POS0686 EFFECTIVENESS OF UPADACITINIB IN THE TREATMENT OF RHEUMATOID ARTHRITIS: ANALYSIS OF 6-MONTH REAL-WORLD DATA FROM THE UNITED RHEUMATOLOGY NORMALIZED INTEGRATED COMMUNITY EVIDENCE (UR-NICETM) DATABASE

Background

The efficacy of upadacitinib (UPA), an oral Janus kinase inhibitor (JAKi), in the treatment of rheumatoid arthritis (RA) has been demonstrated in the phase 3 SELECT clinical trial program.1–6 However, few real-world data have been reported to date.

Objectives

To assess the 6-month effectiveness of UPA in patients (pts) with RA initiating UPA treatment in clinical practice.

Methods

This observational study included US-based pts from the United Rheumatology Normalized Integrated Community Evidence (UR-NICE) database who initiated UPA 15 mg once daily from Aug 2019 to the data cut-off in Nov 2021. Pts with ≥6 months of baseline (BL) data before UPA initiation, and with Clinical Disease Activity Index (CDAI) score recorded at BL and 6 months (±45 days) after initiation, were included in the analysis. Effectiveness measures included CDAI score, Routine Assessment of Patient Index Data 3 (RAPID3), and Disease Activity Score in 28 joints based on C-reactive protein (DAS28-CRP); patient-reported outcomes (PROs) including Health Assessment Questionnaire-Disability Index (HAQ-DI), Pain, and Patient’s Global Assessment of Disease Activity (PtGA); and Physician’s Global Assessment of Disease Activity (PhGA). Subgroup analyses were conducted by prior tumor necrosis factor inhibitor (TNFi) and tofacitinib (TOFA) treatment history.

Results

363 pts were included in the analysis and most were female (80.2%) (Table 1). 140 (39%) received UPA monotherapy and 223 (61%) received UPA plus conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs). 83% of pts received prior csDMARDs, 72% prior biologics (TNFi 55%), and 41% JAKis (TOFA 39%). Overall, 46% (166/363), 23% (57/245), and 55% (95/173) of pts achieved LDA by CDAI, RAPID3, and DAS28-CRP, respectively, and 14% (51/363), 16% (39/245), and 36% (62/173) of pts achieved remission (REM) by CDAI, RAPID3, and DAS28-CRP, respectively. Results were similar regardless of prior TNFi or TOFA exposure (Figure 1). Improvements from BL were seen in PhGA and all PROs in the total population and all subgroups.

Table 1.

Demographic and baseline characteristics

Parameter, n (%)Full analysis setPrior TNFiPrior TOFA(N=363)(n=199)(n=143)Female291 (80.2)156 (78.4)119 (83.2)Age, years<4022 (6.1)11 (5.5)8 (5.6)40–<65240 (66.1)132 (66.3)94 (65.7)≥65101 (27.8)56 (28.1)41 (28.7)Oral steroid use185 (51.0)103 (51.8)83 (58.0)Parameter, mean (SD)NMean (SD)nMean (SD)nMean (SD)Duration of RA, years2764.5 (3.1)1625.1 (3.0)1135.1 (2.9)Body mass index, kg/m232130.0 (6.9)17529.9 (6.6)12529.2 (6.7)Oral steroid dose (prednisone equivalent), mg/day1547.9 (6.9)877.8 (6.5)707.6 (6.1)Methotrexate dose, mg/week11918.3 (4.9)7417.8 (5.2)3718.2 (4.7)C-reactive protein, mg/L2289.6 (16.2)1329.4 (15.0)9011.3 (17.9)CDAI36321.2 (12.8)19922.1 (13.0)14321.7 (13.3)RAPID32684.7 (2.1)1414.7 (2.2)1004.9 (2.1)DAS28-CRP2283.9 (1.3)1324.0 (1.4)904.2 (1.3)HAQ-DIa2732.6 (2.1)1482.8 (2.2)1063.0 (2.2)Painb33859.6 (26.6)18658.4 (27.2)13161.3 (25.1)PtGAb36354.1 (25.6)19954.7 (26.9)14355.9 (25.2)PhGAb36341.3 (26.0)19941.2 (24.8)14340.7 (26.8)

a0–10 visual analog scale. b0–100 visual analog scale. SD, standard deviation.

Conclusion

In this study, almost half (46%) of pts treated with UPA achieved CDAI LDA at 6 months and 14% achieved CDAI REM. Improvements in all PROs and PhGA were observed. Effectiveness of UPA was not impacted by prior TNFi or TOFA exposure, supporting UPA as an effective treatment option in clinical practice, including in pts with prior exposure to advanced therapy.

References

[1]Burmester GR, et al. Lancet 2018;391:2503–12.

[2]Smolen JS, et al. Lancet 2019;393:2303–11.

[3]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800.

[4]Genovese MC, et al. Lancet 2018;391:2513–24.

[5]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20.

