Combination therapy with multiple disease-modifying antirheumatic drugs in rheumatoid arthritis: a preventive strategy

Early persistence on therapy impacts drug-free remission: a case-control study in a cohort of Hispanic patients with recent-onset rheumatoid arthritis

Background

Medication adherence is suboptimal in rheumatoid arthritis (RA) patients and impacts outcomes. DMARD-free remission (DFR) is a sustainable and achievable outcome in a minority of RA patients. Different factors have been associated with DFR, although persistence in therapy (PT), a component of the adherence construct, has never been examined. The study’s primary aim was to investigate the impact of PT’s characteristics on DFR in a cohort of Hispanic patients with recent-onset RA.

Methods

A single data abstractor reviewed the charts from 209 early (symptoms duration ≤ 1 year) RA patients. All the patients had prospective assessments of disease activity and PT and at least 1 year of follow-up, which was required for the DFR definition. DFR was defined when patients achieved ≥ 1 year of continuous Disease Activity Score-28 joints evaluated ≤ 2.6, without DMARDs and corticosteroids. PT was defined based on pre-specified criteria and recorded through an interview from 2004 to 2008 and thereafter through a questionnaire. Cases (patients who achieved ≥ 1 DFR status) were paired with controls (patients who never achieved DFR during their entire follow-up) according to ten relevant variables (1:2). Cox regression analysis estimated hazard ratios (HRs) for DFR according to two characteristics of PT: the % of the patient follow-up PT and early PT (first 2 years of patients’ follow-up).

Results

In March 2022, the population had 112 (55–181) patient/years follow-up. There were 23 patients (11%) with DFR after 74 months (44–122) of follow-up, and the DFR status was maintained during 48 months (18–82). Early PT was associated with DFR, while the % of the patient follow-up PT was not: HR = 3.84 [1.13–13.07] when the model was adjusted for cumulative N of DMARDs/patient and 3.16 [1.14–8.77] when also adjusted for baseline SF-36 physical component score. A lower N of cumulative DMARDs/patient was also retained in the models. Receiving operating curve to define the best cutoff of patient follow-up being PT to predict DFR was 21 months: sensitivity of 0.739, specificity of 0.717, and area under the curve of 0.682 (0.544–0.821).

Conclusions

DFR status might be added to the benefits of adhering to prescribed treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02884-w.

Risk of Total Knee and Hip Arthroplasty in Patients With Rheumatoid Arthritis: A 12-Year Retrospective Cohort Study of 65,898 Patients

BACKGROUND

Rheumatoid arthritis (RA) is an inflammatory disease that causes the destruction of soft tissues and cartilage around joints. Owing to the widespread use of potent disease-modifying antirheumatic drugs, the need for total knee and hip arthroplasties (TKA and THA) has been reduced in patients with RA. However, the current association between RA and either THA or TKA has not been demonstrated in large-scale epidemiological studies.

METHODS

We conducted a large-scale retrospective cohort study of patients diagnosed with RA during a 12-year period (2000-2012) in Taiwan. We recruited 32,949 patients with RA and 32,949 individually propensity score-matched non-RA controls.

RESULTS

After adjusting for confounding factors, we found that the risk of THA or TKA was 4.02 times higher in patients with RA than in those without RA (95% confidence interval [CI], 3.77-4.52). The risk of THA or TKA was highest in patients with RA younger than 40 years (adjusted hazard ratio, 43.18; 95% CI, 16.01-116.47). Compared with non-RA patients, patients with RA were 4.82 times more likely to undergo THA (95% CI, 3.84-6.04), 3.85 times more likely to undergo TKA (95% CI, 3.48-4.25), and 19.06 times more likely to undergo both THA and TKA (95% CI, 8.90-40.80).

CONCLUSION

These findings document a 4.02-fold greater long-term risk of undergoing THA or TKA in RA patients relative to non-RA patients in Taiwan.

Patients with pemphigus are at an increased risk of developing rheumatoid arthritis: a large-scale cohort study

Data regarding the association between pemphigus and rheumatoid arthritis (RA) is inconclusive and yet to be firmly established. In the current study, we aimed to evaluate the risk of developing RA during the course of pemphigus. A large-scale population-based longitudinal cohort study was conducted to evaluate the hazard ratio (HR) of RA among 1985 patients with pemphigus relative to 9874 age-, sex-, and ethnicity-matched control subjects. A multivariate Cox regression model was utilized. The incidence of RA was 1.07 (95% CI, 0.62-1.72) and 0.36 (95% CI, 0.24-0.52) per 1000 person-years among patients with pemphigus and controls, respectively. The lifetime prevalence of RA was 2.3% (95% CI, 1.7-3.1%) among cases and 1.8% (95% CI, 1.5-2.0%) among controls. Patients with pemphigus were more than twice as likely to develop RA as compared to control subjects (adjusted HR, 2.54; 95% confidence interval [CI], 1.31-4.92). The increased risk was robust to a sensitivity analysis that included only cases managed by pemphigus-related systemic medications (adjusted HR, 2.56; 95% CI, 1.30-5.05). In conclusion, pemphigus is associated with an increased risk of RA. Physicians treating patients with pemphigus should be aware of this possible association. Further research is required to better understand the mechanism underlying this association.

Haematological abnormalities in new-onset rheumatoid arthritis and risk of common infections: a population-based study

OBJECTIVES

To describe the prevalence of haematological abnormalities in individuals with RA at the point of diagnosis in primary care and the associations between haematological abnormalities, vaccinations and subsequent risk of common infections.

METHODS

We studied 6591 individuals with newly diagnosed RA between 2004 and 2016 inclusive using the UK Royal College of General Practitioners Research and Surveillance Centre primary care database. The prevalence of haematological abnormalities at diagnosis (anaemia, neutropenia and lymphopenia) was established. Cox proportional hazards models were used to evaluate the association between each haematological abnormality and time to common infections and the influence of vaccination status (influenza and pneumococcal vaccine) on time to common infections in individuals with RA compared with a matched cohort of individuals without RA.

RESULTS

Anaemia was common at RA diagnosis (16.1% of individuals), with neutropenia (0.6%) and lymphopenia (1.4%) less so. Lymphopenia and anaemia were associated with increased infection risk [hazard ratio (HR) 1.18 (95% CI 1.08, 1.29) and HR 1.37 (95% CI 1.08, 1.73), respectively]. There was no evidence of an association between neutropenia and infection risk [HR 0.94 (95% CI 0.60, 1.47)]. Pneumonia was much more common in individuals with early RA compared with controls. Influenza vaccination was associated with reduced risk of influenza-like illness only for individuals with RA [HR 0.58 (95% CI 0.37, 0.90)].

CONCLUSION

At diagnosis, anaemia and lymphopenia, but not neutropenia, increase the risk of common infections in individuals with RA. Our data support the effectiveness of the influenza vaccination in individuals with RA.

The Correlation Between Tenosynovitis Pattern on Two-Phase Bone Scintigraphy and Clinical Manifestation in Patients with Suspected Rheumatoid Arthritis

Purpose

To investigate the correlation between the tenosynovitis pattern on two-phase bone scintigraphy (2P-BS) and clinical manifestation in patients with suspected rheumatoid arthritis (RA).

