[COVID-19 infections and effectiveness of the vaccination among healthcare workers]

INTRODUCTION

New variants of the SARS-CoV-2 coronavirus are constantly appearing, causing the COVID-19 pandemic. From November 2021, most infections were caused by the Omicron coronavirus variant.

OBJECTIVE

The aim of this prospective observational cohort study was to estimate the incidence of COVID-19 infections in the high-risk healthcare workers after two BNT162b2 mRNA Pfizer-BioNTech vaccines and the subsequent booster vaccine, as well as the effectiveness, the safety and the humoral immune response of the vaccines.

METHOD

We started the two Pfizer-BioNTech ((BNT162b29) vaccinations of healthcare workers of the Polyclinic of the Hospitaller Brothers of St. John between January 07 and March 08, 2021. The choice of the type and timing of the third booster vaccination was voluntary. The workers were followed up between January 07, 2021 and June 29, 2022. The infection rate, adverse events of the vaccination, risk factors to infection and the kinetics of anti-spike (S) antibody and anti-nucleocapsid (N) antibody serum level were evaluated.

RESULTS

The data of 294 healthcare workers - 96 medical doctors, 127 nurses and 71 workers in hospital - who had at least three antibody level measurements were analyzed. The third booster vaccine was given to 280 workers, the distribution of the vaccines was the following: Pfizer-BioNTech (BNT162b29) vaccine (n = 210), Moderna COVID-19 (mRNA-1273) vaccine (n = 37), Sinopharm COVID-19 vaccine (n = 21), Janssen COVID-19 (n = 10), AstraZeneca (ChAdOx1 nCoV-19) vaccine (n = 2). Infection occurred in 121 cases (41%) during the observation period. The course of the COVID-19 infections was mostly mild (97%) and recovered within a week. During the observational period, 2 workers died: a 56-year-old woman died after two vaccinations for reason unrelated to COVID-19 infection, and a 58-year-old man died after the booster vaccination, following COVID-19 infection. The incidence of infection did not correlate with age, sex, comorbidities, smoking, occupation and BMI. The median titre of anti-S antibody serum level increased one month after the second vaccination of the basic immunization (1173.0 U/ml) and decreased slowly until the 8th month (678.5-625.8-538.0 U/ml) after the basic vaccination. One month after the booster vaccination, the median titre of anti-S antibody serum level increased significantly (16 535 U/ml), and showed a decreasing trend in the 3rd month after the booster vaccination (9697.7 U/ml). An exceptionally high S antibody serum level increasing after the basic (>10 000 U/mL) and booster (>60 000 U/m) vaccination showed a correlation with prior COVID-19 infection. The median cut-off index (COI) of anti-N antibody was not affected by vaccination, the increasing of the titre is related to the infection.

CONCLUSION

The booster vaccination had less effect on the infection caused by Omicron variant, but the course of the infection was milder. Compared to the basic immunisation, the booster vaccination caused a significant increase in the S antibody level. An exceptionally high S antibody level correlated with prior COVID-19 infection. Orv Hetil. 2023; 164(5): 163-171.

Autoantibodies against complement factor B in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disorder affecting the joints. Many patients carry anti-citrullinated protein autoantibodies (ACPA). Overactivation of the complement system seems to be part of the pathogenesis of RA, and autoantibodies against the pathway initiators C1q and MBL, and the regulator of the complement alternative pathway, factor H (FH), were previously reported. Our aim was to analyze the presence and role of autoantibodies against complement proteins in a Hungarian RA cohort. To this end, serum samples of 97 ACPA-positive RA patients and 117 healthy controls were analyzed for autoantibodies against FH, factor B (FB), C3b, C3-convertase (C3bBbP), C1q, MBL and factor I. In this cohort, we did not detect any patient with FH autoantibodies but detected C1q autoantibodies in four patients, MBL autoantibodies in two patients and FB autoantibodies in five patients. Since the latter autoantibodies were previously reported in patients with kidney diseases but not in RA, we set out to further characterize such FB autoantibodies. The isotypes of the analyzed autoantibodies were IgG2, IgG3, IgGκ, IgGλ and their binding site was localized in the Bb part of FB. We detected in vivo formed FB-autoanti-FB complexes by Western blot. The effect of the autoantibodies on the formation, activity and FH-mediated decay of the C3 convertase in solid phase convertase assays was determined. In order to investigate the effect of the autoantibodies on complement functions, hemolysis assays and fluid phase complement activation assays were performed. The autoantibodies partially inhibited the complement-mediated hemolysis of rabbit red blood cells, inhibited the activity of the solid phase C3-convertase and C3 and C5b-9 deposition on complement activating surfaces. In summary, in ACPA-positive RA patients we identified FB autoantibodies. The characterized FB autoantibodies did not enhance complement activation, rather, they had inhibitory effect on complement. These results support the involvement of the complement system in the pathomechanism of RA and raise the possibility that protective autoantibodies may be generated in some patients against the alternative pathway C3 convertase. However, further analyses are needed to assess the exact role of such autoantibodies.

Efficacy and Safety of ABBV-3373, a Novel Anti-Tumor Necrosis Factor Glucocorticoid Receptor Modulator Antibody Drug Conjugate, in Adults with Moderate to Severe Rheumatoid Arthritis Despite Methotrexate Therapy: a Randomized, Double-Blind, Active-Controlled Proof-of-Concept Phase 2a Trial

OBJECTIVE

To assess the efficacy and safety of ABBV-3373, a novel antibody drug conjugate (ADC) composed of the anti-tumor necrosis factor (TNF) monoclonal antibody adalimumab linked to a glucocorticoid receptor modulator (GRM), versus adalimumab in patients with rheumatoid arthritis (RA).

METHODS

In this randomized, double-blind, active-controlled proof-of-concept trial (NCT03823391), adults with moderate/severe RA on background methotrexate received intravenous ABBV-3373 100 mg every other week (EOW) for 12 weeks, followed by placebo for 12 weeks, or subcutaneous adalimumab 80 mg EOW for 24 weeks.

PRIMARY ENDPOINT

change from baseline in DAS28(CRP) at week 12 with two pre-specified primary comparisons of ABBV-3373 versus historical adalimumab (80 mg EOW or equivalent dose) and versus combined in-trial/historical adalimumab. Secondary endpoints: change from baseline in CDAI, SDAI, and DAS28(ESR); proportion of patients achieving DAS28(CRP) ≤3.2 and ACR50.

RESULTS

48 patients were randomized to ABBV-3373 (n=31) or adalimumab (n=17). At week 12, ABBV-3373 reduced DAS28(CRP) versus historical adalimumab (-2.65 versus -2.13; P=0.022) and combined in-trial/historical adalimumab (-2.65 versus -2.29; probability=89.9%), with numerically greater improvement than in-trial adalimumab (-2.51). For secondary endpoints, greater efficacy was observed with ABBV-3373 versus historical adalimumab; ABBV-3373 was predicted with 79.3-99.5% probability to be better than adalimumab based on combined in-trial/historical adalimumab data. Of the ABBV-3373-treated patients that achieved DAS28(CRP) ≤3.2 at week 12, 70.6% maintained this response at week 24 despite switching to placebo. Four serious adverse events (SAEs) were reported with ABBV-3373 (non-cardiac chest pain, pneumonia, upper respiratory tract infection, and anaphylactic shock) and two SAEs with adalimumab (breast abscess and bronchitis). After increasing the duration of ABBV-3373 IV administration from 3 min to 15-30 min, no similar events of anaphylactic shock were reported.

CONCLUSION

Data from this proof-of-concept trial support the continued development of a TNF-GRM-ADC for the treatment of RA, with the potential to achieve superior outcomes compared to currently available therapies.

