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Gurudas S, Vasconcelos JC, Prevost AT, Raman R, Rajalakshmi R, Ramasamy K, Mohan V, Rani PK, Das T, Conroy D, Tapp RJ, Sivaprasad S. National prevalence of vision impairment and blindness and associated risk factors in adults aged 40 years and older with known or undiagnosed diabetes: results from the SMART-India cross-sectional study. Lancet Glob Health 2024; 12:e838-e847. [PMID: 38430915 DOI: 10.1016/s2214-109x(24)00035-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND National estimates of the prevalence of vision impairment and blindness in people with diabetes are required to inform resource allocation. People with diabetes are more susceptible to conditions such as diabetic retinopathy that can impair vision; however, these are often missed in national studies. This study aims to determine the prevalence and risk factors of vision impairment and blindness in people with diabetes in India. METHODS Data from the SMART-India study, a cross-sectional survey with national coverage of 42 147 Indian adults aged 40 years and older, collected using a complex sampling design, were used to obtain nationally representative estimates for the prevalence of vision impairment and blindness in people with diabetes in India. Vulnerable adults (primarily those who did not have capacity to provide consent); pregnant and breastfeeding women; anyone deemed too ill to be screened; those who did not provide consent; and people with type 1 diabetes, gestational diabetes, or secondary diabetes were excluded from the study. Vision impairment was defined as presenting visual acuity of 0·4 logMAR or higher and blindness as presenting a visual acuity of 1·0 logMAR or higher in the better-seeing eye. Demographic, anthropometric, and laboratory data along with geographic distribution were analysed in all participants with available data. Non-mydriatic retinal images were used to grade diabetic retinopathy, and risk factors were also assessed. FINDINGS A total of 7910 people with diabetes were included in the analysis, of whom 5689 had known diabetes and 2221 were undiagnosed. 4387 (55·5%) of 7909 participants with available sex data were female and 3522 (44·5%) participants were male. The estimated national prevalence of vision impairment was 21·1% (95% CI 15·7-27·7) and blindness 2·4% (1·7-3·4). A higher prevalence of any vision impairment (29·2% vs 19·6%; p=0·016) and blindness (6·7% vs 1·6%; p<0·0001) was observed in those with ungradable images. In known diabetes, diabetic retinopathy (adjusted odds ratio [aOR] 3·06 [95% CI 1·25-7·51]), vision-threatening diabetic retinopathy (aOR 7·21 [3·52-14·75]), and diabetic macular oedema (aOR 5·41 [2·20-13·33]) were associated with blindness in adjusted analysis. Common sociodemographic risk factors for vision impairment and blindness include older age, lower educational attainment, and unemployment. INTERPRETATION Based on the estimated 101 million people with diabetes in 2021 and the interpretation of the data from this study, approximately 21 million people with diabetes have vision impairment in India, of whom 2·4 million are blind. Higher prevalence is observed in those from lower socio-economic strata and policy makers should focus on these groups to reduce inequalities in health care. FUNDING Global Challenge Research Fund of United Kingdom Research and Innovation through the Medical Research Council.
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Affiliation(s)
- Sarega Gurudas
- Vision Sciences, UCL Institute of Ophthalmology, London, UK; Centre for Intelligent Healthcare, Coventry University, Coventry, UK; NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - Rajiv Raman
- Retina Department, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Ramachandran Rajalakshmi
- Department of Diabetology and Ophthalmology, Madras Diabetes Research Foundation, Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Kim Ramasamy
- Retina Department, Aravind Medical Research Foundation, Madurai, India
| | - Viswanathan Mohan
- Department of Diabetology and Ophthalmology, Madras Diabetes Research Foundation, Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Padmaja K Rani
- Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, Hyderabad Eye Research Foundation, LV Prasad Eye Institute, Hyderabad, India
| | - Taraprasad Das
- Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, Hyderabad Eye Research Foundation, LV Prasad Eye Institute, Hyderabad, India
| | - Dolores Conroy
- Vision Sciences, UCL Institute of Ophthalmology, London, UK
| | - Robyn J Tapp
- Centre for Intelligent Healthcare, Coventry University, Coventry, UK
| | - Sobha Sivaprasad
- Vision Sciences, UCL Institute of Ophthalmology, London, UK; NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.
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Cope AP, Jasenecova M, Vasconcelos JC, Filer A, Raza K, Qureshi S, D'Agostino MA, McInnes IB, Isaacs JD, Pratt AG, Fisher BA, Buckley CD, Emery P, Ho P, Buch MH, Ciurtin C, van Schaardenburg D, Huizinga T, Toes R, Georgiou E, Kelly J, Murphy C, Prevost AT. Abatacept in individuals at high risk of rheumatoid arthritis (APIPPRA): a randomised, double-blind, multicentre, parallel, placebo-controlled, phase 2b clinical trial. Lancet 2024; 403:838-849. [PMID: 38364839 DOI: 10.1016/s0140-6736(23)02649-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/10/2023] [Accepted: 11/23/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Individuals with serum antibodies to citrullinated protein antigens (ACPA), rheumatoid factor, and symptoms, such as inflammatory joint pain, are at high risk of developing rheumatoid arthritis. In the arthritis prevention in the pre-clinical phase of rheumatoid arthritis with abatacept (APIPPRA) trial, we aimed to evaluate the feasibility, efficacy, and acceptability of treating high risk individuals with the T-cell co-stimulation modulator abatacept. METHODS The APIPPRA study was a randomised, double-blind, multicentre, parallel, placebo-controlled, phase 2b clinical trial done in 28 hospital-based early arthritis clinics in the UK and three in the Netherlands. Participants (aged ≥18 years) at risk of rheumatoid arthritis positive for ACPA and rheumatoid factor with inflammatory joint pain were recruited. Exclusion criteria included previous episodes of clinical synovitis and previous use of corticosteroids or disease-modifying antirheumatic drugs. Participants were randomly assigned (1:1) using a computer-generated permuted block randomisation (block sizes of 2 and 4) stratified by sex, smoking, and country, to 125 mg abatacept subcutaneous injections weekly or placebo for 12 months, and then followed up for 12 months. Masking was achieved by providing four kits (identical in appearance and packaging) with pre-filled syringes with coded labels of abatacept or placebo every 3 months. The primary endpoint was the time to development of clinical synovitis in three or more joints or rheumatoid arthritis according to American College of Rheumatology and European Alliance of Associations for Rheumatology 2010 criteria, whichever was met first. Synovitis was confirmed by ultrasonography. Follow-up was completed on Jan 13, 2021. All participants meeting the intention-to-treat principle were included in the analysis. This trial was registered with EudraCT (2013-003413-18). FINDINGS Between Dec 22, 2014, and Jan 14, 2019, 280 individuals were evaluated for eligibility and, of 213 participants, 110 were randomly assigned to abatacept and 103 to placebo. During the treatment period, seven (6%) of 110 participants in the abatacept group and 30 (29%) of 103 participants in the placebo group met the primary endpoint. At 24 months, 27 (25%) of 110 participants in the abatacept group had progressed to rheumatoid arthritis, compared with 38 (37%) of 103 in the placebo group. The estimated proportion of participants remaining arthritis-free at 12 months was 92·8% (SE 2·6) in the abatacept group and 69·2% (4·7) in the placebo group. Kaplan-Meier arthritis-free survival plots over 24 months favoured abatacept (log-rank test p=0·044). The difference in restricted mean survival time between groups was 53 days (95% CI 28-78; p<0·0001) at 12 months and 99 days (95% CI 38-161; p=0·0016) at 24 months in favour of abatacept. During treatment, abatacept was associated with improvements in pain scores, functional wellbeing, and quality-of-life measurements, as well as low scores of subclinical synovitis by ultrasonography, compared with placebo. However, the effects were not sustained at 24 months. Seven serious adverse events occurred in the abatacept group and 11 in the placebo group, including one death in each group deemed unrelated to treatment. INTERPRETATION Therapeutic intervention during the at-risk phase of rheumatoid arthritis is feasible, with acceptable safety profiles. T-cell co-stimulation modulation with abatacept for 12 months reduces progression to rheumatoid arthritis, with evidence of sustained efficacy beyond the treatment period, and with no new safety signals. FUNDING Bristol Myers Squibb.
