Clinical, Imaging, and Pathological Suppression of Synovitis in Rheumatoid Arthritis: Is the Disease Curable?

Janus kinase inhibitors effectively improve pain across different disease activity states in rheumatoid arthritis

Pain remains one of the most difficult-to-treat domains in patients with rheumatoid arthritis (RA). In clinical trials, the Janus kinase inhibitors (JAKis) have demonstrated good efficacy in pain relief. Aim of our study was to evaluate the real-life effectiveness of JAKis in improving pain in patients with RA in different states of baseline disease activity. A monocentric prospective cohort of 181 RA patients starting treatment with JAKis was studied. Pain was evaluated on a 0-100 mm visual analogue scale (VAS). Clinically meaningful improvements over 24 weeks were defined as follows: proportion of patients achieving ≥ 30%, ≥ 50%, and ≥ 70% pain relief, and remaining pain ≤ 20 or ≤ 10 mm. Results were analysed after stratification for baseline inflammatory activity; patients with swollen joints and C-reactive protein ≤ 1 at treatment start were considered pauci-inflammatory. Proportion of patients who achieved ≥ 30%, ≥ 50% and ≥ 70% pain improvement at 24 weeks was 61.4%, 49.3% and 32.9%. Furthermore, 40.6% and 28.5% of the patients achieved thresholds of remaining pain equivalent to mild pain or no/limited pain. Pain improvements were more evident in patients naive to previous biologics, although nearly 30% of multiple failures achieved VAS ≤ 20 mm. No significant differences were observed in relation to monotherapy. Pauci-inflammatory patients at treatment start achieved good outcomes, with 40.4% experiencing ≥ 70% pain improvement, and 35.7% VAS ≤ 10 mm. JAKis show efficacy in pain relief in real life. The improvement of painful symptoms also in those patients with limited objective inflammation may open new perspectives on the management of difficult-to-treat RA.

Limiting factors to Boolean remission differ between autoantibody-positive and -negative patients in early rheumatoid arthritis

Background:

The patient global assessment of disease activity (PGA) is the major limiting factor to Boolean remission in patients with established rheumatoid arthritis (RA). Here, we investigated the limiting variables to disease remission in patients with early RA treated with conventional synthetic disease modifying anti-rheumatic drugs, also in relation to autoantibody status.

Methods:

Data were retrieved from 535 early RA patients (<12 months of symptoms) with an observation period of 6–12 months upon initiation of therapy with methotrexate aimed at the achievement of low disease activity based on the 28-joints disease activity score. Near-remission was defined as any of the four core items of Boolean remission >1 with the remaining three all ⩽1. Reasons for missing Boolean remission and predictors of near-remission subcategories were analyzed in relation to baseline disease variables.

Results:

After 6 and 12 months, near-remission was two-times more frequent than Boolean remission (25.6% and 26.9% at the two time-points). A 28-swollen joint count (SJC28) >1 was responsible for the majority of near-remission (56.2% and 57.6% at 6 and 12 months, respectively), and PGA > 1 accounted for approximatively 35% of the cases. Autoantibody-positivity independently predicted the risk of missing remission because of SJC28 > 1 [adjusted odds ratio (OR) 95% confidence interval (CI) 2.81 (1.59–4.9) at 6 months and 1.73 (1.01–3.01) at 12 months], whilst autoantibody-negativity was an independent predictor of PGA near-remission [adjusted OR (95% CI) 2.45 (1.25–4.80) at 6 months and 5.71 (2.47–13.2) at 12 months].

Conclusion:

In early RA, Boolean remission is more frequently missed because of persistent swollen joints. However, barriers to full-remission vary in relation to the autoantibody status. Autoantibody-positive patients more commonly experience residual swollen joints, whilst PGA more frequently impairs remission in autoantibody-negative patients. Efforts to target full-remission in early RA may thus require different strategies according to autoantibody profile.

Rheumatoid Arthritis: Defining Clinical and Ultrasound Deep Remission

The prognosis of patients with rheumatoid arthritis (RA) has improved substantially in the last two decades due to the appearance of biological therapies, but above all, due to the improvement in the strategy and management of the disease. Our goal in RA should be to achieve remission, or in its absence, the lowest inflammatory activity. Achieving remission will prevent from structural and functional damage highly associated with RA itself. Clinical remission is defined as the absence of significant signs and symptoms of inflammatory disease activity, as well as the abrogation of any signs of systemic inflammation. Currently, there are some controversies about remission. Which is the real remission? Which remission criteria should be used and when? Does clinical remission mean ultrasound remission? In the present review, we try to answer and put some light into it, focusing on clinical and ultrasound deep remission.

Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI

Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.

The Clinical Value of Autoantibodies in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a highly heterogeneous syndrome in terms of clinical presentation, progression, and response to therapy. In such a complicated context, the identification of disease-related biomarkers would be undoubtedly helpful in assisting tailored approaches for every patient. Despite remarkable efforts, however, progress in new biomarker development and validation is dramatically slow. At present, none of the candidate genetic, cellular, or molecular biomarker has yet surpassed the clinical value of RA-specific autoantibodies, including rheumatoid factor (RF) and anti-citrullinated protein autoantibodies (ACPA). Rather, recent years have witnessed significant advancements in our understanding of the multiple roles that RF and ACPA play in RA pathophysiology. This has helped clarifying the mechanistic basis of the clinical associations of autoantibodies in RA. In this short review, we will briefly summarize the effector functions of RF and ACPA, and analyse how autoantibodies may help subclassifying RA patients in terms of clinical presentation and response to therapy.