Impact of the COVID-19 Pandemic on People Living with Rheumatoid Arthritis: Experiences and Preferences in Accessing Healthcare Across Five Countries

INTRODUCTION

The global coronavirus 2019 (COVID-19) pandemic created many challenges in healthcare provision. This study aimed to evaluate the global impact of the COVID-19 pandemic on people living with rheumatoid arthritis (RA).

METHODS

The RA Narrative COVID-19 survey was conducted online among people with RA who resided in Brazil, Canada, France, Japan, and the US from August to September 2021. The survey examined disease management, healthcare access and experiences, and participant preferences for interactions with their doctor.

RESULTS

Overall, 500 participants completed the survey: 100 each resided in Brazil, Canada, France, Japan, and the US. Emotional well-being was the aspect of disease management most reported to be negatively impacted by the pandemic (55% of participants); 'having more anxiety and/or stress' during the pandemic was the top factor that made controlling RA symptoms more difficult (49% of participants). In comparison, the top factor that made controlling RA symptoms easier was 'having a less busy schedule' (35% of participants). More participants had virtual appointments during versus pre-pandemic (53% vs. 13%, respectively) and participants were equally satisfied with the overall quality of care received via virtual and in-person appointments (76% of participants were 'satisfied' or 'very satisfied' with both). However, participants generally preferred in-person over virtual appointments, except for prescription refills, for which preferences were similar (39% vs. 36%, respectively).

CONCLUSIONS

This survey suggests that the COVID-19 pandemic did negatively impact some aspects of disease management for people living with RA but had positive impacts on the utilization of virtual care. Although participants generally preferred in-person appointments, these results position virtual care as an appropriate means for routine follow-ups.

An online survey among US patients with immune-mediated conditions: Attitudes about biosimilars

BACKGROUND: Few surveys about biosimilars have been conducted among US patients. OBJECTIVE: To evaluate attitudes about biosimilars among patients with rheumatoid arthritis (RA), psoriasis and/or psoriatic arthritis (PsO/A), and/or inflammatory bowel disease (IBD). METHODS: WebMD, LLC fielded a 16-item online survey to members of the US Dynata consumer panel meeting these criteria: aged 18 years or older; self-reported specialist diagnosis of RA, PsO/A, or IBD of at least 1 year; and not currently receiving an infliximab biosimilar. A quota of 500 was set, stratified by region and condition. The survey was exempt by the institutional review board, exploratory, and not registered. RESULTS: Overall, 44% (n = 221) of patients were on a biologic; 56% (n = 279) were not on a biologic (40% [n = 199] were biologic naive and 16% [n = 80] used biologics in the past). Among all patients, 66% were unaware of biosimilars and 24% were aware (10% unsure). After being shown the US Food and Drug Administration definition of a biosimilar, main concerns were side effects (59%), long-term safety (50%), and not knowing a lot (46%). Among current users, 43% would switch to a biosimilar and 26% would not (32% unsure). Of those unwilling to switch, 51% were concerned about side effects, 42% about financial support, and 40% about efficacy. When those not on a biologic were asked if their doctor prescribed an original anti-tumor necrosis factor α but their insurance required its biosimilar, 49% would switch and 8% would not (43% unsure). 51% of patients surveyed thought pharmacist-level substitution of an interchangeable biosimilar was acceptable with notification. Survey findings were consistent among the RA, PsO/A, and IBD subgroups. CONCLUSIONS: Although two-thirds of patients surveyed were unaware of biosimilars, the majority were potentially receptive to biosimilar treatment after being provided with the definition of a biosimilar. Patients expressed a desire to know more about biosimilars in general, how they compare with original biologics, their benefits, and cost. DISCLOSURES: This study was funded by Boehringer Ingelheim Pharmaceuticals Inc. (BIPI). WebMD, LLC, fielded the survey. BIPI was given the opportunity to review the article for medical and scientific accuracy and intellectual property considerations. Dr Gibofsky is a consultant/advisor for AbbVie Inc., Biosplice Therapeutics, Lilly, Novartis Pharmaceuticals Corporation, and Pfizer Inc., and he is on the speakers' bureau for AbbVie Inc., Amgen, Lilly, and Pfizer Inc., and has stock ownership in AbbVie Inc., Amgen, Bristol-Myers Squibb Company, Horizon Pharma plc, and Pfizer Inc. Dr Peyrin-Biroulet reports that he has received personal consulting fees from Merck Sharp & Dohme, AbbVie, Janssen, Takeda, Celltrion, Pfizer, Bristol-Myers Squibb Company, Pharmacosmos, Shire, Genentech, Mitsubishi, Ferring, Norgine, Tillots, Vifor, UCB-Pharma, Hospira, BIPI, and Lilly. Dr McCabe is an employee of BIPI. Dr McGrath was an employee of BIPI at the time the survey was conducted. Mr Jacobson, Mr Franklin, and Ms O'Hara-Levi report no disclosures.

