What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis

Metabolic Syndrome and Rheumatoid Arthritis Activity: An Analysis of Clinical, Laboratory, and Ultrasound Parameters

(1) Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease associated with an increased incidence of metabolic syndrome (MetS). The aim of this study was to determine if there is an association between MetS and parameters of RA activity, as well as between metabolic parameters and indices of RA activity. (2) Methods: This study involved 65 patients with RA. MetS was diagnosed according to the 2009 IDF/AHA/NHLBI criteria. The comparative analysis was conducted between RA patients with MetS (RA (MetS (+)) and without MetS (RA (MetS (-)). The activity of RA was assessed using clinical, laboratory, and ultrasound (US) parameters. (3) Results: Compared with RA MetS (-) patients, RA MetS (+) patients were characterized by higher disease activity, according to Disease Activity Score (DAS28), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI). RA MetS (+) patients had significantly higher tender and swollen joint counts, and values of erythrocyte sedimentation rate, C-reactive protein, and US parameters (grey-scale (GSUS), power Doppler (PDUS)). Significant correlations were found between metabolic parameters (waist circumference, cholesterol and glucose concentrations) and indices of RA activity. (4) Conclusion: The results of this study show that, in patients with RA, the presence of MetS is associated with higher disease activity, based on several clinical, laboratory, and US parameters.

Real-World Treatment with Nivolumab or Cabozantinib for Metastatic Renal Cell Carcinoma (mRCC) in the Veneto Region of Italy: Results of AMOUR Study

Background

Second- or third-line treatment options for metastatic renal cell carcinoma (mRCC) have dramatically changed in the last few years. There are no criteria for the choice between nivolumab and cabozantinib, which both demonstrated overall survival (OS) gain in pivotal trials.

Objective

We conducted an analysis of oncological outcomes in patients treated in the Veneto Region (Italy), studying different sequences of TKI-nivolumab-cabozantinib or TKI-cabozantinib-nivolumab in a publicly funded healthcare system.

Patients and Methods

We conducted a retrospective, real-world analysis of all consecutive patients with mRCC treated with nivolumab or cabozantinib in 2017–2018 at 19 Oncology Units in the Veneto Region.

Results

We identified 170 patients, 73 % males, median age 68.4 years. All patients started second-line treatment, 59 % received a third-line therapy. Patients with NLR > 3 had a shorter OS (p < 0.0001). In the second-line treatment, nivolumab was administered to 108 patients (63 %), cabozantinib to 29 (17 %); in the third-line treatment nivolumab was administered to 42 patients (25 %), cabozantinib to 49 (29 %). Median OS and PFS in second line treatment were 28.4 and 6.6 months for nivolumab, 16.8 and 6.6 months for cabozantinib. Median OS and PFS in third-line treatment were 27 and 5.2 months for nivolumab, 16.6 and 7.5 months for cabozantinib. Median OS for nivolumab>cabozantinib sequence versus cabozantinib > nivolumab was 28.8 versus 19.9 months (p = 0.2); median PFS for both the sequences were similar at 5.7 months. A cost effectiveness per month of survival of the two sequences analysis was performed: the cost per month for the nivolumab > cabozantinib sequence was 1738.60whereas the cost for the other one was €1624.80.

Conclusions

In our real-world cohort, most patients received nivolumab as second-line treatment. Outcomes of single drugs are superimposable with those in the published literature. Both the sequences of nivolumab and cabozantinib appear to be viable, effective strategies from an OS and cost-effective perspective.

Importance of baseline musculoskeletal ultrasound findings in the prognosis of rheumatoid arthritis

OBJECTIVES

To investigate the prognostic value of baseline musculoskeletal ultrasound (MSUS) findings for rheumatoid arthritis (RA).

METHOD

We retrospectively analyzed 138 patients with RA. Patients' first MSUS record was considered as the baseline expression. The subsequent MSUS changes that showed alleviation or progression were regarded as the cutoff point. Grayscale ultrasound (GSUS) synovitis, power Doppler ultrasound (PDUS) synovitis, PDUS tenosynovitis (TS), and bone erosion were scored using a semi-quantitative scale. According to the ultrasound (US) results of the cutoff point, patients were divided into the alleviation group and the progression group. Laboratory results (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], rheumatoid factor [RF], anticyclic citrullinated peptide [anti-CCP] antibody, and anti-keratin antibody [AKA]), disease activity score in 28 joints (DAS28)-ESR, and US scores were compared between the two groups to analyze the prognostic value of US findings in RA.

