1
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Sullivan MM, Pham MM, Marks LA, Aslam F. Intra-articular therapy with methotrexate or tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic review. BMC Musculoskelet Disord 2021; 22:792. [PMID: 34525992 PMCID: PMC8444402 DOI: 10.1186/s12891-021-04651-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/05/2021] [Indexed: 11/29/2022] Open
Abstract
Background Persistent monoarthritis in otherwise well-controlled rheumatoid arthritis presents a therapeutic challenge. Intra-articular (IA) steroids are a mainstay of treatment, though some have queried whether IA disease modifying anti-rheumatic drugs (DMARD) and biologics can be used in those who fail steroid injections. Methods A systematic literature review was conducted using four medical databases to identify randomized, controlled trials assessing IA therapies in RA patients. Included studies underwent Cochrane Risk of Bias 2 assessment for quality. Results Twelve studies were included, 6 of which examined intra-articular (IA) TNF inhibitors (TNFi), and 6 studies evaluating IA methotrexate. Of those evaluating IA TNFi, one study reported statistical improvement in TNFi therapy when compared with placebo. The remaining 5 studies compared IA TNFi therapy with steroid injections. IA TNFi had statistically improved symptom scores and clinical assessments comparable with IA steroid treatments. In the 6 studies evaluating IA methotrexate, the addition of methotrexate to steroid intra-articular therapy was not found to be beneficial, and singular methotrexate injection was not superior to the control arms (saline or triamcinolone). Risk-of-bias (ROB) assessment with the Revised Cochrane ROB tool indicated that 2 of 6 TNFi studies were at some risk or high risk for bias, compared with 5 out of 6 methotrexate studies. Conclusion For persistent monoarthritis in rheumatoid arthritis, IA methotrexate was not found to have clinical utility. Intra-articular TNFi therapy appears to have equal efficacy to IA steroids, though the optimal dose and frequency of injections is yet unknown. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04651-5.
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Affiliation(s)
- Megan M Sullivan
- Division of Rheumatology, Department of Internal Medicine Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Michael M Pham
- Division of Rheumatology, Department of Internal Medicine Mayo Clinic, Scottsdale, AZ, USA
| | - Lisa A Marks
- Mayo Clinic Libraries Arizona, Mayo Clinic, Scottsdale, AZ, USA
| | - Fawad Aslam
- Division of Rheumatology, Department of Internal Medicine Mayo Clinic, Scottsdale, AZ, USA
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2
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Salem RM, El-Deeb AE, Elsergany M, Elsaadany H, El-Khouly R. Intra-articular injection of etanercept versus glucocorticoids in rheumatoid arthritis patients. Clin Rheumatol 2020; 40:557-564. [PMID: 32623650 DOI: 10.1007/s10067-020-05235-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study was conducted to assess the safety and efficacy of intra-articular injection of etanercept and compare it with corticosteroid injection in rheumatoid arthritis (RA) patients. METHODS Fifty patients with RA who suffered from activity in one joint were randomized into two groups, received an intra-articular injection of either etanercept or corticosteroid guided by musculoskeletal ultrasound. All patients were assessed for disease activity by disease activity score (DAS28), functional assessment using the Modified Health Assessment Questionnaire (MHAQ), and laboratory investigations (erythrocyte sedimentation rate and C-reactive protein). Joints affected were evaluated for pain by visual analog scale (VAS), tenderness, and swelling scores and by ultrasound for estimation of synovial hypertrophy, synovial effusion, and power Doppler. Follow-up of the patients was done at weeks 1, 4, and 12 after injection by clinical assessment and ultrasound. RESULTS There was a significant improvement of joint pain assessed by VAS, tenderness, and swelling scores in the etanercept group at week 1 and week 4 follow-up periods but there were insignificant changes at week 12. There was a significant decrease in synovial effusion at week 1 and week 4 and in power Doppler at week 1 but no significant change was noticed in synovial hypertrophy during the follow-up periods. In comparison of the two groups, etanercept has shown better results on joint scores at week 1; however, glucocorticoid had more sustained effects. No major or life-threatening side effects were noticed following intra-articular injection of etanercept. CONCLUSION Intra-articular injection of etanercept is a safe and promising option; with comparable results to intra-articular injection of corticosteroid; however, its rapid absorption from the synovium may necessitate frequent injections. Key Points • Persistent inflammatory mono-arthritis is a common clinical problem that is often difficult to treat; it is a debilitating and destructive condition. • Intra-articular injection of TNF inhibitors is an encouraging treatment modality in managing refractory mono-arthritis in rheumatoid arthritis.
