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Bergström B, Selldén T, Bollmann M, Svensson MND, Ekwall AKH. Methotrexate promotes the release of granulocyte-macrophage colony-stimulating factor from rheumatoid arthritis fibroblast-like synoviocytes via autocrine interleukin-1 signaling. Arthritis Res Ther 2024; 26:178. [PMID: 39394168 PMCID: PMC11468154 DOI: 10.1186/s13075-024-03406-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 09/23/2024] [Indexed: 10/13/2024] Open
Abstract
BACKGROUND Activated fibroblast-like synoviocytes (FLS) are drivers of synovitis and structural joint damage in rheumatoid arthritis (RA). Despite the use of disease-modifying drugs, only about 50% of RA patients reach remission in real-world settings. We used an unbiased approach to investigate the effects of standard-of-care methotrexate (MTX) and a Janus kinase inhibitor, tofacitinib (TOFA), on gene expression in RA-FLS, in order to identify untargeted disease mediators. METHODS Primary RA-FLS were activated by stimulation with interleukin-1β (IL-1β) or platelet-derived growth factor + IL-1β in the presence or absence of MTX or TOFA, with or without additional inhibitors. Co-cultures of synovial cells were performed in direct and indirect systems. Cells were collected for RNA sequencing or qPCR, and supernatants were analyzed for protein concentrations. RESULTS Six thousand three hundred fifty genes were differentially expressed, the majority being upregulated, in MTX-treated activated RA-FLS and 970 genes, the majority being downregulated, in TOFA-treated samples. Pathway analysis showed that MTX had largest effects on 'Molecular mechanisms of cancer' and TOFA on 'Interferon signaling'. Targeted analysis of disease-associated genes revealed that MTX increased the expression of cell cycle-regulating genes but also of pro-inflammatory mediators like IL-1α (IL1A) and granulocyte-macrophage colony-stimulating factor, GM-CSF (CSF2). The MTX-promoted expression of CSF2 in activated RA-FLS peaked at 48 h, could be mediated via either NF-κB or AP-1 transcription factors, and was abrogated by IL-1 inhibitors (IRAK4 inhibitor and anakinra). In a co-culture setting, MTX-treatment of activated RA-FLS induced IL1B expression in macrophages. CONCLUSIONS MTX treatment induces secretion of IL-1 from activated RA-FLS which by autocrine signaling augments their release of GM-CSF. This unexpected effect of MTX might contribute to the persistence of synovitis.
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Affiliation(s)
- Beatrice Bergström
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tilia Selldén
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Miriam Bollmann
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- SciLifeLab, University of Gothenburg, Gothenburg, Sweden
| | - Mattias N D Svensson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- SciLifeLab, University of Gothenburg, Gothenburg, Sweden
| | - Anna-Karin Hultgård Ekwall
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Rheumatology, Division 3, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Gehringer CK, Martin GP, Van Calster B, Hyrich KL, Verstappen SMM, Sergeant JC. How to develop, validate, and update clinical prediction models using multinomial logistic regression. J Clin Epidemiol 2024; 174:111481. [PMID: 39067542 DOI: 10.1016/j.jclinepi.2024.111481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/14/2024] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES Multicategory prediction models (MPMs) can be used in health care when the primary outcome of interest has more than two categories. The application of MPMs is scarce, possibly due to added methodological complexities compared to binary outcome models. We provide a guide of how to develop, validate, and update clinical prediction models based on multinomial logistic regression. STUDY DESIGN AND SETTING We present guidance and recommendations based on recent methodological literature, illustrated by a previously developed and validated MPM for treatment outcomes in rheumatoid arthritis. Prediction models using multinomial logistic regression can be developed for nominal outcomes, but also for ordinal outcomes. This article is intended to supplement existing general guidance on prediction model research. RESULTS This guide is split into three parts: 1) outcome definition and variable selection, 2) model development, and 3) model evaluation (including performance assessment, internal and external validation, and model recalibration). We outline how to evaluate and interpret the predictive performance of MPMs. R code is provided. CONCLUSION We recommend the application of MPMs in clinical settings where the prediction of a multicategory outcome is of interest. Future methodological research could focus on MPM-specific considerations for variable selection and sample size criteria for external validation.
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Affiliation(s)
- Celina K Gehringer
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK; Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Glen P Martin
- Division of Informatics, Imaging and Data Sciences, Centre for Health Informatics, University of Manchester, Manchester, UK
| | - Ben Van Calster
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands; Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Suzanne M M Verstappen
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jamie C Sergeant
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK; Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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Hidayat R, Fauzia F, Parlindungan F, Wibowo SAK, Ariane A, Damanik J, Araminta AP. Predictive factors of methotrexate monotherapy success in patients with rheumatoid arthritis in a national referral center: a cohort study. BMC Rheumatol 2024; 8:42. [PMID: 39261961 PMCID: PMC11391786 DOI: 10.1186/s41927-024-00412-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 09/02/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND Methotrexate (MTX) remains the recommended first-line treatment for rheumatoid arthritis (RA); however, its response varies and is influenced by various factors. This study aimed to identify predictors of MTX monotherapy treatment success in an Indonesian cohort. METHODS This retrospective cohort study included newly diagnosed RA patients receiving MTX monotherapy. Treatment success was defined as achieving remission or low disease activity according to Disease Activity Score-28 with erythrocyte sedimentation rate (DAS28-ESR) after 12 months of MTX therapy. The association between demographic, clinical, and laboratory factors and achieving therapy targets was evaluated using multivariate logistic regression analysis. RESULTS Among 254 subjects, 59.4% achieved treatment success with MTX monotherapy, with remission attained in 33% and low disease activity in 26.4%. Most subjects were female (95.7%) with a mean age of 48 ± 11 years. Multivariate analysis revealed that lower disease activity (OR 1.97; 95% CI [1.04-3.72]), normal ESR (OR 2.58; 95% CI [1.05-6.34]), normoweight (OR 2.55, 95% CI [1.45-4.49]), and tender joint count ≤ 5 (OR 2.45, 95% CI [1.31-4.58]) were significant predictors of treatment success. CONCLUSION The rate of MTX monotherapy success in our study was 59.4%. Lower disease activity, normal ESR, normoweight, and fewer tender joints at baseline were significant predictors of treatment success.
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Affiliation(s)
- Rudy Hidayat
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Fara Fauzia
- Jakarta Rheumatic & Autoimmune Disease Study Group (Jak-RAIDS), Jakarta, Indonesia
| | - Faisal Parlindungan
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia.
- Medical Staff Group of Internal Medicine, Universitas Indonesia Hospital, Depok, Indonesia.
| | - Suryo Anggoro Kusumo Wibowo
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Anna Ariane
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Johanda Damanik
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Abirianty Priandani Araminta
- Rheumatology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
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Fechtner S, Allen BE, Chriswell ME, Jubair WK, Robertson CE, Kofonow JN, Frank DN, Holers VM, Kuhn KA. 3,3-Dimethyl-1-Butanol and its Metabolite 3,3-Dimethylbutyrate Ameliorate Collagen-induced Arthritis Independent of Choline Trimethylamine Lyase Activity. Inflammation 2024:10.1007/s10753-024-02126-y. [PMID: 39153148 DOI: 10.1007/s10753-024-02126-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/18/2024] [Accepted: 08/08/2024] [Indexed: 08/19/2024]
Abstract
Conflicting data exist in rheumatoid arthritis and the collagen-induced arthritis (CIA) murine model of autoimmune arthritis regarding the role of bacterial carnitine and choline metabolism into the inflammatory product trimethylamine (TMA), which is oxidized in the liver to trimethylamine-N-oxide (TMAO). Using two published inhibitors of bacterial TMA lyase, 3,3-dimethyl-1-butanol (DMB) and fluoromethylcholine (FMC), we tested if TMA/TMAO were relevant to inflammation in the development of CIA. Surprisingly, DMB-treated mice demonstrated > 50% reduction in arthritis severity compared to FMC and vehicle-treated mice, but amelioration of disease was independent of TMA/TMAO production. Given the apparent contradiction that DMB did not inhibit TMA, we then investigated the mechanism of protection by DMB. After verifying that DMB acted independently of the intestinal microbiome, we traced the metabolism of DMB within the host and identified a novel host-derived metabolite of DMB, 3,3-dimethyl-1-butyric acid (DMBut). In vivo studies of mice treated with DMB or DMBut demonstrated efficacy of both molecules in significantly reducing disease and proinflammatory cytokines in CIA, while in vitro studies suggest these molecules may act by modulating secretion of proinflammatory cytokines from macrophages. Altogether, our study suggests that DMB and/or its metabolites are protective in CIA through direct immunomodulatory effects rather than inhibition of bacterial TMA lyases.
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Affiliation(s)
- Sabrina Fechtner
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Brendan E Allen
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Meagan E Chriswell
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Widian K Jubair
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Charles E Robertson
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer N Kofonow
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel N Frank
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - V Michael Holers
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kristine A Kuhn
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Sweeney M, Adas MA, Cope A, Norton S. Longitudinal effects of affective distress on disease outcomes in rheumatoid arthritis: a meta-analysis and systematic review. Rheumatol Int 2024; 44:1421-1433. [PMID: 38775824 PMCID: PMC11222178 DOI: 10.1007/s00296-024-05574-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/29/2024] [Indexed: 07/05/2024]
Abstract
Patients with rheumatoid arthritis have higher rates of mental health conditions compared to the general population. It is believed that affective distress and rheumatoid arthritis have a bi-directional relationship. This review will examine the associations between affective distress and rheumatoid arthritis outcomes over time. Several disease outcomes are included covering disease activity, function, and disability to provide a broad picture of the various ways patients are impacted. A quality assessment was also conducted. There were 71 studies included in the review. Three measures (disease activity, disability, and mortality) had enough data to complete meta-analyses of odds ratios or hazard ratios. The outcomes included were disease activity, tender joint count, swollen joints, pain, physician global assessment, patient global assessment, physical disability, acute phase reactants, stiffness, fatigue, work disability, and mortality. Numerous measures were included for most of the outcomes due to the variability across studies of measures used. Patients with affective distress had lower rates of remission according to the DAS-28, greater disability, and higher mortality. All of the outcomes covered had studies with mixed results, but swollen joint count, tender joint count, patient global assessment, and physician global assessment had the strongest evidence that they were associated with mental health longitudinally. The relationships between affective distress and disease outcomes are complex and vary depending on the measures. Overall, the effects fade over time. It is important for clinicians to be aware of the differing manifestations of the relationship between affective distress and rheumatoid arthritis outcomes.
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Affiliation(s)
- Melissa Sweeney
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 5th Floor, Bermondsey Wing, Guy's Hospital, Great Maze Pond, London, SE19RT, UK.
| | - Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Andrew Cope
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Sam Norton
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 5th Floor, Bermondsey Wing, Guy's Hospital, Great Maze Pond, London, SE19RT, UK
- Centre for Rheumatic Diseases, King's College London, London, UK
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6
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Madsen SF, Sinkeviciute D, Thudium CS, Karsdal MA, Bay-Jensen AC. The fibroid phenotype of biological naïve patients with rheumatoid arthritis are less likely to respond to anti-IL-6R treatment. Sci Rep 2024; 14:10751. [PMID: 38730088 PMCID: PMC11087519 DOI: 10.1038/s41598-024-61435-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 05/06/2024] [Indexed: 05/12/2024] Open
Abstract
Type III collagen gene expression is upregulated in the synovium of patients with rheumatoid arthritis (RA) presenting the fibroid phenotype. The soluble type III collagen formation biomarker, PRO-C3, is known to measure fibrogenesis in fibrotic diseases. In this exploratory study, we aimed to investigate the association between fibrogenesis (PRO-C3) and the disease- and treatment response in patients with RA. We measured PRO-C3 in subsets of two clinical trials assessing the effect of the anti-interleukin-6 (IL-6) receptor treatment tocilizumab (TCZ) as monotherapy or polytherapy with methotrexate. PRO-C3 levels had weak or very weak correlations with the clinical parameters (Spearman's). However, when the patients were divided into Disease Activity Score-28 groups characterized by the erythrocyte sedimentation rate (DAS28-ESR), there was a statistical difference between the PRO-C3 levels of the different groups (p < 0.05). To determine the response in relation to PRO-C3, a cut-off based on PRO-C3 levels and patients in remission (DAS28-ESR ≤ 2.6) was identified. This showed that a reduction in PRO-C3 after treatment initiation was associated with decreased DAS28-ESR and a higher response rate in patients with low PRO-C3 levels than in those with high PRO-C3 levels. This indicates that a fibrotic component affects the responsiveness of patients.
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Affiliation(s)
- Sofie Falkenløve Madsen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.
- ImmunoScience, Nordic Bioscience, Herlev Hovedgade 205, 2730, Herlev, Denmark.
| | - Dovile Sinkeviciute
- ImmunoScience, Nordic Bioscience, Herlev Hovedgade 205, 2730, Herlev, Denmark
| | - Christian S Thudium
- ImmunoScience, Nordic Bioscience, Herlev Hovedgade 205, 2730, Herlev, Denmark
| | - Morten A Karsdal
- ImmunoScience, Nordic Bioscience, Herlev Hovedgade 205, 2730, Herlev, Denmark
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Escal J, Neel T, Hodin S, Boussoualim K, Amouzougan A, Coassy A, Locrelle H, Thomas T, Delavenne X, Marotte H. Proteomics analyses of human plasma reveal triosephosphate isomerase as a potential blood marker of methotrexate resistance in rheumatoid arthritis. Rheumatology (Oxford) 2024; 63:1368-1376. [PMID: 37527020 DOI: 10.1093/rheumatology/kead390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/02/2023] [Accepted: 07/09/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVE The objective of this study was to assess differentially expressed blood proteins between patients with active RA and patients in remission after MTX treatment, with the aim of identifying a biomarker of MTX resistance (MTXR). METHODS Two populations of RA patients treated with a stable dose of s.c. MTX for at least 3 months were constituted according to the DAS28: remission (DAS28 < 2.6; n = 24) and active disease (DAS28 > 3.2; n = 32). The two groups of RA patients were homogeneous regarding their epidemiological characteristics, except for the duration of treatment, which was longer in the remission group. After collection of a blood sample, plasma protein digestion was performed, followed by untargeted proteomics analysis. Then, a targeted analysis was performed to confirm the results of the untargeted approach. RESULTS Untargeted proteomics analysis revealed eight plasma proteins that were differentially expressed between the two groups of patients. Among them, triosephosphate isomerase (TPI-1) and glucose-6-phosphate isomerase (GPI), which are main actors in glycolysis, were found down-regulated in the active group. This result was confirmed for TPI-1 in the targeted proteomics analysis. CONCLUSION A first step was achieved in the search for biomarkers of MTXR, with the identification of two actors in glycolysis (TPI-1 and GPI). The next step will be to confirm these results in a larger cohort, including samples from treatment-naive patients, to assess the predictive potential of these protein markers.
