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Birkner B, Rech J, Edelmann E, Verheyen F, Schett G, Stargardt T. Treatment patterns of individualized real-life tapering approaches based on shared decision-making in rheumatoid arthritis. Z Rheumatol 2024; 83:142-150. [PMID: 37351593 PMCID: PMC10901995 DOI: 10.1007/s00393-023-01380-z] [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] [Accepted: 03/15/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE To provide real-world evidence on patient-individual tapering patterns of disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) patients in daily clinical practice. METHODS Data obtained through a controlled prospective cohort study in Germany conducted from July 2018 to March 2021 were analyzed. Participants consist of RA patients in sustained remission who were eligible for DMARD tapering at enrolment. Data from RA patients who experienced tapering of DMARDs at least once during the observational period (n = 200) were used. Descriptive analyses of medical outcomes at baseline and at time of first tapering, time to first tapering, tapering patterns by substance group, and tapering intensity were documented. RESULTS We did not observe meaningful differences in either disease activity or quality of life measures between substance groups at enrolment, time of first tapering, and at 6 or 12 months after tapering. Median time until first tapering varied between substance groups (csDMARDs: 108 days; bDMARDs: 189 days; combination: 119 days). Most patients received one iteration of tapering only (147/200 patients, 73.5%). Dose reduction was applied for patients treated with csDMARDs (79/86 patients, 91.8%), spacing of interval was the most frequent strategy for patients treated with bDMARDs only (43/48 patients, 89.5%). Necessity for increased DMARD dosage was observed in only 10% of patients (20/200). Tapering intensity by substance was overall heterogenous, indicating high individualization. CONCLUSION We identify highly heterogeneous tapering patterns between substance groups and within substances. Identification and recognition of patient-individual approaches of tapering will help to further improve the management of RA for both patients and rheumatologists.
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Affiliation(s)
- Benjamin Birkner
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Esplanade 36, 20354, Hamburg, Germany.
| | - Jürgen Rech
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany.
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054, Erlangen, Germany.
| | - Edmund Edelmann
- Berufsverband Deutscher Rheumatologen e.V, Hauptstraße 9, 13055, Berlin, Germany
| | - Frank Verheyen
- Techniker Krankenkasse, Bramfelder Straße 140, 22305, Hamburg, Germany
| | - Georg Schett
- Medizinische Klinik 3 - Rheumatologie und Immunologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
- Deutsches Zentrum Immuntherapie, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054, Erlangen, Germany
| | - Tom Stargardt
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Esplanade 36, 20354, Hamburg, Germany
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Birkner B, Rech J, Edelmann E, Verheyen F, Schett G, Stargardt T. Patient-individual tapering of DMARDs in rheumatoid arthritis patients in a real-world setting. Rheumatology (Oxford) 2022; 62:1476-1484. [PMID: 35980267 DOI: 10.1093/rheumatology/keac472] [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: 03/06/2022] [Revised: 07/17/2022] [Accepted: 07/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We aim to provide real-world evidence on the effectiveness of patient-individual tapering of DMARDs for patients with rheumatoid arthritis (RA) in daily clinical practice using medical records and claims data. METHODS We utilize data obtained through a controlled prospective cohort study in Germany conducted from July 2018 to March 2021. Participants consist of RA patients in sustained remission (>6 months) who were eligible for tapering at enrolment. Patients treated with individual tapering based on shared decision making (n = 200) are compared with patients without any dose-reduction (n = 237). The risk of loss of remission and the risk of flare is assessed with risk-adjusted Kaplan-Meier estimators and Cox-Regressions. We evaluate differences in costs one year before and after baseline based on claims data for the subgroup of patients insured at one major sickness fund in Germany (n = 76). RESULTS The risk of flare (HR 0.88 95%-CI: 0.59-1.30) or loss of remission (HR 1.04 95%-CI: 0.73, 1.49) was not statistically different between the individual tapering group and the continuation group. Minor increases of disease activity and decreases of quality of life were observed 12 months after baseline, again with no statistically significant difference. Drug costs decreased by 1,017€in the individual tapering group while increased by 1,151€in the continuation group (p< 0.01). CONCLUSION Individual tapering of DMARDs does not increase the average risk of experiencing flares or loss of remission. Encouraging rheumatologists and patients to apply tapering in shared decision may be a feasible approach to allow individualisation of treatment in RA.
