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Meng CF, Rajesh DA, Jannat-Khat DP, Jivanelli B, Bykerk V. The Gap in Knowledge about Tapering Targeted Therapy being used as Monotherapy in Rheumatoid Arthritis: A Systematic Review. Curr Rheumatol Rev 2024; 20:46-56. [PMID: 37641998 DOI: 10.2174/1573397119666230828160108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/24/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Up to 30% of patients with RA are being treated with biologic (b)-disease modifying anti-rheumatic drugs (DMARDs) as monotherapy. Monotherapy with Interleukin (IL)-6 inhibitors(i) and Janus-kinase (JAK)-i has been shown to be effective. Whether patients can taper targeted therapy (bDMARDs and JAK-i) used as monotherapy (targeted monotherapy) is unknown. OBJECTIVE To determine the feasibility of tapering of targeted monotherapy in patients with controlled RA. METHODS We conducted a literature search in Medline, Embase and Cochrane Library for prospective studies reporting remission outcomes after tapering targeted monotherapy in RA patients, from 1/2014 - 8 /2021. RESULTS 5 randomized studies which met our inclusion criteria, evaluating tapering of monotherapy with tumor necrosis factor-inhibitors, tocilizumab, abatacept and baricitinib in RA. Studies were heterogeneous. Three trials studied early RA. Three studies gradually tapered therapy, including 1 dose reduction study. Three studies tapered both biological and conventional-synthetic (cs)-DMARDs. No study compared stopping targeted monotherapy to continuing it. Remission rates were low 14-28% across all studies that stopped targeted monotherapy. The highest remission rate of 72% was reported by the dose reduction study. Trials that studied early RA reported remission rates after tapering ranging 27-72%. Trials tapering therapy in established RA reported rates of remission from 14-20%. CONCLUSION There is a crucial gap in published literature to inform on tapering targeted monotherapy in patients with RA. Stopping targeted monotherapy is unlikely to maintain disease control in RA. Dose reduction strategies and early treatment of disease may be associated with more successful tapering, and warrant future study.
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Affiliation(s)
- Charis F Meng
- Division of Rheumatology, Hospital for Special Surgery, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, USA
| | - Diviya A Rajesh
- Division of Rheumatology, Hospital for Special Surgery, New York, USA
| | - Deanna P Jannat-Khat
- Division of Rheumatology, Epidemiology and Biostatistics CORE, Hospital for Special Surgery, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, USA
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, HSS Education Institute, Hospital for Special Surgery, New York, NY, Weill Cornell Medical College, New York, USA
| | - Vivian Bykerk
- Division of Rheumatology, Hospital for Special Surgery, New York, USA
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Ward MM, Madanchi N, Yazdanyar A, Shah NR, Constantinescu F. Prevalence and predictors of sustained remission/low disease activity after discontinuation of induction or maintenance treatment with tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic and scoping review. Arthritis Res Ther 2023; 25:222. [PMID: 37986101 PMCID: PMC10659063 DOI: 10.1186/s13075-023-03199-0] [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: 07/26/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND To determine the prevalence of sustained remission/low disease activity (LDA) in patients with rheumatoid arthritis (RA) after discontinuation of tumor necrosis factor inhibitors (TNFi), separately in induction treatment and maintenance treatment studies, and to identify predictors of successful discontinuation. METHODS We performed a systematic literature review of studies published from 2005 to May 2022 that reported outcomes after TNFi discontinuation among patients in remission/LDA. We computed prevalences of successful discontinuation by induction or maintenance treatment, remission criterion, and follow-up time. We performed a scoping review of predictors of successful discontinuation. RESULTS Twenty-two induction-withdrawal studies were identified. In pooled analyses, 58% (95% confidence interval (CI) 45, 70) had DAS28 < 3.2 (9 studies), 52% (95% CI 35, 69) had DAS28 < 2.6 (9 studies), and 40% (95% CI 18, 64) had SDAI ≤ 3.3 (4 studies) at 37-52 weeks after discontinuation. Among patients who continued TNFi, 62 to 85% maintained remission. Twenty-two studies of maintenance treatment discontinuation were also identified. At 37-52 weeks after TNFi discontinuation, 48% (95% CI 38, 59) had DAS28 < 3.2 (10 studies), and 47% (95% CI 33, 62) had DAS28 < 2.6 (6 studies). Heterogeneity among studies was high. Data on predictors in induction-withdrawal studies were limited. In both treatment scenarios, longer duration of RA was most consistently associated with less successful discontinuation. CONCLUSIONS Approximately one-half of patients with RA remain in remission/LDA for up to 1 year after TNFi discontinuation, with slightly higher proportions in induction-withdrawal settings than with maintenance treatment discontinuation.