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Affiliation(s)
- Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London, UK.
| | | | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials & Epidemiology Unit, King's College London, London, UK
| | - Andrew Filer
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Karim Raza
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Sumera Qureshi
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Maria Antonietta D'Agostino
- Division of Rheumatology, Fondazione Policlinico Universitario A Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Iain B McInnes
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
| | - John D Isaacs
- Translational & Clinical Research Institute, Newcastle University and Musculoskeletal Unit, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Arthur G Pratt
- Translational & Clinical Research Institute, Newcastle University and Musculoskeletal Unit, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Benjamin A Fisher
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | | | - Paul Emery
- Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Pauline Ho
- Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Maya H Buch
- Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Division of Medicine, University College London, London, UK
| | - Dirkjan van Schaardenburg
- Amsterdam University Medical Centres, Reade, Amsterdam Rheumatology and Immunology Centre, Amsterdam, Netherlands
| | - Thomas Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, Netherlands
| | - René Toes
- Department of Rheumatology, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Joanna Kelly
- King's Clinical Trials Unit, King's College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit, King's College London, London, UK
| | - A Toby Prevost
- Nightingale-Saunders Clinical Trials & Epidemiology Unit, King's College London, London, UK
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Rajalakshmi R, Vasconcelos JC, Prevost AT, Sivaprasad S, Deepa M, Raman R, Ramasamy K, Anjana RM, Conroy D, Das T, Hanif W, Mohan V. Burden of undiagnosed and suboptimally controlled diabetes in selected regions of India: Results from the SMART India population-level diabetes screening study. Diabet Med 2023; 40:e15165. [PMID: 37307016 DOI: 10.1111/dme.15165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/13/2023]
Abstract
AIMS To estimate the prevalence of undiagnosed diabetes and suboptimally controlled diabetes and the associated risk factors by community screening in India. METHODS In this multi-centre, cross-sectional study, house-to-house screening was conducted in people aged ≥40 years in urban and rural areas across 10 states and one union territory in India between November 2018 and March 2020. Participants underwent anthropometry, clinical and biochemical assessments. Capillary random blood glucose and point-of-care glycated haemoglobin (HbA1c ) were used to diagnose diabetes. The prevalence of undiagnosed diabetes and suboptimal control (HbA1c ≥53 mmol/mol [≥7%]) among those with known diabetes was assessed. RESULTS Among the 42,146 participants screened (22,150 urban, 19,996 rural), 5689 had known diabetes. The age-standardised prevalence of known diabetes was 13.1% (95% CI 12.8-13.4); 17.2% in urban areas and 9.4% in rural areas. The age-standardised prevalence of undiagnosed diabetes was 6.0% (95% CI 5.7-6.2); similar in both urban and rural areas with the highest proportions seen in the East (8.0%) and South (7.8%) regions. When we consider all people with diabetes in the population, 22.8% of individuals in urban areas and 36.7% in rural areas had undiagnosed diabetes. Almost 75% of the individuals with known diabetes had suboptimal glycaemic control. CONCLUSIONS High prevalence of undiagnosed diabetes and suboptimally controlled diabetes emphasises the urgent need to identify and optimally treat people with diabetes to reduce the burden of diabetes.
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Affiliation(s)
- Ramachandran Rajalakshmi
- Department of Diabetology, Ophthalmology and Epidemiology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Vision Sciences, UCL Institute of Ophthalmology, London, UK
| | - Mohan Deepa
- Department of Diabetology, Ophthalmology and Epidemiology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Rajiv Raman
- Retina Department, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Kim Ramasamy
- Retina Department, Aravind Medical Research Foundation, Madurai, India
| | - Ranjit Mohan Anjana
- Department of Diabetology, Ophthalmology and Epidemiology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Dolores Conroy
- Vision Sciences, UCL Institute of Ophthalmology, London, UK
| | - Taraprasad Das
- Anant Bajaj Retina Institute-Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, Hyderabad Eye Research Foundation, LV Prasad Eye Institute, Hyderabad, India
| | - Wasim Hanif
- Department of Diabetology and Endocrinology, University Hospital Birmingham, Birmingham, UK
| | - Viswanathan Mohan
- Department of Diabetology, Ophthalmology and Epidemiology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
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Raman R, Vasconcelos JC, Rajalakshmi R, Prevost AT, Ramasamy K, Mohan V, Mohan D, Rani PK, Conroy D, Das T, Sivaprasad S, Surya J, Gopal L, Ramakrishnan R, Roy R, Das S, Manayath G, Pooleeswaran VT, Anantharaman G, Gopalakrishnan M, Natarajan S, Krishnan R, Mani SL, Agarwal M, Behera U, Bhattacharjee H, Barman M, Sen A, Saxena M, Sil AK, Chakrabarty S, Cherian T, Jitesh R, Naigaonkar R, Desai A, Kulkarni S. Prevalence of diabetic retinopathy in India stratified by known and undiagnosed diabetes, urban-rural locations, and socioeconomic indices: results from the SMART India population-based cross-sectional screening study. Lancet Glob Health 2022; 10:e1764-e1773. [PMID: 36327997 DOI: 10.1016/s2214-109x(22)00411-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/06/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND National and subnational estimates of the prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy (VTDR) are needed to inform the stepwise implementation of systematic retinal screening for people with diabetes in India to decrease the rate of blindness. We aimed to assess these national and subnational estimates and to stratify the prevalence of diabetic retinopathy and VTDR on the basis of people with known versus undiagnosed diabetes, urban versus rural residence, and epidemiological transition level (ETL) and Socio-demographic Index (SDI) categories of states. METHODS We did a multicentre cross-sectional screening study for diabetic retinopathy using a complex cluster sampling design in people aged 40 years or older in ten Indian states and one union territory between Dec 20, 2018, and March 20, 2020. We did non-mydriatic retinal screening and assessed risk factor burden for people with diabetes. We estimated nationally weighted prevalence of diabetic retinopathy and VTDR for individuals with known and undiagnosed diabetes by urban versus rural residence, and by state categorisation by ETL and SDI. We also assessed adjusted risk factors. FINDINGS From 42 146 participants screened, 7910 (18·8%) were identified to have diabetes. Of these, 6133 (77·5%; 4350 with known diabetes and 1783 with undiagnosed diabetes) had gradable retinal images. 3411 (56%) participants were women and 2722 (44%) were men, and the median age was 56 years (IQR 49-65). The estimated national prevalence was 12·5% (95% CI 11·0-14·2) for diabetic retinopathy and 4·0% (3·4-4·8) for VTDR, with no significant differences between urban and rural residence for diabetic retinopathy. Compared with individuals with undiagnosed diabetes, we observed a higher prevalence of diabetic retinopathy (15·5% [13·4-17·8] vs 8·0% [6·3-10·1]) and VTDR (5·3% [4·5-6·3] vs 2·4% [1·6-3·6]) in individuals with known diabetes. The prevalence was significantly lower in low ETL-SDI states compared with high and middle ETL-SDI states for diabetic retinopathy (by 7·0%, 1·9-12·2, p=0·024) and VTDR (by 4·8%, 3·0-6·6, p<0·0001). Hyperglycaemia was the strongest modifiable risk factor. INTERPRETATION We estimate that, in absolute numbers, approximately 3 million people aged 40 years or older have VTDR in India, with a higher prevalence in those with known diabetes residing in high and middle ETI-SDI states. FUNDING UKRI Global Challenge Research Fund.
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Affiliation(s)
- Rajiv Raman
- Retina Department, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - Ramachandran Rajalakshmi
- Department of Diabetology and Ophthalmology, Madras Diabetes Research Foundation, Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's College London, London, UK
| | - Kim Ramasamy
- Retina Department, Aravind Medical Research Foundation, Madurai, India
| | - Viswanathan Mohan
- Department of Diabetology and Ophthalmology, Madras Diabetes Research Foundation, Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - Deepa Mohan
- Department of Diabetology and Ophthalmology, Madras Diabetes Research Foundation, Dr Mohan's Diabetes Specialities Centre, Chennai, India
| | - Padmaja K Rani
- Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, Hyderabad Eye Research Foundation, LV Prasad Eye Institute, Hyderabad, India
| | - Dolores Conroy
- Vision Sciences, UCL Institute of Ophthalmology, University College London, London, UK
| | - Taraprasad Das
- Srimati Kanuri Santhamma Centre for Vitreoretinal Diseases, Hyderabad Eye Research Foundation, LV Prasad Eye Institute, Hyderabad, India
| | - Sobha Sivaprasad
- Vision Sciences, UCL Institute of Ophthalmology, University College London, London, UK; NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.
