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Huynh NCN, Ling R, Komagamine M, Shi T, Tsukasaki M, Matsuda K, Okamoto K, Asano T, Muro R, Pluemsakunthai W, Kollias G, Kaneko Y, Takeuchi T, Tanaka S, Komatsu N, Takayanagi H. Oncostatin M-driven macrophage-fibroblast circuits as a drug target in autoimmune arthritis. Inflamm Regen 2024; 44:36. [PMID: 39080781 DOI: 10.1186/s41232-024-00347-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 06/30/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Recent single-cell RNA sequencing (scRNA-seq) analysis revealed the functional heterogeneity and pathogenic cell subsets in immune cells, synovial fibroblasts and bone cells in rheumatoid arthritis (RA). JAK inhibitors which ameliorate joint inflammation and bone destruction in RA, suppress the activation of various types of cells in vitro. However, the key cellular and molecular mechanisms underlying the potent clinical effects of JAK inhibitors on RA remain to be determined. Our aim is to identify a therapeutic target for JAK inhibitors in vivo. METHODS We performed scRNA-seq analysis of the synovium of collagen-induced arthritis (CIA) mice treated with or without a JAK inhibitor, followed by a computational analysis to identify the drug target cells and signaling pathways. We utilized integrated human RA scRNA-seq datasets and genetically modified mice administered with the JAK inhibitor for the confirmation of our findings. RESULTS scRNA-seq analysis revealed that oncostatin M (OSM) driven macrophage-fibroblast interaction is highly activated under arthritic conditions. OSM derived from macrophages, acts on OSM receptor (OSMR)-expressing synovial fibroblasts, activating both inflammatory and tissue-destructive subsets. Inflammatory synovial fibroblasts stimulate macrophages, mainly through IL-6, to exacerbate inflammation. Tissue-destructive synovial fibroblasts promote osteoclast differentiation by producing RANKL to accelerate bone destruction. scRNA-seq analysis also revealed that OSM-signaling in synovial fibroblasts is the main signaling pathway targeted by JAK inhibitors in vivo. Mice specifically lacking OSMR in synovial fibroblasts (Osmr∆Fibro) displayed ameliorated inflammation and joint destruction in arthritis. The JAK inhibitor was effective on the arthritis of the control mice while it had no effect on the arthritis of Osmr∆Fibro mice. CONCLUSIONS OSM functions as one of the key cytokines mediating pathogenic macrophage-fibroblast interaction. OSM-signaling in synovial fibroblasts is one of the main signaling pathways targeted by JAK inhibitors in vivo. The critical role of fibroblast-OSM signaling in autoimmune arthritis was shown by a combination of mice specifically deficient for OSMR in synovial fibroblasts and administration of the JAK inhibitor. Thus, the OSM-driven synovial macrophage-fibroblast circuit is proven to be a key driver of autoimmune arthritis, serving as a crucial drug target in vivo.
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Affiliation(s)
- Nam Cong-Nhat Huynh
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
- Unit of Prosthodontics, Faculty of Odonto-Stomatology, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Rui Ling
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatsugu Komagamine
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tianshu Shi
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masayuki Tsukasaki
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kotaro Matsuda
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuo Okamoto
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
- Division of Immune Environment Dynamics, Cancer Research Institute of Kanazawa University, Kakuma-Machi, Kanazawa, Japan
| | - Tatsuo Asano
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Muro
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Warunee Pluemsakunthai
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - George Kollias
- Institute for Bioinnovation, Biomedical Sciences Research Center (BSRC), Alexander Fleming', Vari, Attika, Greece
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Saitama Medical University, Saitama, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Noriko Komatsu
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
- Department of Immune Regulation, Medical Research Institute, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.
| | - Hiroshi Takayanagi
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Tanaka Y, Kishimoto M, Sonomoto K, Amano K, Harigai M, Onofrei A, O'Brien J, Margolin Z, Barr C, Mizuno Y, Agarwal E, Sugiyama N, Yamanaka H. Methotrexate, Tofacitinib, and Biologic Disease-Modifying Antirheumatic Drug Safety and Effectiveness Among Patients with Rheumatoid Arthritis in Japan: CorEvitas Registry Observational Study. Rheumatol Ther 2024:10.1007/s40744-024-00700-2. [PMID: 39066962 DOI: 10.1007/s40744-024-00700-2] [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: 04/20/2024] [Accepted: 07/05/2024] [Indexed: 07/30/2024] Open
Abstract
INTRODUCTION The evolution of disease-modifying antirheumatic drugs (DMARDs) for the treatment of rheumatoid arthritis (RA) has improved patient prognosis. However, more real-world safety/effectiveness data comparing methotrexate (MTX), tofacitinib, tumor necrosis factor inhibitors (TNFi), and non-TNFi biologic DMARDs (bDMARDs) are warranted. METHODS The CorEvitas RA Japan registry was used to identify patients with rheumatologist-diagnosed RA who initiated MTX/tofacitinib/TNFi/non-TNFi bDMARDs. Safety outcomes included incidence of major adverse cardiovascular events (MACE), total cardiovascular disease, total serious infections, total herpes zoster, and total malignancies (excluding non-melanoma skin cancer). Effectiveness outcomes included change from baseline (Δ) in Clinical Disease Activity Index (CDAI) and proportion of patients achieving a minimum clinically important difference (MCID) in CDAI at month 6. Adjusted regression models were fit; marginal means were estimated. RESULTS Overall, 1972 patients were included in the safety cohort: MTX (N = 298); tofacitinib (N = 253); TNFi (N = 663); non-TNFi (N = 758). Mean follow-up time was 3.8, 2.9, 3.0, and 2.9 years for MTX, tofacitinib, TNFi, and non-TNFi, respectively. Adjusted incidence rates (IRs, patients with events/100 patient-years [95% confidence intervals]) for MACE and total cardiovascular disease, respectively, were numerically lower for MTX (0.34 [0, 0.83]; 0.42 [0, 0.92]) and TNFi (0.09 [0, 0.27]; 0.61 [0.15, 1.07]) versus tofacitinib (0.48 [0, 1.20]; 2.30 [0.38, 4.22]) and non-TNFi (0.77 [0.35, 1.19]; 1.28 [0.73, 1.82]). Serious infections were numerically higher for non-TNFi (4.47 [3.38, 5.56]); herpes zoster was higher for tofacitinib (7.41 [4.52, 10.29]), versus other groups. IRs for malignancies were comparable between groups. Mean ΔCDAI and rates of achieving MCID in CDAI at month 6 were generally greater with tofacitinib versus other groups. CONCLUSION Some variations in incidence of safety outcomes were observed between treatments, while certain effectiveness outcomes favored tofacitinib. Sample size variation between groups and low number of safety events limited the analysis. Further studies are warranted to investigate observed differences. CLINICALTRIALS GOV: NCT05572567.
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Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata-nishi, Kitakyushu, 807-8555, Japan.
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Koshiro Sonomoto
- Department of Clinical Nursing, School of Health Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | | | | | | | | | | | | | | | - Hisashi Yamanaka
- Sanno Medical Center, Tokyo, Japan
- Department of Rheumatology, International University of Health and Welfare, Narita, Chiba, Japan
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Ochi S, Sonomoto K, Nakayamada S, Tanaka Y. Predictors of functional improvement and pain reduction in rheumatoid arthritis patients who achieved low disease activity with disease-modifying antirheumatic drugs: a retrospective study of the FIRST Registry. Arthritis Res Ther 2024; 26:140. [PMID: 39061106 PMCID: PMC11282705 DOI: 10.1186/s13075-024-03369-8] [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: 02/19/2024] [Accepted: 07/05/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) patients sometimes exhibit different levels of improvement in health assessment questionnaire-disability index (HAQ-DI) and subjective pain visual analogue score (VAS) even after achieving low disease activities (LDA). This study aimed to identify factors associated with improvement in HAQ-DI and pain VAS among those who achieved LDA. METHODS Data of the FIRST registry, a multi-institutional cohort of RA patients treated with biological and targeted-synthetic DMARDs (b/tsDMARDs) were analyzed. Patients who were enrolled from August 2013 to February 2023 and who achieved clinical LDA [clinical disease activity index (CDAI) ≤ 10.0] at 6 months after starting treatment were included. Multiple logistic regression analyses were conducted to identify the factors that associated with achieving HAQ-DI normalization (< 0.5), HAQ-DI improvement (by > 0.22), or pain VAS reduction (≤ 40 mm). RESULTS Among 1424 patients who achieved LDA at 6 months, 732 patients achieved HAQ-DI normalization and 454 achieved pain VAS reduction. The seropositivity and the use of JAK inhibitor compared with TNF inhibitor were associated with both HAQ-DI < 0.5 and pain VAS reduction at 6 months. On the other hand, older age, past failure in ≥ 2 classes of b/tsDMARDs, higher HAQ-DI at baseline, and use of glucocorticoid were associated with the lower likelihood of HAQ-DI normalization and pain VAS reduction. Longer disease duration, being female, and higher disease activity at baseline was negatively associated HAQ-DI normalization alone. Comorbidities were not associated with the outcomes. CONCLUSIONS These results suggest some preferable treatment may exist for improvement of HAQ-DI and pain VAS reduction in the early stage of the treatment, which is a clue to prevention of a criteria of difficult-to-treat RA.
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Affiliation(s)
- Sae Ochi
- Department of Laboratory Medicine, The Jikei University School of Medicine, Nishishinbashi 3-25-8, Minato-ku, Tokyo, 105-8461, Japan.