Method

2P-BS including technetium-99m-methylene diphosphonate blood pool and bone phase imaging in 402 consecutive patients with clinically suspected RA were retrospectively reviewed. According to 2010 RA Classification Criteria, patients were grouped as RA and non-RA. Visual assessment of all fingers, toes, wrists, and ankles on 2P-BS was performed. Clinical suspected tenosynovitis was evaluated on physical examination. Rheumatoid factor, anti-cyclic citrullinated protein antibody, C-reactive protein, and estimated sedimentation rate were obtained. Radiographic findings were also used to define early and established arthritis.

Results

Tenosynovitis pattern was detected in 12.7% (51/402 patients) on 2P-BS. A total of 94.1% (48/51) were diagnosed as RA vs. 5.9% (3/51) as non-RA. Of the 48 RA patients with positive 2P-BS finding, 85.4% (41/48) had early arthritis and 14.6% (7/48) had established arthritis. On physical examination, tenosynovitis was suspected in 21.9% (88/402). A total of 56.8% (50/88) belonged to the RA group and 43.2% (38/88) to the non-RA group. The tenosynovitis pattern of 2P-BS and physical examination showed statistical difference and moderate agreement. The positive tenosynovitis pattern on 2P-BS represented up to 26.408 of odds ratio which was highest among the RA-associated factors.

Conclusion

Tenosynovitis pattern on 2P-BS was more commonly detected in the RA group and was more frequently associated with early arthritis pattern. Therefore, 2P-BS could give additional information for the detection of subclinical tenosynovitis in early or preclinical RA patients.

The applications of anti-CD20 antibodies to treat various B cells disorders

B-lymphocyte antigen CD20 (called CD20) is known as an activated-glycosylated phosphoprotein which is expressed on the surface of all B-cells. CD20 is involved in the regulation of trans-membrane Ca²⁺ conductance and also play critical roles in cell-cycle progression during human B cell proliferation and activation. The appearance of monoclonal antibody (mAb) technology provided an effective field for targeted therapy in treatment of a variety of diseases such as cancer, and autoimmune diseases. Anti-CD20 is one of important antibodies which could be employed in treatment of several diseases. Increasing evidences revealed that efficacy of different anti-CD20 antibodies is implicated by their function. Hence, evaluation of anti-CD20 antibodies function could provide and introduce new anti-CD20 based therapies. In the present study, we summarized several applications of anti-CD20 antibodies in various immune related disorders including B-CLL (B-cell chronic lymphocytic leukemia), rheumatoid arthritis (RA), multiple sclerosis (MS) and melanoma.

Attenuation of inflammation and cartilage degradation by sulfasalazine-containing hyaluronic acid on osteoarthritis rat model

The aim of this study was to investigate the effects of a sulfasalazine-containing hyaluronic acid (SASP/HA) systems on in vitro anti-inflammation and the alleviation of cartilage degradation in both lipopolysaccharide (LPS)-stimulated synoviocytes and a rat model of monosodium iodoacetate (MIA)-induced osteoarthritis (OA). The SASP/HA resulted in long-term release of SASP from the SASP/HA for up to 60 days in a sustained manner. In vitro studies performed using real-time polymerase chain reaction (PCR) assay revealed that the SASP/HA was able to effectively and dose-dependently inhibit the mRNA expression levels of pro-inflammatory cytokines such as matrix metalloproteinases-3 (MMP-3), cyclooxygenase-2 (COX-2), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) in LPS-stimulated synoviocytes. In vivo studies showed that intra articular injection of SASP/HA greatly reduced the MIA-stimulated mRNA expression of MMP-3, COX-2, IL-6, and TNF-α in blood. Furthermore, these significant anti-inflammatory effects of SASP/HA contributed markedly to the alleviation of progression of MIA-induced OA and cartilage degradation, as demonstrated by X-ray, micro-computed tomography (micro-CT), gross findings, and histological evaluations. Therefore, our findings indicated that the long-term and sustained delivery of SASP using HA can play a therapeutic role in alleviating inflammation as well as protecting against cartilage damage in OA.

Up-regulation of YPEL1 and YPEL5 and down-regulation of ITGA2 in erlotinib-treated EGFR-mutant non-small cell lung cancer: A bioinformatic analysis

PURPOSE

This study aimed to identify genes with significant alteration following treatment of epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) with tyrosine kinase inhibitors (TKIs).

METHODS

We downloaded microarray data of GSE67051 from the Gene Expression Omnibus (GEO) database. Genes with differential expression were identified in two groups: erlotinib-treated versus DMSO-treated PC9 cells and erlotinib-treated versus DMSO-treated HCC827 cells. Functional enrichment analysis and protein-protein interaction (PPI) network were performed on the overlapping differentially expressed genes (DEGs). Additionally, miRNAs that can regulate the DEGs were predicted. Small-molecule drugs, with possible synergistic or antagonistic actions with respect to erlotinib, were screened; data validation using another dataset was conducted.

RESULTS

In total, 1466 and 839 DEGs were identified in the aforementioned comparison groups, respectively, among which 267 overlapping up-regulated and 73 down-regulated were observed. The overlapping up- and down-regulated genes were significantly associated with different functions and pathways. ITGA2 had higher centrality scores in the PPI network. Seventy small-molecule drugs, with either possible synergistic or antagonistic roles with erlotinib, were identified. Moreover, up-regulated YPEL1, YPEL2, and YPEL5 were enriched in the miRNA-target regulatory network. Implementing data validation, we found YPEL1, YPEL5, and ITGA2 displayed similar expression profiles in the two datasets.

CONCLUSION

YPEL1 and YPEL5 may be related to the action of erlotinib, and down-regulation of ITGA2 may be associated with the development of acquired resistance to erlotinib in EGFR-mutant NSCLCs. Furthermore, several small-molecule drugs that may have synergistic and antagonistic roles with erlotinib were identified.

Improvement in 5-year mortality in incident rheumatoid arthritis compared with the general population-closing the mortality gap

OBJECTIVE

Excess mortality in rheumatoid arthritis (RA) is expected to have improved over time, due to improved treatment. Our objective was to evaluate secular 5-year mortality trends in RA relative to general population controls in incident RA cohorts diagnosed in 1996-2000 vs 2001-2006.

METHODS

We conducted a population-based cohort study, using administrative health data, of all incident RA cases in British Columbia who first met RA criteria between January 1996 and December 2006, with general population controls matched 1:1 on gender, birth and index years. Cohorts were divided into earlier (RA onset 1996-2000) and later (2001-2006) cohorts. Physician visits and vital statistics data were obtained until December 2010. Follow-up was censored at 5 years to ensure equal follow-up in both cohorts. Mortality rates, mortality rate ratios and HRs for mortality (RA vs controls) using proportional hazard models adjusting for age, were calculated. Differences in mortality in RA versus controls between earlier and later incident cohorts were tested via interaction between RA status (case/control) and cohort (earlier/later).

RESULTS

24 914 RA cases and controls experienced 2747 and 2332 deaths, respectively. Mortality risk in RA versus controls differed across incident cohorts for all-cause, cardiovascular diseases (CVD) and cancer mortality (interactions p<0.01). A significant increase in mortality in RA versus controls was observed in earlier, but not later, cohorts (all-cause mortality adjusted HR (95% CI): 1.40 (1.30 to 1.51) and 0.97 (0.89 to 1.05), respectively).