RESULTS

The alleviation group had higher levels of CRP, synovitis, TS, GSUS synovitis, PDUS synovitis, PDUS TS, and US total scores at baseline than the progression group (p < 0.05). The alleviation group received more aggressive treatment in their initial approach than the progression group (p < 0.05). The frequency of US examinations in the alleviation group was more than that in the progression group at follow-up (p < 0.05). Presence of baseline synovitis (OR 0.248, p = 0.006) and a higher GSUS synovitis score (OR 0.521, p = 0.006) were negatively correlated with RA progression.

CONCLUSIONS

Presence of baseline synovitis and higher GSUS synovitis score do not always indicate worse prognosis of RA, which can be improved with aggressive treatment. Regular MSUS follow-up may have positive influences on prognosis. Key Points • The presence of synovitis at baseline and higher GSUS synovitis score do not necessarily imply poor prognosis of RA. • Prompt and powerful therapy and regular ultrasound follow-up can slow down the progression of RA and improve its prognosis. • Patients with slight and less arthritis at baseline might be ignored and get worse prognosis due to mild treatment strategies and irregular MSUS examination.

Region specificity of rheumatoid foot symptoms associated with ultrasound-detected synovitis and joint destruction

OBJECTIVES

We aimed to clarify the clinical implication of ultrasound (US)-detected foot joint inflammation in tightly controlled patients with rheumatoid arthritis (RA).

METHODS

We evaluated bilateral foot joints (second to fifth metatarsophalangeal joints of forefoot; tarsometatarsal, cuneonavicular and midtarsal joints of midfoot) of 430 RA patients for synovitis using Power Doppler (PD) imaging by US. We made a cross-sectional and a 3-year longitudinal analysis about the associations of US-detected synovitis with clinical, laboratory and radiographic data as well as foot-specific outcomes using a self-administered foot evaluation questionnaire (SAFE-Q).

RESULTS

The US-detected foot synovitis was seen in 28% of patients. The US-detected synovitis was closely related to 28 joint-disease activity score (DAS28) more in the forefoot than in the midfoot, while related to joint destruction in both. Multiple regression analyses showed significant associations between midfoot PD positivity and SAFE-Q in the remission group. SAFE-Q was worsened after the 3-year interval, but PD positivity at baseline did not contribute to the changes. On the other hand, destruction of the joints with US-detected synovitis significantly progressed in 3 years than with not.

CONCLUSIONS

US-detected synovitis on foot joints were related to systemic inflammation, clinical symptoms, and future joint destruction with region specificity.

Biomarkers of tolerance in immune-mediated inflammatory diseases: a new era in clinical management?

Modern therapeutic agents and treatment regimens have made sustained remission an attainable target for many patients across a spectrum of immune-mediated inflammatory diseases, albeit at the risk of adverse events and the expense of drug prescription and safety monitoring. Clinicians and patients are thus increasingly faced with a novel treatment dilemma: whether and how best to stop immunomodulatory treatment in patients who achieve remission. In this final paper in a Series on therapeutic tolerance induction, we summarise our current knowledge of biomarkers of immune homeostasis in immune-mediated inflammatory diseases and their application to the prediction and attainment of sustained drug-free remission. We summarise evidence from prospective studies of immunomodulatory drug cessation across a range of immune-mediated inflammatory diseases, including rheumatoid arthritis, juvenile idiopathic arthritis, and inflammatory bowel disease. We also consider current evidence for clinical, serological, proteomic, metabolomic, cellular, and microbiomic biomarkers of immune homeostasis. Finally, we discuss the steps necessary for clinical translation of these biomarkers, as well as the potential transformative effect of these biomarkers on management of patients with immune-mediated inflammatory diseases if clinical translation is successfully achieved.

