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Almayali AAH, Boers M, Hartman L, Opris D, Bos R, Kok MR, Da Silva JA, Griep E, Klaasen R, Allaart CF, Baudoin P, Raterman HG, Szekanecz Z, Buttgereit F, Masaryk P, Lems W, Smulders Y, Cutolo M, Ter Wee MM. Three-month tapering and discontinuation of long- term, low-dose glucocorticoids in senior patients with rheumatoid arthritis is feasible and safe: placebo-controlled double blind tapering after the GLORIA trial. Ann Rheum Dis 2023; 82:1307-1314. [PMID: 37541762 DOI: 10.1136/ard-2023-223977] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 02/21/2023] [Accepted: 06/22/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE The randomised placebo-controlled GLORIA (Glucocorticoid LOw-dose in RheumatoId Arthritis) trial evaluated the benefits and harms of prednisolone 5 mg/day added to standard care for 2 years in patients aged 65+ years with rheumatoid arthritis (RA). Here, we studied disease activity, flares and possible adrenal insufficiency after blinded withdrawal of study medication. METHODS Per protocol, patients successfully completing the 2-year trial period linearly tapered and stopped blinded study medication in 3 months. We compared changes in disease activity after taper between treatment groups (one-sided testing). Secondary outcomes (two-sided tests) comprised disease flares (DAS28 (Disease Activity Score 28 joints) increase >0.6, open-label glucocorticoids or disease-modifying antirheumatic drug (DMARD) increase/switch after week 4 of tapering) and symptoms/signs of adrenal insufficiency. In a subset of patients from 3 Dutch centres, cortisol and ACTH were measured in spot serum samples after tapering. RESULTS 191 patients were eligible; 36 met treatment-related flare criteria and were only included in the flare analysis. Mean (SD) DAS28 change at follow-up: 0.2 (1.0) in the prednisolone group (n=76) vs 0.0 (1.2) in placebo (n=79). Adjusted for baseline, the between-group difference in DAS28 increase was 0.16 (95% confidence limit -0.06, p=0.12). Flares occurred in 45% of prednisolone patients compared with 33% in placebo, relative risk (RR) 1.37 (95% CI 0.95 to 1.98; p=0.12). We found no evidence for adrenal insufficiency. CONCLUSIONS Tapering prednisolone moderately increases disease activity to the levels of the placebo group (mean still at low disease activity levels) and numerically increases the risk of flare without evidence for adrenal insufficiency. This suggests that withdrawal of low-dose prednisolone is feasible and safe after 2 years of administration.
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Affiliation(s)
| | - Maarten Boers
- Department of Epidemiology & Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Linda Hartman
- Department of Epidemiology & Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Daniela Opris
- Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Reinhard Bos
- Department of Rheumatology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Marc R Kok
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Jose Ap Da Silva
- Rheumatology Department, University of Coimbra Faculty of Medicine, Coimbra, Portugal
| | - Ed Griep
- Department of Rheumatology, Antonius Hospital, Sneek, The Netherlands
| | - Ruth Klaasen
- Department of Rheumatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul Baudoin
- Rheumatology, Reumazorg Flevoland, Emmeloord, The Netherlands
| | - Hennie G Raterman
- Department of Rheumatology, Northwest Clinics, Alkmaar, The Netherlands
| | - Zoltan Szekanecz
- Department of Rheumatology, University of Debrecen, Debrecen, Hungary
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Pavol Masaryk
- Rheumatology, National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - Willem Lems
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Yvo Smulders
- Department of Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Maurizio Cutolo
- Department of Internal Medicine, Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Genova, Italy
| | - Marieke M Ter Wee
- Department of Epidemiology & Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
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Boers M, Hartman L, Opris-Belinski D, Bos R, Kok MR, Da Silva JA, Griep EN, Klaasen R, Allaart CF, Baudoin P, Raterman HG, Szekanecz Z, Buttgereit F, Masaryk P, Klausch LT, Paolino S, Schilder AM, Lems WF, Cutolo M. Low dose, add-on prednisolone in patients with rheumatoid arthritis aged 65+: the pragmatic randomised, double-blind placebo-controlled GLORIA trial. Ann Rheum Dis 2022; 81:925-936. [PMID: 35641125 PMCID: PMC9209692 DOI: 10.1136/annrheumdis-2021-221957] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [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: 12/02/2021] [Accepted: 03/02/2022] [Indexed: 12/12/2022]
Abstract