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Affiliation(s)
- Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 10CRC, Room 4-1339, 10 Center Drive, Bethesda, MD, 20892-1468, USA.
| | - Nima Madanchi
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Current address: Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA, USA
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Current address: Division of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nehal R Shah
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Jeljeli MM, Adamopoulos IE. Innate immune memory in inflammatory arthritis. Nat Rev Rheumatol 2023; 19:627-639. [PMID: 37674048 PMCID: PMC10721491 DOI: 10.1038/s41584-023-01009-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 09/08/2023]
Abstract
The concept of immunological memory was demonstrated in antiquity when protection against re-exposure to pathogens was observed during the plague of Athens. Immunological memory has been linked with the adaptive features of T and B cells; however, in the past decade, evidence has demonstrated that innate immune cells can exhibit memory, a phenomenon called 'innate immune memory' or 'trained immunity'. Innate immune memory is currently being defined and is transforming our understanding of chronic inflammation and autoimmunity. In this Review, we provide an up-to-date overview of the memory-like features of innate immune cells in inflammatory arthritis and the crosstalk between chronic inflammatory milieu and cell reprogramming. Aberrant pro-inflammatory signalling, including cytokines, regulates the metabolic and epigenetic reprogramming of haematopoietic progenitors, leading to exacerbated inflammatory responses and osteoclast differentiation, in turn leading to bone destruction. Moreover, imprinted memory on mature cells including terminally differentiated osteoclasts alters responsiveness to therapies and modifies disease outcomes, commonly manifested by persistent inflammatory flares and relapse following medication withdrawal.
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Affiliation(s)
- Maxime M Jeljeli
- Department of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Iannis E Adamopoulos
- Department of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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van Esveld L, Cox JM, Kuijper TM, Bosch TM, Weel-Koenders AE. Cost-utility analysis of tapering strategies of biologicals in rheumatoid arthritis patients in the Netherlands. Ann Rheum Dis 2023; 82:1296-1306. [PMID: 37423648 DOI: 10.1136/ard-2023-224190] [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: 03/23/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Current guidelines recommend tapering biological disease-modifying antirheumatoid drugs (bDMARDs) in rheumatoid arthritis (RA) if the disease is under control. However, guidelines on tapering are lacking. Assessing cost-effectiveness of different tapering strategies might provide broader input for creating guidelines on how to taper bDMARDs in patients with RA. The aim of this study is to evaluate the long-term cost-effectiveness from a societal perspective of bDMARD tapering strategies in Dutch patients with RA, namely 50% dose reduction (tapering), discontinuation and a 50% dose reduction followed by discontinuation (de-escalation). METHODS Using a societal perspective, a Markov model with a life-time horizon of 30 years was used to simulate 3-monthly transitions between Disease Activity 28 (DAS28)-defined health states of remission (<2.6), low disease activity (2.63.2). Transition probabilities were estimated through literature search and random effects pooling. Incremental costs, incremental quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits for each tapering strategy were compared with continuation. Deterministic, probabilistic sensitivity analyses and multiple scenario analyses were performed. RESULTS After 30 years, the ICERs were €115 157/QALY lost, €74 226/QALY lost and €67 137/QALY lost for tapering, de-escalation and discontinuation, respectively; mainly driven by bDMARD cost savings and a 72.8% probability of a loss in quality of life. This corresponds to a 76.1%, 64.3% and 60.1% probability of tapering, de-escalation and discontinuation being cost-effective, provided a willingness-to-accept threshold of €50 000/QALY lost. CONCLUSIONS Based on these analyses, the 50% tapering approach saved the highest cost per QALY lost.