Enzyme-linked immunosorbent assays for monitoring TNF-alpha inhibitors and antibody levels in people with rheumatoid arthritis: a systematic review and economic evaluation

BACKGROUND

Rheumatoid arthritis is a chronic autoimmune disease that primarily causes inflammation, pain and stiffness in the joints. People with severe disease may be treated with biological disease-modifying anti-rheumatic drugs, including tumour necrosis factor-α inhibitors, but the efficacy of these drugs is hampered by the presence of anti-drug antibodies. Monitoring the response to these treatments typically involves clinical assessment using response criteria, such as Disease Activity Score in 28 joints or European League Against Rheumatism. Enzyme-linked immunosorbent assays can also be used to measure drug and antibody levels in the blood. These tests may inform whether or not adjustments to treatment are required or help clinicians to understand the reasons for treatment non-response or a loss of response.

METHODS

Systematic reviews were conducted to identify studies reporting on the clinical effectiveness and cost-effectiveness of using enzyme-linked immunosorbent assays to measure drug and anti-drug antibody levels to monitor the response to tumour necrosis factor-α inhibitors [adalimumab (Humira®; AbbVie, Inc., North Chicago, IL, USA), etanercept (Enbrel®; Pfizer, Inc., New York, NY, USA), infliximab (Remicade®, Merck Sharp & Dohme Limited, Hoddesdon, UK), certolizumab pegol (Cimzia®; UCB Pharma Limited, Slough, UK) and golimumab (Simponi®; Merck Sharp & Dohme Limited)] in people with rheumatoid arthritis who had either achieved treatment target (remission or low disease activity) or shown primary or secondary non-response to treatment. A range of bibliographic databases, including MEDLINE, EMBASE and CENTRAL (Cochrane Central Register of Controlled Trials), were searched from inception to November 2018. The risk of bias was assessed using the Cochrane ROBINS-1 (Risk Of Bias In Non-randomised Studies - of Interventions) tool for non-randomised studies, with adaptations as appropriate. Threshold and cost-utility analyses that were based on a decision tree model were conducted to estimate the economic outcomes of adding therapeutic drug monitoring to standard care. The costs and resource use were considered from the perspective of the NHS and Personal Social Services. No discounting was applied to the costs and effects owing to the short-term time horizon of 18 months that was adopted in the economic analysis. The impact on the results of variations in testing and treatment strategies was explored in numerous clinically plausible sensitivity analyses.

RESULTS

Two studies were identified: (1) a non-randomised controlled trial, INGEBIO, that compared standard care with therapeutic drug monitoring using Promonitor® assays [Progenika Biopharma SA (a Grifols-Progenika company), Derio, Spain] in Spanish patients receiving adalimumab who had achieved remission or low disease activity; and (2) a historical control study. The economic analyses were informed by INGEBIO. Different outcomes from INGEBIO produced inconsistent results in both threshold and cost-utility analyses. The cost-effectiveness of therapeutic drug monitoring varied, from the intervention being dominant to the incremental cost-effectiveness ratio of £164,009 per quality-adjusted life-year gained. However, when the frequency of testing was assumed to be once per year and the cost of phlebotomy appointments was excluded, therapeutic drug monitoring dominated standard care.

LIMITATIONS

There is limited relevant research evidence and much uncertainty about the clinical effectiveness and cost-effectiveness of using enzyme-linked immunosorbent assay-based testing for therapeutic drug monitoring in rheumatoid arthritis patients. INGEBIO had serious limitations in relation to the National Institute for Health and Care Excellence scope: only one-third of participants had rheumatoid arthritis, the analyses were mostly not by intention to treat and the follow-up was 18 months only. Moreover, the outcomes might not be generalisable to the NHS.

CONCLUSIONS

Based on the available evidence, no firm conclusions could be made about the cost-effectiveness of therapeutic drug monitoring in England and Wales.

FUTURE WORK

Further controlled trials are required to assess the impact of using enzyme-linked immunosorbent assays for monitoring the anti-tumour necrosis factors in people with rheumatoid arthritis.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018105195.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 8. See the NIHR Journals Library website for further project information.