Background Low-dose glucocorticoid (GC) therapy is widely used in rheumatoid arthritis (RA) but the balance of benefit and harm is still unclear. Methods The GLORIA (Glucocorticoid LOw-dose in RheumatoId Arthritis) pragmatic double-blind randomised trial compared 2 years of prednisolone, 5 mg/day, to placebo in patients aged 65+ with active RA. We allowed all cotreatments except long-term open label GC and minimised exclusion criteria, tailored to seniors. Benefit outcomes included disease activity (disease activity score; DAS28, coprimary) and joint damage (Sharp/van der Heijde, secondary). The other coprimary outcome was harm, expressed as the proportion of patients with ≥1 adverse event (AE) of special interest. Such events comprised serious events, GC-specific events and those causing study discontinuation. Longitudinal models analysed the data, with one-sided testing and 95% confidence limits (95% CL). Results We randomised 451 patients with established RA and mean 2.1 comorbidities, age 72, disease duration 11 years and DAS28 4.5. 79% were on disease-modifying treatment, including 14% on biologics. 63% prednisolone versus 61% placebo patients completed the trial. Discontinuations were for AE (both, 14%), active disease (3 vs 4%) and for other (including covid pandemic-related disease) reasons (19 vs 21%); mean time in study was 19 months. Disease activity was 0.37 points lower on prednisolone (95% CL 0.23, p<0.0001); joint damage progression was 1.7 points lower (95% CL 0.7, p=0.003). 60% versus 49% of patients experienced the harm outcome, adjusted relative risk 1.24 (95% CL 1.04, p=0.02), with the largest contrast in (mostly non-severe) infections. Other GC-specific events were rare. Conclusion Add-on low-dose prednisolone has beneficial long-term effects in senior patients with established RA, with a trade-off of 24% increase in patients with mostly non-severe AE; this suggests a favourable balance of benefit and harm. Trial registration number NCT02585258.
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Affiliation(s)
- Maarten Boers
- Epidemiology & Data Science, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands .,Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Linda Hartman
- Epidemiology & Data Science, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands.,Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Daniela Opris-Belinski
- Rheumatology, Carol Davila University of Medicine and Pharmacy, Romania, Bucharest, Romania
| | - Reinhard Bos
- Rheumatology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Marc R Kok
- Rheumatology and Clinical Immunology, Maasstad Ziekenhuis, Rotterdam, The Netherlands
| | - Jose Ap Da Silva
- Reumatologia, Faculdade de Medicina e Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | | | - Ruth Klaasen
- Rheumatology, Meander Medisch Centrum, Amersfoort, The Netherlands
| | | | - Paul Baudoin
- Rheumatology, Reumazorg Flevoland, Emmeloord, The Netherlands
| | | | - Zoltan Szekanecz
- Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Frank Buttgereit
- Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Berlin, Germany
| | - Pavol Masaryk
- National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - L Thomas Klausch
- Epidemiology & Data Science, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | | | - Willem F Lems
- Rheumatology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
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Ferreira RJO, Welsing PMJ, Jacobs JW, Gossec L, Ndosi M, Machado PM, van der Heijde D, Da Silva JA. Correspondence on 'Re-examining remission definitions in rheumatoid arthritis: considering the 28-joint Disease Activity Score, C reactive protein level and patient global assessment' by Felson et al. Ann Rheum Dis 2022:annrheumdis-2021-221917. [PMID: 35177410 DOI: 10.1136/annrheumdis-2021-221917] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 11/28/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Ricardo J O Ferreira
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Coimbra, Portugal.,Health Sciences Research Unit: Nursing (UICISA: E), Higher School of Nursing of Coimbra, Coimbra, Coimbra, Portugal
| | - Paco M J Welsing
- Department of Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, Utrecht, The Netherlands
| | - Johannes Wg Jacobs
- Rheumatology and Clinical Immunology F02.127, UMC Utrecht, Utrecht, The Netherlands
| | - Laure Gossec
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France.,APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
| | - Mwidimi Ndosi
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Pedro M Machado
- Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, UK.,Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Désirée van der Heijde
- Rheumatology Department, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Jose Ap Da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Coimbra, Portugal .,Clínica Universitária de Reumatologia and i-CBR Coimbra Institute for Clinical and Biological Research, Faculty of Medicine, University of Coimbra, Coimbra, Coimbra, Portugal