The Role of IgG Fc Region N-Glycosylation in the Pathomechanism of Rheumatoid Arthritis

Anti-citrullinated protein antibodies (ACPAs) are involved in the pathogenesis of rheumatoid arthritis. N-glycosylation pattern of ACPA-IgG and healthy IgG Fc differs. The aim of this study is to determine the relative sialylation and galactosylation level of ACPAs and control IgG to assess their capability of inducing TNFα production, and furthermore, to analyze the correlations between the composition of Fc glycans and inflammatory markers in RA. We isolated IgG from sera of healthy volunteers and RA patients, and purified ACPAs on a citrulline-peptide column. Immunocomplexes (IC) were formed by adding an F(ab)₂ fragment of anti-human IgG. U937 cells were used to monitor the binding of IC to FcγR and to trigger TNFα release determined by ELISA. To analyze glycan profiles, control IgG and ACPA-IgG were digested with trypsin and the glycosylation patterns of glycopeptides were analyzed by determining site-specific N-glycosylation using nano-UHPLC-MS/MS. We found that both sialylation and galactosylation levels of ACPA-IgG negatively correlate with inflammation-related parameters such as CRP, ESR, and RF. Functional assays show that dimerized ACPA-IgG significantly enhances TNFα release in an FcγRI-dependent manner, whereas healthy IgG does not. TNFα production inversely correlates with the relative intensities of the G0 glycoform, which lacks galactose and terminal sialic acid moieties.

Immunogenicity and safety of the BNT162b2 mRNA COVID-19 vaccine in healthcare workers

Összefoglaló. Bevezetés: A SARS-CoV-2 koronavírus okozta COVID-19 általános egészségügyi és gazdasági krízist idézett elő. Célkitűzés: A megfigyeléses vizsgálat célja a BNT162b2 mRNS-Pfizer-BioNTech-vakcina hatásosságának, biztonságosságának és immunogenitásának igazolása a Budai Irgalmasrendi Kórház dolgozóin. Módszer: A vakcina adása után elemeztük a COVID-19-fertőzés előfordulását, az oltások utáni reakciókat, valamint a "spike" (S-) protein és a nukleokapszid (N)-protein elleni ellenanyag szintjének változását. Eredmények: A felmérésben részt vevő 295 dolgozó közül az oltást megelőzően 36 dolgozó esett át COVID-19-fertőzésen (COVID-19-pozitív csoport). A második oltás után a megfigyelési időszak három hónapjában COVID-19-fertőzés nem alakult ki a felmérésben részt vevő oltott dolgozók körében. Az oltási reakciók enyhék voltak. A COVID-19-pozitív csoportban az N-antitestek medián küszöbértékindexe az első vakcina után 4 héttel mérve szignifikánsan magasabb volt (28,37), mint a COVID-19-negatív (0,085) csoportban (p<0,0001). Az első vakcina után 4 héttel az S-antitestek medián értéke (8015 U/ml) a COVID-19-pozitív csoportban szignifikánsan magasabb volt (p<0,0001), mint a COVID-19-negatív csoportban (23,18 U/ml). A COVID-19-negatív csoport S-antitest-középértéke a második vakcina után szignifikáns (p<0,0001), mintegy 500×-os emelkedést mutatott (23,18 U/ml ről 1173 U/ml-re). Egy vakcina hatásosságát a fertőzések terjedésének megakadályozása igazolja. Következtetések: A második vakcina utáni megfigyelési időszakban új COVID-19-fertőzés nem volt az oltott dolgozók körében. A fertőzésen át nem esett COVID-19-negatív egyének esetén az S-antitest emelkedése mérsékelt az első oltás után, míg a második oltás után lényegesen emelkedik. A COVID-19-fertőzésen átesett egyének csoportjában már az első vakcina is jelentős S-antitest-termelődést vált ki. Orv Hetil. 2021; 162(39): 1551-1557.

SUMMARY

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic caused global public health and economic crises.

OBJECTIVE

The aim of this observation study was to estimate the effectiveness, safety and elicited immune response of the BNT162b2 mRNA Pfizer-BioNTech vaccine in healthcare workers of the Buda Hospital of the Hospitaller Order of St. John of God.

METHOD

After vaccination, the infection rate, adverse events and the kinetics of anti-SARS-CoV-2 spike (S) protein and anti-SARS-CoV-2 nucleocapsid (N) protein antibodies were evaluated.

RESULTS

Before vaccination, from the 295 healthcare workers 36 recovered from prior COVID-19 infection (COVID-19-positive group). After the second vaccination, there was no COVID-19 infection during the three-month follow-up period. The adverse events were mild. In the COVID-19-positive group, the median cut-off index of anti-N antibodies measured at 4 weeks after the first vaccination were significantly (p<0.0001) higher (28.37) than in the COVID-19-negative group (0.085). After the first vaccine, the median titer of anti-S antibodies was significantly higher (p<0.0001) in the COVID-19-positive group (8015 U/ml) compared to the COVID-19-negative group (23.18 U/ml). In the COVID-19-negative group, the median titer of anti-S antibodies increased significantly (p<0.0001) after the second vaccine (from 23.18 U/ml to 1173 U/ml), showing an increase of 500×.

CONCLUSIONS

After the second vaccination, there was no COVID-19 infection during the follow-up. In the COVID-19-negative group, the anti-S antibody titer is moderate after the first vaccination and increases significantly after the second vaccine. In the COVID-19-positive group, the first vaccine induces significant anti-S antibody production. Orv Hetil. 2021; 162(39): 1551-1557.

OP0115 EFFICACY AND SAFETY OF ABBV-3373, A NOVEL ANTI-TNF GLUCOCORTICOID RECEPTOR MODULATOR ANTIBODY DRUG CONJUGATE, IN PATIENTS WITH MODERATE TO SEVERE RHEUMATOID ARTHRITIS DESPITE METHOTREXATE THERAPY: A PHASE 2A PROOF OF CONCEPT STUDY

Background:

ABBV-3373 is a novel antibody drug conjugate composed of adalimumab (ADA) linked to a proprietary and highly potent glucocorticoid receptor modulator (the anti-inflammatory payload) currently evaluated for the treatment of rheumatoid arthritis (RA).

Objectives:

To assess the efficacy and safety of ABBV-3373 vs ADA in RA patients (pts).

Methods:

This was a 24-week (wk) randomized, double-blind, double-dummy, active-controlled Phase 2a study of intravenously (IV)-administered ABBV-3373 100 mg (for 12 wks followed by placebo [PBO] for 12 wks) vs subcutaneous injections of ADA 80 mg every other wk (for 24 wks) in pts on background methotrexate. The primary endpoint was the change from baseline (BL) in DAS28(CRP) at Wk 12. Pre-planned statistical methods incorporating pre-specified historical ADA data both alone (pre-specified success criterion, 2-sided P ≤0.1) and supplemented with in-trial ADA data (pre-specified success criterion, probability >95%) were used to achieve adequate statistical power with a reduced trial size. Assay sensitivity was evaluated through construction of a synthetic PBO arm by propensity score matching, using individual pt-level PBO data from 3 recent sponsor-run trials of similar populations and trial settings. Secondary endpoints at Wk 12 included 1) mean change from BL in CDAI, SDAI, DAS28(ESR), HAQ-DI; 2) proportion of pts achieving DAS28(CRP)≤3.2, ACR20/50/70 responses, HAQ-DI≤-0.22. Continuous and categorical efficacy variables were analyzed using mixed effect model repeated measurements and Cochran-Mantel-Haenszel test, respectively; non-responder imputation was applied to missing categorical data. Treatment-emergent adverse events were summarized through Wk 12.