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Affiliation(s)
| | - Juul M Cox
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Tessa M Bosch
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
| | - Angelique Eam Weel-Koenders
- Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Meng CF, Rajesh DA, Jannat-Khah DP, Jivanelli B, Bykerk VP. Can Patients With Controlled Rheumatoid Arthritis Taper Methotrexate From Targeted Therapy and Sustain Remission? A Systematic Review and Metaanalysis. J Rheumatol 2023; 50:36-47. [PMID: 35970524 DOI: 10.3899/jrheum.220152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the risk of not being able to sustain remission after tapering methotrexate (MTX) from targeted therapy in patients with controlled rheumatoid arthritis (RA). METHODS A systematic literature search was conducted in MEDLINE, Embase, and the Cochrane Library for studies reporting remission outcomes after tapering MTX from targeted therapies in RA. Full-text articles and abstracts reported in English were included. Metaanalyses were conducted using random-effects models. Forest and funnel plots were created. RESULTS A total of 10 articles were included. Studies evaluated MTX being tapered from combination treatment with tumor necrosis factor inhibitors, tocilizumab, abatacept, and tofacitinib. A total of 9 studies used a randomized design and 1 was observational. Out of 10 studies, 3 focused on early RA (ie, < 1 yr). The MTX-tapering strategy was gradual in 2 studies and rapid in 8 studies. Follow-up ranged from 3 to 18 months in randomized trials and up to 3 years in the observational study. Our metaanalysis, which included 2000 participants with RA from 10 studies, showed that patients who tapered MTX from targeted therapy had a 10% reduction in the ability to sustain remission and an overall pooled risk ratio of 0.90 (95% CI 0.84-0.97). There was no heterogeneity (I 2 = 0%, P = 0.94). Our funnel plot indicated minimal publication bias. CONCLUSION Patients with controlled RA may taper MTX from targeted therapy with a 10% reduction in the ability to sustain remission for up to 18 months. Longer follow-up studies with attention to radiographic, functional, and patient-reported outcomes are needed. The risk of disease worsening should be discussed with the patient with careful follow-up and prompt retreatment of disease worsening.
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Affiliation(s)
- Charis F Meng
- C.F. Meng MD, V.P. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery, and Department of Medicine, Weill Cornell Medical College.
| | - Diviya A Rajesh
- D.A. Rajesh, BA, Division of Rheumatology, Hospital for Special Surgery
| | - Deanna P Jannat-Khah
- D.P. Jannat-Khah, DRPH, MSPH, Division of Rheumatology, Epidemiology and Biostatistics CORE, Hospital for Special Surgery, and Department of Medicine, Weill Cornell Medical College
| | - Bridget Jivanelli
- B. Jivanelli, MLIS, Kim Barrett Memorial Library, HSS Education Institute, Hospital for Special Surgery, New York, NY, USA
| | - Vivian P Bykerk
- C.F. Meng MD, V.P. Bykerk, MD, Division of Rheumatology, Hospital for Special Surgery, and Department of Medicine, Weill Cornell Medical College
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Alizadegan F, Yalcinbayir O, Ucan Gunduz G, Pehlivan Y. Infliximab therapy in Behçet's uveitis. J Fr Ophtalmol 2022; 45:1036-1041. [DOI: 10.1016/j.jfo.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 03/26/2022] [Accepted: 04/05/2022] [Indexed: 10/14/2022]
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Venetsanopoulou AI, Voulgari PV, Drosos AA. Janus kinase versus TNF inhibitors: where we stand today in rheumatoid arthritis. Expert Rev Clin Immunol 2022; 18:485-493. [PMID: 35535405 DOI: 10.1080/1744666x.2022.2064275] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION In recent decades, Rheumatoid arthritis (RA) treatment landscape has evolved with the induction of new biological and targeted therapies that provide significant therapeutic benefits in patients with sustained disease. AREAS COVERED Tumor necrosis factor inhibitors (TNFi) were the first biologics used in the treatment of RA. Although they present a significant efficacy, an insufficient response of some patients led to further research and discovery of targeted therapies, such as Janus kinase inhibitors (JAKi), which act at a molecular level, regulating many cytokines. Clinical benefits have been seen with both TNFi and JAKi as monotherapy and combined with conventional synthetic disease-modifying antirheumatic drugs. Still, some significant side effects have been reported with JAKi, and several questions remain about their safety and selectivity in action. This review summarizes the current knowledge on the mechanism of action, the clinical efficacy, and safety of TNFi vs. JAKi. EXPERT OPINION TNFi and JAKi are particularly useful in treating inflammatory arthropathies. Both drug categories are recommended by ACR and EULAR institutions in RA patients suffering from moderate to severe disease. Safety data in long-term studies are required to determine the optimal benefit to the risk profile of JAKi use.