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Affiliation(s)
- Jean Escal
- Université Jean Monnet Saint-Étienne, CHU Saint-Etienne, Laboratoire de Pharmacologie et Toxicologie, INSERM, SAINBIOSE U1059, Saint-Etienne, France
| | - Tiphany Neel
- CHU Saint-Étienne, Service de Rhumatologie, Saint-Etienne, France
| | - Sophie Hodin
- Université Jean Monnet Saint-Étienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
| | | | | | - Astrid Coassy
- CHU Saint-Étienne, Service de Rhumatologie, Saint-Etienne, France
| | - Hervé Locrelle
- CHU Saint-Étienne, Service de Rhumatologie, Saint-Etienne, France
| | - Thierry Thomas
- Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Service de Rhumatologie, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
| | - Xavier Delavenne
- Université Jean Monnet Saint-Étienne, CHU Saint-Etienne, Laboratoire de Pharmacologie et Toxicologie, INSERM, SAINBIOSE U1059, Saint-Etienne, France
| | - Hubert Marotte
- Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Service de Rhumatologie, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
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Bay LT, Nielsen DS, Flurey C, Giraldi A, Möller S, Graugaard C, Ellingsen T. Associations of gender with sexual functioning, loneliness, depression, fatigue and physical function amongst patients suffering from rheumatoid arthritis with a particular focus on methotrexate usage. Rheumatol Int 2024; 44:919-931. [PMID: 38483561 PMCID: PMC10980642 DOI: 10.1007/s00296-024-05555-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/31/2024] [Indexed: 04/01/2024]
Abstract
There is a lack of knowledge regarding methotrexate (MTX) usage in patients with rheumatoid arthritis (RA) and its possible links with gender, disease characterization and sexual functioning, loneliness, fatigue and depression. We, therefore, investigated the associations of gender with physical function, fatigue, depression, loneliness and sexual functioning with a particular focus on MTX usage. A cross-sectional study design was used. Inclusion criteria were RA diagnosis, age above 18 years and available data on MTX treatment 1 year after diagnosis. Data consisted of responses from validated questionnaires regarding physical function, fatigue, depression, loneliness and sexual functioning combined with evaluations from medical records. Data were analysed with linear regression models comparing numerical outcome measures between male and female patients and between MTX users and MTX non-users. Amongst 286 patients with RA (69 men and 217 women), 67.8% were MTX users 1 year after diagnosis. Comparing women and men, both overall and within subgroups of MTX usage, we found significantly more adverse outcomes for women than men in physical functioning at diagnosis and in sexual function, depression, fatigue and physical functioning at enrolment in the study. Gender differences were also present when comparing MTX users with MTX non-users divided by gender. There were only significant differences in the HAQ and loneliness scores when comparing MTX users with MTX non-users. Women with RA had more negative outcomes measured by the selected PROMs compared to men with RA, both overall and in subgroups of users and non-users of MTX. These findings call for sharpened attention to the importance of gender in the treatment and care of patients with RA, as well as in future clinical research.
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Affiliation(s)
- Laila T Bay
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, 5000, Odense, Denmark.
- Department of Gynecology, University of Southern Denmark, 5000, Odense, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Dorthe S Nielsen
- Department of Geriatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Caroline Flurey
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Annamaria Giraldi
- Sexological Clinic, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sören Möller
- OPEN, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Christian Graugaard
- Center for Sexology Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Torkell Ellingsen
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, 5000, Odense, Denmark
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9
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Nomair AM, Abdelati A, Dwedar FI, Elnemr R, Kamel YN, Nomeir HM. The impact of folate pathway variants on the outcome of methotrexate therapy in rheumatoid arthritis patients. Clin Rheumatol 2024; 43:971-983. [PMID: 38311638 PMCID: PMC10876746 DOI: 10.1007/s10067-024-06892-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 01/21/2024] [Accepted: 01/27/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND There are currently no validated criteria that entirely explain or predict response to methotrexate (MTX) treatment in rheumatoid arthritis (RA). We tried to identify the connection between three variants (RFC1 G80A (rs1051266), TYMS 2R/3R (rs34743033), and ATIC C347G (rs2372536)) in the folate pathway of MTX metabolism and the response to MTX monotherapy in a cohort of RA cases. METHODS A prospective study on 100 RA patients on MTX monotherapy was performed. Disease activity was measured at the start of treatment and 6 months after treatment with MTX. The patients were then split into two groups: those who responded to the treatment and those who did not. The molecular genetic study for the RFC1 (G80A) variant was employed via the PCR-restriction fragment length polymorphism (PCR-RFLP) technique, the ATIC (C347G) variant was performed using TaqMan allelic discrimination real-time PCR, and the tandem repeat sequences of TYMS (2R/3R) were amplified by conventional PCR and detected by agarose gel electrophoresis. RESULTS The genotype distribution of RFC-1 (G80A) showed significant variations among non-responders and responders in the recessive genetic model. A significant difference was found in TYMS (2R/3R) in the dominant and heterozygous genetic models. However, ATIC (C347G) genotype frequency did not exhibit substantial link with drug response in all genetic models. Furthermore, the genotype and allele rates of the analyzed variants did not show any significant association with adverse events in all genetic models. CONCLUSION The 80AA genotype of RFC-1 G80A and the 2R/3R or 3R/3R genotypes of TYMS 2R/3R are more vulnerable to the good consequences of MTX therapy. Key Points • Current recommendations support the gold standard role of MTX as a first-line monotherapy for RA patients. However, up to 40% of RA patients do not respond or exhibit partial response to MTX. • Persistent disease activity due to treatment unresponsiveness will affect the long-term outcomes in RA patients. • We aimed, through molecular genetic study, to identify the connection between three variants in the folate pathway of MTX metabolism and the response to methotrexate monotherapy in a cohort of RA patients.
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Affiliation(s)
- Azhar M Nomair
- Department of Chemical Pathology, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Abeer Abdelati
- Department of Internal Medicine, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Fatma I Dwedar
- Department of Medical Biochemistry, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Rehab Elnemr
- Department of Physical Medicine Rheumatology and Rehabilitation, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yasmine N Kamel
- Department of Medical Biochemistry, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hanan M Nomeir
- Department of Medical Biochemistry, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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10
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Gehringer CK, Martin GP, Hyrich KL, Verstappen SMM, Sexton J, Kristianslund EK, Provan SA, Kvien TK, Sergeant JC. Developing and externally validating multinomial prediction models for methotrexate treatment outcomes in patients with rheumatoid arthritis: results from an international collaboration. J Clin Epidemiol 2024; 166:111239. [PMID: 38072179 DOI: 10.1016/j.jclinepi.2023.111239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 01/01/2024]
Abstract
OBJECTIVES In rheumatology, there is a clinical need to identify patients at high risk (>50%) of not responding to the first-line therapy methotrexate (MTX) due to lack of disease control or discontinuation due to adverse events (AEs). Despite this need, previous prediction models in this context are at high risk of bias and ignore AEs. Our objectives were to (i) develop a multinomial model for outcomes of low disease activity and discontinuing due to AEs 6 months after starting MTX, (ii) update prognosis 3-month following treatment initiation, and (iii) externally validate these models. STUDY DESIGN AND SETTING A multinomial model for low disease activity (submodel 1) and discontinuing due to AEs (submodel 2) was developed using data from the UK Rheumatoid Arthritis Medication Study, updated using landmarking analysis, internally validated using bootstrapping, and externally validated in the Norwegian Disease-Modifying Antirheumatic Drug register. Performance was assessed using calibration (calibration-slope and calibration-in-the-large), and discrimination (concordance-statistic and polytomous discriminatory index). RESULTS The internally validated model showed good calibration in the development setting with a calibration-slope of 1.01 (0.87, 1.14) (submodel 1) and 0.83 (0.30, 1.34) (submodel 2), and moderate discrimination with a c-statistic of 0.72 (0.69, 0.74) and 0.53 (0.48, 0.59), respectively. Predictive performance decreased after external validation (calibration-slope 0.78 (0.64, 0.93) (submodel 1) and 0.86 (0.34, 1.38) (submodel 2)), which may be due to differences in disease-specific characteristics and outcome prevalence. CONCLUSION We addressed previously identified methodological limitations of prediction models for outcomes of MTX therapy. The multinomial approach predicted outcomes of disease activity more accurately than AEs, which should be addressed in future work to aid implementation into clinical practice.
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Affiliation(s)
- Celina K Gehringer
- Division of Musculoskeletal and Dermatological Sciences, Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK; Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
| | - Glen P Martin
- Division of Informatics, Imaging and Data Sciences, Centre for Health Informatics, University of Manchester, Manchester, UK
| | - Kimme L Hyrich
- Division of Musculoskeletal and Dermatological Sciences, Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Suzanne M M Verstappen
- Division of Musculoskeletal and Dermatological Sciences, Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Joseph Sexton
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Eirik K Kristianslund
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Sella A Provan
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Tore K Kvien
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jamie C Sergeant
- Division of Musculoskeletal and Dermatological Sciences, Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK; Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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11
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Palmowski A, Strehl C, Pfeiffenberger M, Häupl T, Schad M, Kallarackal J, Prothmann U, Dammann D, Bonin M, Brandt A, Schneider U, Gaber T, Buttgereit F. Identification of gene expression biomarkers to predict clinical response to methotrexate in patients with rheumatoid arthritis. Clin Rheumatol 2024; 43:511-519. [PMID: 37978145 PMCID: PMC10774206 DOI: 10.1007/s10067-023-06814-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES To identify biomarkers at the gene expression level to predict response to methotrexate (MTX) in patients with rheumatoid arthritis (RA). METHODS MTX-naïve patients with RA were started on MTX and followed up over three months. The disease activity score 28 (DAS28) was used to classify patients into responders and non-responders. Genome-wide gene expression analysis was performed in CD4 + and CD14 + mononuclear cells sampled from whole blood at baseline to identify differentially expressed genes in responders versus non-responders. Gene selection methods and prediction modelling obtained the most relevant differentially expressed genes. A logistic regression prediction model was subsequently constructed and validated via bootstrapping. The area under the receiver operating characteristic (AUC) curve was calculated to judge model quality. RESULTS Seventy-nine patients with RA (53.4 ± 13.9 years, 74.7% females) were enrolled, and 70 finished the study with a documented treatment EULAR response (77.1% responders). Forty-six differentially expressed genes were found. The most promising genes were KRTAP4-11, LOC101927584, and PECAM1 in CD4 + cells and PSMD5 and ID1 in CD14 + cells. The final prediction model using these genes reached an AUC of 90%; the validation set's AUC was 82%. CONCLUSIONS Our prediction model constructed via genome-wide gene expression analysis in CD4 + and CD14 + mononuclear cells yielded excellent predictions. Our findings necessitate confirmation in other cohorts of MTX-naïve RA patients. Especially if used in conjunction with previously identified clinical and laboratory (bio)markers, our results could help predict response to MTX in RA to guide treatment decisions. Key Points • Patients with rheumatoid arthritis may or may not respond to treatment with methotrexate, which is the recommended first-line drug in guidelines around the world. • In non-responders, valuable time is lost until second-line treatments are started. • This study aimed at predicting response to methotrexate by identifying differentially expressed genes from peripheral blood samples. • The final prediction model yielded excellent prognostic values, but validation in other cohorts is necessary to corroborate these findings.
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Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany.
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
| | - Cindy Strehl
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Institute of the Leibniz Association, 10117, Berlin, Germany
| | - Moritz Pfeiffenberger
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany
| | - Thomas Häupl
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Institute of the Leibniz Association, 10117, Berlin, Germany
| | | | | | - Ulrich Prothmann
- Klinik Püttlingen - Knappschaftsklinikum Saar, Püttlingen, Germany
| | - Denise Dammann
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Institute of the Leibniz Association, 10117, Berlin, Germany
| | - Mark Bonin
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Institute of the Leibniz Association, 10117, Berlin, Germany
| | - Andreas Brandt
- medac Gesellschaft Für Klinische Spezialpräparate mbH, Wedel, Germany
| | - Udo Schneider
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany
| | - Timo Gaber
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Institute of the Leibniz Association, 10117, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, 10117, Berlin, Germany
- German Rheumatism Research Centre (DRFZ) Berlin, Institute of the Leibniz Association, 10117, Berlin, Germany
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12
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Nayebirad S, Javinani A, Javadi M, Yousefi-Koma H, Farahmand K, Atef Yekta R, Tamartash Z, Mohammadzadegan AM, Salehi S, Kavosi H. The effect of smoking on response to methotrexate in rheumatoid arthritis patients: A systematic review and meta-analysis. Mod Rheumatol 2023; 34:68-78. [PMID: 36688574 DOI: 10.1093/mr/road013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/03/2023] [Accepted: 01/08/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVES In the current study, we aimed to investigate the effect of smoking on inadequate response to methotrexate (MTX-IR) in rheumatoid arthritis (RA) patients. METHODS We searched PubMed, Embase, and Web of Science until 6 June 2022. Observational or interventional studies investigating MTX-IR in RA patients based on smoking status were included. Two independent reviewers assessed the risk of bias and the certainty of the evidence using the Risk of Bias in Nonrandomized Studies-of Interventions and Grades of Recommendation, Assessment, Development, and Evaluation tools, respectively. RESULTS We included 23 studies in the systematic review and 13 in the meta-analysis. Of the 13 included studies, 6 had a moderate risk, 3 had a serious risk, and 4 had a critical risk of bias. The overall random-effect meta-analysis suggested that smokers were 58% more likely to be MTX-IR when compared with nonsmokers [odds ratio (OR) 1.58, 95% confidence interval 1.21-2.06; P = .001; I2 = 69.3%]. The common-effect meta-analysis of the adjusted ORs demonstrated an overall OR of 2.69 (1.88-3.83; P < .001; I2 = 27.1%). CONCLUSIONS The current study showed that smoking is a significant predictor of MTX-IR, especially in disease-modifying antirheumatic drug-naïve early RA patients, as most of the included studies in the meta-analysis consisted of this population.
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Affiliation(s)
- Sepehr Nayebirad
- Rheumatology Research Center, Shariati Hospital, Kargar Avenue, PO-Box: 1411713137, Tehran, Iran
| | - Ali Javinani
- Rheumatology Research Center, Shariati Hospital, Kargar Avenue, PO-Box: 1411713137, Tehran, Iran
| | - Minoo Javadi
- Rheumatology Research Center, Shariati Hospital, Kargar Avenue, PO-Box: 1411713137, Tehran, Iran
| | | | - Kimia Farahmand
- Rheumatology Research Center, Shariati Hospital, Kargar Avenue, PO-Box: 1411713137, Tehran, Iran
| | - Reza Atef Yekta
- Department of Anesthesiology, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Tamartash
- Rheumatology Research Center, Shariati Hospital, Kargar Avenue, PO-Box: 1411713137, Tehran, Iran
| | | | - Samira Salehi
- Rheumatology Research Center, Shariati Hospital, Kargar Avenue, PO-Box: 1411713137, Tehran, Iran
| | - Hoda Kavosi
- Rheumatology Research Center, Shariati Hospital, Kargar Avenue, PO-Box: 1411713137, Tehran, Iran
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13
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Hebing RCF, Bartelink IH, Gosselt HR, Heil SG, de Rotte MCFJ, de Jong PHP, Nurmohamed MT, de Jonge R, Mathôt RAA. Methotrexate Polyglutamates Exposure - Response Modeling in a Large Cohort of Rheumatoid Arthritis Patients Starting Methotrexate. Clin Pharmacol Ther 2023; 114:893-903. [PMID: 37313979 DOI: 10.1002/cpt.2974] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/30/2023] [Indexed: 06/15/2023]
Abstract
Methotrexate polyglutamates (MTX-PG) concentrations in red blood cells (RBCs) have been suggested as a biomarker of response in patients with rheumatoid arthritis (RA) receiving low-dose MTX therapy. We investigated the association and interpatient variability between RBC-MTX-PG3-5 -exposure and response in patients with RA starting MTX. Data of three prospective cohorts were available. The relationship between exposure and Disease Activity Score in 28 joints (DAS28) was analyzed using a population pharmacokinetic-pharmacodynamic model. Relevant covariates were tested using full covariate modeling and backward elimination. From 395 patients, 3,401 MTX-PG concentrations and 1,337 DAS28 measurements were available between 0 and 300 days after MTX treatment onset. The developed model adequately described the time course of MTX-PG3-5 and DAS28. The median MTX-PG3-5 level at month 1 was 30.9 nmol/L (interquartile range (IQR): 23.6-43.7; n = 41) and at month 3: 69.3 nmol/L (IQR: 17.9-41.2; n = 351). Clearance of MTX-PG3-5 from RBCs was 28% lower (95% confidence interval (CI): 23.6-32.8%) in a woman and 10% lower (95% CI: 7.7-12.4%) in a 65-year-old compared with a 35-year-old patient. MTX-PG3-5 concentrations associated with DAS28: half-maximal effective concentration (EC50 ) was 9.14 nmol/L (95% CI: 4.2 nmol/L-14.1 nmol/L). EF at 80% (EC80 ) above 47 nmol/L was regarded as the optimal response. Independent of the MTX-PG 3-5 - response association, co-administration of disease-modifying antirheumatic drugs and corticosteroids improved response (additive effect on maximum effect (Emax )), whereas smoking, high body mass index and low albumin decreased Emax . In patients with RA starting MTX, RBC-MTX-PG3-5 was associated with clinical response. A dose increase is suggested when MTX-PG3-5 at month 1 is below 9.15 nmol/L, continued with the same dose when the concentration is above 47 nmol/L, and consider other treatment options above 78 nmol/L from 3 months onwards.