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Iseigaoka1-1, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan.
| | - Koshiro Sonomoto
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Iseigaoka1-1, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
- Department of Clinical Nursing, School of Health Sciences, University of Occupational and Environmental Health, Japan, Iseigaoka1-1, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Iseigaoka1-1, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Iseigaoka1-1, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan.
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Novella-Navarro M, Ruiz-Esquide V, López-Juanes N, Chacur CA, Monjo-Henry I, Nuño L, Peiteado D, Villalba A, Fernández-Fernandez E, Sanz-Jardón M, Kafati M, Sanmartí R, Plasencia-Rodríguez C, Balsa A. Subsequent biologic and targeted synthetic disease modifying anti rheumatic drugs after fulfilling difficult-to-treat rheumatoid arthritis criteria: a survival analysis. Clin Rheumatol 2024:10.1007/s10067-024-07070-8. [PMID: 39009920 DOI: 10.1007/s10067-024-07070-8] [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: 06/17/2024] [Revised: 06/17/2024] [Accepted: 07/11/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVES To evaluate the survival of different biologic or targeted-synthetic disease-modifying antirheumatic drugs (b/tsDMARD) administered after fulfilling difficult-to-treat rheumatoid arthritis (D2TRA) criteria, and to assess factors related to treatment discontinuation. METHODS Retrospective study including D2TRA patients. Drug retention of the b/tsDMARD administered after fulfilling D2TRA was assessed by Kaplan-Meier plots and the log-rank test. Cox hazard models were used to identify factors affecting treatment discontinuation. RESULTS Of the 122 patients included, 75 maintained active treatment (61.5%) with a subsequent line after D2T compared to 47 (38.5%) who discontinued and required more successive lines of b/tsDMARDs. The median survival of the treatments was 78.3(7.6) months and the treatment after D2T with the better rate of survival was rituximab, followed by JAKi and IL6Ri, while worse survival rates were associated with abatacept and TNFi. Significant differences were noted among b/tsDMARDs (log-rank p < 0.01) and to evaluate these differences, a Cox regression was performed, taking each b/tsDMARD as a reference and comparing it with the others. DAS28 values 6-months after initiation of treatment were higher in those patients who discontinued treatment [4.4(1.2) vs 3.5(1.3), p = 0.01]. The multivariate cox regression model revealed that treatment choice after D2T [HR = 1.26(95%CI 1.06-1.05)] and lower DAS28 values at 6 months [HR = 1.49(95%CI 1.16-1.52)] were independent risk factors associated with treatment discontinuation. CONCLUSIONS Once patients met the D2TRA criteria, the subsequent line of b/tsDMARDs with the best survival rates were rituximab, JAKi and IL6Ri. Moreover, DAS28 at 6-months of treatment after D2T was an independent risk factor for drug discontinuation. Key Points • Rituximab, IL6Ri and JAKi have better retention rates in patients after fulfilling D2TRA criteria • Clinical disease activity in the first six months after fulfillment of D2TRA criteria is an independent risk factor of subsequent treatment survival.
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Affiliation(s)
- Marta Novella-Navarro
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain.
| | | | - Natalia López-Juanes
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain
| | | | - Irene Monjo-Henry
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain
| | - Laura Nuño
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain
| | - Diana Peiteado
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain
| | - Alejandro Villalba
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain
| | | | - María Sanz-Jardón
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain
| | - Mónica Kafati
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain
| | | | | | - Alejandro Balsa
- Rheumatology Department, Hospital Universitario La Paz, Paseo de La Castellana 261, Madrid, Spain
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Takanashi S, Takeuchi T, Kaneko Y. Five-year follow-up of patients with difficult-to-treat rheumatoid arthritis. Rheumatology (Oxford) 2024:keae325. [PMID: 38851883 DOI: 10.1093/rheumatology/keae325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/09/2024] [Accepted: 05/27/2024] [Indexed: 06/10/2024] Open
Abstract
OBJECTIVES To elucidate the long-term outcomes of patients with difficult-to-treat rheumatoid arthritis (D2T RA). METHODS We collected data on the clinical course of patients who had been identified as D2T RA in 2018 until 2023. We stratified the patients according to outcomes at the last visit: resolved D2T RA, persistent D2T RA, and mortality. We compared their clinical characteristics and investigated the predictive factors for the resolution of D2T RA or mortality. Furthermore, we investigated the impact of the causes of D2T RA identified in 2018, multidrug resistance, comorbidities, and socioeconomic factors on outcomes in 2023. RESULTS Of 173 patients identified as D2T RA in 2018, 150 were included in the analysis. Among them, D2T RA was resolved in 67 (45%), 75 (50%) remained as D2T RA, and 8 (5%) died. Patients with resolved D2T RA were significantly younger at the latest visit (p= 0.02), had a higher proportion of treatment changes during five years (p= 0.002), and had a higher proportion of interleukin-6 receptor inhibitors use in 2023 (p= 0.04) than those in patients with persistent D2T RA or those who died. D2T RA resolved in 38% of patients with multidrug resistance, mainly with treatment changes. Rheumatic disease comorbidity index and glucocorticoid dose escalation were independent risk factors for mortality (odds ratio [OR], 3.50; p= 0.02 and OR, 31.9; p= 0.002, respectively). CONCLUSION Further modifications in RA treatment are useful for resolving D2T RA. Multiple comorbidities and glucocorticoid use are associated with mortality.
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Affiliation(s)
- Satoshi Takanashi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Saitama Medical University
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Moysidou GS, Dara A. JAK Inhibition as a Potential Treatment Target in Systemic Lupus Erythematosus. Mediterr J Rheumatol 2024; 35:37-44. [PMID: 38756931 PMCID: PMC11094445 DOI: 10.31138/mjr.231123.jia] [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: 11/23/2023] [Revised: 12/10/2023] [Accepted: 12/15/2023] [Indexed: 05/18/2024] Open
Abstract
Janus kinase (JAK)/signal transducers and activators of transcription (STATs) are a group of molecules responsible for signal transduction of multiple cytokines and growth factors in different cell types, involved in the maintenance of immune tolerance. Thus, the dysregulation of this pathway plays a crucial role in the pathogenesis of multiple autoimmune, inflammatory, and allergic diseases and is an attractive treatment target. JAK inhibitors (JAKinibs) have been approved in the treatment of multiple autoimmune diseases including rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (SPA). In SLE, there is a plethora of ongoing trials evaluating their efficacy, with tofacitinib, baricitinib and deucravacitinib showing promising results, without major safety concerns. In this review, we will discuss the rationale of targeting JAKinibs in SLE and summarize the clinical data of efficacy and safety of JAKinibs in SLE patients.
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Affiliation(s)
- Georgia-Savina Moysidou
- National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece; Inflammation and Autoimmunity Lab, Biomedical Research Foundation of the Academy of Athens (BRFAA), Athens, Greece
| | - Athanasia Dara
- Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Michitsuji T, Fukui S, Morimoto S, Endo Y, Nishino A, Nishihata S, Tsuji Y, Shimizu T, Umeda M, Sumiyoshi R, Koga T, Iwamoto N, Origuchi T, Ueki Y, Yoshitama T, Eiraku N, Matsuoka N, Okada A, Fujikawa K, Ohtsubo H, Takaoka H, Hamada H, Tsuru T, Nawata M, Arinobu Y, Hidaka T, Tada Y, Kawakami A, Kawashiri SY. Clinical and ultrasound features of difficult-to-treat rheumatoid arthritis: A multicenter RA ultrasound cohort study. Scand J Rheumatol 2024; 53:123-129. [PMID: 38085537 DOI: 10.1080/03009742.2023.2277542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/27/2023] [Indexed: 02/27/2024]
Abstract
OBJECTIVE The optimal strategy for difficult-to-treat (D2T) rheumatoid arthritis (RA) has not been identified, and the ultrasound characteristics of D2T RA have not been reported. We investigated the clinical characteristics and factors contributing to the outcome in D2T RA in a multicentre RA ultrasound observational cohort. METHOD We reviewed 307 Japanese patients diagnosed with RA who underwent treatment with biological and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs). We compared the differences in patient characteristics between the D2T RA and non-D2T RA groups. We examined the factors contributing to a good response [defined as b/tsDMARD continuation and Clinical Disease Activity Index (CDAI) ≤ 10 at 12 months] in the D2T RA patient group. RESULTS Forty-three patients (14%) were categorized as D2T RA and the remaining 264 (86%) as non-D2T RA at baseline. The grey-scale (GS) score, disease duration, and CDAI at the initiation of treatment were significantly higher in the D2T RA group than in the non-D2T RA group. In contrast, the power Doppler (PD) score was not significantly different between the two groups. Of the 43 D2T RA patients, 20 achieved a good response. The introduction of CTLA4-Ig (n = 5) was significantly associated with a good response in analysis based on inverse probability weighting with propensity score. GS and PD scores at baseline were not significantly associated with therapeutic response at 12 months in D2T RA patients. CONCLUSIONS Patients with D2T RA had high clinical and ultrasound activity and poor responses to treatment with b/tsDMARDs. CTLA4-Ig was associated with a good response at 12 months in D2T RA patients.
