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Tornero Molina J, Hernández-Cruz B, Corominas H. Initial Treatment with Biological Therapy in Rheumatoid Arthritis. J Clin Med 2023; 13:48. [PMID: 38202055 PMCID: PMC10779475 DOI: 10.3390/jcm13010048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND We aimed to analyse the effectiveness, efficiency, and safety of initial treatment with biological therapies in rheumatoid arthritis (RA). METHODS Qualitative study. A group of RA experts was selected. A scoping review in Medline was conducted to analyse the evidence of initial RA treatment with biological therapies. Randomised clinical trials were selected. Two reviewers analysed the articles and compiled the data, whose quality was assessed using the Jadad scale. The experts discussed the review's findings and generated a series of general principles: Results: Seventeen studies were included. Most of the included patients were middle-aged women with early RA (1-7 months) and multiple poor prognostic factors. Initial treatment with TNF-alpha inhibitors combined with methotrexate (MTX) and an IL6R inhibitor (either in mono or combination therapy) is effective (activity, function, radiographic damage, quality of life), safe, and superior to MTX monotherapy in the short and medium term. In the long term, patients who received initial treatment with biologicals presented better results than those whose initial therapy was with MTX. CONCLUSIONS Initial treatment of RA with biological therapies is effective, efficient, and safe in the short, medium, and long term, particularly for patients with poor prognostic factors.
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Affiliation(s)
- Jesús Tornero Molina
- Departamento de Reumatología, Hospital de Guadalajara, 19002 Guadalajara, Spain
- Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá, 28805 Madrid, Spain
| | - Blanca Hernández-Cruz
- Departamento de Reumatología, Hospital Universitario Virgen Macarena, 41009 Sevilla, Spain;
| | - Héctor Corominas
- Departamento de Reumatología, Hospital Universitari de Sant Pau & Hospital Dos de Maig, 08025 Barcelona, Spain;
- Medicine Faculty, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
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2
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Pokharel G, Deardon R, Johnson SR, Tomlinson G, Hull PM, Hazlewood GS. Effectiveness of initial methotrexate-based treatment approaches in early rheumatoid arthritis: an elicitation of rheumatologists' beliefs. Rheumatology (Oxford) 2021; 60:3570-3578. [PMID: 33367919 DOI: 10.1093/rheumatology/keaa803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/12/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To quantify rheumatologists' beliefs about the effectiveness of triple therapy (MTX + HCQ + SSZ) and other commonly used initial treatments for RA. METHODS In a Bayesian belief elicitation exercise, 40 rheumatologists distributed 20 chips, each representing 5% of their total weight of belief on the probability that a typical patient with moderate-severe early RA would have an ACR50 response within 6 months with MTX (oral and s.c.), MTX + HCQ (dual therapy) and triple therapy. Parametric distributions were fit, and used to calculate pairwise median relative risks (RR), with 95% credible intervals, and estimate sample sizes for new trials to shift these beliefs. RESULTS In the pooled analysis, triple therapy was perceived to be superior to MTX (RR 1.97; 1.35, 2.89) and dual therapy (RR 1.32; 1.03, 1.73). A pessimistic subgroup (n = 10) perceived all treatments to be similar, whereas an optimistic subgroup (n = 10) believed triple therapy to be most effective of all (RR 4.03; 2.22, 10.12). Similar variability was seen for the comparison between oral and s.c. MTX. Assuming triple therapy is truly more effective than MTX, a trial of 100 patients would be required to convince the pessimists; if triple therapy truly has no-modest effect (RR <1.5), a non-inferiority trial of 475 patients would be required to convince the optimists. CONCLUSION Rheumatologists' beliefs regarding the effectiveness of triple therapy vary, which may partially explain the variability in its use. Owing to the strength of beliefs, some may be reluctant to shift, even with new evidence.
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Affiliation(s)
- Gyanendra Pokharel
- Department of Mathematics and Statistics, Faculty of Science, University of Winnipeg, Winnipeg, Canada
| | - Rob Deardon
- Departments of Mathematics and Statistics and Production Animal Health, Faculties of Science and Veterinary Medicine, University of Calgary, Calgary, Canada
| | - Sindhu R Johnson
- Division of Rheumatology, Toronto Western Hospital, Mount Sinai Hospital, Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Pauline M Hull
- Department of Community Health Sciences, Calgary, Canada
| | - Glen S Hazlewood
- Department of Community Health Sciences, Calgary, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
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3
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Hazlewood GS, Loyola-Sanchez A, Bykerk V, Hull PM, Marshall D, Pham T, Barber CEH, Barnabe C, Sirois A, Pope J, Schieir O, Richards D, Proulx L, Bartlett SJ. Patient and Rheumatologist Perspectives on Tapering DMARDs in Rheumatoid Arthritis: A Qualitative Study. Rheumatology (Oxford) 2021; 61:606-616. [PMID: 33878168 DOI: 10.1093/rheumatology/keab330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/06/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To understand the perspectives of patients and rheumatologists for tapering DMARDs in RA. METHODS Using semi-structured interview guides, we conducted individual interviews and focus groups with RA patients and rheumatologists, which were audiotaped and transcribed. We conducted a pragmatic thematic analysis to identify major themes, comparing and contrasting different views on DMARD tapering between patients and rheumatologists. RESULTS We recruited 28 adult patients with RA (64% women; disease duration 1-54 years) and 23 rheumatologists (52% women). Attitudes across both groups towards tapering DMARDs were ambivalent, ranging from wary to enthusiastic. Both groups expressed concerns, particularly the inability to 'recapture' the same level of disease control, while also acknowledging potential positive outcomes such as reduced drug harms. Patient tapering perspectives (whether to and when) changed over time and commonly included non-biologic DMARDs. Patient preferences were influenced by lived experiences, side effects, previous tapering experiences, disease trajectory, remission duration, and current life roles. Rheumatologists' perspectives varied on timing and patient profile to initiate tapering, and were informed by both data and clinical experience. Patients expressed interest in shared decision making (SDM) and close monitoring during tapering, with ready access to their healthcare team if problems arose. Rheumatologists were generally open to tapering (not stopping), though sometimes only when requested by their patients. CONCLUSION The perspectives of patients and rheumatologists on tapering DMARDs in RA vary and evolve over time. Rheumatologists should periodically discuss DMARD tapering with patients as part of SDM, and ensure monitoring and flare management plans are in place.
