1
|
Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| |
Collapse
|
2
|
Harrold LR, Bryson J, Lehman T, Zhuo J, Gao S, Han X, Schrader A, Rebello S, Pappas DA, Sommers T, Kremer JM. Association Between Baseline Anti-cyclic Citrullinated Peptide Antibodies and 6-Month Clinical Response Following Abatacept or TNF Inhibitor Treatment: A Real-World Analysis of Biologic-Experienced Patients with RA. Rheumatol Ther 2021; 8:937-953. [PMID: 34047953 PMCID: PMC8217398 DOI: 10.1007/s40744-021-00310-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Anti-cyclic citrullinated peptide (anti-CCP) antibodies are associated with poor prognosis in patients with rheumatoid arthritis (RA). Previous data from randomized controlled trials and clinical practice have shown anti-CCP-positive (+) patients had a better response to treatment with abatacept or tumor necrosis factor inhibitor (TNFi) treatment than those who were anti-CCP negative. This study assessed the association between baseline anti-CCP2 [a surrogate for anti-citrullinated protein antibody (ACPA)] concentration and 6-month treatment responses to abatacept or TNFi in patients with RA. METHODS This real-world analysis included biologic-experienced patients from CERTAIN (Comparative Effectiveness Registry to study Therapies for Arthritis and Inflammatory CoNditions) who initiated abatacept or TNFi, had prior biologic disease-modifying drug exposure and baseline anti-CCP2 concentration/serostatus and serum samples (baseline and 6 months). Baseline demographics and disease characteristics were compared. Change from baseline at 6 months in Clinical Disease Activity Index (CDAI) score and patient-reported outcomes [PROs: pain, fatigue, patient global assessment (PtGA), modified Health Assessment Questionnaire (mHAQ) score], by baseline anti-CCP2 quartile and binary cut-off (> 10-250 and > 250 U/ml), were evaluated separately in the abatacept and TNFi groups using a linear regression model adjusted for age, sex, CDAI/PROs, comorbidity index, and methotrexate use. RESULTS Included were 138 abatacept and 137 TNFi initiators who were anti-CCP2+. At baseline, there were significant differences between anti-CCP2 quartiles and mean CDAI, swollen joint count 28, C-reactive protein (CRP), Disease Activity Score 28 (CRP), rheumatoid factor (RF), mHAQ and physician global assessment among abatacept initiators, and in mean RF, mHAQ, and PtGA among TNFi initiators. Among abatacept (but not TNFi) initiators, CDAI numerically improved (p = 0.208) and PROs significantly improved (p < 0.05) with increasing baseline anti-CCP2. CONCLUSIONS In patients treated with abatacept, not TNFi, higher anti-CCP2 concentrations at baseline were associated with numerically greater improvements in CDAI and significant improvements in PROs after 6 months. CLINICAL TRIAL NUMBER NCT01625650.
Collapse
Affiliation(s)
- Leslie R Harrold
- CorEvitas, LLC, 1440 Main Street, Suite 310, Waltham, MA, 02451, USA.