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Affiliation(s)
- T Michitsuji
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - S Fukui
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - S Morimoto
- Innovation Platform & Office for Precision Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Y Endo
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - A Nishino
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - S Nishihata
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Y Tsuji
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Shimizu
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - M Umeda
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - R Sumiyoshi
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - N Iwamoto
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Origuchi
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Y Ueki
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - T Yoshitama
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - N Eiraku
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - N Matsuoka
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - A Okada
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - K Fujikawa
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - H Ohtsubo
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - H Takaoka
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - H Hamada
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - T Tsuru
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - M Nawata
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - Y Arinobu
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - T Hidaka
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - Y Tada
- Kyushu Multicenter Rheumatoid Arthritis Ultrasound Prospective Observational Cohort Study Group, Kyushu, Japan
| | - A Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - S-Y Kawashiri
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Center for Collaborative Medical Education and Development, Nagasaki University Institute of Biomedical Sciences, Nagasaki, Japan
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Philippoteaux C, Delepine T, Cailliau E, Philippe P, Taisne N, Pascart T, Cortet B, Paccou J, Flipo RM, Letarouilly JG. Characteristics of difficult-to-treat axial spondyloarthritis: Results of a real-world multicentric study. Joint Bone Spine 2024; 91:105670. [PMID: 38036061 DOI: 10.1016/j.jbspin.2023.105670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/15/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE The EULAR task force recently published the difficult-to-treat RA (D2T RA) definition, however, a definition of D2T axSpA is still lacking and limitations in this definition exist. The objectives were to study the characteristics of D2T axSpA patients using the EULAR definition and to study a subgroup of patients with a predefined more stringent definition including a temporal criterion. METHODS A multicentric retrospective study was performed. D2T axSpA was defined as failure of≥2 b/tsDMARDs with different mechanism of action. Very D2T axSpA was defined as failure of≥2 b/tsDMARDs in less than 2 years of follow-up. D2T and Very D2T axSpA patients were compared to non-D2T (nD2T) axSpA patients. RESULTS Three hundred and eleven axSpA patients were included: 88 D2T axSpA (28.3%) and 223 non-D2T (nD2T) axSpA (71.7%). Peripheral involvement was more prevalent in the D2T group (34.9 vs. 21.4%; P=0.015). BASDAI level at baseline was higher in the D2T group (63.7±16.5 vs. 58.8±14.7; P=0.015). Fibromyalgia was found to be more frequent in the D2T group vs nD2T group (P<0.001). Twelve patients (3.8%) were categorized as very D2T axSpA. Compared to nD2T, Very D2T patients had a higher CRP level at baseline (42.0±31.3 vs. 17.8±23.1; P=0.010). IBD prevalence at baseline was higher in the very D2T group (41.7 vs. 3.1%; P<0.001). None of the very D2T patients presented a fibromyalgia. CONCLUSION D2T axSpA was associated with higher disease activity, peripheral involvement, extra-musculoskeletal manifestations and fibromyalgia. Very D2T patients represented a minim proportion of patients after applying a more stringent definition including a temporal criterion of 2 years and might be independent from fibromyalgia.
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Affiliation(s)
| | - Thibaut Delepine
- Rheumatology Department, Valenciennes Hospital, Valenciennes, France
| | - Emeline Cailliau
- Biostatistics Department, Lille University Hospital, Lille, France
| | - Peggy Philippe
- Rheumatology Department, Lille University Hospital, Lille, France
| | - Nicolas Taisne
- Rheumatology Department, Valenciennes Hospital, Valenciennes, France
| | - Tristan Pascart
- Rheumatology Department, Saint-Philibert Catholic University Hospital, Lomme, France
| | - Bernard Cortet
- Rheumatology Department, Lille University Hospital, Lille, France
| | - Julien Paccou
- Rheumatology Department, Lille University Hospital, Lille, France
| | - René-Marc Flipo
- Rheumatology Department, Lille University Hospital, Lille, France
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9
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Tanaka H, Okada Y, Nakayamada S, Miyazaki Y, Sonehara K, Namba S, Honda S, Shirai Y, Yamamoto K, Kubo S, Ikari K, Harigai M, Sonomoto K, Tanaka Y. Extracting immunological and clinical heterogeneity across autoimmune rheumatic diseases by cohort-wide immunophenotyping. Ann Rheum Dis 2024; 83:242-252. [PMID: 37903543 PMCID: PMC10850648 DOI: 10.1136/ard-2023-224537] [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: 06/09/2023] [Accepted: 09/13/2023] [Indexed: 11/01/2023]
Abstract
OBJECTIVE Extracting immunological and clinical heterogeneity across autoimmune rheumatic diseases (AIRDs) is essential towards personalised medicine. METHODS We conducted large-scale and cohort-wide immunophenotyping of 46 peripheral immune cells using Human Immunology Protocol of comprehensive 8-colour flow cytometric analysis. Dataset consisted of >1000 Japanese patients of 11 AIRDs with deep clinical information registered at the FLOW study, including rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). In-depth clinical and immunological characterisation was conducted for the identified RA patient clusters, including associations of inborn human genetics represented by Polygenic Risk Score (PRS). RESULTS Multimodal clustering of immunophenotypes deciphered underlying disease-cell type network in immune cell, disease and patient cluster resolutions. This provided immune cell type specificity shared or distinct across AIRDs, such as close immunological network between mixed connective tissue disease and SLE. Individual patient-level clustering dissected patients with AIRD into several clusters with different immunological features. Of these, RA-like or SLE-like clusters were exclusively dominant, showing immunological differentiation between RA and SLE across AIRDs. In-depth clinical analysis of RA revealed that such patient clusters differentially defined clinical heterogeneity in disease activity and treatment responses, such as treatment resistance in patients with RA with SLE-like immunophenotypes. PRS based on RA case-control and within-case stratified genome-wide association studies were associated with clinical and immunological characteristics. This pointed immune cell type implicated in disease biology such as dendritic cells for RA-interstitial lung disease. CONCLUSION Cohort-wide and cross-disease immunophenotyping elucidate clinically heterogeneous patient subtypes existing within single disease in immune cell type-specific manner.
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Affiliation(s)
- Hiroaki Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
- Department of Statistical Genetics, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
| | - Yukinori Okada
- Department of Statistical Genetics, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
- Department of Genome Informatics, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
- Laboratory for Systems Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
- Laboratory of Statistical Immunology, Immunology Frontier Research Center (WPI-IFReC), Osaka University, Suita, Japan
- Premium Research Institute for Human Metaverse Medicine (WPI-PRIMe), Osaka University, Suita, Japan
| | - Shingo Nakayamada
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Yusuke Miyazaki
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Kyuto Sonehara
- Department of Statistical Genetics, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
- Department of Genome Informatics, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
- Laboratory for Systems Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Shinichi Namba
- Department of Statistical Genetics, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
| | - Suguru Honda
- Department of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Yuya Shirai
- Department of Statistical Genetics, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
- Laboratory of Statistical Immunology, Immunology Frontier Research Center (WPI-IFReC), Osaka University, Suita, Japan
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kenichi Yamamoto
- Department of Statistical Genetics, Osaka University School of Medicine Graduate School of Medicine, Suita, Osaka, Japan
- Laboratory of Children's health and Genetics, Division of Health Science, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Satoshi Kubo
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Katsunori Ikari
- Department of Orthopedics, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University, Shinjuku-ku, Tokyo, Japan
| | - Koshiro Sonomoto
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
- Department of Clinical Nursing, School of Health Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
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10
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Fujii T, Murata K, Onizawa H, Onishi A, Tanaka M, Murakami K, Nishitani K, Furu M, Watanabe R, Hashimoto M, Ito H, Fujii T, Mimori T, Morinobu A, Matsuda S. Management and treatment outcomes of rheumatoid arthritis in the era of biologic and targeted synthetic therapies: evaluation of 10-year data from the KURAMA cohort. Arthritis Res Ther 2024; 26:16. [PMID: 38195572 PMCID: PMC10775516 DOI: 10.1186/s13075-023-03251-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/21/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Advances in rheumatoid arthritis (RA) treatment, highlighted by biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs), have altered the paradigm of RA treatment in the last decade. Therefore, real-world clinical evidence is needed to understand how treatment strategies and outcomes have changed. METHODS Using an observational cohort of RA from 2012 to 2021, we collected cross-sectional data of RA patients annually to analyze a trend in RA management. For patients who initiated b/tsDMRDs, we evaluated treatment outcomes between b/tsDMARDs. Mixed-effect models were applied to examine the statistical implications of changes over time in treatment outcomes with a background adjustment. RESULTS We analyzed annual cross-sectional data from 5070 patients and longitudinal data from 1816 patients in whom b/tsDMARDs were initiated between 2012 and 2021. b/tsDMARD use increased, whereas glucocorticoid use decreased from 2012 to 2021. Disease activity and functional disability measures improved over time. The percentage of tsDMARD prescriptions considerably increased. All b/tsDMARDs showed clinical improvements in disease activity and functional disability. Statistically, TNFi showed better short-term improvements in b/tsDMARD-naïve patients, while IL6Ri demonstrated significant long-term benefits. IL6Ri had better retention rates in switched patients. After adjustment for patient characteristics, the annual change of RA disease activity and functional disability fared significantly better from 2012 to 2021. CONCLUSIONS With the development of new RA therapeutics, overall treatment outcomes advanced in the past decade.
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Affiliation(s)
- Takayuki Fujii
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan.