Results:

A total of 48 pts were randomized and treated (ABBV-3373: 31; ADA: 17); 46 pts (96%) completed 12 wks of study treatment. BL demographics and disease characteristics were indicative of established RA and similar among the 2 treatment arms and the synthetic PBO arm. ABBV-3373 demonstrated significant improvement in mean DAS28(CRP) at Wk 12 vs the pre-specified historical ADA (-2.65 vs -2.13; P=0.022) and numerically greater improvement vs the combined in-trial and historical ADA arm (-2.65 vs -2.29; probability 90%; Figure). Comparable improvements in disease activity and targets were observed for ABBV-3373 and in-trial ADA. Assay sensitivity was supported by the fact that both ABBV-3373 and ADA arms were superior to synthetic PBO (P<0.001). For secondary endpoints, greater efficacy was observed with ABBV-3373 vs historical ADA; ABBV-3373 was predicted with 79-99% probability to be better than ADA based on the combined in-trial and historical ADA data. 2 serious infections were reported with ABBV-3373 (pneumonia, upper respiratory tract infection) and none with ADA through Wk 12 (Table). 1 event of anaphylactic shock reaction was reported with ABBV-3373. After increasing the duration of IV administration from 3 min to 15-30 min, no similar events were observed.

Table 1.

Treatment Emergent Adverse Events up to Week 12

Event, n (%)ADA(N = 17)ABBV-3373(N = 31)Adverse event (AE)12 (70.6)11 (35.5)AE with reasonable possibility of being drug related$3 (17.6)2 (6.5)Severe AE01 (3.2)Serious AE04 (12.9) #AE leading to Discontinuation of Study Drug1 (5.9)1 (3.2)Serious infections02 (6.5)Opportunistic infection excluding Tuberculosis00Allergic Reactions Including Hypersensitivity, Angioedema, and Anaphylaxis2 (11.8) &1 (3.2) ^Systemic glucocorticoid events00All deaths00

$As assessed by investigator. #Serious AEs: 1 non-cardiac chest pain, 1 pneumonia, 1 upper respiratory tract disease and 1 anaphylactic shock. &1 Type I hypersensitivity, 1 Pruritus ^1 Anaphylactic shock

Conclusion:

These data demonstrate the clinical efficacy of ABBV-3373 and its potential to provide improved outcomes for RA pts compared to ADA. The safety profile of ABBV-3373 was generally similar to ADA.

Acknowledgements:

AbbVie and the authors we thank the patients, trial sites, and investigators who participated in this clinical trial. AbbVie, Inc was the trial sponsor, contributed to trial design, data collection, analysis & interpretation, and to writing, reviewing, and approval of final version. No honoraria or payments were made for authorship. The authors thank Yang Yang of AbbVie Inc for supporting the statistical analysis and data reporting. Medical writing support was provided by Ramona Vladea, PhD of AbbVie, Inc.

Disclosure of Interests:

Frank Buttgereit Consultant of: AstraZeneca, AbbVie, Grünenthal, Horizon Pharma, Pfizer, and Roche, Grant/research support from: AbbVie, Horizon Pharma, Pfizer, and Roche, Jacob Aelion Grant/research support from: AbbVie, Amgen, AstraZeneca, BMS, Celgene, Eli Lilly, Galapagos/Gilead, Genentech, GlaxoSmithKline, Horizon, Janssen, Mallinckrodt, Nektar, Nichi-Iko, Novartis, Pfizer, Regeneron, Roche, Sanofi-Aventis, Selecta, UCB, Bernadette Rojkovich: None declared, Anna Zubrzycka-Sienkiewicz Consultant of: Astellas and Roche, Grant/research support from: AbbVie, Astellas, Galapagos NV, Gilead Sciences, Janssen, Lilly, Mabion, Pfizer, Roche, and UCB SA, Timothy Radstake Shareholder of: AbbVie, Employee of: AbbVie, Su Chen Shareholder of: AbbVie, Employee of: AbbVie, Dilek Arikan Shareholder of: AbbVie, Employee of: AbbVie, Hartmut Kupper Shareholder of: AbbVie, Employee of: AbbVie, Howard Amital Consultant of: Abbvie, Janssen, Novartis, Roche, Perrigo, Pfizer, Neopharm, Elly Lilly, Gilead, Sanofi, Teva and Rafa, Grant/research support from: Yansen, Pfizer

Treatment Satisfaction, Patient Preferences, and the Impact of Suboptimal Disease Control in a Large International Rheumatoid Arthritis Cohort: SENSE Study

BACKGROUND

Patients' needs and perspectives are important determinants of treatment success in rheumatoid arthritis (RA). Assessing patients' perspectives can help identify unmet needs and enhance the understanding of treatment benefits.

OBJECTIVE

The SENSE study assessed the impact of inadequate response to disease-modifying antirheumatic drugs (DMARDs) on treatment satisfaction, disease outcomes, and patient perspectives related to RA disease management.

METHODS

SENSE was a noninterventional, cross-sectional study conducted in 18 countries across Europe, Asia, and South America. Adult patients with poorly controlled RA of moderate/high disease activity were eligible. Patient satisfaction was assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM v1.4). Treatment adherence, healthcare resource utilization (HRU), quality of life (QoL), work ability, digital health literacy (DHL), patient preference information, and treatment strategy were also assessed.

RESULTS

A total of 1624 patients were included in the study: most were female (84.2%) and middle-aged, and mean disease duration was 10.5 years. Mean TSQM global satisfaction subscore was 60.9, with only 13.5% of patients reporting good treatment satisfaction (TSQM global ≥80). The strongest predictor of good treatment satisfaction was treatment with advanced therapies. Most patients (87.4%) reported good treatment adherence. In general, patients had impaired QoL and work ability, high HRU, and 67.4% had poor DHL. Leading treatment expectations were "general improvement of arthritis" and "less joint pain". Most patients preferred oral RA medications (60.7%) and rapid (≤1 week) onset of action (71.1%). "Increased risk for malignancies" and "increased risk for cardiovascular disease" were the least acceptable side effects. Despite suboptimal control, advanced therapies were only used in a minority of patients, and DMARD switches were planned for only half of the patients.

CONCLUSION

Suboptimal disease control negatively impacts treatment satisfaction, work ability, QoL, and HRU. Data collected on patient perspectives may inform shared decision-making and optimize treat-to-target strategies for improving patient outcomes in RA.

SAT0123 TREATMENT SATISFACTION, EXPECTATIONS, PATIENT PREFERENCES AND CHARACTERISTICS, INCLUDING DIGITAL HEALTH LITERACY (DHL), AND THE IMPACT OF SUBOPTIMAL DISEASE CONTROL IN A LARGE INTERNATIONAL COHORT OF PATIENTS WITH RHEUMATOID ARTHRITIS (RA): THE SENSE STUDY

Background:

Patient characteristics, their treatment preferences and goals are important determinants of treatment success in rheumatoid arthritis (RA).

Objectives:

SENSE study aimed at assessing the impact of inadequate response to disease-modifying anti-rheumatic drugs on disease outcomes, and analyze their attitude, their treatment and disease.

Methods:

Non-interventional, cross-sectional study conducted in 18 countries in Europe, Asia, and America. Adult RA patients with moderate/high disease activity were eligible. Patient satisfaction was assessed by Treatment Satisfaction Questionnaire for Medication, Version 1.4 (TSQM v1.4). Treatment adherence, patient preferences, and expectations were evaluated by visual analog scale. eHealth Literacy Scale was employed for evaluating DHL. Work Productivity and Activity Impairment Questionnaire-Rheumatoid Arthritis, v2.0 (WPAI-RA) was used to assess workability and patient documentation for healthcare resource utilization (HRU).

Results:

1624 patients were included in this analysis; most were female (84.2%), middle-aged, and had a mean (standard deviation [SD]) disease duration of 10.5 (9.3) years. 11.9% of the patients had retired early and 6.0% were unemployed due to RA. Mean (SD) total WPAI-RA score was 55.1% (26.7). In the previous 3 months, the mean (SD) number of healthcare professional and emergency room visits were 2.2 (2.5) and 1.6 (1.3), respectively. Mean (SD) TSQM v1.4 global satisfaction subscore was 60.9 (20.9), with only 13.5% reporting good treatment satisfaction (TSQM global ≥80). The leading treatment expectations were ‘general improvement of arthritis’, ‘less joint pain’, and ‘lasting relief of RA symptoms,’ with mean (SD) scores of 5.7 (1.6–1.7) for each. 60.7% of patients preferred oral administration and 31.3% preferred not to use drug combinations for RA. Preferred time to effect was predominantly ‘up to one week’ (71.1%). Least frequently side effects rated ‘acceptable’ were ‘increased risk for malignancies’ (3.5%) and ‘increased risk for cardiovascular diseases’ (3.3%). Most patients (67.4%) had poor DHL. Good adherence (in 87.4% of patients) was significantly associated with lower levels of joint pain.