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Affiliation(s)
- Renske C F Hebing
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC Location Reade, Amsterdam, The Netherlands
| | - Imke H Bartelink
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Helen R Gosselt
- Department of Clinical Chemistry, Amsterdam University Medical Center - Location VUmc, Amsterdam, The Netherlands
| | - Sandra G Heil
- Department of Clinical Chemistry, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mauritis C F J de Rotte
- Department of Clinical Chemistry, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Pascal H P de Jong
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Mike T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC Location Reade, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam University Medical Center - Location VUmc, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, The Netherlands
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14
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Wilantri S, Grasshoff H, Lange T, Gaber T, Besedovsky L, Buttgereit F. Detecting and exploiting the circadian clock in rheumatoid arthritis. Acta Physiol (Oxf) 2023; 239:e14028. [PMID: 37609862 DOI: 10.1111/apha.14028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/24/2023]
Abstract
Over the past four decades, research on 24-h rhythms has yielded numerous remarkable findings, revealing their genetic, molecular, and physiological significance for immunity and various diseases. Thus, circadian rhythms are of fundamental importance to mammals, as their disruption and misalignment have been associated with many diseases and the abnormal functioning of many physiological processes. In this article, we provide a brief overview of the molecular regulation of 24-h rhythms, their importance for immunity, the deleterious effects of misalignment, the link between such pathological rhythms and rheumatoid arthritis (RA), and the potential exploitation of chronobiological rhythms for the chronotherapy of inflammatory autoimmune diseases, using RA as an example.
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Affiliation(s)
- Siska Wilantri
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Institute of the Leibniz Association, Berlin, Germany
| | - Hanna Grasshoff
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - Tanja Lange
- Department of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Timo Gaber
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Institute of the Leibniz Association, Berlin, Germany
| | | | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Deutsches Rheuma-Forschungszentrum (DRFZ), Institute of the Leibniz Association, Berlin, Germany
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15
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Fechtner S, Allen BE, Chriswell ME, Jubair WK, Robertson CE, Kofonow JN, Frank DN, Holers VM, Kuhn KA. 3,3-dimethyl-1-butanol and its metabolite 3,3-dimethylbutyrate ameliorate collagen-induced arthritis independent of choline trimethylamine lyase activity. RESEARCH SQUARE 2023:rs.3.rs-3297018. [PMID: 37720032 PMCID: PMC10503834 DOI: 10.21203/rs.3.rs-3297018/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Previous studies have identified significant alterations in intestinal carnitine metabolism in mice with collagen-induced arthritis (CIA), potentially linking bacterial dysbiosis with autoimmunity. Bacterial trimethylamine (TMA) lyases metabolize dietary carnitine to TMA, which is oxidized in the liver to trimethylamine-N-oxide (TMAO). TMAO is associated with inflammatory diseases, such as atherosclerosis, whose immunologic processes mirror that of rheumatoid arthritis (RA). Therefore, we investigated the possibility of ameliorating CIA by inhibiting TMA lyase activity using 3,3-dimethyl-1-butanol (DMB) or fluoromethylcholine (FMC). During CIA, mice were treated with 1% vol/vol DMB, 100mg/kg FMC, or vehicle. DMB-treated mice demonstrated significant (>50%) reduction in arthritis severity compared to FMC and vehicle-treated mice. However, in contrast to FMC, DMB treatment did not reduce cecal TMA nor circulating TMAO concentrations. Using gas chromatography, we confirmed the effect of DMB is independent of TMA lyase inhibition. Further, we identified a novel host-derived metabolite of DMB, 3,3-dimethyl-1-butyric acid (DMBut), which also significantly reduced disease and proinflammatory cytokines in CIA mice. Altogether, our study suggests that DMB the immunomodulatory activity of DMB and/or its metabolites are protective in CIA. Elucidating its target and mechanism of action may provide new directions for RA therapeutic development.
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16
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Guo H, Li L, Liu B, Lu P, Cao Z, Ji X, Li L, Ouyang G, Nie Z, Lyu A, Lu C. Inappropriate treatment response to DMARDs: A pathway to difficult-to-treat rheumatoid arthritis. Int Immunopharmacol 2023; 122:110655. [PMID: 37481847 DOI: 10.1016/j.intimp.2023.110655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/03/2023] [Accepted: 07/12/2023] [Indexed: 07/25/2023]
Abstract
In recent years, difficult-to-treat rheumatoid arthritis (D2T RA) has attracted significant attention from rheumatologists due to its poor treatment response and the persistent symptoms or signs experienced by patients. The therapeutic demands of patients with D2T RA are not properly met due to unclear pathogenic causes and a lack of high-quality data for current treatment options, creating considerable management difficulties with this patient population. This review describes the clinical challenges associated with disease-modifying antirheumatic drugs (DMARDs) and explores contributing factors associated with inappropriate response to DMARDs that may lead to D2T RA and related immunological dysregulation. It is now understood that D2T RA is a highly heterogeneous pathological status that involves multiple factors. These factors include but are not limited to genetics, environment, immunogenicity, comorbidities, adverse drug reactions, inappropriate drug application, poor adherence, and socioeconomic status. Besides, these factors may manifest in the selection and utilization of specific DMARDs, either individually or in combination, thereby contributing to inadequate treatment response. Finding these variables may offer hints for enhancing DMARD therapy plans and bettering the condition of D2T RA patients.
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Affiliation(s)
- Hongtao Guo
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16# Dongzhimen Nei Nan Xiao Jie, Dongcheng District, Beijing 100700, China; Department of Rheumatology, the First Affiliated Hospital of Henan University of TCM, Zhengzhou 450000, China
| | - Li Li
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16# Dongzhimen Nei Nan Xiao Jie, Dongcheng District, Beijing 100700, China
| | - Bin Liu
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16# Dongzhimen Nei Nan Xiao Jie, Dongcheng District, Beijing 100700, China
| | - Peipei Lu
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16# Dongzhimen Nei Nan Xiao Jie, Dongcheng District, Beijing 100700, China
| | - Zhiwen Cao
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16# Dongzhimen Nei Nan Xiao Jie, Dongcheng District, Beijing 100700, China
| | - Xinyu Ji
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16# Dongzhimen Nei Nan Xiao Jie, Dongcheng District, Beijing 100700, China
| | - Li Li
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16# Dongzhimen Nei Nan Xiao Jie, Dongcheng District, Beijing 100700, China
| | - Guilin Ouyang
- Shanghai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China
| | - Zhixin Nie
- Shanghai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China
| | - Aiping Lyu
- Shanghai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China; School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Cheng Lu
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16# Dongzhimen Nei Nan Xiao Jie, Dongcheng District, Beijing 100700, China.
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17
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Bordean L, Chis M, Cimpean AM, Barb AC, Cosma AA, Fenesan MP, Cotoi OS, Nicolescu L, Nicolescu CM, Avram C. Age, Sex, Metabolic and Pharmacologic Factors May Predict Nonresponse Status to Rheumatoid Arthritis Therapies. In Vivo 2023; 37:2387-2401. [PMID: 37652478 PMCID: PMC10500531 DOI: 10.21873/invivo.13344] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND/AIM A real challenge for patients with rheumatoid arthritis (RA) and rheumatologists is primary nonresponse status (PNRS) or secondary nonresponse status (SNRS) to various therapies. Despite their detrimental influence on patient life quality, PNRS and SNRS have no accurate definition and no early predictive criteria for their development exist. Patients with RA under 40 years of age are rare, hence PNRS and SNRS data for this age group are scarce. This study examined the PNRS and SNRS according to sex, age, BMI, therapy type, and duration. PATIENTS AND METHODS Retrospectively, 115 patients with RA having PNRS and/or SNRS were stratified by age (22-39, 40-59, and 60-81). The association between body mass index (BMI), proinflammatory cytokines inhibitors, JAK inhibitors, and TNF-alpha inhibitors, sex, age, and PNRS and SNRS was examined. RESULTS All three proinflammatory cytokine inhibitors (rituximab, tocilizumab, and abatacept) were associated with PNRS and SNRS in women with a high BMI aged 40-59 years. Abatacept-related PNRS and SNRS was significant in women with normal BMI aged 60-81 years. Adalimumab, infliximab, and golimumab affected SNRS differently in women with normal BMI aged 22-39 years and women with high BMI aged 60-81 years. Etanercept and infliximab were associated with SNRS status in men with high-BMI aged 40-59 years. CONCLUSION PNRS and SNRS development in patients with RA is significantly influenced by age, sex, and BMI, but most importantly is closely and differentially related to therapy type and duration.
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Affiliation(s)
- Liliana Bordean
- Department ME2/Rheumatology, Rehabilitation, Physical Medicine and Balneology, Faculty of Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş (UMPhST), Targu Mures, Romania
- Clinic of Rheumatology, Emergency County Hospital of Târgu Mureş, Targu Mures, Romania
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Monica Chis
- Department ME2/Rheumatology, Rehabilitation, Physical Medicine and Balneology, Faculty of Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş (UMPhST), Targu Mures, Romania;
- Clinic of Rheumatology, Emergency County Hospital of Târgu Mureş, Targu Mures, Romania
| | - Anca Maria Cimpean
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania;
- Center of Expertise for Rare Vascular Disease in Children, Emergency Hospital for Children Louis Turcanu, Timisoara, Romania
| | - Alina Cristina Barb
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
- OncoHelp Hospital, Timisoara, Romania
| | - Andrei Alexandru Cosma
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
- OncoHelp Hospital, Timisoara, Romania
| | - Mihaela Pasca Fenesan
- Doctoral School, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
- Department of Microscopic Morphology/Histology, Victor Babes University of Medicine and Pharmacy Timisoara, Timisoara, Romania
- OncoHelp Hospital, Timisoara, Romania
| | - Ovidiu Simion Cotoi
- Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Targu Mures, Romania
- Department of Pathology, County Clinical Hospital Mureș, Targu Mures, Romania
| | - Laura Nicolescu
- Department of Medicine, Faculty of Medicine, Vasile Goldiş Western University of Arad, Arad, Romania
- Department of Physical Medicine and Rehabilitation, Emergency County Hospital, Arad, Romania
| | - Cristian Mircea Nicolescu
- Department of Anesthesia and Intensive Care, Emergency County Hospital, Arad, Romania
- Department of Biology and Life Sciences, Vasile Goldiş Western University of Arad, Arad, Romania
| | - Claudiu Avram
- Department XVI/Balneology, Rehabilitation and Rheumatology, University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
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Huang Y, Chatterjee S, Agarwal SK, Chen H, Johnson ML, Aparasu RR. Factors influencing prescribing the first add-on disease-modifying antirheumatic drugs in patients initiating methotrexate for rheumatoid arthritis. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 11:100296. [PMID: 37521021 PMCID: PMC10372178 DOI: 10.1016/j.rcsop.2023.100296] [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: 11/21/2022] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 08/01/2023] Open
Abstract
Background Advances in Disease-Modifying Antirheumatic Drugs (DMARDs) have expanded the treatment landscape for Rheumatoid Arthritis (RA). Guidelines recommend adding either conventional synthetic (cs), biologic (b), or targeted synthetic (ts) DMARDs to methotrexate (MTX) for managing RA. Limited evidence exists regarding the factors that contribute to adding a DMARD agent to the MTX regimen. This study examined the factors associated with adding the first DMARD in RA patients initiating MTX. Methods This retrospective cohort study utilized the MarketScan data (2012-2014) involving adults (aged ≥18) with RA initiating an MTX (index date) between Jul 1, 2012 and Dec 30, 2013, and with continuous enrollment for the 6-month pre-index period. The combination therapy users received the first treatment addition of DMARD starting from day 30 after the index MTX over one year period. The study focused on the addition of csDMARDs, Tumor Necrosis Factor Inhibitors (TNFi) bDMARDs, non-TNFi bDMARDs, or tsDMARDs. Baseline covariates were measured in the 6-month pre-index and grouped into predisposing, enabling, and need factors, as per the Andersen Behavior Model. Multivariable logistic regression examined the factors associated with the addition of TNFi compared to adding a csDMARD. An additional regression model evaluated the factors associated with adding any biologic (combining TNFi and non-TNFi biologics). Results Among 8350 RA patients starting MTX, 31.92% (n = 2665) initiated any DMARD within the 1-year post-index period. Among RA patients initiating a DMARD prescription after starting MTX, 945 (11.32%) received combination therapy with treatment addition of a DMARD to MTX regimen; majority added TNFi (550, 58%), followed by csDMARD (352, 37%); non-TNF biologic (40, 4%), or tsDMARD (3, 0.3%). The tsDMARD group was limited and was not included for further analysis. The multivariable model found Preferred Provider Organization insurance coverage (odds ratio [OR], 1.43; 95% confidence interval (CI), 1.06-1.93), chronic pulmonary disease (OR, 1.98; 95% CI, 1.14-3.44), liver disease (OR, 5.24; 95% CI, 1.77-15.49), and Elixhauser score (OR, 0.91; 95% CI, 0.86-0.97) were significantly associated with the addition of TNF-α inhibitors. The separate multivariable model additionally found that patients from metropolitan areas (OR, 1.50; 95% CI, 1.04-2.16) were positively associated with adding any biological agent. Conclusions TNFi are often added to MTX for managing RA. Enabling and need factors contribute to the prescribing of a TNFi add-on therapy in RA. Future research should examine the impact of these combination therapies on RA management.
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Affiliation(s)
- Yinan Huang
- Department of Pharmacy Administration, University of Mississippi, Oxford, MS, United States of America
| | - Satabdi Chatterjee
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States of America
| | - Sandeep K. Agarwal
- Section of Immunology, Allergy & Rheumatology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States of America
| | - Michael L. Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States of America
| | - Rajender R. Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, TX, United States of America
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19
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Wang SS, Lewis MJ, Pitzalis C. DNA Methylation Signatures of Response to Conventional Synthetic and Biologic Disease-Modifying Antirheumatic Drugs (DMARDs) in Rheumatoid Arthritis. Biomedicines 2023; 11:1987. [PMID: 37509625 PMCID: PMC10377185 DOI: 10.3390/biomedicines11071987] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Rheumatoid arthritis (RA) is a complex condition that displays heterogeneity in disease severity and response to standard treatments between patients. Failure rates for conventional, target synthetic, and biologic disease-modifying rheumatic drugs (DMARDs) are significant. Although there are models for predicting patient response, they have limited accuracy, require replication/validation, or for samples to be obtained through a synovial biopsy. Thus, currently, there are no prediction methods approved for routine clinical use. Previous research has shown that genetics and environmental factors alone cannot explain the differences in response between patients. Recent studies have demonstrated that deoxyribonucleic acid (DNA) methylation plays an important role in the pathogenesis and disease progression of RA. Importantly, specific DNA methylation profiles associated with response to conventional, target synthetic, and biologic DMARDs have been found in the blood of RA patients and could potentially function as predictive biomarkers. This review will summarize and evaluate the evidence for DNA methylation signatures in treatment response mainly in blood but also learn from the progress made in the diseased tissue in cancer in comparison to RA and autoimmune diseases. We will discuss the benefits and challenges of using DNA methylation signatures as predictive markers and the potential for future progress in this area.
