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Harnden K, Di Matteo A, Howell K, Mankia K. Rapid onset pembrolizumab-induced inflammatory arthritis diagnosed using musculoskeletal ultrasound. BMJ Case Rep 2024; 17:e258706. [PMID: 38663895 PMCID: PMC11043772 DOI: 10.1136/bcr-2023-258706] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Immune checkpoint inhibitors have revolutionised the treatment of cancer. While very effective, they commonly cause a wide spectrum of immune-related adverse events. These immune-related adverse events can be fatal and often have significant effects on quality of life. They therefore require prompt recognition and management. We report the case of a woman presenting with widespread joint pain and stiffness 6 hours after her first pembrolizumab infusion. She had no joint swelling on physical examination but an ultrasound scan revealed widespread musculoskeletal inflammation, confirming the diagnosis of inflammatory arthritis. To the best of our knowledge, this is the fastest reported inflammatory arthritis onset following immune checkpoint inhibitor treatment. It highlights the importance of timely imaging in patients on immune checkpoint inhibitors who present with new non-specific musculoskeletal pain. Her symptoms improved dramatically with intramuscular triamcinolone injection.
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Affiliation(s)
- Kate Harnden
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
| | - Andrea Di Matteo
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Kulveer Mankia
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, West Yorkshire, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Di Matteo A, Mankia K, Garcia-Montoya L, Sharrack S, Duquenne L, Nam JL, Mahler M, Emery P. Utility of testing for third-generation anticyclic citrullinated peptide (anti-CCP3) antibodies in individuals who present with new musculoskeletal symptoms but have a negative second-generation anticyclic citrullinated peptide (anti-CCP2) antibody test. RMD Open 2024; 10:e003927. [PMID: 38599655 PMCID: PMC11015229 DOI: 10.1136/rmdopen-2023-003927] [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] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/22/2024] [Indexed: 04/12/2024] Open
Abstract
OBJECTIVES To investigate the role of third-generation anticyclic citrullinated peptide (anti-CCP3) antibodies in predicting progression to inflammatory arthritis (IA) in individuals with new musculoskeletal (MSK) symptoms and a negative second-generation anti-CCP antibody test (anti-CCP2-). METHODS 469 anti-CCP2- individuals underwent baseline anti-CCP3 testing (QUANTA Lite CCP3; Inova Diagnostics) and received a post enrolment 12-month questionnaire. A rheumatologist confirmed or excluded diagnosis of IA. Univariable/multivariable analyses were performed to assess the value of anti-CCP3 in predicting IA development in these anti-CCP2- individuals. RESULTS Only 16/469 (3.4%) anti-CCP2- individuals had a positive anti-CCP3 test. Of these 16 individuals, 4 developed IA. In addition, 61/469 (13.0%) anti-CCP2- individuals self-reported, to have developed, IA. Progression was confirmed in 43/61 of them (70.5%); of whom 30/43 (69.8%) and 13/43 (30.2%) were given a diagnosis of IA and rheumatoid arthritis (RA), respectively. In qualitative univariable analysis, anti-CCP3 positivity was associated with self-reported progression (p<0.01) and IA (p=0.03), but not with RA. Anti-CCP3 levels differed significantly between progressors and non-progressors (p<0.01) for all three categories. At the manufacturer's cut-off, OR for progression ranged from 2.4 (95% CI 0.5 to 18.6; RA) to 7.5 (95% CI 2.3 to 24.0; self-reported progression). Interestingly, when cut-offs for anti-CCP3 were optimised, lower values (≥5 units) significantly increased the OR for progression in all three categories. In multivariable analysis, anti-CCP3 positivity at the manufacturer's cut-off did not remain associated with IA progression, while this lower cut-off value (≥5 units) was associated with diagnosis of RA (p=0.02). CONCLUSIONS Anti-CCP3 testing could improve the prediction of IA development in anti-CCP2- individuals with new MSK symptoms.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sana Sharrack
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Michael Mahler
- Werfen Autoimmunity Technology Center, San Diego, California, USA