CONCLUSIONS

In our population-based incident RA cohort, mortality compared with the general population improved over time. Increased mortality in the first 5 years was observed in people with RA onset before, but not after, 2000.

Nimesulide improves the symptomatic and disease modifying effects of leflunomide in collagen induced arthritis

Nimesulide is a COX-2 inhibitor used for symptomatic relief of rheumatoid arthritis. Leflunomide is an anti-pyrimidine used to manage the progression of rheumatoid arthritis. Herein we studied the influence of nimesulide and leflunomide combination in terms of disease symptoms and progression using collagen-induced arthritis model in mice, as a model for rheumatoid arthritis. Collagen induced arthritis was induced by immunization with type II collagen. Assessment of joint stiffness and articular hyperalgesia were evaluated using a locomotor activity cage and the Hargreaves method, respectively. Disease progression was assessed via arthritic index scoring, X-ray imaging, myeloperoxidase enzyme activity and histopathologic examination. Nimesulide induced only transient symptomatic alleviation on the top of decreased leucocytic infiltration compared to arthritis group. However, nimesulide alone failed to induce any significant improvement in the radiological or pathological disease progression. Leflunomide alone moderately alleviates the symptoms of arthritis and moderately retarded the radiological and pathological disease progression. Combination of nimesulide and leflunomide significantly improved symptomatic (analgesia and joint stiffness) and arthritic disease progression (radiological, pathological and Myeloperoxidase enzyme activity) in collagen induced arthritis animal model.

Antibiotics for the treatment of rheumatoid arthritis

Antibiotic treatment for rheumatoid arthritis (RA) commenced in the 1930s with the use of sulfasalazine. Later, tetracyclines were successfully used for the treatment of RA. In double-blind and randomized studies, levofloxacin and macrolide antibiotics (including clarithromycin and roxithromycin) were also shown to be effective in the treatment of RA. There have been several reports in the literature indicating that periodontal pathogens are a possible cause of RA. Oral bacteria are one possible cause of RA. In this review, we aimed to investigate the effects of different antibiotics in RA treatment.

Patterns of disease-modifying antirheumatic drug use in rheumatoid arthritis patients after 2002: a systematic review

OBJECTIVE

To report and synthesize patterns of disease-modifying antirheumatic drug (DMARD) use reported in observational studies of patients with established and early rheumatoid arthritis (RA) after publication of the American College of Rheumatology guidelines promoting universal DMARD use.

METHODS

We searched PubMed for full-length articles in English published between January 1, 2002 and October 1, 2012 that examined DMARD use. The data abstracted from articles included the patient characteristics, country of study, time period studied, patient source, and treating physician type. Study quality was assessed using a modified Newcastle-Ottawa Quality Assessment Scale.

RESULTS

We reviewed 1,287 abstracts; 98 full-length articles were selected for additional review and 27 studies describing 28 cohorts of patients were included. Twelve studies described data from cohorts of patients with established RA, and DMARD use in this group of studies ranged from 73-100%. Five studies described data from patients sourced through administrative data and demonstrated consistently lower DMARD use, ranging from 30-63%. Three studies conducted population-based surveys to define cases of RA where DMARD use ranged from 47-73%. Eight studies investigated patients with early RA. DMARD use among patients followed by rheumatologists ranged from 77-98%, whereas DMARD use reported for patients seen by a mix of physicians was significantly lower (39-63%).

CONCLUSION

DMARD use in studies from RA cohorts or registries (in which patients were followed by rheumatologists) ranged from 73-100%, compared with 30-73% in studies from administrative data or population-based surveys (in which patients were not necessarily receiving rheumatology subspecialty care).

Patients' views about treatment with combination therapy for rheumatoid arthritis: a comparative qualitative study

BACKGROUND

Combinations of disease-modifying anti-rheumatic drugs (DMARDs) are increasingly used to control active rheumatoid arthritis (RA); however there is little information about patients' perspectives, their expectations, concerns and experiences of this intensive treatment.

METHOD

We interviewed a quota sample of 18 patients from a single tertiary outpatient clinic, stratified by gender, ethnicity and age, based on the outpatient clinic population. Patients with early RA (<2 years) received combined conventional DMARDs; patients with established RA (>2 years) received combined conventional DMARDs or DMARDs with biologics.

RESULTS

Four main themes emerged from the analytical framework: (i) patients' expectations about the combined treatment focuses mainly on physical symptoms; (ii) the impact of the treatment on quality of life varied with the new medication in both groups (iii) concerns about new interventions concentrated mainly on potential side effects; and (iv) combination therapy can be self-managed in close collaboration with clinic staff, but this requires individualised management approaches. These themes resonate with von Korff's collaborative management of chronic illness model.

CONCLUSION

To our knowledge this is the first qualitative study that examined systematically in patients with early and established RA their expectations, impact on quality of life, concerns about side effects and the management of the treatment when taking combined medication with DMARDs or DMARDs and biologics. Patients have generally positive views of combination DMARDs. Within routine practice settings, achieving medication concordance with complex combined DMARD regimens is challenging, and the concerns vary between patients; careful individual assessments are essential to successfully deliver such intensive treatment.

Formulation and in vitro evaluation of ufasomes for dermal administration of methotrexate

Dermal drug delivery system that is required to localizes methotrexate (MTX) in the synovial joint is needed to treat inflammation in rheumatoid arthritis (RA). The present investigation aims at exploring the potential of fatty acid vesicles for the topical delivery of methotrexate. Vesicles were prepared by film hydration method using oleic acid as a fatty acid principal component. Developed vesicles were characterized for size, size distribution, shape, in vitro release, pH dependent, and storage stability. Interaction between MTX and oleic acid was investigated using differential scanning calorimetry. The MTX amount permeated through rat skin was three- to fourfold higher using oleic acid compared to those from plain drug solution or carbopol gel. At the end of the skin permeation assay using ufasomes, up to 50% of the administered dose was found in the skin. These results suggest that methotrexate encapsulated in oleic acid vesicles may be of value for the topical administration of MTX in the treatment of psoriasis.

Differential expression of NK receptors CD94 and NKG2A by T cells in rheumatoid arthritis patients in remission compared to active disease

Objective

TNF inhibitors (TNFi) have revolutionised the treatment of rheumatoid arthritis (RA). Natural killer (NK) cells and Natural Killer Cell Receptor⁺ T (NKT) cells comprise important effector lymphocytes whose activity is tightly regulated through surface NK receptors (NKRs). Dysregulation of NKRs in patients with autoimmune diseases has been shown, however little is known regarding NKRs expression in patients with TNFi-induced remission and in those who maintain remission vs disease flare following TNFi withdrawal.

Methods

Patients with RA were recruited for this study, (i) RA patients in clinical remission following a minimum of one year of TNFi therapy (n = −15); (2) Active RA patients, not currently or ever receiving TNFi (n = 18); and healthy control volunteers (n = 15). Patients in remission were divided into two groups: those who were maintained on TNFi and those who withdrew from TNFi and maintained on DMARDS. All patients underwent full clinical assessment. Peripheral blood mononuclear cells were isolated and NKR (CD94, NKG2A, CD161, CD69, CD57, CD158a, CD158b) expression on T-(CD3⁺CD56⁻), NK-(CD3⁻CD56⁺) and NKT-(CD3⁺CD56⁺) cells was determined by flow cytometry.