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Affiliation(s)
- Benjamin Birkner
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Hamburg, Germany
| | - Jürgen Rech
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Tom Stargardt
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Hamburg, Germany
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Geng M, Xu K, Meng L, Xu J, Jiang C, Guo Y, Ren X, Li X, Peng Y, Wang S, Huang F, Zhang J, Wang X, Zhu W, Lu S. Up-regulated DERL3 in fibroblast-like synoviocytes exacerbates inflammation of rheumatoid arthritis. Clin Immunol 2020; 220:108579. [PMID: 32866644 DOI: 10.1016/j.clim.2020.108579] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/26/2020] [Indexed: 12/23/2022]
Abstract
Endoplasmic reticulum (ER) stress associated proteins contribute to the pathogenesis of rheumatoid arthritis (RA) through affecting synoviocyte proliferation and proinflammatory cytokine production. The role of DERL3, an ER-associated degradation component, in joint inflammation of RA was explored. Synovial tissues from RA and osteoarthritis (OA) patients were collected, and in RA synovial tissue, DERL3 showed up-regulation and significantly positive correlation with the expression of tumor necrosis factor alpha (TNF-α), interleukin (IL)-6 and matrix metalloproteinase (MMP)-1. Immunofluorescence result suggested DERL3 was located in fibroblast-like synoviocytes (FLS). Among different inflammatory stimuli, DERL3 could be up-regulated by TNF-α stimulation in FLS. Under TNF-α stimulation, knocking down DERL3, the expression of IL-6, IL-8, MMP-1, MMP-13 was reduced and the activation of nuclear factor kappa B (NF-κB) signaling pathway was inhibited. In pristane-induced arthritis (PIA) rat model, Derl3 was up-regulated in synovial tissue and disease was attenuated after intraarticular injection of siDerl3. Overall, we conclude that TNF-α inducing DERL3 expression promotes the inflammation of FLS through activation of NF-κB signaling pathway, suggesting DERL3 plays important roles in the pathogenesis of RA and is a promising therapeutic target.
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Affiliation(s)
- Manman Geng
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China; Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, China
| | - Ke Xu
- Xi'an Hong Hui Hospital, the Affiliated Hospital of Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Liesu Meng
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China; Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, China
| | - Jing Xu
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Congshan Jiang
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yuanxu Guo
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xiaoyu Ren
- Xi'an Hong Hui Hospital, the Affiliated Hospital of Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xiaowei Li
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Yizhao Peng
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Si Wang
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Fumeng Huang
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Jing Zhang
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xipeng Wang
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Wenhua Zhu
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China; Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, China.
| | - Shemin Lu
- Institute of Molecular and Translational Medicine, Xi'an Jiaotong University Health Science Center, Xi'an, China; Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China; Key Laboratory of Environment and Genes Related to Diseases (Xi'an Jiaotong University), Ministry of Education of China, Xi'an, China.
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Precision medicine and management of rheumatoid arthritis. J Autoimmun 2020; 110:102405. [PMID: 32276742 DOI: 10.1016/j.jaut.2020.102405] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 12/20/2022]
Abstract
Precision medicine (PM) is a very commonly used term that implies a highly individualized and tailored approach to patient management. There are, however, many layers of precision, as for example taking an appropriate patient history, or performing additional lab or imaging tests are already helping to better tailor treatments to the right patient. All this adds to the narrower definition of PM, which implies using the unique molecular characteristics of a patient for management decisions. Big data has become an essential part of PM, including as much information as possible to improve precision of disease management, although integration of multi-source data continues to be a challenge in practical application. In research big data can identify new (sub-)phenotypes in unsupervised analyses, which ultimately advance precision by allowing new targeted therapeutic approaches. We will discuss the current status of PM in rheumatoid arthritis (RA) in the management areas of diagnosis, prognosis, selection of therapy, and decision to reduce therapy. PM markers for diagnosis of RA are usually markers of RA classification rather than diagnosis, and subtypes of RA are potentially underrecognized. Prognostic precision is well established for RA, including markers of disease activity or structure, as well as autoantibodies and genetics. The choice of the right compound in a patient identified to have a poor prognosis, however, remains widely arbitrary. Finally and most recently, the most reliable markers for a safe withdrawal of therapy continue to be lower levels of disease activity and longer presence of remission.