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Pennington B, Alshreef A, Flight L, Metry A, Poku E, Hykin P, Sivaprasad S, Prevost AT, Vasconcelos JC, Murphy C, Kelly J, Yang Y, Lotery A, Williams M, Brazier J. Correction to: Cost Effectiveness of Ranibizumab vs Aflibercept vs Bevacizumab for the Treatment of Macular Oedema Due to Central Retinal Vein Occlusion: The LEAVO Study. Pharmacoeconomics 2021; 39:1099. [PMID: 34148190 PMCID: PMC8352804 DOI: 10.1007/s40273-021-01057-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Becky Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Abualbishr Alshreef
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andrew Metry
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Philip Hykin
- NIHR Moorfields Biomedical Research Centre, London, UK
| | | | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit at King's Clinical Trials Unit, King's College London, London, UK
| | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials and Epidemiology Unit at King's Clinical Trials Unit, King's College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Yit Yang
- Wolverhampton Eye Infirmary, Wolverhampton, UK
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael Williams
- Centre for Medical Education, Queen's University of Belfast, Belfast, UK
| | - John Brazier
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Pennington B, Alshreef A, Flight L, Metry A, Poku E, Hykin P, Sivaprasad S, Prevost AT, Vasconcelos JC, Murphy C, Kelly J, Yang Y, Lotery A, Williams M, Brazier J. Cost Effectiveness of Ranibizumab vs Aflibercept vs Bevacizumab for the Treatment of Macular Oedema Due to Central Retinal Vein Occlusion: The LEAVO Study. Pharmacoeconomics 2021; 39:913-927. [PMID: 33900585 PMCID: PMC8298346 DOI: 10.1007/s40273-021-01026-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND We aimed to assess the cost effectiveness of intravitreal ranibizumab (Lucentis), aflibercept (Eylea) and bevacizumab (Avastin) for the treatment of macular oedema due to central retinal vein occlusion. METHODS We calculated costs and quality-adjusted life-years from the UK National Health Service and Personal Social Services perspective. We performed a within-trial analysis using the efficacy, safety, resource use and health utility data from a randomised controlled trial (LEAVO) over 100 weeks. We built a discrete event simulation to model long-term outcomes. We estimated utilities using the Visual-Functioning Questionnaire-Utility Index, EQ-5D and EQ-5D with an additional vision question. We used standard UK costs sources for 2018/19 and a cost of £28 per bevacizumab injection. We discounted costs and quality-adjusted life-years at 3.5% annually. RESULTS Bevacizumab was the least costly intervention followed by ranibizumab and aflibercept in both the within-trial analysis (bevacizumab: £6292, ranibizumab: £13,014, aflibercept: £14,328) and long-term model (bevacizumab: £18,353, ranibizumab: £30,226, aflibercept: £35,026). Although LEAVO did not demonstrate bevacizumab to be non-inferior for the visual acuity primary outcome, the three interventions generated similar quality-adjusted life-years in both analyses. Bevacizumab was always the most cost-effective intervention at a threshold of £30,000 per quality-adjusted life-year, even using the list price of £243 per injection. CONCLUSIONS Wider adoption of bevacizumab for the treatment of macular oedema due to central retinal vein occlusion could result in substantial savings to healthcare systems and deliver similar health-related quality of life. However, patients, funders and ophthalmologists should be fully aware that LEAVO could not demonstrate that bevacizumab is non-inferior to the licensed agents.
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Affiliation(s)
- Becky Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Abualbishr Alshreef
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andrew Metry
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Philip Hykin
- NIHR Moorfields Biomedical Research Centre, London, UK
| | | | - A Toby Prevost
- Nightingale-Saunders Clinical Trials and Epidemiology Unit at King's Clinical Trials Unit, King's College London, London, UK
| | - Joana C Vasconcelos
- Nightingale-Saunders Clinical Trials and Epidemiology Unit at King's Clinical Trials Unit, King's College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Yit Yang
- Wolverhampton Eye Infirmary, Wolverhampton, UK
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael Williams
- Centre for Medical Education, Queen's University of Belfast, Belfast, UK
| | - John Brazier
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Hykin P, Prevost AT, Sivaprasad S, Vasconcelos JC, Murphy C, Kelly J, Ramu J, Alshreef A, Flight L, Pennington R, Hounsome B, Lever E, Metry A, Poku E, Yang Y, Harding SP, Lotery A, Chakravarthy U, Brazier J. Intravitreal ranibizumab versus aflibercept versus bevacizumab for macular oedema due to central retinal vein occlusion: the LEAVO non-inferiority three-arm RCT. Health Technol Assess 2021; 25:1-196. [PMID: 34132192 PMCID: PMC8287375 DOI: 10.3310/hta25380] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Licensed ranibizumab (0.5 mg/0.05 ml Lucentis®; Novartis International AG, Basel, Switzerland) and aflibercept (2 mg/0.05 ml Eylea®; Bayer AG, Leverkusen, Germany) and unlicensed bevacizumab (1.25 mg/0.05 ml Avastin®; F. Hoffmann-La Roche AG, Basel, Switzerland) are used to treat macula oedema due to central retinal vein occlusion, but their relative clinical effectiveness, cost-effectiveness and impact on the UK NHS and Personal Social Services have never been directly compared over the typical disease treatment period. OBJECTIVE The objective was to compare the clinical effectiveness and cost-effectiveness of three intravitreal antivascular endothelial growth factor agents for the management of macula oedema due to central retinal vein occlusion. DESIGN This was a three-arm, double-masked, randomised controlled non-inferiority trial. SETTING The trial was set in 44 UK NHS ophthalmology departments, between 2014 and 2018. PARTICIPANTS A total of 463 patients with visual impairment due to macula oedema secondary to central retinal vein occlusion were included in the trial. INTERVENTIONS The participants were treated with repeated intravitreal injections of ranibizumab (n = 155), aflibercept (n = 154) or bevacizumab (n = 154). MAIN OUTCOME MEASURES The primary outcome was an increase in the best corrected visual acuity letter score from baseline to 100 weeks in the trial eye. The null hypothesis that aflibercept and bevacizumab are each inferior to ranibizumab was tested with a non-inferiority margin of -5 visual acuity letters over 100 weeks. Secondary outcomes included additional visual acuity, and imaging outcomes, Visual Function Questionnaire-25, EuroQol-5 Dimensions with and without a vision bolt-on, and drug side effects. Cost-effectiveness was estimated using treatment costs and Visual Function Questionnaire-Utility Index to measure quality-adjusted life-years. RESULTS The adjusted mean changes at 100 weeks in the best corrected visual acuity letter scores were as follows - ranibizumab, 12.5 letters (standard deviation 21.1 letters); aflibercept, 15.1 letters (standard deviation 18.7 letters); and bevacizumab, 9.8 letters (standard deviation 21.4 letters). Aflibercept was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference 2.23 letters, 95% confidence interval -2.17 to 6.63 letters; p = 0.0006), but not superior. The study was unable to demonstrate that bevacizumab was non-inferior to ranibizumab in the intention-to-treat population (adjusted mean best corrected visual acuity difference -1.73 letters, 95% confidence interval -6.12 to 2.67 letters; p = 0.071). A post hoc analysis was unable to demonstrate that bevacizumab was non-inferior to aflibercept in the intention-to-treat population (adjusted mean best corrected visual acuity difference was -3.96 letters, 95% confidence interval -8.34 to 0.42 letters; p = 0.32). All per-protocol population results were the same. Fewer injections were required with aflibercept (10.0) than with ranibizumab (11.8) (difference in means -1.8, 95% confidence interval -2.9 to -0.8). A post hoc analysis showed that more bevacizumab than aflibercept injections were required (difference in means 1.6, 95% confidence interval 0.5 to 2.7). There were no new safety concerns. The model- and trial-based cost-effectiveness analyses estimated that bevacizumab was the most cost-effective treatment at a threshold of £20,000-30,000 per quality-adjusted life-year. LIMITATIONS The comparison of aflibercept and bevacizumab was a post hoc analysis. CONCLUSION The study showed aflibercept to be non-inferior to ranibizumab. However, the possibility that bevacizumab is worse than ranibizumab and aflibercept by 5 visual acuity letters cannot be ruled out. Bevacizumab is an economically attractive treatment alternative and would lead to substantial cost savings to the NHS and other health-care systems. However, uncertainty about its relative effectiveness should be discussed comprehensively with patients, their representatives and funders before treatment is considered. FUTURE WORK To obtain extensive patient feedback and discuss with all stakeholders future bevacizumab NHS use. TRIAL REGISTRATION Current Controlled Trials ISRCTN13623634. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Philip Hykin
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Sobha Sivaprasad
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Jayashree Ramu