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. Medical writing support was provided by Laura Chalmers, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests

Allan Gibofsky Shareholder of: AbbVie, Amgen, Johnson & Johnson, and Pfizer (stocks), Consultant of: AbbVie, Celgene, Eli Lilly, Flexion, Pfizer, Relburn Pharma, and Samumed (consulting fees); and Gerson Lehrman Group (paid consultant with investment analysts), Mark E. Pearson Shareholder of: AbbVie (may own stock or options), Andrew Concoff Speakers bureau: Flexion Therapeutics and Exagen, Consultant of: Flexion Therapeutics and Exagen, Anna Shmagel Shareholder of: AbbVie (may own stock or options), Employee of: AbbVie, Patrick Zueger Shareholder of: AbbVie (may own stock or options), Employee of: AbbVie, Yanna Song Shareholder of: AbbVie (may own stock or options), Employee of: AbbVie, Lauren Smith Shareholder of: AbbVie (may own stock or options), Employee of: AbbVie, Grace C. Wright Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Exagen, Myriad Autoimmune, Novartis, Sanofi/Regeneron, UCB, and Vindico, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Exagen, Gilead, Janssen, Myriad Autoimmune, Novartis, Pfizer, Sanofi/Regeneron, and UCB, Employee of: Association of Women in Rheumatology (President and Founder)

POS0436 PATIENT CHARACTERISTICS AND OUTCOMES IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH UPADACITINIB: THE OM1 RA REGISTRY

Background:

Upadacitinib (UPA) has demonstrated efficacy in the treatment of rheumatoid arthritis (RA) in randomized controlled trials,1-6 but there are limited data available on its real-world use and effectiveness in patients with RA.

Objectives:

To describe the characteristics and clinical outcomes at 3 months among real-world patients with RA initiating UPA.

Methods:

The data source for this study was the OM1 RA Registry, a subset of the OM1 Real-World Data Cloud (OM1, Inc, Boston, MA, US), a large, linked clinical and administrative dataset derived from medical and pharmacy claims, electronic medical record data, and death data. This analysis includes data collected in patients who initiated UPA during or after August 2019. Patients had ≥1 prescription for UPA (index date was first UPA prescription), were ≥18 years of age at index date, had ≥6 months of available data in the OM1 RA Registry prior to index date (ie, baseline period), ≥1 baseline disease activity measure, and ≥1 follow-up disease activity measure (3 or 6 months post-index). Disease activity was based on RAPID3 or CDAI. Multivariate analyses were conducted using a mixed-effects linear model adjusting for age, sex, and baseline scores. Outcomes were also assessed by therapy status (monotherapy or combination therapy) and targeted immunomodulator (TIM) use (naïve vs experienced).

Results:

Inclusion criteria were met by 1,102 patients, of whom 620 were on monotherapy and 482 were on combination therapy at index. Mean age was 57.7 years, 83% were female, 75% had prior treatment with a biologic, and 47% had prior treatment with a Janus kinase inhibitor. Of 651 patients with known disease activity category, 113 (17%) were in low disease activity (LDA)/remission. At baseline, overall mean±SD scores were 19.9±12.3 for CDAI, 4.5±2.4 for RAPID3, 5.7±2.8 for pain, 5.2±3.0 for fatigue, 3.1±2.7 for MDHAQ Physician Global Assessment (PGA), 5.2±2.8 for MDHAQ Patient Global Assessment (PtGA), and 3.1±2.3 for MDHAQ Functional Index. At 3 months post-UPA initiation, mean (95% CI) change in CDAI was –5.1 (–7.5 to –2.7) in the monotherapy group and –5.9 (–8.7 to –3.0) in the combination group. At 3 months, 29% (109/374) of patients were in LDA/remission and 32% (120/374) of patients showed improvement in disease activity. Of 94 patients with moderate disease at baseline, 34 (36%) were in LDA/remission at 3 months. Of 215 patients with high disease at baseline, 30 (14%) were in LDA/remission and 49 (23%) had moderate disease at 3 months. RAPID3 and other outcomes also improved at 3 months in the monotherapy and combination therapy groups (Figure 1). Improvements in disease activity were observed at 3 months and maintained at 6 months post-UPA initiation. Of 1,102 patients, 16% were TIM naïve and 84% TIM experienced. Both TIM-naïve and TIM-experienced patients achieved significant mean changes in CDAI (–5.7 [–10.8 to –0.6] and–5.0 [–7.0 to –3.0], respectively) and RAPID3 (–1.0 [–1.6 to –0.4] and –0.5 [–0.8 to –0.1]) at 3 months (Table 1). Improvements in clinical outcomes were maintained at 6 months in both TIM-naïve and TIM-experienced patients.

Conclusion:

Significant improvements in disease activity were consistently observed at 3 months and maintained at 6 months post-UPA initiation regardless of monotherapy, combination therapy, or prior TIM use.

References:

[1]Fleischmann R. Arthritis Rheumatol. 2019;71:1788–800.

[2]Smolen JS. Lancet. 2019;393:2303–11.

[3]Burmester GR. Lancet. 2018;382:2505–12.

[4]Genovese MC. Lancet. 2018;391:2513–24.

[5]van Vollenhoven R. Arthritis Rheumatol. 2020;72:1607–20.

[6]Rubbert-Roth A. N Engl J Med. 2020;383:1511–21.

Table 1.

