebo group. At 10 years, the respective proportions of patients in strict NEO-RACo remission and in Disease Activity Score using 28 joints remission in the FIN-RACo + IFX and FIN-RACo + placebo groups were 46% and 38% (P = 0.46) and 82% and 72% (P = 0.29), respectively. The mean total Sharp/van der Heijde score was 9.8 in the FIN-RACo + IFX and 7.3 in the FIN-RACo + placebo group (P = 0.34). During the 10-year follow-up, 26% of the FIN-RACo + IFX group and 30% of the FIN-RACo + placebo group had received biologics (P = 0.74). CONCLUSION In early RA, excellent results can be maintained up until 10 years in most patients treated with initial combination csDMARDs and remission-targeted strategy, regardless of initial IFX/placebo infusions.
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Affiliation(s)
| | - Tia Sandström
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Timo Möttönen
- Turku University Central Hospital and University of Turku, Turku, Finland
| | | | | | - Markku J Kauppi
- Päijät-Häme Central Hospital, Lahti, and Tampere University, Tampere, Finland
| | | | - Timo Malmi
- Seinäjoki Central Hospital, Seinäjoki, Finland
| | | | | | - Hannu Kautiainen
- Kuopio University Hospital, Kuopio, and Folkhälsan Research Center, Helsinki, Finland
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16
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Stropuvienė S, Baranauskaitė A, Bukauskienė L, Zaikauskienė J. The impact of anti-cyclic citrullinated peptide antibody status on the management of patients with early rheumatoid arthritis: observational study results from Lithuania. Acta Med Litu 2018; 25:112-123. [PMID: 30210246 PMCID: PMC6130926 DOI: 10.6001/actamedica.v25i2.3765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background To provide data on the use of anti-cyclic citrullinated peptide antibody (anti-CCP) and other routinely used clinical parameters and to assess the impact of anti-CCP status on therapeutic decisions, an observational study was conducted in patients with rheumatoid arthritis (RA). Methods Sixty-seven adult patients with a recent diagnosis of RA were recruited from four rheumatology centres in Lithuania and were prospectively observed for 12 months. Data collection was based on the review of medical records and routine examination of patients. Patients completed the Health Assessment Questionnaire - Disability Index and Patient Global Assessment of disease activity using a visual analogue scale. Physicians were asked about the importance of the anti-CCP results and other factors important for therapeutic decisions. Results Of the 67 patients enrolled, 54 (80.6%) completed the study. At the beginning of the study, physicians considered anti-CCP results to be important for decision-making in 87.0% of patients. The perceived importance of anti-CCP results did not change significantly throughout the study. After one year of treatment, factors that were considered more important than the anti-CCP results included the presence of erosions, significantly increased C-reactive protein, duration of morning stiffness, multi-articular expanding, and rheumatoid factor status. For nearly half of the patients (n = 26; 48.1%), physicians would not change the treatment strategy if the patient had the opposite anti-CCP results at baseline. Conclusions The study revealed that decision-making in the management of RA was based on multifactorial data. The role of anti-CCP as a single test in treatment decisions needs further investigation.
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Affiliation(s)
- Sigita Stropuvienė
- Clinic of Rheumatology, Traumatology Orthopaedics, and Reconstructive Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Asta Baranauskaitė
- Department of Rheumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Loreta Bukauskienė
- Department of Rheumatology, Klaipėda University Hospital, Klaipėda, Lithuania
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17
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Wailoo A, Hock ES, Stevenson M, Martyn-St James M, Rawdin A, Simpson E, Wong R, Dracup N, Scott DL, Young A. The clinical effectiveness and cost-effectiveness of treat-to-target strategies in rheumatoid arthritis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 21:1-258. [PMID: 29206093 DOI: 10.3310/hta21710] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Treat to target (TTT) is a broad concept for treating patients with rheumatoid arthritis (RA). It involves setting a treatment target, usually remission or low disease activity (LDA). This is often combined with frequent patient assessment and intensive and rapidly adjusted drug treatment, sometimes based on a formal protocol. OBJECTIVE To investigate the clinical effectiveness and cost-effectiveness of TTT compared with routine care. DATA SOURCES Databases including EMBASE and MEDLINE were searched from 2008 to August 2016. REVIEW METHODS A systematic review of clinical effectiveness was conducted. Studies were grouped according to comparisons made: (1) TTT compared with usual care, (2) different targets and (3) different treatment protocols. Trials were subgrouped by early or established disease populations. Study heterogeneity precluded meta-analyses. Narrative synthesis was undertaken for the first two comparisons, but was not feasible for the third. A systematic review of cost-effectiveness was also undertaken. No model was constructed as a result of the heterogeneity among studies identified in the clinical effectiveness review. Instead, conclusions were drawn on the cost-effectiveness of TTT from papers relating to these studies. RESULTS Sixteen clinical effectiveness studies were included. They differed in terms of treatment target, treatment protocol (where one existed) and patient visit frequency. For several outcomes, mixed results or evidence of no difference between TTT and conventional care was found. In early disease, two studies found that TTT resulted in favourable remission rates, although the findings of one study were not statistically significant. In established disease, two studies showed that TTT may be beneficial in terms of LDA at 6 months, although, again, in one case the finding was not statistically significant. The TICORA (TIght COntrol for RA) trial found evidence of lower remission rates for TTT in a mixed population. Two studies reported cost-effectiveness: in one, TTT dominated usual care; in the other, step-up combination treatments were shown to be cost-effective. In 5 of the 16 studies included the clinical effectiveness review, no cost-effectiveness conclusion could be reached, and in one study no conclusion could be drawn in the case of patients denoted low risk. In the remaining 10 studies, and among patients denoted high risk in one study, cost-effectiveness was inferred. In most cases TTT is likely to be cost-effective, except where biological treatment in early disease is used initially. No conclusions could be drawn for established disease. LIMITATIONS TTT refers not to a single concept, but to a range of broad approaches. Evidence reflects this. Studies exhibit substantial heterogeneity, which hinders evidence synthesis. Many included studies are at risk of bias. FUTURE WORK Future studies comparing TTT with usual care must link to existing evidence. A consistent definition of remission in studies is required. There may be value in studies to establish the importance of different elements of TTT (the setting of a target, the intensive use of drug treatments and protocols pertaining to those drugs and the frequent assessment of patients). CONCLUSION In early RA and studies of mixed early and established RA populations, evidence suggests that TTT improves remission rates. In established disease, TTT may lead to improved rates of LDA. It remains unclear which element(s) of TTT (the target, treatment protocols or increased frequency of patient visits) drive these outcomes. Future trials comparing TTT with usual care and/or different TTT targets should use outcomes comparable with existing literature. Remission, defined in a consistent manner, should be the target of choice of future studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017336. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma S Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Andrew Rawdin
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David L Scott
- King's College Hospital NHS Foundation Trust, London, UK
| | - Adam Young
- West Hertfordshire Hospitals NHS Trust, Watford, UK
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18
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Sjö AS, Bergsten U. Patients' experiences of frequent encounters with a rheumatology nurse-A tight control study including patients with rheumatoid arthritis. Musculoskeletal Care 2018; 16:305-312. [PMID: 29808592 DOI: 10.1002/msc.1348] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 04/04/2018] [Accepted: 04/06/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic inflammatory disease that is treated with both pharmacological and nonpharmacological methods. The treatment works well for patients who are knowledgeable about their disease and situation. However, this may be different for others as, among other things, it depends on how well informed the patients are in relation to their condition. Available research primarily focuses on patients in remission. One way of supporting and strengthening the group who experience a lack of well-being due to their disease and providing them with increased knowledge about their situation can be to give them access to a nurse-led clinic based on person-centred care. AIM The aim of the study was to describe the experience of patients with RA attending person-centred, nurse-led clinics over a 12-month period. METHODS A qualitative method was employed to deepen the understanding of the phenomenon. Fifteen participants were interviewed, and the text of the interviews was analysed using the phenomenographic method. RESULTS The analysis resulted in three categories that described participants' experiences of their encounters with a nurse. The three categories describe a process with interrelated concepts: first, Encountering competence, followed by Experiencing a sustainable relationship and, finally, Making a personal journey. CONCLUSION Patients with RA who had frequent meetings with a nurse experienced being strengthened on several levels and having gained increased knowledge about their disease. The person-centred approach made them feel that they had been met on their own level, in accordance with their needs and level of knowledge.