Results

Following TNFi withdrawal, percentages and numbers of circulating T cells, NK cells or NKT cell populations were unchanged in patients in remission versus active RA or HCs. Expression of the NKRs CD161, CD57, CD94 and NKG2A was significantly increased on CD3⁺CD56-T cells from patients in remission compared to active RA (p<0.05). CD3⁺CD56-T cell expression of CD94 and NKG2A was significantly increased in patients who remained in remission compared with patients whose disease flared (p<0.05), with no differences observed for CD161 and CD57. CD3⁺CD56⁻ cell expression of NKG2A was inversely related to DAS28 (r = −0.612, p<0.005).

Conclusion

High CD94/NKG2A expression by T cells was demonstrated in remission patients following TNFi therapy compared to active RA, while low CD94/NKG2A were associated with disease flare following withdrawal of therapy.

Comparative quality of life in patients with depression and rheumatoid arthritis

We assessed the inter-relationships between the Short Form 36 (SF-36) physical and mental function in 220 patients with onset cases of mild and moderate depression and 913 adults with early and established rheumatoid arthritis (RA) through secondary analysis and compared both scores with the UK general population norms. In depression and RA the SF-36 total scores showed significant impairment across the spectrum of both domains compared with age-specific UK normative score. In RA mental health and role, mental scores were highly correlated with other SF-36 domains. In depression there was little evidence of such inter-relationships. Mental health and role mental domains were lowest in active RA (disease activity scores (DAS28) over 5.1). They had strong correlations with the vitality and social function SF-36 sub-scores and weak correlations with the physical function and role emotional sub-scores. Patients with long-term conditions require comprehensive care. At present it is unclear how best to combine treatment of RA synovitis with the management of mental health problems. Mental health symptoms are present from the earliest stages of RA and it may be appropriate to initiate multidisciplinary care as soon as practicable, although its efficacy requires a further detailed study across primary and secondary care.

Receipt of disease-modifying antirheumatic drugs among patients with rheumatoid arthritis in Medicare managed care plans

CONTEXT

In 2005, the Healthcare Effectiveness Data and Information Set (HEDIS) introduced a quality measure to assess the receipt of disease-modifying antirheumatic drugs (DMARDs) among patients with rheumatoid arthritis (RA).

OBJECTIVE

To identify sociodemographic, community, and health plan factors associated with DMARD receipt among Medicare managed care enrollees.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed individual-level HEDIS data for 93,143 patients who were at least 65 years old with at least 2 diagnoses of RA within a measurement year (during 2005-2008). Logistic regression models with generalized estimating equations were used to determine factors associated with DMARD receipt and logistic regression was used to adjust health plan performance for case mix.

MAIN OUTCOME MEASURES

Receipt or nonreceipt of DMARD.

RESULTS

The mean age of patients was 74 years; 75% were women and 82% were white. Overall performance on the HEDIS measure for RA was 59% in 2005, increasing to 67% in 2008 (P for trend <.001). The largest difference in performance was based on age: patients aged 85 years and older had a 30 percentage point lower rate of DMARD receipt (95% confidence interval [CI], -29 to -32 points; P < .001), compared with patients 65 to 69 years of age, even after adjusting for other factors. Lower percentage point rates were also found for patients who were men (-3 points; 95% CI, -5 to -2 points; P < .001), of black race (-4 points; 95% CI, -6 to -2 points; P < .001), with low personal income (-6 points; 95% CI, -8 to -5 points; P < .001), with the lowest zip code-based socioeconomic status (-4 points; 95% CI, -6 to 2 points; P < .001), or enrolled in for-profit health plans (-4 points; 95% CI, -7 to 0 points; P < .001); and in the Middle Atlantic region (-7 points; 95% CI, -13 to -2 points; P < .001) and South Atlantic regions (-11 points; 95% CI, -20 to -3 points; P < .001) as compared with the Pacific region. Performance varied widely by health plan, ranging from 16% to 87%.

CONCLUSIONS

Among Medicare managed care enrollees carrying a diagnosis of RA between 2005 and 2008, 63% received a DMARD. Receipt of DMARDs varied based on demographic factors, socioeconomic status, geographic location, and health plan.

Predictors of the use of physical therapy services among patients with rheumatoid arthritis

BACKGROUND

Although physical therapy is a proven and recommended intervention for managing rheumatoid arthritis (RA), few studies have explored correlates of physical therapy service use among people with RA.

OBJECTIVE

The purposes of this study were: (1) to describe physical therapy use among people with RA and (2) to identify biopsychosocial factors associated with physical therapy use. It was expected that use of physical therapy services would be lower than previously reported, considering recent medical advancements, and that including contextual factors may lead to identification of new factors associated with physical therapy use.

DESIGN

This was a cohort study.

METHODS

Of 1,032 patients prospectively recruited from a large hospital registry, 772 completed baseline and laboratory assessments, received a physical examination, and completed a 1-year follow-up survey regarding physical therapy service use. Measures included: demographics (ie, age, sex, marital status, race, employment, disability status, insurance, income, comorbidities, and education), disease duration, RA medications, self-efficacy (assessed with the Arthritis Self-Efficacy Scale), social support (assessed with the Berkman-Syme Social Network Index), function (assessed with the Multi-Dimensional Health Assessment Questionnaire), and disease activity (assessed with the Rheumatoid Arthritis Disease Activity Index). Self-reported use of physical therapy (yes/no) was assessed at the 1-year follow-up. A staged regression approach, based on a theoretical model, was used to select and enter variables into the regression to develop a parsimonious set of predictors.

RESULTS

The patients were well educated and had modestly high incomes, and most had health insurance. Approximately 15.3% of the patients used physical therapy services during the designated follow-up period. Using multivariable modeling, the most significant predictors of physical therapy service use were moderate to high disease activity (odds ratio [OR]=1.4, 95% confidence interval [CI]=1.1-1.8), less than a college education (OR=0.5, 95% CI=0.2-0.8), greater social networks (OR=2.1, 95% CI=1.3-3.5), and being on disability (OR=2.4, 95% CI=1.3-4.6).

LIMITATIONS

The limitations of this study were use of a convenience sample and the potential for misclassification of physical therapy service use.

CONCLUSIONS

Patients with less than college education were less likely to receive physical therapy services, and those with more active disease, those who were on disability, and those who had greater social networks were more likely to receive physical therapy services.

Therapeutic potential of splice-switching oligonucleotides

Alternative splicing enables a single pre-messenger RNA transcript to yield multiple protein isoforms, making it a major contributor to the diversity of the proteome. While this process is essential for normal development, aberrations in alternative splicing are the cause of a multitude of human diseases. Methods for manipulating alternative splicing would thus be of therapeutic value. Chemically modified antisense oligonucleotides that alter alternative splicing by directing splice site selection have been developed to achieve this end. These splice-switching oligonucleotides (SSOs) have been applied to correct aberrant splicing, induce expression of a therapeutic splice variant, or induce expression of a novel therapeutic splice variant in a number of disease-relevant genes. Recently, in vivo efficacy of SSOs has been reported using animal disease models, as well as in results from the first clinical trial.