Change in clinical outcomes from baseline at 3 months: TIM-naïve and TIM-experienced groups

TIM naïve(N=179)TIM experienced(N=923)nMean changenMean changeCDAI36–5.7*160–5.0*RAPID367–1.0*189–0.5*Pain (VAS)76–1.5*237–0.9*Fatigue46–0.7149–0.5MDHAQ PGA65–0.7*251–0.7*MDHAQ PtGA97–0.6*383–0.3MDHAQ Functional Index72–0.7*215–0.2

*Statistically significant change from baseline (P<0.05).

Acknowledgements:

Funding statement: Financial support for the study was provided by AbbVie. AbbVie participated in the interpretation of data, review, and approval of the abstract. All authors contributed to the development of the publication and maintained control over the final content.

Acknowledgment:

Medical writing services were provided by Joann Hettasch of Fishawack Facilitate Ltd, part of Fishawack Health, and funded by AbbVie.

Disclosure of Interests:

Martin Bergman Shareholder of: JNJ (parent of Janssen), Speakers bureau: AbbVie, Amgen, BMS, Genentech, Gilead, Janssen, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sandoz, Consultant of: AbbVie, Amgen, BMS, Genentech, Gilead, Janssen, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sandoz, Namita Tundia Shareholder of: AbbVie, Employee of: AbbVie, Allison Bryant: None declared, Ia Topuria: None declared, Tom Brecht: None declared, Kendall Dunlap Shareholder of: AbbVie, Employee of: AbbVie, Allan Gibofsky Shareholder of: AbbVie, Amgen, Horizon, J&J, Pfizer, Regeneron, Speakers bureau: AbbVie, Acquist, Amgen, Lilly, Merck, Pfizer, Sandoz, Samumed, Consultant of: AbbVie, Acquist, Amgen, Lilly, Merck, Pfizer, Sandoz, Samumed

POS0666 TREATMENT EFFECTIVENESS OF UPADACITINIB AT 3 MONTHS IN US PATIENTS WITH RHEUMATOID ARTHRITIS FROM THE UNITED RHEUMATOLOGY NORMALIZED INTEGRATED COMMUNITY EVIDENCE (NICE[TM]) REAL-WORLD DATA

Background:

Upadacitinib (UPA), an oral Janus kinase inhibitor (JAKi), has demonstrated efficacy in the phase 3 SELECT clinical program, conducted across a range of patients (pts) with rheumatoid arthritis (RA).1–6 Real-world data for UPA, including in pts previously treated with a JAKi, have not yet been reported since global approvals beginning in 2019.

Objectives:

To assess the characteristics of US-based pts receiving UPA and its effectiveness in clinical practice at 3 months.

Methods:

This observational study included US-based pts from the United Rheumatology Normalized Integrated Community Evidence (UR-NICE) database who initiated UPA 15 mg once daily from FDA approval (August 2019) to July 31, 2020 and had ≥6-month pre-baseline data available. Effectiveness was assessed in pts with a reported Clinical Disease Activity Index (CDAI) score at 3 months after UPA initiation and included proportions of pts achieving CDAI remission (≤2.8), CDAI low disease activity (≤10), other disease activity measures, and pt-reported outcomes. A subgroup analysis assessed UPA effectiveness in pts with or without prior tofacitinib (TOFA) treatment.

Results:

This analysis included 252 pts treated with UPA 15 mg, of whom 98 (38.9%) received UPA monotherapy and 154 (61.1%) received UPA combined with conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs). 64.3% of pts were from the Southern region of the USA. 86.1%, 72.2%, and 47.6% of pts had been previously treated with csDMARDs, biologic DMARDs, and JAKis, respectively. Baseline characteristics were largely similar between UPA monotherapy and combination therapy groups and those with or without prior TOFA treatment (Table 1). Pts with prior TOFA treatment had a longer duration of RA since diagnosis and higher steroid use versus those without. UPA 15 mg improved disease activity scores (including CDAI) and pt-reported outcomes (including physical function and pain) after 3 months of treatment (Figure 1). Similar effectiveness was observed with UPA 15 mg in pts with or without prior TOFA treatment.

Conclusion:

In the UR-NICE real-world database of US-based pts, improvements in clinical and pt-reported outcomes were observed at 3 months in UPA-treated pts with RA, including those with or without prior TOFA treatment, despite the treatment-refractory population included in this dataset.

References:

[1]Burmester GR, et al. Lancet 2018;391:2503–12.

[2]Smolen JS, et al. Lancet 2019;393:2303–11.

[3]Fleischmann R, et al. Arthritis Rheumatol 2019;71:1788–800.

[4]Genovese MC, et al. Lancet 2018;391:2513–24.

[5]van Vollenhoven R, et al. Arthritis Rheumatol 2020;72:1607–20.

[6]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

Table 1.