Conclusion:

Suboptimal disease control has a significant impact on satisfaction, workability, and HRU. Our results can support shared decision-making when setting RA treatment strategy.

Disclosure of Interests: :

Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, CODRINA ANCUTA Consultant of: AbbVie, Pfizer, Roche, Novartis, UCB, Ewopharma, Merck Sharpe and Dohme, and Eli Lilly, Speakers bureau: AbbVie, Pfizer, Roche, Novartis, UCB, Ewopharma, Merck Sharpe and Dohme, and Eli Lilly, Orsolya Nagy Shareholder of: AbbVie, Employee of: AbbVie, Maria DeLaVega: None declared, Andrey Gordeev Speakers bureau: AbbVie, Eli Lilly, Pfizer, Sanofi, Bristol-Myers Squibb, Merck Sharpe and Dohme, Roche, and UCB., Radka Jankova Speakers bureau: AbbVie, Eli Lilly, Pfizer, Sanofi, Bristol-Myers Squibb, Merck Sharpe and Dohme, Roche, and UCB, Umut Kalyoncu Consultant of: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB., Speakers bureau: AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB., Ivan Lagunes-Galindo Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Jadranka Morovic-Vergles Speakers bureau: Abbvie., Roche, MSD, Eli Lilly, Pfizer, Mylan, Amgen, Fresenius Kabi, Mariana Peixoto GU e Silva de Souza Grant/research support from: AbbVie, UCB, Bristol-Myers Squibb, Pfizer, and GSK, Consultant of: AbbVie, Roche, UCB, Pfizer, and Jansen, Speakers bureau: AbbVie, Roche, UCB, Pfizer, and Jansen, Bernadette Rojkovich: None declared, Prodromos Sidiropoulos: None declared, Atsushi Kawakami: None declared

Patients with rheumatoid arthritis facing sick leave or work disability meet varying regulations: a study among rheumatologists and patients from 44 European countries

Objectives

To describe and explore differences in formal regulations around sick leave and work disability (WD) for patients with rheumatoid arthritis (RA), as well as perceptions by rheumatologists and patients on the system’s performance, across European countries.

Methods

We conducted three cross-sectional surveys in 50 European countries: one on work (re-)integration and social security (SS) system arrangements in case of sick leave and long-term WD due to RA (one rheumatologist per country), and two among approximately 15 rheumatologists and 15 patients per country on perceptions regarding SS arrangements on work participation. Differences in regulations and perceptions were compared across categories defined by gross domestic product (GDP), type of social welfare regime, European Union (EU) membership and country RA WD rates.

Results

Forty-four (88%) countries provided data on regulations, 33 (75%) on perceptions of rheumatologists (n=539) and 34 (77%) on perceptions of patients (n=719). While large variation was observed across all regulations across countries, no relationship was found between most of regulations or income compensation and GDP, type of SS system or rates of WD. Regarding perceptions, rheumatologists in high GDP and EU-member countries felt less confident in their role in the decision process towards WD (β=−0.5 (95% CI −0.9 to −0.2) and β=−0.5 (95% CI −1.0 to −0.1), respectively). The Scandinavian and Bismarckian system scored best on patients’ and rheumatologists’ perceptions of regulations and system performance.

Conclusions

There is large heterogeneity in rules and regulations of SS systems across Europe in relation to WD of patients with RA, and it cannot be explained by existing welfare regimes, EU membership or country’s wealth.

Affinity Purification and Comparative Biosensor Analysis of Citrulline-Peptide-Specific Antibodies in Rheumatoid Arthritis

BACKGROUND

In rheumatoid arthritis (RA), anti-citrullinated protein/peptide antibodies (ACPAs) are responsible for disease onset and progression, however, our knowledge is limited on ligand binding affinities of autoantibodies with different citrulline-peptide specificity.

METHODS

Citrulline-peptide-specific ACPA IgGs were affinity purified and tested by ELISA. Binding affinities of ACPA IgGs and serum antibodies were compared by surface plasmon resonance (SPR) analysis. Bifunctional nanoparticles harboring a multi-epitope citrulline-peptide and a complement-activating peptide were used to induce selective depletion of ACPA-producing B cells.

RESULTS

K_D values of affinity-purified ACPA IgGs varied between 10^-6 and 10^-8 M and inversely correlated with disease activity. Based on their cross-reaction with citrulline-peptides, we designed a novel multi-epitope peptide, containing Cit-Gly and Ala-Cit motifs in two-two copies, separated with a short, neutral spacer. This peptide detected antibodies in RA sera with 66% sensitivity and 98% specificity in ELISA and was recognized by 90% of RA sera, while none of the healthy samples in SPR. When coupled to nanoparticles, the multi-epitope peptide specifically targeted and depleted ACPA-producing B cells ex vivo.

CONCLUSIONS

The unique multi-epitope peptide designed based on ACPA cross-reactivity might be suitable to develop better diagnostics and novel therapies for RA.

Induction and Differentiation of IL-10-Producing Regulatory B Cells from Healthy Blood Donors and Rheumatoid Arthritis Patients

The most important feature of B cells is the production of Abs upon activation; additionally, B cells produce pro- and anti-inflammatory cytokines in response to certain stimuli. IL-10-producing B cells represent a major subset of regulatory B cells (Bregs) that suppress autoimmune and inflammatory responses. B cells play a crucial role in the development and maintenance of the chronic inflammatory autoimmune disease rheumatoid arthritis (RA); however, controversial data are available on IL-10- producing Bregs in RA. Our aim was to identify the optimal conditions that induce IL-10⁺ Bregs and, furthermore, to shed light on the signaling pathways that are responsible for their expansion. The results show that dual stimulation by CpG and CD40L for 48 h is optimal for IL-10 induction, and this can be synergistically boosted by IL-21. We identified the CD19⁺CD27⁺ memory B cell population as the major source of IL-10⁺ Bregs. We detected significantly fewer CD19⁺CD27⁺IL-10⁺ cells in RA patients compared with healthy controls, and these were functionally defective in suppressing IFN-γ production by CD4⁺ T cells in coculture. IL-21 drastically increased the number of IL-10⁺ Bregs within the CD19⁺CD27⁺ and CD19⁺CD27^- populations; furthermore, it induced the appearance of IL-10⁺Blimp-1⁺ plasmablasts. Monitoring the phosphorylation of key signaling molecules revealed that activation of ERK, p38, and CREB is indispensable for the induction of IL-10 production, whereas phosphorylation of STAT3 further enhances IL-10 expression in human Bregs. We conclude that CREB and STAT3 are the key transcription factors responsible for the expansion and differentiation of human IL-10-producing Bregs.

In vitro eradication of citrullinated protein specific B-lymphocytes of rheumatoid arthritis patients by targeted bifunctional nanoparticles

BACKGROUND

Autoreactive B cells are crucial players in the pathogenesis of rheumatoid arthritis (RA). Autoantibodies specific for citrullinated proteins (ACPA), present in the serum of approximately 60-70 % of patients, have a pathogenic role in the disease. B cell depleting therapies may result in a transient immunosuppression, increasing the risk of infections. Our aim was to develop a new therapeutic approach to selectively deplete the ACPA producing autoreactive B cells.