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan.
| | - Koichi Murata
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Hideo Onizawa
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Akira Onishi
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Masao Tanaka
- Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Kosaku Murakami
- Center for Cancer Immunotherapy and Immunobiology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Kohei Nishitani
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Moritoshi Furu
- Furu Clinic, 1098 Terasho, Konancho, Koka, Shiga, 5203301, Japan
| | - Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahicho, Abeno, Osaka, 5450051, Japan
| | - Motomu Hashimoto
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, 1-5-7 Asahicho, Abeno, Osaka, 5450051, Japan
| | - Hiromu Ito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kuchiki, Okayama, 7100052, Japan
| | - Takao Fujii
- Department of Rheumatology and Clinical Immunology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 6410012, Japan
| | - Tsuneyo Mimori
- Takeda Clinic for Rheumatic Diseases, 606-3-2, Higashi-Shiokojicho, Sanoh Kyotoekimae Building 1F, Kyoto, 6008216, Japan
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo, Kyoto, 6068507, Japan
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11
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Yamanaka H, Kishimoto M, Nishijima N, Yamashita K, Matsushima J, O'Brien J, Blachley T, Eliot M, Margolin Z, Dave SS, Tanaka Y. Socioeconomic impact of treatment with biological disease-modifying antirheumatic drugs in Japanese patients with rheumatoid arthritis. Mod Rheumatol 2023; 34:27-36. [PMID: 36629510 DOI: 10.1093/mr/roac160] [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: 09/05/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES We evaluate the socioeconomic impact of treatment with biological and targeted synthetic disease-modifying antirheumatic drugs in Japanese patients with rheumatoid arthritis. METHODS We analysed data retrospectively from the prospective observational CorEvitas RA Japan Registry (March 2016-February 2020). Patients were categorised into paid workers (PWs) and home workers (HWs) and further based on drug classes. We assessed medication persistence, treatment outcomes, health care resource utilisation, and socioeconomic impact over 12 months, including direct (drugs and health care resource utilisation) and indirect (loss of productivity) costs. RESULTS Overall, 187 PWs and 114 HWs were identified. Over 12 months, medication persistence was high, treatment outcomes improved, and outpatient visits reduced in both groups. Following treatment initiation, direct costs increased, whereas indirect (loss of productivity) costs decreased in both groups. The unadjusted socioeconomic impact [Japanese yen (JPY)] increased across all drug classes in PWs (range: 29,700-151,700) and HWs (range: -28,700 to 83,000). Adjusted change in monthly socioeconomic impact was JPY 29,700-138,900 for PWs and JPY -28,000 to 92,800 for HWs. CONCLUSIONS In this study of Japanese patients with rheumatoid arthritis, the socioeconomic burden increased across patient groups and drug classes. The decrease in indirect (loss of productivity) costs partially offset the increase in direct costs.
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Affiliation(s)
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | | | | | | | | | - Taylor Blachley
- CorEvitas, LLC, Waltham, MA, USA
- Syneos Health, Morrisville, NC, USA
| | | | | | | | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
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12
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Hecquet S, Combier A, Steelandt A, Pons M, Wendling D, Molto A, Miceli-Richard C, Allanore Y, Avouac J. Characteristics of patients with difficult-to-treat rheumatoid arthritis in a French single-centre hospital. Rheumatology (Oxford) 2023; 62:3866-3874. [PMID: 36961324 DOI: 10.1093/rheumatology/kead143] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 03/25/2023] Open
Abstract
OBJECTIVES To compare the features of difficult-to-treat rheumatoid arthritis (D2TRA) patients using two different definitions according to the previous failure of targeted therapies. METHODS We stratified consecutive RA patients treated at Cochin Hospital into two groups, a D2TRA group and a non-D2TRA group, according to two definitions of D2TRA. Both definitions defined D2TRA as RAs failing at least two targeted therapies, with a different mechanism of action for the EULAR-D2TRA definition or without prejudging the mechanism of action and for the Alternative D2TRA definition. RESULTS We included 320 consecutive RA patients. We identified 76 EULAR-D2TRA and 244 non-DTRA patients, and 120 Alternative D2TRA and 200 non-DTRA patients. Compared with non-D2TRA, D2TRA patients from both definitions were more likely to have lower socioeconomic level, positive rheumatoid factor, interstitial lung disease, higher DAS28-CRP and were more likely to respond to rituximab and Janus kinase inhibitors. Although EULAR and Alternative D2TRA patients displayed similar clinical and biological features, they were characterized by different therapeutic profiles. We observed fewer patients receiving methotrexate in the Alternative D2TRA group (53% vs 64%, P = 0.046). Patients with Alternative D2TRA not fulfilling the EULAR definition (n = 44) had all received two successive first-line TNF inhibitors, a monoclonal antibody and a soluble receptor, and were comparable to EULAR-D2TRA patients with regards to all other characteristics. CONCLUSION Low socioeconomic status, diabetes, interstitial lung disease and absence of combination with methotrexate allow identification of D2TRA. In addition, the inclusion as 'early-D2TRA' of patients failing two TNF inhibitors in the EULAR definition of D2TRA would facilitate the rapid identification of D2TRA patients.
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Affiliation(s)
- Sophie Hecquet
- Department of Rheumatology, Cochin Hospital, APHP, Université Paris Cité, Paris, France
- Department of Rheumatology, CHU Besançon, Besançon, France
| | - Alice Combier
- Department of Rheumatology, Cochin Hospital, APHP, Université Paris Cité, Paris, France
| | - Alexia Steelandt
- Department of Rheumatology, Cochin Hospital, APHP, Université Paris Cité, Paris, France
| | - Marion Pons
- Department of Rheumatology, Cochin Hospital, APHP, Université Paris Cité, Paris, France
| | | | - Anna Molto
- Department of Rheumatology, Cochin Hospital, APHP, Université Paris Cité, Paris, France
| | | | - Yannick Allanore
- Department of Rheumatology, Cochin Hospital, APHP, Université Paris Cité, Paris, France
| | - Jérôme Avouac
- Department of Rheumatology, Cochin Hospital, APHP, Université Paris Cité, Paris, France
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13
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Conran C, Kolfenbach J, Kuhn K, Striebich C, Moreland L. A Review of Difficult-to-Treat Rheumatoid Arthritis: Definition, Clinical Presentation, and Management. Curr Rheumatol Rep 2023; 25:285-294. [PMID: 37776482 DOI: 10.1007/s11926-023-01117-6] [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] [Indexed: 10/02/2023]
Abstract
PURPOSE OF REVIEW A subset of patients with rheumatoid arthritis (RA) who fail multiple biologic therapies are deemed to have "difficult-to-treat" (D2T) RA. In 2021, a European Alliance of Associations for Rheumatology (EULAR) task force proposed a clinical definition of D2T RA. Here we review RA phenotypes and clinical assessment of RA, propose a different definition of D2T RA, discuss possible D2T RA risk factors, and summarize existing literature on the management of D2T RA. RECENT FINDINGS High disease activity at the time of diagnosis or prior to treatment with a biologic is associated with the development of D2T RA. Prolonged time from diagnosis to beginning treatment has been consistently associated with the development of D2T RA. Other clinical factors such as burden of disease, extraarticular disease, obesity, smoking, pain, fatigue, and psychological conditions have inconsistent associations with D2T RA according to current literature. D2T RA is a relatively new concept that represents an area of great need for research regarding the characterization of those with the disease as well as how best to treat the disease. With this gained knowledge, rheumatologists will be able to better identify patients at the time of diagnosis that are likely to develop D2T RA to help guide management.
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Affiliation(s)
- Carly Conran
- Department of Medicine, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA.
| | - Jason Kolfenbach
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA
| | - Kristine Kuhn
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA
| | - Christopher Striebich
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA
| | - Larry Moreland
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, 12631 East 17th Avenue, Aurora, CO, 80045, USA
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14
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Philippoteaux C, Marty-Ane A, Cailliau E, Labreuche J, Philippe P, Cortet B, Paccou J, Flipo RM, Letarouilly JG. Characteristics Of Difficult-To-Treat Psoriatic Arthritis: A Comparative Analysis. Semin Arthritis Rheum 2023; 63:152275. [PMID: 37852155 DOI: 10.1016/j.semarthrit.2023.152275] [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: 05/28/2023] [Revised: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE The EULAR task force recently published the difficult-to-treat rheumatoid arthritis (D2T RA) criteria, however, a definition of D2T patients in psoriatic arthritis (PsA) is still lacking. To date, we have little data concerning D2T PsA, especially in real-world. One of the limitations of the D2T RA EULAR definition is the absence of a temporal criterion. The primary endpoint of this work was to study the characteristics of D2T PsA patients using the EULAR definition. The second objective was to study a sub-group of patients with a predefined more stringent definition including a temporal criterion. METHODS A retrospective study was performed in a tertiary center. D2T PsA was defined as failure of ≥ 2 b/tsDMARDs with different mechanism of action. Very D2T PsA was defined as failure of ≥ 2 b/tsDMARDs in less than 2 years of follow-up. D2T and Very D2T PsA patients were compared to nD2T PsA patients using statistical tests. RESULTS 150 PsA patients were included (from 2004 to 2015): 49 D2T PsA and 101 nD2T PsA. D2T PsA was associated with a higher prevalence of axial involvement (p=0.030), axial and/or peripheral structural damage (p=0.007) at baseline and more bDMARDs discontinuation due to poor dermatological control (p=0.005). There was no significant difference regarding comorbidities such as obesity, smoking status, fibromyalgia or depression. In multivariate analysis, peripheral structural damage at baseline was found to be a predictive factor for D2T PsA with an OR of 2.57 (1.16 to 5.69; p=0.020). 17 PsA (11.3%) patients were categorized as Very D2T PsA. When compared to nD2T group, proportion of obesity was higher (p=0.015) and axial involvement was more prevalent in the Very D2T group (p=0.020). CONCLUSION D2T PsA patients had a higher prevalence of axial involvement, peripheral structural damage and therapeutic discontinuation due to poor dermatological control whereas Very D2T PsA patients were more likely obese with axial involvement. Very D2T PsA represent a minim proportion among patients when applying a more stringent definition. Pending the PsA D2T definition by the European and American societies, this study highlights some characteristics that may help practitioners better identify D2T patients.