Baseline characteristics

n (%), unless otherwise statedFull analysis set(n=252)Pts with prior TOFA treatment(n=113)Pts without prior TOFA treatment (n=139)Mean (SD) exposure, days219.7 (112.1)215.7 (116.7)222.9 (108.5)Female199 (79.0)85 (75.2)114 (82.0)Age ≥65 years75 (29.8)34 (30.1)41 (29.5)Oral steroid use140 (55.6)70 (61.9)70 (50.4)Prior csDMARDs217 (86.1)102 (90.3)115 (82.7)Prior TOFA113 (44.8)113 (100.0)0Prior biologic DMARDs182 (72.2)86 (76.1)96 (69.1)Tumor necrosis factor inhibitor147 (58.3)66 (58.4)81 (58.3)Interleukin-6 receptor inhibitor87 (34.5)47 (41.6)40 (28.8)nMean (SD)nMean (SD)nMean (SD)Duration of RA diagnosis, years1884.0 (3.0)895.1 (2.9)993.1 (2.8)Methotrexate dose, mg/week8817.0 (5.1)2817.8 (5.0)6016.6 (5.2)SJC282394.8 (5.7)1084.5 (5.0)1315.0 (6.2)TJC282376.5 (6.7)1076.5 (6.8)1306.5 (6.6)CDAI22520.4 (13.4)10520.2 (13.5)12020.6 (13.3)Routine assessment of patient index data 31654.2 (2.3)724.2 (2.4)934.3 (2.2)Disease Activity Score in 28 joints based on C-reactive protein1673.9 (1.5)833.9 (1.5)843.9 (1.5)Health Assessment Questionnaire-Disability Index1702.5 (2.1)742.4 (2.2)962.5 (2.1)Pain(0–10)22956.5 (28.5)10456.9 (29.3)12556.1 (28.0)SD, standard deviation; S/TJC, swollen/tender joint count

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Hilary Wong, PhD, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Allan Gibofsky Shareholder of: AbbVie, Amgen, Johnson & Johnson, and Pfizer, Consultant of: AbbVie, Celgene, Eli Lilly, Flexion, Pfizer, Relburn Pharma, and Samumed. Paid consultant with investment analysts on behalf of the Gerson Lehrman Group, Bhavna Dhillon Shareholder of: May own stock or options in United Rheumatology, Employee of: United Rheumatology, Mark E. Pearson Shareholder of: May own AbbVie stock or options, Namita Tundia Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Kendall Dunlap Shareholder of: May own stocks or shares in AbbVie, Employee of: AbbVie, Grace Wright Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Exagen, Myriad Autoimmune, Novartis, Sanofi/Regeneron, UCB, and Vindico, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Exagen, Gilead, Janssen, Myriad Autoimmune, Novartis, Pfizer, Sanofi/Regeneron, and UCB, Employee of: President and Founder of the Association of Women in Rheumatology

A Phase 2b randomized trial of lorecivivint, a novel intra-articular CLK2/DYRK1A inhibitor and Wnt pathway modulator for knee osteoarthritis

OBJECTIVE

Lorecivivint (LOR; SM04690), an investigational Wnt pathway modulator, previously demonstrated patient-reported and radiographic outcome improvements vs placebo in clinically relevant subjects with moderate to severe knee osteoarthritis (OA). This study's objective was to identify effective LOR doses.

DESIGN

Subjects in this 24-week, Phase 2b, multicenter, randomized, double-blind, placebo (PBO)-controlled trial received an intra-articular injection of 2 mL LOR (0.03, 0.07, 0.15, or 0.23 mg), PBO, or dry-needle sham. The primary efficacy endpoints were changes in Pain NRS [0-10], WOMAC Pain [0-100], WOMAC Function [0-100], and radiographic mJSW outcomes, which were measured using baseline-adjusted analysis of covariance at Week 24. Multiple Comparison Procedure-Modeling (MCP-Mod) was performed for dose modeling.

RESULTS

In total, 695/700 subjects were treated. Pain NRS showed significant improvements vs PBO after treatment with 0.07 mg and 0.23 mg LOR at Weeks 12 (-0.96, 95% CI [-1.54, -0.37], P = 0.001; -0.78 [-1.39, -0.17], P = 0.012) and 24 (-0.70 [-1.34, -0.06], P = 0.031; -0.82 [-1.51, -0.12], P = 0.022). Additionally, 0.07 mg LOR significantly improved WOMAC Pain and Function subscores vs PBO at Week 12 (P = 0.04, P = 0.021), and 0.23 mg LOR significantly improved both WOMAC subscores at Week 24 (P = 0.031, P = 0.017). No significant differences from PBO were observed for other doses. No radiographic progression was observed in any group at Week 24. MCP-Mod identified 0.07 mg LOR as the lowest effective dose.

CONCLUSION

This 24-week Phase 2b trial demonstrated the efficacy of LOR on PROs in knee OA subjects. The optimal dose for future studies was identified as 0.07 mg LOR.

A novel Wnt pathway inhibitor, SM04690, for the treatment of moderate to severe osteoarthritis of the knee: results of a 24-week, randomized, controlled, phase 1 study

OBJECTIVE

To assess the safety, pharmacokinetics, and exploratory efficacy of SM04690, a novel Wnt pathway inhibitor, as a potential disease modifying treatment for knee osteoarthritis (OA).