Nimesulide improves the disease modifying anti-rheumatic profile of methotrexate in mice with collagen-induced arthritis

Methotrexate is a disease modifying anti-rheumatic drug that is widely used for the treatment of rheumatoid arthritis. Nimesulide is a non-steroidal anti-inflammatory drug which is frequently used as adjuvant therapy for symptomatic alleviation of rheumatoid arthritis. In this study, we have evaluated the potential influence of nimesulide on the disease modifying anti-rheumatic properties of methotrexate using the collagen-induced arthritis model. Mice were immunized with collagen type II for the induction of arthritis and treated with methotrexate (2.5mg/kg) twice a week, nimesulide (20mg/kg) every other day or a combination of both drugs. Treatment started one week after the onset of arthritis until day 40. An arthritic index was used to compare the severity of arthritis between different treatments. In addition, articular hyperalgesia, joint stiffness, radiological deterioration and intra-articular leucocytic infiltration were evaluated. Methotrexate alone showed modest but significant analgesic and anti-inflammatory effects, and the effects of nimesulide were comparable. On the other hand, nimesulide significantly improved the disease modifying anti-rheumatic profile of methotrexate in terms of arthritic index and joint mobility. Furthermore, although nimesulide failed to show any radiological evidence of articular protection, it significantly improved methotrexate-induced joint protection as judged by X-ray analysis.

Impact of biologics on the prevalence of orthopedic surgery in the National Database of Rheumatic Diseases in Japan

The aim of this study was to investigate changes in the treatment strategy of rheumatoid arthritis (RA) and the prevalence of RA-related surgeries after approval of biologics in Japan and to analyze the impact of biologics on the incidence of orthopedic surgeries using a nationwide observational cohort database of rheumatic diseases [National Database of Rheumatic Diseases by iR-net in Japan (NinJa)]. The proportion of patients using biologics linearly increased from 2004 (1.8%) to 2007 (10.0%), but neither the number nor type of RA-related surgery significantly changed during this period. Patients treated with biologics exhibited relatively more severe disease activity and lower physical function. Among patients using biologics, those who underwent RA-related surgeries exhibited background characteristics of longer disease duration and worse physical function, while disease activity was not different from patients without surgery. These results suggest that the potential value of biologics in avoiding surgical procedure is limited in patients with severe functional disorders caused by long disease duration. Further investigation with a longer observation period is required to obtain more definite conclusions as to the impact of biologics usage on orthopedic surgeries.

Development of a framework for reporting health service models for managing rheumatoid arthritis

The purpose of this study was to develop a framework for reporting health service models for managing rheumatoid arthritis (RA). We conducted a search of the health sciences literature for primary studies that described interventions which aimed to improve the implementation of health services in adults with RA. Thereafter, a nominal group consensus process was used to synthesize the evidence for the development of the reporting framework. Of the 2,033 citations screened, 68 primary studies were included which described 93 health service models for RA. The origin and meaning of the labels given to these health service delivery models varied widely and, in general, the reporting of their components lacked detail or was absent. The six dimensions underlying the framework for reporting RA health service delivery models are: (1) Why was it founded? (2) Who was involved? (3) What were the roles of those participating? (4) When were the services provided? (5) Where were the services provided/received? (6) How were the services/interventions accessed and implemented, how long was the intervention, how did individuals involved communicate, and how was the model supported/sustained? The proposed framework has the potential to facilitate knowledge exchange among clinicians, researchers, and decision makers in the area of health service delivery. Future work includes the validation of the framework with national and international stakeholders such as clinicians, health care administrators, and health services researchers.

Diagnosis and referral of rheumatoid arthritis by primary care physician: results of a pilot study on the city of Pisa, Italy

The aims of the present study were to evaluate, in the city of Pisa: (1) the prevalence of rheumatoid arthritis; (2) the reliability of the prevalence estimated by primary care physicians, using the rheumatologist's diagnosis as the "gold standard" and (3) the economic impact of the disease. The Tuscany registry of primary care physicians constituted the framework from which a sample of subjects was selected. The rheumatoid arthritis (RA) subjects >18 years followed by each primary care physician constituted the population studied. Each general practitioner (GP) was asked to fill out a questionnaire regarding their patients affected by RA and to send it to the tertiary rheumatologic centre, where the diagnosis was confirmed/discarded, the clinical and epidemiological data were collected in a standardized form and a number of data for the estimation of costs were gathered. The estimated prevalence of RA was 5.1 per thousand (CI, 4.4-5.7). The reliability of general practitioners in the diagnosis of rheumatoid arthritis was on the whole 69%. However, when an analysis of every physician was carried out, a high degree of heterogeneity in the prevalence of RA per physician was found. Overall, the mean annual cost per patient with RA was estimated at about 5,878 euro (euro; median, 6,434 euro; inter quartile range, 669-7,052 euro), with a high variability mainly dependent on the degree of patient disability. More than 90% of the overall annual cost per patient was due to the medical and non-medical direct components of costs. The prevalence of RA in Tuscany seems highly comparable with similar prevalence studies in Italy. The annual cost per patient with RA was highly variable and strictly dependent on the level of disability. More than 90% of the overall cost was due to the direct burden of costs.

Improving healthcare consumer effectiveness: an Animated, Self-serve, Web-based Research Tool (ANSWER) for people with early rheumatoid arthritis

BACKGROUND

People with rheumatoid arthritis (RA) should use DMARDs (disease-modifying anti-rheumatic drugs) within the first three months of symptoms in order to prevent irreversible joint damage. However, recent studies report the delay in DMARD use ranges from 6.5 months to 11.5 months in Canada. While most health service delivery interventions are designed to improve the family physician's ability to refer to a rheumatologist and prescribe treatments, relatively little has been done to improve the delivery of credible, relevant, and user-friendly information for individuals to make treatment decisions. To address this care gap, the Animated, Self-serve, Web-based Research Tool (ANSWER) will be developed and evaluated to assist people in making decisions about the use of methotrexate, a type of DMARD. The objectives of this project are: 1) to develop ANSWER for people with early RA; and 2) to assess the extent to which ANSWER reduces people's decisional conflict about the use of methotrexate, improves their knowledge about RA, and improves their skills of being 'effective healthcare consumers'.

METHODS/DESIGN

Consistent with the International Patient Decision Aid Standards, the development process of ANSWER will involve: 1.) creating a storyline and scripts based on the best evidence on the use of methotrexate and other management options in RA, and the contextual factors that affect a patient's decision to use a treatment as found in ERAHSE; 2.) using an interactive design methodology to create, test, analyze and refine the ANSWER prototype; 3.) testing the content and user interface with health professionals and patients; and 4.) conducting a pilot study with 51 patients, who are diagnosed with RA in the past 12 months, to assess the extent to which ANSWER improves the quality of their decisions, knowledge and skills in being effective consumers.

DISCUSSION

We envision that the ANSWER will help accelerate the dissemination of knowledge and skills necessary for people with early RA to make informed choices about treatment and to manage their health. The latest in animation and online technology will ensure ANSWER fills a knowledge translation gap, focusing on the next generation of people living with RA.