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Affiliation(s)
- Susan Siyu Wang
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London and Barts Health NIHR BRC & NHS Trust, London EC1M 6BQ, UK
| | - Myles J Lewis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London and Barts Health NIHR BRC & NHS Trust, London EC1M 6BQ, UK
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Queen Mary University of London and Barts Health NIHR BRC & NHS Trust, London EC1M 6BQ, UK
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20
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Duquesne J, Bouget V, Cournède PH, Fautrel B, Guillemin F, de Jong PHP, Heutz JW, Verstappen M, van der Helm-van Mil AHM, Mariette X, Bitoun S. Machine learning identifies a profile of inadequate responder to methotrexate in rheumatoid arthritis. Rheumatology (Oxford) 2023; 62:2402-2409. [PMID: 36416134 PMCID: PMC10321123 DOI: 10.1093/rheumatology/keac645] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/06/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Around 30% of patients with RA have an inadequate response to MTX. We aimed to use routine clinical and biological data to build machine learning models predicting EULAR inadequate response to MTX and to identify simple predictive biomarkers. METHODS Models were trained on RA patients fulfilling the 2010 ACR/EULAR criteria from the ESPOIR and Leiden EAC cohorts to predict the EULAR response at 9 months (± 6 months). Several models were compared on the training set using the AUROC. The best model was evaluated on an external validation cohort (tREACH). The model's predictions were explained using Shapley values to extract a biomarker of inadequate response. RESULTS We included 493 therapeutic sequences from ESPOIR, 239 from EAC and 138 from tREACH. The model selected DAS28, Lymphocytes, Creatininemia, Leucocytes, AST, ALT, swollen joint count and corticosteroid co-treatment as predictors. The model reached an AUROC of 0.72 [95% CI (0.63, 0.80)] on the external validation set, where 70% of patients were responders to MTX. Patients predicted as inadequate responders had only 38% [95% CI (20%, 58%)] chance to respond and using the algorithm to decide to initiate MTX would decrease inadequate-response rate from 30% to 23% [95% CI: (17%, 29%)]. A biomarker was identified in patients with moderate or high activity (DAS28 > 3.2): patients with a lymphocyte count superior to 2000 cells/mm3 are significantly less likely to respond. CONCLUSION Our study highlights the usefulness of machine learning in unveiling subgroups of inadequate responders to MTX to guide new therapeutic strategies. Further work is needed to validate this approach.
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Affiliation(s)
| | | | - Paul Henry Cournède
- CentraleSupélec, Lab of Mathematics and Computer Science (MICS), Université Paris-Saclay, Gif-sur-Yvette, France
| | - Bruno Fautrel
- Groupe Hospitalier Pitié Salpêtrière, Service de Rhumatologie, Sorbonne Université – Assistance Publique Hôpitaux de Paris, Paris, France
- Inserm UMRS 1136, Équipe PEPITES (Pharmaco-épidémiologie et Évaluation des Soins), Institut Pierre Louis d’Épidémiologie et Santé Publique, Paris, France
| | | | - Pascal H P de Jong
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Judith W Heutz
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marloes Verstappen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Samuel Bitoun
- Correspondence to: Samuel Bitoun, Department of Rheumatology, Université Paris Saclay, INSERM UMR 1184, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, FHU CARE, Hôpital Bicêtre 78 avenue du General Leclerc, Le Kremlin Bicêtre France. E-mail:
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21
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Drafi F, Bauerova K, Chrastina M, Taghdisiesfejír M, Rocha J, Direito R, Figueira ME, Sepodes B, Ponist S. Rhodiola rosea L. Extract, a Known Adaptogen, Evaluated in Experimental Arthritis. Molecules 2023; 28:5053. [PMID: 37446715 DOI: 10.3390/molecules28135053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023] Open
Abstract
Rhodiola rosea L. extract (RSE) is mostly known for its adaptogen properties, but not for its antiarthritic activities, therefore monotherapy and combination with low-dose methotrexate (MTX) was studied. The collagen-induced arthritis (CIA) model was used to measure the functional score, and the change in hind paw volume (HPV). Both parameters had significant antiarthritic effects. Based on these preliminary results, an adjuvant arthritis (AA) model was further applied to assess another parameters. The experiment included these animal groups: healthy controls, untreated AA, AA administered with RSE (150 mg/kg b.w. daily, p.o.), AA administered by MTX (0.3 mg/kg b.w. twice a week, p.o.), and AA treated with the combination of RSE+MTX. The combination of RSE+MTX significantly reduced the HPV and increased the body weight. The combination significantly decreased HPV when compared to MTX monotherapy. The plasmatic levels of inflammatory markers (IL-6, IL-17A, MMP-9 and CRP) were significantly decreased by MTX+RSE treatment. The RSE monotherapy didn't influence any of the inflammatory parameters studied. In CIA, the RSE monotherapy significantly decreased the arthritic parameters studied. In summary, the combination of RSE and sub-therapeutic MTX was significantly effective in AA by improving inflammatory and arthritic parameters.
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Affiliation(s)
- Frantisek Drafi
- Institute of Experimental Pharmacology and Toxicology, Centre of Experimental Medicine SAS, 841 04 Bratislava, Slovakia
| | - Katarina Bauerova
- Institute of Experimental Pharmacology and Toxicology, Centre of Experimental Medicine SAS, 841 04 Bratislava, Slovakia
| | - Martin Chrastina
- Institute of Experimental Pharmacology and Toxicology, Centre of Experimental Medicine SAS, 841 04 Bratislava, Slovakia
- Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Malá Hora 10701/4A, 036 01 Martin, Slovakia
| | - Mohsen Taghdisiesfejír
- Institute of Experimental Pharmacology and Toxicology, Centre of Experimental Medicine SAS, 841 04 Bratislava, Slovakia
- Faculty of Natural Sciences, Comenius University in Bratislava, Ilkovičova 6, 842 15 Bratislava, Slovakia
| | - João Rocha
- Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003 Lisbon, Portugal
- Laboratory of Systems Integration Pharmacology, Clinical and Regulatory Science, Research Institute for Medicines of the University of Lisbon (iMED.ULisboa), Avenida Professor Gama Pinto, 1649-003 Lisbon, Portugal
| | - Rosa Direito
- Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003 Lisbon, Portugal
- Laboratory of Systems Integration Pharmacology, Clinical and Regulatory Science, Research Institute for Medicines of the University of Lisbon (iMED.ULisboa), Avenida Professor Gama Pinto, 1649-003 Lisbon, Portugal
| | - Maria Eduardo Figueira
- Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003 Lisbon, Portugal
- Laboratory of Systems Integration Pharmacology, Clinical and Regulatory Science, Research Institute for Medicines of the University of Lisbon (iMED.ULisboa), Avenida Professor Gama Pinto, 1649-003 Lisbon, Portugal
| | - Bruno Sepodes
- Faculdade de Farmácia, Universidade de Lisboa, Avenida Professor Gama Pinto, 1649-003 Lisbon, Portugal
- Laboratory of Systems Integration Pharmacology, Clinical and Regulatory Science, Research Institute for Medicines of the University of Lisbon (iMED.ULisboa), Avenida Professor Gama Pinto, 1649-003 Lisbon, Portugal
| | - Silvester Ponist
- Institute of Experimental Pharmacology and Toxicology, Centre of Experimental Medicine SAS, 841 04 Bratislava, Slovakia
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22
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Cheng DH, Huang ZG. Therapeutic drug monitoring of disease-modifying antirheumatic drugs in circulating leukocytes in immune-mediated inflammatory diseases. Inflammopharmacology 2023:10.1007/s10787-023-01243-8. [PMID: 37160525 DOI: 10.1007/s10787-023-01243-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/07/2023] [Indexed: 05/11/2023]
Abstract
The treatment of immune-mediated inflammatory diseases (IMIDs) is one of the main challenges of modern medicine. Although a number of disease-modifying antirheumatic drugs (DMARDs) are available, there is wide variability in clinical response to treatment among individuals. Therapeutic drug monitoring (TDM) has been proposed to optimize treatment; however, some patients still experience unsatisfactory outcomes, although the blood concentrations of drugs in these patients remain in the therapeutic range. One possible reason for this is that the conventional samples (e.g., whole blood or plasma) used in TDM may not accurately reflect drug concentrations or concentrations of their metabolites at the target site. Hence, more refined TDM approaches to guide clinical decisions related to dose optimization are necessary. Circulating leukocytes or white blood cells have a critical role in driving the inflammatory process. They are recruited to the site of injury, infection and inflammation, and the main target of small molecule DMARDs is within immune cells. Given this, assaying drug concentrations in leukocytes has been proposed to be of possible relevance to the interpretation of outcomes. This review focuses on the clinical implications and challenges of drug monitoring of DMARDs in peripheral blood leukocytes from therapeutic or toxicological perspectives in IMIDs.
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Affiliation(s)
- Dao-Hai Cheng
- Department of Pharmacy, First Affiliated Hospital of Guangxi Medical University, Nanning, China.
| | - Zhen-Guang Huang
- Department of Pharmacy, First Affiliated Hospital of Guangxi Medical University, Nanning, China
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23
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Zaragoza-García O, Gutiérrez-Pérez IA, Briceño O, Villafan-Bernal JR, Navarro-Zarza JE, Parra-Rojas I, Falfán-Valencia R, Guzmán-Guzmán IP. IFABP2 as a new prognostic biomarker for secondary non-response in rheumatoid arthritis. Int Immunopharmacol 2023; 119:110090. [PMID: 37044032 DOI: 10.1016/j.intimp.2023.110090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/09/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Increased intestinal permeability promotes the translocation of bacterial products from the local microbiome to the circulation, inducing inflammation and increasing clinical activity in rheumatoid arthritis (RA). This study evaluates whether intestinal fatty acid binding protein 2 (IFABP2) serum levels are prognostic biomarkers of non-response to conventional synthetic disease-modifying antirheumatic drug therapy (csDMARDs) in RA. METHODS The therapeutic schemes administered to 60 women with RA for at least 18 months were assessed retrospectively, and the treatment response was classified according to the change in DAS28-ESR over time. Serum levels of IFABP2 and TNF-α were determined by ELISA. Receiver operating characteristics (ROC) curve analysis and logistic regression models were used to assess the predictive value and the association of IFABP2 with the non-responder phenotype in RA patients. RESULTS Eleven women had a responder phenotype, 23 had a primary non-responder phenotype, and 26 had a secondary non-responder phenotype. Secondary non-responders showed higher DAS28-ESR (P = 0.009) and higher IFABP2 serum levels compared to the responder group (P = 0.023) and the primary non-responder group (P = 0.018). IFABP2 serum levels were positively correlated with chloroquine dose (r = 0.581, P = 0.007) and negatively correlated with total cholesterol (r = -0.456, P = 0.019) in secondary non-responders. The area under the curve (AUC) value of IFABP2 for predicting secondary non-response was 0.736, and IFABP2 serum levels > 9.311 ng/mL were associated with secondary non-response to csDMARDs (OR = 6.00, P = 0.003). CONCLUSION IFABP2 serum levels are potentially a new biomarker predictive of secondary non-response to csDMARDs in RA, although our findings should be validated externally and in a larger cohort.
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Affiliation(s)
- Oscar Zaragoza-García
- Faculty of Chemical-Biological Sciences, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico
| | | | - Olivia Briceño
- Infectious Diseases Research Center, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - José Rafael Villafan-Bernal
- Laboratory of Immunogenomics and Metabolic Diseases, Instituto Nacional de Medicina Genomica, Mexico City, Mexico
| | - José Eduardo Navarro-Zarza
- Department of Medical Internal. Hospital General Dr. RaymundAbarca Alarcón. Chilpancingo, Guerrero, Mexico
| | - Isela Parra-Rojas
- Faculty of Chemical-Biological Sciences, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Mexico City, Mexico
| | - Iris Paola Guzmán-Guzmán
- Faculty of Chemical-Biological Sciences, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico.
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24
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Eektimmerman F, Swen JJ, den Broeder AA, Hazes JMW, Kurreeman FS, Verstappen SMM, Nair N, Pawlik A, Nurmohamed MT, Dolžan V, Böhringer S, Allaart CF, Guchelaar HJ. Genome-wide Association Study of Methotrexate-Induced Liver Injury in Rheumatoid Arthritis Patients. Clin Pharmacol Ther 2023; 113:916-923. [PMID: 36708065 DOI: 10.1002/cpt.2858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/17/2023] [Indexed: 01/29/2023]
Abstract
Hepatotoxicity is a serious adverse drug reaction related to methotrexate (MTX). However, the cause of drug-induced liver injury (DILI) is still unclear and unpredictable. Genetic risk factors may predispose for MTX-DILI. Therefore, we conducted a nested case-control genome-wide association study to explore genetic risk factors associated with MTX-DILI. Seven international groups contributed blood samples and data of patients with rheumatoid arthritis who used MTX. MTX-DILI was defined as an alanine aminotransferase (ALT) level of at least three times the upper limit of normal (ULN), to increase contrast controls ALT levels did not raise above two times the ULN. Per study site, control subjects and patients with MTX-DILI (ratio 3:1) were matched for age, gender, and duration of MTX use. Patients were genotyped using Illumina GSA MD-24v1-0 and data were imputed using the 1000 Genomes reference panel. Single-nucleotide polymorphisms (SNPs) were analyzed using an additive genetic model, corrected for sex, country, and age. A P-value of ≤ 5 × 10-8 was considered significant, whereas a P-value of ≤ 5 × 10-6 was considered suggestive. A total of 108 MTX-DILI cases and 311 controls were included for association analysis. None of the SNPs were significantly associated with MTX-DILI. However, we found seven suggestive genetic variants associated with MTX-DILI (P-values 7.43 × 10-8 to 4.86 × 10-6 ). Of those, five SNPs were in the intronic protein-coding regions of FTCDNL1, BCOR, FGF14, RBMS3, and PFDN4/DOK5. Investigation of candidates SPATA9 (rs72783407), PLCG2 (rs60427389), RAVER2 (rs72675408), JAK1 (rs72675451), PTPN2 (rs2476601), MTHFR C677T (rs1801133), and into the HLA region did not show significant findings. No genetic variants associated with MTX-DILI were found, whereas suggestive SNPs need further investigation.