DESIGN

Subjects with Kellgren-Lawrence grade 2-3 knee OA were randomized in successive dose-escalation cohorts to receive a knee intra-articular (IA) injection with 0.03, 0.07, or 0.23 mg SM04690, or placebo (PBO) (4:1 ratio). Safety, pharmacokinetics, efficacy (WOMAC Total/Function/Pain, Pain VAS, Physician Global Assessment [MDGA], and OMERACT-OARSI Response), OA-related biomarker (P1NP, ß-CTX, and cartilage oligomeric matrix protein [COMP]), and radiographic/imaging data were collected at baseline and during 24-week follow-up.

RESULTS

61 subjects (SM04690 n = 50; PBO n = 11) enrolled. Two dose limiting toxicities (DLTs), increased pain following injection and paroxysmal tachycardia (also the single serious AE), were reported in the 0.07 mg cohort. A total of 72 AEs were reported; Sixteen (occurring in eight subjects) were considered related to study medication. There were three discontinuations; one due to an AE (0.03 mg cohort). Bone marrow edema (BME) remained constant for most subjects. No doses were excluded from further study due to DLT criteria. Plasma levels of SM04690 were below the limit of detection at all time points. At Week 24, improvements from baseline were seen in all cohorts for the exploratory measures WOMAC Total, WOMAC Function, WOMAC Pain, MDGA, Pain VAS, and OMERACT-OARSI response. Joint space width (JSW) improvement was observed in the 0.07 mg cohort (P = 0.02 vs PBO).

CONCLUSION

SM04690 appeared safe and well tolerated, with no evidence of systemic exposure. Exploratory efficacy analyses suggested positive trends for measurements of OA pain, function and disease-modifying osteoarthritis drug (DMOAD) properties. CLINICALTRIALS.

GOV REGISTRATION

NCT02095548.

Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force

BACKGROUND

Reaching the therapeutic target of remission or low-disease activity has improved outcomes in patients with rheumatoid arthritis (RA) significantly. The treat-to-target recommendations, formulated in 2010, have provided a basis for implementation of a strategic approach towards this therapeutic goal in routine clinical practice, but these recommendations need to be re-evaluated for appropriateness and practicability in the light of new insights.

OBJECTIVE

To update the 2010 treat-to-target recommendations based on systematic literature reviews (SLR) and expert opinion.

METHODS

A task force of rheumatologists, patients and a nurse specialist assessed the SLR results and evaluated the individual items of the 2010 recommendations accordingly, reformulating many of the items. These were subsequently discussed, amended and voted upon by >40 experts, including 5 patients, from various regions of the world. Levels of evidence, strengths of recommendations and levels of agreement were derived.

RESULTS

The update resulted in 4 overarching principles and 10 recommendations. The previous recommendations were partly adapted and their order changed as deemed appropriate in terms of importance in the view of the experts. The SLR had now provided also data for the effectiveness of targeting low-disease activity or remission in established rather than only early disease. The role of comorbidities, including their potential to preclude treatment intensification, was highlighted more strongly than before. The treatment aim was again defined as remission with low-disease activity being an alternative goal especially in patients with long-standing disease. Regular follow-up (every 1-3 months during active disease) with according therapeutic adaptations to reach the desired state was recommended. Follow-up examinations ought to employ composite measures of disease activity that include joint counts. Additional items provide further details for particular aspects of the disease, especially comorbidity and shared decision-making with the patient. Levels of evidence had increased for many items compared with the 2010 recommendations, and levels of agreement were very high for most of the individual recommendations (≥9/10).

CONCLUSIONS

The 4 overarching principles and 10 recommendations are based on stronger evidence than before and are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA.

Morning stiffness response with delayed-release prednisone after ineffective course of immediate-release prednisone

Objective: To assess morning stiffness in rheumatoid arthritis (RA) patients switched from immediate-release (IR) to delayed-release (DR) prednisone.

Method: Circadian Administration of Prednisone in Rheumatoid Arthritis-1 (CAPRA-1) is a 12-week, randomized, multicentre, active-controlled study of morning stiffness that consisted of a double-blind phase and a 9-month open-label extension. Patients receiving IR prednisone with no significant improvement after the double-blind study were switched to DR prednisone. Morning stiffness duration and median absolute and relative changes in pain and global assessment were evaluated (3, 6, and 9 months).

Results: In patients switched from IR to DR prednisone (n = 110), statistically significant reductions in morning stiffness occurred over 3 months and were sustained for 9 months. Absolute reduction of morning stiffness was ~50 min with > 40% relative reduction at each visit. Interleukin (IL)-6 levels were reduced by the same amount. Statistically significant and clinically meaningful mean reductions in morning stiffness were maintained at > 67 min at each visit along with significant improvements in pain and patient global assessment. There was no evidence of tachyphylaxis seen over the 9-month study.

Conclusions: Patients receiving disease-modifying anti-rheumatic drugs (DMARDs) and IR prednisone who had not had significant reductions in morning stiffness demonstrated statistically significant and clinically meaningful improvements when switched to DR prednisone.

Outcome measures in placebo-controlled trials of osteoarthritis: responsiveness to treatment effects in the REPORT database

INTRODUCTION

Treatment response in randomized clinical trials (RCT) of osteoarthritis (OA) has been assessed by multiple primary and secondary outcomes, including pain, function, patient and clinician global measures of status and response to treatment, and various composite and responder measures. Identifying outcome measures with greater responsiveness to treatment is important to increase the assay sensitivity of RCTs.