Prescriber Perspectives on Biosimilar Adoption and Potential Role of Clinical Pharmacology: A Workshop Summary

The approval and adoption of biosimilar products are essential to contain increasing healthcare costs and provide more affordable choices for patients. Despite steady progress in the number of the US Food and Drug Administration (FDA) biosimilar approvals over the years, biosimilar adoption in the United States has been slow and gradual, largely driven by payers rather than clinicians. In order to better understand the barriers to biosimilar adoption in the clinic, the University of Maryland Center of Excellence in Regulatory Science and Innovation (M-CERSI) and the FDA jointly hosted a virtual workshop on April 13, 2022, titled "Biosimilars: A Decade of Experience and Future Directions - Strategies for Improving Biosimilar Adoption and the Potential Role of Clinical Pharmacology." This summary documents the experiences of four leading academic clinicians with specialties in oncology, rheumatology, gastroenterology, and endocrinology and their perspectives on how to increase biosimilar adoption, including the role of clinical pharmacology. Besides systemic changes in pricing and reimbursement, there is a need for additional education of a broad range of providers, including advanced care practitioners, and patients themselves. Educational efforts highlighting the rigor of the studies that support the approval of biosimilars-including the clinical pharmacology studies-and the benefits of biosimilars, can play a major role in improving biosimilar acceptance.

Provider and patient knowledge gaps on biosimilars: insights from surveys

Beyond the legal and regulatory limitations associated with biosimilar availability in the United States, the adoption of biosimilars is contingent on the willingness of health care providers (HCPs) to prescribe them and of patients to accept them. In this dynamic market, it is of paramount importance to understand the current awareness, attitudes, and preferences of a broad spectrum of stakeholders if uptake of biosimilars is to be optimized. In this article, we highlight knowledge gaps among US HCPs and patients regarding biosimilars for immune-mediated inflammatory diseases as assessed in published survey literature over the last 5 years. Although HCP familiarity and understanding of biosimilars appears to have improved over the last 5 years, survey data suggest that some physicians and pharmacists still approach use of biosimilars with caution owing to concerns regarding nonmedical switching, interchangeability, pharmacist-led substitution, and the extent of any cost savings. Patients understand the potential cost benefits of biosimilars but share many of the HCPs' concerns. A large majority of patients were also concerned that biosimilars would not treat their disease as well as the reference product and that switching may cause more adverse effects. Consequently, nonmedical switching is a major concern for patients, with the majority reporting that they would attempt to avoid a switch. Although patients trust their physicians' treatment recommendations and express confidence in biosimilars, they have mixed views on automatic substitution by pharmacists. The areas of concern identified can be used to guide further education programs for HCPs and patients, and, in doing so, improve biosimilar uptake.

Biosimilars for immune-mediated inflammatory diseases: a managed care perspective

Biosimilars hold the promise of substantial potential cost savings in health care with no compromise in the efficacy and safety of treatment. Despite this, their adoption in the United States has been substantially slower than might have been expected. In addition to patient and provider barriers to their widespread adoption as discussed in the second article in this supplement, additional potential barriers to their use are inherent to the current US health care system. In this article, we examine biosimilar agents from a managed care perspective and discuss some of the reasons behind their delayed adoption in the United States.

Overview of biosimilars for immune-mediated inflammatory diseases: summary of current evidence

Biosimilars offer the potential to deliver substantial cost savings in biologic therapy and to contribute to increased patient access to biologic treatments, both of which are particularly relevant for immune-mediated inflammatory diseases, given the number of patients affected by and receiving treatment for these conditions. For the United States to benefit from bringing biosimilar pipeline products to the market, legal and price-related barriers to competition must be addressed. In addition, education of prescribers, patients, payers, and providers is essential to increase uptake as biosimilars reach the market. This article discusses biosimilars currently available for the treatment of immune-mediated inflammatory diseases in the United States, reviews the main concepts related to regulatory approval of biosimilars by the FDA, and considers potential barriers to the uptake of biosimilars.

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.

US rheumatologists' beliefs and knowledge about biosimilars: a survey

Objectives

We sought to evaluate perceptions of biosimilar products among US rheumatologists who prescribe TNF-α inhibitors, given that 10 TNF-α inhibitor biosimilars and two rituximab biosimilars have Food and Drug Administration (FDA) approval.

Methods

A 19-question self-administered online survey was conducted from 6 May to 1 June 2019, and fielded by WebMD, LLC. Rheumatologists (n = 9050) who were members of Medscape.com and its partner panels were invited to participate. Likert and other rating scales were used to collect responses, which were summarized descriptively.

Results

Responses were obtained from 320 board-certified US rheumatologists, 85% of whom were fellows of the ACR. Nearly all respondents were familiar with the FDA definition of a biosimilar product and were aware that an infliximab biosimilar was FDA approved; fewer realized that adalimumab, etanercept and rituximab biosimilars were also FDA approved. Most respondents (84%) were aware that an approved biosimilar was not automatically deemed interchangeable by the FDA. Rheumatologists were more likely to initiate biosimilar treatment for a biologic treatment-naïve patient with RA (73%) than they were to switch to the biosimilar for a patient with RA doing well on the reference product (35%).

Conclusions

The results of this survey suggest that US rheumatologists have a good understanding and acceptance of biosimilar products, particularly for the initiation of treatment in biologic-naïve individuals. They were hesitant to switch from a reference product to a biosimilar for a patient doing well on the reference product. Additional education on biosimilars is required to help inform treatment decisions by rheumatologists.

A plain language summary of this article has been uploaded as supplementary material, available at Rheumatology online.

Impact of COVID-19 on vulnerable patients with rheumatic disease: results of a worldwide survey

OBJECTIVE

There is emerging evidence that COVID-19 disproportionately affects people from racial/ethnic minority and low socioeconomic status (SES) groups. Many physicians across the globe are changing practice patterns in response to the COVID-19 pandemic. We sought to examine the practice changes among rheumatologists and what they perceive the impact to be on their most vulnerable patients.