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Affiliation(s)
| | - Anne Marty-Ane
- Rheumatology Department, Lille University Hospital, Lille, France
| | - Emeline Cailliau
- Biostatistics Department, Lille University Hospital, Lille, France
| | - Julien Labreuche
- Biostatistics Department, Lille University Hospital, Lille, France
| | - Peggy Philippe
- Rheumatology Department, Lille University Hospital, Lille, France
| | - Bernard Cortet
- Rheumatology Department, Lille University Hospital, Lille, France
| | - Julien Paccou
- Rheumatology Department, Lille University Hospital, Lille, France
| | - Rene-Marc Flipo
- Rheumatology Department, Lille University Hospital, Lille, France
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15
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Pavlov-Dolijanovic S, Bogojevic M, Nozica-Radulovic T, Radunovic G, Mujovic N. Elderly-Onset Rheumatoid Arthritis: Characteristics and Treatment Options. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1878. [PMID: 37893596 PMCID: PMC10608066 DOI: 10.3390/medicina59101878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/01/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
Elderly-onset rheumatoid arthritis (EORA) is a distinct clinical entity defined as the onset of rheumatoid arthritis (RA) in individuals aged over 60 years. EORA presents unique clinical features, including a more equitable distribution of sexes, a potential predilection for male involvement, a higher incidence of acute onset characterized by constitutional symptoms, a propensity for systemic manifestations, elevated sedimentation rates at disease onset, a reduced occurrence of rheumatoid factor positivity, increased titers of anti-citrullinated protein antibodies, a preference for involvement of large joints, elevated disease activity, the presence of bone erosions, and heightened patient disability. RA is recognized to consist of three partially overlapping subsets. One subset mirrors the classical RA clinical presentation, while the remaining subsets exhibit either a polymyalgia rheumatica-like phenotype or present with remitting seronegative symmetrical synovitis accompanied by pitting edema syndrome. In the initial stages of EORA management, non-steroidal anti-inflammatory drugs (NSAIDs) are not typically the first-line treatment choice, because seniors are much more prone to develop side effects due to NSAIDs, and the use of NSAIDs is in reality contraindicated to the majority of seniors due to comorbidities. Disease-modifying antirheumatic drugs (DMARDs), frequently methotrexate, are introduced immediately after the diagnosis is made. In cases where elderly patients demonstrate resistance to conventional DMARD therapy, the introduction of biological or targeted synthetic DMARDs becomes a viable treatment option. EORA presents a unique clinical profile, necessitating tailored treatment strategies. Our study emphasizes the challenges of NSAID use in seniors, highlighting the imperative shift toward DMARDs such as methotrexate. Future research should explore personalized DMARD approaches based on disease activity, comorbidities, and safety considerations, aiming to optimize treatment outcomes and minimize glucocorticoid reliance, thereby enhancing the quality of care for EORA patients.
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Affiliation(s)
| | - Milan Bogojevic
- Clinical Centre of Montenegro, Department of Rheumatology, 81000 Podgorica, Montenegro;
| | - Tatjana Nozica-Radulovic
- Faculty of Medicine, Institute for Physical Medicine and Rehabilitation and Orthopedic Surgery “Dr. Miroslav Zotovic”, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina;
| | - Goran Radunovic
- University of Belgrade, Faculty of Medicine, Institute of Rheumatology, 11000 Belgrade, Serbia;
| | - Natasa Mujovic
- University of Belgrade, Faculty of Medicine, Center for Physical Medicine and Rehabilitation, University Clinical Centre of Serbia, 11000 Belgrade, Serbia;
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Harrington R, Harkins P, Conway R. Janus Kinase Inhibitors in Rheumatoid Arthritis: An Update on the Efficacy and Safety of Tofacitinib, Baricitinib and Upadacitinib. J Clin Med 2023; 12:6690. [PMID: 37892827 PMCID: PMC10607454 DOI: 10.3390/jcm12206690] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/14/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
Janus kinase inhibitors (JAKis) are the most recent new drug class to arrive to the market for rheumatoid arthritis (RA) treatment. While they have proven to be a very effective treatment option, there remains significant concern regarding the risk of cardiovascular events, thrombosis and malignancy, particularly given the findings of the post-marketing ORAL Surveillance study and FDA black box warnings. This article reviews the key findings of the most impactful cohort of studies and registry data since ORAL Surveillance. It also evaluates the role of JAKis in practice and offers guidance on risk stratifying patients and determining their suitability for a JAKi.
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Affiliation(s)
- Robert Harrington
- Department of Rheumatology, St. James’s Hospital, James Street, Dublin 8, D08 NHY1 Dublin, Ireland;
| | | | - Richard Conway
- Department of Rheumatology, St. James’s Hospital, James Street, Dublin 8, D08 NHY1 Dublin, Ireland;
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Miyata H, Sonomoto K, Fukuyo S, Nakayamada S, Nakano K, Iwata S, Miyazaki Y, Kawabe A, Aoki T, Tanaka Y. Computed tomography for malignancy screening in patients with rheumatoid arthritis before initiation of disease modifying antirheumatic drug. Rheumatology (Oxford) 2023; 62:3339-3349. [PMID: 36782362 DOI: 10.1093/rheumatology/kead075] [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: 11/11/2022] [Revised: 01/14/2023] [Accepted: 02/01/2023] [Indexed: 02/15/2023] Open
Abstract
OBJECTIVES This study aimed to clarify the usefulness of screening for malignancies using CT before the initiation of biologic and targeted synthetic DMARDs (b/tsDMARDs) in patients with active RA. METHODS We examined 2192 patients with RA who underwent plain CT scans prior to the initiation of b/tsDMARDs. The sensitivity for detecting malignancy was measured and compared with that of regular screening (physical examination and X-ray). We then evaluated the clinical characteristics, prognosis and treatment of patients with RA with concomitant malignancies. Additionally, we determined the incidence rate of malignancy in patients with RA who were initiated on b/tsDMARDs after CT screening. RESULTS Of the 2192 patients, 33 (1.5%) were diagnosed with malignancy after CT screening. Whereas regular screening detected only seven malignancies, CT screening further detected 26 (including 19 at the early stage). On the other hand, 86% of the malignancies detectable by regular screening were at an advanced stage. Patients diagnosed with early-stage malignancies received RA treatments that included b/tsDMARDs after curative resection; 80% of these patients achieved low disease activity after 1 year. This rate was comparable to the patients without malignancy detection after screening (70%). The 5 year incidence of malignancy after the initiation of b/tsDMARDs after CT screening was lower than that of the RA cohort without CT screening (standardized incidence ratio: 0.35). CONCLUSION Screening in patients with RA using CT before the initiation of b/tsDMARDs allows for the early detection and treatment of malignancy, resulting in safer and more stable b/tsDMARD treatments.
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Affiliation(s)
- Hiroko Miyata
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Koshiro Sonomoto
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
- Department of Clinical Nursing, School of Health Sciences, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Shunsuke Fukuyo
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
- Department of Rheumatology, Wakamatsu Hospital of the University of the Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
- Department of Rheumatology, Kawasaki Medical School, Okayama, Japan
| | - Shigeru Iwata
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
- Department of Rheumatology, Wakayama Medical University, Wakayama, Japan
| | - Yusuke Miyazaki
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Akio Kawabe
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Takatoshi Aoki
- Department of Radiology, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
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Garcia-Salinas R, Sanchez-Prado E, Mareco J, Ronald P, Ruta S, Gomez R, Magri S. Difficult to treat rheumatoid arthritis in a comprehensive evaluation program: frequency according to different objective evaluations. Rheumatol Int 2023; 43:1821-1828. [PMID: 37269430 DOI: 10.1007/s00296-023-05349-8] [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: 04/25/2023] [Accepted: 05/22/2023] [Indexed: 06/05/2023]
Abstract
Difficult-to-treat Rheumatoid Arthritis (RA-D2T) is a condition in which patients do not achieve the treatment target despite multiple advanced therapies, more others features. Aims: to estimate the frequency of RA-D2T in a cohort comprehensively evaluated (clinical, serology, imaging), and to analyze the associated characteristics. In a second part, the frequency of RA-D2T after 1 year of follow-up, analyzing the predictive variables at baseline and therapeutic behavior. Cross-sectional and prospective study, consecutive RA were included, then those who completed the one-year follow-up were evaluated. RA-D2T frequency was estimated (DAS28-CDAI-SDAI-Ultrasonography (US)-HAQ) at baseline and 1 year. The variables associated and those baseline predictive characteristics of D2T at 1 year, and their independent association by logistic regression were analyzed. The treatment approach was described. Two hundred seventy-six patients completed the evaluation, frequency of RA-D2T (all scores): 27.5%. Anemia, RF high titers and higher HAQ score were independent associated. At year, 125 competed follow-up. RA-D2T (all scores): 33%, D2T-US and D2T-HAQ were 14 and 18.4% (p 0.001). Predictive baseline characteristics D2T (all score): ACPA + (OR: 13.7) and X-ray erosion (OR: 2.9). D2T-US: X-ray erosion (OR: 19.7). Conventional DMARDs, corticosteroids and TNF-blockers were the drugs most used by D2T patients, Jaki were the most used in the switch. We showed different frequencies of RA-D2T according to different objective parameters (scores, images) and their association with patient characteristics. In turn, predictive variables (erosions-ACPA) for RA-D2T at 1 year were analyzed. It was shown that the Jaki were the most used drug in these patients.
