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Das D, Choy E. Non-inflammatory pain in inflammatory arthritis. Rheumatology (Oxford) 2023; 62:2360-2365. [PMID: 36478185 PMCID: PMC10321089 DOI: 10.1093/rheumatology/keac671] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/19/2022] [Indexed: 07/20/2023] Open
Abstract
'Non-inflammatory' pain, pain that is not associated with measures of inflammation, is common in patients with inflammatory arthritis including RA. One important cause of non-inflammatory pain is concomitant fibromyalgia. Systematic review has shown that fibromyalgia is common in inflammatory arthritis including RA affecting 1 in 5 patients and is associated with higher disease activity scores due to inflated tender joint count and patient global assessment. Consequently, many patients with RA and concomitant fibromyalgia may fail to reach treatment target and switch to alternate disease modifying drugs frequently. European Alliance of Association for Rheumatology has highlighted that concomitant fibromyalgia is an important consideration in assessing difficult-to-treat RA. The incidence and prevalence of fibromyalgia are higher in RA than the general population, raising the possibility that fibromyalgia may be 'secondary' to RA rather than a concomitant disease. The precise mechanisms whereby patients with RA develop fibromyalgia are unknown. In this review, we discussed fibromyalgia in RA, its clinical impact and epidemiology as well as data suggesting fibromyalgia might be 'secondary'. Lastly, we reviewed potential pathogenic mechanisms which included inflammatory cytokines sensitizing nociceptive neurones, temporal summation, also known as windup, from chronic pain and impaired coping from poor quality sleep and mental well-being. Deciphering the exact mechanisms may lead to treatment strategies that prevent development of secondary fibromyalgia and will address a common factor associated with difficult-to-treat RA.
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Affiliation(s)
- Dhivya Das
- Consultant Rheumatologist, Northern Care Alliance NHS Foundation Trust, University School of Medicine (Formerly with Cardiff), Cardiff, UK
| | - Ernest Choy
- Correspondence to: Ernest Choy, CREATE Centre, Section of Rheumatology, Division of Infection and Immunity, Cardiff University, Tenovus Building, Heath Park Campus, Cardiff CF14 4XN, UK. E-mail:
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Astrike-Davis EM, Cleveland RJ, Louis Bridges S, Jonas BL, Callahan LF. Associations of Socioeconomic Status With Disease Progression in African Americans With Early Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:85-91. [PMID: 35468261 PMCID: PMC9592673 DOI: 10.1002/acr.24896] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 03/15/2022] [Accepted: 04/12/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In prior cross-sectional analyses of African American patients with rheumatoid arthritis (RA), measures of socioeconomic status (SES) were associated with clinical joint damage and poorer patient-reported outcome scores. The purpose of this study was to determine whether SES measures are associated with disease progression in a cohort of African American patients with early RA (<2 years duration). METHODS We analyzed baseline SES and change in 60-month clinical radiographs and patient-reported outcomes data (n = 101 and 177, respectively) in individuals with early RA. SES measures were educational attainment, occupation, homeownership, household income, and block group poverty. Outcomes were based on radiographs (total erosion and joint space narrowing [JSN] scores on hands and feet) and patient-reported outcomes (pain, fatigue, disability, and learned helplessness). We used logistic regression with mixed effects accounting for study site to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS Both low education and occupation status were associated with worsening pain (adjusted OR 5.86 [95% CI 3.05-11.3] and adjusted OR 2.55 [95% CI 1.54-4.21], respectively). Patients without a high-school diploma were more likely to have worsened reports of learned helplessness (OR 1.92 [95% CI 1.37-2.67]). Community measures of SES were also significantly associated with patient-reported outcomes score changes. Patients living in areas of block group poverty ≥20% were twice as likely to experience increased disability scores over 60 months of disease duration (OR 1.95 [95% CI 1.17-3.25]). We found no association between SES measures and erosion or JSN score progression. CONCLUSION Low educational attainment and nonprofessional occupation status were associated with increased worsening of patient-reported outcomes. However, there were no corresponding increases in radiographically assessed erosion or JSN score progression.