METHODS

We administered an online survey to a convenience sample of rheumatologists worldwide during the initial height of the pandemic (between 8 April and 4 May 2020) via social media and group emails. We surveyed rheumatologists about their opinions regarding patients from low SES and racial/ethnic minority groups in the context of the COVID-19 pandemic. Mainly, what their specific concerns were, including the challenges of medication access; and about specific social factors (health literacy, poverty, food insecurity, access to telehealth video) that may be complicating the management of rheumatologic conditions during this time.

RESULTS

548 rheumatologists responded from 64 countries and shared concerns of food insecurity, low health literacy, poverty and factors that preclude social distancing such as working and dense housing conditions among their patients. Although 82% of rheumatologists had switched to telehealth video, 17% of respondents estimated that about a quarter of their patients did not have access to telehealth video, especially those from below the poverty line. The majority of respondents believed these vulnerable patients, from racial/ethnic minorities and from low SES groups, would do worse, in terms of morbidity and mortality, during the pandemic.

CONCLUSION

In this sample of rheumatologists from 64 countries, there is a clear shift in practice to telehealth video consultations and widespread concern for socially and economically vulnerable patients with rheumatic disease.

Geographical variations in COVID-19 perceptions and patient management: a national survey of rheumatologists

OBJECTIVE

To investigate the perceptions and behaviors of rheumatologists in the United States (US) regarding the risk of COVID-19 for their autoimmune patients and the subsequent management of immunosuppressive and anti-inflammatory medications.

METHODS

We administered an online survey to a convenience sample of rheumatologists in the US from 4/8/20-5/4/20 via social media and group emails. Survey respondents provided demographic information such as, age, gender, state of practice, and practice type. We asked questions about COVID-19 risk in rheumatic patients, as well as their medication management during the pandemic. We conducted descriptive analysis and Multivariable regression models.

RESULTS

271 respondents completed the survey nationally. 48% of respondents either agreed or strongly agreed with the statement "Patients with rheumatic diseases are at a higher risk of COVID-19 irrespective of their immunosuppressive medications". 50% disagreed or strongly disagreed with the statement "The pandemic has led you to reduce the use/dosage/frequency of biologics", while 56% agreed or strongly agreed with the statement "The pandemic has led you to reduce the use/dosage/frequency of steroids". A third of respondents indicated that at least 10% of their patients had self-discontinued or reduced at least one immunosuppressive medication to mitigate their risk of COVID-19. Responses to these questions as well as to questions regarding NSAID prescription patterns were significantly different in the Northeast region of US compared to other regions.

CONCLUSION

In this national sample of rheumatologists, there are variations regarding perceptions of patients' risk of COVID-19, and how to manage medications such as NSAIDs, biologics and steroids during the pandemic. These variations are more pronounced in geographical areas where COVID-19 disease burden was high.

Lorecivivint, a Novel Intraarticular CDC-like Kinase 2 and Dual-Specificity Tyrosine Phosphorylation-Regulated Kinase 1A Inhibitor and Wnt Pathway Modulator for the Treatment of Knee Osteoarthritis: A Phase II Randomized Trial

OBJECTIVE

To assess the safety and efficacy of a novel Wnt pathway modulator, lorecivivint (SM04690), for treating pain and inhibiting structural progression in moderately to severely symptomatic knee osteoarthritis (OA).

METHODS

Subjects in this 52-week, phase IIa, multicenter, randomized, double-blind, placebo-controlled, dose-ranging trial received a single 2-ml intraarticular injection of lorecivivint (dose of 0.03 mg, 0.07 mg, or 0.23 mg) or placebo. Efficacy was assessed based on change from baseline on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score subscales for pain and function (scale 0-100 for each) and change from baseline in the radiographic medial joint space width (JSW). Baseline-adjusted analysis of covariance with multiple imputation was performed separately to evaluate efficacy. This proof-of-concept study evaluated the intent-to-treat population as well as a prespecified group of subjects with unilateral symptoms of knee OA (designated UNI) and an additional post hoc subgroup of subjects with unilateral symptoms but without widespread pain (designated UNI WP-).

RESULTS

In this trial, 455 subjects were randomized to a treatment group. The primary end point, significant improvement in the WOMAC pain score compared with placebo at week 13, was not met by any lorecivivint dose group (mean ± SD change from baseline, -23.3 ± 2.2 in the 0.03 mg group, -23.5 ± 2.1 in the 0.07 mg group, -21.3 ± 2.2 in the 0.23 mg group, and -22.1 ± 2.1 in the placebo group; each P > 0.05 versus placebo). All groups (including placebo) demonstrated clinically meaningful (≥20-point) improvements from baseline in the WOMAC pain score. The durability of response was evaluated through week 52. In the prespecified UNI group and post hoc UNI WP- group at week 52, treatment with 0.07 mg lorecivivint significantly improved the WOMAC pain score (between-group difference versus placebo, -8.73, 95% confidence interval [95% CI] -17.44, -0.03 [P = 0.049] and -11.21, 95% CI -20.99, -1.43 [P = 0.025], respectively) and WOMAC function score (between-group difference versus placebo, -10.26, 95% CI -19.82, -0.69 [P = 0.036] and -13.38, 95% CI -24.33, -2.43 [P = 0.017], respectively). Relative to baseline, the mean change in the medial JSW at week 52 was -0.04 mm in the 0.03 mg cohort, -0.09 mm in the 0.07 mg cohort, -0.16 mm in the 0.23 mg cohort, and -0.14 mm in the placebo cohort; no treatment group achieved a significant change in medial JSW compared with placebo at week 52. In both unilateral symptom subgroups, the 0.07 mg lorecivivint dose significantly increased medial JSW compared with placebo at week 52 (medial JSW 0.39 mm, 95% CI 0.06, 0.72 in the UNI group [P = 0.021] and 0.42 mm, 95% CI 0.04, 0.80 in the UNI WP- group [P = 0.032]). Changes observed in the 0.03 mg and 0.23 mg dose groups were not significantly different from those in the placebo group for any of these measures. Lorecivivint appeared safe and well tolerated.