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Affiliation(s)
- Glen S Hazlewood
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Arthritis Research Canada, Richmond, BC, Canada.,McCaig Institute for Bone and Joint Health, Calgary, Canada
| | - Adalberto Loyola-Sanchez
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Vivian Bykerk
- Hospital for Special Surgery, Weill Cornell Medical College, New York New York, USA
| | - Pauline M Hull
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Deborah Marshall
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Arthritis Research Canada, Richmond, BC, Canada.,McCaig Institute for Bone and Joint Health, Calgary, Canada
| | - Tram Pham
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Claire E H Barber
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Arthritis Research Canada, Richmond, BC, Canada.,McCaig Institute for Bone and Joint Health, Calgary, Canada
| | - Cheryl Barnabe
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.,Arthritis Research Canada, Richmond, BC, Canada.,McCaig Institute for Bone and Joint Health, Calgary, Canada
| | - Alexandra Sirois
- Faculty of Graduate Studies, McGill University, Montreal, Quebec, Canada
| | - Janet Pope
- St. Joseph's Health Care London, University of Western Ontario, London, Ontario, Canada
| | - Orit Schieir
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Dawn Richards
- Canadian Arthritis Patient Alliance, Toronto, Ontario, Canada
| | - Laurie Proulx
- Canadian Arthritis Patient Alliance, Toronto, Ontario, Canada
| | - Susan J Bartlett
- Division of Clinical Epidemiology, Department of Medicine, McGill University and Centre for Outcomes Research and Evaluation, Research Institute-McGill University Health Centre, Montreal, Quebec, Canada
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4
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Widdifield J, Bernatsky S, Pope JE, Kuriya B, Barber CEH, Eder L, Ahluwalia V, Ling V, Gozdyra P, Hofstetter C, Lyddiatt A, Paterson JM, Thorne C. Evaluation of Rheumatology Workforce Supply Changes in Ontario, Canada, from 2000 to 2030. ACTA ACUST UNITED AC 2021; 16:119-134. [PMID: 33720829 PMCID: PMC7957360 DOI: 10.12927/hcpol.2021.26428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs). Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists. We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030. Over time, we observed greater feminization of the workforce and increasing age of workforce members. We identified a large regional variation in rheumatology supply. Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care. Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed.
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Affiliation(s)
- Jessica Widdifield
- Scientist, Sunnybrook Research Institute Holland Bone & Joint Program; Assistant Professor, University of Toronto, Institute of Health Policy, Management & Evaluation Toronto, ON; Scientist, ICES Toronto, ON
| | - Sasha Bernatsky
- Rheumatologist and Scientist, Research Institute of the McGill University Health Centre; Associate Professor, Department of Epidemiology, McGill University, Montreal, QC
| | - Janet E Pope
- Rheumatologist, St Joseph's Health Care London; Professor of Medicine Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University London, ON
| | - Bindee Kuriya
- Rheumatologist, Sinai Health System; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON
| | - Claire E H Barber
- Rheumatologist, Assistant Professor, University of Calgary, Calgary, AB; Research Scientist, Arthritis Research Canada, Richmond, BC
| | - Lihi Eder
- Rheumatologist, Clinician Scientist, Women's College Research Institute, Toronto, ON
| | | | | | | | | | | | - J Michael Paterson
- Scientist, ICES, Toronto, ON; Assistant Professor, Department of Family Medicine, McMaster University, Hamilton, ON; Assistant Professor, University of Toronto, Institute of Health Policy, Management & Evaluation, Toronto, ON
| | - Carter Thorne
- Rheumatologist, Southlake Regional Health Centre, Newmarket, ON; Assistant Professor of Medicine, University of Toronto, Toronto, ON
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5
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Hazlewood GS, Marshall DA, Barber CEH, Li LC, Barnabe C, Bykerk V, Tugwell P, Hull PM, Bansback N. Using a Discrete-Choice Experiment in a Decision Aid to Nudge Patients Towards Value-Concordant Treatment Choices in Rheumatoid Arthritis: A Proof-of-Concept Study. Patient Prefer Adherence 2020; 14:829-838. [PMID: 32546977 PMCID: PMC7244245 DOI: 10.2147/ppa.s221897] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 02/27/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To evaluate, in a proof-of-concept study, a decision aid that incorporates hypothetical choices in the form of a discrete-choice experiment (DCE), to help patients with early rheumatoid arthritis (RA) understand their values and nudge them towards a value-centric decision between methotrexate and triple therapy (a combination of methotrexate, sulphasalazine and hydroxychloroquine). PATIENTS AND METHODS In the decision aid, patients completed a series of 6 DCE choice tasks. Based on the patient's pattern of responses, we calculated his/her probability of choosing each treatment, using data from a prior DCE. Following pilot testing, we conducted a cross-sectional study to determine the agreement between the predicted and final stated preference, as a measure of value concordance. Secondary outcomes including time to completion and usability were also evaluated. RESULTS Pilot testing was completed with 10 patients and adjustments were made. We then recruited 29 patients to complete the survey: median age 57, 55% female. The patients were all taking treatment and had well-controlled disease. The predicted treatment agreed with the final treatment chosen by the patient 21/29 times (72%), similar to the expected agreement from the mean of the predicted probabilities (68%). Triple therapy was the predicted treatment 24/29 times (83%) and chosen 20/29 (69%) times. Half of the patients (51%) agreed that completing the choice questions helped them to understand their preferences (38% neutral, 10% disagreed). The tool took an average of 15 minutes to complete, and median usability scores were 55 (system usability scale) indicating "OK" usability. CONCLUSION Using a DCE as a value-clarification task within a decision aid is feasible, with promising potential to help nudge patients towards a value-centric decision. Usability testing suggests further modifications are needed prior to implementation, perhaps by having the DCE exercises as an "add-on" to a simpler decision aid.