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Affiliation(s)
| | | | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medical College, New York, New York
| | - Beth L Jonas
- University of North Carolina at Chapel Hill School of Medicine
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Juanola X, Ramos MJM, Belzunegui JM, Fernández-Carballido C, Gratacós J. Treatment Failure in Axial Spondyloarthritis: Insights for a Standardized Definition. Adv Ther 2022; 39:1490-1501. [PMID: 35201604 PMCID: PMC8990961 DOI: 10.1007/s12325-022-02064-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/26/2022] [Indexed: 12/17/2022]
Abstract
Axial spondyloarthritis is a chronic inflammatory rheumatic disease that affects the axial skeleton and causes severe pain and disability. It may be also associated with extra-articular manifestations. Early diagnosis and appropriate treatment can reduce the severity of the disease and the risk of progression. The biological disease-modifying antirheumatic drugs (bDMARDs) tumor necrosis factor alpha (TNFα) inhibitors (TNFi) and the anti-interleukin (IL)-17A antibodies secukinumab and ixekizumab are effective agents to reduce disease activity and minimize the inflammation that damages the joints. New alternatives such as Janus kinase (JAK) inhibitors are also available. Unfortunately, response rates to bDMARDs are far from optimal, and many patients experience so-called treatment failure. The definition of treatment failure definition is often vague and may depend on the rigorousness of the therapeutic goal, the inclusion or not of peripheral symptoms/extra-articular manifestations, or patients' overall health. After an exhaustive bibliographic review, we propose a definition based on loss of the following status: low disease activity assessed by Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP, absence of extra-articular manifestations, and low disease impact on the patients' general health. Apart from discontinuing the therapy because of safety or intolerance reasons, two types of treatment failure can be differentiated depending on when it occurs: primary failure (no response within 6 months after treatment initiation, or lack of efficacy) and secondary failure (response within 6 months but lost thereafter, or loss of efficacy over time). Physicians should carefully consider the moment and the reason for the treatment failure to decide the next therapeutic step. In the case of primary failure on a first TNFi, it seems reasonable to switch to another class of drugs, i.e., an anti-IL-17 agent, as phase III trials showed that the response to IL-17 blockade was higher than to placebo in patients previously exposed to TNFi. When secondary failure occurs, and loss of efficacy is suspected to be caused by antidrug antibodies (ADAs), it is advisable to analyze serum TNFi and ADAs concentrations, if possible; in the presence of ADAs and low TNFi levels, changing the TNFi is rational as it may restore the TNFα blocking capacity. If ADAs are absent/low with adequate drug therapeutic levels, switching to another target might be the best strategy.
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Affiliation(s)
- Xavier Juanola
- Rheumatology Service, University Hospital Bellvitge, IDIBELL, Barcelona, Spain
| | | | | | | | - Jordi Gratacós
- Rheumatology Service, Medicine Department UAB, I3PT, University Hospital Parc Taulí Sabadell, Barcelona, Spain.
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Chiang CC, Li YR, Lai KH, Cheng WJ, Lin SC, Wang YH, Chen PJ, Yang SH, Lin CC, Hwang TL. Aqueous Extract of Kan-Lu-Hsiao-Tu-Tan Ameliorates Collagen-Induced Arthritis in Mice by Inhibiting Oxidative Stress and Inflammatory Responses. Life (Basel) 2020; 10:life10120313. [PMID: 33260891 PMCID: PMC7760413 DOI: 10.3390/life10120313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Kan-Lu-Hsiao-Tu-Tan (KLHTT) exhibits anti-psoriatic effects through anti-inflammatory activity in mice. However, the therapeutic effects of KLHTT on rheumatoid arthritis (RA), another significant autoimmune inflammatory disorder, have not been elucidated. Herein, we explored the anti-arthritic effects of KLHTT on collagen-induced arthritis (CIA) in mice. Methods: KLHTT was extracted by boiling water and subjected to spectroscopic analysis. Chicken collagen type II (CII) with complete Freund’s adjuvant was intradermally injected to induce CIA in DBA/1J mice. Anti-CII antibody, cytokines, malondialdehyde (MDA), and hydrogen peroxide (H2O2) were measured using ELISA, thiobarbituric acid reactive substances, and a hydrogen peroxide assay kit. Splenocyte proliferation was tested using thymidine incorporation. Th1 and Th17 cells were analyzed by flow cytometry. Results: Oral KLHTT treatment (50 and 100 mg/kg) ameliorated mouse CIA by decreasing the levels of interleukin (IL)-1β, IL-6, IL-17A, and tumour necrosis factor-α in the paw homogenates and serum. KLHTT also suppressed anti-CII antibody formation, splenocyte proliferation, and splenic Th1 and Th17 cell numbers. Additionally, KLHTT showed antioxidant activity by reducing the concentrations of MDA and H2O2 in paw tissues. Conclusions: The therapeutic effects of KLHTT in CIA mice were through regulating oxidative stress and inflammatory responses. Our results suggest that KLHTT has potential to treat RA.