The changing role of ultrasonography examination in patients with rheumatoid arthritis in light of recent studies

For many years, ultrasonography (US) has been a widely accepted modality used for joint assessment in patients with rheumatoid arthritis (RA). Given the efficacy of present day therapies, there is scepticism whether it is required in the first place. The most recent clinical Targeting synovitis in Early Rheumatoid Arthritis (TaSER) and Clinical Tight Control Therapy (ARCTIC) trials’ results appear to contradict it, yet this does not necessarily mean ultrasound has no place in modern rheumatology. The possibility of detecting inflammation at a subclinical level carries a tremendous predictive value, enabling identification of patients likely to experience an exacerbation in the coming months. Therefore, US should be a part of the decision-making process regarding treatment modification or introduction of any additional interventions, such as glucocorticosteroid injections.

The results of the most recent clinical trials do not negate the usefulness of US, but merely suggest that it ought to be used in moderation.

Musculoskeletal ultrasound imaging - An exploration of physiotherapists' interests and use in practice

BACKGROUND

Musculoskeletal ultrasound imaging (MSKUSI) has gained popularity; several professions have expressed an interest in this application but the clinical use by physiotherapists has not been fully researched.

OBJECTIVES

To explore physiotherapists' interests and use of MSKUSI in practice.

DESIGN

Sequential mixed-methods; questionnaire followed by semi-structured interviews.

METHOD

A questionnaire was developed and distributed to gain initial information, (75 responses). Analysis informed topic-guide development and enabled a purposive-sampling strategy for semi-structured interviews that explored physiotherapists' interests, education and clinical use of MSKUSI (n = 11). Interview data were analysed thematically.

RESULTS

Five themes were identified: 1. Professional skill set - physiotherapists' suitability for MSKUSI. 2. Factors that have impacted physiotherapists' ability to use MSKUSI. 3. Physiotherapists' motivation to use ultrasound - improving patient focused care. 4. Quality assurance strategies. 5. Application of biopsychosocial model. Themes revealed links between physiotherapists' core skills, knowledge and professional experiences that align with MSKUSI requirements. Some participants reported support accessing education but many described challenges finding appropriate mentorship. Participants observed education did not always reflect practice typical of physiotherapists. Application of clinical reasoning processes utilised by physiotherapists was regarded as integral to patient-focused scanning.

CONCLUSIONS

Physiotherapists' professional training and musculoskeletal practice are seen as a foundation for education in MSKUSI. Accessing education can be challenging, in particular mentorship that fully incorporates the biopsychosocial model. Proposed roles for MSKUSI for physiotherapists include verification of clinical assessment findings for diagnosis and facilitation of patient education. The potential to streamline patient pathways and optimise resource management warrants investigation.

Management of rheumatoid arthritis: 2019 updated consensus recommendations from the Hong Kong Society of Rheumatology

The expanding range of treatment options for rheumatoid arthritis (RA), from conventional synthetic disease-modifying antirheumatic drugs (DMARDs) to biological DMARDs (bDMARDs), biosimilar bDMARDs, and targeted synthetic DMARDs, has improved patient outcomes but increased the complexity of treatment decisions. These updated consensus recommendations from the Hong Kong Society of Rheumatology provide guidance on the management of RA, with a focus on how to integrate newly available DMARDs into clinical practice. The recommendations were developed based on evidence from the literature along with local expert opinion. Early diagnosis of RA and prompt initiation of effective therapy remain crucial and we suggest a treat-to-target approach to guide optimal sequencing of DMARDs in RA patients to achieve tight disease control. Newly available DMARDs are incorporated in the treatment algorithm, resulting in a greater range of second-line treatment options. In the event of treatment failure or intolerance, switching to another DMARD with a similar or different mode of action may be considered. Given the variety of available treatments and the heterogeneity of patients with RA, treatment decisions should be tailored to the individual patient taking into consideration prognostic factors, medical comorbidities, drug safety, cost of treatment, and patient preference.