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Affiliation(s)
- Glen S Hazlewood
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint Health, University of Calgary, Calgary, Canada
- Arthritis Research Canada, Vancouver, BC, Canada
- Correspondence: Glen S Hazlewood Departments of Medicine and Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, 3AA10, CalgaryAB T2N 4Z6, CanadaTel +1 403 220-5903Fax +1 403 210-3899 Email
| | - Deborah A Marshall
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint Health, University of Calgary, Calgary, Canada
- Arthritis Research Canada, Vancouver, BC, Canada
| | - Claire E H Barber
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint Health, University of Calgary, Calgary, Canada
- Arthritis Research Canada, Vancouver, BC, Canada
| | - Linda C Li
- Arthritis Research Canada, Vancouver, BC, Canada
| | - Cheryl Barnabe
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint Health, University of Calgary, Calgary, Canada
- Arthritis Research Canada, Vancouver, BC, Canada
| | - Vivian Bykerk
- Weill Cornell Medical College, Cornell University, New York, NY, USA
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Peter Tugwell
- Department of Medicine, Department of Epidemiology and Community Medicine, Canada Research Chair, University of Ottawa, Institute of Population Health, Ottawa, Canada
| | | | - Nick Bansback
- Arthritis Research Canada, Vancouver, BC, Canada
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada
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6
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Pokharel G, Deardon R, Barnabe C, Bykerk V, Bartlett SJ, Bessette L, Boire G, Hitchon CA, Keystone E, Pope J, Schieir O, Tin D, Thorne C, Hazlewood GS. Joint Estimation of Remission and Response for Methotrexate-Based DMARD Options in Rheumatoid Arthritis: A Bivariate Network Meta-Analysis. ACR Open Rheumatol 2019; 1:471-479. [PMID: 31777827 PMCID: PMC6858043 DOI: 10.1002/acr2.11052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 06/04/2019] [Indexed: 12/21/2022] Open
Abstract
Objective To jointly estimate American College of Rheumatology (ACR50) response (a more commonly reported outcome) and remission (a more clinically relevant outcome) for methotrexate (MTX)‐based treatment options in rheumatoid arthritis (RA). Methods We conducted a bivariate network meta‐analysis (NMA) to compare MTX monotherapy and MTX‐based conventional and biologic disease‐modifying antirheumatic drug (DMARD) combinations for RA. The correlation between the outcomes was derived from an incident RA cohort study, whereas the treatment effects were derived from randomized trials in the network of evidence. The analyses were conducted separately for MTX‐naïve and MTX–inadequate response (IR) populations in a Bayesian framework with uninformative priors. Results From the cohort study, the correlation between ACR50 response and Disease Activity Score 28 remission at 6 months was moderate (Pearson correlation coefficient = 0.58). In the bivariate NMA for MTX‐naïve populations, most combinations of MTX with either biologic or tofacitinib were statistically superior to MTX alone for both ACR50 response and remission. Triple therapy (MTX + sulfasalazine + hydroxychloroquine) was the only nonbiologic DMARD statistically superior to MTX for either ACR50 response (odds ratio [OR] 95% credible interval: 2.1 [1.0, 4.3]) or remission (OR: 2.5 [1.0, 5.8]). In the MTX‐IR analysis, all treatments except MTX + sulfasalazine were statistically superior to MTX alone. Compared to analyzing the outcomes separately, the bivariate model often resulted in more precise estimates and allowed remission to be estimated for all treatments. Conclusion Borrowing the strength of correlation between outcomes allowed us to demonstrate a statistically significant benefit for remission across most MTX‐based DMARD combinations, including triple therapy.
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Affiliation(s)
| | - Rob Deardon
- University of Calgary, Calgary, Alberta, Canada
| | | | - Vivian Bykerk
- Cornell University, New York, New York and Hospital for Special Surgery, New York, New York
| | - Susan J Bartlett
- McGill University, Montreal, Quebec, Canada, and Johns Hopkins University, Baltimore, Maryland
| | | | - Gilles Boire
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | | | - Janet Pope
- Western University, London, Ontario, Canada
| | | | - Diane Tin
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | - Carter Thorne
- Southlake Regional Health Center, Newmarket, Ontario, Canada
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7
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Yates M, Bechman K, Norton S, Nikiphorou E, Galloway J. Centre effects and case-mix in early rheumatoid arthritis observational cohorts: a narrative review. Rheumatology (Oxford) 2019; 58:1991-1999. [PMID: 31329968 DOI: 10.1093/rheumatology/kez151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/21/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Observational cohort studies in early RA are a key source of evidence, despite inconsistencies in methodological approaches. This narrative review assesses the spectrum of methodologies used in addressing centre-level effect and case-mix adjustment in early RA observational cohort studies. METHODS An electronic search was undertaken to identify observational prospective cohorts of >100 patients recruited from two or more centres, within 2 years of an RA or early inflammatory arthritis diagnosis. References and author publication lists of all studies from eligible cohorts were assessed for additional cohorts. RESULTS Thirty-four unique cohorts were identified from 204 studies. Seven percent of studies considered centre in their analyses, most commonly as a fixed effect in regression modelling. Reporting of case-mix variables in analyses varied widely. The number of variables considered in case-mix adjustment was higher following publication of the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement in 2007. CONCLUSION Centre effect is unreported or inadequately accounted for in the majority of RA observational cohorts, potentially leading to spurious inferences and obstructing comparisons between studies. Inadequate case-mix adjustment precludes meaningful comparisons between centres. Appropriate methodology to account for centre and case-mix adjustment should be considered at the outset of analyses.