CONCLUSION

This phase IIa, proof-of-concept trial in patients with symptomatic knee OA did not meet its primary end point. Nevertheless, the study identified a target population in whom to evaluate the potential efficacy of lorecivivint for the treatment of knee OA.

Hydroxychloroquine and Chloroquine in COVID-19: A Survey of Prescription Patterns Among Rheumatologists

OBJECTIVE

With hydroxychloroquine (HCQ) and chloroquine (CQ) emerging as potential therapies for coronavirus disease 2019 (COVID-19), shortages have been reported. We aimed to understand how rheumatologists, one of the most common prescribers of HCQ/CQ, prescribed these medications to manage COVID-19 and to understand if their patients are affected by shortages.

METHODS

Between April 8 and April 27, 2020, an online survey was distributed to a convenience sample of rheumatologists who practice medicine in a diverse range of settings globally, resulting in 506 responses. Adjusted Poisson regression models were calculated.

RESULTS

Only 6% of respondents prescribed HCQ/CQ for COVID-19 prophylaxis, and only 12% for outpatient treatment of COVID-19. Compared to the United States, the likelihood of prescribing HCQ/CQ for prophylaxis was higher in India (adjusted risk ratio [aRR], 6.7; 95% confidence interval [CI], 2.7-16.8; p < 0.001). Further, compared to the United States and those with 1 to 5 years of experience, rheumatologists in Europe (aRR, 2.9; 95% CI, 1.6-5.3; p < 0.001) and those with 10+ years of experience (11-20 years: aRR, 2.5; 95% CI, 1.2-5.3; p = 0.015; 21+ years: aRR = 3.3; 95% CI, 1.4-7.4; p = 0.004) had a higher likelihood of prescribing HCQ/CQ for outpatient treatment. Of note, 71% of all rheumatologists reported that their patients were directly affected by HCQ/CQ shortages.

CONCLUSION

The results suggest that only a small percentage of rheumatologists are prescribing HCQ/CQ for prophylaxis or outpatient treatment of COVID-19. Medication shortages experienced by large numbers of autoimmune disease patients are concerning and should play a role in decisions, especially given poor efficacy data for HCQ/CQ in COVID-19.

Longterm Drug Survival of Tumor Necrosis Factor Inhibitors in Patients with Rheumatoid Arthritis

OBJECTIVE

To evaluate longterm drug survival (proportion of patients still receiving treatment) and discontinuation of etanercept (ETN), infliximab (IFX), adalimumab (ADA), certolizumab pegol (CZP), and golimumab (GOL) using observational data from patients with rheumatoid arthritis (RA).

METHODS

Following a systematic literature review, drug survival at 12 and 12-24 months of followup was estimated by summing proportions of patients continuing treatment and dividing by number of studies. Drug survival at ≥ 36 months of followup was estimated through Metaprop.

RESULTS

There were 170 publications included. In the first-line setting, drug survival at 12 months with ETN, IFX, or ADA was 71%, 69%, and 70%, respectively, while at 12-24 months the corresponding rates were 63%, 57%, and 59%. In the second-line setting, drug survival at 12 months with ETN, IFX, or ADA was 61%, 69%, and 55%, respectively, while at 12-24 months the corresponding rates were 53%, 39%, and 43%. Drug survival at ≥ 36 months with ETN, IFX, or ADA in the first-line setting was 59% (95% CI 46-72%), 49% (95% CI 43-54%), and 51% (95% CI 41-60%), respectively, while in the second-line setting the corresponding rates were 56% (95% CI 52-61%), 48% (95% CI 40-55%), and 41% (95% CI 36-47%). Discontinuation of ETN, IFX, and ADA at 36 months of followup was 38-48%, 42-62%, and 38-59%, respectively. Data on CZP and GOL were scarce.

CONCLUSION

After > 12 months of followup, more patients with RA receiving ETN remain on treatment compared with other tumor necrosis factor inhibitors.

Short-term costs associated with non-medical switching in autoimmune conditions

OBJECTIVES

To estimate short-term costs associated with non-medical switch (NMS) from originator biologics to biosimilars among stable patients with autoimmune conditions in rheumatology, gastroenterology, and dermatology from a US provider's and third-party payer's perspective.

METHODS

An economic model was constructed to estimate switching costs related to physician time and healthcare resource utilisation (HRU) at the initial NMS visit and over 3 months. The proportion of patients with relevant conditions treated with originators and expected NMS rate, physician time, HRU, and payer reimbursement were derived from a physician survey. Switching costs were estimated for a practice of 1,000 patients with relevant conditions by therapeutic area and for an insurance plan with 1 million individuals by therapeutic area and all areas combined. Switching cost drivers were assessed with one-way sensitivity analyses.