METHODS

To target B cells synthetic citrullinated peptide derived from the β chain of fibrin, β60-74Cit 60,72,74 (β60-74Cit), the predominant epitope recognized by ACPA was used. Complement dependent cytotoxicity (CDC) was induced by a modified peptide derived from gp120 of HIV-1. To trigger CDC both the targeting peptide and the complement activating peptide were covalently coupled in multiple copies to the surface of poly (DL-lactic-co-glycolic acid) nanoparticles (NPs). Ex vivo antibody synthesis was examined by ELISA and ELISpot. CDC was tested after dead cell staining by flow cytometry.

RESULTS

The β60-74Cit peptide was selectively recognized by a small subset of B cells from RA patients having high level of peptide specific serum antibody, suggesting that the peptide can target diseased B cells. The modified gp120 peptide covalently coupled to NPs induced the formation of the complement membrane attack complex, C5b-9 in human serum. We show here for the first time that bifunctional NPs coupled to multiple copies of both the targeting peptide and the complement activating effector peptide on their surface significantly reduce β60-74Cit peptide specific ex vivo ACPA production, by inducing complement dependent lysis of the citrullinated peptide specific B cells of seropositive RA patients.

CONCLUSIONS

Bifunctional NPs covalently coupled to autoantigen epitope peptide and to a lytic peptide activating complement may specifically target and deplete the peptide specific autoreactive B-cells.

The EULAR Study Group for Registers and Observational Drug Studies: comparability of the patient case mix in the European biologic disease modifying anti-rheumatic drug registers

OBJECTIVE

Under the auspices of the European League Against Rheumatism (EULAR), a study group of investigators representing European biologic DMARD (bDMARD) registers was convened. The purpose of this initial assessment was to collect and compare a cross section of patient characteristics and collate information on the availability of potential confounders within these registers.

METHODS

Baseline characteristics of patients starting their first bDMARD in an arbitrary year (2008) for the treatment of RA, including demographic and disease characteristics, bDMARD drug details and co-morbidities, were collected and compared across 14 European bDMARD registers.

RESULTS

A total of 5320 patients were included. Half the registers had restricted recruitment to certain bDMARDs during the study year. All registers` collected data on age, gender, disease duration, seropositivity for IgM-RF and 28-joint DAS (DAS28). The mean DAS28 ranged from 4.2 to 6.6 and the mean HAQ from 0.8 to 1.9. Current smoking ranged from 9% to 34%. Nine registers reported co-morbidities with varying prevalence.

CONCLUSION

In addition to demonstrating European-wide collaboration across rheumatology bDMARD registers, this assessment identified differences in prescribing patterns, recruitment strategies and data items collected. These differences need to be considered when applying strategies for combined analysis. The lack of a common data model across Europe calls for further work to harmonize data collection across registers.

TGFβ activated kinase 1 (TAK1) at the crossroad of B cell receptor and Toll-like receptor 9 signaling pathways in human B cells

B cell development and activation are regulated by combined signals mediated by the B cell receptor (BCR), receptors for the B-cell activating factor of the tumor necrosis factor family (BAFF-R) and the innate receptor, Toll-like receptor 9 (TLR9). However, the underlying mechanisms by which these signals cooperate in human B cells remain unclear. Our aim was to elucidate the key signaling molecules at the crossroads of BCR, BAFF-R and TLR9 mediated pathways and to follow the functional consequences of costimulation.Therefore we stimulated purified human B cells by combinations of anti-Ig, B-cell activating factor of the tumor necrosis factor family (BAFF) and the TLR9 agonist, CpG oligodeoxynucleotide. Phosphorylation status of various signaling molecules, B cell proliferation, cytokine secretion, plasma blast generation and the frequency of IgG producing cells were investigated. We have found that BCR induced signals cooperate with BAFF-R- and TLR9-mediated signals at different levels of cell activation. BCR and BAFF- as well as TLR9 and BAFF-mediated signals cooperate at NFκB activation, while BCR and TLR9 synergistically costimulate mitogen activated protein kinases (MAPKs), ERK, JNK and p38. We show here for the first time that the MAP3K7 (TGF beta activated kinase, TAK1) is responsible for the synergistic costimulation of B cells by BCR and TLR9, resulting in an enhanced cell proliferation, plasma blast generation, cytokine and antibody production. Specific inhibitor of TAK1 as well as knocking down TAK1 by siRNA abrogates the synergistic signals. We conclude that TAK1 is a key regulator of receptor crosstalk between BCR and TLR9, thus plays a critical role in B cell development and activation.

Subjective health expectations at biological therapy initiation: a survey of rheumatoid arthritis patients and rheumatologists

Subjective health expectations of patients with rheumatoid arthritis (RA) and rheumatologists remain understudied. We measured subjective expectations regarding treatment effects of biologicals as well as future length and quality of life. Moreover, we compared expectations regarding treatment effects to actual treatment effects. We recruited a sample of Hungarian RA patients initiating treatment with biologicals. Expectations regarding treatment effects and future health were obtained through a written questionnaire from patients and physicians, including functional impairment (HAQ-DI), health status (EQ-5D) and disease activity (DAS28). After three months, actual treatment effects were obtained. Ninety-two RA patients (females N = 81, 88%) with mean age of 51 (SD 12) and disease duration of 9 (SD 8) years with high average disease activity (DAS28: 6.1) were included. Patients expected significant and large health improvement within three months with mean changes on the HAQ-DI of -0.8 and on the EQ-5D of +0.4. Rheumatologists' estimates were similar, and they expected significant decrease of 2.3 on the DAS28. Actual scores after three months were obtained for 77 patients. The measured scores were significantly lower than expected scores for the HAQ-DI and EQ-5D. Rheumatologists' expectations for the DAS28 score were not significantly different from measured scores. Patients' average expectations regarding quality of life scores for ages 60, 70, 80 and 90 were 0.44, 0.24, 0.06 and -0.02, respectively. Our results suggest that both RA patients and rheumatologists expect quick and significant health improvements from biological drugs and tend to overestimate actual short term treatment effects. Nonetheless, RA patients expect a sharp deterioration of future health.

Acceptability of less than perfect health states in rheumatoid arthritis: the patients' perspective

Some health problems are considered by many individuals as a 'normal' part of ageing. Our aim was to investigate whether patients with rheumatoid arthritis (RA) consider different types and levels of health losses as acceptable beyond a certain age. A multicenter cross-sectional survey was performed involving RA patients at the initiation of the first biological therapy. The EQ-5D and the Health Assessment Questionnaire Disability Index (HAQ-DI) questionnaires were used to describe domain-specific health states. Patients were asked to indicate for each domain from what age and onward (between ages 30 and 80 years in 10 year intervals) they considered moderate and severe problems acceptable or alternatively never acceptable. Seventy-seven RA patients (females 86%, mean age 50.3, disease duration 9.1 years) completed the questionnaire. Disease activity (DAS28), EQ-5D and HAQ-DI scores were mean 6.00 (SD 0.85), 0.35 (SD 0.36), 1.48 (SD 0.66), respectively. The majority of the patients considered age 70 and beyond as acceptable to have some health problems (EQ-5D: self-care 42%, pain/discomfort 34%, mobility 33%, usual activities 33%, anxiety/depression 27%), whilst at ages 30 and 40 as not acceptable. Severe health problems were mostly (57-69%) considered never acceptable, except the 'Usual activities' domain (acceptable from age 80 by 50.6%). The great majority of the patients (77-96%) were younger than what they indicated as the acceptability age limit. Similar results were found for the HAQ-DI. This small experimental study suggests that RA patients consider some health problems acceptable. This acceptability is age related and varies by health areas. Further larger studies are needed to explore explanatory variables and to compare with other diseases. Owing to the impact acceptability might have on RA patients' self-evaluation of current health state and decision-making, the topic deserves methodological improvement and further investigation.