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Affiliation(s)
- Mark Yates
- Centre for Rheumatic Disease, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Disease, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Sam Norton
- Centre for Rheumatic Disease, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Disease, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - James Galloway
- Centre for Rheumatic Disease, Division of Immunology, Infection and Inflammatory Disease, Faculty of Life Sciences & Medicine, King's College London, London, UK
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Carr ECJ, Patel JN, Ortiz MM, Miller JL, Teare SR, Barber CEH, Marshall DA. Co-design of a patient experience survey for arthritis central intake: an example of meaningful patient engagement in healthcare design. BMC Health Serv Res 2019; 19:355. [PMID: 31164176 PMCID: PMC6549374 DOI: 10.1186/s12913-019-4196-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 05/28/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND To describe the process of patient engagement to co-design a patient experience survey for people with arthritis referred to central intake. METHODS We used a participatory design to engage with patients to co-design a patient experience survey that comprised three connected phases: 1) Identifying the needs of patients with arthritis, 2) Developing a set of key performance indicators, and 3) Determining the survey items for the patient experience survey. RESULTS Patient recommendations for high quality healthcare care means support to manage arthritis, to live a meaningful life by providing the right knowledge, professional support, and professional relationship. The concept of integrated care was a core requirement from the patients' perspective for the delivery of high quality arthritis care. Patients experience with care was ranked in the top 10 of 28 Key Performance Indicators for the evaluation of central intake, with 95% of stakeholders rating it as 9/10 for importance. A stakeholder team, including Patient and Community Engagement Researchers (PaCER), mapped and rated 41 survey items from four validated surveys. The final patient experience survey had 23 items. CONCLUSION The process of patient engagement to co-design a patient experience survey, for people with arthritis, identified aspects of care that had not been previously recognized. The linear organization of frameworks used to report patient engagement in research does not always capture the complexity of reality. Additional resources of cost, time and expertise for patient engagement in co-design activity are recognized and should be included, where possible, to ensure high quality data is captured.
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Affiliation(s)
- Eloise C. J. Carr
- Faculty of Nursing, University of Calgary, PF2237, 2500 University Drive NW, Calgary, Alberta T2N 1N4 Canada
| | - Jatin N. Patel
- Pan-SCN Manager, Strategic Clinical Networks™, Alberta Health Services, 10030 – 107 Street NW, Edmonton, Alberta T5J 3E4 Canada
| | - Mia M. Ortiz
- Faculty of Nursing, University of Calgary, PF2237, 2500 University Drive NW, Calgary, Alberta T2N 1N4 Canada
| | - Jean L. Miller
- O’Brien Institute for Public Health, University of Calgary, 3280, Hospital Dr. NW, Calgary, Alberta T2N 4Z6 Canada
| | - Sylvia R. Teare
- O’Brien Institute for Public Health, University of Calgary, 3280, Hospital Dr. NW, Calgary, Alberta T2N 4Z6 Canada
| | - Claire E. H. Barber
- Arthritis Research Center, University of Calgary, HRIC 3AA20, 3280, Hospital Dr. NW, Calgary, Alberta T2N 4Z6 Canada
| | - Deborah A. Marshall
- Cumming School of Medicine, University of Calgary, Health Research Innovation Centre (HRIC) – 3C56, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6 Canada
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9
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Yates M, Galloway J, Bukhari M. Better is possible. Rheumatology (Oxford) 2019; 58:741-742. [DOI: 10.1093/rheumatology/key193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mark Yates
- Academic Rheumatology Department, King’s College London, Weston Education Centre, London
| | - James Galloway
- Academic Rheumatology Department, King’s College London, Weston Education Centre, London
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10
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Pope JE, Hazlewood GS. Randomized Trials, Meta-Analyses, and Systematic Reviews: Using Examples from Rheumatology. Rheum Dis Clin North Am 2018; 44:295-305. [PMID: 29622296 DOI: 10.1016/j.rdc.2018.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article introduces contemporary ideas and standards for clinical research in rheumatology for randomized trials, systematic reviews, and meta-analyses. Examples of different randomized trials in rheumatic diseases are provided to understand the methods for trials and the rationale for outcomes within trials. Insights from meta-analyses and systematic literature reviews, including network meta-analyses within rheumatology treatment, are provided. Ethical considerations, sample size calculations, and types of randomized controlled trials are discussed.
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Affiliation(s)
- Janet E Pope
- Rheumatology, University of Western Ontario, St. Joseph's Health Care, D2, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada.
| | - Glen S Hazlewood
- Department of Medicine, University of Calgary, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada; Department of Community Health Sciences, University of Calgary, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
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11
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Hazlewood GS. Measuring Patient Preferences: An Overview of Methods with a Focus on Discrete Choice Experiments. Rheum Dis Clin North Am 2018; 44:337-347. [PMID: 29622300 DOI: 10.1016/j.rdc.2018.01.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
There is increasing recognition of the importance of patient preferences and methodologies to measure them. In this article, methods to quantify patient preferences are reviewed, with a focus on discrete choice experiments. In a discrete choice experiment, patients are asked to choose between 2 or more treatments. The results can be used to quantify the relative importance of treatment outcomes and/or other considerations relevant to medical decision making. Conducting and interpreting a discrete choice experiment requires multiple steps and an understanding of the potential biases that can arise, which we review in this article with examples in rheumatic diseases.