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Affiliation(s)
- Frank Eektimmerman
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Pharmacy, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Radboudumc and Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Johanna M W Hazes
- Department of Rheumatology, ErasmusMC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Fina S Kurreeman
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Suzanne M M Verstappen
- Division of Musculoskeletal and Dermatological Sciences, Centre for Epidemiology Versus Arthritis, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Nisha Nair
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Division of Musculoskeletal Sciences, Centre for Genetics and Genomics Versus Arthritis, The University of Manchester, Manchester, UK
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University, Szczecin, Poland
| | - Mike T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Vita Dolžan
- Faculty of Medicine, Institute of Biochemistry and Molecular Genetics, University of Ljubljana, Ljubljana, Slovenia
| | - Stefan Böhringer
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
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25
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Rheumatoid arthritis: advances in treatment strategies. Mol Cell Biochem 2023; 478:69-88. [PMID: 35725992 DOI: 10.1007/s11010-022-04492-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/31/2022] [Indexed: 01/17/2023]
Abstract
Rheumatoid arthritis (RA) is characterised by severe joint and bone damage due to heightened autoimmune response at the articular sites. Worldwide annual incidence and prevalence rate of RA is 3 cases per 10,000 population and 1%, respectively. Several genetic and environmental (microbiota, smoking, infectious agents) factors contribute to its pathogenesis. Although convention treatment strategies, predominantly Disease Modifying Anti Rheumatic Drugs (DMARDs) and Glucocorticoids (GC), are unchanged as the primary line of treatment; novel strategies consisting of biological DMARDs, are being developed and explored. Personalized approaches using biologicals targetspecific pathways associated with disease progression. However, considering the economic burden and side-effects associated with these, there is an unmet need on strategies for early stratification of the inadequate responders with cDMARDs. As RA is a complex disease with a variable remission rate, it is important not only to evaluate the current status of drugs in clinical practice but also those with the potential of personalised therapeutics. Here, we provide comprehensive data on the treatment strategies in RA, including studies exploring various combination strategies in clinical trials. Our systematic analysis of current literature found that conventional DMARDs along with glucocorticoid may be best suited for early RA cases and a combination of conventional and targeted DMARDs could be effective for treating seronegative patients with moderate to high RA activity. Clinical trials with insufficient responders to Methotrexate suggest that adding biologicals may help in such cases. However, certain adverse events associated with the current therapy advocate exploring novel therapeutic approaches such as gene therapy, mesenchymal stem cell therapy in future.
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26
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Almutairi K, Inderjeeth C, Preen DB, Keen H, Nossent J. The prevalence of rheumatoid arthritis in Western Australia. BMC Rheumatol 2022; 6:93. [PMID: 36585680 PMCID: PMC9804946 DOI: 10.1186/s41927-022-00324-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/15/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is the most common form of autoimmune arthritis, but the prevalence in Australia is unknown. We estimated RA period prevalence and identified factors associated with frequent RA hospitalisations, using linked administrative health and state-specific Australian Pharmaceutical Benefits Scheme (PBS) datasets in Western Australia (WA) from 1995 to 2014. METHODS This was a longitudinal population-based cohort study using two independent datasets to identify prevalent RA patients. RA prevalence was calculated per 1000 hospital separations and biological therapy users. RA patients were identified in the WA linked health dataset using ICD codes 714.0-714.9 and M05.00-M06.99. Dispensing data on biological therapy for RA were obtained from PBS records and converted to defined daily doses /1000 population/day. Multivariable logistic regression was used to analyse factors associated with frequent RA hospitalisations (> 2/year), controlling for sex, age, and geographic locations. Potential interactions were assessed using logistic regression in a stepwise approach. RESULTS A total of 17,125 RA patients had 50,353 hospital separations between 1995 and 2014, averaging three hospitalisations per patient over 20 years. The RA period prevalence was 3.4 per 1000 separations (0.34%; 95% CI 0.33-0.34), while the RA period prevalence based on biological therapy use was 0.36% (95% CI 0.35-0.37). The corrected RA prevalence based on biological therapy usage was 0.36% (95% CI 0.35-0.37) for the 2005-2009 and increased to 0.72% (95% CI 0.70-0.74) in 2010-2014 period. Associated factors for frequent RA hospitalisations were being female [1.21 (95% CI 1.15-1.26)], aged 60-69 years [4.45 (95% CI 3.74-5.30)], living in rural areas [1.12 (95% CI 1.02-1.24)]. The odd ratio of interaction between these associated factors was 1.34 (95% CI 1.16-1.55). CONCLUSION The minimal prevalence of RA in Western Australia is 0.34-0.36%, which falls within the literature range. Older female RA patients in rural were more likely to be hospitalised, suggesting unmet primary care for needs.
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Affiliation(s)
- Khalid Almutairi
- grid.1012.20000 0004 1936 7910Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia ,grid.415280.a0000 0004 0402 3867King Fahd Specialist Hospital, Burydah, Saudi Arabia
| | - Charles Inderjeeth
- grid.1012.20000 0004 1936 7910Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia ,Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia
| | - David B Preen
- grid.1012.20000 0004 1936 7910Faculty of Health and Medical Sciences, School of Population and Global Health, University of Western Australia, Perth, WA Australia
| | - Helen Keen
- grid.1012.20000 0004 1936 7910Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia ,grid.459958.c0000 0004 4680 1997Fiona Stanley Hospital, Murdoch, WA Australia
| | - Johannes Nossent
- grid.1012.20000 0004 1936 7910Faculty of Health and Medical Sciences, School of Medicine, The University of Western Australia, 35 Stirling Highway, Perth, WA 6009 Australia ,Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Australia
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Sutcliffe M, Nair N, Oliver J, Morgan AW, Isaacs JD, Wilson AG, Verstappen SMM, Viatte S, Hyrich KL, Morris AP, Barton A, Plant D. Pre-defined gene co-expression modules in rheumatoid arthritis transition towards molecular health following anti-TNF therapy. Rheumatology (Oxford) 2022; 61:4935-4944. [PMID: 35377444 PMCID: PMC9707314 DOI: 10.1093/rheumatology/keac204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/31/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND No reliable biomarkers to predict response to TNF inhibitors (TNFi) in RA patients currently exist. The aims of this study were to replicate changes in gene co-expression modules that were previously reported in response to TNFi therapy in RA; to test if changes in module expression are specific to TNFi therapy; and to determine whether module expression transitions towards a disease-free state in responding patients. METHOD Published transcriptomic data from the whole blood of disease-free controls (n = 10) and RA patients, treated with the TNFi adalimumab (n = 70) or methotrexate (n = 85), were studied. Treatment response was assessed using the EULAR response criteria following 3 or 6 months of treatment. Change in transcript expression between pre- and post-treatment was recorded for previously defined modules. Linear mixed models tested whether modular expression after treatment transitioned towards a disease-free state. RESULTS For 25 of the 27 modules, change in expression between pre- and post-treatment in the adalimumab cohort replicated published findings. Of these 25 modules, six transitioned towards a disease-free state by 3 months (P < 0.05), irrespective of clinical response. One module (M3.2), related to inflammation and TNF biology, significantly correlated with response to adalimumab. Similar patterns of modular expression, with reduced magnitude, were observed in the methotrexate cohort. CONCLUSION This study provides independent validation of changes in module expression in response to therapy in RA. However, these effects are not specific to TNFi. Further studies are required to determine whether specific modules could assist molecular classification of therapeutic response.
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Affiliation(s)
- Megan Sutcliffe
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal Sciences, The University of Manchester
| | - Nisha Nair
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal Sciences, The University of Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester
| | - James Oliver
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal Sciences, The University of Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester
| | - Ann W Morgan
- School of Medicine, University of Leeds & NIHR Leeds Biomedical Research Centre and NIHR In Vitro Diagnostic Co-operative, Leeds Teaching Hospitals NHS Trust, University of Leeds, Leeds
| | - John D Isaacs
- Translational & Clinical Research Institution, Newcastle University & Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle University, Newcastle upon Tyne, UK
| | - Anthony G Wilson
- School of Medicine & Medical Science, Conway Institute, University College Dublin, Bellfield, Dublin 4, Ireland
| | - Suzanne M M Verstappen
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester.,Versus Arthritis Centre for Epidemiology, Centre for Musculoskeletal Research
| | - Sebastien Viatte
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal Sciences, The University of Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester.,Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Kimme L Hyrich
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester.,Versus Arthritis Centre for Epidemiology, Centre for Musculoskeletal Research
| | - Andrew P Morris
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal Sciences, The University of Manchester
| | - Anne Barton
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal Sciences, The University of Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester
| | - Darren Plant
- Versus Arthritis Centre for Genetics and Genomics, Division of Musculoskeletal Sciences, The University of Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester
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Min HK, Kim SH, Lee SH, Kim HR. Baseline bony erosions and time-averaged DAS28 predict discontinuation of TNF inhibitors in rheumatoid arthritis. Sci Rep 2022; 12:19951. [PMID: 36402804 PMCID: PMC9675786 DOI: 10.1038/s41598-022-24027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022] Open
Abstract
The present study evaluated the predictive role of baseline radiographic change and disease activity on drug retention and clinical response in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor inhibitor (TNFi). Korean Observational Study Network for Arthritis (KORONA) registry was evaluated to identify RA patients treated with a TNFi. Disease activity score-28 (DAS28) was evaluated at baseline and 1 year after TNFi initiation or at termination of TNFi due to inefficacy (within 1 year). The retention rate of TNFi was compared in patients with and without bony erosions. The hazard ratio (HR) for drug retention was evaluated by Cox regression analysis, as was the odds ratio (OR) for achieving remission (DAS28 < 2.6). This study included 109 RA patients, including 97 (89%) women and 30 (27.5%) with erosions, who were treated with a TNFi. Higher baseline DAS28 was negatively associated with achievement of remission (OR = 0.56, 95% CI 0.35-0.88). The TNFi retention rate was significantly lower in RA patients with than in those without erosions (p = 0.04). Factors significantly associated with drug discontinuation included the presence of erosions (HR = 2.45, 95% CI 1.08-5.51) and higher time-averaged DAS28 (HR = 2.17, 95% CI 1.47-3.20), whereas concomitant methotrexate was associated with lack of drug discontinuation (HR = 0.40, 95% CI 0.17-0.95). The presence of erosions and high time-averaged disease activity could predict poor retention of TNFi by RA patients. Higher baseline DAS28 was associated with a reduced clinical response in patients with RA.Trial registration Clinical Research Information Service of South Korea https://cris.nih.go.kr : KCT0000086, registered May 26, 2009.
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Affiliation(s)
- Hong Ki Min
- grid.411120.70000 0004 0371 843XDivision of Rheumatology, Department of Internal Medicine, Konkuk University Medical Center, 120-1 Neungdong-Ro, Gwangjin-Gu, Seoul, Republic of Korea
| | - Se Hee Kim
- grid.411120.70000 0004 0371 843XDivision of Rheumatology, Department of Internal Medicine, Konkuk University Medical Center, 120-1 Neungdong-Ro, Gwangjin-Gu, Seoul, Republic of Korea
| | - Sang-Heon Lee
- grid.411120.70000 0004 0371 843XDivision of Rheumatology, Department of Internal Medicine, Research Institute of Medical Science, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-Ro, Gwangjin-Gu, Seoul, Republic of Korea
| | - Hae-Rim Kim
- grid.411120.70000 0004 0371 843XDivision of Rheumatology, Department of Internal Medicine, Research Institute of Medical Science, Konkuk University Medical Center, Konkuk University School of Medicine, 120-1 Neungdong-Ro, Gwangjin-Gu, Seoul, Republic of Korea
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Gehringer CK, Martin GP, Hyrich KL, Verstappen SM, Sergeant JC. Clinical prediction models for methotrexate treatment outcomes in patients with rheumatoid arthritis: A systematic review and meta-analysis. Semin Arthritis Rheum 2022; 56:152076. [DOI: 10.1016/j.semarthrit.2022.152076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022]
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Fonseca Peixoto R, Ewerton Maia Rodrigues C, Henrique de Sousa Palmeira P, Cézar Comberlang Queiroz Davis Dos Santos F, Keesen de Souza Lima T, de Sousa Braz A. Immune hallmarks of rheumatoid arthritis management: A brief review. Cytokine 2022; 158:156007. [PMID: 35985174 DOI: 10.1016/j.cyto.2022.156007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/31/2022] [Accepted: 08/08/2022] [Indexed: 11/17/2022]
Abstract
The purpose of this review was to examine current evidence on immunomodulation mediated by conventional drugs and the use of novel biological agents for the treatment of rheumatoid arthritis (RA). Currently, treatment is focused on maximizing quality of life through sustained clinical remission and/or attenuating disease activity. To do so, disease-modifying antirheumatic drugs, especially methotrexate, are used alone or in combination with other drugs, including leflunomide, biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs). The most recent strategies modulate the immune response of the individual RA patient using tsDMARDs such as JAK inhibitors and bDMARDs such as ig-CTLA-4, anti- IL6R, anti-TNF-α and anti-CD20. To better understand current immunopharmacological interventions, we also looked at documented mechanisms of RA-mediated immunomodulation, highlighting perspectives potentially boosting RA treatment.
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Affiliation(s)
- Rephany Fonseca Peixoto
- Laboratory of Immunology of Infectious Diseases, Department of Cellular and Molecular Biology, Federal University of Paraiba, João Pessoa, Paraíba 58051-900, Brazil
| | - Carlos Ewerton Maia Rodrigues
- Post‑Graduate Program in Medical Sciences, Medical School, University of Fortaleza (Unifor), Fortaleza, Brazil; Department of Internal Medicine, Federal University of Ceará, Brazil.
| | - Pedro Henrique de Sousa Palmeira
- Laboratory of Immunology of Infectious Diseases, Department of Cellular and Molecular Biology, Federal University of Paraiba, João Pessoa, Paraíba 58051-900, Brazil
| | | | - Tatjana Keesen de Souza Lima
- Laboratory of Immunology of Infectious Diseases, Department of Cellular and Molecular Biology, Federal University of Paraiba, João Pessoa, Paraíba 58051-900, Brazil
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Duong SQ, Crowson CS, Athreya A, Atkinson EJ, Davis JM, Warrington KJ, Matteson EL, Weinshilboum R, Wang L, Myasoedova E. Clinical predictors of response to methotrexate in patients with rheumatoid arthritis: a machine learning approach using clinical trial data. Arthritis Res Ther 2022; 24:162. [PMID: 35778714 PMCID: PMC9248180 DOI: 10.1186/s13075-022-02851-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Methotrexate is the preferred initial disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis (RA). However, clinically useful tools for individualized prediction of response to methotrexate treatment in patients with RA are lacking. We aimed to identify clinical predictors of response to methotrexate in patients with rheumatoid arthritis (RA) using machine learning methods. METHODS Randomized clinical trials (RCT) of patients with RA who were DMARD-naïve and randomized to placebo plus methotrexate were identified and accessed through the Clinical Study Data Request Consortium and Vivli Center for Global Clinical Research Data. Studies with available Disease Activity Score with 28-joint count and erythrocyte sedimentation rate (DAS28-ESR) at baseline and 12 and 24 weeks were included. Latent class modeling of methotrexate response was performed. The least absolute shrinkage and selection operator (LASSO) and random forests methods were used to identify predictors of response. RESULTS A total of 775 patients from 4 RCTs were included (mean age 50 years, 80% female). Two distinct classes of patients were identified based on DAS28-ESR change over 24 weeks: "good responders" and "poor responders." Baseline DAS28-ESR, anti-citrullinated protein antibody (ACPA), and Health Assessment Questionnaire (HAQ) score were the top predictors of good response using LASSO (area under the curve [AUC] 0.79) and random forests (AUC 0.68) in the external validation set. DAS28-ESR ≤ 7.4, ACPA positive, and HAQ ≤ 2 provided the highest likelihood of response. Among patients with 12-week DAS28-ESR > 3.2, ≥ 1 point improvement in DAS28-ESR baseline-to-12-week was predictive of achieving DAS28-ESR ≤ 3.2 at 24 weeks. CONCLUSIONS We have developed and externally validated a prediction model for response to methotrexate within 24 weeks in DMARD-naïve patients with RA, providing variably weighted clinical features and defined cutoffs for clinical decision-making.