- National Institute for Health Research Moorfields Biomedical Research Centre, London, UK
| | - Abualbishr Alshreef
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rebekah Pennington
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Ellen Lever
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Andrew Metry
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Yit Yang
- The Eye Infirmary, New Cross Hospital, Wolverhampton, UK
| | - Simon P Harding
- Eye and Vision Science, University of Liverpool, and St Paul's Eye Unit, Royal Liverpool University Hospitals, Liverpool, UK
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Usha Chakravarthy
- Department of Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - John Brazier
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Hardeman W, Mitchell J, Pears S, Van Emmenis M, Theil F, Gc VS, Vasconcelos JC, Westgate K, Brage S, Suhrcke M, Griffin SJ, Kinmonth AL, Wilson ECF, Prevost AT, Sutton S. Evaluation of a very brief pedometer-based physical activity intervention delivered in NHS Health Checks in England: The VBI randomised controlled trial. PLoS Med 2020; 17:e1003046. [PMID: 32142507 PMCID: PMC7059905 DOI: 10.1371/journal.pmed.1003046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 01/31/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The majority of people do not achieve recommended levels of physical activity. There is a need for effective, scalable interventions to promote activity. Self-monitoring by pedometer is a potentially suitable strategy. We assessed the effectiveness and cost-effectiveness of a very brief (5-minute) pedometer-based intervention ('Step It Up') delivered as part of National Health Service (NHS) Health Checks in primary care. METHODS AND FINDINGS The Very Brief Intervention (VBI) Trial was a two parallel-group, randomised controlled trial (RCT) with 3-month follow-up, conducted in 23 primary care practices in the East of England. Participants were 1,007 healthy adults aged 40 to 74 years eligible for an NHS Health Check. They were randomly allocated (1:1) using a web-based tool between October 1, 2014, and December 31, 2015, to either intervention (505) or control group (502), stratified by primary care practice. Participants were aware of study group allocation. Control participants received the NHS Health Check only. Intervention participants additionally received Step It Up: a 5-minute face-to-face discussion, written materials, pedometer, and step chart. The primary outcome was accelerometer-based physical activity volume at 3-month follow-up adjusted for sex, 5-year age group, and general practice. Secondary outcomes included time spent in different intensities of physical activity, self-reported physical activity, and economic measures. We conducted an in-depth fidelity assessment on a subsample of Health Check consultations. Participants' mean age was 56 years, two-thirds were female, they were predominantly white, and two-thirds were in paid employment. The primary outcome was available in 859 (85.3%) participants. There was no significant between-group difference in activity volume at 3 months (adjusted intervention effect 8.8 counts per minute [cpm]; 95% CI -18.7 to 36.3; p = 0.53). We found no significant between-group differences in the secondary outcomes of step counts per day, time spent in moderate or vigorous activity, time spent in vigorous activity, and time spent in moderate-intensity activity (accelerometer-derived variables); as well as in total physical activity, home-based activity, work-based activity, leisure-based activity, commuting physical activity, and screen or TV time (self-reported physical activity variables). Of the 505 intervention participants, 491 (97%) received the Step it Up intervention. Analysis of 37 intervention consultations showed that 60% of Step it Up components were delivered faithfully. The intervention cost £18.04 per participant. Incremental cost to the NHS per 1,000-step increase per day was £96 and to society was £239. Adverse events were reported by 5 intervention participants (of which 2 were serious) and 5 control participants (of which 2 were serious). The study's limitations include a participation rate of 16% and low return of audiotapes by practices for fidelity assessment. CONCLUSIONS In this large well-conducted trial, we found no evidence of effect of a plausible very brief pedometer intervention embedded in NHS Health Checks on objectively measured activity at 3-month follow-up. TRIAL REGISTRATION Current Controlled Trials (ISRCTN72691150).
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Affiliation(s)
- Wendy Hardeman
- Behavioural and Implementation Science Group, School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich, United Kingdom
- * E-mail:
| | - Joanna Mitchell
- Behavioural Science Group, Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - Sally Pears
- Behavioural Science Group, Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - Miranda Van Emmenis
- Behavioural Science Group, Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - Florence Theil
- Behavioural Science Group, Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - Vijay S. Gc
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
- Centre for Health Economics, University of York, York, United Kingdom
| | | | - Kate Westgate
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Søren Brage
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Marc Suhrcke
- Centre for Health Economics, University of York, York, United Kingdom
- Luxembourg Institute of Socio-Economic Research, Esch-sur-Alzette, Luxembourg
| | - Simon J. Griffin
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
- Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - Ann Louise Kinmonth
- Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - Edward C. F. Wilson
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
- Cambridge Centre for Health Services Research, Department of Public Health and Primary Care, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - A. Toby Prevost
- Imperial Clinical Trials Unit, Imperial College London, London, United Kingdom
| | - Stephen Sutton
- Behavioural Science Group, Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, Cambridge, United Kingdom
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Hykin P, Prevost AT, Vasconcelos JC, Murphy C, Kelly J, Ramu J, Hounsome B, Yang Y, Harding SP, Lotery A, Chakravarthy U, Sivaprasad S. Clinical Effectiveness of Intravitreal Therapy With Ranibizumab vs Aflibercept vs Bevacizumab for Macular Edema Secondary to Central Retinal Vein Occlusion: A Randomized Clinical Trial. JAMA Ophthalmol 2019; 137:1256-1264. [PMID: 31465100 PMCID: PMC6865295 DOI: 10.1001/jamaophthalmol.2019.3305] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance The comparative clinical effectiveness of ranibizumab, aflibercept, and bevacizumab for the management of macular edema due to central retinal vein occlusion (CRVO) is unclear. Objective To determine whether intravitreal aflibercept or bevacizumab compared with ranibizumab results in a noninferior mean change in vision at 100 weeks for eyes with CRVO-related macular edema. Design, Setting, and Participants This prospective, 3-arm, double-masked, randomized noninferiority trial (Lucentis, Eylea, Avastin in Vein Occlusion [LEAVO] Study) took place from December 12, 2014, through December 16, 2016, at 44 UK National Health Service ophthalmology departments. Inclusion criteria included age 18 years or older, visual impairment due to CRVO-related macular edema of less than 12 months with best-corrected visual acuity (BCVA) Early Treatment Diabetic Retinopathy Study letter score (approximate Snellen equivalent) in the study eye between 19 (20/400) and 78 (20/32), and spectral domain optical coherence tomography imaging central subfield thickness of 320 μm or greater. Data were analyzed from March 4, 2019, to April 26, 2019. Interventions Participants were randomized (1:1:1) to receive repeated intravitreal injections of ranibizumab (0.5 mg/0.05 mL) (n = 155), aflibercept (2.0 mg/0.05 mL) (n = 154), or bevacizumab (1.25 mg/0.05 mL) (n = 154) for 100 weeks. Main Outcomes and Measures Adjusted mean change in BCVA in the study eye at 100 weeks wherein noninferiority was concluded if the lower bounds of the 95% CI of both the intention-to-treat and the per protocol analyses were above -5 letters. Results Of 463 participants, 265 (57.2%) were male, with a mean (SD) age of 69.1 (13.0) years. The mean (SD) gain in BCVA letter score was 12.5 (21.1) for ranibizumab, 15.1 (18.7) for aflibercept, and 9.8 (21.4) for bevacizumab at 100 weeks. Aflibercept was noninferior to ranibizumab (intention-to-treat-adjusted mean BCVA difference, 2.23 letters; 95% CI, -2.17 to 6.63 letters; P < .001). Bevacizumab was not noninferior to ranibizumab (intention-to-treat-adjusted mean BCVA difference, -1.73 letters; 95% CI, -6.12 to 2.67 letters; P = .07). The per protocol analysis conclusions were similar. Fewer mean injections were given in the aflibercept group (10.0) than in the ranibizumab (11.8) group (mean difference at 100 weeks, -1.9; 95% CI, -2.9 to -0.8). Conclusions and Relevance Mean changes in vision after treatment of macular edema due to CRVO were no worse using aflibercept compared with ranibizumab. Mean changes in vision using bevacizumab compared with ranibizumab were inconclusive regarding vision outcomes (ie, the change in visual acuity from baseline, on average, may be worse or may not be worse when using bevacizumab compared with ranibizumab). Trial Registration ISRCTN13623634.