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Affiliation(s)
- Chih-Chao Chiang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; or or
- Puxin Fengze Chinese Medicine Clinic, Taoyuan 326, Taiwan
| | - Yi-Rong Li
- Changhua Christian Hospital, Thoracic Medicine Research Center, Changhua 500, Taiwan; or
| | - Kuei-Hung Lai
- Research Center for Chinese Herbal Medicine, Research Center for Food and Cosmetic Safety, and Graduate Institute of Health Industry Technology, Chang Gung University of Science and Technology, Taoyuan 333, Taiwan; or
- Graduate Institute of Pharmacognosy, College of Pharmacy, Taipei Medical University, Taipei 110, Taiwan
| | - Wei-Jen Cheng
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; or or
- Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Shih-Chao Lin
- National Center for Biodefense and Infectious Diseases, School of Systems Biology, George Mason University, Manassas, VA 20110, USA;
- Bachelor Degree Program in Marine Biotechnology, National Taiwan Ocean University, Keelung 202, Taiwan
| | - Yi-Hsuan Wang
- Graduate Institute of Natural Products, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; or
| | - Po-Jen Chen
- Department of Cosmetic Science, Providence University, Taichung 433, Taiwan; or
| | - Sien-Hung Yang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; or or
- Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Correspondence: (S.-H.Y.); (C.-C.L.); (T.-L.H.)
| | - Chi-Chien Lin
- Institute of Biomedical Science, College of Life Sciences, National Chung-Hsing University, 250 Guoguang Road, Taichung 402, Taiwan
- Department of Pharmacology, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence: (S.-H.Y.); (C.-C.L.); (T.-L.H.)
| | - Tsong-Long Hwang
- Research Center for Chinese Herbal Medicine, Research Center for Food and Cosmetic Safety, and Graduate Institute of Health Industry Technology, Chang Gung University of Science and Technology, Taoyuan 333, Taiwan; or
- Graduate Institute of Natural Products, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan; or
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Department of Chemical Engineering, Ming Chi University of Technology, New Taipei City 243, Taiwan
- Correspondence: (S.-H.Y.); (C.-C.L.); (T.-L.H.)
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Landgren E, Bremander A, Lindqvist E, Nylander M, Van der Elst K, Larsson I. "Mastering a New Life Situation" - Patients' Preferences of Treatment Outcomes in Early Rheumatoid Arthritis - A Longitudinal Qualitative Study. Patient Prefer Adherence 2020; 14:1421-1433. [PMID: 32884244 PMCID: PMC7431595 DOI: 10.2147/ppa.s253507] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To explore patients' preferred treatment outcomes during their first two years with rheumatoid arthritis (RA). PATIENTS AND METHODS A qualitative, longitudinal, multicenter study with interviews at two time points was performed in Sweden. Individual interviews were conducted at time point 1 with 31 patients with RA, defined as disease duration of ≤1 year and treatment for 3-7 months. Seven focus group interviews and five individual interviews were conducted at time point 2 with 22 patients 12-20 months after treatment initiation. The interviews were analyzed using the Qualitative Analysis Guide of Leuven. A core category with four related concepts emerged. RESULTS The core finding of patient-preferred treatment outcomes was "mastering a new life situation". Patients preferred to experience control of the disease by controlling the symptoms and by experiencing absence of disease. To experience autonomy by regaining former activity level, experiencing independence, and being empowered was another preferred outcome. Patients preferred to regain identity through being able to participate, experience well-being, and regain former self-image. To experience joy in everyday life through vitality and believing in the future was another preferred outcome. Patients' preferences developed over time from the acute phase of controlling the symptoms and wanting to return to the life they lived prior to diagnosis, to a more preventive way of self-management and empowerment to master the new life situation. CONCLUSION The patients' preferred treatment outcomes during the first two years with RA were to master their new life situation and changed from a preference to return to a life lived prior disease onset, to a preference of living with quality of life, despite RA. This study increases the understanding of patients' preferred treatment outcomes in the early disease course and can be a foundation for tailoring interventions to be more person-centered and to improve long-term treatment outcomes.