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Affiliation(s)
- Stephanie Q Duong
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Cynthia S Crowson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.,Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Arjun Athreya
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | | | - John M Davis
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kenneth J Warrington
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric L Matteson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Richard Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
| | - Elena Myasoedova
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA. .,Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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Bergman M, Tundia N, Martin N, Suboticki JL, Patel J, Goldschmidt D, Song Y, Wright GC. Patient-reported outcomes of upadacitinib versus abatacept in patients with rheumatoid arthritis and an inadequate response to biologic disease-modifying antirheumatic drugs: 12- and 24-week results of a phase 3 trial. Arthritis Res Ther 2022; 24:155. [PMID: 35751108 PMCID: PMC9229430 DOI: 10.1186/s13075-022-02813-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 05/13/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND In previous clinical trials, patients with active rheumatoid arthritis (RA) treated with upadacitinib (UPA) have improved patient-reported outcomes (PROs). This post hoc analysis of SELECT-CHOICE, a phase 3 clinical trial, evaluated the impact of UPA vs abatacept (ABA) with background conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) on PROs in patients with RA with inadequate response or intolerance to biologic disease-modifying antirheumatic drugs (bDMARD-IR). METHODS Patients in SELECT-CHOICE received UPA (oral 15 mg/day) or ABA (intravenous). PROs evaluated included Patient Global Assessment of Disease Activity (PtGA) by visual analog scale (VAS), patient's assessment of pain by VAS, Health Assessment Questionnaire Disability Index (HAQ-DI), morning stiffness duration and severity, 36-Item Short Form Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Work Productivity and Activity Impairment (WPAI), and EQ-5D 5-Level (EQ-5D-5L) index score. Least squares mean (LSM) changes from baseline to weeks 12 and 24 were based on an analysis of covariance model. Proportions of patients reporting improvements ≥ minimal clinically important differences (MCID) were compared using chi-square tests. RESULTS Data from 612 patients were analyzed (UPA, n=303; ABA, n=309). Mean age was 56 years and mean disease duration was 12 years. One-third received ≥2 prior bDMARDs and 72% received concomitant methotrexate at baseline. At week 12, UPA- vs ABA-treated patients had significantly greater improvements in PtGA, pain, HAQ-DI, morning stiffness severity, EQ-5D-5L, 2/4 WPAI domains, and 3/8 SF-36 domains and Physical Component Summary (PCS) scores (P<0.05); significant differences persisted at week 24 for HAQ-DI, morning stiffness severity, SF-36 PCS and bodily pain domain, and WPAI activity impairment domain. At week 12, significantly more UPA- vs ABA-treated patients reported improvements ≥MCID in HAQ-DI (74% vs 64%) and SF-36 PCS (79% vs 66%) and 4/8 domain scores (P<0.05). CONCLUSIONS At week 12, UPA vs ABA treatment elicited greater improvements in key domains of physical functioning, pain, and general health and earlier improvements in HAQ-DI. Overall, more UPA- vs ABA-treated patients achieved ≥MCID in most PROs at all timepoints; however, not all differences were statistically significant. These data, however, highlight the faster response to UPA treatment. TRIAL REGISTRATION NCT03086343 , March 22, 2017.
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Affiliation(s)
- Martin Bergman
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | | | | | | | | | - Yan Song
- Analysis Group, Inc., Boston, MA, USA.
| | - Grace C Wright
- Grace C Wright MD PC; Association of Women in Rheumatology; United Rheumatology, New York, NY, USA
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Krasselt M, Gruz N, Pierer M, Baerwald C, Wagner U. IL-10 Induced by mTNF Crosslinking-Mediated Reverse Signaling in a Whole Blood Assay Is Predictive of Response to TNFi Therapy in Rheumatoid Arthritis. J Pers Med 2022; 12:jpm12061003. [PMID: 35743787 PMCID: PMC9225532 DOI: 10.3390/jpm12061003] [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: 05/06/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: To date, the response of patients with rheumatoid arthritis (RA) to the various biologic DMARD available cannot be predicted due to a lack of reliable biomarkers. Based on our preliminary work on tmTNF reverse signaling, we developed a whole-blood assay measuring tmTNF crosslinking-induced IL-10 production to predict the response to TNF inhibitor (TNFi) therapy. (2) Methods: This prospective study included patients with active RA. Depending on the clinical judgment of the attending rheumatologist, either therapy with a TNF or JAK inhibitor was initiated. Clinical parameters and blood samples were obtained at baseline and after 8 weeks of therapy. The blood samples were collected using a newly developed whole-blood assay based on the principle of tmTNF reverse signalling. Subsequently, IL-10 was measured via enzyme-linked immunosorbent assay (ELISA) technique. (3) Results: 63 patients with RA were enrolled. In fifteen patients, TNFi therapy was initiated, while eight patients started a JAKi treatment. The cross-sectional analysis of all patients showed a positive correlation between tmTNF crosslinking-induced IL-10 and parameters of disease activity (CRP [r = 0.4091, p = 0.0009], DAS28 [r = 0.3303, p = 0.0082]) at baseline. In the TNFi treatment study, IL-10 was found to be significantly higher in EULAR responders than in non-responders (p = 0.0033). After initiation of JAKi treatment, in contrast, IL-10 induction was not linked to response. Longitudinal analysis of the TNFi-treated patients revealed IL-10 to decrease in responders (p = 0.04), but not in non-responders after 8 weeks of therapy. Of importance, the IL-10 production at baseline correlated inversely with TNFi response determined by ΔDAS28 in patients with TNFi treatment (r = −0.5299, p = 0.0422) while no such link was observed under JAKi therapy (p = 0.22). Receiver operation characteristics (ROC) analysis demonstrated a high performance of tmTNF/crosslinking-induced IL-10 in predicting a TNFi therapy response according to the EULAR criteria (AUC = 0.9286, 95% Confidence interval 0.7825–1.000, p = 0.0055). (4) Conclusions: In this pilot investigation, we demonstrated the feasibility of a whole-blood assay measuring tmTNF-induced IL-10 to predict clinical response to TNF inhibitor treatment. This approach might support rheumatologists in their decision for an individually tailored RA therapy.
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Affiliation(s)
- Marco Krasselt
- Correspondence: ; Tel.: +49-341-97-24710; Fax: +49-341-97-24709
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Myasoedova E, Athreya AP, Crowson CS, Davis JM, Warrington KJ, Walchak RC, Carlson E, Kalari KR, Bongartz T, Tak PP, van Vollenhoven RF, Padyukov L, Emery P, Morgan A, Wang L, Weinshilboum RM, Matteson EL. Toward Individualized Prediction of Response to Methotrexate in Early Rheumatoid Arthritis: A Pharmacogenomics-Driven Machine Learning Approach. Arthritis Care Res (Hoboken) 2022; 74:879-888. [PMID: 34902228 DOI: 10.1002/acr.24834] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To test the ability of machine learning (ML) approaches with clinical and genomic biomarkers to predict methotrexate treatment response in patients with early rheumatoid arthritis (RA). METHODS Demographic, clinical, and genomic data from 643 patients of European ancestry with early RA (mean age 54 years; 70% female) subdivided into a training (n = 336) and validation cohort (n = 307) were used. The genomic data comprised 160 single-nucleotide polymorphisms (SNPs) previously associated with RA or methotrexate metabolism. Response to methotrexate monotherapy was defined as good or moderate by the European Alliance of Associations for Rheumatology (EULAR) response criteria at the 3-month follow-up. Supervised ML methods were trained with 5 repeats and 10-fold cross-validation using the training cohort. Prediction performance was validated in the independent validation cohort. RESULTS Supervised ML methods combining age, sex, smoking, rheumatoid factor, baseline Disease Activity Score in 28 joints (DAS28) scores and 160 SNPs predicted EULAR response at 3 months with the area under the receiver operating curve of 0.84 (P = 0.05) in the training cohort and achieved a prediction accuracy of 76% (P = 0.05) in the validation cohort (sensitivity 72%, specificity 77%). Intergenic SNPs rs12446816, rs13385025, rs113798271, and ATIC (rs2372536) had variable importance above 60.0 and along with baseline DAS28 scores were among the top predictors of methotrexate response. CONCLUSION Pharmacogenomic biomarkers combined with baseline DAS28 scores can be useful in predicting response to methotrexate in patients with early RA. Applying ML to predict treatment response holds promise for guiding effective RA treatment choices, including timely escalation of RA therapies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Paul P Tak
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands, and Candel Therapeutics, Needham, Massachusetts
| | | | - Leonid Padyukov
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Paul Emery
- University of Leeds and NIHR Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ann Morgan
- University of Leeds and NIHR Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Bellan M, Scotti L, Ferrante D, Calzaducca E, Manfredi GF, Sainaghi PP, Barone-Adesi F. Risk of Severe Infection among Rheumatoid Arthritis Patients on Biological DMARDs: A Population-Based Cohort Study. J Clin Med 2022; 11:jcm11112955. [PMID: 35683344 PMCID: PMC9181346 DOI: 10.3390/jcm11112955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/14/2022] [Accepted: 05/22/2022] [Indexed: 12/15/2022] Open
Abstract
Biological disease-modifying anti-rheumatic drugs (bDMARDs) are widely used for the management of rheumatoid arthritis, although their benefits are counterweight by an increased risk of infections. In the present study, we used administrative data to compare the risk of severe infections among different classes of bDMARDs. A retrospective cohort study was conducted using Administrative Health Databases of the Piedmont Region, Italy. Relevant data were obtained from: (1) the inhabitants registry, (2) hospital discharge records, and (3) the co-payment exemption registry and (4) drug claims registry. Fine and Gray competing risk models were fitted to evaluate the association between the use of different types of bDMARDs and occurrence of severe infection accounting for treatment interruption as competing risk. A total of 1780 new users of bDMARDs were identified. Among them, 50 hospitalizations for infection occurred during the study period. The use of Tocilizumab was associated with an increased risk of infection, compared to tumor necrosis factor (TNF) inhibitor drugs (sub-distribution hazard ratios-sHR: 2.510; 95% CI: 1.279–4.926), whereas no difference in the risk of severe infection was found for abatacept (sHR: 0.584; 95% CI: 0.234–1.457). bDMARDs treatment is generally safe in clinical practice with slight but important differences among classes. The increased risk of infection associated with tocilizumab use should be taken into account when balancing the risk and benefits of starting a treatment with this drug.
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Affiliation(s)
- Mattia Bellan
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
- Department of Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria Maggiore Della Carità, 28100 Novara, Italy
- Center for Translational Research on Autoimmune and Allergic Diseases (CAAD), Università del Piemonte Orientale (UPO), 28100 Novara, Italy
| | - Lorenza Scotti
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
| | - Daniela Ferrante
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
| | - Elisa Calzaducca
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
- Department of Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria Maggiore Della Carità, 28100 Novara, Italy
| | - Giulia Francesca Manfredi
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
- Department of Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria Maggiore Della Carità, 28100 Novara, Italy
| | - Pier Paolo Sainaghi
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
- Department of Internal Medicine and Rheumatology Unit, Azienda Ospedaliero-Universitaria Maggiore Della Carità, 28100 Novara, Italy
- Center for Translational Research on Autoimmune and Allergic Diseases (CAAD), Università del Piemonte Orientale (UPO), 28100 Novara, Italy
- Correspondence: ; Tel.: +39-0321-3737512
| | - Francesco Barone-Adesi
- Department of Translational Medicine (DiMet), Università del Piemonte Orientale (UPO), Via Solaroli 17, 28100 Novara, Italy; (M.B.); (L.S.); (D.F.); (E.C.); (G.F.M.); (F.B.-A.)
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Adas MA, Norton S, Balachandran S, Alveyn E, Russell MD, Esterine T, Amlani-Hatcher P, Oyebanjo S, Lempp H, Ledingham J, Kumar K, Galloway JB, Dubey S. Worse outcomes linked to ethnicity for early inflammatory arthritis in England and Wales: a national cohort study. Rheumatology (Oxford) 2022; 62:169-180. [PMID: 35536178 PMCID: PMC9788810 DOI: 10.1093/rheumatology/keac266] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/01/2022] [Accepted: 04/19/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To assess variability in care quality and treatment outcomes across ethnicities in early inflammatory arthritis (EIA). METHODS We conducted an observational cohort study in England and Wales from May 2018 to March 2020, including patients with a suspected/confirmed EIA diagnosis. Care quality was assessed against six metrics defined by national guidelines. Clinical outcomes were measured using DAS28. Outcomes between ethnic groups ('White', 'Black', 'Asian', 'Mixed', 'Other') were compared, and adjusted for confounders. RESULTS A total of 35 807 eligible patients were analysed. Of those, 30 643 (85.6%) were White and 5164 (14.6%) were from ethnic minorities: 1035 (2.8%) Black; 2617 (7.3%) Asian; 238 (0.6%) Mixed; 1274 (3.5%) Other. In total, 12 955 patients had confirmed EIA, of whom 11 315 were White and 1640 were from ethnic minorities: 314 (2.4%) Black; 927 (7.1%) Asian; 70 (0.5%) Mixed; 329 (2.5%) Other. A total of 14 803 patients were assessed by rheumatology within three weeks, and 5642 started treatment within six weeks of referral. There were no significant differences by ethnicity. Ethnic minority patients had lower odds of disease remission at three months [adjusted odds ratio 0.79 (95% CI: 0.65, 0.96)] relative to White patients. Ethnic minorities were significantly less likely to receive initial treatment withMTX[0.68 (0.52, 0.90)] or with glucocorticoids [0.63 (0.49, 0.80)]. CONCLUSION We demonstrate that some ethnic minorities are less likely to achieve disease remission in three months following EIA diagnosis. This is not explained by delays in referral or time to treatment. Our data highlight the need for investigation into the possible drivers of these inequitable outcomes and reappraisal of EIA management pathways.
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Affiliation(s)
| | | | | | - Edward Alveyn
- Centre for Rheumatic Disease, Department of Inflammatory Biology
| | - Mark D Russell
- Centre for Rheumatic Disease, Department of Inflammatory Biology
| | | | | | | | - Heidi Lempp
- Centre for Rheumatic Disease, Department of Inflammatory Biology
| | - Joanna Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth
| | - Kanta Kumar
- Institute of Clinical Sciences, University of Birmingham, Birmingham
| | - James B Galloway
- Correspondence to: James Galloway, Weston Education Centre, 10 Cutcombe Road, SE5 9RJ London, UK. E-mail:
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Sherbini AA, Gwinnutt JM, Hyrich KL, Verstappen SMM. Rates and predictors of methotrexate-related adverse events in patients with early rheumatoid arthritis: results from a nationwide UK study. Rheumatology (Oxford) 2022; 61:3930-3938. [PMID: 35078225 PMCID: PMC9536779 DOI: 10.1093/rheumatology/keab917] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To estimate prevalence rates and identify baseline predictors of adverse events (AEs) over the first year of treatment in patients with rheumatoid arthritis (RA) starting methotrexate (MTX). METHODS Data came from the UK Rheumatoid Arthritis Medication Study (RAMS), a prospective cohort of patients with RA starting MTX. This analysis included patients aged ≥ 18 years with physician diagnosed RA and symptom duration ≤ two years, who were commencing MTX for the first time. AEs were recorded by interviewing patients at six- and twelve-month follow-up visits. The period prevalence rates of AEs are reported for 0-6 months, 6-12 months, and 0-12 months of follow-up. The associations between baseline characteristics and AEs were assessed using multivariable logistic regression. RESULTS A total of 1069 patients were included in the analysis. Overall, 77.5% experienced at least one AE. The most commonly reported AEs were: gastrointestinal (42.0%), neurological (28.6%), mucocutaneous (26.0%), pulmonary (20.9%), elevated alanine transaminase (18.0%) and haematologic AEs (5.6%).Factors associated with increased odds of AEs were: women vs men (gastrointestinal, mucocutaneous, neurological), and alcohol consumption (nausea, alopecia, mucocutaneous). Older age, higher estimated Glomerular Filtration Rate (eGFR), and alcohol consumption were associated with less reporting of haematologic AEs. CONCLUSIONS AEs were common among patients over the first year of MTX, although most were not serious. Knowledge of the rates and factors associated with AEs occurrence are valuable when communicating risks prior to commencing MTX. This can help patients make informed decisions whether to start MTX, potentially increasing adherence to treatment.