RHEUMATOID ARTHRITIS: THE PROBLEMS OF REMISSION AND THERAPY RESISTANCE

Rheumatoid arthritis (RA) is an immunoinflammatory (autoimmune) rheumatic disease of unknown etiology, which is characterized by chronic erosive arthritis and systemic visceral organ damage that results in early disability and shorter patient survival. Despite RA treatment advances associated with the design of novel drugs and the improvement of treatment strategies to achieve remission in many patients, there are still many theoretical and clinical problems concerning both the definition of the concept of remission, its characteristics and types and approaches to the optimum policy of symptomatic and pathogenetic drug therapy at different stages of the disease, the use of which will be able to rapidly induce and maintain remission in the long-term. Further investigations are needed to study the nature of heterogeneity of pathogenetic mechanisms of RA and approaches to early diagnosis, to improve methods for monitoring disease activity and biomarkers for the efficiency of and resistance to therapy and, finally, to develop differentiation therapy, including those related to a search for new therapeutic targets.

The Cost-effectiveness of Sequences of Biological Disease-modifying Antirheumatic Drug Treatment in England for Patients with Rheumatoid Arthritis Who Can Tolerate Methotrexate

OBJECTIVE

To ascertain whether strategies of treatment with a biological disease-modifying antirheumatic drug (bDMARD) are cost-effective in an English setting. Results are presented for those patients with moderate to severe rheumatoid arthritis (RA) and those with severe RA.

METHODS

An economic model to assess the cost-effectiveness of 7 bDMARD was developed. A systematic literature review and network metaanalysis was undertaken to establish relative clinical effectiveness. The results were used to populate the model, together with estimates of Health Assessment Questionnaire (HAQ) score following European League Against Rheumatism response; annual costs, and utility, per HAQ band; trajectory of HAQ for patients taking bDMARD; and trajectory of HAQ for patients using nonbiologic therapy (NBT). Results were presented as those associated with the strategy with the median cost-effectiveness. Supplementary analyses were undertaken assessing the change in cost-effectiveness when only patients with the most severe prognoses taking NBT were provided with bDMARD treatment. The costs per quality-adjusted life-year (QALY) values were compared with reported thresholds from the UK National Institute for Health and Care Excellence of £20,000 to £30,000 (US$24,700 to US$37,000).

RESULTS

In the primary analyses, the cost per QALY of a bDMARD strategy was £41,600 for patients with severe RA and £51,100 for those with moderate to severe RA. Under the supplementary analyses, the cost per QALY fell to £25,300 for those with severe RA and to £28,500 for those with moderate to severe RA.

CONCLUSION

The cost-effectiveness of bDMARD in RA in England is questionable and only meets current accepted levels in subsets of patients with the worst prognoses.

PP001 Ultrasound To Guide Treatment Decisions In Rheumatoid Arthritis

INTRODUCTION:

Ultrasound (US) detects synovitis more accurately than clinical examination (CE) in people with rheumatoid arthritis (RA). This review aimed to investigate the use of US, compared to CE alone, in treatment strategies for RA, and to estimate its potential to be cost-effective in making treatment decisions.

METHODS:

A systematic review was conducted of studies: investigating RA treatment response or strategies that compared US with CE-assessed synovitis; and of tapering RA treatment (1). A model was constructed to investigate the potential cost-effectiveness of US in (i) selecting patients suitable for treatment tapering; and (ii) avoiding treatment escalation (2).

RESULTS:

Seven prospective cohort studies suggested US-detected synovitis was significantly associated with a treatment response or tapering failure, whereas in most cases clinical examination alone was not. Two randomized controlled trials (RCTs) identified suggested that US added to the Disease Activity Index (DAS)-based treatment strategies but did not significantly improve primary outcomes, but was associated with improved rate of DAS remission. The evidence showed that some patients (proportions varied widely) who had achieved low disease activity could have treatment tapered, with no, or little, short-term harm to the patient.

The model estimated that an average reduction of 2.5 percent in the costs of biological disease-modifying anti-rheumatic drug (bDMARDs) was sufficient to cover the costs of performing US every three months. This value increased to 4 percent and 13 percent for the costs of conventional disease-modifying anti-rheumatic drug (cDMARDs) depending on the assumed regimen.

CONCLUSIONS:

Use of US to monitor synovitis could potentially be a cost-effective approach, given that low proportions of patients for whom clinicians consider amending treatment, would need to taper treatment, or remain on therapy without escalation. US could provide clinicians with more confidence in reducing the drug burden. However, there is considerable uncertainty in this conclusion due to lack of robust data relating to key parameters.