RESULTS

Physicians expected extra 6 minutes for the NMS visit and 22 minutes over 3 months; NMS rates of 14.4%, 15.5%, and 17.7%; and 11.3%, 16.2%, and 33.2% of time not reimbursed for gastroenterology, rheumatology, and dermatology, respectively. The total switching costs for payer's were $771,460 (for n = 3,609 patients with an NMS rate of 16.6%), mostly due to follow-up visits and additional laboratory tests/procedures. In sensitivity analyses, the NMS rate was the main cost driver. Increasing the NMS rate to 25% and 50% increased payer's total switching costs to $1.19 and $2.39 million, respectively.

CONCLUSIONS

Originator-to-biosimilar NMS in stable patients with autoimmune conditions could result in considerable switching costs for both providers and payers.

Comparison of patient and physician perspectives in the management of rheumatoid arthritis: results from global physician- and patient-based surveys

Background

In order to better understand the perspectives of patients and physicians regarding the treatment and management of rheumatoid arthritis (RA), we present and compare results from a patient-based and a physician-based survey developed by the RA NarRAtive advisory panel.

Methods

The RA NarRAtive initiative is directed by a global advisory panel of 39 healthcare providers and patient organization leaders from 17 countries. A survey of patients self-reporting a diagnosis of RA and a physician-based survey, designed by the advisory panel, were fielded online by Harris Poll from September 2014 to April 2016, and from August 2015 to October 2015, respectively.

Results

We present findings from 1805 patients whose RA was primarily managed by a rheumatologist, and 1736 physicians managing patients with RA. Results confirmed that RA carries a substantial disease burden; half of the patients surveyed reported stopping participation in certain activities as a result of their disease. While 90% of physicians were satisfied with their communications with their patients regarding RA treatment, 61% of patients felt uncomfortable raising concerns or fears with their physician. Of the patients providing responses, 52% felt that improved dialogue/discussion would optimize their RA management, and 68% of physicians wished that they and their patients talked more about their RA goals and treatment. Overall, 88% of physicians agreed that patients involved in making treatment decisions tend to be more satisfied with their treatment experience.

Conclusion

The results of these surveys highlight the impact of RA on patients, and a discrepancy between patient and physician views on communication. Further research, focused on improving patient–physician dialogue, shared goal-setting, and treatment planning, is needed.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-1035-3) contains supplementary material, which is available to authorized users.

Cluster-Randomized Trial of a Behavioral Intervention to Incorporate a Treat-to-Target Approach to Care of US Patients With Rheumatoid Arthritis

Objective

To assess the feasibility and efficacy of implementing a treat‐to‐target approach versus usual care in a US‐based cohort of rheumatoid arthritis patients.

Methods

In this behavioral intervention trial, rheumatology practices were cluster‐randomized to provide treat‐to‐target care or usual care. Eligible patients with moderate/high disease activity (Clinical Disease Activity Index [CDAI] score >10) were followed for 12 months. Both treat‐to‐target and usual care patients were seen every 3 months. Treat‐to‐target providers were to have monthly visits with treatment acceleration at a minimum of every 3 months in patients with CDAI score >10; additional visits and treatment acceleration were at the discretion of usual care providers and patients. Coprimary end points were feasibility, assessed by rate of treatment acceleration conditional on CDAI score >10, and achievement of low disease activity (LDA; CDAI score ≤10) by an intent‐to‐treat analysis.

Results

A total of 14 practice sites per study arm were included (246 patients receiving treat‐to‐target and 286 receiving usual care). The groups had similar baseline demographic and clinical characteristics. Rates of treatment acceleration (treat‐to‐target 47% versus usual care 50%; odds ratio [OR] 0.92 [95% confidence interval (95% CI) 0.64, 1.34]) and achievement of LDA (treat‐to‐target 57% versus usual care 55%; OR 1.05 [95% CI 0.60, 1.84]) were similar between groups. Treat‐to‐target providers reported patient reluctance and medication lag time as common barriers to treatment acceleration.

Conclusion

This study is the first to examine the feasibility and efficacy of a treat‐to‐target approach in typical US rheumatology practice. Treat‐to‐target care was not associated with increased likelihood of treatment acceleration or achievement of LDA, and barriers to treatment acceleration were identified.

Effects of non-medical switching on outcomes among patients prescribed tumor necrosis factor inhibitors

OBJECTIVE

To evaluate health care use and outcomes among patients who experienced a non-medical switch of their prescribed anti-tumor-necrosis-factor biological agent (anti-TNF) for cost containment reasons.

METHODS

Retrospective evaluation of Humedica electronic health records of patients ≥18 years old with anti-TNF treatment for immune conditions. Using natural language processing, stable patients who experienced a non-medical switch (for cost reasons) of their anti-TNF between 2007 and 2013 were identified (NMS cohort, n = 158) and matched to patients who did not (control cohort, n = 4804). Rates of office visits, emergency department visits, and hospitalizations at 30, 90, and 365 days following were evaluated. Medication-related adverse events, defined as subsequent medication change due to a side effect and/or efficacy-related reason were also compared.