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Affiliation(s)
- Philip Hykin
- National Institute for Health Research, Moorfields Biomedical Research Centre, London, United Kingdom
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, United Kingdom
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, United Kingdom
| | - Caroline Murphy
- King's Clinical Trials Unit, King's Health Partners, King's College London, London, United Kingdom
| | - Joanna Kelly
- King's Clinical Trials Unit, King's Health Partners, King's College London, London, United Kingdom
| | - Jayashree Ramu
- National Institute for Health Research, Moorfields Biomedical Research Centre, London, United Kingdom
| | - Barry Hounsome
- King's Clinical Trials Unit, King's Health Partners, King's College London, London, United Kingdom
| | - Yit Yang
- Wolverhampton Eye Infirmary, Wolverhampton, United Kingdom
| | - Simon P Harding
- Eye and Vision Science, University of Liverpool, St Paul's Eye Unit, Royal Liverpool University Hospitals, Members of Liverpool Health Partners, Liverpool, United Kingdom
| | - Andrew Lotery
- Department of Medicine, University of Southampton, Southampton, United Kingdom
| | - Usha Chakravarthy
- Biomedical Sciences, Queen's University of Belfast, Belfast, United Kingdom
| | - Sobha Sivaprasad
- National Institute for Health Research, Moorfields Biomedical Research Centre, London, United Kingdom
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Al-Laith M, Jasenecova M, Abraham S, Bosworth A, Bruce IN, Buckley CD, Ciurtin C, D'Agostino MA, Emery P, Gaston H, Isaacs JD, Filer A, Fisher BA, Huizinga TWJ, Ho P, Jacklin C, Lempp H, McInnes IB, Pratt AG, Östor A, Raza K, Taylor PC, van Schaardenburg D, Shivapatham D, Wright AJ, Vasconcelos JC, Kelly J, Murphy C, Prevost AT, Cope AP. Arthritis prevention in the pre-clinical phase of RA with abatacept (the APIPPRA study): a multi-centre, randomised, double-blind, parallel-group, placebo-controlled clinical trial protocol. Trials 2019; 20:429. [PMID: 31307535 PMCID: PMC6633323 DOI: 10.1186/s13063-019-3403-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/06/2019] [Indexed: 01/01/2023] Open
Abstract
TRIAL DESIGN We present a study protocol for a multi-centre, randomised, double-blind, parallel-group, placebo-controlled trial that seeks to test the feasibility, acceptability and effectiveness of a 52-week period of treatment with the first-in-class co-stimulatory blocker abatacept for preventing or delaying the onset of inflammatory arthritis. METHODS The study aimed to recruit 206 male or female subjects from the secondary care hospital setting across the UK and the Netherlands. Participants who were at least 18 years old, who reported inflammatory sounding joint pain (clinically suspicious arthralgia) and who were found to be positive for serum autoantibodies associated with rheumatoid arthritis (RA) were eligible for enrolment. All study subjects were randomly assigned to receive weekly injections of investigational medicinal product, either abatacept or placebo treatment over the course of a 52-week period. Participants were followed up for a further 52 weeks. The primary endpoint was defined as the time to development of at least three swollen joints or to the fulfilment of the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for RA using swollen but not tender joints, whichever endpoint was met first. In either case, swollen joints were confirmed by ultrasonography. Participants, care givers, and those assessing the outcomes were all blinded to group assignment. Clinical assessors and ultrasonographers were also blinded to each other's assessments for the duration of the study. CONCLUSIONS There is limited experience of the design and implementation of trials for the prevention of inflammatory joint diseases. We discuss the rationale behind choice and duration of treatment and the challenges associated with defining the "at risk" state and offer pragmatic solutions in the protocol to enrolling subjects at risk of RA. TRIAL REGISTRATION Current Controlled Trials, ID: ISRCTN46017566 . Registered on 4 July 2014.
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Affiliation(s)
- Mariam Al-Laith
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK.
| | - Marianna Jasenecova
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Sonya Abraham
- Department of Rheumatology, National Institute for Health Research-Wellcome Clinical Research Facility, Hammersmith Hospital, Imperial College, London, W12 0HS, UK
| | - Aisla Bosworth
- National RA Society, The Switchback Office Park, Gardner Road, Maidenhead, SL6 7RJ, UK
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- National Institute for Health Research Biomedical Research Centre and the Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Christopher D Buckley
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Coziana Ciurtin
- Department of Adolescent and Adult Rheumatology, University College London Hospitals NHS Trust, 3rd Floor Central, 250 Euston Road, London, NW1 2PG, UK
| | - Maria-Antonietta D'Agostino
- Rheumatology Department, Hôpital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - Paul Emery
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, UK NIHR Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, LS4 7SA, UK
| | - Hill Gaston
- Department of Medicine, University of Cambridge and Addenbrookes Hospital NHS Trust, Cambridge, UK
| | - John D Isaacs
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, 3rd Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Andrew Filer
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Benjamin A Fisher
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Thomas W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Pauline Ho
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- National Institute for Health Research Biomedical Research Centre and the Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Clare Jacklin
- National RA Society, The Switchback Office Park, Gardner Road, Maidenhead, SL6 7RJ, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, 120 University Place, Glasgow, G12 8TA, UK
| | - Arthur G Pratt
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, 3rd Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Andrew Östor
- Department of Medicine, University of Cambridge and Addenbrookes Hospital NHS Trust, Cambridge, UK
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - Dirkjan van Schaardenburg
- Amsterdam Rheumatology and immunology Center, locations Reade and Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Dharshene Shivapatham
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Alison J Wright
- Clinical, Education & Health Psychology Division of Psychology & Language Sciences, Faculty of Brain Sciences, University College London, London, WC1E 6BT, UK
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, King's College London, Institute of Psychiatry, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Caroline Murphy
- King's Clinical Trials Unit, King's College London, Institute of Psychiatry, 16 De Crespigny Park, London, SE5 8AF, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK.
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Nicholson L, Crosby-Nwaobi R, Vasconcelos JC, Prevost AT, Ramu J, Riddell A, Bainbridge JW, Hykin PG, Sivaprasad S. Mechanistic Evaluation of Panretinal Photocoagulation Versus Aflibercept in Proliferative Diabetic Retinopathy: CLARITY Substudy. Invest Ophthalmol Vis Sci 2018; 59:4277-4284. [PMID: 30372756 PMCID: PMC6108778 DOI: 10.1167/iovs.17-23509] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 07/30/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to study the effects of panretinal photocoagulation (PRP) and intravitreal aflibercept on retinal vessel oxygen saturations, area of retinal nonperfusion, and area of neovascularization in proliferative diabetic retinopathy. Methods This is a prospective randomized single center study. Forty patients with proliferative diabetic retinopathy were randomized to PRP or intravitreal aflibercept treatment for 52 weeks. Retinal oximetry and ultra-widefield angiography were performed at baseline and week 52. Ultra-widefield color fundus imaging was performed at baseline, week 12, and week 52. The outcomes were retinal arterio-venous oximetry differences (AVD), area of retinal nonperfusion, and area of neovascularization in disc areas (DA). Results The AVD in the PRP group increased from 36.7% at baseline to 39.7%, whereas it decreased from 33.4% to 32.5% in the aflibercept group. The difference in AVD between groups at week 52 was 4.0% (95% confidence interval, -0.08, 8.8; P = 0.10). The baseline mean area of retinal nonperfusion of 125.1 DA and 131.2 DA in the PRP and aflibercept groups increased to 156.1 DA and 158.4 DA, respectively, at week 52 (P = 0.46). The median baseline area of neovascularization decreased from 0.98 DA to 0.68 DA in the PRP group and from 0.70 DA to 0 DA in the aflibercept group at week 12 (P = 0.019). At week 52, this measured 0.24 DA in the PRP group and 0 DA in the aflibercept group (P = 0.45). Conclusions Intravitreal aflibercept achieved an earlier and complete regression of neovascularization in proliferative diabetic retinopathy compared with PRP. There were no significant differences in global change in intravascular oxygen saturation or areas of retinal nonperfusion between the two groups by 52 weeks.