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Stamp LK, Chan SJ, Marra C, Helme C, Treharne GJ. Tapering biologic therapy for people with rheumatoid arthritis in remission: A review of patient perspectives and associated clinical evidence. Musculoskeletal Care 2019; 17:161-169. [PMID: 31148375 DOI: 10.1002/msc.1404] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/10/2019] [Accepted: 04/13/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Biologic therapies have increased the control of disease activity in rheumatoid arthritis (RA). Questions remain about tapering biologics when remission is achieved in RA. The patient perspective has to be incorporated in pragmatic applications of tapering but is rarely accounted for in clinical studies of tapering. The aim of the present review was to summarize the evidence about RA patient perspectives on biologic tapering. METHODS We provided a narrative summary of the currently small body of research on patient perspectives retrieved through systematic searches with an emphasis on seeking qualitative research. In addition, we provided an update on relevant clinical research and financial considerations that frame the findings on patient perspectives. RESULTS Financial considerations around commencing/continuing on biologic therapies in RA vary internationally and have implications for patient perspectives. Recent clinical studies indicate that the benefit of tapering biologic therapy when in remission are predicted by drug concentration and aspects of disease activity, severity and duration. Three major concerns have been identified from studies of patient perspectives on biologic tapering: (a) disease relapse; (b) access to treatment in the case of disease flare when tapering; and (c) local motivation for dose reduction (i.e., driven by funding or health benefit). CONCLUSIONS More research is needed on tapering biologics, and should include studies of patient perspectives as well as health economic evaluations. Patient decision aids are a potential way of applying clinical and patient-focused evidence to help all parties come to a decision, but require developmental research and pragmatic evaluation.
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Affiliation(s)
- Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, Aotearoa/New Zealand
| | - Suz Jack Chan
- School of Pharmacy, University of Otago, Dunedin, Aotearoa/New Zealand
| | - Carlo Marra
- School of Pharmacy, University of Otago, Dunedin, Aotearoa/New Zealand
| | - Caitlin Helme
- Department of Psychology, University of Otago, Dunedin, Aotearoa/New Zealand
| | - Gareth J Treharne
- Department of Psychology, University of Otago, Dunedin, Aotearoa/New Zealand
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Henaux S, Ruyssen-Witrand A, Cantagrel A, Barnetche T, Fautrel B, Filippi N, Lukas C, Raffeiner B, Rossini M, Degboé Y, Constantin A. Risk of losing remission, low disease activity or radiographic progression in case of bDMARD discontinuation or tapering in rheumatoid arthritis: systematic analysis of the literature and meta-analysis. Ann Rheum Dis 2017; 77:515-522. [DOI: 10.1136/annrheumdis-2017-212423] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 01/14/2023]
Abstract
ObjectivesTo assess the risk of losing remission, low disease activity (LDA) or radiographic progression in the case of (1) discontinuing or (2) tapering doses of biological disease-modifying antirheumatic drugs (bDMARDs) compared with continuation of the initial treatment regimen in rheumatoid arthritis (RA) patients with remission or LDA.Materials and methodsA systematic literature analysis was carried out through May 2017 on the PubMed, Embase, Cochrane and international congress databases, selecting controlled trials comparing bDMARDs discontinuation/tapering versus continuation in RA patients with remission or LDA. The meta-analysis assessed the risk ratio (RR) and 95% CI of losing remission or LDA and the risk of radiographic progression after (1) discontinuing and (2) tapering doses of bDMARDs versus continuing the initial treatment.ResultsThe meta-analysis comparing bDMARDs discontinuation versus continuation performed on nine trials showed an increased risk of losing remission (RR (95% CI)=1.97(1.43 to 2.73), P<0.0001) or LDA (RR (95% CI)=2.24(1.52 to 3.30), P<0.0001) and an increased risk of radiographic progression (RR (95% CI)=1.09(1.02 to 1.17), P=0.01) in case of bDMARD discontinuation. The meta-analysis comparing bDMARDs tapering versus continuation performed on 11 trials showed an increased risk of losing remission (RR (95% CI)=1.23(1.06 to 1.42), P=0.006) but no increased risk of losing LDA (RR (95% CI)=1.02 (0.85 to 1.23), P=0.81) nor any increased risk of radiographic progression (RR (95% CI)=1.09(0.94 to 1.26), P=0.26) in case of bDMARD tapering.ConclusionDiscontinuation of bDMARDs leads to an increased risk of losing remission or LDA and radiographic progression, while tapering doses of bDMARDs does not increase the risk of relapse (LDA) or radiographic progression, even though there is an increased risk of losing remission.
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