- University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Joshua Bryson
- Bristol Myers Squibb, 100 Nassau Park Blvd #300, Princeton, NJ, 08540, USA
| | - Thomas Lehman
- Bristol Myers Squibb, 100 Nassau Park Blvd #300, Princeton, NJ, 08540, USA
| | - Joe Zhuo
- Bristol Myers Squibb, 100 Nassau Park Blvd #300, Princeton, NJ, 08540, USA
| | - Sheng Gao
- Bristol Myers Squibb, 100 Nassau Park Blvd #300, Princeton, NJ, 08540, USA
| | - Xue Han
- Bristol Myers Squibb, 100 Nassau Park Blvd #300, Princeton, NJ, 08540, USA
| | - Amy Schrader
- CorEvitas, LLC, 1440 Main Street, Suite 310, Waltham, MA, 02451, USA
| | - Sabrina Rebello
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, Massachusetts, 02460, USA
| | - Dimitrios A Pappas
- CorEvitas, LLC, 1440 Main Street, Suite 310, Waltham, MA, 02451, USA
- Department of Medicine, Columbia University, 630 West 168th Street, New York, NY, USA
| | - Tanya Sommers
- CorEvitas, LLC, 1440 Main Street, Suite 310, Waltham, MA, 02451, USA
| | - Joel M Kremer
- Albany Medical College and the Center for Rheumatology, 47 New Scotland Ave, Albany, NY, 12208, USA
| |
Collapse
|
3
|
Archer R, Hock E, Hamilton J, Stevens J, Essat M, Poku E, Clowes M, Pandor A, Stevenson M. Assessing prognosis and prediction of treatment response in early rheumatoid arthritis: systematic reviews. Health Technol Assess 2019; 22:1-294. [PMID: 30501821 DOI: 10.3310/hta22660] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic, debilitating disease associated with reduced quality of life and substantial costs. It is unclear which tests and assessment tools allow the best assessment of prognosis in people with early RA and whether or not variables predict the response of patients to different drug treatments. OBJECTIVE To systematically review evidence on the use of selected tests and assessment tools in patients with early RA (1) in the evaluation of a prognosis (review 1) and (2) as predictive markers of treatment response (review 2). DATA SOURCES Electronic databases (e.g. MEDLINE, EMBASE, The Cochrane Library, Web of Science Conference Proceedings; searched to September 2016), registers, key websites, hand-searching of reference lists of included studies and key systematic reviews and contact with experts. STUDY SELECTION Review 1 - primary studies on the development, external validation and impact of clinical prediction models for selected outcomes in adult early RA patients. Review 2 - primary studies on the interaction between selected baseline covariates and treatment (conventional and biological disease-modifying antirheumatic drugs) on salient outcomes in adult early RA patients. RESULTS Review 1 - 22 model development studies and one combined model development/external validation study reporting 39 clinical prediction models were included. Five external validation studies evaluating eight clinical prediction models for radiographic joint damage were also included. c-statistics from internal validation ranged from 0.63 to 0.87 for radiographic progression (different definitions, six studies) and 0.78 to 0.82 for the Health Assessment Questionnaire (HAQ). Predictive performance in external validations varied considerably. Three models [(1) Active controlled Study of Patients receiving Infliximab for the treatment of Rheumatoid arthritis of Early onset (ASPIRE) C-reactive protein (ASPIRE CRP), (2) ASPIRE erythrocyte sedimentation rate (ASPIRE ESR) and (3) Behandelings Strategie (BeSt)] were externally validated using the same outcome definition in more than one population. Results of the random-effects meta-analysis suggested substantial uncertainty in the expected predictive performance of models in a new sample of patients. Review 2 - 12 studies were identified. Covariates examined included anti-citrullinated protein/peptide anti-body (ACPA) status, smoking status, erosions, rheumatoid factor status, C-reactive protein level, erythrocyte sedimentation rate, swollen joint count (SJC), body mass index and vascularity of synovium on power Doppler ultrasound (PDUS). Outcomes examined included erosions/radiographic progression, disease activity, physical function and Disease Activity Score-28 remission. There was statistical evidence to suggest that ACPA status, SJC and PDUS status at baseline may be treatment effect modifiers, but not necessarily that they are prognostic of response for all treatments. Most of the results were subject to considerable uncertainty and were not statistically significant. LIMITATIONS The meta-analysis in review 1 was limited by the availability of only a small number of external validation studies. Studies rarely investigated the interaction between predictors and treatment. SUGGESTED RESEARCH PRIORITIES Collaborative research (including the use of individual participant data) is needed to further develop and externally validate the clinical prediction models. The clinical prediction models should be validated with respect to individual treatments. Future assessments of treatment by covariate interactions should follow good statistical practice. CONCLUSIONS Review 1 - uncertainty remains over the optimal prediction model(s) for use in clinical practice. Review 2 - in general, there was insufficient evidence that the effect of treatment depended on baseline characteristics. STUDY REGISTRATION This study is registered as PROSPERO CRD42016042402. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Rachel Archer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Munira Essat