OBJECTIVE

To assess and compare the responsiveness of different outcome measures used in placebo-controlled RCTs of OA.

SEARCH STRATEGY

The Resource for Evaluating Procedures and Outcomes of Randomized Trials database includes placebo-controlled clinical trials of pharmacologic treatments (oral, topical, or transdermal) for OA identified from a systematic literature search of RCTs published or publicly available before August 5, 2009, which was conducted using PubMed, the Cochrane collaboration, publicly-available websites, and reference lists of retrieved publications.

DATA COLLECTION AND ANALYSIS

Data collected included: (1) pain assessed with single-item ratings and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale; (2) patient and clinician global measures of status, improvement, and treatment response; (3) function assessed by the WOMAC function subscale; (4) stiffness assessed by the WOMAC stiffness subscale; and (5) the WOMAC and Lequesne Algofunctional Index composite outcomes. Measures were grouped according to the total number of response categories (i.e., <10 categories or ≥10 categories). The treatment effect (difference in mean change from baseline between the placebo and active therapy arms) and standardized effect size (SES) were estimated for each measure in a meta-analysis using a random effects model.

RESULTS

There were 125 RCTs with data to compute the treatment effect for at least one measure; the majority evaluated non-steroidal anti-inflammatory drugs (NSAIDs), followed by opioids, glucosamine and/or chondroitin, and acetaminophen. In general, the patient-reported pain outcome measures had comparable responsiveness to treatment as shown by the estimates of treatment effects and SES. Treatment effects and SESs were generally higher for patient-reported global measures compared with clinician-rated global measures but generally similar for the WOMAC and Lequesne composite measures.

CONCLUSIONS

Comparing different outcome measures using meta-analysis and selecting those that have the greatest ability to identify efficacious treatments may increase the efficiency of clinical trials of treatments for OA. Improvements in the quality of the reporting of clinical trial results are needed to facilitate meta-analyses to evaluate the responsiveness of outcome measures and to also address other issues related to assay sensitivity.

Treating rheumatoid arthritis to target: recommendations of an international task force

Background

Aiming at therapeutic targets has reduced the risk of organ failure in many diseases such as diabetes or hypertension. Such targets have not been defined for rheumatoid arthritis (RA).

Objective

To develop recommendations for achieving optimal therapeutic outcomes in RA.

Methods

A task force of rheumatologists and a patient developed a set of recommendations on the basis of evidence derived from a systematic literature review and expert opinion; these were subsequently discussed, amended and voted upon by >60 experts from various regions of the world in a Delphi-like procedure. Levels of evidence, strength of recommendations and levels of agreement were derived.

Results

The treat-to-target activity resulted in 10 recommendations. The treatment aim was defined as remission with low disease activity being an alternative goal in patients with long-standing disease. Regular follow-up (every 1–3 months during active disease) with appropriate therapeutic adaptation to reach the desired state within 3 to a maximum of 6 months was recommended. Follow-up examinations ought to employ composite measures of disease activity which include joint counts. Additional items provide further details for particular aspects of the disease. Levels of agreement were very high for many of these recommendations (≥9/10).

Conclusion

The 10 recommendations are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA based on evidence and expert opinion.

Patient Preference for Placebo, Acetaminophen (paracetamol) or Celecoxib Efficacy Studies (PACES): two randomised, double blind, placebo controlled, crossover clinical trials in patients with knee or hip osteoarthritis

BACKGROUND

Acetaminophen (paracetamol) is recommended as the initial pharmacological treatment for knee or hip osteoarthritis. However, survey and clinical trial data indicate greater efficacy for non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 specific inhibitors.

DESIGN

Two randomised, double blind, placebo controlled, crossover multicentre clinical trials, Patient Preference for Placebo, Acetaminophen or Celecoxib Efficacy Studies (PACES).

PATIENTS

Osteoarthritis of knee or hip.

INTERVENTION

"Wash out" of treatment; randomisation; 6 weeks of celecoxib 200 mg/day, acetaminophen 1000 mg four times a day, or placebo; second "wash out;" crossover to 6 weeks of second treatment.

MEASUREMENTS

Western Ontario McMaster Osteoarthritis Index (WOMAC), visual analogue pain scale, patient preference between two treatments.

RESULTS

Celecoxib was more efficacious than acetaminophen in both periods in both studies; WOMAC and pain scale scores differed at p<0.05 in period II and both periods combined of PACES-a and in periods I and II and both periods combined in PACES-b, but not in period I of PACES-a. Acetaminophen was more efficacious than placebo, generally p<0.05 in PACES-b, and >0.05 in PACES-a. Patient preferences were 53% celecoxib v 24% acetaminophen in PACES-a (p<0.001) and 50% v 32% in PACES-b (p = 0.009); 37% acetaminophen v 28% placebo in PACES-a (p = 0.340) and 48% v 24% in PACES-b (p = 0.007). No clinically or statistically significant differences were seen in adverse events or tolerability among the three treatment groups.