An endogenous TNF-alpha antagonist induced by splice-switching oligonucleotides reduces inflammation in hepatitis and arthritis mouse models

Tumor necrosis factor-alpha (TNF-alpha) is a key mediator of inflammatory diseases, including rheumatoid arthritis (RA), and anti-TNF-alpha drugs such as etanercept are effective treatments. Splice-switching oligonucleotides (SSOs) are a new class of drugs designed to induce therapeutically favorable splice variants of targeted genes. In this work, we used locked nucleic acid (LNA)-based SSOs to modulate splicing of TNF receptor 2 (TNFR2) pre-mRNA. The SSO induced skipping of TNFR2 exon 7, which codes the transmembrane domain (TM), switching endogenous expression from the membrane-bound, functional form to a soluble, secreted form (Delta7TNFR2). This decoy receptor protein accumulated in the circulation of treated mice, antagonized TNF-alpha, and altered disease in two mouse models: TNF-alpha-induced hepatitis and collagen-induced arthritis (CIA). This is the first report of upregulation of the endogenous, circulating TNF-alpha antagonist by oligonucleotide-induced splicing modulation.

Management of established rheumatoid arthritis with an emphasis on pharmacotherapy

The goals for the management of established rheumatoid arthritis (RA) differ slightly from the goals for the management of early RA. In established RA, in most cases, joint damage will be present, therefore the main goals are aimed at keeping the disease activity as low as possible to prevent joint damage progression. Furthermore, patients with RA have a reduced life expectancy, mainly due to co-morbid conditions such as cardiovascular disease. As in early disease, pharmacotherapy is the cornerstone of the management of patients with established RA. In this article we will discuss the characteristic manifestations of established RA, the pharmacological treatment strategies available for reaching the management goals of established RA, the role of prognostic factors and the measurements available for evaluating the outcomes of the management of individual patients with established RA in daily clinical practice.

Work disability in early rheumatoid arthritis: higher rates but better clinical status in Finland compared with the US

OBJECTIVE

To analyse and compare work disability attributed to rheumatoid arthritis in two cohorts of patients with early disease: one in the US and the other in Finland.

PATIENTS AND METHODS

Two cohorts of patients who were working and aged <65 years at the time of their first symptom of rheumatoid arthritis were studied: 269 patients in Nashville, TN, USA (median age 46 years, 72.5% females), and 364 patients from Jyväskylä, Finland, (median age 47.1 years, 70.9% females). The cohorts were analysed and compared for measures of clinical status and work disability status over a median (interquartile range) of 38.9 months in Nashville and 48.4 months in Jyväskylä.

RESULTS

The probability of working at 36 months was 0.89 (0.84-0.92) for patients from Nashville and 0.84 (0.80-0.88) for patients from Jyväskylä (p = 0.02). These rates were lower than in earlier decades. Patients from Jyväskylä had significantly higher rates of work disability (p = 0.02) than those from Nashville, but better scores for self-report physical function (p<0.001), pain (p<0.001) and global status (p<0.001) at last observation. The likelihood of being disabled from work was 2.6-fold higher in Jyväskylä compared to Nashville (95% confidence interval 1.44 to 4.59, p = 0.001), after adjustment for demographic and disease-specific variables.

CONCLUSION

Rates of work disability in both early rheumatoid arthritis cohorts were improved from earlier decades, but differed significantly in two different social systems. Higher work disability rates with better clinical status was seen in the Finnish early rheumatoid arthritis cohort than in the US cohort.

Are American College of Rheumatology 50% response criteria superior to 20% criteria in distinguishing active aggressive treatment in rheumatoid arthritis clinical trials reported since 1997? A meta-analysis of discriminant capacities

OBJECTIVE

To carry out a meta-analysis designed to compare the discriminant capacities of American College of Rheumatology 50% (ACR50) with 20% (ACR20) responses in clinical trials on rheumatoid arthritis reported after 1997 and to analyse whether ACR50 can be as informative as ACR20 in distinguishing active from control treatments in more recent trials.

METHODS

Clinical trials on rheumatoid arthritis reported since 1997 were identified, which included aggressive combinations of disease-modifying antirheumatic drugs and glucocorticoids, as well as powerful new agents-leflunomide, etanercept, infliximab, anakinra, adalimumab, abatacept, tacrolimus and rituximab. A meta-analysis of ACR20 compared with ACR50 responses for 21 clinical trials was carried out on differences in proportions of responders for active and control treatments and corresponding odds ratios (ORs).

RESULTS

In all but one clinical trial on rheumatoid arthritis published since 1997 with data available on ACR20 and ACR50, more than 50% of patients who were ACR20 responders among those randomised to active treatment were also ACR50 responders. This phenomenon was seen for control groups in 38% of trials, many of which included treatment with methotrexate. A meta-analysis of the clinical trials indicated a slight advantage to ACR50 for quantifying treatment comparisons, not significant for differences in proportions but significant for ORs.

CONCLUSION

ACR20 and ACR50 seem to be similar in distinguishing active from control treatments in clinical trials on rheumatoid arthritis reported since 1997. As ACR50 represents a considerably stronger clinical response, ACR50 may be a preferred end point for contemporary clinical trials on rheumatoid arthritis.

Rheumatoid arthritis: an overview of new and emerging therapies

Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic autoimmune disorder characterized by symmetric inflammation of synovial joints leading to progressive erosion of cartilage and bone. The aim of treatment is to mitigate joint destruction, preserve function, and prevent disability. The American College of Rheumatology guidelines for the treatment of RA recommend that newly diagnosed patients with RA begin treatment with disease-modifying antirheumatic drugs (DMARDs) within 3 months of diagnosis. Methotrexate remains the most commonly prescribed DMARD and is the standard by which recent new and emerging therapies are measured. Increasing knowledge regarding the immunologic basis of RA and advances in biotechnology have resulted in new, targeted biological therapies against proinflammatory cytokines that have dramatically changed the treatment paradigm and outcomes of patients with RA. This article reviews the pharmacological rationale underlying RA therapy, with a focus on currently available biological therapies and new therapies in development.

Methotrexate dosage reduction in patients with rheumatoid arthritis beginning therapy with infliximab: the Infliximab Rheumatoid Arthritis Methotrexate Tapering (iRAMT) trial

OBJECTIVE

Infliximab plus methotrexate (MTX) is approved for the treatment of rheumatoid arthritis (RA). Based on the benefit/risk profile of this combination therapy, lower doses of MTX would be preferable when infliximab efficacy can be maintained. We evaluated the ability of patients receiving infliximab plus MTX to achieve and maintain a clinical response while the dose of MTX was tapered.

METHODS

Infliximab infusions were administered at a minimum dosage of 3 mg/kg at 8-week intervals (following three loading doses at weeks 0, 2, and 6) to patients who had an inadequate response to MTX. MTX tapering was initiated at week 22 or later when at least a 40% improvement in the combined tender and swollen joint count was achieved; dosages were reduced by 5 mg every 8 weeks to a protocol-specified minimum dosage of 5 mg per week. If the required dosage of MTX after a flare was greater than the baseline dosage, the patient was considered a treatment failure.

RESULTS

Of the 210 patients enrolled, 159 (76%) achieved a 40% or better improvement in the combined tender and swollen joint count and had their MTX doses tapered. In these 159 responders, the median (mean) dose of MTX was reduced from 15 (16.5) mg per week at baseline to 5 (7.1) mg per week at week 54. From the time of initial response, 79% of these patients had a zero- or a one-vial increase in infliximab, corresponding to an approximate dose increase of 1 mg/kg, through week 54.