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Affiliation(s)
- Rehab Mahmoud Salem
- Physical Medicine, Rheumatology, and Rehabilitation Department, Faculty of Medicine, Tanta University, Geish Street, Tanta, Gharbia, Egypt
| | - A E El-Deeb
- Physical Medicine, Rheumatology, and Rehabilitation Department, Faculty of Medicine, Tanta University, Geish Street, Tanta, Gharbia, Egypt
| | - Mervat Elsergany
- Physical Medicine, Rheumatology, and Rehabilitation Department, Faculty of Medicine, Tanta University, Geish Street, Tanta, Gharbia, Egypt
| | - Hanan Elsaadany
- Physical Medicine, Rheumatology, and Rehabilitation Department, Faculty of Medicine, Tanta University, Geish Street, Tanta, Gharbia, Egypt
| | - Radwa El-Khouly
- Physical Medicine, Rheumatology, and Rehabilitation Department, Faculty of Medicine, Tanta University, Geish Street, Tanta, Gharbia, Egypt.
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3
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Wang S, Wang X, Liu Y, Sun X, Tang Y. Ultrasound-guided intra-articular triamcinolone acetonide injection for treating refractory small joints arthritis of rheumatoid arthritis patients. Medicine (Baltimore) 2019; 98:e16714. [PMID: 31415364 PMCID: PMC6831351 DOI: 10.1097/md.0000000000016714] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate the efficiency and clinical safety of intra-articular triamcinolone acetonide (TA) injection under the guide of ultrasonography combined with standard treatment for treating refractory small joints arthritis in rheumatoid arthritis (RA) patients.TA was injected upon confirmation of the needle inserting into the articular cavity. The dose was 40 mg for the wrist, 20 mg for the metacarpophalangeal (MCP) joint and 20 mg for the proximal interphalangeal (PIP) joint, respectively. Visual analogue scale (VAS) for joint pain, swelling, tenderness, synovial hyperplasia and power Doppler signal scores were evaluated at pretreatment, and post-treatment 24 hours, 1 week, 4 weeks as well as 12 weeks.The VAS for pain and tenderness scores showed gradual improvement at 24 hours, 1 week, 4 weeks and 12 weeks after treatment compared with the baseline levels (P' < .005). The swelling showed no changes at 24 hours after treatment compared with the baseline, and showed gradual improvement at 1 week, 4 weeks and 12 weeks after treatment (P' < .005). Significant decrease was noticed in the synovial hyperplasia score at 4 weeks and 12 weeks compared with the baseline level. Power Doppler signal score showed significant decrease at post-treatment 24 hours, which showed further decrease at 1 week and 4 weeks.Ultrasound-guided intra-articular TA injection is effective for treating RA patients with refractory small joints arthritis without changing the original treatment plan.
