Remission, a Therapeutic Goal in Inflammatory Arthropathies?

Clinical and radiographic study of partial arthrodesis for rheumatoid wrists

OBJECTIVES

To retrospectively investigate the clinical and radiographic results of partial arthrodesis for the wrists with rheumatoid arthritis (RA).

METHODS

Forty-one wrists with RA were treated by radiolunate (RL) or radiolunotriquetral (RLT) arthrodesis with ulnar head resection. The average follow-up period after surgery was 7.1 years. Preoperative radiographs of all wrists were classified according to Schulthess classification. We performed RL arthrodesis for all Type II (n = 26) and Type III wrists (n = 7), and RLT arthrodesis for Type III wrists (n = 8). Pre- and postoperative pain score (visual analog scale), grip strength, range of motion, and radiographic parameters were statistically compared.

RESULTS

Pain scores in all groups were significantly improved at final follow-up (P < 0.05). Grip strength increased from 5.9 to 12.4 (kg) significantly in Type II wrists (P < 0.01), from 7.2 to 9.1 in Type III wrists after RLT arthrodesis, but decreased from 6.9 to 6.0 in Type III wrists after RL arthrodesis. In all groups, the arc of pronation and supination improved significantly (P < 0.05), and all radiographic parameters improved.

CONCLUSIONS

RL arthrodesis for Type II wrists showed satisfactory clinical results. RLT arthrodesis would be a reliable method in case of unstable wrist joint.

Update on the surgical treatment for rheumatoid arthritis of the wrist and hand

Surgical procedures for the treatment of rheumatoid arthritis are aimed at restoring function and decreasing pain. Over the past four decades multiple procedures have been described in the management of early and late disease. This article will review the most common forms of surgery used in the treatment of rheumatoid arthritis.

Drug persistence, effectiveness and safety assessment of anti-TNF therapies in psoriatic arthritis

INTRODUCTION

Anti-TNF therapies have been introduced for the management of psoriatic arthritis (PsA). There is a need to assess their effectiveness and safety in clinical practice.

AREAS COVERED

This review examines the emerging evidence of effectiveness, safety and drug persistence of anti-TNF therapies in PsA. It also assesses their impact on quality of life and physical functioning in patients with PsA, as well as potential predictors associated with changes in these domains. Several studies from different countries have demonstrated the effectiveness of the anti-TNF therapies in the management of PsA. These therapies have also been shown to be safe and well tolerated over a median usage of 3 years when compared to conventional disease modifying antirheumatic drugs. They also improved quality of life and physical functioning of patients suffering from PsA.

EXPERT OPINION

Anti-TNF therapies are effective and safe in the management of PsA. Improvements in disease activity have been shown to be associated with improvements in quality of life of PsA patients receiving anti-TNF therapies.

Current status and new developments in the treatment of psoriasis and psoriatic arthritis with biological agents

Psoriasis is a chronic inflammatory disease affecting 1-3% of the general population. Among psoriatic patients, 5-40% are affected by psoriatic arthritis. Due to the chronic nature of the disease, patients suffer from substantial psychological and financial burdens, thus adding to a significantly impaired quality of life. Traditional systemic therapies for psoriasis, such as methotrexate, cyclosporin A, retinoids or PUVA therapy, have a potential for long-term toxicity and may not always provide sufficient improvement of the disease. The development of novel therapies targeting key steps in the pathogenesis of psoriasis and psoriatic arthritis now provide new and efficient treatment options. Biological therapies for the treatment of psoriasis and/or psoriatic arthritis are defined by their mode of action and can be classified into three categories: the T-cell modulating agents (alefacept and efalizumab), the inhibitors of tumour necrosis factor-alpha (TNFalpha blockers, e.g. adalimumab, certolizumab, etanercept, golimumab and infliximab) and the inhibitors of interleukin (IL) 12 and IL-23 (e.g. ustekinumab and briakinumab). This article provides a brief overview of the currently approved biological agents in the European Union and of some newer agents, such as briakinumab, certolizumab and golimumab.

Clinical remission and/or minimal disease activity in patients receiving adalimumab treatment in a multinational, open-label, twelve-week study

OBJECTIVE

To evaluate the effect of adalimumab treatment on clinical remission and/or minimal disease activity (MDA) in 6,610 patients with active rheumatoid arthritis (RA) who were enrolled in the Research in Active RA trial, a multinational, open-label, 12-week study with an optional extension period.

METHODS

Clinical remission was defined as a Disease Activity Score in 28 joints (DAS28)<2.6, Simplified Disease Activity Index (SDAI) score<or=3.3, or Clinical Disease Activity Index (CDAI) score<or=2.8. MDA required absence of tender and swollen joints plus erythrocyte sedimentation rate (ESR)<or=10 mm/hour; DAS28 score<or=2.85; or achievement of 5 of 7 core criteria for pain, swollen/tender joints, physical function, physician/patient global assessment, and ESR. Time to and time in remission/MDA and response predictors were analyzed using Kaplan-Meier estimates and Cox proportional hazards regression analysis, respectively.

RESULTS

A total of 38%, 24%, and 27% of patients achieved remission defined as DAS28<2.6, SDAI<or=3.3, and CDAI<or=2.8, respectively. MDA was observed in 45% of patients by DAS28<or=2.85, in 43% by the core set of criteria, and in 13% by absence of tender/swollen joints plus ESR<or=10 mm/hour. Median times in continuous remission and MDA were 3.4 and 4.4 months, respectively. Predictors for remission (DAS28<2.6) and MDA (DAS28<or=2.85) were male sex; younger age; concomitant disease-modifying antirheumatic drug use; lower baseline DAS28, CRP concentration, and Health Assessment Questionnaire disease index score; <or=1 comorbidity; and tumor necrosis factor antagonist naivety.

CONCLUSION

During adalimumab treatment, 25% of patients experienced clinical remission and nearly half achieved MDA. To our knowledge, this analysis represents the largest prospective clinical trial data set to be assessed using Outcome Measures in Rheumatology Clinical Trials MDA criteria.

Treatment of the wrist in rheumatoid arthritis

Wrist involvement is common in rheumatoid arthritis and affects up to 50% of patients within the first 2 years after the onset of the disease, including bilateral involvement. It is a progressive disease that destroys the articular cartilage and surrounding soft tissues, thus leading to severe deformities. Radiological changes are characteristic and include narrowing of the joint line, cysts, and periarticular osteoporosis. Clinical changes are characterized by different scoring systems, indicating different therapeutic options. Surgical orthopedic treatment options include joint-preserving techniques to prevent further damage (radiosynoviorthesis, synovectomy, or axial correction with tendon transfers in earlier stages) and joint replacing techniques to restore function (arthrodesis, resection arthroplasty or total joint arthroplasty in later stages). This article reviews pathologic changes in the rheumatoid hand and their surgical treatment alternatives.