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Affiliation(s)
- Ann-Sofi Sjö
- Rheumatology Department, Sahlgrenska Hospital, Gothenburg, Sweden
| | - Ulrika Bergsten
- Research and Development Department at Region Halland, Halmstad, Sweden
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19
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Steunebrink LMM, Versteeg LGA, Vonkeman HE, Ten Klooster PM, Hoekstra M, van de Laar MAFJ. Radiographic progression in early rheumatoid arthritis patients following initial combination versus step-up treat-to-target therapy in daily clinical practice: results from the DREAM registry. BMC Rheumatol 2018; 2:1. [PMID: 30886952 PMCID: PMC6390778 DOI: 10.1186/s41927-018-0009-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 01/07/2018] [Indexed: 02/08/2023] Open
Abstract
Background Early and intensive targeted treatment with disease modifying anti-rheumatic drugs (DMARDs) has been shown to lead to substantial reductions in disease activity and radiograph damage in patients with early rheumatoid arthritis (RA). The aim of this quasi-experimental study was to compare the first-year radiographic progression rates between a treat-to-target (T2 T) strategy with initial combination therapy (strategy II, started in 2012) versus an initial step-up monotherapy (strategy I, started in 2006). Methods A total of 128 patients from strategy II was individually matched with 128 patients from strategy I on sex, age (± 5 yrs.) and baseline disease activity (± 0.5 on the DAS28). Differences in radiographic progression (Sharp/van der Heijde) scores (SHS) and the number of patients experiencing a minimal clinically important difference (MCID; ≥ 5 SHS points) between both strategies were tested with Mann Whitney U and chi-square tests. Next, linear and logistic regression analyses were performed to examine which baseline variables were associated with radiographic progression scores and the probability of experiencing an MCID within 1 year. Results Patients with initial combination therapy had slightly higher baseline disease activity scores and pain scores, but better mental health scores. Patients with initial monotherapy had significantly more, and more frequently clinically relevant, radiographic progression after 1 year. Experiencing a MCID was independently associated with fewer tender joints (p = 0.050) and higher erythrocyte sedimentation rate (p = 0.015) at baseline. Conclusion Treating early RA patients with initial combination therapy results in better radiographic outcomes than initial monotherapy in daily clinical practice. Trial registration Netherlands Trial Register NTR578, 12 January 2006.
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Affiliation(s)
- Laura M M Steunebrink
- 1Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO BOX 50 000, 7500 KA Enschede, The Netherlands.,2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Letty G A Versteeg
- 1Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO BOX 50 000, 7500 KA Enschede, The Netherlands.,2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Harald E Vonkeman
- 1Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO BOX 50 000, 7500 KA Enschede, The Netherlands.,2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Peter M Ten Klooster
- 2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | | | - Mart A F J van de Laar
- 1Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO BOX 50 000, 7500 KA Enschede, The Netherlands.,2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
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20
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Hamre HJ, Pham VN, Kern C, Rau R, Klasen J, Schendel U, Gerlach L, Drabik A, Simon L. A 4-year non-randomized comparative phase-IV study of early rheumatoid arthritis: integrative anthroposophic medicine for patients with preference against DMARDs versus conventional therapy including DMARDs for patients without preference. Patient Prefer Adherence 2018; 12:375-397. [PMID: 29588576 PMCID: PMC5859899 DOI: 10.2147/ppa.s145221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND While disease-modifying antirheumatic drugs (DMARDs) are a mainstay of therapy for rheumatoid arthritis (RA), some patients with early RA refuse DMARDs. In anthroposophic medicine (AM), a treatment strategy for early RA without DMARDs has been developed. Preliminary data suggest that RA symptoms and inflammatory markers can be reduced under AM, without DMARDs. PATIENTS AND METHODS Two hundred and fifty-one self-selected patients aged 16-70 years, starting treatment for RA of <3 years duration, without prior DMARD therapy, participated in a prospective, non-randomized, comparative Phase IV study. C-patients were treated in clinics offering conventional therapy including DMARDs, while A-patients had chosen treatment in anthroposophic clinics, without DMARDs. Both groups received corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs). Primary outcomes were intensity of RA symptoms measured by self-rating on visual analog scales, C-reactive protein, radiological progression, study withdrawals, serious adverse events (SAE), and adverse drug reactions in months 0-48. RESULTS The groups were similar in most baseline characteristics, while A-patients had longer disease duration (mean 15.1 vs 10.8 months, p<0.0001), slightly more bone destruction, and a much higher proportion of women (94.6% vs 69.7%, p<0.0001). In months 0-12, corticosteroids were used by 45.7% and 81.6% (p<0.0001) and NSAIDs by 52.8% and 68.5% (p=0.0191) of A- and C-patients, respectively. During follow-up, both groups not only had marked reduction of RA symptoms and C-reactive protein, but also some radiological disease progression. Also, 6.2% of A-patients needed DMARDs. Apart from adverse drug reactions (50.4% and 69.7% of A- and C-patients, respectively, p=0.0020), none of the primary outcomes showed any significant between-group difference. CONCLUSION Study results suggest that for most patients preferring anthroposophic treatment, satisfactory results can be achieved without use of DMARDs and with less use of corticosteroids and NSAIDs than in conventional care. LIMITATION Because of the non-randomized study design, with A-patients choosing anthroposophic treatment, one cannot infer how this treatment would have worked for C-patients.
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Affiliation(s)
- Harald J Hamre
- Institute for Applied Epistemology and Medical Methodology at the Witten/Herdecke University, Freiburg, Germany
- Correspondence: Harald J Hamre, Institute for Applied Epistemology and Medical Methodology at the University of Witten-Herdecke, Zechenweg 6, 79111 Freiburg, Germany, Tel +49 761 1560 307, Fax +49 761 6125 6125, Email
| | - Van N Pham
- Institute of Statistics in Medicine, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Christian Kern
- Department of Integrative Medicine, Asklepios Westklinikum, Hamburg, Germany
| | - Rolf Rau
- Department of Rheumatology, Evangelisches Fachkrankenhaus Ratingen, Ratingen, Germany
| | - Jörn Klasen
- Department of Integrative Medicine, Asklepios Westklinikum, Hamburg, Germany
| | - Ute Schendel
- Department of Rheumatology, m&i-Fachklinik Bad Pyrmont, Bad Pyrmont, Germany
| | - Lars Gerlach
- Department of Internal Medicine and Gastroenterology, Filderklinik, Filderstadt, Germany
| | - Attyla Drabik
- Institute of Statistics in Medicine, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Ludger Simon
- Department of Internal Medicine and Gastroenterology, Filderklinik, Filderstadt, Germany
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Konijn NPC, van Tuyl LHD, Boers M, den Uyl D, ter Wee MM, van der Wijden LKM, Bultink IEM, Kerstens PJSM, Voskuyl AE, van Schaardenburg D, Nurmohamed MT, Lems WF. Similar efficacy and safety of initial COBRA-light and COBRA therapy in rheumatoid arthritis: 4-year results from the COBRA-light trial. Rheumatology (Oxford) 2017; 56:1586-1596. [DOI: 10.1093/rheumatology/kex223] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Indexed: 12/26/2022] Open
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Fleischmann R, Tongbram V, van Vollenhoven R, Tang DH, Chung J, Collier D, Urs S, Ndirangu K, Wells G, Pope J. Systematic review and network meta-analysis of the efficacy and safety of tumour necrosis factor inhibitor-methotrexate combination therapy versus triple therapy in rheumatoid arthritis. RMD Open 2017; 3:e000371. [PMID: 28123782 PMCID: PMC5237767 DOI: 10.1136/rmdopen-2016-000371] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/18/2016] [Accepted: 11/28/2016] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Clinical trials have not consistently demonstrated differences between tumour necrosis factor inhibitor (TNFi) plus methotrexate and triple therapy (methotrexate plus hydroxychloroquine plus sulfasalazine) in rheumatoid arthritis (RA). The study objective was to estimate the efficacy, radiographic benefits, safety and patient-reported outcomes of TNFi-methotrexate versus triple therapy in patients with RA. METHODS A systematic review and network meta-analysis (NMA) of randomised controlled trials of TNFi-methotrexate or triple therapy as one of the treatment arms in patients with an inadequate response to or who were naive to methotrexate was conducted. American College of Rheumatology 70% response criteria (ACR70) at 6 months was the prespecified primary endpoint to evaluate depth of response. Data from direct and indirect comparisons between TNFi-methotrexate and triple therapy were pooled and quantitatively analysed using fixed-effects and random-effects Bayesian models. RESULTS We analysed 33 studies in patients with inadequate response to methotrexate and 19 in patients naive to methotrexate. In inadequate responders, triple therapy was associated with lower odds of achieving ACR70 at 6 months compared with TNFi-methotrexate (OR 0.35, 95% credible interval (CrI) 0.19 to 0.64). Most secondary endpoints tended to favour TNFi-methotrexate in terms of OR direction; however, no clear increased likelihood of achieving these endpoints was observed for either therapy. The odds of infection were lower with triple therapy than with TNFi-methotrexate (OR 0.08, 95% CrI 0.00 to 0.57). There were no differences observed between the two regimens in patients naive to methotrexate. CONCLUSIONS In this NMA, triple therapy was associated with 65% lower odds of achieving ACR70 at 6 months compared with TNFi-methotrexate in patients with inadequate response to methotrexate. Although secondary endpoints numerically favoured TNFi-methotrexate, no clear differences were observed. The odds of infection were greater with TNFi-methotrexate. No differences were observed for patients naive to methotrexate. These results may help inform care of patients who fail methotrexate first-line therapy.