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4
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Sivera F, Alunno A, Najm A, Avcin T, Baraliakos X, Bijlsma JW, Badreh S, Burmester G, Cikes N, Da Silva JA, Damjanov N, Dougados M, Dudler J, Edwards CJ, Iagnocco A, Lioté F, Nikiphorou E, van Onna M, Stones SR, Vassilopoulos D, Haines C, Ramiro S. 2019 EULAR points to consider for the assessment of competences in rheumatology specialty training. Ann Rheum Dis 2020; 80:65-70. [PMID: 32788400 DOI: 10.1136/annrheumdis-2020-218015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/23/2020] [Accepted: 07/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Striving for harmonisation of specialty training and excellence of care in rheumatology, the European League Against Rheumatism (EULAR) established a task force to develop points to consider (PtCs) for the assessment of competences during rheumatology specialty training. METHODS A systematic literature review on the performance of methods for the assessment of competences in rheumatology specialty training was conducted. This was followed by focus groups in five selected countries to gather information on assessment practices and priorities. Combining the collected evidence with expert opinion, the PtCs were formulated by the multidisciplinary task force, including rheumatologists, medical educationalists, and people with rheumatic and musculoskeletal diseases. The level of agreement (LoA) for each PtC was anonymously voted online. RESULTS Four overarching principles and 10 PtCs were formulated. The overarching principles highlighted the importance of assessments being closely linked to the rheumatology training programme and protecting sufficient time and resources to ensure effective implementation. In the PtCs, two were related to overall assessment strategy (PtCs 1 and 5); three focused on formative assessment and portfolio (PtCs 2-4); three focused on the assessment of knowledge, skills or professionalism (PtCs 6-8); one focused on trainees at risk of failure (PtC 9); and one focused on training the trainers (PtC 10). The LoA (0-10) ranged from 8.75 to 9.9. CONCLUSION These EULAR PtCs provide European guidance on assessment methods throughout rheumatology training programmes. These can be used to benchmark current practices and to develop future strategies, thereby fostering continuous improvement in rheumatology learning and, ultimately, in patient care.
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Affiliation(s)
- Francisca Sivera
- Department of Clinical Medicine, Miguel Hernandez University of Elche, Elche, Spain .,Department of Rheumatology, Hospital General Universitario Elda, Elda, Spain
| | - Alessia Alunno
- Department of Medicine, Rheumatology Unit, University of Perugia, Perugia, Italy
| | - Aurélie Najm
- INSERM UMR1238, University of Medicine, CHU Nantes, Nantes, France.,Institute of Infection, Immunity and Inflammation, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Xenofon Baraliakos
- Rheumazentrum Ruhrgebiet, Herne, Germany.,Ruhr University Bochum, Bochum, Nordrhein-Westfalen, Germany
| | - Johannes W Bijlsma
- Department of Rheumatology and Clinical Immunology, UMCUtrecht, Utrecht, Netherlands
| | - Sara Badreh
- EULAR Patient Research Partner, Stockholm, Sweden
| | - Gerd Burmester
- Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - Nada Cikes
- Division of Clinical Immunology and Rheumatology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jose Ap Da Silva
- Reumatologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Nemanja Damjanov
- Institute of Rheumatology, University of Belgrade School of Medicine, Belgrade, Serbia
| | - Maxime Dougados
- Rheumatologie B, Hopital Cochin, Paris, Île-de-France, France
| | - Jean Dudler
- Service de Rhumatologie, HFR Fribourg, Hôpital Cantonal, Fribourg, Switzerland
| | - Christopher J Edwards
- Musculoskeletal Research Unit, NIHR Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Annamaria Iagnocco
- Academic Rheumatology Center, Università degli Studi di Torino, Torino, Italy
| | - Frédéric Lioté
- Department of Rhumatologie, Hôpital Lariboisière, Paris, France.,INSERM UMR-1132, University of Paris, Paris, France
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, London, UK
| | - Marloes van Onna
- Department of Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands.,School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | | | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, Athens University School of Medicine, Athens, Greece
| | - Catherine Haines
- Center for Teaching and Learning, University of Oxford, Oxford, UK
| | - Sofia Ramiro
- Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
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