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| |
Collapse
|
4
|
Verhoeven MMA, Welsing PMJ, Bijlsma JWJ, van Laar JM, Lafeber FPJG, Tekstra J, Jacobs JWG. Effectiveness of Remission Induction Strategies for Early Rheumatoid Arthritis: a Systematic Literature Review. Curr Rheumatol Rep 2019; 21:24. [PMID: 31016409 PMCID: PMC6478774 DOI: 10.1007/s11926-019-0821-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To review the effectiveness of remission induction strategies compared to single csDMARD-initiating strategies according to current guidelines in early RA. RECENT FINDINGS Twenty-nine studies, heterogeneous on, e.g., specific treatment strategy and remission outcome used, were identified. Using DAS28-remission over 12 months, 13 (76%) of 17 remission induction strategies showed significantly more patients achieving remission. Pooled relative "risk" was 1.73 [95%CI 1.59-1.88] for bDMARD-based remission induction strategies and 1.20 [95%CI 1.03-1.40] for combination csDMARD-based remission induction strategies compared to single csDMARD-initiating strategies. When additional glucocorticoid "bridging therapy" was used in single csDMARD-initiating strategies, the higher proportion patients achieving remission in remission induction strategies was no longer statistically significant (pooled RR 1.06 [95%CI 0.83-1.35]). For other remission outcomes, results were in line with above. Remission induction strategies are more effective in achieving remission compared to single csDMARD-initiating strategies, possibly more so in bDMARD-based induction strategies. However, compared to single csDMARD-initiating strategies with glucocorticoids, induction strategies may not be more effective.
Collapse
Affiliation(s)
- M M A Verhoeven
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, G02.228, P.O. Box 85500, 3508GA, Utrecht, The Netherlands.
| | - P M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, G02.228, P.O. Box 85500, 3508GA, Utrecht, The Netherlands
| | - J W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, G02.228, P.O. Box 85500, 3508GA, Utrecht, The Netherlands
| | - J M van Laar
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, G02.228, P.O. Box 85500, 3508GA, Utrecht, The Netherlands
| | - F P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, G02.228, P.O. Box 85500, 3508GA, Utrecht, The Netherlands
| | - J Tekstra
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, G02.228, P.O. Box 85500, 3508GA, Utrecht, The Netherlands
| | - J W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht University, G02.228, P.O. Box 85500, 3508GA, Utrecht, The Netherlands
| |
Collapse
|
5
|
Gullick NJ, Ibrahim F, Scott IC, Vincent A, Cope AP, Garrood T, Panayi GS, Scott DL, Kirkham BW. Real world long-term impact of intensive treatment on disease activity, disability and health-related quality of life in rheumatoid arthritis. BMC Rheumatol 2019; 3:6. [PMID: 30886994 PMCID: PMC6390620 DOI: 10.1186/s41927-019-0054-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/25/2019] [Indexed: 12/25/2022] Open
Abstract
Background The emphasis on treating rheumatoid arthritis (RA) intensively reduces disease activity but its impact in routine care is uncertain. We evaluated temporal changes in disease activities and outcomes in a 10-year prospective observational cohort study of patients in routine care at one unit. Methods The Guy’s and St Thomas’ RA cohort was established in 2005. It involved most RA patients managed in this hospital. Clinical diagnoses of RA were made by rheumatologists. Patients were seen regularly in routine care. Each visit included measurement of disease activity scores for 28 joints (DAS28), health assessment questionnaire scores (HAQ) and EuroQol scores. Patients received intensive treatments targeting DAS28 remission. Results In 1693 RA patients mean DAS28 scores fell from 2005 to 15 by 11% from 4.08 (95% CI: 3.91, 4.25) in 2005 to 3.64 (3.34, 3.78); these falls were highly significant (p < 0.001). DAS28 components: swollen joint counts fell by 32% and ESR by 24%; in contrast tender joint counts and patient global