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Affiliation(s)
- Roy Fleischmann
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Metroplex Clinical Research Center, Dallas, Texas, USA
| | | | | | - Derek H Tang
- Amgen Inc., Thousand Oaks, California, USA
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | | | | | - Shilpa Urs
- Oxford Outcomes, ICON plc, Morristown, New Jersey, USA
- Doctors’ Hospital of Michigan, Pontiac, Michigan, USA
| | | | - George Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Janet Pope
- Department of Rheumatology, St. Joseph's Health Care, London, Ontario, Canada
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Bijlsma JWJ, Welsing PMJ, Woodworth TG, Middelink LM, Pethö-Schramm A, Bernasconi C, Borm MEA, Wortel CH, Ter Borg EJ, Jahangier ZN, van der Laan WH, Bruyn GAW, Baudoin P, Wijngaarden S, Vos PAJM, Bos R, Starmans MJF, Griep EN, Griep-Wentink JRM, Allaart CF, Heurkens AHM, Teitsma XM, Tekstra J, Marijnissen ACA, Lafeber FPJ, Jacobs JWG. Early rheumatoid arthritis treated with tocilizumab, methotrexate, or their combination (U-Act-Early): a multicentre, randomised, double-blind, double-dummy, strategy trial. Lancet 2016; 388:343-355. [PMID: 27287832 DOI: 10.1016/s0140-6736(16)30363-4] [Citation(s) in RCA: 170] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND For patients with newly diagnosed rheumatoid arthritis, treatment aim is early, rapid, and sustained remission. We compared the efficacy and safety of strategies initiating the interleukin-6 receptor-blocking monoclonal antibody tocilizumab with or without methotrexate (a conventional synthetic disease-modifying antirheumatic drug [DMARD]), versus initiation of methotrexate monotherapy in line with international guidelines. METHODS We did a 2-year, multicentre, randomised, double-blind, double-dummy, strategy study at 21 rheumatology outpatient departments in the Netherlands. We included patients who had been diagnosed with rheumatoid arthritis within 1 year before inclusion, were DMARD-naive, aged 18 years or older, met current rheumatoid arthritis classification criteria, and had a disease activity score assessing 28 joints (DAS28) of at least 2·6. We randomly assigned patients (1:1:1) to start tocilizumab plus methotrexate (the tocilizumab plus methotrexate arm), or tocilizumab plus placebo-methotrexate (the tocilizumab arm), or methotrexate plus placebo-tocilizumab (the methotrexate arm). Tocilizumab was given at 8 mg/kg intravenously every 4 weeks with a maximum of 800 mg per dose. Methotrexate was started at 10 mg per week orally and increased stepwise every 4 weeks by 5 mg to a maximum of 30 mg per week, until remission or dose-limiting toxicity. We did the randomisation using an interactive web response system. Masking was achieved with placebos that were similar in appearance to the active drug; the study physicians, pharmacists, monitors, and patients remained masked during the study, and all assessments were done by masked assessors. Patients not achieving remission on their initial regimen switched from placebo to active treatments; patients in the tocilizumab plus methotrexate arm switched to standard of care therapy (typically methotrexate combined with a tumour necrosis factor inhibitor). When sustained remission was achieved, methotrexate (and placebo-methotrexate) was tapered and stopped, then tocilizumab (and placebo-tocilizumab) was also tapered and stopped. The primary endpoint was the proportion of patients achieving sustained remission (defined as DAS28 <2·6 with a swollen joint count ≤four, persisting for at least 24 weeks) on the initial regimen and during the entire study duration, compared between groups with a two-sided Cochran-Mantel-Haenszel test. Analysis was based on an intention-to-treat method. This trial was registered at ClinicalTrials.gov, number NCT01034137. FINDINGS Between Jan 13, 2010, and July 30, 2012, we recruited and assigned 317 eligible patients to treatment (106 to the tocilizumab plus methotrexate arm, 103 to the tocilizumab arm, and 108 to the methotrexate arm). The study was completed by a similar proportion of patients in the three groups (range 72-78%). The most frequent reasons for dropout were adverse events or intercurrent illness: 27 (34%) of dropouts, and insufficient response: 26 (33%) of dropouts. 91 (86%) of 106 patients in the tocilizumab plus methotrexate arm achieved sustained remission on the initial regimen, compared with 86 (84%) of 103 in the tocilizumab arm, and 48 (44%) of 108 in the methotrexate arm (relative risk [RR] 2·00, 95% CI 1·59-2·51 for tocilizumab plus methotrexate vs methotrexate, and 1·86, 1·48-2·32 for tocilizumab vs methotrexate, p<0·0001 for both comparisons). For the entire study, 91 (86%) of 106 patients in the tocilizumab plus methotrexate arm, 91 (88%) of 103 in the tocilizumab arm, and 83 (77%) of 108 in the methotrexate arm achieved sustained remission (RR 1·13, 95% CI 1·00-1·29, p=0·06 for tocilizumab plus methotrexate vs methotrexate, 1·14, 1·01-1·29, p=0·0356 for tocilizumab vs methotrexate, and p=0·59 for tocilizumab plus methotrexate vs tocilizumab). Nasopharyngitis was the most common adverse event in all three treatment groups, occurring in 38 (36%) of 106 patients in the tocilizumab plus methotrexate arm, 40 (39%) of 103 in the tocilizumab arm, and 37 (34%) of 108 in the methotrexate arm. The occurrence of serious adverse events did not differ between the treatment groups (17 [16%] of 106 patients in the tocilizumab plus methotrexate arm vs 19 [18%] of 103 in the tocilizumab arm and 13 [12%] of 108 in the methotrexate arm), and no deaths occurred during the study. INTERPRETATION For patients with newly diagnosed rheumatoid arthritis, strategies aimed at sustained remission by immediate initiation of tocilizumab with or without methotrexate are more effective, and with a similar safety profile, compared with initiation of methotrexate in line with current standards. FUNDING Roche Nederland BV.
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Affiliation(s)
- Johannes W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Thasia G Woodworth
- Division of Rheumatology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Reinhard Bos
- Medical Center Leeuwarden, Leeuwarden, Netherlands
| | | | | | | | | | | | - Xavier M Teitsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Janneke Tekstra
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anne Carien A Marijnissen
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Floris P J Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Johannes W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, Netherlands.
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The Efficacy and Safety of the Combination of Total Glucosides of Peony and Leflunomide for the Treatment of Rheumatoid Arthritis: A Systemic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 2016:9852793. [PMID: 27143990 PMCID: PMC4842062 DOI: 10.1155/2016/9852793] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 12/29/2015] [Indexed: 12/29/2022]
Abstract
Objective. To evaluate the efficacy and safety of the total glucosides of peony (TGP) and leflunomide (LEF) for the treatment of rheumatoid arthritis (RA). Methods. Randomized controlled trials (RCTs) on the efficacy and safety of the combination of TGP and LEF versus LEF alone for the treatment of RA were retrieved by searching PubMed, EMBASE, Cochrane Library, the China National Knowledge Infrastructure database, and Wanfang database. Results. Eight RCTs including 643 RA patients were included in the present meta-analysis. The quality of included studies was poor. The levels of ESR (P < 0.0001), CRP (P < 0.0001), and RF (P < 0.0001) in RA patients who received the combination of TGP and LEF were significantly lower than RA patients who received LEF therapy alone. The pooled results suggest that the combination of TGP and LEF caused less abnormal liver function than LEF alone (P = 0.02). No significant difference in the gastrointestinal discomfort was identified between the combination of TGP and LEF and LEF alone groups (P = 0.18). Conclusion. The combination of TGP and LEF in treatment of RA presented the characteristics of notably decreasing the levels of laboratory indexes and higher safety in terms of liver function. However, this conclusion should be further investigated based on a larger sample size.