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Affiliation(s)
- Glen S Hazlewood
- Department of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N4Z6, Canada; Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N4Z6, Canada.
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12
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Varela-Rosario N, Arroyo-Ávila M, Fred-Jiménez RM, Díaz-Correa LM, Pérez-Ríos N, Rodríguez N, Ríos G, Vilá LM. Long-Term Outcomes in Puerto Ricans with Rheumatoid Arthritis (RA) Receiving Early Treatment with Disease-Modifying Anti-Rheumatic Drugs using the American College of Rheumatology Definition of Early RA. Open Rheumatol J 2018; 11:136-144. [PMID: 29387286 PMCID: PMC5750682 DOI: 10.2174/1874312901711010136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/17/2017] [Accepted: 12/14/2017] [Indexed: 11/22/2022] Open
Abstract
Background Early treatment of rheumatoid arthritis (RA) results in better long-term outcomes. However, the optimal therapeutic window has not been clearly established. Objective To determine the clinical outcome of Puerto Ricans with RA receiving early treatment with conventional and/or biologic disease-modifying anti-rheumatic drugs (DMARDs) based on the American College of Rheumatology (ACR) definition of early RA. Methods A cross-sectional study was performed in a cohort of Puerto Ricans with RA. Demographic features, clinical manifestations, disease activity, functional status, and pharmacotherapy were determined. Early treatment was defined as the initiation of DMARDs (conventional and/or biologic) in less than 6 months from the onset of symptoms attributable to RA. Patients who received early (< 6months) and late (≥6 months) treatments were compared using bivariate and multivariate analyses. Results The cohort comprised 387 RA patients. The mean age at study visit was 56.0 years. The mean disease duration was 14.9 years and 337 (87.0%) patients were women. One hundred and twenty one (31.3%) patients received early treatment. In the multivariate analysis adjusted for age and sex, early treatment was associated with better functional status, lower probability of joint deformities, intra-articular injections and joint replacement surgeries, and lower scores in the physician's assessments of global health, functional impairment and physical damage of patients. Conclusion Using the ACR definition of early RA, this group of patients treated with DMARDs within 6 months of disease had better long-term outcomes with less physical damage and functional impairment.
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Affiliation(s)
- Noemí Varela-Rosario
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Mariangelí Arroyo-Ávila
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Ruth M Fred-Jiménez
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Leyda M Díaz-Correa
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Naydi Pérez-Ríos
- Puerto Rico Clinical and Translational Research Center, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Noelia Rodríguez
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Grissel Ríos
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Luis M Vilá
- Division of Rheumatology, Department of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
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Tornero-Molina J, Andreu JL, Martín-Martínez MA, Corominas H, Pérez Venegas JJ, Román-Ivorra JA, Sánchez-Alonso F. Methotrexate in patients with rheumatoid arthritis in Spain: Subanalysis of the AR Excellence project. ACTA ACUST UNITED AC 2017; 15:338-342. [PMID: 29273497 DOI: 10.1016/j.reuma.2017.11.007] [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: 09/20/2017] [Revised: 11/21/2017] [Accepted: 11/21/2017] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The AR Excellence project evaluates clinical monitoring in patients with rheumatoid arthritis (RA) in Spain. The aim of the study was to analyze the use of methotrexate (MTX) in the AR Excellence cohort and to compare it with current recommendations. PATIENTS AND METHODS We collected data from RA patients who initiated treatment with MTX. They included demographics, dose and routes of administration, switching among them, highest dose in each route, combinations with other disease-modifying antirheumatic drugs (DMARDs), time to combination with another DMARD (either conventional or biological) and adverse events. RESULTS Six hundred twenty-five patients with RA (mean age 55 years; 70.6% women) were included, with an average disease duration of 21 months. Ninety percent of the patients initiated treatment with MTX. Therapy was begun with a mean dose of 11mg per week; this initial dose was increased in 58% of the individuals. The average time to reach the full dose of MTX (20mg a week) was 6,67 months. Time to combination of MTX with another DMARD, either synthetic or biological, was 3 months. In all, 67.4% of the patients received oral MTX and the route was subcutaneous in 18.6%. In 12% of the cases, there was a change in the route of administration after a period of 6 months. In 544 patients, folate supplements were added to MTX; MTX-related adverse events were detected in 17.3% of the patients. CONCLUSION MTX is currently the pivotal treatment in RA. The subanalysis of the AR Excellence project demonstrates that MTX escalation to its full doses is not done with adequate speed. The subcutaneous route is used in a small proportion of patients.