Recognition of new citrulline-containing peptide epitopes by autoantibodies produced in vivo and in vitro by B cells of rheumatoid arthritis patients

Anti-citrullinated peptide/protein antibodies (ACPAs) are highly sensitive and specific markers of rheumatoid arthritis (RA). Identification of peptide epitopes that may detect different subgroups of RA patients might have diagnostic and prognostic significance. We have investigated citrulline- and arginine-containing peptide pairs derived from filaggrin, collagen or vimentin, and compared this citrulline-peptide panel with the serological assays conventionally used to detect ACPAs. Furthermore, we studied if the same citrulline-peptides identify antibody-secreting cells in in vitro cultures of RA B cells. Recognition of citrulline- and arginine-containing filaggrin, vimentin and collagen peptide epitopes were tested by Multipin ELISA system, by indirect ELISA and by a peptide-specific microarray. B cells were purified from blood by negative selection; antibody-producing cells were enumerated by ELISPOT assay. The panel composed of citrulline-peptide epitopes of filaggrin, collagen and vimentin was recognized by RA sera with a sensitivity and specificity comparable with the currently used tests. Moreover, the combined citrulline-peptide panel including the new short epitope peptide of filaggrin, fil311-315, also identified nearly one-third of RA cases that were negative for antibodies against cyclic citrullinated peptides, mutated citrullinated vimentin or for rheumatoid factor. The results with the peptide-specific microarray have shown that although most ACPAs recognizing the four citrulline peptides are IgG, some of them specifically recognizing citrulline-containing filaggrin peptides (fil311-315 and fil306-326) are IgM, and so may be produced either by newly formed activated B cells or by unswitched B memory cells. Furthermore, the citrulline-peptides of filaggrin and vimentin detect ACPA-producing cells, and so could also be applied to study the B cells of RA patients.

Safety, pharmacokinetics, and biologic activity of pateclizumab, a novel monoclonal antibody targeting lymphotoxin α: results of a phase I randomized, placebo-controlled trial

INTRODUCTION

Pateclizumab (MLTA3698A) is a humanized mAb against lymphotoxin α (LTα), a transiently expressed cytokine on activated B and T cells (Th1, Th17), which are implicated in rheumatoid arthritis (RA) pathogenesis. This study was conducted to assess the safety, tolerability, < NOTE: For clarity and per AMA/S-W Style, please restore the use of Oxford/serial commas (ie: David likes vanilla, strawberry, and chocolate ice cream) throughout. and biologic activity of single and multiple doses of intravenous (IV) or subcutaneous (SC) pateclizumab in RA patients.

METHODS

The single ascending dose (SAD) phase in patients with stable RA consisted of six cohorts (4:1 active:placebo at 0.3 mg/kg IV, 1.0 mg/kg IV, 1.0 mg/kg SC, 3.0 mg/kg IV, 3.0 mg/kg SC, and 5.0 mg/kg IV; n = 5/cohort). In the multiple ascending dose (MAD) phase, patients with prespecified RA disease activity received three doses of pateclizumab or placebo (4:1) every 2 weeks (1.0 mg/kg SC, n = 10; 3.0 mg/kg SC, n = 20; or 5.0 mg/kg IV, n = 5). Safety and tolerability were assessed throughout, and clinical activity was determined after three doses (Week 6).

RESULTS

We observed no serious adverse events (AEs) or dose-limiting toxicities, and the majority of AEs were mild to moderate. The pharmacokinetic profiles were linear, and clearance was independent of dose. Reductions in levels of serum CXCL13 were observed, supporting the biologic activity of pateclizumab on the LTα pathway. Patients receiving pateclizumab in the 3.0 mg/kg MAD group (3.0 mg/kg SC) demonstrated ACR20, ACR50, and ACR70 response rates at week 6 of 75%, 56% and 25%, respectively, compared with 57%, 29%, and 0% in the placebo group. The median Disease Activity Score in 28 joints, C-reactive protein, reduction was 28% for pateclizumab, versus 8.4% for placebo.

CONCLUSIONS

Pateclizumabwas generally well-tolerated in RA patients. Preliminary evidence of clinical activity was observed in active RA patients at the dose level targeted for clinical effect.

Safety, tolerability, pharmacokinetics, pharmacodynamics and efficacy of the monoclonal antibody ASK8007 blocking osteopontin in patients with rheumatoid arthritis: a randomised, placebo controlled, proof-of-concept study

OBJECTIVES

Osteopontin is an extracellular matrix protein with diverse immunomodulatory functions. The authors assessed the safety, tolerability, pharmacokinetics, pharmacodynamics and initial efficacy of the humanised monoclonal antibody ASK8007, which blocks osteopontin.

METHODS

In this double-blind, multicentre, combined first-in-man, single-dose escalation (phase I, part A) and proof-of-concept, multiple-dose (phase IIA, part B) study, rheumatoid arthritis (RA) patients with active disease were randomly assigned to receive ASK8007 or placebo intravenously. Safety monitoring, pharmacokinetic and pharmacodynamic analyses and clinical assessments were performed throughout the study. The expression of phenotypic cell markers was evaluated in synovial tissue biopsy samples obtained at baseline and 43 days after initiation of treatment (part B) by immunohistochemistry and digital image analysis. Two co-primary efficacy endpoints were the change from baseline in the disease activity score evaluated in 28 joints (DAS28) and the change from baseline in the number of CD68 synovial sublining macrophages, both assessed on day 43 (part B).

RESULTS

ASK8007 was overall safe and well tolerated up to the highest studied dose (20 mg/kg). Quantifiable concentrations of ASK8007 were detected in synovial fluid. No differences were observed for changes from baseline in DAS28 and CD68 sublining macrophages between ASK8007 and placebo-treated patients. Within the ASK8007 treatment group, there were also no apparent clinical responses or changes in sublining macrophages. In addition, ASK8007 treatment did not change other assessed biomarkers.

CONCLUSIONS

Osteopontin blockade is well tolerated and not related to safety concerns. These results consistently show that osteopontin blockade is unlikely to induce robust clinical improvement in RA patients.

Smokers and non smokers with rheumatoid arthritis have similar clinical status: data from the multinational QUEST-RA database

OBJECTIVES

To analyse clinical severity/activity of rheumatoid arthritis (RA) according to smoking status.

METHODS

The QUEST-RA multinational database reviews patients for Core Data Set measures including 28 swollen and tender joint count, physician global estimate, erythrocyte sedimentation rate (ESR), HAQ-function, pain, and patient global estimate, as well as DAS28, rheumatoid factor (RF), nodules, erosions and number of DMARDs were recorded. Smoking status was assessed by self-report as 'never smoked', 'currently smoking' and 'former smokers'. Patient groups with different smoking status were compared for demographic and RA measures.

RESULTS

Among the 7,307 patients with smoking data available, status as 'never smoked,' 'current smoker' and 'former smoker' were reported by 65%, 15% and 20%. Ever smokers were more likely to be RF-positive (OR 1.32;1.17-1.48, p<0.001). Rheumatoid nodules were more frequent in ever smokers (OR 1.41;1.24-1.59, p<0.001). The percentage of patients with erosive arthritis and extra-articular disease was similar in all smoking categories. Mean DAS28 was 4.4 (SD 1.6) in non-smokers vs. 4.0 (SD 1.6) in those who had ever smoked. However, when adjusted by age, sex, disease duration, and country gross domestic product, only ESR remained significantly different among Core Data Set measures (mean 31.7mm in non-smokers vs. 26.8mm in ever smoked category).

CONCLUSIONS

RA patients who had ever smoked were more likely to have RF and nodules, but values for other clinical status measures were similar in all smoking categories (never smoked, current smokers and former smokers).

Ofatumumab, a human anti-CD20 monoclonal antibody, for treatment of rheumatoid arthritis with an inadequate response to one or more disease-modifying antirheumatic drugs: results of a randomized, double-blind, placebo-controlled, phase I/II study

OBJECTIVE

To investigate the safety and efficacy of ofatumumab, a novel human anti-CD20 monoclonal antibody (mAb), in patients with active rheumatoid arthritis (RA) whose disease did not respond to > or = 1 disease-modifying antirheumatic drug.