assessments showed minimal or no reductions. The reduction in DAS28 scores was predominantly between 2005 and 2010, with no falls from 2011 onwards. Associated with falls in mean DAS28s, patients achieving remission increased (18% in 2005; 27% in 2015) and the number with active disease (DAS28 > 5.1) decreased (25% in 2005; 16% in 2015). In 752 patients seen at least annually for 3 years, persisting remission (68 patients) and intermittent remission (376 patients) were associated with less disability and better health related quality of life. Over time biologic use increased, but they were used infrequently in patients in persistent remission. Conclusions Over 10 years an intensive management strategy in a routine practice setting increased combination DMARD and biologic use: disease activity levels declined; this association is in keeping with a causal relationship. Patients who achieved remission, even transiently, had better functional outcomes than patients never achieving remission. Electronic supplementary material The online version of this article (10.1186/s41927-019-0054-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nicola J Gullick
- 1Department of Rheumatology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Fowzia Ibrahim
- 2Department of Rheumatology, 3rd Floor, Weston Education Centre, King's College London, Cutcombe Road, London, UK
| | - Ian C Scott
- 3Research Institute for Primary Care & Health Sciences, Primary Care Sciences, Keele University, Keele, Staffordshire UK.,4Department of Rheumatology, Haywood Hospital, High Lane, Burslem, Staffordshire UK.,6Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, 1st Floor, New Hunt's House, Guy's Campus, King's College London, Great Maze Pond, London, UK
| | - Alexandra Vincent
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - Andrew P Cope
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK.,6Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, 1st Floor, New Hunt's House, Guy's Campus, King's College London, Great Maze Pond, London, UK
| | - Toby Garrood
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - Gabriel S Panayi
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | - David L Scott
- 2Department of Rheumatology, 3rd Floor, Weston Education Centre, King's College London, Cutcombe Road, London, UK
| | - Bruce W Kirkham
- 5Department of Rheumatology, Guy's and St Thomas' NHS Trust, 4th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London, UK
| | | |
Collapse
|
6
|
Euesden J, Matcham F, Hotopf M, Steer S, Cope AP, Lewis CM, Scott IC. The Relationship Between Mental Health, Disease Severity, and Genetic Risk for Depression in Early Rheumatoid Arthritis. Psychosom Med 2017; 79:638-645. [PMID: 28282363 PMCID: PMC5638421 DOI: 10.1097/psy.0000000000000462] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Reduced mental health (MH) is prevalent in rheumatoid arthritis (RA). Although longitudinal studies are limited, there is evidence that depression is associated with worse disease outcomes. We evaluated reciprocal relationships between MH, RA severity, and genetic risks for depression for 2 years in a well-characterized cohort of RA patients. METHODS We evaluated 520 early RA patients previously enrolled to two clinical trials. MH was measured using the short form-36 MH domain and mental component summary scores (MCS). MCS/MH associations over 2 years with disease activity (disease activity score on a 28-joint count), disability (health assessment questionnaire), pain visual analog scale scores, and a weighted genetic risk score for depression were tested using linear mixed-effects and regression models. RESULTS Poorer MH was associated with worse RA outcomes. Lower MCS scores (indicating worse MH) were seen in patients with a greater genetic risk for depression (weighted genetic risk score: coefficient = -1.21, p = .013). Lower baseline MCS was associated with lower 2-year improvements in disease activity score on a 28-joint count (coefficient = -0.02, p < .001), pain (coefficient = -0.33, p < .001), and health assessment questionnaire (coefficient = -0.01, p = .006). Baseline MCS was associated with changes in the swollen joint count (coefficient = -0.09, p < .001) and patient global assessment (coefficient = -0.28, p < .001) but not the tender joint count (p = .983) and erythrocyte sedimentation rate (p = .973). Only baseline pain visual analog scale (coefficient = -0.07, p = .002) was associated with 2-year changes in MCS. CONCLUSIONS Reduced baseline MH was associated with lower improvements in disease activity, disability, and pain for 2 years, supporting current national guidelines recommending screening for depression in RA. Pain had a bidirectional relationship with MH. Depression genetic risk had a significant association with MH.