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Affiliation(s)
- Rodrigo Garcia-Salinas
- Rheumatology Unit, Hospital Italiano de La Plata, 51 Street, 1725, 1900, La Plata, Buenos Aires Province, Argentina.
| | - Einer Sanchez-Prado
- Rheumatology Unit, Hospital Italiano de La Plata, 51 Street, 1725, 1900, La Plata, Buenos Aires Province, Argentina
| | - Jonatan Mareco
- Rheumatology Unit, Hospital Italiano de La Plata, 51 Street, 1725, 1900, La Plata, Buenos Aires Province, Argentina
- Rheumatolgy Unit, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Perez Ronald
- Rheumatology Unit, Hospital Italiano de La Plata, 51 Street, 1725, 1900, La Plata, Buenos Aires Province, Argentina
| | - Santiago Ruta
- Rheumatology Unit, Hospital Italiano de La Plata, 51 Street, 1725, 1900, La Plata, Buenos Aires Province, Argentina
| | - Ramiro Gomez
- Rheumatolgy Unit, Hospital Nacional Alejandro Posadas, Buenos Aires, Argentina
| | - Sebastian Magri
- Rheumatology Unit, Hospital Italiano de La Plata, 51 Street, 1725, 1900, La Plata, Buenos Aires Province, Argentina
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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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Tanaka Y. Making a prescribing choice for rheumatoid arthritis: a focus on small molecule drugs vs. biologics for the most favourable patient outcome. Expert Opin Pharmacother 2023; 24:1791-1798. [PMID: 37563102 DOI: 10.1080/14656566.2023.2247325] [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: 06/10/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION The molecular targeted therapies available for rheumatoid arthritis include 10 types of biological disease-modifying antirheumatic drugs (bDMARDs) and five types of Janus kinase (JAK) inhibitors. This article reviews the differential and proper use of bDMARDs and JAK inhibitors, focusing on their efficacy and safety, based mainly on phase III clinical trials. AREA COVERED The JAK inhibitors approved for treating rheumatoid arthritis are compared with bDMARDs based on the evidence derived from global phase III trials. EXPERT OPINION In patients with inadequate responses to bDMARDs and JAK inhibitors, switching between these drugs is comparable in efficacy in both directions. Head-to-head comparison demonstrated that baricitinib and upadacitinib are more efficacious than tumor necrosis factor (TNF) inhibitors. However, the ORAL Surveillance study demonstrated that JAK inhibitors are associated with higher incidences of death, major adverse cardiovascular events, malignancies and thrombosis than TNF inhibitors in at-risk patients. The need for risk assessment by pre-treatment screening, regular monitoring during treatment, and appropriate systemic management in adverse events should be recognized. Meanwhile, some JAK-inhibitors were efficacious even for difficult-to-treat disease. These results suggest the need for establishing therapeutic strategies considering the balance between safety and efficacy in individual patients.
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Affiliation(s)
- Yoshiya Tanaka
- University of Occupational and Environmental Health Japan, Kitakyushu, Japan
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21
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Parigi TL, D'Amico F, Abreu MT, Dignass A, Dotan I, Magro F, Griffiths AM, Jairath V, Iacucci M, Mantzaris GJ, O'Morain C, Reinisch W, Sachar DB, Turner D, Yamamoto T, Rubin DT, Peyrin-Biroulet L, Ghosh S, Danese S. Difficult-to-treat inflammatory bowel disease: results from an international consensus meeting. Lancet Gastroenterol Hepatol 2023; 8:853-859. [PMID: 37423233 DOI: 10.1016/s2468-1253(23)00154-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 07/11/2023]
Abstract
Many patients with inflammatory bowel disease (IBD) have persistent symptoms and disease activity despite the best available medical or surgical treatments. These patients are commonly referred to as having difficult-to-treat IBD and need additional therapeutic strategies. However, the absence of standard definitions has impeded clinical research efforts and comparisons of data. Under the guidance of the endpoints cluster of the International Organization for the Study of Inflammatory Bowel Disease, we held a consensus meeting to propose a common operative definition for difficult-to-treat IBD. 16 participants from 12 countries voted on 20 statements covering various elements of difficult-to-treat IBD, such as failure of medical and surgical treatments, disease phenotypes, and specific complaints from patients. "Agreement" was defined as at least 75% consensus. The group agreed that difficult-to-treat IBD is defined by the failure of biologics and advanced small molecules with at least two different mechanisms of action, or postoperative recurrence of Crohn's disease after two surgical resections in adults, or one in children. In addition, chronic antibiotic-refractory pouchitis, complex perianal disease, and comorbid psychosocial complications that impair disease management also qualified as difficult-to-treat IBD. Adoption of these criteria could serve to standardise reporting, guide enrolment in clinical trials, and help identify candidates for enhanced treatment strategies.
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Affiliation(s)
- Tommaso Lorenzo Parigi
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Ferdinando D'Amico
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Maria T Abreu
- Division of Gastroenterology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Axel Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt, Germany
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fernando Magro
- Unit of Pharmacology and Therapeutics, Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Anne M Griffiths
- Division of Gastroenterology, SickKids Hospital, University of Toronto, Toronto, ON, Canada
| | - Vipul Jairath
- Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Marietta Iacucci
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK; APC Microbiome Ireland, College of Medicine and Health, University College Cork, Cork, Ireland
| | | | - Colm O'Morain
- Department of Gastroenterology, Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Walter Reinisch
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David B Sachar
- The Dr Henry J Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dan Turner
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - David T Rubin
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, IL, USA
| | | | - Subrata Ghosh
- APC Microbiome Ireland, College of Medicine and Health, University College Cork, Cork, Ireland
| | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy; Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Favalli EG, Cincinelli G, Germinario S, Di Taranto R, Orsini F, Maioli G, Biggioggero M, Ferrito M, Caporali R. The impact of EMA recommendations on the real-life use of Janus kinases inhibitors for rheumatoid arthritis: the Expanded Risk Score in RA as a tool to quantify the risk of cardiovascular events. Front Immunol 2023; 14:1225160. [PMID: 37720218 PMCID: PMC10500057 DOI: 10.3389/fimmu.2023.1225160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/10/2023] [Indexed: 09/19/2023] Open
Abstract
Objective To evaluate in patients with rheumatoid arthritis (RA) the impact of EMA recommendations on the real-life prescription of JAK inhibitors (JAKis) and the use of the Expanded Risk Score in RA (ERS-RA) to quantify the risk of major adverse cardiac events (MACE). Methods We conducted a retrospective analysis of real-life RA patients treated with JAKis. Patients were classified as ineligible for JAKis if they fulfilled EMA criteria (>65 years-old, history of malignancy, or increased risk of venous thromboembolic events [VTE] or MACE including smoking). Risk of MACE was defined according to ORAL Surveillance trial inclusion criteria (ORALSURV) or by using the ERS-RA. Results Of 194 patients enrolled, 57.9% were classified as ineligible according to EMA definition (ORALSURV criteria). The most frequent reason for ineligibility was increased MACE risk (70.2%), followed by age>65 (34.2%), smoking (30.7%), and increased risk of VTE (20.2%) or malignancy (7%). The use of the ERS-RA reduced the rate of patients carrying an increased CV risk to 18.6% (p<0.001 versus ORALSURV), leading to 46.4% overall ineligible patients. Over a drug-exposure of 337 patient/years, we observed 2 VTE, one MACE (non-fatal stroke), and one solid malignancy (all in the group of patients classified as ineligible according to both the definitions). Conclusions Rigorous application of EMA indications in clinical practice could result in the exclusion of a large proportion of RA patients from treatment with JAKis. A proper quantification of the risk for MACE by dedicated tools as ERS-RA is advocated to better tailor the management of RA.