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Affiliation(s)
- Luke Nicholson
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, United Kingdom
| | - Roxanne Crosby-Nwaobi
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, United Kingdom
| | - Joana C. Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, United Kingdom
| | - A. Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, United Kingdom
| | - Jayashree Ramu
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, United Kingdom
| | - Amy Riddell
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, United Kingdom
| | - James W. Bainbridge
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, United Kingdom
| | - Philip G. Hykin
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, United Kingdom
| | - Sobha Sivaprasad
- National Institute for Health Research Moorfields Biomedical Research Centre, Moorfields Eye Hospital and University College London Institute of Ophthalmology, London, United Kingdom
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Sivaprasad S, Vasconcelos JC, Prevost AT, Holmes H, Hykin P, George S, Murphy C, Kelly J, Arden GB. Clinical efficacy and safety of a light mask for prevention of dark adaptation in treating and preventing progression of early diabetic macular oedema at 24 months (CLEOPATRA): a multicentre, phase 3, randomised controlled trial. Lancet Diabetes Endocrinol 2018; 6. [PMID: 29519744 PMCID: PMC5908782 DOI: 10.1016/s2213-8587(18)30036-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND We aimed to assess 24-month outcomes of wearing an organic light-emitting sleep mask as an intervention to treat and prevent progression of non-central diabetic macular oedema. METHODS CLEOPATRA was a phase 3, single-blind, parallel-group, randomised controlled trial undertaken at 15 ophthalmic centres in the UK. Adults with non-centre-involving diabetic macular oedema were randomly assigned (1:1) to wearing either a light mask during sleep (Noctura 400 Sleep Mask, PolyPhotonix Medical, Sedgefield, UK) or a sham (non-light) mask, for 24 months. Randomisation was by minimisation generated by a central web-based computer system. Outcome assessors were masked technicians and optometrists. The primary outcome was the change in maximum retinal thickness on optical coherence tomography (OCT) at 24 months, analysed using a linear mixed-effects model incorporating 4-monthly measurements and baseline adjustment. Analysis was done using the intention-to-treat principle in all randomised patients with OCT data. Safety was assessed in all patients. This trial is registered with Controlled-Trials.com, number ISRCTN85596558. FINDINGS Between April 10, 2014, and June 15, 2015, 308 patients were randomly assigned to wearing the light mask (n=155) or a sham mask (n=153). 277 patients (144 assigned the light mask and 133 the sham mask) contributed to the mixed-effects model over time, including 246 patients with OCT data at 24 months. The change in maximum retinal thickness at 24 months did not differ between treatment groups (mean change -9·2 μm [SE 2·5] for the light mask vs -12·9 μm [SE 2·9] for the sham mask; adjusted mean difference -0·65 μm, 95% CI -6·90 to 5·59; p=0·84). Median compliance with wearing the light mask at 24 months was 19·5% (IQR 1·9-51·6). No serious adverse events were related to either mask. The most frequent adverse events related to the assigned treatment were discomfort on the eyes (14 with the light mask vs seven with the sham mask), painful, sticky, or watery eyes (14 vs six), and sleep disturbance (seven vs one). INTERPRETATION The light mask as used in this study did not confer long-term therapeutic benefit on non-centre-involving diabetic macular oedema and the study does not support its use for this indication. FUNDING The Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health Research partnership.
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Affiliation(s)
- Sobha Sivaprasad
- National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK.
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Helen Holmes
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Philip Hykin
- National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - Sheena George
- Hillingdon Hospital, Hillingdon Hospitals National Health Service Foundation Trust, Uxbridge, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Geoffrey B Arden
- Institute of Ophthalmology and Moorfields Eye Hospital, London, UK
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Sivaprasad S, Prevost AT, Vasconcelos JC, Riddell A, Murphy C, Kelly J, Bainbridge J, Tudor-Edwards R, Hopkins D, Hykin P. Clinical efficacy of intravitreal aflibercept versus panretinal photocoagulation for best corrected visual acuity in patients with proliferative diabetic retinopathy at 52 weeks (CLARITY): a multicentre, single-blinded, randomised, controlled, phase 2b, non-inferiority trial. Lancet 2017; 389:2193-2203. [PMID: 28494920 DOI: 10.1016/s0140-6736(17)31193-5] [Citation(s) in RCA: 227] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 04/16/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Proliferative diabetic retinopathy is the most common cause of severe sight impairment in people with diabetes. Proliferative diabetic retinopathy has been managed by panretinal laser photocoagulation (PRP) for the past 40 years. We report the 1 year safety and efficacy of intravitreal aflibercept. METHODS In this phase 2b, single-blind, non-inferiority trial (CLARITY), adults (aged ≥18 years) with type 1 or 2 diabetes and previously untreated or post-laser treated active proliferative diabetic retinopathy were recruited from 22 UK ophthalmic centres. Patients were randomly assigned (1:1) to repeated intravitreal aflibercept (2 mg/0·05 mL at baseline, 4 weeks, and 8 weeks, and from week 12 patients were reviewed every 4 weeks and aflibercept injections were given as needed) or PRP standard care (single spot or mutlispot laser at baseline, fractionated fortnightly thereafter, and from week 12 patients were assessed every 8 weeks and treated with PRP as needed) for 52 weeks. Randomisation was by minimisation with a web-based computer generated system. Primary outcome assessors were masked optometrists. The treating ophthalmologists and participants were not masked. The primary outcome was defined as a change in best-corrected visual acuity at 52 weeks with a linear mixed-effect model that estimated adjusted treatment effects at both 12 weeks and 52 weeks, having excluded fluctuations in best corrected visual acuity owing to vitreous haemorrhage. This modified intention-to-treat analysis was reapplied to the per protocol participants. The non-inferiority margin was prespecified as -5 Early Treatment Diabetic Retinopathy Study letters. Safety was assessed in all participants. This trial is registered with ISRCTN registry, number 32207582. FINDINGS We recruited 232 participants (116 per group) between Aug 22, 2014 and Nov 30, 2015. 221 participants (112 in aflibercept group, 109 in PRP group) contributed to the modified intention-to-treat model, and 210 participants (104 in aflibercept group and 106 in PRP group) within per protocol. Aflibercept was non-inferior and superior to PRP in both the modified intention-to-treat population (mean best corrected visual acuity difference 3·9 letters [95% CI 2·3-5·6], p<0·0001) and the per-protocol population (4·0 letters [2·4-5·7], p<0·0001). There were no safety concerns. The 95% CI adjusted difference between groups was more than the prespecified acceptable margin of -5 letters at both 12 weeks and 52 weeks. INTERPRETATION Patients with proliferative diabetic retinopathy who were treated with intravitreal aflibercept had an improved outcome at 1 year compared with those treated with PRP standard care. FUNDING The Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health Research partnership.
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Affiliation(s)
- Sobha Sivaprasad
- National Institute for Health Research, Moorfields Biomedical Research Centre, London, UK.
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Amy Riddell
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - Joanna Kelly
- King's Clinical Trials Unit at King's Health Partners, King's College London, London, UK
| | - James Bainbridge
- University College London Institute of Ophthalmology, London, UK
| | - Rhiannon Tudor-Edwards
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Gwynedd, UK
| | - David Hopkins
- Department of Diabetes and Endocrinology, King's College Hospital NHS Foundation Trust, London, UK
| | - Philip Hykin
- National Institute for Health Research, Moorfields Biomedical Research Centre, London, UK
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Kirkham B, Chaabo K, Hall C, Garrood T, Mant T, Allen E, Vincent A, Vasconcelos JC, Prevost AT, Panayi GS, Corrigall VM. Safety and patient response as indicated by biomarker changes to binding immunoglobulin protein in the phase I/IIA RAGULA clinical trial in rheumatoid arthritis. Rheumatology (Oxford) 2016; 55:1993-2000. [PMID: 27498355 PMCID: PMC5854092 DOI: 10.1093/rheumatology/kew287] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 06/28/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Binding immunoglobulin protein (BiP) is a human endoplasmic reticulum-resident stress protein. In pre-clinical studies it has anti-inflammatory properties due to the induction of regulatory cells. This randomized placebo-controlled, dose ascending double blind phase I/IIA trial of BiP in patients with active RA, who had failed accepted therapies, had the primary objective of safety. Potential efficacy was measured by DAS28-ESR and changes in biomarkers. METHODS Twenty-four patients with active RA who had failed one or more DMARDs were sequentially assigned to three groups each of eight patients randomly allocated to receive placebo (two patients) or BiP (six patients), 1, 5 or 15 mg. Patients received a single i.v. infusion over 1 h and were observed as inpatients overnight. A 12-week follow-up for clinical, rheumatological and laboratory assessments for safety, efficacy (DAS28-ESR) and biomarker analysis was performed. RESULTS No infusion reactions or serious adverse drug reactions were noted. Adverse events were evenly distributed between placebo and BiP groups with no BiP-related toxicities. Haematological, renal and metabolic parameters showed no drug-related toxicities. Remission was only achieved by patients in the 5 and 15 mg groups, and not patients who received placebo or 1 mg BiP. Good DAS28-ESR responses were achieved in all treatment groups. The BiP responding patients showed significantly lower serum concentrations of CRP, 2 weeks post-infusion compared with pre-infusion levels, and of VEGF and IL-8 from the placebo group. CONCLUSION BiP (⩽15 mg) is safe in patients with active RA. Some patients had clinical and biological improvements in RA activity. BiP merits further study. TRIAL REGISTRATION ISRCTN registry, http://isrctn.com, ISRCTN22288225 and EudraCT, https://eudract.ema.europa.eu, 2011-005831-19.