CONCLUSION

Approximately 75% of the patients participating in this trial achieved at least a 40% reduction in the combined swollen and tender joint count (correlating with an American College of Rheumatology 20% [ACR20] response in 83% of patients) while reducing the mean MTX dose by 57%.

Patients seen for standard rheumatoid arthritis care have significantly better articular, radiographic, laboratory, and functional status in 2000 than in 1985

OBJECTIVE

A comprehensive quantitative analysis of measures of disease activity and joint damage has not been available to compare patients in different eras in the same clinical setting. This study was undertaken to determine whether the clinical status of patients with rheumatoid arthritis (RA) has improved on average in recent years.

METHODS

A quantitative cross-sectional evaluation, which included joint count, radiographic, laboratory, patient questionnaire, and physical function measures, and therapies, was performed in 125 consecutive RA patients seen from 1984 through 1986 ("1985 cohort"). A virtually identical assessment was performed in 150 patients seen from 1999 through 2001 ("2000 cohort"), in the same weekly academic clinic. Measures were compared using descriptive statistics and a median regression model, adjusted for age, duration of disease, level of formal education, and rheumatoid factor.

RESULTS

Patients in 1985 had significantly poorer status compared with those in 2000: median 12 versus 5 swollen joints, Larsen radiographic score 20 versus 3, erythrocyte sedimentation rate 33 mm/hour versus 20, and modified Health Assessment Questionnaire 1.0 versus 0.4 (P < 0.019). Severe Disease Activity Scores >5.1 were seen in 69% of 1985 patients, compared with 30% in 2000. Methotrexate was taken by 10% of patients in 1985, versus 76% in 2000. The proportion of patients not taking any disease-modifying antirheumatic drugs was 66% in 1985 versus 13% in 2000.

CONCLUSION

Patients receiving standard care for RA in this setting had significantly better status, including radiographic scores, in 2000 than in 1985, associated with aggressive treatment strategies, prior to the introduction of biologic agents.

Clinical trials in rheumatic diseases: designs and limitations

Randomized controlled clinical trials provide the best method to distinguish a drug from placebo without the inevitable selection biases that are seen in standard clinical care. This article reviews designs and limitations of clinical trials that are used in rheumatic diseases. The primary design in clinical trials is a parallel, in which patients are randomized in parallel to different therapies at different dosages or placebo. In recent years, other designs have been used increasingly, including "step-up," "step-down," and "cross-over" designs. Limitations of clinical trials in chronic diseases include a short time frame versus the long duration of disease, inclusion and exclusion criteria, use of surrogate markers that may not represent clinically relevant markers, statistical significance does not necessarily indicate clinical significance necessarily, and the fact that a control group does not assure the absence of bias. Therefore, long-term databases are needed to supplement clinical trials in analyzing results of therapy for rheumatoid arthritis.

Gaps in care for rheumatoid arthritis: A population study

OBJECTIVE

Treatment guidelines for rheumatoid arthritis (RA) now recommend early, aggressive, and persistent use of disease-modifying antirheumatic drugs (DMARDs) to prevent joint damage in all people with active inflammation, and evaluation by a rheumatologist, when possible. This research assesses whether care for RA, at a population level, is consistent with current treatment guidelines.

METHODS

Using administrative billing data from the Ministry of Health in 1996-2000, all prevalent RA cases in British Columbia, Canada were identified. Data were obtained on all medications and all provincially-funded health care services.

RESULTS

We identified 27,710 RA cases, yielding a prevalence rate of 0.76%, consistent with epidemiologic studies. DMARD use was inappropriately low. Only 43% of the entire RA cohort received a DMARD at least once over 5 years, and 35% over 2 years. When used, DMARDs were started in a timely fashion, but were not used consistently. Care by a rheumatologist increased DMARD use 31-fold. Yet, only 48% and 34% saw a rheumatologist over 5 and 2 years, respectively. DMARD use was significantly more frequent, persistent, and more often used as combination therapy with continuous rheumatologist care. DMARDs were used by 84% and 73%, 40%, and 10% of people followed by rheumatologists continuously and intermittently, internists, and family physicians, respectively (P < 0.001). NSAID use, physiotherapy, and orthopedic surgeries were similar across these 4 care groups.

CONCLUSION

RA care in the British Columbia population was not consistent with current treatment guidelines. Efforts to educate family physicians and consumers about the shift in RA treatment paradigms and to improve access to rheumatologists are needed.

The PREMIER study: A multicenter, randomized, double-blind clinical trial of combination therapy with adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in patients with early, aggressive rheumatoid arthritis who had not had previous methotrexate treatment

OBJECTIVE

To compare the efficacy and safety of adalimumab plus methotrexate (MTX) versus MTX monotherapy or adalimumab monotherapy in patients with early, aggressive rheumatoid arthritis (RA) who had not previously received MTX treatment.

METHODS

This was a 2-year, multicenter, double-blind, active comparator-controlled study of 799 RA patients with active disease of < 3 years' duration who had never been treated with MTX. Treatments included adalimumab 40 mg subcutaneously every other week plus oral MTX, adalimumab 40 mg subcutaneously every other week, or weekly oral MTX. Co-primary end points at year 1 were American College of Rheumatology 50% improvement (ACR50) and mean change from baseline in the modified total Sharp score.

RESULTS

Combination therapy was superior to both MTX and adalimumab monotherapy in all outcomes measured. At year 1, more patients receiving combination therapy exhibited an ACR50 response (62%) than did patients who received MTX or adalimumab monotherapy (46% and 41%, respectively; both P < 0.001). Similar superiority of combination therapy was seen in ACR20, ACR70, and ACR90 response rates at 1 and 2 years. There was significantly less radiographic progression (P < or = 0.002) among patients in the combination treatment arm at both year 1 and year 2 (1.3 and 1.9 Sharp units, respectively) than in patients in the MTX arm (5.7 and 10.4 Sharp units) or the adalimumab arm (3.0 and 5.5 Sharp units). After 2 years of treatment, 49% of patients receiving combination therapy exhibited disease remission (28-joint Disease Activity Score <2.6), and 49% exhibited a major clinical response (ACR70 response for at least 6 continuous months), rates approximately twice those found among patients receiving either monotherapy. The adverse event profiles were comparable in all 3 groups.

CONCLUSION

In this population of patients with early, aggressive RA, combination therapy with adalimumab plus MTX was significantly superior to either MTX alone or adalimumab alone in improving signs and symptoms of disease, inhibiting radiographic progression, and effecting clinical remission.

The influence of previous and concomitant leflunomide on the efficacy and safety of infliximab therapy in patients with rheumatoid arthritis; a longitudinal observational study

OBJECTIVE

To investigate the influence of previous and concomitant leflunomide on the efficacy and safety of infliximab therapy in rheumatoid arthritis (RA) and to compare it to infliximab in combination with other disease-modifying anti-rheumatic drugs.

METHODS

RA patients starting infliximab therapy were prospectively followed from January 2000. Every 3 months data were collected regarding disease activity (DAS28), adverse events and treatment changes. In the primary analyses all patients were classified into a leflunomide group (LEF group) if they had used leflunomide during infliximab therapy or within 6 months prior to starting infliximab therapy, the latter because of the long half-life of leflunomide. All other patients were considered as controls (non-LEF group). Secondary drug survival analyses were performed with the LEF group consisting only of patients on active leflunomide at the start of infliximab (active LEF group).