CONCLUSIONS

Greater efficacy was seen for celecoxib v acetaminophen v placebo, while adverse events and tolerability were similar. Variation in results and statistical significance in the two different trials are of interest.

A diagnostic approach to musculoskeletal pain

Musculoskeletal pain or inflammation is one of the most common causes of primary care office visits. Musculoskeletal disorders exact a high toll in distress, disability, and direct health care costs. Given the wide range of disorders that may cause or contribute to musculoskeletal symptoms, differential diagnosis is challenging and a systematic approach is necessary. Patient history is the single most valuable source of diagnostic information, followed by a careful physical examination. The history also suggests which laboratory tests and imaging studies, if any, are indicated. The chronology, duration, and pattern of pain distribution offer clues to establishing an accurate diagnosis, along with evidence of other organ system involvement or underlying disease. Helpful distinctions are those between articular and nonarticular pain, between monarthritis and multiple joint involvement, and between inflammatory and noninflammatory conditions.

The arthritogenic properties of microbial antigens. Their implications in disease states

The sharing of antigenic determinants between host and microbe is a common event and new microbial-tissue cross-reactions are being recognized each year. Almost every human organ has been implicated as a possible target. The purpose of this article is to examine the arthritogenic properties of these microbial antigens and to explore the mechanisms by which they induce pathologic damage and disease.

Rheumatic fever. The relationships between host, microbe, and genetics

Acute rheumatic fever is a delayed, nonsuppurative sequela of a pharyngeal infection with the group A streptococcus. The onset of the disease is usually characterized by an acute febrile illness; however, there may be chronic involvement of the heart and/or central nervous system. The article explores the relationship between the initial infection and host-microbial interactions that may be operative in disease pathogenesis.

The co-occurrence of acute rheumatic fever and AIDS

We describe a patient with advanced acquired immunodeficiency syndrome (AIDS) who presented with evidence of carditis, arthritis, and chorea in the setting of fever, and serologic evidence for recent streptococcal infection. Several features atypical for rheumatic fever were present and included persistently high titer of antistreptolysin O, the simultaneous occurrence of chorea and arthritis, and the presence of chorea in a sexually mature adult man. The differential diagnosis of arthritis in a host at risk for human immunodeficiency virus should be expanded to include acute rheumatic fever, which may manifest atypical features.

Liability issues in the treatment of patients with rheumatic diseases

In clinical practice, risk management focuses primarily on concerns regarding adverse occurrences and the possibility of resulting civil litigation. Tort law, one of the major branches of civil law, is most relevant to clinical risk management. Duty, breach, causation, and damages are the four elements of the tort of professional liability, i.e., medical malpractice. Liability concerns in clinical practice commonly involve adverse drug reactions. Other potential liability concerns include informed consent, adverse outcomes, and economic considerations.

Legal issues in allergy and clinical immunology

Clinical risk management for the allergist focuses primarily on concerns regarding adverse occurrences and the possibility of civil litigation as a result of negligence or professional liability. Risk is substantially reduced with an understanding of such predictable drug reactions as overdosage, side effects, secondary effects, and drug interactions. In addition, all clinicians who prescribe have a duty to disclose to their patients the possibility of unpredictable reactions, including intolerance, idiosyncrasy, and allergy or hypersensitivity. This disclosure should be part of a comprehensive discussion of the risks and benefits of, and alternatives to, therapeutic agents and procedures they recommend. The process of informed consent becomes even more critical with the increasing influence of hospital and managed care formularies on prescribing decisions. Although cost effectiveness is an important factor in prescribing decisions, the possibility of adverse effects, treatment failure, noncompliance, and other negative considerations must also be weighed.

Rheumatic fever and poststreptococcal reactive arthritis

Rheumatic fever is a catastrophic illness in many parts of the world, particularly in developing nations, where the incidence has been estimated to be between 10 and 15 million new cases each year. In the United States, rheumatic fever had become a rarity, having virtually disappeared by the mid 1960s. Of increasing concern, however, was the abrupt rise in the incidence of rheumatic fever in the United States in the mid 1980s, with reported "outbreaks" in middle-class communities in five cities and two military camps. Recently, a number of cases of poststreptococcal reactive arthritis have been reported. On close examination, however, these are most likely alternate clinical presentations of rheumatic fever. It is widely accepted that rheumatic fever occurs following an overactive immune response by a genetically susceptible host to oropharyngeal infection with group A beta-hemolytic streptococci. Nevertheless, details of pathogenesis at a level allowing more effective intervention remain obscure. The question of pathogenesis holds a deep interest, because rheumatic fever is one of the few autoimmune diseases with a known infectious etiology.

Marriage, social support, and adjustment to rheumatic disease

The family is an important source of support for the patient with RA. At the same time, the illness creates stresses for family members that may affect their well-being or inhibit their ability to provide support to the patient. In designing support interventions, one cannot assume that difficulties in adjusting to chronic illness reflect a lack of support from the family or that the patient should be the sole target of intervention.

Risk management in endoscopic practice

As illustrated, the practice of gastrointestinal endoscopy is not without risks. All physicians who perform endoscopy should be mindful of the tenets of risk management and how they apply to their endoscopic practices. Retrospective review of individual endoscopic practice habits should be performed yearly and modifications made where necessary. Hospital quality assurance committees should have gastrointestinal endoscopist representation. These committees should have as a component of their responsibilities a commitment to physician education.