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Affiliation(s)
- Ahmad A Sherbini
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Manchester, UK
| | - James M Gwinnutt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Manchester, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Suzanne M M Verstappen
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, the University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Yan H, Su R, Xue H, Gao C, Li X, Wang C. Pharmacomicrobiology of Methotrexate in Rheumatoid Arthritis: Gut Microbiome as Predictor of Therapeutic Response. Front Immunol 2022; 12:789334. [PMID: 34975886 PMCID: PMC8719371 DOI: 10.3389/fimmu.2021.789334] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/01/2021] [Indexed: 12/12/2022] Open
Abstract
Rheumatoid arthritis (RA) is a disabling autoimmune disease with invasive arthritis as the main manifestation and synovitis as the basic pathological change, which can cause progressive destruction of articular cartilage and bone, ultimately leading to joint deformity and loss of function. Since its introduction in the 1980s and its widespread use in the treatment of RA, low-dose methotrexate (MTX) therapy has dramatically changed the course and outcome of RA treatment. The clinical use of this drug will be more rational with a better understanding of the pharmacology, anti-inflammatory mechanisms of action and adverse reaction about it. At present, the current clinical status of newly diagnosed RA is that MTX is initiated first regardless of the patients’ suitability. But up to 50% of patients could not reach adequate clinical efficacy or have severe adverse events. Prior to drug initiation, a prognostic tool for treatment response is lacking, which is thought to be the most important cause of the situation. A growing body of studies have shown that differences in microbial metagenomes (including bacterial strains, genes, enzymes, proteins and/or metabolites) in the gastrointestinal tract of RA patients may at least partially determine their bioavailability and/or subsequent response to MTX. Based on this, some researchers established a random forest model to predict whether different RA patients (with different gut microbiome) would respond to MTX. Of course, MTX, in turn, alters the gut microbiome in a dose-dependent manner. The interaction between drugs and microorganisms is called pharmacomicrobiology. Then, the concept of precision medicine has been raised. In this view, we summarize the characteristics and anti-inflammatory mechanisms of MTX and highlight the interaction between gut microbiome and MTX aiming to find the optimal treatment for patients according to individual differences and discuss the application and prospect of precision medicine.
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Affiliation(s)
- Huanhuan Yan
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Rui Su
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Hongwei Xue
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Chong Gao
- Pathology, Joint Program in Transfusion Medicine, Brigham and Women's Hospital/Children' s Hospital, Harvard Medical School, Boston, MA, United States
| | - Xiaofeng Li
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Caihong Wang
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, China
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Rastogi S, Pandey P. Grand rounds in Ayurvedic rheumatology: Fine-tuning the clinical precepts and appropriating the interventions for improving the outcome in Ayurvedic rheumatology clinics. Int J Ayurveda Res 2022. [DOI: 10.4103/ijar.ijar_3_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lim AJW, Lim LJ, Ooi BNS, Koh ET, Tan JWL, Chong SS, Khor CC, Tucker-Kellogg L, Leong KP, Lee CG. Functional coding haplotypes and machine-learning feature elimination identifies predictors of Methotrexate Response in Rheumatoid Arthritis patients. EBioMedicine 2022; 75:103800. [PMID: 35022146 PMCID: PMC8808170 DOI: 10.1016/j.ebiom.2021.103800] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/19/2021] [Accepted: 12/20/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Major challenges in large scale genetic association studies include not only the identification of causative single nucleotide polymorphisms (SNPs), but also accounting for SNP-SNP interactions. This study thus proposes a novel feature engineering approach integrating potentially functional coding haplotypes (pfcHap) with machine-learning (ML) feature selection to identify biologically meaningful, possibly causative genetic factors, that take into consideration potential SNP-SNP interactions within the pfcHap, to best predict for methotrexate (MTX) response in rheumatoid arthritis (RA) patients. METHODS Exome sequencing from 349 RA patients were analysed, of which they were split into training and unseen test set. Inferred pfcHaps were combined with 30 non-genetic features to undergo ML recursive feature elimination with cross-validation using the training set. Predictive capacity and robustness of the selected features were assessed using six popular machine learning models through a train set cross-validation and evaluated in an unseen test set. FINDINGS Significantly, 100 features (95 pfcHaps, 5 non-genetic factors) were identified to have good predictive performance (AUC: 0.776-0.828; Sensitivity: 0.656-0.813; Specificity: 0.684-0.868) across all six ML models in an unseen test dataset for the prediction of MTX response in RA patients. INTERPRETATION Majority of the predictive pfcHap SNPs were predicted to be potentially functional and some of the genes in which the pfcHap resides in were identified to be associated with previously reported MTX/RA pathways. FUNDING Singapore Ministry of Health's National Medical Research Council (NMRC) [NMRC/CBRG/0095/2015; CG12Aug17; CGAug16M012; NMRC/CG/017/2013]; National Cancer Center Research Fund and block funding Duke-NUS Medical School.; Singapore Ministry of Education Academic Research Fund Tier 2 grant MOE2019-T2-1-138.
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Affiliation(s)
- Ashley J W Lim
- Dept of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lee Jin Lim
- Dept of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Brandon N S Ooi
- Dept of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ee Tzun Koh
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Justina Wei Lynn Tan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Samuel S Chong
- Dept of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chiea Chuen Khor
- Division of Human Genetics, Genome Institute of Singapore, Singapore
| | - Lisa Tucker-Kellogg
- Centre for Computational Biology, and Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore
| | - Khai Pang Leong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore; Clinical Research & Innovation Office, Tan Tock Seng Hospital, Singapore.
| | - Caroline G Lee
- Dept of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Div of Cellular & Molecular Research, Humphrey Oei Institute of Cancer Research, National Cancer Centre Singapore, Singapore; Duke-NUS Medical School, Singapore; NUS Graduate School, National University of Singapore, Singapore.
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Putative Association between Low Baseline Gene Expression in the Peripheral Blood and Clinical Remission in Rheumatoid Arthritis Patients Treated with Tofacitinib. Life (Basel) 2021; 11:life11121385. [PMID: 34947916 PMCID: PMC8705250 DOI: 10.3390/life11121385] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 12/24/2022] Open
Abstract
We investigated the importance of the baseline expression of genes involved in energy generation, as prognostic biomarkers of the treatment response to tofacitinib in patients with rheumatoid arthritis (RA). Peripheral blood samples were obtained from 28 patients with RA who received 3 months of tofacitinib therapy from 26 healthy controls. Clinical response was evaluated based on the disease activity score, the erythrocyte sedimentation rate (DAS28-ESR), and the serum levels of ACPA, RF, CRP, and ESR. Clinical remission was assessed based on DAS28 score <2.6. Protein concentrations were measured using ELISA. Total RNA isolated from whole blood was used for gene expression analysis using quantitative RT-PCR. All patients were diagnosed with Steinbrocker’s radiographic stage II-III at baseline, and most showed erosive arthritis with ACPA and RF positivity. Tofacitinib treatment significantly decreased the disease activity. Upon study completion, seven patients showed remission. Before and after TOFA therapy, a significantly higher expression of succinate dehydrogenase and pyruvate kinase genes was observed in all the examined patients compared to healthy subjects. However, the pre-therapy expression of these genes and corresponding proteins was significantly (p ≤ 0.05) lower in patients who showed remission than in other patients with RA. Moreover, we observed that, during follow-up, patients who developed remission showed an increasing trend in the expression of the examined genes, whereas the others showed some decreases in gene expression, although this was not statistically significant. We concluded that, compared with RA patients maintaining persistent moderate or high disease activity, those with clinical remission following tofacitinib treatment showed a significantly lower baseline expression of genes involved in energy generation.
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Santos-Moreno P, Martinez S, Ibatá L, Villarreal L, Rivero M, Rojas-Villarraga A. Certolizumab Can Also Be Effective in Monotherapy for the Treatment of Rheumatoid Arthritis Patients. Biologics 2021; 15:433-440. [PMID: 34712042 PMCID: PMC8547595 DOI: 10.2147/btt.s322860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/30/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Although it is known that methotrexate (MTX) increases the effectiveness of biological drugs (mainly anti-TNFs) in patients with rheumatoid arthritis (RA), in real life, it is known that many patients using anti-TNFs are on monotherapy due to many causes. This article compares the effectiveness of certolizumab as monotherapy as combined with MTX or leflunomide (LFN) in RA patients with failure to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) in a real-world setting. METHODS A retrospective observational cohort study was conducted at a specialized centre for RA management in Colombia. Patients treated with certolizumab as monotherapy or in combination with MTX, LFN, or MTX+LFN, between 2011 and 2020 with a minimum 3-month follow-up were included. Demographics and RA clinical characteristics were recorded; effectiveness was assessed as the improvement in Disease Activity Score (DAS28) getting remission or low disease activity at 3, 6, and 12 months of treatment. RESULTS A total of 181 patients were included, 24 received certolizumab as monotherapy, 62 certolizumab plus MTX, 47 certolizumab plus LFN and 48 certolizumab plus MTX+LFN. At 3 months of follow-up, 80% of the patients showed decreased disease activity, with no significant differences between groups; at 12 months of treatment, response in certolizumab monotherapy group was 94.4% compared to 81.8% in combination with MTX, 80.5% in combination with LFN and 51.4% in combination with MTX+LFN. Response at 3 months (OR 4.04; 95% CI 1.28-12.69) and positive anti-CCP (OR 3.83; 95% CI 1.11-13.21) were associated with 12-month response. CONCLUSION Certolizumab seems to be effective as monotherapy in the treatment of RA patients with failure to csDMARDs.
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Affiliation(s)
| | | | - Linda Ibatá
- Epidemiology, Biomab IPS, Bogotá, DC, Colombia
| | | | | | - Adriana Rojas-Villarraga
- Rheumatology, Research División, Fundación Universitaria de Ciencias de la Salud – FUCS, Bogotá, DC, Colombia
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Gwinnutt JM, Alsafar H, Hyrich KL, Lunt M, Barton A, Verstappen SMM. Do people with rheumatoid arthritis maintain their physical activity level at treatment onset over the first year of methotrexate therapy? Rheumatology (Oxford) 2021; 60:4633-4642. [PMID: 33605404 PMCID: PMC8487269 DOI: 10.1093/rheumatology/keab060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/14/2021] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To describe how many people with RA reduce their baseline physical activity level over the first year of MTX treatment, and which factors predict this. METHODS Data came from the Rheumatoid Arthritis Medication Study (RAMS), a prospective cohort of people with early RA starting MTX. Participants reported demographics and completed questionnaires at baseline, and 6 and 12 months, including reporting the number of days per week they performed ≥20 min of physical activity, coded as none, low (1-3 days) or high (4-7 days). The physical activity levels of participants over 12 months are described. Predictors of stopping physical activity were assessed using multivariable logistic regression. RESULTS In total, 1468 participants were included [median (interquartile range) age 60 (50, 69) years; 957 (65.2%) women]. At baseline, the physical activity levels of the people with RA were: none = 408 (27.8%), low = 518 (35.3%) and high = 542 (36.9%). Eighty percent of participants maintained some physical activity or began physical activity between assessments (baseline to 6 months = 79.3%, 6 months to 12 months = 80.7%). In total, 24.1% of participants reduced physical activity and 11.3% of participants stopped performing physical activity between baseline and 6 months (6 months to 12 months: 22.6% and 10.2%, respectively). Baseline smoking, higher disability and greater socioeconomic deprivation were associated with stopping physical activity. CONCLUSION Many people with early RA were not performing physical activity when starting MTX, or stopped performing physical activity over the first year of treatment. These people may require interventions to stay active. These interventions need to be mindful of socioeconomic barriers to physical activity participation.
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Affiliation(s)
- James M Gwinnutt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester
| | - Husain Alsafar
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust
| | - Mark Lunt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester
| | - Anne Barton
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust.,Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Suzanne M M Verstappen
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust
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Salt E, Wiggins AT, Harrington NG, Rayens MK, Lohr K. Evaluation of a medication optimization intervention and predictors of medication adherence, patient satisfaction and medication adverse events in patients with rheumatoid arthritis. Musculoskeletal Care 2021; 20:321-329. [PMID: 34529310 DOI: 10.1002/msc.1590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Because effective treatment for rheumatoid arthritis (RA) is dependent on medication use, medication optimization is critically important. Medication adherence, patient satisfaction with care and medication adverse events are core concepts of medication optimization that are either a significant problem and/or understudied in patients with RA. OBJECTIVE To (1) evaluate treatment effects from a medication optimization intervention; (2) assess treatment differences and changes over time in medication adherence, patient satisfaction, and medication adverse events; and (3) to determine whether age, gender, provider trust, and disease activity affect these outcomes. METHODS We conducted a prospective, longitudinal intervention study (N = 143 RA patients) using repeated measures models. RESULTS We did not identify significant intervention effects. For both the medication adherence and patient satisfaction models, the significant predictors in the model included age, gender and trust in provider. Older age, female gender (relative to male), and greater trust in the provider were associated with increased medication adherence scores and patient satisfaction. For the adverse events model, the only significant predictor in the model was gender. Compared with males, females were more likely to report experiencing adverse events. Time was significantly associated with decreased experiences of adverse events. CONCLUSION This study has identified important predictors of medication adherence, patient satisfaction and medication adverse events in a sample of patients with RA which can facilitate targeted approaches to improve adherence in those high-risk groups.
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Affiliation(s)
- Elizabeth Salt
- College of Nursing, University of Kentucky, Lexington, Kentucky, USA
| | - Amanda T Wiggins
- College of Nursing, Biostatistics, University of Kentucky, Lexington, Kentucky, USA
| | | | - Mary Kay Rayens
- College of Nursing, Biostatistics, University of Kentucky, Lexington, Kentucky, USA
| | - Kristine Lohr
- Division of Rheumatology, University of Kentucky, Lexington, Kentucky, USA
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Muller IB, Lin M, Lems WF, Ter Wee MM, Wojtuszkiewicz A, Nurmohamed MT, Cloos J, Assaraf YG, Jansen G, de Jonge R. Association of altered folylpolyglutamate synthetase pre-mRNA splicing with methotrexate unresponsiveness in early rheumatoid arthritis. Rheumatology (Oxford) 2021; 60:1273-1281. [PMID: 32940699 PMCID: PMC7937028 DOI: 10.1093/rheumatology/keaa428] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 05/23/2020] [Indexed: 02/06/2023] Open
Abstract
Objectives An efficient pharmacological response to MTX treatment in RA patients relies on the retention and accumulation of intracellular MTX-polyglutamates catalysed by the enzyme folylpolyglutamate synthetase (FPGS). We recently identified a partial retention of FPGS intron 8 (8PR) as a prominent splice variant conferring FPGS dysfunction and decreased MTX polyglutamylation in acute lymphoblastic leukaemia. Here, we explored the association between FPGS 8PR levels and lack of MTX responsiveness in RA patients. Methods Thirty-six patients undergoing MTX treatment were enrolled from the Combinatie behandeling Reumatoide Artritis (COBRA)-light trial. RNA was isolated from blood samples at baseline, 13 weeks and 26 weeks of therapy, from patients in either COBRA-light (n = 21) or COBRA (n = 15) treatment arms. RT-qPCR analysis was used to assess RNA levels of FPGS 8PR over wild-type FPGS (8WT). Results In the COBRA-light treatment arm, higher baseline ratios of 8PR/8WT were significantly associated with higher 44-joint disease activity score (DAS44) at 13 and 26 weeks. Higher baseline ratios of 8PR/8WT also trended towards not obtaining low disease activity (DAS <1.6) and becoming a EULAR non-responder at 13 and 26 weeks. In the COBRA-treatment arm, a significant association was observed between high baseline 8PR/8WT ratios and higher DAS44 score at 26 weeks. Higher 8PR/8WT ratios were associated with non-response at week 26 based on both low disease activity and EULAR criteria. Conclusion This study is the first to associate alterations in FPGS pre-mRNA splicing levels with reduced responsiveness to MTX treatment in RA patients. Trial registration ISRCTN55552928.