RESULTS

A total of 162 RA patients started infliximab therapy (57 in the LEF group, 105 in the non-LEF group). No statistically significant differences in baseline characteristics were observed between the groups. Maximum follow-up time was 46 months for both groups. No differences in drug survival, disease activity or adverse events were observed between the groups. In both groups an increase in patients positive for antinuclear antibodies (ANA) was seen. ANA positivity at start did not predict DAS28 or the occurrence of adverse events. Secondary drug survival analyses showed no differences between the active LEF group and the non-LEF group.

CONCLUSION

The results indicate that the administration of infliximab after or simultaneously with leflunomide is safe and efficacious in RA patients.

Plant alkaloid tetrandrine downregulates IkappaBalpha kinases-IkappaBalpha-NF-kappaB signaling pathway in human peripheral blood T cell

Plant alkaloid tetrandrine (Tet), purified from Chinese herb Han-Fang Chi, is a potent immunomodulator used to treat rheumatic disorders, silicosis and hypertension in mainland China. We previously demonstrated that Tet effectively suppresses cytokine production and proliferation of CD28-costimulated T cells. In the present study, we investigated the possible involvement of nuclear factor kappa B (NF-kappaB) transcription factors, critical in CD28 costimulation, in Tet-mediated immunosuppression in human peripheral blood T cells. We showed that Tet inhibited NF-kappaB DNA-binding activities induced by various stimuli, including CD28 costimulation. At equal molar concentrations, Tet was as strong as methotrexate in suppressing CD28-costimulated NF-kappaB activities. Since Tet itself did not affect NF-kappaB binding to its corresponding DNA sequence, the results suggested that Tet might regulate NF-kappaB upstream signaling molecules. Further studies demonstrated that Tet could prevent the degradation of IkappaBalpha and inhibit nuclear translocation of p65 by blocking IkappaBalpha kinases alpha and beta activities. In addition, the activation of mitogen-activated protein kinases such as c-jun N-terminal kinase, p38 and extracellular signal-regulated kinase and activator protein-1 DNA-binding activity were all downregulated by Tet. Transfection assays performed in purified human peripheral blood T cells also confirmed the inhibition of NF-kappaB transcriptional activity by Tet. When four Tet analogues were readily compared, dauricine appeared to preserve the most potent inhibition on CD28-costimulated but not on H(2)O(2)-induced NF-kappaB DNA-binding activities. Our results provide the molecular basis of immunomodulation of Tet for being a potential disease-modifying antirheumatic drug in the therapy of autoimmune disorders like rheumatoid arthritis.

Methotrexate loaded poly(L-lactic acid) microspheres for intra-articular delivery of methotrexate to the joint

A controlled release delivery system that localizes methotrexate (MTX) in the synovial joint is needed to treat inflammation in rheumatoid arthritis (RA). The purpose of this work was to develop and characterize MTX loaded poly(l-lactic acid) (PLLA) microspheres and evaluate in vivo tolerability and MTX plasma concentrations following intra-articular injection into healthy rabbits. MTX loaded PLLA (2 kg/mole) microspheres were prepared using the solvent evaporation method and characterized in terms of size, molecular weight, thermal properties, and release rates into phosphate buffered saline (PBS) (pH 7.4) at 37 degrees C. Biocompatibility was evaluated by observing the swelling of the joints of the rabbits and histological analysis following the injection of the microspheres. MTX concentrations in the plasma and urine samples of rabbits were evaluated by high-performance liquid chromatography (HPLC). MTX loaded microspheres showed a rapid burst phase followed by a slow release phase. MTX loaded and control microspheres were biocompatible and plasma concentrations of MTX were tenfold higher in rabbits injected intra-articularly with free MTX than MTX microspheres. MTX microspheres may retain the drug in the joint by reducing clearance from the joint into the blood.

The use of anakinra, an interleukin-1 receptor antagonist, in the treatment of rheumatoid arthritis

Interleukin-1 (IL-1) is a primary cytokine that is involved in the pathogenesis of rheumatoid arthritis; it contributes to inflammation and joint destruction. Anakinra (Kineret) is an IL-1 receptor antagonist that blocks the biologic activity of IL-1. It was approved by the U.S. Food and Drug Administration (FDA) for the treatment of rheumatoid arthritis in 2001. Anakinra is safe and effective in the treatment of rheumatoid arthritis, both as monotherapy and in combination with other disease-modifying antirheumatic drugs. This article reviews the preclinical, clinical, and postmarketing data on the safety and efficacy of anakinra in the treatment of rheumatoid arthritis and focuses on the pivotal clinical trials that led to FDA approval.

Perceived importance of activities of daily living and arthritis helplessness in rheumatoid arthritis; a prospective investigation

OBJECTIVE

To examine the contribution of perceived importance of activities of daily living (ADL) to arthritis-specific helplessness in a sample of rheumatoid arthritis (RA) patients over a 1-year period.

METHOD

Forty-two individuals from an outpatient rheumatology clinic completed measures of ADL importance, helplessness, depression, pain, and disability; the physician's assistant provided objective ratings of disability.

RESULTS

Time 1 importance of ADL predicted a significant amount of variance in Time 2 arthritis helplessness after statistically controlling disease and psychological covariates. Moreover, increased perceived ADL importance predicted decreased arthritis helplessness over the 1-year period.

CONCLUSIONS

Results indicate that RA patients' experience of arthritis-specific helplessness may be minimized over time when performing ADL is perceived as important. Furthermore, these findings provide preliminary evidence for one possible antecedent to increased perceptions of arthritis helplessness in individuals with RA.

Decreases in rates of hospitalizations for manifestations of severe rheumatoid arthritis, 1983-2001

OBJECTIVE

To determine whether the rates of hospitalization for 4 manifestations of severe rheumatoid arthritis (RA), which are used as indicators of long-term health outcomes, have changed from 1983 to 2001.

METHODS

Data on all patients with RA who were hospitalized with rheumatoid vasculitis or to undergo splenectomy for Felty's syndrome, cervical spine fusion for myelopathy, or total knee arthroplasty at hospitals in California were abstracted from a state hospitalization database. Changes in rates of hospitalization from 1983 to 2001 were examined in this serial cross-sectional study.

RESULTS

Rates of hospitalization for rheumatoid vasculitis and splenectomy in Felty's syndrome decreased progressively over time. The risk of hospitalization for rheumatoid vasculitis was one-third lower in 1998-2001 than in 1983-1987. The risk of hospitalization for splenectomy in Felty's syndrome was 71% lower in 1998-2001 than in 1983-1987. There were no significant decreases in the rates of hospitalization for cervical spine surgery or total knee arthroplasty (primary and revision), although in 1998-2001 there was a reversal of the trend of increasing rates of total knee arthroplasty. The risk of hospitalization for primary total knee arthroplasty was significantly lower in 1998-2001 than in 1990-1993 (rate ratio 0.90, 95% confidence interval 0.86-0.95; P < 0.0001).

CONCLUSION

Rates of hospitalization for rheumatoid vasculitis and splenectomy in Felty's syndrome have decreased over the past 19 years, and there has been a recent decrease in the rates of primary total knee arthroplasty in patients with RA. Although several factors may account for these decreases, these findings suggest that since the early 1980s, the long-term health outcomes of patients with RA have improved.