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Nair SC, Jacobs JWG, Bakker MF, Jahangier ZN, Bijlsma JWJ, van Laar JM, Lafeber FPJG, Welsing PMJ. Determining the Lowest Optimally Effective Methotrexate Dose for Individual RA Patients Using Their Dose Response Relation in a Tight Control Treatment Approach. PLoS One 2016; 11:e0148791. [PMID: 26987073 PMCID: PMC4795693 DOI: 10.1371/journal.pone.0148791] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 01/22/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To determine the optimal methotrexate dose in individual patients and to explore whether this optimal dose and the level of disease activity at that dose could be predicted. METHODS Data from CAMERA II trial comparing MTX and MTX with 10 mg of prednisone both in a tight control treatment strategy in early RA was used. For each patient a curve for disease activity over time was fitted and the MTX dose after which further step-up did not result in relevant improvement in disease activity anymore was determined the 'lowest optimally effective MTX dose (LOED)'. The association of demographic and clinical characteristics at baseline with this LOED and with the level of disease activity reached at LOED was studied. RESULTS In 204 (100 MTX and 104 MTX with prednisone) out of 236 patients LOED could be defined. 10 mg/wk was the most prevalent LOED in patients treated with MTX and prednisone and 10 mg/wk, 20 mg/wk and 30 mg/wk in the MTX strategy. Although the specific LOED could not reliably be predicted, higher baseline disease activity, height and lower weight were associated with higher LOEDs (i.e at least 15 mg/wk). A score was presented to decide on a starting dose of 10 mg/wk or (at least) 15 mg/wk. The level of disease activity at LOED could not be reliably predicted. CONCLUSION A starting dose of 10 mg/wk might be a good choice for most patients and is frequently already the optimal dose. However, a subgroup of patient can be determined who would require higher MTX doses.
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Affiliation(s)
- Sandhya C. Nair
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
- * E-mail:
| | - Johannes W. G. Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - Marije F. Bakker
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | | | - Johannes W. J. Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - Jacobs M. van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - Floris P. J. G. Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
| | - Paco M. J. Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
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Malmborg P, Hildebrand H. The emerging global epidemic of paediatric inflammatory bowel disease--causes and consequences. J Intern Med 2016; 279:241-58. [PMID: 26355194 DOI: 10.1111/joim.12413] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Two decades ago, paediatric inflammatory bowel disease (IBD) drew only modest interest from the international paediatric community. Since then, dramatically globally increasing incidence rates have made childhood-onset IBD a priority for most paediatric gastroenterologists. The emerging pandemia of paediatric IBD has fuelled a quest to identify the recent changes in early life exposures that could explain the increasing risk for IBD amongst today's children. Treatment of children with IBD should aim for symptom control but should also target restoration of growth and prevention of pubertal delay. The paediatric IBD phenotype seems to be characterized by more extensive disease location, and some comparative studies have suggested that childhood-onset IBD also represents a more severe phenotype than the adult-onset IBD form. In this review, we analyse recent global incidence trends of paediatric IBD. We present an update on the known and suggested risk factors that could explain the emerging global epidemia of paediatric IBD. We also draw attention to differences in treatment between children and adults with IBD. Finally, we highlight latest follow-up studies that question the proposed dynamic and aggressive nature of childhood-onset IBD.
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Affiliation(s)
- P Malmborg
- Department of Women's and Children's Health, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - H Hildebrand
- Department of Women's and Children's Health, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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Monti S, Montecucco C, Bugatti S, Caporali R. Rheumatoid arthritis treatment: the earlier the better to prevent joint damage. RMD Open 2015; 1:e000057. [PMID: 26557378 PMCID: PMC4632152 DOI: 10.1136/rmdopen-2015-000057] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 05/18/2015] [Accepted: 05/22/2015] [Indexed: 01/12/2023] Open
Abstract
The management of rheumatoid arthritis has undergone major advances in recent years, both in terms of the drugs armamentarium and therapeutic strategy. Treating disease to target, aiming at remission, through a tight control protocol is regarded as the standard of care. Reaching clinical and radiographic disease remission has therefore become an achievable goal. Increasing evidence has demonstrated that early diagnosis, prompt treatment initiation and early achievement of remission are the major predictors of long-term clinical, functional and radiographic outcomes. Concentrating efforts in controlling disease activity in a very early window of opportunity offers unique sustained benefits. In this short review, we analysed the available evidence supporting the value of treating rheumatoid arthritis early and the impact on disease outcomes, with particular focus on radiographic progression.
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Affiliation(s)
- Sara Monti
- Division of rheumatology , University of Pavia; early Arthritis Clinic, IRCCS Policlinico S. Matteo Foundation , Pavia , Italy
| | - Carlomaurizio Montecucco
- Division of rheumatology , University of Pavia; early Arthritis Clinic, IRCCS Policlinico S. Matteo Foundation , Pavia , Italy
| | - Serena Bugatti
- Division of rheumatology , University of Pavia; early Arthritis Clinic, IRCCS Policlinico S. Matteo Foundation , Pavia , Italy
| | - Roberto Caporali
- Division of rheumatology , University of Pavia; early Arthritis Clinic, IRCCS Policlinico S. Matteo Foundation , Pavia , Italy
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Favalli EG, Becciolini A, Biggioggero M. Structural integrity versus radiographic progression in rheumatoid arthritis. RMD Open 2015; 1:e000064. [PMID: 26557381 PMCID: PMC4632139 DOI: 10.1136/rmdopen-2015-000064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 04/07/2015] [Accepted: 05/01/2015] [Indexed: 12/18/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic, progressive and inflammatory disease often leading to irreversible destruction of articular structures and consequent disability. The key steps of RA pathogenetic mechanisms are the break of immune tolerance and the production of autoantibodies, followed by systemic and local inflammation resulting in damage of both subchondral bone (erosion) and cartilage (joint space narrowing (JSN)). Evidences from clinical trials suggest that erosions and JSN are the result of inter-related but partly independent pathogenetic pathways, in both cases mediated by pro-inflammatory cytokines, even if a direct effect of cyclic citrullinated peptides (anticitrullinated protein antibodies, ACPAs) on bone damage had been postulated. As a consequence, the suppression of inflammation provided by synthetic and biological disease-modifying antirheumatic drugs results in a decreased progression of bone and cartilage damage, supporting the effectiveness of the treat-to-target strategy. Nevertheless, radiographic progression may also be detected in patients achieving a sustained clinical remission. Two main reasons for this apparent uncoupling between clinical synovitis and damage progression should be considered. First, in some cases, the use of composite indices to define remission may not be completely adequate to identify residual disease activity, requiring the concomitant introduction of more sensible tools such as imaging. Second, the direct effect of biological drugs on bone destruction inducers, such as pro-inflammatory cytokines, may explain the suppression of radiographic progression despite the persistence of clinical synovitis. In this review, we discuss the link between autoimmunity, inflammation, joint damage and disability, focusing on how radiographic progression may predict functional disability.