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4
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Zhang F, Ma C. Comparison of the effectiveness on intra-articular and subcutaneous TNF inhibitor in rheumatoid arthritis patients. Clin Rheumatol 2017; 37:199-204. [PMID: 28871338 DOI: 10.1007/s10067-017-3806-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
The objective of this study is to evaluate the efficacy of single intra-articular (IA) injection of tumor necrosis factor α (TNFα) inhibitor in knee joints comparing with subcutaneous injection in rheumatoid arthritis (RA) patients. Forty-eight RA patients with 73 knee arthritis were divided into three groups, group A: received a single injection of TNF inhibitor into knee joints; group B: received regular subcutaneous injection; and group C: received both of the regimen as groups A and B. Ultrasound, erythrocyte sedimentation rate, C-reactive protein (CRP), patients' global visual analogue scale (VAS), and 28-joint Disease Activity Score (DAS28) were collected pre- and post-therapy 4 weeks. The results of the study are as follows: (1) CRP, VAS, and DAS28 of all groups improved significantly post-therapy (p < 0.05); (2) After therapy, synovial hypertrophy (SH) decreased significantly from 4.40 ± 1.86 mm to 2.74 ± 1.88 mm (p < 0.05) and power Doppler (PD) signal decreased significantly from 2.63 ± 0.75 to 1.50 ± 0.93 (p < 0.01) in group A. Synovial effusion (SE), SH, and PD showed no significant improvement in group B. SE decreased significantly from 9.84 ± 4.70 mm to 5.89 ± 4.47 mm (p < 0.05), SH decreased significantly from 4.52 ± 1.97 mm to 2.49 ± 1.73 mm (p < 0.01), and PD decreased significantly from 2.46 ± 0.66 to 1.38 ± 1.04 (p < 0.01) in group C; and (3) The improvement rate of SH and PD in both groups A and C was obviously higher than that of group B (p < 0.05). Single IA injection of TNFα inhibitor was an effective treatment in improvement of SH and PD of knee joints than subcutaneous injection in RA patients.
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Affiliation(s)
- Fangze Zhang
- Department of Internal Medicine, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130033, China
| | - Cuili Ma
- Department of Rheumatology and Immunology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, 130033, China.
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5
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Carubbi F, Zugaro L, Cipriani P, Conchiglia A, Gregori L, Danniballe C, Letizia Pistoia M, Liakouli V, Ruscitti P, Ciccia F, Triolo G, Masciocchi C, Giacomelli R. Safety and efficacy of intra-articular anti-tumor necrosis factor α agents compared to corticosteroids in a treat-to-target strategy in patients with inflammatory arthritis and monoarthritis flare. Int J Immunopathol Pharmacol 2015; 29:252-66. [PMID: 26684633 DOI: 10.1177/0394632015593220] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 05/26/2015] [Indexed: 11/15/2022] Open
Abstract
The aim of this study was to assess safety and efficacy of ultrasonography (US)-guided intra-articular injections using tumor necrosis factor (TNF) blockers compared to corticosteroids in rheumatoid arthritis (RA) or psoriatic arthritis (PsA) patients, experiencing refractory monoarthritis despite the current systemic therapy. Eighty-two patients were randomized to receive three intra-articular injections monthly of either corticosteroid or TNF blockers. Primary endpoints were the safety and an improvement greater than 20% for visual analogic scales of involved joint pain in patients injected with anti-TNFα. Further clinical, US, and magnetic resonance imaging (MRI) evaluations were considered secondary endpoints. Intra-articular TNF blockers are a safe strategy, determining a significant reduction of patient and physician reported clinical outcomes and US/MRI scores, in RA and PsA patients, when compared to intra-articular injections of corticosteroids. US guidance excluded the possibility to inject the drug in the wrong site, maximizing local effects, reducing systemic effects, and increasing the safety of the procedure. Patients with inflammatory monoarthritis could be successfully treated with US-guided intra-articular TNF blockers that are a safe and well tolerated procedure, to achieve a longstanding clinical and radiological good clinical response and/or disease remission.