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Affiliation(s)
- Ittai B Muller
- Department of Clinical Chemistry, Amsterdam, The Netherlands
| | - Marry Lin
- Department of Clinical Chemistry, Amsterdam, The Netherlands
| | - Willem F Lems
- Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Marieke M Ter Wee
- Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Anna Wojtuszkiewicz
- Department of Hematology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Michael T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, location Reade, Amsterdam, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Yehuda G Assaraf
- The Fred Wyszkowski Cancer Research Laboratory, Department of Biology, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gerrit Jansen
- Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam, The Netherlands
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Gwinnutt JM, Norton S, Hyrich KL, Lunt M, Barton A, Cordingley L, Verstappen SMM. Changes in the illness perceptions of patients with rheumatoid arthritis over the first year of methotrexate therapy. Rheumatology (Oxford) 2021; 60:2355-2365. [PMID: 33188696 PMCID: PMC8121436 DOI: 10.1093/rheumatology/keaa615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/23/2020] [Indexed: 12/14/2022] Open
Abstract
Objectives To describe the illness perceptions of patients with RA over the first year of MTX treatment, and the association between illness perceptions and outcomes. Methods Data came from the Rheumatoid Arthritis Medication Study (RAMS), a UK multicentre cohort study of RA patients starting MTX for the first time. Patients were assessed at baseline, and at 6 and 12 months. Patients completed the Brief Illness Perception Questionnaire (B-IPQ) at each assessment, as well as other patient-reported outcomes (PROs). The inflammation score (2-component DAS28) was calculated. Subgroups of patients with similar trajectories across the eight (B-IPQ) items were identified using a latent class growth model. Predictors of group membership were identified using multinomial logistic regression. Associations between subgroups and PROs over follow-up were assessed using linear mixed models. Results Three subgroups were identified in the analysis population (N = 1087): Positive illness perceptions (N = 322), Negative illness perceptions (N = 534) and Improvers (N = 231) who switched from negative to positive illness perceptions over follow-up. Baseline disability was associated with group membership [Positive vs Negative: relative risk ratio (RRR) 0.37, 95% CI: 0.25, 0.54; Improvers vs Negative: RRR 0.60, 95% CI: 0.43, 0.83], as were other PROs (pain, fatigue, anxiety, depression). The Negative group had worse disability, pain and fatigue over follow-up compared with the other groups, controlling for inflammation. Conclusion Negative illness perceptions are associated with poor PROs over time. The Improvers subgroup illustrated that illness perceptions can change in RA. Illness perceptions represent a potential therapeutic target that should be assessed using randomized trials.
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Affiliation(s)
- James M Gwinnutt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester
| | - Sam Norton
- Health Psychology section, Institute of Psychiatry, Psychology and Neuroscience.,Department of Inflammation Biology, Faculty of Life Sciences and Medicine, King's College London, London
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre and the
| | - Mark Lunt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester
| | - Anne Barton
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre and the.,Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lis Cordingley
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre and the
| | - Suzanne M M Verstappen
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre and the
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47
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Jansen G, de Rotte MCFJ, de Jonge R. Smoking and Methotrexate Inefficacy in Rheumatoid Arthritis: What About Underlying Molecular Mechanisms? J Rheumatol 2021; 48:1495-1497. [PMID: 34329189 DOI: 10.3899/jrheum.210217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The study by Safy-Khan, et al in the current issue of The Journal of Rheumatology 1 reports that in a methotrexate (MTX)-based treatment regimen for patients with early arthritis, current smoking was significantly associated with a smaller reduction of Disease Activity Score in 28 joints (DAS28) over time compared to noncurrent smoking. This negative effect of current smoking on DAS28 was dose-dependent: patients who smoked 10-19 cigarettes per day did worse than patients who smoked 1-9 cigarettes per day.
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Affiliation(s)
- Gerrit Jansen
- G. Jansen, PhD, Biochemist, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, location VUmc; M.C. de Rotte, PhD, Clinical Chemist, R. de Jonge, PhD, Professor of Clinical Chemistry, Department of Clinical Chemistry, Amsterdam University Medical Center, Amsterdam, the Netherlands. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. G. Jansen, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, location VUmc, CCA - Rm 2.46, De Boelelaan 1117, 1081 HV Amsterdam, Amsterdam, the Netherlands,
| | - Maurits C F J de Rotte
- G. Jansen, PhD, Biochemist, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, location VUmc; M.C. de Rotte, PhD, Clinical Chemist, R. de Jonge, PhD, Professor of Clinical Chemistry, Department of Clinical Chemistry, Amsterdam University Medical Center, Amsterdam, the Netherlands. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. G. Jansen, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, location VUmc, CCA - Rm 2.46, De Boelelaan 1117, 1081 HV Amsterdam, Amsterdam, the Netherlands,
| | - Robert de Jonge
- G. Jansen, PhD, Biochemist, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, location VUmc; M.C. de Rotte, PhD, Clinical Chemist, R. de Jonge, PhD, Professor of Clinical Chemistry, Department of Clinical Chemistry, Amsterdam University Medical Center, Amsterdam, the Netherlands. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. G. Jansen, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, location VUmc, CCA - Rm 2.46, De Boelelaan 1117, 1081 HV Amsterdam, Amsterdam, the Netherlands,
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48
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Amin Shipa MR, Yeoh SA, Embleton-Thirsk A, Mukerjee D, Ehrenstein MR. The synergistic efficacy of hydroxychloroquine with methotrexate is accompanied by increased erythrocyte mean corpuscular volume. Rheumatology (Oxford) 2021; 61:787-793. [PMID: 33944915 PMCID: PMC8824424 DOI: 10.1093/rheumatology/keab403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/29/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine whether concomitant hydroxychloroquine modulates the increase in erythrocyte mean corpuscular volume (MCV) caused by methotrexate therapy, and whether this is associated with improved clinical response in rheumatoid arthritis (RA). METHODS A retrospective observational analysis was conducted on two independent hospital datasets of biologic-naïve, early-RA patients who started oral methotrexate. Baseline characteristics, DAS28-ESR and monthly MCV after starting methotrexate were obtained. Conventional and machine-learning statistical approaches were applied to the discovery cohort (Cohort-1, 655 patients) and results validated using Cohort 2 (225 patients). RESULTS Hydroxychloroquine therapy with methotrexate was associated with a two-fold increase in the likelihood of response defined in this study as clinical remission or low disease activity at 6 months (p < 0.001). The improved clinical outcome of combination hydroxychloroquine and methotrexate therapy was associated with an accelerated rise in MCV from 2 months after commencing therapy. The increase in MCV at three months was equivalent to the contemporaneous reduction in the disease activity score (DAS28-ESR) in predicting clinical response at 6 months. Using latent class mixed modelling, five trajectories of MCV change over six months from baseline were identified. The odds ratio of response to treatment was 16.2 (95% CI 5.7 to 46.4, <ip > <0.001) in those receiving combination therapy classified within the MCV elevation >5fL class, which contained the most patients, compared to methotrexate alone. CONCLUSION Our data provides mechanistic insight into the synergistic clinical benefit of concomitant hydroxychloroquine with methotrexate, boosting the rise in MCV which could serve as a companion biomarker of treatment response.
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Affiliation(s)
- Muhammad Ruhu Amin Shipa
- Centre for Rheumatology, Division of Medicine, University College London, London, UK. Rayne Institute, 5 University St, Bloomsbury, London WC1E 6JF
| | - Su-Ann Yeoh
- Centre for Rheumatology, Division of Medicine, University College London, London, UK. Rayne Institute, 5 University St, Bloomsbury, London WC1E 6JF
| | - Andrew Embleton-Thirsk
- Comprehensive Clinical Trials Unit, University College London, Institute of Clinical Trials & Methodology, Faculty of Population Health Sciences. 90 High Holborn, Holborn, London WC1V 6LJ
| | - Dev Mukerjee
- Department of Rheumatology, North Middlesex University Hospital NHS Trust, London, UK. Sterling Way, London N18 1QX
| | - Michael R Ehrenstein
- Centre for Rheumatology, Division of Medicine, University College London, London, UK. Rayne Institute, 5 University St, Bloomsbury, London WC1E 6JF
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49
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Floris A, Perra D, Cangemi I, Congia M, Chessa E, Angioni MM, Mangoni AA, Erre GL, Mathieu A, Piga M, Cauli A. Current smoking predicts inadequate response to methotrexate monotherapy in rheumatoid arthritis patients naïve to DMARDs: Results from a retrospective cohort study. Medicine (Baltimore) 2021; 100:e25481. [PMID: 33907096 PMCID: PMC8084001 DOI: 10.1097/md.0000000000025481] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Identifying predictors of inadequate response to methotrexate (MTX) in rheumatoid arthritis (RA) is key to move from a "trial and error" to a "personalized medicine" treatment approach where patients less likely to adequately respond to MTX monotherapy could start combination therapy at an earlier stage. This study aimed to identify potential predictors of inadequate response to MTX in RA patients naïve to disease modifying anti-rheumatic drugs.Data from a real-life cohort of newly diagnosed RA patients starting MTX (baseline, T0) as first-line therapy were analyzed. Outcomes, assessed after 6 months (T1), were defined as failure to achieve a disease activity score 28 (DAS28) low disease activity (LDA) or a good/moderate response to MTX, according to the European League Against Rheumatism (EULAR) response criteria. Logistic regression was used to assess the associations between baseline variables and the study outcomes.Overall, 294 patients (60.5% females, median age 54.5 years) with a median disease duration of 7.9 months were recruited. At T1, 47.3% of subjects failed to achieve LDA, and 29.3% did not have any EULAR-response. In multivariate analysis, significant associations were observed between no LDA and current smoking (adjusted odds ratio [adjOR] 1.79, P = .037), female gender (adjOR 1.68, P = .048), and higher DAS28 (adjOR 1.31, P = .013); and between no EULAR-response and current smoking (adjOR: 2.04, P = .019), age (adjOR: 0.72 per 10-years increases, P = .001), and higher erythrocyte sedimentation rate (adjOR: 0.49; P = .020). By contrast, there were no associations between past smoker status and study outcomes.In summary, in our real-life cohort of disease modifying anti-rheumatic drug naïve RA patients, current smoking habit independently predicts inadequate response to MTX. This, together with other independent predictors of response to treatment identified in our study, might assist with personalized monitoring in RA patients. Further studies are required to investigate whether smoking quitting strategies enhance the therapeutic response to MTX.
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Affiliation(s)
- Alberto Floris
- Rheumatology Unit, University of Cagliari and AOU University Clinic of Cagliari, Monserrato, Italy
| | - Daniela Perra
- Rheumatology Unit, University of Cagliari and AOU University Clinic of Cagliari, Monserrato, Italy
| | - Ignazio Cangemi
- Rheumatology Unit, University of Cagliari and AOU University Clinic of Cagliari, Monserrato, Italy
| | - Mattia Congia
- Rheumatology Unit, University of Cagliari and AOU University Clinic of Cagliari, Monserrato, Italy
| | - Elisabetta Chessa
- Rheumatology Unit, University of Cagliari and AOU University Clinic of Cagliari, Monserrato, Italy
| | - Maria Maddalena Angioni
- Rheumatology Unit, University of Cagliari and AOU University Clinic of Cagliari, Monserrato, Italy
| | - Arduino Aleksander Mangoni
- Department of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Gian Luca Erre
- Rheumatology Unit, University of Sassari and AOU University of Sassari, Sassari, Italy
| | - Alessandro Mathieu
- Rheumatology Unit, University of Cagliari and AOU University Clinic of Cagliari, Monserrato, Italy
| | - Matteo Piga
- Rheumatology Unit, University of Cagliari and AOU University Clinic of Cagliari, Monserrato, Italy
| | - Alberto Cauli
- Rheumatology Unit, University of Sassari and AOU University of Sassari, Sassari, Italy
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50
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Barton A, Jani M, Bundy C, Bluett J, McDonald S, Keevil B, Dastagir F, Aris M, Bruce I, Ho P, McCarthy E, Bruce E, Parker B, Hyrich K, Gorodkin R. Translating research into clinical practice: quality improvement to halve non-adherence to methotrexate. Rheumatology (Oxford) 2021; 60:125-131. [PMID: 32596718 PMCID: PMC7785311 DOI: 10.1093/rheumatology/keaa214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/19/2020] [Indexed: 12/23/2022] Open
Abstract
Objective MTX remains the cornerstone for therapy for RA, yet research shows that non-adherence is significant and correlates with response to therapy. This study aimed to halve self-reported non-adherence to MTX at the Kellgren Centre for Rheumatology. Methods An anonymous self-report adherence questionnaire was developed and data collected for 3 months prior to the introduction of interventions, and then regularly for the subsequent 2.5 years. A series of interventions were implemented, including motivational interviewing training, consistent information about MTX and development of a summary bookmark. Information on clinic times was collected for consultations with and without motivational interviewing. Surveys were conducted to ascertain consistency of messages about MTX. A biochemical assay was used to test MTX serum levels in patients at two time points: before and 2.8 years following introduction of the changes. Remission rates at 6 and 12 months post-MTX initiation were retrieved from patient notes and cost savings estimated by comparing actual numbers of new biologic starters compared with expected numbers based on the numbers of consultants employed at the two time points. Results Between June and August 2016, self-reported non-adherence to MTX was 24.7%. Following introduction of the interventions, self-reported non-adherence rates reduced to an average of 7.4% between April 2018 and August 2019. Clinic times were not significantly increased when motivational interviewing was employed. Consistency of messages by staff across three key areas (benefits of MTX, alcohol guidance and importance of adherence) improved from 64% in September 2016 to 94% in January 2018. Biochemical non-adherence reduced from 56% (September 2016) to 17% (June 2019), whilst remission rates 6 months post-initiation of MTX improved from 13% in 2014/15 to 37% in 2017/18, resulting is estimated cost savings of £30 000 per year. Conclusion Non-adherence to MTX can be improved using simple measures including focussing on the adherence and the benefits of treatment, and providing consistent information across departments.
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Affiliation(s)
- Anne Barton
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,Versus Arthritis Centre for Genetics and Genomics, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Christine Bundy
- College of Biomedical and Life Sciences, School of Healthcare Sciences, Cardiff University, Cardiff.,Division of Musculoskeletal and Dermatological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - James Bluett
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,Versus Arthritis Centre for Genetics and Genomics, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Stephen McDonald
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Brian Keevil
- Department of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Faraz Dastagir
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Melissa Aris
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Ian Bruce
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,Centre for Epidemiology Versus Arthritis, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Pauline Ho
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Eoghan McCarthy
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Ellen Bruce
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Ben Parker
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,Centre for Epidemiology Versus Arthritis, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Kimme Hyrich
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,Centre for Epidemiology Versus Arthritis, Manchester Academic Health Science Centre, The University of Manchester, Manchester
| | - Rachel Gorodkin
- Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
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