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Affiliation(s)
| | - Andrea Becciolini
- Department of Clinical Sciences and Health Community, Division of Rheumatology , Gaetano Pini Institute, University of Milan , Milan , Italy
| | - Martina Biggioggero
- Department of Clinical Sciences and Health Community, Division of Rheumatology , Gaetano Pini Institute, University of Milan , Milan , Italy
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Scott DL, Ibrahim F, Farewell V, O'Keeffe AG, Ma M, Walker D, Heslin M, Patel A, Kingsley G. Randomised controlled trial of tumour necrosis factor inhibitors against combination intensive therapy with conventional disease-modifying antirheumatic drugs in established rheumatoid arthritis: the TACIT trial and associated systematic reviews. Health Technol Assess 2015; 18:i-xxiv, 1-164. [PMID: 25351370 DOI: 10.3310/hta18660] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is initially treated with methotrexate and other disease-modifying antirheumatic drugs (DMARDs). Active RA patients who fail such treatments can receive tumour necrosis factor inhibitors (TNFis), which are effective but expensive. OBJECTIVE We assessed whether or not combination DMARDs (cDMARDs) give equivalent clinical benefits at lower costs in RA patients eligible for TNFis. DESIGN An open-label, 12-month, pragmatic, randomised, multicentre, two-arm trial [Tumour necrosis factor inhibitors Against Combination Intensive Therapy (TACIT)] compared these treatment strategies. We then systematically reviewed all comparable published trials. SETTING The TACIT trial involved 24 English rheumatology clinics. PARTICIPANTS Active RA patients eligible for TNFis. INTERVENTIONS The TACIT trial compared cDMARDs with TNFis plus methotrexate or another DMARD; 6-month non-responders received (a) TNFis if in the cDMARD group; and (b) a second TNFi if in the TNFi group. MAIN OUTCOME MEASURES The Heath Assessment Questionnaire (HAQ) was the primary outcome measure. The European Quality of Life-5 Dimensions (EQ-5D), joint damage, Disease Activity Score for 28 Joints (DAS28), withdrawals and adverse effects were secondary outcome measures. Economic evaluation linked costs, HAQ changes and quality-adjusted life-years (QALYs). RESULTS In total, 432 patients were screened; 104 started on cDMARDs and 101 started on TNFis. The initial demographic and disease assessments were similar between the groups. In total, 16 patients were lost to follow-up (nine in the cDMARD group, seven in the TNFi group) and 42 discontinued their intervention but were followed up (23 in the cDMARD group and 19 in the TNFi group). Intention-to-treat analysis with multiple imputation methods used for missing data showed greater 12-month HAQ score reductions with initial cDMARDs than with initial TNFis [adjusted linear regression coefficient 0.15, 95% confidence interval (CI) -0.003 to 0.31; p = 0.046]. Increases in 12-month EQ-5D scores were greater with initial cDMARDs (adjusted linear regression coefficient -0.11, 95% CI -0.18 to -0.03; p = 0.009) whereas 6-month changes in HAQ and EQ-5D scores and 6- and 12-month changes in joint damage were similar between the initial cDMARD group and the initial TNFi group. Longitudinal analyses (adjusted general estimating equations) showed that the DAS28 was lower in the initial TNFi group in the first 6 months (coefficient -0.63, 95% CI -0.93 to -0.34; p < 0.001) but there were no differences between the groups in months 6-12. In total, 36 patients in the initial cDMARD group and 44 in the initial TNFi group achieved DAS28 remission. The onset of remission did not differ between groups (p = 0.085 on log-rank test). In total, 10 patients in the initial cDMARD group and 18 in the initial TNFi group experienced serious adverse events; stopping therapy because of toxicity occurred in 10 and six patients respectively. Economic evaluation showed that the cDMARD group had similar or better QALY outcomes than TNFi with significantly lower costs at 6 and 12 months. In the systematic reviews we identified 32 trials (including 20-1049 patients) on early RA and 19 trials (including 40-982 patients) on established RA that compared (1) cDMARDs with DMARD monotherapy; (2) TNFis/methotrexate with methotrexate monotherapy; and (3) cDMARDs with TNFis/methotrexate. They showed that cDMARDs and TNFis had similar efficacies and toxicities. CONCLUSIONS Active RA patients who have failed methotrexate and another DMARD achieve equivalent clinical benefits at a lower cost from starting cDMARDs or from starting TNFis (reserving TNFis for non-responders). Only a minority of patients achieve sustained remission with cDMARDs or TNFis; new strategies are needed to maximise the frequency of remission. TRIAL REGISTRATION Current Control Trials ISRCTN37438295. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Department of Rheumatology, King's College London School of Medicine, London, UK
| | - Fowzia Ibrahim
- Department of Rheumatology, King's College London School of Medicine, London, UK
| | - Vern Farewell
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, UK
| | - Aidan G O'Keeffe
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, UK
| | - Margaret Ma
- Department of Rheumatology, King's College London School of Medicine, London, UK
| | - David Walker
- Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Margaret Heslin
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
| | - Anita Patel
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
| | - Gabrielle Kingsley
- Department of Rheumatology, King's College London School of Medicine, London, UK
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Parida JR, Misra DP, Wakhlu A, Agarwal V. Is non-biological treatment of rheumatoid arthritis as good as biologics? World J Orthop 2015; 6:278-283. [PMID: 25793168 PMCID: PMC4363810 DOI: 10.5312/wjo.v6.i2.278] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 04/10/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
The management of rheumatoid arthritis (RA) in the past three decades has undergone a paradigm shift from symptomatic relief to a “treat-to-target” approach. This has been possible through use of various conventional and biologic disease modifying anti-rheumatic drugs (DMARDs) which target disease pathogenesis at a molecular level. Cost and infection risk preclude regular use of biologics in resource-constrained settings. In the recent years, evidence has emerged that combination therapy with conventional DMARDs is not inferior to biologics in the management of RA and is a feasible cost-effective option.
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31
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Bykerk VP. Nonimmunosuppressive disease-modifying antirheumatic drugs. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00055-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Lee CH, Srikhum W, Burghardt AJ, Virayavanich W, Imboden JB, Link TM, Li X. Correlation of structural abnormalities of the wrist and metacarpophalangeal joints evaluated by high-resolution peripheral quantitative computed tomography, 3 Tesla magnetic resonance imaging and conventional radiographs in rheumatoid arthritis. Int J Rheum Dis 2014; 18:628-39. [DOI: 10.1111/1756-185x.12495] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Chan Hee Lee
- Department of Radiology and Biomedical Imaging; University of California, San Francisco; San Francisco California USA
- Division of Rheumatology; Department of Internal Medicine; National Health Insurance Service Ilsan Hospital; Goyang-si South Korea
| | - Waraporn Srikhum
- Department of Radiology and Biomedical Imaging; University of California, San Francisco; San Francisco California USA
- Department of Radiology; Thammasat University; Pathumthani Thailand
| | - Andrew J. Burghardt
- Department of Radiology and Biomedical Imaging; University of California, San Francisco; San Francisco California USA
| | - Warapat Virayavanich
- Department of Radiology and Biomedical Imaging; University of California, San Francisco; San Francisco California USA
- Department of Radiology; Ramathibodi Hospital; Mahidol University; Bangkok Thailand
| | - John B. Imboden
- Department of Medicine; University of California; San Francisco California USA
- Division of Rheumatology; San Francisco General Hospital; San Francisco California USA
| | - Thomas M. Link
- Department of Radiology and Biomedical Imaging; University of California, San Francisco; San Francisco California USA
| | - Xiaojuan Li
- Department of Radiology and Biomedical Imaging; University of California, San Francisco; San Francisco California USA
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Markusse IM, de Vries-Bouwstra JK, Han KH, van der Lubbe PAHM, Schouffoer AA, Kerstens PJSM, Lems WF, Huizinga TWJ, Allaart CF. Feasibility of tailored treatment based on risk stratification in patients with early rheumatoid arthritis. Arthritis Res Ther 2014; 16:430. [PMID: 25253199 PMCID: PMC4203912 DOI: 10.1186/s13075-014-0430-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 08/18/2014] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Personalized medicine is the holy grail of medicine. The EULAR recommendations for the management of rheumatoid arthritis (RA) support differential treatment between patients with baseline characteristics suggestive of a non-poor prognosis (non-PP) or poor prognosis (PP) (presence of autoantibodies, a high inflammatory activity and damage on radiographs). We aimed to determine which prognostic risk groups benefit more from initial monotherapy or initial combination therapy. METHODS 508 patients were randomized to initial monotherapy (iMono) or initial combination therapy (iCombo). Disease outcomes of iMono and iCombo were compared within non-PP or PP groups as determined on baseline characteristics RESULTS PP patients treated with iCombo after three months more often achieved ACR20 (70% vs 38%, P <0.001), ACR50 (48% vs 13%, P <0.001) and ACR70 response (24% vs 4%, P <0.001) than those treated with iMono, and had more improvement in HAQ (median decrease 0.75 vs 0.38, P <0.001). After 1 year, differences in ACR20 response and DAS-remission remained; PP patients treated with iCombo (vs iMono) had less radiographic progression (median 0.0 vs 1.5, P =0.001). CONCLUSIONS Since PP and non-PP patients benefit equally from iCombo through earlier clinical response and functional improvement than with iMono, we conclude that personalized medicine as suggested in the guidelines is not yet feasible. The choice of treatment strategy should depend more on rapid relief of symptoms than on prognostic factors. TRIAL REGISTRATION Netherlands Trial Register NTR262 (registered 7 September 2005) and NTR265 (8 September 2005).