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Affiliation(s)
- Francesco Carubbi
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | - Luigi Zugaro
- Department of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | | | - Lorenzo Gregori
- Department of Radiology, University of L'Aquila, L'Aquila, Italy
| | | | - Maria Letizia Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | - Vasiliki Liakouli
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
| | - Francesco Ciccia
- Rheumatology Unit, Internal Medicine Department, University of Palermo, Palermo, Italy
| | - Giovanni Triolo
- Rheumatology Unit, Internal Medicine Department, University of Palermo, Palermo, Italy
| | - Carlo Masciocchi
- Department of Radiology, University of L'Aquila, L'Aquila, Italy
| | - Roberto Giacomelli
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila, L'Aquila, Italy
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6
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Intra-articular etanercept treatment in inflammatory arthritis: A randomized double-blind placebo-controlled proof of mechanism clinical trial validating TNF as a potential therapeutic target for local treatment. Joint Bone Spine 2015; 82:338-44. [DOI: 10.1016/j.jbspin.2015.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 03/03/2015] [Indexed: 12/31/2022]
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7
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Zufferey P, Perreau M, So A. High level of anti-drug antibodies after intra-articular injection of anti-TNF. Rheumatology (Oxford) 2015; 54:2291-2. [PMID: 26320135 DOI: 10.1093/rheumatology/kev325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pascal Zufferey
- Service de rhumatologie, département de l'appareil locomoteur and
| | - Mathieu Perreau
- Service d'immunologie, Centre hospitalier universitaire vaudois, Lausanne, Switzerland
| | - Alexander So
- Service de rhumatologie, département de l'appareil locomoteur and
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8
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Kimmerling K, Furman B, Mangiapani D, Moverman M, Sinclair S, Huebner J, Chilkoti A, Kraus V, Setton L, Guilak F, Olson S. Sustained intra-articular delivery of IL-1RA from a thermally-responsive elastin-like polypeptide as a therapy for post-traumatic arthritis. Eur Cell Mater 2015; 29:124-39; discussion 139-40. [PMID: 25636786 PMCID: PMC4358781 DOI: 10.22203/ecm.v029a10] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Post-traumatic arthritis (PTA) is a rapidly progressive form of arthritis that develops due to joint injury, including articular fracture. Current treatments are limited to surgical restoration and stabilization of the joint; however, evidence suggests that PTA progression is mediated by the upregulation of pro-inflammatory cytokines, such as interleukin-1 (IL-1) or tumor necrosis factor-α (TNF-α). Although these cytokines provide potential therapeutic targets for PTA, intra-articular injections of anti-cytokine therapies have proven difficult due to rapid clearance from the joint space. In this study, we examined the ability of a cross-linked elastin-like polypeptide (xELP) drug depot to provide sustained intra-articular delivery of IL-1 and TNF-α inhibitors as a beneficial therapy. Mice sustained a closed intra-articular tibial plateau fracture; treatment groups received a single intra-articular injection of drug encapsulated in xELP. Arthritic changes were assessed 4 and 8 weeks after fracture. Inhibition of IL-1 significantly reduced the severity of cartilage degeneration and synovitis. Inhibition of TNF-α alone or with IL-1 led to deleterious effects in bone morphology, articular cartilage degeneration, and synovitis. These findings suggest that IL-1 plays a critical role in the pathogenesis of PTA following articular fracture, and sustained intra-articular cytokine inhibition may provide a therapeutic approach for reducing or preventing joint degeneration following trauma.
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Affiliation(s)
- K.A. Kimmerling
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA,Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - B.D. Furman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - D.S. Mangiapani
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - M.A. Moverman
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - S.M. Sinclair
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - J.L. Huebner
- Duke Molecular Physiology Institute, Durham, NC, USA
| | - A. Chilkoti
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - V.B. Kraus
- Duke Molecular Physiology Institute, Durham, NC, USA,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - L.A. Setton
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA,Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - F. Guilak
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA,Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - S.A. Olson
- Department of Biomedical Engineering, Duke University, Durham, NC, USA,Address for correspondence: Steven A. Olson, M.D., Duke University Medical Center, Box 3389, Durham, NC 27710, USA, Telephone Number: 1-919-668-3000, FAX Number: 1-919-668-2933,
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9
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Curtis EM, Marks JL. Optimal dose of etanercept in the treatment of rheumatoid arthritis. Open Access Rheumatol 2014; 6:27-38. [PMID: 27790032 PMCID: PMC5045112 DOI: 10.2147/oarrr.s41409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Etanercept (ETN) is one of a number of biological therapies targeting the proinflammatory cytokine tumor necrosis factor-alpha that have demonstrated efficacy in the management of rheumatoid arthritis (RA). As experience has grown, a number of different treatment strategies have been investigated to ascertain the optimal conditions for use of ETN in RA and maximize the clinical gains from therapy. These have included the use of higher- and lower-dose treatment regimens, ETN as a monotherapy or in combination with other nonbiologic disease-modifying antirheumatic drugs, the use of ETN in very early clinical disease, and intraarticular ETN administration for resistant synovitis. Recent trials have focused on phased dose reduction or withdrawal of ETN in patients achieving low disease activity states or clinical remission. This review summarizes existing data regarding the optimal timing of ETN initiation and dosing regimens and also evaluates more recent evidence regarding dose-reduction strategies that offer the possibility of biologic-free remission in RA.