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Affiliation(s)
- Ennio Giulio Favalli
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gilberto Cincinelli
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Sabino Germinario
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Raffaele Di Taranto
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Francesco Orsini
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gabriella Maioli
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Martina Biggioggero
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
| | - Matteo Ferrito
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Roberto Caporali
- Department of Rheumatology and Medical Sciences, ASST Gaetano Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
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Benucci M, Bardelli M, Cazzato M, Laurino E, Bartoli F, Damiani A, Li Gobbi F, Panaccione A, Di Cato L, Niccoli L, Frediani B, Mosca M, Guiducci S, Cantini F. ReLiFiRa (Real Life Filgotinib in Rheumatoid Arthritis): Retrospective Study of Efficacy and Safety in Common Clinical Practice. J Pers Med 2023; 13:1303. [PMID: 37763071 PMCID: PMC10532886 DOI: 10.3390/jpm13091303] [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: 08/01/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Filgotinib (FIL) is a selective JAK1 inhibitor with an affinity 30-fold higher than JAK2, approved to treat moderate to severe active rheumatoid arthritis (RA), in adults with inadequate response or intolerance to one or more disease-modifying antirheumatic drugs (DMARDs). METHODS We conducted a retrospective, multicentric study in order to evaluate efficacy and safety of FIL 200 mg daily therapy, after 3 and 6 months, in 120 patients affected by RA, managed in Tuscany and Umbria rheumatological centers. The following clinical records were analyzed: demographical data, smoking status, previous presence of comorbidities (Herpes zoster -HZ- infection, venous thromboembolism -VTE-, major adverse cardiovascular events -MACE-, cancer, diabetes, and hypertension), disease duration, presence of anti-citrullinated protein antibodies (ACPA), rheumatoid factor (RF), number of biological failures, and prior csDMARDs utilized. At baseline, and after 3 (T3) and 6 (T6) months of FIL therapy, we evaluated mean steroid dosage, csDMARDs intake, clinimetric indexes (DAS28, CDAI, HAQ, patient and doctor PGA, VAS), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and body mass index (BMI). RESULTS At baseline, the mean disease duration was 9.4 ± 7.5 years; the prevalence of previous HZ infection, VTE, MACE, and cancer was respectively 4.12%, 0%, 7.21%, and 0.83%, respectively. In total, 76.3% of patients failed one or more biologics (one biological failure, 20.6%; two biological failures, 27.8%; three biological failures, 16.5%; four biological failures, 10.3%; five biological failures, 1.1%). After 3 months of FIL therapy, all clinimetric index results significantly improved from baseline, as well as after 6 months. Also, ESR and CRP significatively decreased at T3 and T6. Two cases of HZ were recorded, while no new MACE, VTE, or cancer were recorded during the observation time. CONCLUSION Despite the limitations of the retrospective study and of the observational period of only 6 months, real-life data on the treatment of RA patients with FIL demonstrate that this Jak inhibitor therapy is safe in terms of CV, VTE events, and occurrence of cancer, and is also effective in a population identified as "difficult to treat" due to failure of previous b-DMARD therapy.
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Affiliation(s)
- Maurizio Benucci
- Rheumatology Unit, San Giovanni di Dio Hospital, 50143 Florence, Italy;
| | - Marco Bardelli
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy; (M.B.); (B.F.)
| | - Massimiliano Cazzato
- Unit of Rheumatology, University Hospital of Pisa, 56126 Pisa, Italy; (M.C.); (E.L.); (M.M.)
| | - Elenia Laurino
- Unit of Rheumatology, University Hospital of Pisa, 56126 Pisa, Italy; (M.C.); (E.L.); (M.M.)
| | - Francesca Bartoli
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (A.D.); (S.G.)
| | - Arianna Damiani
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (A.D.); (S.G.)
| | | | - Anna Panaccione
- Internal Medicine and Rheumatology Unit, Santa Maria General Hospital, 05100 Terni, Italy; (A.P.); (L.D.C.)
| | - Luca Di Cato
- Internal Medicine and Rheumatology Unit, Santa Maria General Hospital, 05100 Terni, Italy; (A.P.); (L.D.C.)
| | - Laura Niccoli
- Division of Rheumatology, Prato Hospital, 59100 Prato, Italy; (L.N.); (F.C.)
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy; (M.B.); (B.F.)
| | - Marta Mosca
- Unit of Rheumatology, University Hospital of Pisa, 56126 Pisa, Italy; (M.C.); (E.L.); (M.M.)
| | - Serena Guiducci
- Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy; (F.B.); (A.D.); (S.G.)
| | - Fabrizio Cantini
- Division of Rheumatology, Prato Hospital, 59100 Prato, Italy; (L.N.); (F.C.)
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Amirdzhanova VN, Karateev AE, Pogozheva EY, Filatova ES, Samigullina RR, Mazurov VI, Anoshenkova ON, Lapkina NA, Baranov AA, Grineva TY, Lila AM, Nasonov EL. Are the Goals of Therapy Achievable in Patients with Rheumatoid Arthritis Receiving Upadacitinib in Real Clinical Practice? DOKL BIOCHEM BIOPHYS 2023; 511:180-186. [PMID: 37833604 PMCID: PMC10739522 DOI: 10.1134/s1607672923700308] [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: 04/20/2023] [Revised: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 10/15/2023]
Abstract
The aim of the study was to evaluate the effectiveness of UPA in RA patients in real clinical practice after 3 and 6 months of therapy. The study included 63 RA patients with high activity of the disease. Activity was assessed according to the DAS28(ESR), DAS28(CRP), SDAI, CDAI; functional ability to HAQ; quality of life to the EQ-5D; disease activity according to the patient's RAPID-3 index; the level of depression and anxiety to the HADS scale. The effectiveness of therapy was evaluated after 3 (n = 45) and 6 (n = 31) months of UPA therapy. Remission or low activity of the disease by 3 months of therapy was achieved by most patients: remission of 69.8% of patients, low activity of the disease-16.3% of patients. Moderate or high activity persisted in 13.9% of patients. By the 6th month of UPA therapy, the number of remissions reached 90%, low activity 3.3%, moderate activity persisted in 6.7% of patients, high activity of the disease was not in any patient. 20% improvement in function was achieved in 71.8% of patients by the 3rd month of therapy and in 77.8% by the 6th month of treatment; the difference in average HAQ values by the 3rd month of therapy was 0.38 points, by the 6th month-0.58 points. After 3 months of follow-up, 31.1% of patients continued taking GC, by 6 months-24.2%. The dose of GC was reduced from an average of 7.23 to 5.6 mg/s. The percentage of patients requiring NSAIDs decreased from 95.2 to 35.6% and 33.3%, respectively. DMARDs continued to be received by 75.6% of patients by 3 months and 69.7% by 6 months of follow-up. Achieving remission or low activity of the disease in patients with RA receiving UPA in real clinical practice is possible in most patients. A rapid decrease in inflammatory activity is accompanied by a significant improvement in the functional state and quality of life of patients. UPA therapy reduces the need for the use of NSAIDs and reduces the dose of GC in a third of patients.
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Affiliation(s)
| | - A E Karateev
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - E Yu Pogozheva
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - E S Filatova
- Nasonova Research Institute of Rheumatology, Moscow, Russia
| | - R R Samigullina
- Mechnikov Northwestern State Medical University, Ministry of Health of the Russian Federation, St. Petersburg, Russia
| | - V I Mazurov
- Mechnikov Northwestern State Medical University, Ministry of Health of the Russian Federation, St. Petersburg, Russia
| | | | - N A Lapkina
- Yaroslavl State Medical University, Ministry of Health of the Russian Federation, Yaroslavl, Russia
| | - A A Baranov
- Yaroslavl State Medical University, Ministry of Health of the Russian Federation, Yaroslavl, Russia
| | - T Yu Grineva
- Vologda Regional Clinical Hospital No. 1, Vologda, Russia
| | - A M Lila
- Nasonova Research Institute of Rheumatology, Moscow, Russia
- Russian Medical Academy of Continuing Professional Education, Ministry of Health of the Russian Federation, Moscow, Russia
| | - E L Nasonov
- Nasonova Research Institute of Rheumatology, Moscow, Russia
- Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
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Taylor PC, Laedermann C, Alten R, Feist E, Choy E, Haladyj E, De La Torre I, Richette P, Finckh A, Tanaka Y. A JAK Inhibitor for Treatment of Rheumatoid Arthritis: The Baricitinib Experience. J Clin Med 2023; 12:4527. [PMID: 37445562 DOI: 10.3390/jcm12134527] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Baricitinib, an oral selective Janus kinase (JAK)1/JAK2 inhibitor, is approved as monotherapy or in combination with methotrexate for treating adults with moderate-to-severe active rheumatoid arthritis (RA) and provides improvements in clinical signs, symptoms and patient-reported outcomes. Currently, baricitinib is approved for treating RA in more than 75 countries. In several pivotal Phase II and III RA trials (RA-BALANCE, RA-BEGIN, RA-BEAM, RA-BUILD, RA-BEACON, RA-BEYOND), up to seven years of baricitinib treatment was well tolerated and provided rapid and sustained efficacy, which was confirmed in real-world settings. Safety signals for another JAK inhibitor, tofacitinib, have emerged, as observed in the post-marketing Phase IIIb/IV trial Oral Rheumatoid Arthritis Trial (ORAL) Surveillance; safety signals were subsequently highlighted in a retrospective study of baricitinib and consequently new recommendations and warnings and precautions for all JAK inhibitors have been issued. Ongoing studies to further characterise and clarify the benefit:risk of JAK inhibitors include registries and controlled trials. This capstone review summarises clinical and real-world data outlining the benefit:risk profile of baricitinib, confirming that the improved disease activity and physical function of patients with RA treated with this JAK inhibitor observed in clinical trials is translated into effectiveness in clinical practice, with a low rate of discontinuations.