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Affiliation(s)
- Jesús Tornero-Molina
- Servicio de Reumatología, Hospital Universitario de Guadalajara, Guadalajara, Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá, Madrid, España.
| | - José Luis Andreu
- Servicio de Reumatología, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, España
| | | | - Héctor Corominas
- Servicio de Reumatología, Hospital Moisès Broggi, Hospital General de L'Hospitalet, Barcelona, España
| | | | - José Andrés Román-Ivorra
- Servicio de Reumatología, Hospital Universitari i Politècnic La Fe, Facultad de Medicina, Universidad Católica de Valencia, Valencia, España
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Rannio T, Asikainen J, Hannonen P, Yli-Kerttula T, Ekman P, Pirilä L, Kuusalo L, Mali M, Puurtinen-Vilkki M, Kortelainen S, Paltta J, Taimen K, Kauppi M, Laiho K, Nyrhinen S, Mäkinen H, Isomäki P, Uotila T, Aaltonen K, Kautiainen H, Sokka T. Three out of four disease-modifying anti-rheumatic drug-naïve rheumatoid arthritis patients meet 28-joint Disease Activity Score remission at 12 months: results from the FIN-ERA cohort. Scand J Rheumatol 2017; 46:425-431. [DOI: 10.1080/03009742.2016.1266029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- T Rannio
- Department of Rheumatology, Central Hospital of Central Finland, Jyväskylä, Finland
| | - J Asikainen
- Department of Rheumatology, Central Hospital of Central Finland, Jyväskylä, Finland
| | - P Hannonen
- Department of Rheumatology, Central Hospital of Central Finland, Jyväskylä, Finland
| | - T Yli-Kerttula
- Department of Rheumatology, Satakunta Central Hospital, Rauma, Finland
| | - P Ekman
- Department of Rheumatology, Satakunta Central Hospital, Rauma, Finland
| | - L Pirilä
- Department of Rheumatology, Internal Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - L Kuusalo
- Department of Rheumatology, Internal Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - M Mali
- Department of Rheumatology, Internal Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - M Puurtinen-Vilkki
- Department of Rheumatology, Internal Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - S Kortelainen
- Department of Rheumatology, Internal Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - J Paltta
- Department of Rheumatology, Internal Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - K Taimen
- Department of Rheumatology, Internal Medicine, Department of Clinical Medicine, University of Turku, Turku, Finland
| | - M Kauppi
- Department of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
| | - K Laiho
- Department of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
| | - S Nyrhinen
- Department of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
| | - H Mäkinen
- Department of Rheumatology, Tampere University Hospital, Tampere, Finland
| | - P Isomäki
- Department of Rheumatology, Tampere University Hospital, Tampere, Finland
| | - T Uotila
- Department of Rheumatology, Tampere University Hospital, Tampere, Finland
| | - K Aaltonen
- Faculty of Pharmacy, University of Helsinki, Helsinki, Finland
| | - H Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - T Sokka
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Crowson CS, Rollefstad S, Kitas GD, van Riel PLCM, Gabriel SE, Semb AG. Challenges of developing a cardiovascular risk calculator for patients with rheumatoid arthritis. PLoS One 2017; 12:e0174656. [PMID: 28334012 PMCID: PMC5363942 DOI: 10.1371/journal.pone.0174656] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/13/2017] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Cardiovascular disease (CVD) risk calculators designed for use in the general population do not accurately predict the risk of CVD among patients with rheumatoid arthritis (RA), who are at increased risk of CVD. The process of developing risk prediction models involves numerous issues. Our goal was to develop a CVD risk calculator for patients with RA. METHODS Thirteen cohorts of patients with RA originating from 10 different countries (UK, Norway, Netherlands, USA, Sweden, Greece, South Africa, Spain, Canada and Mexico) were combined. CVD risk factors and RA characteristics at baseline, in addition to information on CVD outcomes were collected. Cox models were used to develop a CVD risk calculator, considering traditional CVD risk factors and RA characteristics. Model performance was assessed using measures of discrimination and calibration with 10-fold cross-validation. RESULTS A total of 5638 RA patients without prior CVD were included (mean age: 55 [SD: 14] years, 76% female). During a mean follow-up of 5.8 years (30139 person years), 389 patients developed a CVD event. Event rates varied between cohorts, necessitating inclusion of high and low risk strata in the models. The multivariable analyses revealed 2 risk prediction models including either a disease activity score including a 28 joint count and erythrocyte sedimentation rate (DAS28ESR) or a health assessment questionnaire (HAQ) along with age, sex, presence of hypertension, current smoking and ratio of total cholesterol to high-density lipoprotein cholesterol. Unfortunately, performance of these models was similar to general population CVD risk calculators. CONCLUSION Efforts to develop a specific CVD risk calculator for patients with RA yielded 2 potential models including RA disease characteristics, but neither demonstrated improved performance compared to risk calculators designed for use in the general population. Challenges encountered and lessons learned are discussed in detail.