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Affiliation(s)
- Bruce Kirkham
- Department of Rheumatology, Guys and St Thomas' NHS Foundation Trust Hospital
| | - Khaldoun Chaabo
- Department of Rheumatology, Guys and St Thomas' NHS Foundation Trust Hospital
| | - Christopher Hall
- Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, King's College London
| | - Toby Garrood
- Department of Rheumatology, Guys and St Thomas' NHS Foundation Trust Hospital
| | | | | | - Alexandra Vincent
- Department of Rheumatology, Guys and St Thomas' NHS Foundation Trust Hospital
| | - Joana C Vasconcelos
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Andrew T Prevost
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Gabriel S Panayi
- Department of Rheumatology, Guys and St Thomas' NHS Foundation Trust Hospital
- Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, King's College London
| | - Valerie M Corrigall
- Academic Department of Rheumatology, Centre for Molecular and Cellular Biology of Inflammation, King's College London
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Mitchell J, Hardeman W, Pears S, Vasconcelos JC, Prevost AT, Wilson E, Sutton S. Effectiveness and cost-effectiveness of a very brief physical activity intervention delivered in NHS Health Checks (VBI Trial): study protocol for a randomised controlled trial. Trials 2016; 17:303. [PMID: 27350131 PMCID: PMC4924271 DOI: 10.1186/s13063-016-1413-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 05/25/2016] [Indexed: 01/01/2023] Open
Abstract
Background Physical activity interventions that are targeted at individuals can be effective in encouraging people to be more physically active. However, most such interventions are too long or complex and not scalable to the general population. This trial will test the effectiveness and cost-effectiveness of a very brief physical activity intervention when delivered as part of preventative health checks in primary care (National Health Service (NHS) Health Check). Methods/design The Very Brief Intervention (VBI) Trial is a two parallel-group, randomised, controlled trial with 1:1 individual allocation and follow-up at 3 months. A total of 1,140 participants will be recruited from 23 primary care practices in the east of England. Participants eligible for an NHS Health Check and who are considered suitable to take part by their doctor and able to provide written informed consent are eligible for the trial. Participants are randomly assigned at the beginning of the NHS Health Check to either 1) the control arm, in which they receive only the NHS Health Check, or 2) the intervention arm, in which they receive the NHS Health Check plus ‘Step It Up’ (a very brief intervention that can be delivered in 5 minutes by nurses and/or healthcare assistants at the end of the Health Check). ‘Step It Up’ includes (1) a face-to-face discussion, including feedback on current activity level, recommendations for physical activity, and information on how to use a pedometer, set step goals, and monitor progress; (2) written material supporting the discussion and tips and links to further resources to help increase physical activity; and (3) a pedometer to wear and a step chart for monitoring progress. The primary outcome is accelerometer counts per minute at 3-month follow-up. Secondary outcomes include the time spent in the different levels of physical activity, self-reported physical activity and economic measures. Trial recruitment is underway. Discussion The VBI trial will provide evidence on the effectiveness and cost-effectiveness of the Step It Up intervention delivered during NHS Health Checks and will inform policy decisions about introducing very brief interventions into routine primary care practice. Trial registration ISRCTN Registry, ISRCTN72691150. Registered on 17 July 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1413-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joanna Mitchell
- Behavioural Science Group, Department of Public Health and Primary Care, Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Wendy Hardeman
- School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Sally Pears
- Behavioural Science Group, Department of Public Health and Primary Care, Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - Ed Wilson
- Department of Public Health and Primary Care, Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK
| | - Stephen Sutton
- Behavioural Science Group, Department of Public Health and Primary Care, Institute of Public Health, Forvie Site, University of Cambridge School of Clinical Medicine, Box 113, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK.
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Kelly JD, Dudderidge TJ, Wollenschlaeger A, Okoturo O, Burling K, Tulloch F, Halsall I, Prevost T, Prevost AT, Vasconcelos JC, Robson W, Leung HY, Vasdev N, Pickard RS, Williams GH, Stoeber K. Bladder cancer diagnosis and identification of clinically significant disease by combined urinary detection of Mcm5 and nuclear matrix protein 22. PLoS One 2012; 7:e40305. [PMID: 22792272 PMCID: PMC3392249 DOI: 10.1371/journal.pone.0040305] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 06/04/2012] [Indexed: 01/15/2023] Open
Abstract
Background Urinary biomarkers for bladder cancer detection are constrained by inadequate sensitivity or specificity. Here we evaluate the diagnostic accuracy of Mcm5, a novel cell cycle biomarker of aberrant growth, alone and in combination with NMP22. Methods 1677 consecutive patients under investigation for urinary tract malignancy were recruited to a prospective blinded observational study. All patients underwent ultrasound, intravenous urography, cystoscopy, urine culture and cytologic analysis. An immunofluorometric assay was used to measure Mcm5 levels in urine cell sediments. NMP22 urinary levels were determined with the FDA-approved NMP22® Test Kit. Results Genito-urinary tract cancers were identified in 210/1564 (13%) patients with an Mcm5 result and in 195/1396 (14%) patients with an NMP22 result. At the assay cut-point where sensitivity and specificity were equal, the Mcm5 test detected primary and recurrent bladder cancers with 69% sensitivity (95% confidence interval = 62–75%) and 93% negative predictive value (95% CI = 92–95%). The area under the receiver operating characteristic curve for Mcm5 was 0.75 (95% CI = 0.71–0.79) and 0.72 (95% CI = 0.67–0.77) for NMP22. Importantly, Mcm5 combined with NMP22 identified 95% (79/83; 95% CI = 88–99%) of potentially life threatening diagnoses (i.e. grade 3 or carcinoma in situ or stage ≥pT1) with high specificity (72%, 95% CI = 69–74%). Conclusions The Mcm5 immunoassay is a non-invasive test for identifying patients with urothelial cancers with similar accuracy to the FDA-approved NMP22 ELISA Test Kit. The combination of Mcm5 plus NMP22 improves the detection of UCC and identifies 95% of clinically significant disease. Trials of a commercially developed Mcm5 assay suitable for an end-user laboratory alongside NMP22 are required to assess their potential clinical utility in improving diagnostic and surveillance care pathways.
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Affiliation(s)
- John D. Kelly
- Department of Pathology and Cancer Institute, University College London, London, United Kingdom
| | - Tim J. Dudderidge
- Department of Pathology and Cancer Institute, University College London, London, United Kingdom
- The Royal Marsden National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Alex Wollenschlaeger
- Wolfson Institute for Biomedical Research, University College London, London, United Kingdom
- * E-mail: (AW)
| | - Odu Okoturo
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Keith Burling
- Department of Clinical Biochemistry, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Fiona Tulloch
- Department of Clinical Biochemistry, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ian Halsall
- Department of Clinical Biochemistry, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Teresa Prevost
- Department of Public Health and Primary Care, Centre for Applied Medical Statistics, University of Cambridge, Institute of Public Health, Cambridge, United Kingdom
| | - Andrew Toby Prevost
- Department of Primary Care and Public Health Sciences, King’s College London, London, United Kingdom
| | - Joana C. Vasconcelos
- Department of Public Health and Primary Care, Centre for Applied Medical Statistics, University of Cambridge, Institute of Public Health, Cambridge, United Kingdom
| | - Wendy Robson
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Hing Y. Leung
- Beatson Institute for Cancer Research, University of Glasgow, Bearsden, Glasgow, United Kingdom
| | - Nikhil Vasdev
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Robert S. Pickard
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Gareth H. Williams
- Department of Pathology and Cancer Institute, University College London, London, United Kingdom
- Wolfson Institute for Biomedical Research, University College London, London, United Kingdom
- * E-mail: (AW)
| | - Kai Stoeber
- Department of Pathology and Cancer Institute, University College London, London, United Kingdom
- Wolfson Institute for Biomedical Research, University College London, London, United Kingdom
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Marteau TM, Mann E, Prevost AT, Vasconcelos JC, Kellar I, Sanderson S, Parker M, Griffin S, Sutton S, Kinmonth AL. Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): randomised trial. BMJ 2010; 340:c2138. [PMID: 20466791 PMCID: PMC2869404 DOI: 10.1136/bmj.c2138] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To compare the effect of an invitation promoting informed choice for screening with a standard invitation on attendance and motivation to engage in preventive action. DESIGN Randomised controlled trial. SETTING Four English general practices. PARTICIPANTS 1272 people aged 40-69 years, at risk for diabetes, identified from practice registers using a validated risk score and invited to attend for screening. INTERVENTION Intervention was a previously validated invitation to inform the decision to attend screening, presenting diabetes as a serious potential problem, and providing details of possible costs and benefits of screening and treatment in text and pie charts. This was compared with a brief, standard invitation simply describing diabetes as a serious potential problem. MAIN OUTCOME MEASURES The primary end point was attendance for screening. The secondary outcome measures were intention to make changes to lifestyle and satisfaction with decisions made among attenders. RESULTS The primary end point was analysed for all 1272 participants. 55.8% (353/633) of those in the informed choice group attended for screening, compared with 57.6% (368/639) in the standard invitation group (mean difference -1.8%, 95% confidence interval -7.3% to 3.6%; P=0.51). Attendance was lower among the more deprived group (most deprived third 47.5% v least deprived third 64.3%; P<0.001). Interaction between deprivation and effect of invitation type on attendance was not significant. Among attenders, intention to change behaviour was strong and unaffected by invitation type. CONCLUSIONS Providing information to support choice did not adversely affect attendance for screening for diabetes. Those from more socially deprived groups were, however, less likely to attend, regardless of the type of invitation received. Further attention to invitation content alone is unlikely to achieve equity in uptake of preventive services. TRIAL REGISTRATION Current Controlled Trials ISRCTN 73125647.