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Affiliation(s)
- Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | | | - Rieke Alten
- Internal Medicine II, Rheumatology, SCHLOSSPARK-KLINIK, University Medicine Berlin, 14059 Berlin, Germany
| | - Eugen Feist
- Department of Rheumatology, Helios Clinic Vogelsang-Gommern, Cooperation Partner of the Otto-von-Guericke University Magdeburg, 39245 Magdeburg, Germany
| | - Ernest Choy
- Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff CF14 4YS, UK
| | - Ewa Haladyj
- Eli Lilly and Company, Indianapolis, IN 46285, USA
| | | | - Pascal Richette
- Service de Rhumatologie, Hôpital Lariboisière, 75010 Paris, France
- Inserm, UMR-S 1132, Bioscar, Université de Paris, 75010 Paris, France
| | - Axel Finckh
- Division of Rheumatology, Department of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu 807-0804, Japan
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Luppino AF, Cincinelli G, Orenti A, Boracchi P, Favalli EG, Caporali R, Ingegnoli F. Tight control in patients with rheumatoid arthritis treated with targeted therapies across the COVID-19 pandemic era. J Telemed Telecare 2023:1357633X221150724. [PMID: 36694430 PMCID: PMC9892820 DOI: 10.1177/1357633x221150724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/27/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To analyze the impact of different patterns of healthcare delivery on remission of rheumatoid arthritis (RA) patients treated with targeted therapies during the first wave (2020) and second/third waves (2021) of the pandemic compared to the pre-pandemic period (2019). METHODS In this observational real-life study, data from RA patients treated with biologic or targeted synthetic drugs were extracted from a longitudinal registry. Clinical Disease Activity Index (CDAI) was analyzed in the same period from the 22nd of February to the 18th of May for three consecutive years. These three periods were characterized by different patterns of healthcare delivery: (1) before the pandemic (2019) only in-person visits, (2) during the first wave (2020) both in-person visits and telehealth, and (3) during the second/third waves (2021) only in-person visits. A generalized linear model with the binomial error was fitted to evaluate the difference in the proportion of patients in CDAI remission. Quantile regression was used to compare the median of CDAI in difficult-to-treat (D2T) patients. RESULTS In the three periods, we included 407, 450, and 540 RA patients respectively. The percentages of patients in CDAI remission were similar in the three periods (prevalence ratio 1.07, p value 0.423 between 2020 and 2019, and 1.01, p-value 0.934 between 2021 and 2019). The CDAI remission rate was 40.55% (N = 163), 43.18% (N = 155) and 40.82% (N = 220) in 2019, 2020 and 2021, respectively. Among our cohort of D2T patients, CDAI remission was similar across the three periods (N = 30, 22.22%; N = 27, 23.68%; and N = 34, 21.52% respectively). CONCLUSION Although the pandemic has imposed changes in our healthcare delivery, these different strategies seem to be effective in ensuring satisfactory management of RA treated with targeted therapies. The approaches modulated in the context of the different periods have been a feasible compensation for ensuring disease control even in D2T patients.
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Affiliation(s)
- Angela Flavia Luppino
- Clinical Rheumatology Unit, ASST Gaetano Pini-CTO, Department of Clinical Sciences & Community Health, Università degli Studi di Milano, Milano, Italy
| | - Gilberto Cincinelli
- Clinical Rheumatology Unit, ASST Gaetano Pini-CTO, Department of Clinical Sciences & Community Health, Università degli Studi di Milano, Milano, Italy
| | - Annalisa Orenti
- Lab of Medical Statistics, Biometry and Epidemiology “GA Maccacaro”, Department of Clinical Sciences & Community Health, Università degli Studi di Milano, Milano, Italy
| | - Patrizia Boracchi
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, Milano, Italy
| | - Ennio Giulio Favalli
- Clinical Rheumatology Unit, ASST Gaetano Pini-CTO, Department of Clinical Sciences & Community Health, Università degli Studi di Milano, Milano, Italy
| | - Roberto Caporali
- Clinical Rheumatology Unit, ASST Gaetano Pini-CTO, Department of Clinical Sciences & Community Health, Università degli Studi di Milano, Milano, Italy
| | - Francesca Ingegnoli
- Clinical Rheumatology Unit, ASST Gaetano Pini-CTO, Department of Clinical Sciences & Community Health, Università degli Studi di Milano, Milano, Italy
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Šenolt L. JAK inhibition in the treatment of inflammatory rheumatic diseases. VNITRNI LEKARSTVI 2023; 69:181-188. [PMID: 37468313 DOI: 10.36290/vnl.2023.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
The most common immune-mediated inflammatory rheumatic diseases, rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis and have reached significant advances in recent years with the introduction of biological therapies against cytokines and immune cells, but also against intracellular enzymes, specifically Janus kinases (JAKs). Intracellular JAK signalling is activated by binding of various cytokines or growth factors to the respective cellular receptors, allowing the activation of STAT (Signal Transducers and Activators of Transcription) transcription factors and ultimately the transcription of genes with important roles during the innate and adaptive immune response. Four Janus kinases have been described: JAK1, JAK2, JAK3 and tyrosine kinase-2 (TYK2). Four JAK inhibitors (tofacitinib, baricitinib, upadacitinib and filgotinib) are currently approved for the treatment of rheumatoid arthritis, and some for the treatment of psoriatic arthritis and axial spondyloarthritis. JAK inhibitors have varying selectivity against individual kinases. Some JAK inhibitors are being tested in other rarer systemic connective tissue diseases. The general advantages of JAK inhibitors are oral administration, rapid onset of action, and efficacy in monotherapy. The safety profile of JAK inhibitors compared with biologic therapy appears to be comparable, with a higher incidence of herpes zoster, and an increased incidence of major cardiovascular disease, thromboembolic complications, and cancer in at-risk patients is discussed. The aim of this paper will be to summarize the latest findings on JAK inhibitors in approved indications for the most common rheumatic diseases.
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28
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Watanabe R, Okano T, Gon T, Yoshida N, Fukumoto K, Yamada S, Hashimoto M. Difficult-to-treat rheumatoid arthritis: Current concept and unsolved problems. Front Med (Lausanne) 2022; 9:1049875. [PMID: 36353219 PMCID: PMC9637686 DOI: 10.3389/fmed.2022.1049875] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 10/06/2022] [Indexed: 08/15/2023] Open
Abstract
Over the past several decades, the treatment of rheumatoid arthritis (RA) has advanced significantly, and clinical, structural, and functional remission are achievable therapeutic goals. However, a substantial number of patients show resistance to multiple drugs. In particular, patients whose disease activity cannot be controlled despite the use of two or more biological disease-modifying antirheumatic drugs (DMARDs) or targeted synthetic DMARDs (tsDMARDs) with different mechanisms of action (MOA) have recently been referred to as having difficult-to-treat RA (D2T RA). D2T RA is a heterogeneous and multifactorial disease state, and the major problems are uncontrolled disease activity and decreased quality of life, as well as the economic burden due to frequent healthcare utilization and multiple admissions. Since the concept of D2T RA is relatively new and publication regarding D2T RA is limited, the mechanism underlying DMARD inefficacy and which factors form a "difficult-to-treat" state in such patients are not yet fully understood. It is also possible that factors contributing to D2T RA may differ by patient, sex, country, and race. The present Mini Review introduces the current concept and unsolved problems of D2T RA, including the definition, prevalence, and factors contributing to D2T RA. We then discuss the management and therapeutic strategies for D2T RA. Finally, we explore a clinical approach to prevent patients from developing D2T RA.
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Affiliation(s)
- Ryu Watanabe
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Tadashi Okano
- Department of Orthopaedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takaho Gon
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Naofumi Yoshida
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Fukumoto
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shinsuke Yamada
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Motomu Hashimoto
- Department of Clinical Immunology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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29
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Novella-Navarro M, Balsa A. Difficult-to-Treat Rheumatoid Arthritis in Older Adults: Implications of Ageing for Managing Patients. Drugs Aging 2022; 39:841-849. [PMID: 36104655 PMCID: PMC9626415 DOI: 10.1007/s40266-022-00976-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 11/30/2022]
Abstract
Difficult-to-treat rheumatoid arthritis is a heterogeneous term in which patients may present with difficulties in their management for different reasons. This can ultimately lead to patients being exposed to multiple treatments because of inefficacy (resulting from mechanisms intrinsic to rheumatoid arthritis or from non-inflammatory causes such as chronic pain syndrome or structural damage, among others), toxicity or adverse effects that may be linked to comorbidities. One particular group in which such characteristics may be more patent is older patients. Increasing life expectancy, an ageing population and the late onset of rheumatoid arthritis have led to an increased interest in the particularities of treating older patients. This may pose a challenge for physicians, as ageing has implications for optimal patient treatment owing to the potential presence of comorbidities, the risk of adverse events and perceptions of disease status by both physicians and patients. All of these factors may have implications for classifying and managing patients aged > 65 years as difficult-to-treat rheumatoid arthritis, as these patients could be misclassified. This can occur when a significant proportion may still exhibit signs of active disease but not necessarily be difficult to treat because the treatment criterion has not been fulfilled. Alternatively, patients may be exposed to multiple biologic/targeted disease-modifying antirheumatic drugs because of contraindications and/or comorbid conditions. Treatment-to-target strategies and an adequate assessment of inflammatory rheumatoid arthritis activity in older patients should be undertaken, taking special care with associated comorbidities, polypharmacy and risk profiles. Such an approach can help to ensure appropriate treatment for older adults and avoid the misclassification of difficult-to-treat patients.
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Affiliation(s)
| | - Alejandro Balsa
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
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30
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Yoshii I, Sawada N, Chijiwa T. Clinical characteristics and variants that predict prognosis of difficult-to-treat rheumatoid arthritis. Rheumatol Int 2022; 42:1947-1954. [DOI: 10.1007/s00296-022-05124-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/21/2022] [Indexed: 11/30/2022]
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