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Ciubotariu E, Gabay C, Finckh A. Joint damage progression in patients with rheumatoid arthritis in clinical remission: do biologics perform better than synthetic antirheumatic drugs? J Rheumatol 2014; 41:1576-82. [PMID: 25028383 DOI: 10.3899/jrheum.130767] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Randomized controlled studies have demonstrated protective advantages of biologic therapies over the synthetic disease-modifying antirheumatic drugs (DMARD) in slowing joint damage progression in patients with rheumatoid arthritis (RA). This effect appears to be largely independent of the clinical disease control. We measured the rate of radiographic progression in patients with RA in clinical remission treated with synthetic versus biologic DMARD. METHODS This is an observational cohort study of patients with RA in clinical remission, nested within the Swiss Clinical Quality Management in Rheumatoid Arthritis (SCQM-RA) Registry. The primary study outcome was the rate of radiographic progression (Ratingen erosion score), and a secondary outcome was functional disability [Health Assessment Questionnaire-Disability Index (HAQ-DI)] progression. We compared the rate of progression between synthetic and biologic DMARD using a multivariate regression model for longitudinal data, adjusting for potential confounders. RESULTS A total of 2055 patients in the SCQM-RA registry were in remission at least once from 1999 to 2012 and met the study inclusion criteria. Baseline characteristics of patients in remission receiving synthetic and biologic DMARD were not significantly different in terms of prognostic factors for joint damage progression. During followup, erosion progression differed significantly between the 2 groups [1.4% (95% CI: 1.1-1.6) vs 0.9% (95% CI: 0.5-1.2) of progression over 3 years, respectively, p < 0.001], with less damage progression in patients treated with biologic DMARD than with synthetic DMARD. This difference remained significant after adjusting for confounding factors. The evolution of the HAQ-DI score was also statistically better in the biologic group (p < 0.001). CONCLUSION This observational study confirms that the rate of structural damage progression in clinical remission is decreased taking biologics compared to synthetic DMARD. However, while the difference is statistically significant it is probably not relevant from a clinical perspective.
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Affiliation(s)
- Elena Ciubotariu
- From the Division of Rheumatology, University Hospital Sacré Coeur de Montréal, Montréal, Canada; Division of Rheumatology, University Hospital of Geneva; and Division of Clinical Epidemiology, University Hospital of Geneva, Geneva, Switzerland.E. Ciubotariu, MD, MSc, Division of Rheumatology, University Hospital Sacré Coeur of Montréal; C. Gabay, MD, PhD, Professor, Division of Rheumatology, University Hospital of Geneva; A. Finckh, MD, PhD, Adjoint Professor Division of Rheumatology; Division of Clinical Epidemiology, University Hospital of Geneva.
| | - Cem Gabay
- From the Division of Rheumatology, University Hospital Sacré Coeur de Montréal, Montréal, Canada; Division of Rheumatology, University Hospital of Geneva; and Division of Clinical Epidemiology, University Hospital of Geneva, Geneva, Switzerland.E. Ciubotariu, MD, MSc, Division of Rheumatology, University Hospital Sacré Coeur of Montréal; C. Gabay, MD, PhD, Professor, Division of Rheumatology, University Hospital of Geneva; A. Finckh, MD, PhD, Adjoint Professor Division of Rheumatology; Division of Clinical Epidemiology, University Hospital of Geneva
| | - Axel Finckh
- From the Division of Rheumatology, University Hospital Sacré Coeur de Montréal, Montréal, Canada; Division of Rheumatology, University Hospital of Geneva; and Division of Clinical Epidemiology, University Hospital of Geneva, Geneva, Switzerland.E. Ciubotariu, MD, MSc, Division of Rheumatology, University Hospital Sacré Coeur of Montréal; C. Gabay, MD, PhD, Professor, Division of Rheumatology, University Hospital of Geneva; A. Finckh, MD, PhD, Adjoint Professor Division of Rheumatology; Division of Clinical Epidemiology, University Hospital of Geneva.
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Katayama K, Okubo T, Sato T, Ito H, Fukai R, Baba H. Inhibition of radiographic joint damage in rheumatoid arthritis patients in DAS28 remission using single- or combined with methotrexate non biological disease-modifying antirheumatic drug therapy in routine clinical practice. Mod Rheumatol 2014; 25:50-5. [DOI: 10.3109/14397595.2014.924385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Kou Katayama
- Katayama Orthopaedic Rheumatology Clinic, Asahikawa, Japan
| | - Takanobu Okubo
- Katayama Orthopaedic Rheumatology Clinic, Asahikawa, Japan
| | - Toshikazu Sato
- Katayama Orthopaedic Rheumatology Clinic, Asahikawa, Japan
| | - Hiroshi Ito
- Department of Orthopaedic Surgery, Asahikawa Medical University, Asahikawa, Japan
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ter Wee MM, den Uyl D, Boers M, Kerstens P, Nurmohamed M, van Schaardenburg D, Voskuyl AE, Lems WF. Intensive combination treatment regimens, including prednisolone, are effective in treating patients with early rheumatoid arthritis regardless of additional etanercept: 1-year results of the COBRA-light open-label, randomised, non-inferiority trial. Ann Rheum Dis 2014; 74:1233-40. [DOI: 10.1136/annrheumdis-2013-205143] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 04/13/2014] [Indexed: 11/04/2022]
Abstract
BackgroundRecently, we documented the likely non-inferiority of Combinatietherapie Bij Reumatoïde Artritis (COBRA)-light therapy (methotrexate increased to 25 mg/week with initial prednisolone 30 mg/day) compared with the original COBRA therapy (methotrexate 7.5 mg/week, sulfasalazine 2 g/day, with initial prednisolone 60 mg/day) after 26 weeks in patients with early active rheumatoid arthritis (RA).ObjectiveTo assess the non-inferiority of COBRA-light versus COBRA after 1 year in terms of disease activity (DAS44), functional outcome (Health Assessment Questionnaire (HAQ)) and radiographic progression (Sharp/van der Heijde score (SHS)), and to assess the effect of adding etanercept.MethodsAn open-label, randomised controlled, non-inferiority trial of 162 patients with active early RA, following a treat-to-target protocol incorporating the addition of etanercept if DAS44 ≥1.6 at weeks 26 or 39.ResultsBoth groups showed major improvements in DAS44 after 52 weeks: mean (SD) −2.41 (1.2) in the COBRA and −2.02 (1.0) in the COBRA-light group (p=ns). In both groups, functional ability improved and radiological progression of joints was minimal. At least one adverse event was reported in 96% of the patients in both groups. In total, 25 serious adverse events occurred: 9 vs 16 in COBRA and COBRA-light, respectively. Treatment actually instituted was often less intensive than required by the protocol: of the total population, 108 patients (67%) required etanercept (more in the COBRA-light group), but only 67 of these (62%) actually received it.ConclusionsIntensive COBRA or COBRA-light therapy has major, comparably favourable effects on disease activity, functional ability and radiological outcome after 1 year in patients with early RA. Protocolised addition of etanercept was often not implemented by treating rheumatologists, and patients receiving it appeared to have limited added benefit, probably because of low disease activity levels at its initiation.Trial registration number:ISRCTN55552928.
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Hmamouchi I, Combe B, Fautrel B, Rincheval N, Lukas C. Prevalence and concordance of early and sustained remission assessed by various validated indices in the early arthritis "ESPOIR" cohort. Joint Bone Spine 2014; 81:409-15. [PMID: 24703402 DOI: 10.1016/j.jbspin.2014.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To assess the prevalence of remission in early arthritis, to evaluate the concordance across different criteria sets in defining this state, and to look for predictive factors for early and sustained remission. METHODS Patients from the ESPOIR cohort were followed-up every 6months. We analysed early remission and sustained remission in 3 groups of patients: patients having rheumatoid arthritis (RA) according to 2010 ACR/EULAR criteria, undifferentiated arthritis (UA), and the whole cohort. Remission was defined according to ACR/EULAR criteria, 28 Joint Disease Activity Score (DAS28<2.6), and Simplified Disease Activity Index (SDAI≤3.3). Agreement was evaluated by k-coefficient. Predictive factors for sustained remission at 1, 3 and 5year in RA patients were analyzed. RESULTS Eight hundred and nineteen patients were included. Early remission rates in the RA/UA/ESPOIR groups were observed in respectively 29.2% (181/682), 51.4% (55/123) and 32.7% (239/813) of patients by DAS28; 15.7%, 29.1% and 18% by SDAI; and 11.2%, 29.1% and 12.8% by ACR/EULAR criteria. Agreement between classifications of remission was low for DAS28 vs. ACR/EULAR (k=0.44), high for SDAI vs. ACR/EULAR (k=0.78), and moderate for SDAI vs. DAS28 (k=0.54). Lower baseline disease activity scores, non-menopausal status and younger age were the best predictive factors for sustained remission, with consistent results across the 3 definitions of remission. CONCLUSION Our study showed that the rate of early and sustained remission in early arthritis is dependent on the definition used, with a variable degree of agreement across criteria sets, but with consistent predictive factors of favourable outcome in patients finally diagnosed with RA.