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Affiliation(s)
- Elizabeth Mary Curtis
- Department of Rheumatology, University Hospital Southampton, Southampton, Hampshire, UK
| | - Jonathan Lewis Marks
- Department of Rheumatology, University Hospital Southampton, Southampton, Hampshire, UK
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10
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Smolen JS, Landewé R, Breedveld FC, Buch M, Burmester G, Dougados M, Emery P, Gaujoux-Viala C, Gossec L, Nam J, Ramiro S, Winthrop K, de Wit M, Aletaha D, Betteridge N, Bijlsma JWJ, Boers M, Buttgereit F, Combe B, Cutolo M, Damjanov N, Hazes JMW, Kouloumas M, Kvien TK, Mariette X, Pavelka K, van Riel PLCM, Rubbert-Roth A, Scholte-Voshaar M, Scott DL, Sokka-Isler T, Wong JB, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014; 73:492-509. [PMID: 24161836 PMCID: PMC3933074 DOI: 10.1136/annrheumdis-2013-204573] [Citation(s) in RCA: 1433] [Impact Index Per Article: 143.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 10/05/2013] [Accepted: 10/11/2013] [Indexed: 02/07/2023]
Abstract
In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
| | - Robert Landewé
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Atrium Medical Center, Heerlen, The Netherlands
| | - Ferdinand C Breedveld
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maya Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Maxime Dougados
- Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital, Montpellier I University, Nimes, France
| | - Laure Gossec
- Rheumatology Department, Paris 06 UPMC University, AP-HP, Pite-Salpetriere Hospital, Paris, France
| | - Jackie Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sofia Ramiro
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Hospital Garcia de Orta, Almada, Portugal
| | - Kevin Winthrop
- Oregon Health and Science University, Portland, Oregon, USA
| | - Maarten de Wit
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Neil Betteridge
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten Boers
- VU University Medical Center, Amsterdam, The Netherlands
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Bernard Combe
- Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
| | - Maurizio Cutolo
- Academic Clinical Unit of Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Nemanja Damjanov
- 2nd Hospital Department, Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center, Dr Molewaterplein, Rotterdam, The Netherlands
| | - Marios Kouloumas
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Xavier Mariette
- Hopitaux Universitaires Paris Sud, AP-HP, and Université Paris-Sud, Le Kremlin Bicetre, France
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Piet L C M van Riel
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Marieke Scholte-Voshaar
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - David L Scott
- King's College School of Medicine, Weston Education Centre, London, UK
| | | | - John B Wong
- Division of Clinical Decision Making, Informatics and Telemedicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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11
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Lethaby A, Lopez‐Olivo MA, Maxwell LJ, Burls A, Tugwell P, Wells GA. Etanercept for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev 2013; 2013:CD004525. [PMID: 23728649 PMCID: PMC10771320 DOI: 10.1002/14651858.cd004525.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Etanercept is a soluble tumour necrosis factor alpha-receptor disease-modifying anti-rheumatic drug (DMARD) for the treatment of rheumatoid arthritis (RA). OBJECTIVES The purpose of this review was to update the previous Cochrane systematic review published in 2003 assessing the benefits and harms of etanercept for the treatment of RA. In addition, we also evaluated the benefits and harms of etanercept plus DMARD compared with DMARD monotherapy in those people with RA who are partial responders to methotrexate (MTX) or any other traditional DMARD. SEARCH METHODS Five electronic databases were searched from 1966 to February 2003 with no language restriction. The search was updated to January 2012. Attempts were made to identify other studies by contact with experts, searching reference lists and searching trial registers. SELECTION CRITERIA All controlled trials (minimum 24 weeks' duration) comparing four possible combinations: 1) etanercept (10 mg or 25 mg twice weekly) plus a traditional DMARD (either MTX or sulphasalazine) versus a DMARD, 2) etanercept plus DMARD versus etanercept alone, 3) etanercept alone versus a DMARD or 4) etanercept versus placebo. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of the trials. MAIN RESULTS Three trials were included in the original version of the review. An additional six trials, giving a total of 2842 participants, were added to the 2012 update of the review. The trials were generally of moderate to low risk of bias, the majority funded by pharmaceutical companies. Follow-up ranged from six months to 36 months.BenefitAt six to 36 months the American College of Rheumatology (ACR) 50 response rate was statistically significantly improved with etanercept plus DMARD treatment when compared with a DMARD in those people who had an inadequate response to any traditional DMARD (risk ratio (RR) 2.0; 95% confidence interval (CI) 1.3 to 2.9, absolute treatment benefit (ATB) 38%; 95% CI 13% to 59%) and in those people who were partial responders to MTX (RR 11.7; 95% CI 1.7 to 82.5, ATB 36%). Similar results were observed when pooling data from all participants (responders or not) (ACR 50 response rates at 24 months: RR 1.9; 95% CI 1.3 to 2.8, ATB 29%; 36 months: RR 1.6; 95% CI 1.3 to 1.9, ATB 24%). Statistically significant improvement in physical function and a higher proportion of disease remission were observed in combination-treated participants compared with DMARDs alone ((mean difference (MD) -0.36; 95% CI -0.43 to -0.28 in a 0-3 scale) and (RR 1.92; 95% CI 1.60 to 2.31), respectively) in those people who had an inadequate response to any traditional DMARD. All changes in radiographic scores were statistically significantly less with combination treatment (etanercept plus DMARD) compared with MTX alone for all participants (responders or not) (Total Sharp Score (TSS) (scale = 0 to 448): MD -2.2, 95% CI -3.0 to -1.4; Erosion Score (ES) (scale = 0 to 280): MD -1.6; 95% CI -2.4 to -0.9; Joint Space Narrowing Score (JSNS) (scale = 0 to 168): MD -0.7; 95% CI -1.1 to -0.2), and with combination treatment compared with etanercept alone (TSS: MD -1.1; 95% CI -1.8 to -0.5; ES: MD -0.7; 95% CI -1.1 to -0.2; JSNS: MD -0.5, 95% CI -0.7 to -0.2). The estimate of irreversible physical disability over 10 years given the radiographic findings was 0.45 out of 3.0.When etanercept monotherapy was compared with DMARD monotherapy, there was generally no evidence of a difference in ACR50 response rates when etanercept 10 mg or 25 mg was used; at six months etanercept 25 mg was significantly more likely to achieve ACR50 than DMARD monotherapy but this difference was not found at 12, 24 or 36 months. TSS and ES radiographic scores were statistically significantly improved with etanercept 25 mg monotherapy compared with DMARD (TSS: MD -0.7; 95% CI -1.4 to 0.1; ES: MD -0.7; 95% CI -1.0 to -0.3) but there was no evidence of a statistically significant difference between etanercept 10 mg monotherapy and MTX.HarmsThere was no evidence of statistically significant differences in infections or serious infections between etanercept plus DMARD and DMARD alone at any point in time. Infection rates were higher in people receiving etanercept monotherapy compared with DMARD; however, there were no differences regarding serious infections. For those participants who had an inadequate response to DMARDs, the rate of total withdrawals was lower for the etanercept plus DMARD group compared with DMARD alone (RR 0.53; 95% CI 0.36 to 0.77, ATB 18%). No other statistically significant differences were observed in any of the assessed comparisons. AUTHORS' CONCLUSIONS Etanercept 25 mg administered subcutaneously twice weekly together with MTX was more efficacious than either etanercept or MTX monotherapy for ACR50 and it slowed joint radiographic progression after up to three years of treatment for all participants (responders or not). There was no evidence of a difference in the rates of infections between groups.