Collapse
|
7
|
Hambardzumyan K, Saevarsdottir S, Forslind K, Petersson IF, Wallman JK, Ernestam S, Bolce RJ, van Vollenhoven RF. A Multi-Biomarker Disease Activity Score and the Choice of Second-Line Therapy in Early Rheumatoid Arthritis After Methotrexate Failure. Arthritis Rheumatol 2017; 69:953-963. [PMID: 27992691 PMCID: PMC5516230 DOI: 10.1002/art.40019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 12/06/2016] [Indexed: 12/20/2022]
Abstract
Objective To investigate whether the Multi‐Biomarker Disease Activity (MBDA) score predicts optimal add‐on treatment in patients with early rheumatoid arthritis (RA) who were inadequate responders to MTX (MTX‐IRs). Methods We analyzed data from 157 MTX‐IRs (with a Disease Activity Score using the erythrocyte sedimentation rate [DAS28‐ESR] >3.2) from the Swedish Pharmacotherapy (SWEFOT) trial who were randomized to receive triple therapy (MTX plus sulfasalazine plus hydroxychloroquine) versus MTX plus infliximab. The MBDA score as a predictor of the subsequent DAS28‐based response to each second‐line treatment was analyzed at randomization with the Breslow‐Day test for 2 × 2 groups, using both validated categories (low [<30], moderate [30–44], and high [>44]) and dichotomized categories (lower [≤38] versus higher [>38]). Results Among the 157 patients, 12% had a low MBDA score, 32% moderate, and 56% high. Of those with a low MBDA score, 88% responded to subsequent triple therapy, and 18% responded to MTX plus infliximab (P = 0.006); for those with a high MBDA score, the response rates were 35% and 58%, respectively (P = 0.040). When using 38 as a cutoff for the MBDA score (29% patients with lower scores versus 71% with higher scores), the differential associations with response to triple therapy versus MTX plus infliximab were 79% versus 44% and 36% versus 58%, respectively (P = 0.001). Clinical and inflammatory markers had poorer predictive capacity for response to triple therapy or MTX plus infliximab. Conclusion In patients with RA who had an inadequate response to MTX, the MBDA score categories were differentially associated with response to subsequent therapies. Thus, patients with post‐MTX biochemical improvements (lower MBDA scores) were more likely to respond to triple therapy than to MTX plus infliximab. If confirmed, these results may help to improve treatment in RA.
Collapse
Affiliation(s)
| | | | | | | | | | - Sofia Ernestam
- Institution LIME Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | | | | |
Collapse
|
8
|
Ajeganova S, van Steenbergen HW, van Nies JAB, Burgers LE, Huizinga TWJ, van der Helm-van Mil AHM. Disease-modifying antirheumatic drug-free sustained remission in rheumatoid arthritis: an increasingly achievable outcome with subsidence of disease symptoms. Ann Rheum Dis 2015; 75:867-73. [DOI: 10.1136/annrheumdis-2014-207080] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 04/23/2015] [Indexed: 11/03/2022]
|
9
|
Fearon U, Veale DJ. Key Challenges in Rheumatic and Musculoskeletal Disease Translational Research. EBioMedicine 2014; 1:95-6. [PMID: 26137513 PMCID: PMC4457412 DOI: 10.1016/j.ebiom.2014.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 11/15/2014] [Indexed: 12/02/2022] Open
Affiliation(s)
- Ursula Fearon
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Douglas J Veale
- St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| |
Collapse
|