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Affiliation(s)
- Ellen Landgren
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden
- Spenshult Research and Development Centre, Halmstad, Sweden
| | - Ann Bremander
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
- Spenshult Research and Development Centre, Halmstad, Sweden
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sonderborg, Denmark
| | - Elisabet Lindqvist
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
- Department of Rheumatology, Skåne University Hospital, Lund, Sweden
| | - Maria Nylander
- Spenshult Research and Development Centre, Halmstad, Sweden
- Swedish Rheumatism Association, Stockholm, Sweden
| | | | - Ingrid Larsson
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
- Spenshult Research and Development Centre, Halmstad, Sweden
- School of Health and Welfare, Halmstad University, Halmstad, Sweden
- Correspondence: Ingrid Larsson School of Health and Welfare, Halmstad University, PO Box 823, HalmstadS-30118, SwedenTel +46 35 167965 Email
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Batko B, Batko K, Krzanowski M, Żuber Z. Physician Adherence to Treat-to-Target and Practice Guidelines in Rheumatoid Arthritis. J Clin Med 2019; 8:E1416. [PMID: 31500394 PMCID: PMC6780913 DOI: 10.3390/jcm8091416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/26/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022] Open
Abstract
Principles of treat-to-target (T2T) have been widely adopted in both multinational and regional guidelines for rheumatoid arthritis (RA). Several questionnaire studies among physicians and real-world data have suggested that an evidence-practice gap exists in RA management. Investigating physician adherence to T2T, which requires a process measure, is difficult. Different practice patterns among physicians are observed, while adherence to protocolized treatment declines over time. Rheumatologist awareness, agreement, and claims of adherence to T2T guidelines are not always consistent with medical records. Comorbidities, a difficult disease course, communication barriers, and individual preferences may hinder an intensive, proactive treatment stance. Interpreting deviations from protocolized treatment/T2T guidelines requires sufficient clinical context, though higher adherence seems to improve clinical outcomes. Nonmedical constraints in routine care may consist of barriers in healthcare structure and socioeconomic factors. Therefore, strategies to improve the institution of T2T should be tailored to local healthcare. Educational interventions to improve T2T adherence among physicians may show a moderate, although beneficial effect. Meanwhile, a proportion of patients with inadequately controlled RA exists, while management decisions may not be in accordance with T2T. Physicians tend to be aware of current guidelines, but their institution in routine practice seems challenging, which warrants attention and further study.
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Affiliation(s)
- Bogdan Batko
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, Gustawa Herlinga-Grudźińskiego 1 St, 30-705 Cracow, Poland.
- Department of Rheumatology, J. Dietl Specialist Hospital, Skarbowa 1 St, 31-121 Cracow, Poland.
| | - Krzysztof Batko
- Chair and Head of Nephrology, Jagiellonian University Medical College, Kopernika St 15c, 31-501 Cracow, Poland.
| | - Marcin Krzanowski
- Chair and Head of Nephrology, Jagiellonian University Medical College, Kopernika St 15c, 31-501 Cracow, Poland.
| | - Zbigniew Żuber
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, Gustawa Herlinga-Grudźińskiego 1 St, 30-705 Cracow, Poland.
- Ward for Older Children with Neurology and Rheumatology Subdivision, St. Louis Regional Specialised Children's Hospital, 31-503 Cracow, Poland.
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Dalbeth N, Frampton C, Fung M, Baumgartner S, Nicolaou S, Choi HK. Concurrent validity of provisional remission criteria for gout: a dual-energy CT study. Arthritis Res Ther 2019; 21:150. [PMID: 31227018 PMCID: PMC6588898 DOI: 10.1186/s13075-019-1941-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/11/2019] [Indexed: 11/21/2022] Open
Abstract
Background Provisional gout remission criteria including five domains (serum urate, tophus, flares, pain due to gout, and patient global assessment) have been proposed. The aim of this study was to test the concurrent validity of the provisional gout remission criteria by comparing the criteria with dual-energy CT (DECT) findings. Methods Patients with gout on allopurinol ≥ 300 mg daily were prospectively recruited into a multicenter DECT study. Participants attended a standardized study visit which recorded gout flare frequency in the preceding 12 months, physical examination for tophus, serum urate, and patient questionnaires. DECT scans of both hands/wrists, feet/ankles/Achilles, and knees were analyzed by two DECT radiologists. The relationship between the DECT urate crystal volume and deposition with individual domains as well as the provisional remission criteria set was analyzed. Results The provisional remission criteria were fulfilled in 23 (15.1%) participants. DECT urate crystal deposition was observed less frequently in those fulfilling the provisional remission criteria (44%), compared with those not fulfilling the criteria (73.6%, odds ratio 0.28, P = 0.004). The median (range) DECT urate crystal volume was 0.00 (0.00–0.46) cm3 for those fulfilling the remission criteria, compared with 0.08 (0.00–19.53) cm3 for those not fulfilling the criteria (P = 0.002). In multivariate regression analysis, the serum urate and tophus domains were most strongly associated with DECT urate crystal deposition. Conclusions In people with gout established on allopurinol, a state of remission as defined by the provisional remission criteria is associated with less DECT urate crystal deposition. While this study provides support for the validity of the provisional gout remission criteria, it also demonstrates that some crystal deposition may be present in people achieving these criteria. Electronic supplementary material The online version of this article (10.1186/s13075-019-1941-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicola Dalbeth
- Bone and Joint Research Group, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland, 1023, New Zealand.
| | | | - Maple Fung
- Formerly Ardea Biosciences, Inc., San Diego, CA, USA
| | | | - Savvas Nicolaou
- Vancouver General Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Hyon K Choi
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
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