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Affiliation(s)
- Cynthia S. Crowson
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research and Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Silvia Rollefstad
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - George D. Kitas
- Dudley Group NHS Foundation Trust, West Midlands, United Kingdom
| | - Piet L. C. M. van Riel
- Department of Rheumatic Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Sherine E. Gabriel
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research and Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Anne Grete Semb
- Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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Matucci A, Cammelli D, Cantini F, Goletti D, Marino V, Milano GM, Scarpa R, Tocci G, Maggi E, Vultaggio A. Influence of anti-TNF immunogenicity on safety in rheumatic disease: a narrative review. Expert Opin Drug Saf 2016; 15:3-10. [DOI: 10.1080/14740338.2016.1221398] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Andrea Matucci
- Immunoallergology Unit, Department of Biomedicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Daniele Cammelli
- Immunoallergology Unit, Department of Biomedicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Fabrizio Cantini
- Division of Rheumatology, Misericordia e Dolce Hospital, Prato, Italy
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases, Rome, Italy
| | | | - Giuseppe Maria Milano
- Department of Pediatric Hematology, Oncology and Transplant Unit, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Raffaele Scarpa
- Rheumatology Research Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant’Andrea Hospital, Rome, Italy
- IRCCS Neuromed, Pozzilli, Rome, Italy
| | - Enrico Maggi
- Center for Research, Transfer and High Education DENOTHE, University of Florence, Florence, Italy
| | - Alessandra Vultaggio
- Immunoallergology Unit, Department of Biomedicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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O'Connor A, Thorne C, Kang H, Tin D, Pope JE. The rapid kinetics of optimal treatment with subcutaneous methotrexate in early inflammatory arthritis: an observational study. BMC Musculoskelet Disord 2016; 17:364. [PMID: 27558249 PMCID: PMC4997744 DOI: 10.1186/s12891-016-1213-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Methotrexate (MTX) is standard treatment for RA. Absorption is better in subcutaneous MTX (scMTX), which may impact speed of onset. In RA, earlier time to remission improves long-term results. Our objectives were to determine rapidity of response of subcutaneous methotrexate in early rheumatoid arthritis. Methods The change in several disease activity measures (including DAS28) from 0 to 6 weeks (early period) and 6 to 12 weeks (late period) was compared. The proportion achieving DAS28/CDAI/SDAI remission and/or low disease activity state was also compared. Results One hundred three patients were included from a single site between 2008 and 2014. All received MTX (98.0 % scMTX, 98 % 25 mg/week). There were no dropouts. There was a significantly greater early change in DAS28 (−1.9 vs. −0.2, p < 0.00); this effect was seen for several outcome measures. By 6 weeks, 59 % had achieved either DAS28 remission or low disease activity state, with 74 % achieving either state by 12 weeks. There were a larger proportion of patients achieving CDAI and DAS28 remission in the early versus late period (p < 0.0002 for both). There was significant improvement when using combination MTX and HCQ, however sample size was small (n = 9). The use of intra-articular steroids with MTX yielded the most disease measures that demonstrated early significant improvement. Conclusion Subcutaneous MTX is rapid, as the change in many disease activity scores was significantly greater between 0–6 weeks compared to 6–12 weeks. Combination MTX + HCQ gave added value, although generalizability is limited by combination cohort sample size. Intra-articular steroid injections may contribute to the early effect. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1213-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna O'Connor
- Schulich School of Medicine & Dentistry, University of Western Ontario, 268 Grosvenor St, London, ON, N6A 4V2, Canada
| | | | - Hyeon Kang
- University of Toronto, Toronto, ON, Canada
| | - Diane Tin
- Southlake Regional Health Centre, Newmarket, Canada
| | - Janet E Pope
- Schulich School of Medicine & Dentistry, University of Western Ontario, 268 Grosvenor St, London, ON, N6A 4V2, Canada. .,University of Toronto, Toronto, ON, Canada. .,Rheumatology, St. Joseph's Health Care, London, ON, Canada.
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Hazlewood GS, Bombardier C, Tomlinson G, Thorne C, Bykerk VP, Thompson A, Tin D, Marshall DA. Treatment preferences of patients with early rheumatoid arthritis: a discrete-choice experiment. Rheumatology (Oxford) 2016; 55:1959-1968. [DOI: 10.1093/rheumatology/kew280] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 06/20/2016] [Indexed: 12/27/2022] Open
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Rannio T, Asikainen J, Kokko A, Hannonen P, Sokka T. Early Remission Is a Realistic Target in a Majority of Patients with DMARD-naive Rheumatoid Arthritis. J Rheumatol 2016; 43:699-706. [DOI: 10.3899/jrheum.141480] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 12/28/2022]
Abstract
Objective.We analyzed remission rates at 3 and 12 months in patients with rheumatoid arthritis (RA) who were naive for disease-modifying antirheumatic drugs (DMARD) and who were treated in a Finnish rheumatology clinic from 2008 to 2011. We compared remission rates and drug treatments between patients with RA and patients with undifferentiated arthritis (UA).Methods.Data from all DMARD-naive RA and UA patients from the healthcare district were collected using software that includes demographic and clinical characteristics, disease activity, medications, and patient-reported outcomes. Our rheumatology clinic applies the treat-to-target principle, electronic monitoring of patients, and multidisciplinary care.Results.Out of 409 patients, 406 had data for classification by the 2010 RA criteria of the American College of Rheumatology/European League Against Rheumatism. A total of 68% were female, and mean age (SD) was 58 (16) years. Respectively, 56%, 60%, and 68% were positive for anticyclic citrullinated peptide antibodies (anti-CCP), rheumatoid factor (RF), and RF/anti-CCP, and 19% had erosive disease. The median (interquartile range) duration of symptoms was 6 (4–12) months. A total of 310 were classified as RA and 96 as UA. The patients with UA were younger, had better functional status and lower disease activity, and were more often seronegative than the patients with RA. The 28-joint Disease Activity Score (3 variables) remission rates of RA and UA patients at 3 months were 67% and 58% (p = 0.13), and at 12 months, 71% and 79%, respectively (p = 0.16). Sustained remission was observed in 57%/56% of RA/UA patients. Patients with RA used more conventional synthetic DMARD combinations than did patients with UA. None used biological DMARD at 3 months, and only 2.7%/1.1% of the patients (RA/UA) used them at 12 months (p = 0.36).Conclusion.Remarkably high remission rates are achievable in real-world DMARD-naive patients with RA or UA.