RESULTS

Adjusted rates of office visits were higher among the NMS cohort than the control cohort at 30 (46.4% vs. 31.7%, p < .001), 90 (71.0% vs. 57.0%, p < .001), and 365 days (87.8% vs. 76.8%, p < .001). Rates of emergency department use and hospitalization were comparable between cohorts. The NMS cohort had higher adjusted rates of medication-related adverse consequences (both increased side effects and diminished efficacy) than the control cohort at 30 (13.8% vs. 4.0%, p = .003), 90 (31.6% vs 9.6%, p < .001), and 365 days (54.7% vs. 20.3%, p < .001). Compared with controls, the NMS cohort had higher adjusted rates of subsequent medication change within 1 year (27.82% vs. 13.9%, p = .001).

CONCLUSION

Non-medical switching among patients prescribed anti-TNFs was associated with increased health care use, medication-related side effects, and reports of diminished efficacy.

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.

Sex differences in gout characteristics: tailoring care for women and men

Background

To characterize the differences between women and men with gout.

Methods

We analyzed a US national cohort of gout patients cared for by rheumatologists.

Results

Compared with the 1012 men with gout, women with gout (n = 262) were older (71 vs. 61 years, p < 0.001) and had a greater burden of comorbid conditions (p < 0.001 for hypertension, diabetes, renal disease and obesity). Risk factors for gout differed with women more often taking diuretics (p < 0.001), while men more frequently had dietary triggers (p < 0.05).

Conclusions

The profiles of women and men with gout are markedly different, suggesting a need to tailor treatment recommendations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1465-9) contains supplementary material, which is available to authorized users.

Efficacy and safety of low-dose SoluMatrix meloxicam in the treatment of osteoarthritis pain: a 12-week, phase 3 study

OBJECTIVE

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as meloxicam are commonly used to treat osteoarthritis (OA) but are associated with potentially serious dose-related adverse events (AEs). SoluMatrix meloxicam has been developed with the goal of enabling effective treatment at low doses. This phase 3 study evaluated the efficacy and safety of low-dose SoluMatrix meloxicam capsules 5 mg and 10 mg administered once daily for 12 weeks in patients with OA-related pain.

RESEARCH DESIGN AND METHODS

This randomized, double-blind study enrolled patients ≥40 years of age with confirmed hip or knee OA (Kellgren-Lawrence grade II-III) who were chronic users of NSAIDs and/or acetaminophen for OA pain and had Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale mean scores ≥40 mm. Eligible patients experienced an OA pain flare (defined as a ≥15 mm increase in the WOMAC pain subscale score) following discontinuation of NSAIDs/acetaminophen. Patients were randomized to receive once-daily SoluMatrix meloxicam 5 mg or 10 mg, or placebo for 12 weeks. ClinicalTrials.gov identifier: NCT01787188.

MAIN OUTCOME MEASURES

The primary outcome measure was the mean change from baseline in WOMAC pain subscale score at week 12.

RESULTS

Low-dose SoluMatrix meloxicam 5 mg (-36.52 [2.49]; P = 0.0005) and 10 mg (-34.41 [2.68]; P = 0.0059) once-daily treatment significantly reduced the mean (standard error) WOMAC pain subscale score from baseline at week 12 compared with placebo (-25.68 [2.64]). Patients treated with SoluMatrix meloxicam 5 mg or 10 mg reported significantly greater improvements in total WOMAC score and in WOMAC stiffness and function subscale scores at 12 weeks compared with placebo. The most common AEs in the combined low-dose SoluMatrix meloxicam group were headache, diarrhea, nausea, osteoarthritis, and urinary tract infection.

CONCLUSIONS

Low-dose SoluMatrix meloxicam may have a potential role as a new therapeutic option for the management of OA-related pain.

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.

Low-dose SoluMatrix diclofenac : a review of safety across two Phase III studies in patients with acute and osteoarthritis pain

INTRODUCTION

Similar to other NSAIDs, diclofenac is associated with serious dose-related cardiovascular, gastrointestinal, and renal adverse events. Low-dose SoluMatrix diclofenac , containing submicron particles of diclofenac, was developed to provide effective analgesia at lower drug doses compared with currently available NSAIDs.

AREAS COVERED

The efficacy and safety of low-dose SoluMatrix diclofenac was evaluated in two randomized, placebo-controlled Phase III studies: a study in patients with acute pain following bunionectomy surgery and a study in patients with osteoarthritis pain of the hip or knee. In this review article, we summarize safety data from these studies.

EXPERT OPINION

The safety results from the Phase III studies indicate that all dosing regimens of low-dose SoluMatrix diclofenac up to 12 weeks are generally well tolerated. Few serious gastrointestinal, cardiovascular, renal, or hepatic adverse events commonly associated with NSAID use were reported in these studies. Although not directly compared, the safety of SoluMatrix diclofenac was similar to findings for other diclofenac drug products. The potential for safe and effective management of acute and chronic pain at reduced NSAID doses is attractive; definitive characterization of SoluMatrix diclofenac safety requires confirmation by long-term studies.

Discontinuation of disease-modifying anti-rheumatic drugs and clinical outcomes in the Rheumatoid Arthritis DMARD Intervention and Utilisation Study 2 (RADIUS 2)

OBJECTIVES

The purpose of this analysis was to examine discontinuation and reasons for discontinuation from disease-modifying anti-rheumatic (DMARD) therapies in the RADIUS 2 registry, a long-term, open-label, observational study of patients with moderate to severe rheumatoid arthritis (RA).

METHODS

Patients who participated in RADIUS 2 initiated etanercept (ETN) therapy at study entry and were followed for 5 years. In this post hoc analysis, patients who had received ETN continuously from entry to month 4 were categorised by treatment at month 4: ETN monotherapy, ETN+methotrexate (MTX), ETN+MTX+other DMARDs (OTH), or ETN+OTH. Outcomes were assessed at month 4 and at the time of any subsequent treatment change, and included Clinical Disease Activity Index (CDAI) and Health Assessment Questionnaire Disability Index (HAQ-DI).