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Affiliation(s)
- Theresa M Marteau
- King's College London, Psychology Department (at Guy's), Health Psychology Section, Psychology and Genetics Research Group, Guy's Campus, London SE1 9RT.
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da Silva JAP, Ramiro S, Pedro S, Rodrigues A, Vasconcelos JC, Benito-Garcia E. Patients- and physicians- priorities for improvement. The case of rheumatic diseases. Acta Reumatol Port 2010; 35:192-199. [PMID: 20734542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To compare the health priorities elected by patients with rheumatic diseases and by their attending rheumatologists. PATIENTS AND METHODS We undertook a cross-sectional study among patients and rheumatologists in Portuguese rheumatology outpatient clinics. 75% of all Portuguese Rheumatology Departments agreed to participate. Rheumatologists from non-participating hospital departments were asked to collaborate through their private practices. All patients were eligible for inclusion except if they were under 18 years of age or had a mental disorder that would affect their participation. Data were collected through dedicated questionnaires. Patients were asked to indicate 3 priorities for improvement out of 12 health domains (Arthritis Impact Measurement Scale 2) regarding their rheumatic disease. Rheumatologists were asked similar questions focused around rheumatoid arthritis (RA) and osteoarthritis (OA). RESULTS 1,868 patients and 56 rheumatologists entered the study. The most commonly selected priorities by patients with rheumatic diseases were: "Rheumatic pain" (70%), "Walking and bending" (45%), and "Hand and Finger Function" (40%). The main priority for improvement among patients with RA was "Rheumatic Pain" (69%), while rheumatologists more commonly elected "Work" (55%) as their main priority for these patients. Among patients with OA, "Rheumatic Pain" was the first priority for both patients and doctors (elected by 75%, and 55% of respondents, respectively). CONCLUSIONS Our study showed discordance between the priorities for improvement elected by patients and by their respective physicians. This was more pronounced in RA than in OA. Studying and addressing such differences may support physicians and institutions to better achieve the prime goal of incorporating and responding to patients' needs and preferences.
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Hori S, Patki P, Attar KH, Ismail S, Vasconcelos JC, Shah PJR. Patients’ perspective of botulinum toxin-A as a long-term treatment option for neurogenic detrusor overactivity secondary to spinal cord injury. BJU Int 2009; 104:216-20. [DOI: 10.1111/j.1464-410x.2009.08368.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVES The optimal therapeutic trial duration of anti-TNF-alpha therapy is currently unknown. The British Society for Rheumatology (BSR) guidance states that non-response at 3 months warrants re-evaluation of treatment and recommends not to persist beyond 6 months. The National Institute for Health and Clinical Excellence (NICE) specifies treatment continuation if response is achieved by 6 months, yet the European League against Rheumatism (EULAR) and the American College of Rheumatology (ACR) maintain a 3 month cut-off. No evidence exists to support a 6 month therapeutic trial over 3 months. Thus, we undertook a study to evaluate the proportion of patients who failed to meet NICE response criteria at 3 months but obtained this by 6 months, and to identify predictive factors for this. METHODS Patients who commenced anti-TNF-alpha therapy for RA were studied, counting those who switched to a second or third agent separately for each instigation of therapy (n = 244). Response at 3 and 6 months was defined according to NICE criteria as a >or=1.2 reduction in Disease Activity Score (DAS28). RESULTS Of the 189 patients with available 3 month DAS28 responses, 149 fulfilled response criteria. Of the 40 who failed, 27 continued treatment, of whom 21 were available for follow-up at 6 months. Out of the 21 patients, 12 (57%; 95% CI 36, 78) achieved a response at this time. This data set was too small to investigate predictors of response at 6 months. CONCLUSIONS A substantial proportion of patients who fail NICE response criteria at 3 months and continue on treatment to 6 months achieve a response. These results support a 6 month therapeutic trial over 3 months.
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Affiliation(s)
- J M Pocock
- Department of Rheumatology, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK
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Hori S, Mihaylov I, Vasconcelos JC, McCoubrie M. Patterns of complementary and alternative medicine use amongst outpatients in Tokyo, Japan. BMC Complement Altern Med 2008; 8:14. [PMID: 18433476 PMCID: PMC2375857 DOI: 10.1186/1472-6882-8-14] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2008] [Accepted: 04/23/2008] [Indexed: 11/10/2022]
Abstract
BACKGROUND The use of complementary and alternative medicine (CAM) has been increasing rapidly throughout the world during the past decade. The use of CAM in the general Japanese population has been previously reported to be as high as 76%. This study aims to investigate the patterns of CAM use, perceived effectiveness and disclosure of CAM use to orthodox medical practitioners amongst patients attending typical primary and secondary care clinics in a busy district general hospital in Tokyo, Japan. METHODS The authors analysed data collected during March 2002 on patients attending general outpatient clinics held at Shiseikai Daini Hospital in Tokyo, Japan. Data was collected by use of self-completed questionnaires distributed to patients in the outpatient clinics waiting area. Statistical analysis was performed using chi-square tests of independence. RESULTS 515 adults were approached to participate in this study and the overall response rate was 96% (n = 496). 50% of the patients were using or have used at least 1 CAM therapy within the last 12 months. The 5 most commonly used therapies were massage (n = 106, 43%), vitamins (n = 85, 35%), health foods including dietary supplements (n = 56, 23%), acupressure (n = 51, 21%) and kampo (n = 46, 19%). The majority of CAM users (75%, n = 145) found their CAM treatment to be effective (95% CI = 68-81%). Patients who were more likely to use CAM were females (p = 0.003) and those with a high number of medical conditions (p = < 0.0001). Only a small proportion of patients reported their CAM use to their physician (42%, n = 74). There was no significant difference in CAM use for the different age groups (p = 0.85), education level (p = 0.30) and financial status (p = 0.82). CONCLUSION Patterns of CAM usage in the sample surveyed was high (50%). Despite this high prevalence rate and presumed acceptance of CAM in Japan, the reporting of CAM use by patients to their physicians was low (42%). It is therefore important that physicians are aware of the possibility that their patients may be using CAM and also increase their knowledge and understanding of these treatments.
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Giugliano LG, Bernardi MG, Vasconcelos JC, Costa CA, Giugliano R. Longitudinal study of diarrhoeal disease in a peri-urban community in Manaus (Amazon-Brazil). Ann Trop Med Parasitol 1986; 80:443-50. [PMID: 2878647 DOI: 10.1080/00034983.1986.11812045] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A 20-month longitudinal study of diarrhoeal disease was carried out in a poor peri-urban community of Manaus (Amazon-Brazil), and the attack rate of this disease ranged from 0.2 to 4.8 episodes of diarrhoea per person per year. The age group most affected was 0 to 35 months old. A probable aetiological agent was identified in 68 of the 110 faecal samples collected. The most frequent enteropathogens isolated were enterotoxigenic Escherichia coli and Giardia lamblia. Enterotoxigenic Escherichia coli was also isolated from stream-water and from flies collected inside a household.
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Reis MH, Vasconcelos JC, Trabulsi LR. Prevalence of enterotoxigenic Escherichia coli in some processed raw food from animal origin. Appl Environ Microbiol 1980; 39:270-1. [PMID: 6986850 PMCID: PMC291315 DOI: 10.1128/aem.39.1.270-271.1980] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Eighteen of 1,200 colonies of Escherichia coli isolated from "keebe," hamburger, or sausage produced heat-labile enterotoxin. None of them produced heat-stable enterotoxin. The characteristics of 9 of the 18 strains are presented.
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