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Affiliation(s)
- Ihsane Hmamouchi
- Department of Rheumatology, Lapeyronie Hospital, Montpellier I University, UMR 5535, EA2415, Montpellier, France; Mohammed V-Souissi University, Faculty of Medicine, Laboratory of Biostatistics, Clinical Research and Epidemiology, Rabat, Morocco.
| | - Bernard Combe
- Department of Rheumatology, Lapeyronie Hospital, Montpellier I University, UMR 5535, EA2415, Montpellier, France
| | - Bruno Fautrel
- UFR de médecine, université-Pierre-et-Marie-Curie-Paris-VI, 75013 Paris, France
| | - Nathalie Rincheval
- Department of Rheumatology, Lapeyronie Hospital, Montpellier I University, UMR 5535, EA2415, Montpellier, France
| | - Cédric Lukas
- Department of Rheumatology, Lapeyronie Hospital, Montpellier I University, UMR 5535, EA2415, Montpellier, France
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Meier FMP, Frerix M, Hermann W, Müller-Ladner U. Current immunotherapy in rheumatoid arthritis. Immunotherapy 2014; 5:955-74. [PMID: 23998731 DOI: 10.2217/imt.13.94] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Rheumatoid arthritis is a common autoimmune disease primarily manifesting as chronic synovitis, subsequently leading to a change in joint integrity. Progressive disability and systemic complications are strongly associated with a decreased quality of life. To maintain function and health in patients with rheumatoid arthritis, early, aggressive and guided immunosuppressive therapy is required to induce clinical remission. Antirheumatic drugs are capable of controlling synovial inflammation and are therefore named 'disease-modifying antirheumatic drugs' (DMARDs). This article aims to bridge the beginning of DMARD therapy with agents such as methotrexate, leflunomide, sulfasalazine, injectable gold and (hydroxy)chloroquine with biological therapies, and with the new era of kinase inhibitors. Mechanisms of action, as well as advantages and disadvantages of DMARDs, are discussed with respect to the current literature and current recommendations.
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Affiliation(s)
- Florian M P Meier
- Department of Internal Medicine & Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Klinik, Bad Nauheim, Germany
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Gaujoux-Viala C, Nam J, Ramiro S, Landewé R, Buch MH, Smolen JS, Gossec L. Efficacy of conventional synthetic disease-modifying antirheumatic drugs, glucocorticoids and tofacitinib: a systematic literature review informing the 2013 update of the EULAR recommendations for management of rheumatoid arthritis. Ann Rheum Dis 2014; 73:510-5. [PMID: 24395555 PMCID: PMC3932966 DOI: 10.1136/annrheumdis-2013-204588] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/02/2013] [Accepted: 12/11/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To update a previous systematic review assessing the efficacy of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) in rheumatoid arthritis (RA). METHODS Two systematic reviews of the literature using PubMed, Embase and the Cochrane library were performed from 2009 until January 2013 to assess the efficacy of csDMARDs (as monotherapy or combination therapy) in adults with RA, and the efficacy of glucocorticoids in early RA. A third systematic review was performed until March 2013 to assess the efficacy of tofacitinib by meta-analysis. RESULTS For glucocorticoids, of 222 hits, five publications relating to four new trials were analysed for efficacy, confirming that initial treatment of RA with low-dose prednisone plus methotrexate (MTX) results in better clinical and structural outcomes at 1 and 2 years than treatment with MTX alone. For csDMARDs, of 498 studies, only two new studies were randomised controlled trials comparing MTX monotherapy with MTX in combination with another csDMARD without differences in glucocorticoid usage. Using tight control principles, clinical outcomes were no better with immediate triple therapy than with 'step-up' therapy. For tofacitinib, the pooled analysis of 10 trials showed that tofacitinib was more efficacious on signs and symptoms, disability and appeared to be more efficacious on structural damage than control treatment with placebo (OR (95% CI)--American College of Rheumatology 20% (ACR20) response: 2.44 (1.97 to 3.02)) or treatment with MTX (ACR20 response: 2.38 (1.66 to 3.43)). CONCLUSIONS Addition of low-dose glucocorticoids to csDMARD therapy produces benefits in early RA. Under tight control conditions, combination therapy with csDMARDs is no better than MTX monotherapy. Tofacitinib is a new DMARD with proven efficacy.
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Affiliation(s)
- Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital; EA 2415, Montpellier I University, Nîmes, France
| | - Jackie Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sofia Ramiro
- Department of Clinical Immunology & Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Rheumatology, Hospital Garcia de Orta, Almada, Portugal
| | - Robert Landewé
- Department of Clinical Immunology & Rheumatology, Academic Medical Center/University of Amsterdam & Atrium Medical Center, Heerlen, The Netherlands
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
| | - Laure Gossec
- Department of Rheumatology, UPMC Univ Paris 06, GRC-UPMC 08 (EEMOIS); AP-HP, Pitié Salpêtrière Hospital, Paris, France
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Malviya G, Salemi S, Laganà B, Diamanti AP, D'Amelio R, Signore A. Biological therapies for rheumatoid arthritis: progress to date. BioDrugs 2014; 27:329-45. [PMID: 23558378 DOI: 10.1007/s40259-013-0021-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Biologic drugs for the management of rheumatoid arthritis (RA) have revolutionized the therapeutic armamentarium with the development of several novel monoclonal antibodies, which include murine, chimeric, humanized, fully human antibodies and fusion proteins. These biologics bind to their targets with high affinity and specificity. Since 1998, nine different biologics have been approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) for the treatment of RA, and several others are in different stages of clinical trials. This field is in continuous evolution and new biologics are tested every year. Therefore a precise analysis is required in order to have a detailed and updated state of the art of this field. In this review, our main aim is to analyse all available biological therapies that are FDA and EMA approved for the treatment of RA and also those that are in clinical trials for the management of RA patients.
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MESH Headings
- Animals
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/genetics
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Antirheumatic Agents/adverse effects
- Antirheumatic Agents/pharmacology
- Antirheumatic Agents/therapeutic use
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/immunology
- Arthritis, Rheumatoid/metabolism
- Biological Products/adverse effects
- Biological Products/pharmacology
- Biological Products/therapeutic use
- Drugs, Investigational/adverse effects
- Drugs, Investigational/pharmacology
- Drugs, Investigational/therapeutic use
- Humans
- Immunoglobulin Fab Fragments/adverse effects
- Immunoglobulin Fab Fragments/genetics
- Immunoglobulin Fab Fragments/pharmacology
- Immunoglobulin Fab Fragments/therapeutic use
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/pharmacology
- Immunosuppressive Agents/therapeutic use
- Receptors, Interleukin-1/antagonists & inhibitors
- Receptors, Interleukin-1/metabolism
- Recombinant Fusion Proteins/adverse effects
- Recombinant Fusion Proteins/pharmacology
- Recombinant Fusion Proteins/therapeutic use
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Affiliation(s)
- Gaurav Malviya
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, The Netherlands
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Abstract
Treatment of early rheumatoid arthritis has to be started very early, when the diagnosis is made, preferentially before 6 months of symptoms. Combination therapy with conventional disease-modifying anti-rheumatic drugs (DMARDs) with low-dose, oral glucocorticoids in the induction phase from the start gives the best results. The patient should be monitored systematically, at start between 1 and 3 months, and the patient should have access to additional visits if a flare or arthritis or adverse event occurs. The treatment should aim to remission (no tender and swollen joints, no signs of inflammatory activity), which can be reached by 60-80% of the patients. Intra-articular glucocorticoid injections as part of the treatment strategy increase the suppression of arthritis and retard joint destruction. Biological drugs are reserved for patients who have consistent active disease and who do not respond to conventional combinations.
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Affiliation(s)
- Marjatta Leirisalo-Repo
- Helsinki University Central Hospital, Department of Medicine, and University of Helsinki, Institute of Clinical Medicine, Helsinki, Finland.