RESULTS

Of 3,484 patients analysed (982 ETN; 1,356 ETN+MTX; 537 ETN+MTX+OTH; 609 ETN+OTH), baseline demographic and clinical characteristics were similar across treatments. No treatment change occurred in 62.3%, 49.9%, 33.3%, and 37.1% of ETN, ETN+MTX, ETN+MTX+OTH, and ETN+OTH patients, respectively. The mean time on therapy from month 4 was longer for patients receiving ETN (23.3 months) or ETN+MTX (23.7 months) than those receiving ETN+MTX+OTH (18.0 months) or ETN+OTH (18.3 months). The greatest improvements in CDAI and HAQ-DI were seen in patients who continued on ETN. The most common reasons for discontinuing DMARD therapy were cost and ineffective treatment.

CONCLUSIONS

Most patients who had received ≥4 months of ETN continued on ETN throughout the 5-year observation period. Patients with greatest clinical and disability improvements tended to continue on ETN.

The rheumatoid arthritis treat-to-target trial: a cluster randomized trial within the Corrona rheumatology network

Background

The treat-to-target (T2T) approach to the care of patients with rheumatoid arthritis involves using validated metrics to measure disease activity, frequent follow-up visits for patients with moderate to high disease activity, and escalation of therapy when patients have inadequate therapeutic response as assessed by standard disease activity scores. The study described is a newly launched cluster-randomized behavioral intervention to assess the feasibility and effectiveness of the T2T approach in US rheumatology practices. It is designed to identify patient and provider barriers to implementing T2T management. This initial paper focuses on the novel study design and methods created to provide these insights.

Methods/Design

This trial cluster-randomizes rheumatology practices from the existing Corrona network of private and academic sites rather than patients within sites or individual investigators to provide either T2T or usual care (UC) for qualified patients who meet the 2010 revised American College of Rheumatology criteria for the diagnosis of rheumatoid arthritis and have moderate to high disease activity. Specific medication choices are left to the investigator and patient, rather than being specified in the protocol. Enrollment is expected to be completed by the end of 2013, with 30 practices randomized and enrolling a minimum of 530 patients. During the 12-month follow-up, visits are mandated as frequently as monthly in patients with active disease in the T2T group and every 3 months for the UC group. Safety data are collected at each visit. The coprimary endpoints include a comparison of the proportion of patients achieving low disease activity in the T2T and UC groups and assessment of the feasibility of implementing T2T in rheumatology practices, specifically assessment of the rates of treatment acceleration, frequency of visits, time to next visit conditional on disease activity, and probability of acceleration conditional on disease activity in the 2 groups.

Discussion

This cluster-randomized behavioral intervention study will provide valuable insights on the outcomes and feasibility of employing a T2T treatment approach in clinical practice in the United States.

Trial registration

NCT01407419

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-389) contains supplementary material, which is available to authorized users.

Efficacy and safety of low-dose submicron diclofenac for the treatment of osteoarthritis pain: a 12 week, phase 3 study

OBJECTIVE

NSAIDs, such as diclofenac, are the most commonly used medications to treat osteoarthritis (OA), but they are associated with dose-related adverse events (AEs). Low-dose submicron diclofenac was developed using a new, proprietary dry milling process that creates submicron drug particles (SoluMatrix Fine Particle Technology * ), enabling effective treatment at lower doses than other commercially available diclofenac drug products. This phase 3 study evaluated the efficacy and safety of low-dose submicron diclofenac 35 mg three times daily (tid) and twice daily (bid) in patients with OA pain.

RESEARCH DESIGN AND METHODS

This double-blind study enrolled patients ≥40 years of age with clinically and radiographically confirmed (Kellgren-Lawrence grade II-III) hip or knee OA. Eligible patients were chronic NSAID and/or acetaminophen (APAP) users with baseline Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) pain subscale scores ≥40 mm by visual analog scale and an OA flare (≥15 mm increase in WOMAC pain subscale score following discontinuation of NSAIDs/APAP at screening). Patients were randomized to submicron diclofenac 35 mg tid, submicron diclofenac 35 mg bid, or placebo for 12 weeks. ClinicalTrials.gov identifier: NCT01461369.

MAIN OUTCOME MEASURES

Efficacy parameters included mean change from baseline in WOMAC pain subscale score at week 12 (primary efficacy parameter) and in average total WOMAC score over 12 weeks.

RESULTS

Submicron diclofenac 35 mg tid significantly improved WOMAC pain subscale scores from baseline at 12 weeks (-44.1; p = 0.0024) compared with placebo (-32.5). Submicron diclofenac 35 mg bid provided numerical improvement in pain at week 12 that did not reach statistical significance (-39.0; p = 0.0795) compared with placebo. Submicron diclofenac 35 mg tid (-35.9; p = 0.0002) and 35 mg bid (-30.3; p = 0.0363) improved the average total WOMAC score in treated patients over 12 weeks compared with placebo (-23.2). The most frequent AEs in the submicron diclofenac-treated groups were diarrhea, headache, nausea, and constipation. The inclusion of patients with a documented requirement for analgesic therapy (OA 'flare') at baseline and the high rates of rescue medication usage in the placebo group may have impacted the study outcome for the submicron diclofenac treatment groups.