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Affiliation(s)
- Anne Lethaby
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand1142
| | - Maria Angeles Lopez‐Olivo
- The University of Texas, M.D. Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | - Lara J Maxwell
- University of OttawaCentre for Global Health, Institute of Population Health1 Stewart StreetOttawaOntarioCanadaK1N 6N5
| | - Amanda Burls
- City University LondonSchool of Health SciencesMyddleton StreetLondonUKEC1V 0HB
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaOntarioCanadaK1H 8M5
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanadaK1Y 4E9
- University of OttawaInstitute of Population Health & Department of Epidemiology and Community Medicine1 Stewart StreetOttawaOntarioCanadaK1N 6N5
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaOntarioCanadaK1Y 4W7
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Durigutto P, Macor P, Ziller F, De Maso L, Fischetti F, Marzari R, Sblattero D, Tedesco F. Prevention of arthritis by locally synthesized recombinant antibody neutralizing complement component C5. PLoS One 2013; 8:e58696. [PMID: 23505550 PMCID: PMC3591401 DOI: 10.1371/journal.pone.0058696] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 02/05/2013] [Indexed: 01/25/2023] Open
Abstract
Treatment of patients suffering from chronic diseases such as rheumatoid arthritis with recombinant antibodies is time consuming and fairly expensive and can be associated with side effects due to generalized depletion of the target molecule. We have addressed these issues by developing an alternative approach consisting of the intraarticular injection of a DNA vector encoding for the anti-C5 neutralizing recombinant miniantibody MB12/22. This method allows local production of the antibody in sufficient amount to be effective in preventing joint inflammation in a rat model of antigen-induced arthritis. Injection of the DNA vector in a right knee of normal rats resulted in the production of the minibody detected in the synovial washes by western blot with a strong signal peaking at 3 days after administration. DNA encoding for the minibody was shown for 14 days in the synovial tissue and was undetectable in the controlateral knee and in other organs. The preventive effect of this approach was evaluated in rats receiving a single injection of the vector 3 days before the induction of antigen-induced arthritis and analyzed 3 days later. The treated rats exhibited a lower increase in swelling, associated with a lower number of PMN in the articular washes and reduced deposition of C9 in synovial tissue compared to control rats. These results suggest that treating the inflamed joints with a vector that induces a local production of a neutralizing anti-C5 antibody may represent a useful strategy to inhibit in situ complement activation and to treat patients with monoarthritis. Moreover, this approach may be adopted as a novel therapeutic strategy to prevent monoarthritis as an alternative to local treatment with antibodies commonly used in this form of arthritis, with the advantages of the lower cost and the longer persistence of antibody production.
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Affiliation(s)
- Paolo Durigutto
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Paolo Macor
- Department of Life Sciences, University of Trieste, Trieste, Italy
- * E-mail:
| | - Federica Ziller
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Luca De Maso
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Fabio Fischetti
- Dipartimento Universitario Clinico di Scienze Mediche, Chirurgiche e della Salute, University of Trieste, Trieste, Italy
| | - Roberto Marzari
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Daniele Sblattero
- Department of Medical Sciences and IRCAD, University of Eastern Piedmont, Novara, Italy
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Management of persistent inflammatory large joint monoarthritis. Clin Rheumatol 2012; 31:1657-62. [DOI: 10.1007/s10067-012-2104-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 10/17/2012] [Indexed: 01/01/2023]
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