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Affiliation(s)
- Aliki I Venetsanopoulou
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Paraskevi V Voulgari
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
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The second decade of anti-TNF-a therapy in clinical practice: new lessons and future directions in the COVID-19 era. Rheumatol Int 2022; 42:1493-1511. [PMID: 35503130 PMCID: PMC9063259 DOI: 10.1007/s00296-022-05136-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/12/2022] [Indexed: 11/22/2022]
Abstract
Since the late 1990s, tumor necrosis factor alpha (TNF-α) inhibitors (anti-TNFs) have revolutionized the therapy of immune-mediated inflammatory diseases (IMIDs) affecting the gut, joints, skin and eyes. Although the therapeutic armamentarium in IMIDs is being constantly expanded, anti-TNFs remain the cornerstone of their treatment. During the second decade of their application in clinical practice, a large body of additional knowledge has accumulated regarding various aspects of anti-TNF-α therapy, whereas new indications have been added. Recent experimental studies have shown that anti-TNFs exert their beneficial effects not only by restoring aberrant TNF-mediated immune mechanisms, but also by de-activating pathogenic fibroblast-like mesenchymal cells. Real-world data on millions of patients further confirmed the remarkable efficacy of anti-TNFs. It is now clear that anti-TNFs alter the physical course of inflammatory arthritis and inflammatory bowel disease, leading to inhibition of local and systemic bone loss and to a decline in the number of surgeries for disease-related complications, while anti-TNFs improve morbidity and mortality, acting beneficially also on cardiovascular comorbidities. On the other hand, no new safety signals emerged, whereas anti-TNF-α safety in pregnancy and amid the COVID-19 pandemic was confirmed. The use of biosimilars was associated with cost reductions making anti-TNFs more widely available. Moreover, the current implementation of the “treat-to-target” approach and treatment de-escalation strategies of IMIDs were based on anti-TNFs. An intensive search to discover biomarkers to optimize response to anti-TNF-α treatment is currently ongoing. Finally, selective targeting of TNF-α receptors, new forms of anti-TNFs and combinations with other agents, are being tested in clinical trials and will probably expand the spectrum of TNF-α inhibition as a therapeutic strategy for IMIDs.
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Sellam J, Morel J, Tournadre A, Bouhnik Y, Cornec D, Devauchelle-Pensec V, Dieudé P, Goupille P, Jullien D, Kluger N, Lazaro E, Le Goff B, de Lédinghen V, Lequerré T, Nocturne G, Seror R, Truchetet ME, Verhoeven F, Pham T, Richez C. PRACTICAL MANAGEMENT of patients on anti-TNF therapy: Practical guidelines drawn up by the Club Rhumatismes et Inflammation (CRI). Joint Bone Spine 2021; 88:105174. [PMID: 33992225 DOI: 10.1016/j.jbspin.2021.105174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jérémie Sellam
- Service de Rhumatologie, CHU Saint-Antoine, Paris, France
| | - Jacques Morel
- Service de Rhumatologie, CHU Montpellier, Montpellier, France
| | - Anne Tournadre
- Service de Rhumatologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Yoram Bouhnik
- Service de Gastro-entérologie, CHU Hôpital Beaujon, Clichy, France
| | - Divi Cornec
- Service de Rhumatologie, CHRU La Cavale Blanche, Brest, France
| | | | - Philippe Dieudé
- Service de Rhumatologie, CHU Bichat-Claude Bernard, Paris, France
| | | | | | - Nicolas Kluger
- Dpt Dermatology, Helsinki, Finland; Service de Dermatologie, CHU Bichat-Claude Bernard, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine interne, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | - Victor de Lédinghen
- Unité d'Hépatologie et transplantation hépatique, Hôpital Haut-Lévêque, CHU Bordeaux, Pessac, France
| | | | | | - Raphaèle Seror
- Service de Rhumatologie, Bicêtre, Le Kremlin-Bicêtre, France
| | | | | | - Thao Pham
- Service de Rhumatologie, CHU Sainte-Marguerite, Marseille, France
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Immunological memory in rheumatic inflammation - a roadblock to tolerance induction. Nat Rev Rheumatol 2021; 17:291-305. [PMID: 33824526 DOI: 10.1038/s41584-021-00601-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 12/20/2022]
Abstract
Why do we still have no cure for chronic inflammatory diseases? One reason could be that current therapies are based on the assumption that chronic inflammation is driven by persistent 'acute' immune reactions. Here we discuss a paradigm shift by suggesting that beyond these reactions, chronic inflammation is driven by imprinted, pathogenic 'memory' cells of the immune system. This rationale is based on the observation that in patients with chronic inflammatory rheumatic diseases refractory to conventional immunosuppressive therapies, therapy-free remission can be achieved by resetting the immune system; that is, by ablating immune cells and regenerating the immune system from stem cells. The success of this approach identifies antigen-experienced and imprinted immune cells as essential and sufficient drivers of inflammation. The 'dark side' of immunological memory primarily involves memory plasma cells secreting pathogenic antibodies and memory T lymphocytes secreting pathogenic cytokines and chemokines, but can also involve cells of innate immunity. New therapeutic strategies should address the persistence of these memory cells. Selective targeting of pathogenic immune memory cells could be based on their specificity, which is challenging, or on their lifestyle, which differs from that of protective immune memory cells, in particular for pathogenic T lymphocytes. The adaptations of such pathogenic memory cells to chronic inflammation offers entirely new therapeutic options for their selective ablation and the regeneration of immunological tolerance.
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YAZICI A. Remisyonda olan romatoid artritli hastada tedavi kararı. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.863635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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