CONCLUSIONS

Low-dose submicron diclofenac is an effective therapeutic option for the treatment of OA pain.

Epidemiology, pathophysiology, and diagnosis of rheumatoid arthritis: A Synopsis

Rheumatoid arthritis (RA) is one of the more common autoimmune disorders, affecting approximately 1% of the population worldwide. The exact cause of RA is not known; however, initiation of disease seems to result from an interaction among genetic susceptibility, environmental triggers, and chance. RA is characterized by dysregulated inflammatory processes in the synovium of the joint that eventually leads to the destruction of both cartilaginous and bony elements of the joint, with resulting pain and disability. Systemic inflammation associated with RA is associated with a variety of extra-articular comorbidities, including cardiovascular disease, resulting in increased mortality in patients with RA. RA is also associated with several psychosocial disorders. Classification criteria for RA that were promulgated jointly by the American College of Rheumatology and the European League Against Rheumatism in 2010 emphasize early detection of RA so that effective management can be initiated before pathological changes become irreversible.

Current therapeutic agents and treatment paradigms for the management of rheumatoid arthritis

Effective management of rheumatoid arthritis (RA) is based on early treatment with pharmacological agents that are appropriate for the degree of disease activity and the presence or absence of indicators of poor prognosis. The 2012 American College of Rheumatology (ACR) treatment recommendations provide clear guidance for pharmacologic management of patients with RA. Although the optimal use of biologic and non-biologic disease-modifying drugs has transformed the treatment of RA to the extent that remission is a reasonable expectation, choice of a particular agent for use in a specific clinical situation remains unclear. Recently, Cochrane reviews as well as a Comparative Effectiveness Review by the Agency for Healthcare Research and Quality have examined the safety and efficacy of these drugs, with a particular emphasis on biologics. The conclusions of these reviews will be examined in the context of the ACR treatment recommendations.

Lower-dose diclofenac submicron particle capsules provide early and sustained acute patient pain relief in a phase 3 study

BACKGROUND

Non-steroidal anti-inflammatory drugs are prescribed for the treatment of patients with acute pain but use of such analgesics is associated with dose-dependent adverse events (AEs). Diclofenac submicron particle capsules have been developed using SoluMatrix technology to provide analgesia at lower doses than available solid oral dosing forms. Our study evaluated the analgesic efficacy and safety of lower-dose diclofenac submicron particle capsules in patients with acute pain following elective surgery.

METHODS

A phase 3, multicenter, double-blind study enrolled 428 patients, aged 18 to 65 years, with moderate-to-severe pain following bunionectomy under regional anesthesia. Patients experiencing a pain intensity rating of ≥ 40 mm on a 100-mm Visual Analog Scale were randomized to receive lower-dose diclofenac submicron particle capsules (35 or 18 mg, 3 times daily [TID]), celecoxib (200 mg, twice daily [BID], 400-mg loading dose), or placebo. The primary efficacy parameter was the overall (summed) pain intensity difference measured over 0 to 48 hours (SPID-48). Secondary efficacy parameters included pain intensity difference (PID) at scheduled assessments.

RESULTS

Lower-dose diclofenac submicron particle capsules 35 mg TID (524.05; P < 0.001), 18 mg TID (393.25; P = 0.010), and celecoxib 200 mg BID (390.22; P = 0.011) demonstrated significant pain control compared with placebo (77.10) for the primary efficacy parameter, mean SPID-48. Diclofenac submicron particle capsules 35 mg TID (4.52) provided some pain control (higher mean PID) at 30 minutes following administration, in contrast to celecoxib 200 mg BID (0.80), diclofenac submicron particle capsules 18 mg TID (0.31), and placebo (0.12). Better pain control (PID) was noted across all active treatment groups at 5 hours compared with placebo (P ≤ 0.03), and pain relief was sustained throughout the treatment period. The most frequent non-procedure-related AEs were nausea, headache, dizziness, and vomiting.

CONCLUSION

Lower-dose diclofenac submicron particle capsules provided effective analgesia in this phase 3 clinical study in patients with acute pain and are a potentially promising option for the treatment of patients with acute pain.

Delayed-release prednisone - a new approach to an old therapy

INTRODUCTION

Despite the widespread use of glucocorticoid (GC) treatment for inflammatory conditions, there remains a need to optimize use by improving efficacy and/or reducing adverse consequences. The most advanced approach, already licensed for clinical use, is delayed-release prednisone.

AREAS COVERED

Delayed-release prednisone consists of an inert outer coat containing an inner core of active drug (1, 2, or 5 mg) taken at bedtime (approximately 22:00 h). After a lag time of 4 - 6 h, the coat opens to release prednisone, at the appropriate time to counteract elevated nocturnal levels of pro-inflammatory cytokines associated with the circadian pattern of symptoms seen in rheumatoid arthritis (RA) and other inflammatory conditions. Clinical trials in RA have demonstrated the improved efficacy of delayed-release prednisone with respect to morning stiffness compared with conventional immediate-release prednisone tablets taken in the morning and compared with placebo in patients on disease-modifying antirheumatic treatment; the incidence of adverse events was similar to the comparator. Preliminary studies in polymyalgia rheumatica and asthma suggest that delayed-release prednisone may also have benefits in these conditions.

EXPERT OPINION

Delayed-release prednisone offers an effective way to improve the benefit:risk ratio of GC treatment for inflammatory conditions with circadian features.