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Hazlewood GS, Thorne JC, Pope JE, Lin D, Tin D, Boire G, Haraoui B, Hitchon CA, Keystone EC, Jamal S, Bykerk VP. The comparative effectiveness of oral versus subcutaneous methotrexate for the treatment of early rheumatoid arthritis. Ann Rheum Dis 2015; 75:1003-8. [PMID: 25979945 DOI: 10.1136/annrheumdis-2014-206504] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 04/05/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the comparative effectiveness of oral versus subcutaneous methotrexate (MTX) as initial therapy for patients with early rheumatoid arthritis (ERA). METHODS Patients with ERA (symptoms ≤1 year) initiating MTX therapy were included from a multicentre, prospective cohort study. We compared the effectiveness between starting with oral versus subcutaneous MTX over the first year. Longitudinal multivariable models, adjusted for potential baseline and time-varying confounders, were used to compare treatment changes due to inefficacy or toxicity and treatment efficacy (Disease Activity Score-28 (DAS-28), DAS-28 remission and Health Assessment Questionnaire-Disability Index (HAQ-DI)). RESULTS 666 patients were included (417 oral MTX, 249 subcutaneous MTX). Patients prescribed subcutaneous MTX were prescribed a higher dose of MTX (mean dose over first three months 22.3 mg vs 17.2 mg/week). At 1 year, 49% of patients initially treated with subcutaneous MTX had changed treatment compared with 77% treated with oral MTX. After adjusting for potential confounders, subcutaneous MTX was associated with a lower rate of treatment failure ((HR (95% CI) 0.55 (0.39 to 0.79)). Most treatment failures were due to inefficacy with no difference in failure due to toxicity. In multivariable models, subcutaneous MTX was also associated with lower average DAS-28 scores (mean difference (-0.38 (95% CI -0.64 to -0.10)) and a small difference in DAS-28 remission (OR 1.2 (95% CI 1.1 to 1.3)). There was no significant difference in sustained remission or HAQ-DI (p values 0.43 and 0.75). CONCLUSIONS Initial treatment with subcutaneous MTX was associated with lower rates of treatment changes, no difference in toxicity and some improvements in disease control versus oral MTX over the first year in patients with ERA.
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Affiliation(s)
- Glen S Hazlewood
- Institute of Health, Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada Department of Medicine, University of Calgary, Calgary, Alberta, Canada McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - J Carter Thorne
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Janet E Pope
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Daming Lin
- Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Diane Tin
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Gilles Boire
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke University, Sherbrooke, Quebec, Canada
| | - Boulos Haraoui
- University of Montreal Hospital Research Centre (CRCHUM), Montreal, Quebec, Canada
| | | | | | - Shahin Jamal
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Vivian P Bykerk
- Mount Sinai Hospital, Toronto, Ontario, Canada Hospital for Special Surgery, New York, New York, USA
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Sugihara T, Ishizaki T, Hosoya T, Iga S, Yokoyama W, Hirano F, Miyasaka N, Harigai M. Structural and functional outcomes of a therapeutic strategy targeting low disease activity in patients with elderly-onset rheumatoid arthritis: a prospective cohort study (CRANE). Rheumatology (Oxford) 2014; 54:798-807. [PMID: 25296748 DOI: 10.1093/rheumatology/keu395] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate structural damage and physical disability in patients with elderly-onset RA (EORA) who were treated in clinical practice with a therapeutic strategy targeting low disease activity (LDA). METHODS Data from 151 MTX-naive patients (mean age 74.9 years) with EORA from a prospective, monocentric registry were analysed. Treatment was adjusted every 3 months targeting LDA [28-joint DAS using ESR (DAS28-ESR) <3.2]. Treatment was initiated with non-biologic DMARDs (nbDMARDs), followed by TNF inhibitors (TNFis) or tocilizumab. The primary outcome was change from week 0 to week 52 in the modified total Sharp score (ΔmTSS). Secondary outcomes were derived from the HAQ Disability Index (HAQ-DI) and DAS28 at week 52. Predictors of clinically relevant radiographic progression [CRRP; ΔmTSS/year more than the smallest detectable change (2.1 points)] were examined using multivariate logistic regression models. RESULTS Adherence to the treat-to-target strategy was observed in 83.4% of the 151 patients at week 24 and in 75.5% at week 52. At week 52, 67.6% of the patients were receiving a nbDMARD alone, 31.0% a TNFi with or without MTX and 1.4% tocilizumab. At week 52, structural remission (ΔmTSS/yr ≤0.5) was achieved in 49.7% of the patients, functional remission (HAQ-DI ≤0.5) in 63.4% and LDA in 51.0%. Clinical responses at weeks 12 and 24 were significant independent predictors of CRRP. Cumulative disease activity during the first 12 weeks predicted CRRP with a C-statistic of 0.888. CONCLUSION Achieving structural remission, functional remission and LDA in clinical practice in EORA patients are realistic goals. Our results indicate significant benefits for a therapeutic strategy targeting LDA for EORA patients in clinical practice.
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Affiliation(s)
- Takahiko Sugihara
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuro Ishizaki
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tadashi Hosoya
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Iga
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan
| | - Waka Yokoyama
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan
| | - Fumio Hirano
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobuyuki Miyasaka
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Department of Medicine and Rheumatology and Department of Pharmacovigilance, Tokyo Medical and Dental University, Tokyo, Japan
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Katz SJ, Leung S. Teaching methotrexate self-injection with a web-based video maintains patient care while reducing healthcare resources: a pilot study. Rheumatol Int 2014; 35:93-6. [DOI: 10.1007/s00296-014-3076-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 06/12/2014] [Indexed: 11/30/2022]
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Bornstein C, Craig M, Tin D. Practice guidelines for pharmacists: The pharmacological management of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs. Can Pharm J (Ott) 2014; 147:97-109. [PMID: 24660010 DOI: 10.1177/1715163514521377] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Carolyn Bornstein
- The Arthritis Program, Southlake Regional Health Centre, Newmarket, Ontario
| | - Marie Craig
- The Arthritis Program, Southlake Regional Health Centre, Newmarket, Ontario
| | - Diane Tin
- The Arthritis Program, Southlake Regional Health Centre, Newmarket, Ontario
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