Early Rheumatoid Arthritis

Current Practice Patterns and Educational Needs of Rheumatologists Who Manage Patients with Rheumatoid Arthritis

INTRODUCTION

As the therapeutic landscape for rheumatoid arthritis (RA) continues to change, it is relevant to examine current treatment patterns among rheumatologists. The purpose of this study was to identify attitudes and practices of US rheumatologists with respect to RA.

METHODS

Nine-hundred and one US-practicing rheumatologists were sent electronic invites (via email or fax) to participate in a case-vignette survey in April 2013. All respondents were currently practicing rheumatology and seeing at least one RA patient per week. The survey examined current attitudes, existing knowledge, management choices and perceived barriers in the management of RA. Data collection stopped once 125 responses were received.

RESULTS

Approximately half of the 125 respondents were very familiar with current clinical practice guidelines for RA diagnosis and management. There was no consensus on which validated tools to use when assessing RA severity, with 54% using Physician Global Assessment and 34% using Disease Activity Score 28 at initial assessment. Most respondents (74%) used methotrexate (MTX) as initial therapy for a newly diagnosed RA patient. Eighty-six percent of respondents would add a tumor necrosis factor inhibitor (TNFi) when MTX alone could not control RA. There was no consensus on which treatment should be used when a TNFi is ineffective. The majority of respondents (66% of respondents) would prescribe TNFis indefinitely in patients with continued response. If a patient was in stable remission on MTX and a TNFi, respondents were most likely to maintain this regimen (53% of respondents); a notable minority (43%) would lower the MTX dose. When prescribing biologics, respondents were most concerned with infection; infection was considered a very significant barrier to biologic use. Although 98% of respondents indicated that they personally educate patients about RA, only 42% provide written material.

CONCLUSIONS

The lack of consistency in responses suggests that rheumatologists may benefit from continuing medical education on; clinical practice guidelines; the most recent evidence for management of patients in remission; the use of biologic agents after infection; and management of patients with RA and comorbidities.

A systematic review of serum biomarkers anti-cyclic citrullinated Peptide and rheumatoid factor as tests for rheumatoid arthritis

This systematic review assesses the current status of anti-cyclic citrullinated peptide (anti-CCP) and rheumatoid factor (RF) tests in the diagnosis and prognosis of rheumatoid arthritis (RA). We reviewed publications on tests and biomarkers for early diagnosis of RA from English-language MEDLINE-indexed journals and non-MEDLINE-indexed sources. 85 publications were identified and reviewed, including 68 studies from MEDLINE and 17 non-MEDLINE sources. Anti-CCP2 assays provide improved sensitivity over anti-CCP assays and RF, but anti-CCP2 and RF assays in combination demonstrate a positive predictive value (PPV) nearing 100%, greater than the PPV of either of the tests alone. The combination also appears to be able to distinguish between patients whose disease course is expected to be more severe and both tests are incorporated in the 2010 ACR Rheumatoid Arthritis Classification Criteria. While the clinical value of anti-CCP tests has been established, differences in cut-off values, sensitivities and specificities exist between first-, second- and third-generation tests and harmonization efforts are under way. Anti-CCP and RF are clinically valuable biomarkers for the diagnosis and prognosis of RA patients. The combination of the two biomarkers in conjunction with other clinical measures is an important tool for the diagnosis and management of RA patients.

Intra-articular depot formulation principles: role in the management of postoperative pain and arthritic disorders

The joint cavity constitutes a discrete anatomical compartment that allows for local drug action after intra-articular injection. Drug delivery systems providing local prolonged drug action are warranted in the management of postoperative pain and not least arthritic disorders such as osteoarthritis. The present review surveys various themes related to the accomplishment of the correct timing of the events leading to optimal drug action in the joint space over a desired time period. This includes a brief account on (patho)physiological conditions and novel potential drug targets (and their location within the synovial space). Particular emphasis is paid to (i) the potential feasibility of various depot formulation principles for the intra-articular route of administration including their manufacture, drug release characteristics and in vivo fate, and (ii) how release, mass transfer and equilibrium processes may affect the intra-articular residence time and concentration of the active species at the ultimate receptor site.

Adalimumab

Adalimumab (Humira) is a recombinant, fully human anti-tumor necrosis factor (TNF) monoclonal antibody approved in the US and Europe for the treatment of adult patients with moderate to severe, active rheumatoid arthritis (RA). In combination with methotrexate or standard antirheumatic therapy or as monotherapy, adalimumab effectively reduced signs and symptoms of RA, induced remission, improved physical function and inhibited the progression of structural damage in several randomized, double-blind, placebo-controlled phase III trials. The drug was generally well tolerated, with most adverse events being mild to moderate, and the serious adverse events profile being similar to that generally seen in patients with RA not receiving anti-TNF agents. Adalimumab was at least as cost effective as other anti-TNF agents used in the therapy of RA, and provided significant improvements in patients' health-related quality of life. Overall, adalimumab in combination with methotrexate or standard antirheumatic therapy is valuable as a first-line therapeutic option in patients with early, aggressive RA, and a second-line therapeutic option in patients with long-standing, moderate to severe RA. For the latter indication, adalimumab may also be used as monotherapy.