METHODS

This combined phase I/II study investigated the safety and efficacy of 3 doses of ofatumumab. In part A (phase I), 39 patients received 2 intravenous (i.v.) infusions of ofatumumab (300 mg, 700 mg, or 1,000 mg) or placebo in a 4:1 ratio 2 weeks apart, using a specified premedication and infusion regimen. In part B (phase II), 225 patients received study treatment as per phase I in a 1:1:1:1 ratio. Safety was assessed by adverse events (AEs) and laboratory parameters. Efficacy was assessed by the American College of Rheumatology 20% criteria for improvement (ACR20), the Disease Activity Score in 28 joints, and the European League Against Rheumatism (EULAR) response criteria. B cell pharmacodynamics were also investigated.

RESULTS

AEs were predominantly reported at the first infusion and were mostly mild to moderate in intensity. Rapid and sustained peripheral B cell depletion was observed in all dose groups. In phase II, patients in all ofatumumab dose groups had significantly higher ACR20 response rates (40%, 49%, and 44% for the 300 mg, 700 mg, and 1,000 mg doses, respectively) than did patients receiving placebo (11%) at week 24 (P < 0.001). Overall, 70% of patients receiving ofatumumab had a moderate or good response according to the EULAR criteria at week 24.

CONCLUSION

Our findings indicate that ofatumumab, administered as 2 i.v. infusions of doses up to 1,000 mg, is clinically effective in patients with active RA.

[The assessment of oral NSAID use in patients with rheumatoid arthritis in Hungary--a cross sectional non interventional study]

Continuous NSAID (nonsteroidal anti-inflammatory drug) therapy is associated with gastrointestinal (GI) and cardiovascular (CV) side effects. In this paper, the oral NSAID use of 143 patients with rheumatoid arthritis was assessed focusing on safety and farmacoeconomic aspects in a cross sectional non interventional study. The most widely used NSAIDs were meloxicam (n = 55, 38.5%) and diclofenac (n = 30, 21%). We found that coxibs were overused (n = 13, 9.1%) compared with the average total coxib consumption in Hungary. According to our results, drugs associated with GI friend side effect profile (meloxicam, celecoxib, etoricoxib) were much preferred in patients with previous GI events, than in patients with low GI risk. The previous occurrence of GI events were significantly higher (p = 0.019) in patients currently treated with safer NSAIDs, probably because of the so-called 'indication bias'. No statistically significant difference in patient's quality of life could be proved between NSAID drug groups. The uses of NSAIDs were considered to be rational concerning CV and GI risk as well as cost-effectiveness.

Disparities in rheumatoid arthritis disease activity according to gross domestic product in 25 countries in the QUEST-RA database

OBJECTIVE

To analyse associations between the clinical status of patients with rheumatoid arthritis (RA) and the gross domestic product (GDP) of their resident country.

METHODS

The Quantitative Standard Monitoring of Patients with Rheumatoid Arthritis (QUEST-RA) cohort includes clinical and questionnaire data from 6004 patients who were seen in usual care at 70 rheumatology clinics in 25 countries as of April 2008, including 18 European countries. Demographic variables, clinical characteristics, RA disease activity measures, including the disease activity score in 28 joints (DAS28), and treatment-related variables were analysed according to GDP per capita, including 14 "high GDP" countries with GDP per capita greater than US$24,000 and 11 "low GDP" countries with GDP per capita less than US$11,000.

RESULTS

Disease activity DAS28 ranged between 3.1 and 6.0 among the 25 countries and was significantly associated with GDP (r = -0.78, 95% CI -0.56 to -0.90, r(2) = 61%). Disease activity levels differed substantially between "high GDP" and "low GDP" countries at much greater levels than according to whether patients were currently taking or not taking methotrexate, prednisone and/or biological agents.

CONCLUSIONS

The clinical status of patients with RA was correlated significantly with GDP among 25 mostly European countries according to all disease measures, associated only modestly with the current use of antirheumatic medications. The burden of arthritis appears substantially greater in "low GDP" than in "high GDP" countries. These findings may alert healthcare professionals and designers of health policy towards improving the clinical status of patients with RA in all countries.

Impact of disease progression on health status, quality of life and costs in rheumatoid arthritis in Hungary

A rheumatoid arthritis (RA) krónikus, progresszív, szimmetrikus sokízületi gyulladás. A betegek hosszú távú gondozásához és a költséghatékonysági modellekhez alapvető ismerni és standardizáltan mérni a betegség lefolyását és annak következményeit. Célkitűzés: A betegségprogresszió és az egészségi állapot, életminőség és költségek kapcsolatainak vizsgálata magyarországi RA-s betegeken. Módszer: 2004. április–augusztus között keresztmetszeti kérdőíves vizsgálatot végeztek RA-s betegek bevonásával hat fekvőbeteg-osztályos háttérrel rendelkező járóbeteg-szakambulancián. Standardizált kérdőívekkel vizsgálták a betegség progresszióját kifejező funkcionális állapotot (HAQ), az egészségi állapotot (EQ-5D), a betegségspecifikus életminőséget (RAQoL), felmérték a betegségaktivitást (DAS) és a betegséggel összefüggő költségeket, elemezték e paraméterek kapcsolatát. Eredmények: 255 beteg adatait elemezték [átlagos életkor: 55,5 ± 12,3 év; a betegség fennállása: 9,0 ± 9,3 év; HAQ: 1,38 ± 0,76; EQ-5D: 0,46 ± 0,33; RAQoL: 16,2 ± 8,1; DAS: 5,09 ± 1,42; költség: 1 043 163 (± 844 750) Ft/beteg/év]. Szignifikáns korrelációt találtak az összes esetben ( p < 0,01), függvénykapcsolat volt kimutatható: EQ-5D index = 1,014–0,25 × HAQ–0,041 × DAS és HAQ = 0,314 + 0,065 × RAQoL. Betegségsúlyossági csoportonként (0,5 HAQ-léptékkel) vizsgálva, az egészségi állapot átlaga rosszabbodott (EQ-5D: 0,784; 0,576; 0,504; 0,367; 0,211; 0,022), és az átlagos költség emelkedett (628 280; 888 187; 953 759; 1 291 218; 1 346 112; 1 371 674 Ft/beteg/év) a betegség előrehaladásával. Minimális klinikailag szignifikáns funkciócsökkenés (0,25 HAQ-változás) 0,0705 EQ-5D-csökkenésnek és 1,884 RAQoL-emelkedésnek felelt meg, nem súlyosan aktív (DAS < 5,1) esetekben kisebb a változás (EQ-5D: 0,05725). Következtetések: A betegségprogresszió és az általános egészségi állapot, életminőség és a költségek kapcsolata nem tér el jelentősen a nemzetközi eredményektől. A betegségköltségek nagysága azonban jelentősen kisebb Magyarországon, mint a fejlett országokban. A vizsgálat adatokkal szolgál a hazai egészség-gazdaságtani elemzésekhez.

[Prognostic factors in rheumatoid arthritis]

Rheumatoid arthritis is a chronic, progressive, inflammatory joint disease, affecting primarily the small joints of the hands and feet symmetrically and characterized by joint destruction, progressive disability, and premature death. Rheumatoid arthritis shows a wide spectrum of clinical phenotypes from mild disease to severe arthritis. Aggressive disease implies a rapidly progressive course affecting most joints, with little or no response to drug therapy, and sometimes complicated by life-threatening extraarticular involvement. The eventual multiple joint destruction requires major surgery, and severe disability results in loss of occupation and dependence on others. Many prospective cohort studies have attempted to predict outcomes and develop prognostic markers, especially in early disease. Probably most useful are those factors that independent of disease activity, such as the presence of rheumatoid factor, the so-called shared epitope of HLA-DR. In addition, clinical indicators (e.g., higher affected joint counts, the presence of extra-articular features, subcutaneous nodules, considerable degree of physical disability at onset), laboratory variables (e.g., longstanding increased acute-phase response, decreased hemoglobin) are indicating a poor prognosis. Some sociodemographic markers, such as female sex and a lower level of formal education are associated with a poor prognosis. An ideal prognostic marker should be reliable, simple, accurate and independent of the stage and inflammatory activity of RA so that they can be used early of the disease. Patients with a poor outcome should be treated promptly and aggressively with disease-modifying antirheumatic drugs to limit or prevent further disease progression.