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Harris JA, Bykerk VP, Hitchon CA, Keystone E, Thorne JC, Boire G, Haraoui B, Hazlewood G, Bonner AJ, Pope JE. Determining Best Practices in Early Rheumatoid Arthritis by Comparing Differences in Treatment at Sites in the Canadian Early Arthritis Cohort. J Rheumatol 2013; 40:1823-30. [DOI: 10.3899/jrheum.121316] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.To determine site variation by comparing outcomes across sites in an early rheumatoid arthritis cohort.Methods.Sites from the Canadian Early Arthritis Cohort database with at least 40 patients were studied. Comparisons were made among sites in change in 28-joint Disease Activity Score (DAS28), proportion of patients in DAS28 remission, and treatment strategies.Results.The study included 1138 baseline patients at 8 sites, with baseline (SD) age 52 years (16.9); 72% women; 23% erosions; 54% ever smokers; 51% rheumatoid factor-positive; 37% anticitrullinated protein antibody-positive; disease duration 187 (203) days; DAS28 4.5 (1.4). Site had an effect on outcomes when adjusting for confounders. At 6 and 12 months, sites B and H, the 2 largest sites, had the best changes in DAS28 (−1.82 and −2.09, respectively, at 6 mos, and −2.27 for both at 12 mos; p < 0.001). Site H had the most patients in DAS28 remission at 6 months [64.5% compared to other sites that had from 34.1% to 51.7% (p < 0.001)], and at the last followup, sites B and H had the most in remission. Subcutaneous methotrexate was used more overall and earlier at sites B and H. Those sites used less steroid therapy, and site B had the second-highest use of triple disease-modifying antirheumatic drugs at any visit. Medications were increased more in 2 of the 3 smallest sites. Biologics were used by 9 months most in the smallest (50.0%) and then largest (19.6%) sites.Conclusion.Sites in an early inflammatory arthritis cohort yielded different outcomes. Better outcomes up to 12 months may result from initial treatment with early combination therapy and/or subcutaneous methotrexate.
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Postpublication validation of the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for rheumatoid arthritis: where do we stand? Curr Opin Rheumatol 2013; 25:157-63. [PMID: 23274519 DOI: 10.1097/bor.0b013e32835cfc41] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To summarise the results of the validation studies testing the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for rheumatoid arthritis (RA) to date and highlight the areas for future research. RECENT FINDINGS The 2010 ACR/EULAR classification criteria for RA were developed aiming to identify patients early in the natural history of the disease. Validation studies conducted since their publication have demonstrated that, compared with the 1987 ACR criteria for RA, the 2010 criteria identify more patients earlier in the disease course. Sensitivity for the initiation of disease-modifying antirheumatic drugs and persistent disease is increased, with decreased specificity. Patients who are seronegative may not satisfy the 2010 criteria despite meeting the 1987 criteria at presentation. The 2010 criteria may also incorrectly classify some patients with self-limiting disease as RA. SUMMARY The 2010 criteria appear to be superior to the 1987 criteria in terms of identifying individuals with early RA. Their validity in established disease and their ability to predict worse prognosis in the long term have yet to be determined.
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Rantalaiho V, Kautiainen H, Korpela M, Hannonen P, Kaipiainen-Seppänen O, Möttönen T, Kauppi M, Karjalainen A, Laiho K, Laasonen L, Hakola M, Peltomaa R, Leirisalo-Repo M. Targeted treatment with a combination of traditional DMARDs produces excellent clinical and radiographic long-term outcomes in early rheumatoid arthritis regardless of initial infliximab. The 5-year follow-up results of a randomised clinical trial, the NEO-RACo trial. Ann Rheum Dis 2013; 73:1954-61. [DOI: 10.1136/annrheumdis-2013-203497] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Jämsen E, Virta LJ, Hakala M, Kauppi MJ, Malmivaara A, Lehto MUK. The decline in joint replacement surgery in rheumatoid arthritis is associated with a concomitant increase in the intensity of anti-rheumatic therapy: a nationwide register-based study from 1995 through 2010. Acta Orthop 2013; 84:331-7. [PMID: 23992137 PMCID: PMC3768029 DOI: 10.3109/17453674.2013.810519] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Drug-based treatment of rheumatoid arthritis (RA) has evolved markedly over the past 2 decades. Using nationwide register data, we studied how this has affected the rates of hip, knee, shoulder, and elbow replacement from 1995 to 2010. METHODS The number of primary joint replacements was obtained from the Finnish Arthroplasty Register. To test the hypothesis that improvements in medical treatment of RA reduce the need for joint replacements, we also collected data about purchases of different disease-modifying anti-rheumatic agents (DMARDs) and biological drugs from the nationwide drug registers. RESULTS The annual incidence of primary joint replacements for RA declined from 19 per 10(5) in 1995 to 11 per 10(5) in 2010. The decline was greater for upper-limb operations than for lower-limb operations. At the same time, the numbers of individuals using methotrexate, hydroxychloroquine, and sulfasalazine (the most commonly used DMARDs) increased 2- to 4-fold. INTERPRETATION Our results are in accordance with observations from other countries, and indicate that the use of joint replacements in RA has decreased dramatically. Our data suggest that effective medical therapy is the most likely explanation for this favorable development.
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Affiliation(s)
- Esa Jämsen
- Coxa, Hospital for Joint Replacement, Tampere,School of Medicine, University of Tampere, Tampere
| | - Lauri J Virta
- Research Department, Social Insurance Institution of Finland, Turku
| | - Markku Hakala
- School of Medicine, University of Tampere, Tampere,Päijät-Häme Central Hospital, Lahti
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46
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Hunt L, Buch M. The 'therapeutic window' and treating to target in rheumatoid arthritis. Clin Med (Lond) 2013; 13:387-90. [PMID: 23908511 PMCID: PMC4954308 DOI: 10.7861/clinmedicine.13-4-387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Laura Hunt
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maya Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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47
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Masetto A, Beaulieu MC, Boire G. Prevention of rheumatoid arthritis: the very first steps. J Rheumatol 2013; 40:752-4. [PMID: 23728185 DOI: 10.3899/jrheum.130326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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48
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van Nies JAB, Krabben A, Schoones JW, Huizinga TWJ, Kloppenburg M, van der Helm-van Mil AHM. What is the evidence for the presence of a therapeutic window of opportunity in rheumatoid arthritis? A systematic literature review. Ann Rheum Dis 2013; 73:861-70. [DOI: 10.1136/annrheumdis-2012-203130] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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49
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Modena V, Bianchi G, Roccatello D. Cost-effectiveness of biologic treatment for rheumatoid arthritis in clinical practice: an achievable target? Autoimmun Rev 2012; 12:835-8. [PMID: 23219766 DOI: 10.1016/j.autrev.2012.11.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The burden of illness of rheumatoid arthritis (RA) falls on patients, families and society through the direct costs, indirect costs, and intangible costs. A large number of RA cost-of-illness studies have been performed in recent decades with discrepant results due to patient heterogeneity, and different health-care organization, employment rate or social support, job opportunities, and methodologies used to calculate the costs. The greatest burden of RA is the indirect and the intangible costs, but how to estimate them remains controversial. The systematic use of traditional disease modifying anti rheumatic drugs has changed the evolution of the disease. However, a considerable improvement in the management of RA has been obtained since the advent of biologic response modifiers. The use of these drugs, which have demonstrated greater efficacy than conventional therapies, have tripled the direct costs of RA, which rose from about € 4000 to roughly € 12,000, in a period of five years, from 2000 to 2005. The present paper is aimed to examine the effects of this change in therapeutic strategy.
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Affiliation(s)
- Vittorio Modena
- Department of Rare, Immunologic, Hematologic Diseases and Transfusion Medicine, Research Center of Immunopathology and Rare Diseases (CMID), Giovanni Bosco Hospital and University of Turin, Italy.
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50
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Chandrashekara S, Sachin S. Measures in rheumatoid arthritis: are we measuring too many parameters. Int J Rheum Dis 2012; 15:239-48. [PMID: 22709486 DOI: 10.1111/j.1756-185x.2012.01754.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The disease activity measures in rheumatoid arthritis (RA) have a lot of unmet need for current clinical demand. With available biological and aggressive disease modifying anti-rheumatic drug therapy, the goal of RA treatment has moved toward remission or at least tighter control. The current measures lose their ability to discriminate further once the patient gets into minimal disease or tight control. There are more numbers of parameters, measured to assess disease activity, like joint counts, perception scales and laboratory parameters. There are different composite scores like Disease Activity Score, American College of Rheumatology criteria and clinical disease activity index. In this review we have reviewed the evolution of and changing need for these measures. The relevance of some measures and their use and limitations with reference to various characteristics are presented. Inflammation measures to quantify the RA process is the best way to monitor RA disease activity. C-reactive protein alone or with other biomarkers to specify RA, appear to be good prospective measures.
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Affiliation(s)
- S Chandrashekara
- ChanRe Rheumatology and Immunology Center and Research, Basaweswaranagar, Bangalore, Karnataka, India.
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