Silicone gel filled breast implants and connective tissue disease: an overview

OBJECTIVE

To review the literature examining the association of silicone gel filled implants and connective tissue disease.

METHODS

Computerized literature searches and manual review of bibliographies.

RESULTS

Numerous concerns have arisen regarding the safety of silicone gel filled breast implants. The structure of these prostheses is reviewed. Silicones are not biologically inert. Injectable as well as implantable silicones have proven capable of eliciting inflammatory and fibroproliferative responses. Silicone leakage from silicone gel filled implants is well documented as is distant migration of silicone in the host. In the past decade, over 60 cases of connective tissue disease following mammoplasty with silicone gel filled implants have been reported. About half of these patients developed scleroderma or scleroderma-like illnesses. This reported overrepresentation of scleroderma compared to other rheumatic diseases mimics the Japanese experience with injectable silicones. Possible biological rationale for the association is presented.

CONCLUSION

The physical and biological properties of silicone gel filled implants and their behavior in vivo is compatible with the hypothesis that they may contribute to the development of connective tissue disease. The association seems most likely with scleroderma; however, there is as yet inadequate epidemiological data to definitively establish causality.

Assessing the impact of self-efficacy beliefs on adaptation to rheumatoid arthritis

This article examines the influence of self-efficacy beliefs on problem-solving coping, functional disability, and psychological well-being for 101 recently diagnosed adult patients with rheumatoid arthritis (RA). Data were drawn from a longitudinal study of psychosocial adaptation to the onset of RA. Self-efficacy beliefs were associated with less functional disability assessed concurrently and 1 year later. Self-efficacy beliefs were also associated with greater use of problem-solving coping 1 year later. There was an interaction between pain and self-efficacy beliefs in the prediction of depression 1 year later: at low pain, self-efficacy beliefs were unrelated to depression, but at higher levels of pain, greater self-efficacy was related to greater depression. Finally, problem-solving coping mediated the relationship between disability and initial self-efficacy beliefs. The distinct patterns that emerge for pain, self-efficacy beliefs, and coping, with respect to functional status as compared to psychological status, are discussed.

The genetics of rheumatic fever: relationship to streptococcal infection and autoimmune disease

A large body of evidence suggests that patients with rheumatic fever immunologically respond abnormally both at a humoral and cellular level to streptococcal antigens cross-reactive with mammalian tissues. Implicit in this concept is that this abnormal immune response is genetically programmed. Using a monoclonal antibody called D8/17, a B cell marker has now been identified in 90-100% of all patients with rheumatic fever tested in 5 different geographical and ethnic populations. This trait appears to be inherited in an autosomal recessive fashion. This recognition of a B cell marker unique to individuals with rheumatic fever has important public health implications with respect to identification of individuals susceptible to rheumatic fever, possible prevention of disease and the recognition of prime candidates for future streptococcal vaccines.

Social support as a double-edged sword: the relation of positive and problematic support to depression among rheumatoid arthritis patients

This study considers social network interactions as a potential source of both stress and support for individuals coping with a chronic illness. The sample consisted of 101 recently-diagnosed rheumatoid arthritis patients. Symptoms of depression were assessed using the Center for Epidemiologic Studies Depression scale. Hierarchical multiple regression analyses examined the conjoint effects of social support and problematic interactions on symptoms of depression. Receipt of positive or helpful support from close friends and family was related to lower depression; receipt of problematic support was related to increased depression. A positive x problematic support interaction suggested that the costs of problematic support do not cancel out the benefits of positive support. Patients who reported both little support and a greater degree of problematic interactions experienced the highest level of symptoms. The findings emphasize the need to consider positive and negative aspects of support transactions conjointly in assessing their stress-reducing and health-protective potential.

The role of Fc gamma receptors in mononuclear phagocyte system function

Abnormalities in host mechanisms for the handling of immune complexes (IC) may promote both tissue deposition of pathogenic complexes and interaction of complexes with other immunocompetent cells. Although immune adherence of complexes to erythrocytes may be decreased in patients with autoimmune disease, the significance of this decrease for overall immune complex handling is unclear since many IC release rapidly from the erythrocytes. Little is known about the role of complement receptors in IC uptake by phagocytes. In contrast, the observations of defective Fc gamma receptor-mediated uptake of IgG ligand-coated erythrocytes (one model for erythrocyte-bound complexes) by fixed tissue macrophages in SLE patients demonstrate the role of Fc gamma receptors in the uptake of these complexes. Although partly acquired and related to disease activity in SLE, the Fc-mediated clearance defect may also have a genetic component. Inherited differences in Fc gamma function may reflect structural polymorphisms of the involved Fc receptors. The emerging picture of Fc gamma receptor structural diversity - several different receptor families (Fc gamma RI, Fc gamma RII and Fc gamma RIII) each with different isoforms, the potential for different glycoforms and cell anchoring mechanisms, and allelic variations within the isoforms - provides the basis for structure/function relationships which have clear implications for autoimmune diseases with abnormal Fc receptor function.