Etofenamate levels in human serum and synovial fluid following iontophoresis

The absorption of etofenamate (CAS 30544-47-9, Rheumon gel) by iontophoresis in 11 patients with low back pain and in 13 patients with synovitis of the knee was evaluated. During the 5-day treatment period, the test gel in a quantity corresponding to 100 mg etofenamate was applied to affected body regions every day by 20-min iontophoresis sessions. Two hours after the fifth application, the concentration of etofenamate in serum and synovial fluid (in patients who had knee joint iontophoresis) were measured by HPLC. Iontophoresis of etofenamate into the lumbar region as well as to the knee joint resulted in consistent serum levels: 219 +/- 136.3 micrograms/l and 191 +/- 84.6 micrograms/l, respectively. In patients with synovitis of the knee, the synovial level of etofenamate (368 +/- 109.2 micrograms/l) was almost twice as high than the serum concentration. The authors conclude that with topical application of etofenamate by iontophoresis the drug appears not only in the serum but also--with higher levels--in the synovial fluid.

[Various clinical patterns of relapsing polychondritis in six cases]

Relapsing polychondritis is a relatively rare disease characterized by episodic inflammation and progressive destruction of cartilage involving ears, nasal and laryngotracheal cartilage, cardiovascular system and the eyes. The increasing awareness of its clinically distinct has resulted in recognition of at least 550 reported cases. Six cases are reported to demonstrate the wide variety of clinical pattern. The most common features of the disease are auricular and nasal cartilage inflammation and nondeforming arthritis. Ocular symptoms and vasculitis is relatively rare. Two cases of relapsing polychondritis with laryngotracheobronchial manifestations illustrate the severe clinical features of the disease. Relapsing polychondritis may associate with diverse forms of connective tissue disease, such as rheumatoid arthritis. It seems interesting to note the onset in childhood. Treatment has been primarily symptomatic. In situations of mild symptoms, initial treatment is with nonsteroidal antiinflammatory drugs. For cases with serious manifestation, corticosteroids and immunosuppressants are indicated.

Cyclosporin and sulfasalazine combination in the treatment of early rheumatoid arthritis

The aim of the study was to assess the efficacy of a new formulation of cyclosporin-A (CyA) and sulfasalazine (SASP) combination treatment in preventing disability and reducing inflammatory disease activity in patients with early rheumatoid arthritis, as well as to assess the tolerability, safety, and suitability for long-term treatment. Forty five patients with early, active rheumatoid arthritis, (RA) were treated with CyA and SASP combination therapy for 12 months. The patients were evaluated by disease activity and radiologic measurements. The combined CyA and SASP therapy seems to be effective. Disease activity parameters improved within 3 months. The individual treatment response rate according to EULAR response criteria was 78% after a one year treatment period. Five patients were withdrawn due to gastrointestinal side effect and two patients because of lack of efficacy. CyA and SASP combination treatment seems to be effective in early severe RA, and with careful monitoring, side effects can be kept under control.

Urinary excretion of thiol compounds in patients with rheumatoid arthritis

The objective of the present study was to assess the excretion of urinary thiol compounds in patients with active and inactive rheumatoid arthritis (RA). Urinary thiol compounds were measured by the method of Kokonov (M. T. Kokonov, Lab. Delo 5:273-276, 1965) in 51 outpatients with active and inactive RA. Those with active disease had significantly higher levels of urinary thioamine excretion.

Nabumetone induces less gastrointestinal mucosal changes than diclofenac retard

The aim of the study was to compare the efficacy and the effects on the mucosa of the gastrointestinal tract (GIT) of nabumetone and diclofenac retard in patients with osteoarthritis (OA). An open, multicentre, randomised, comparative, endoscopy-blind parallel group study included 201 patients with nabumetone and 193 patients with diclofenac retard suffering from moderate to severe OA of the knee or hip joint. Twelve clinical efficacy variables were assessed and a portion of the population underwent gastroduodenoscopy. All patients exhibited significant improvement in pain severity and pain relief (p < 0.001 and p < 0.0001, respectively) but there were no differences between the groups for all the efficacy variables. Eleven per cent of patients on nabumetone and 19% on diclofenac experienced GIT side-effects. Sixty-nine patients with nabumetone and 61 with diclofenac underwent gastroduodenoscopy. The differences in the mucosal grade for the oesophagus, stomach and duodenum at baseline were not significant. In the oesophagus there were significantly less changes after treatment with nabumetone (p = 0.007) than with diclofenac; there were similar findings in the stomach (p < 0.001) but the difference in the duodenum was not significant. This study indicates that nabumetone and diclofenac retard have similar efficacy in the treatment of OA, but nabumetone has significantly fewer GIT side-effects.

Day and night pain measurement in rheumatoid arthritis

OBJECTIVE

An attempt was made to see if rheumatoid arthritis (RA) patients can use visual analogue scales (VAS) to distinguish and grade the severity of pain at night, during rest, and on joint movement and to determine if discriminate measurement of these three pain components enhances the value of VAS estimation.

METHODS

Two hundred and fifty two consecutive RA patients were evaluated by a single observer using 10 cm VAS for pain at night, at rest during the day, and on movement. Values were correlated against age, disease duration, joint tenderness, swollen joint count, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and Larsen x ray scores.

RESULTS

Night pain was recorded by 71 (28%) and this component of pain was lower than VAS scores for daytime rest and movement. However, those with nocturnal pain had significantly more joint tenderness (p < 0.0001), swollen joints (p < 0.0001), and higher ESR and CRP. Age, disease duration, and radiographic scores were similar in those with and without night pain. Correlations of joint tenderness were apparent for all three pain scores but only nocturnal pain correlated with swollen joints (p < 0.001) and CRP (p < 0.005). Age, disease duration, and radiographic severity correlated with daytime rest or movement scores but not nocturnal pain.

CONCLUSION

Patients were able to distinguish and estimate the severity of pain at rest, on movement, and at night. The occurrence of night pain characterised those with more active disease and night pain VAS measurement correlated best with measures of joint inflammation whereas daytime pain scores, both at rest and on movement, seemed influenced by the degree of permanent joint damage. Thus, discrete measurement of rest, movement, and nocturnal pain may provide useful information about RA disease status.

[Fatal myocardial lesion in systemic lupus erythematosus]

The authors present the case of a 47-year old female patient. She suffered from a moderate activity SLE for two years. The outcome of SLE was changed by an ulcer because of leg injury, which was repeatedly infected. Severe polyarthritis, leucopenia, thrombocytopenia, clinical signs of vasculitis and in the last two months fever, high ESR, and pericarditis appeared. The angina pectoris, the cardiac decompensation, the electrocardiogram, the echocardiogram was suspect to diffuse myocardial lesion. Cardiac decompensation caused the death of the patient. Besides the activation of her autoimmune disease, infection was suspect in the patient taken immunosuppressive and steroid drugs, though it could not be verified. Autopsy verified besides the recent necrosis of heart without reaction, and multifocal myocardial abscess, which appeared possible in the terminal phase.

[Acetylator phenotype in spondylarthritis ankylopoietica]

The authors studied the distribution of acetylator phenotypes among 136 AS patients (100 male, 36 female). 67 per cent of all patients were slow acetylators, 72 per cent of the males. Both rates are higher than that of the healthy Hungarian population. The authors draw attention to the clinical importance of investigating the acetylator type before sulphasalazine treatment because it may help in prescribing the effective dose and avoiding side effects.