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Disease, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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David P, Di Matteo A, Hen O, Dass S, Marzo-Ortega H, Wakefield RJ, Bissell LA, Nam J, Mankia K, Emery P, Saleem B, McGonagle D. Poly-Refractory Rheumatoid Arthritis: An Uncommon Subset of Difficult to Treat Disease With Distinct Inflammatory and Noninflammatory Phenotypes. Arthritis Rheumatol 2024; 76:510-521. [PMID: 38059326 DOI: 10.1002/art.42767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/09/2023] [Accepted: 11/27/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE To investigate the prevalence of poly-refractory rheumatoid arthritis (RA) defined as failure of all biological (b)/targeted synthetic (ts)-disease-modifying drugs (DMARDs). To further investigate whether patients with persistent inflammatory refractory RA (PIRRA) and noninflammatory refractory RA (NIRRA), determined by objective ultrasound (US) synovitis, have distinct clinical phenotypes in both EULAR difficult-to-treat RA (D2T-RA) and poly-refractory RA groups. METHODS A cross-sectional study of 1,591 patients with RA on b/tsDMARDs that evaluated D2T-RA criteria and subclassified as poly-refractory if inefficacy/toxicity to at least one drug of all classes. PIRRA was defined if US synovitis in one or more swollen joint and NIRRA if absent. Univariate tests and multivariate logistic regression were conducted to investigate factors associated with poly-refractory, PIRRA, and NIRRA phenotypes. RESULTS 122 of 1,591 were excluded due to missing data. 247 of 1,469 (16.8%) had D2T-RA and only 40 of 1,469 (2.7%) poly-refractory RA. This latter group had higher disease activity score 28 C-reactive protein (CRP) (median 5.4 vs 5.02, P < 0.05), CRP levels (median 13 vs 5 mg/l, P < 0.01), and smoking (ever) rates (20% vs 4%, P < 0.01) compared with other D2T patients. Smoking was associated with poly-refractory RA (odds ratio 5.067, 95% CI 1.774-14.472, P = 0.002). Of 107 patients with D2T-RA with recent US, 61 (57%) were PIRRA and 46 (43%), NIRRA. Patients with NIRRA had elevated body mass index (median 30 vs 26, P < 0.001) and higher fibromyalgia prevalence (15% vs 3%, P < 0.05), lower swollen joint count (median: 2 vs 5, P < 0.001), and lower CRP levels (5 vs 10, P < 0.01). CONCLUSION Only 2.7% of D2T-RA failed all classes of b/tsDMARDs. Among D2T-RA, less than 60% had objective signs of inflammation, representing a target for innovative strategies.
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Affiliation(s)
- Paula David
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, United Kingdom
- Sheba Medical Center- Tel Hashomer, Ramat Gan, Israel
| | - Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Or Hen
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, United Kingdom
- Sheba Medical Center- Tel Hashomer, Ramat Gan, Israel
| | - Shouvik Dass
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Helena Marzo-Ortega
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - Jacqueline Nam
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Benazir Saleem
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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Chapman LS, Siddle HJ, Serban S, Mankia K, Rooney CM, Mustufvi Z, Pini S, Vinall-Collier K. 'What is my risk really?': a qualitative exploration of preventive interventions among individuals at risk of rheumatoid arthritis. Rheumatol Adv Pract 2024; 8:rkae023. [PMID: 38495430 PMCID: PMC10939459 DOI: 10.1093/rap/rkae023] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/05/2024] [Indexed: 03/19/2024] Open
Abstract
Objectives Intervention in the pre-arthritis phase of RA could prevent or delay the onset of disease. The primary aim of this study was to explore perspectives of being at risk and potential preventive interventions among individuals at risk of developing RA and to identify factors influencing their engagement with prevention. A secondary aim, established during the analytical process, was to understand and compare different approaches to health-related behaviours related to prevention of RA. Methods Anti-CCP-positive (CCP+) at-risk individuals with musculoskeletal symptoms but no synovitis participated in semi-structured interviews. Data were analysed using reflexive thematic analysis, followed by a secondary ideal-type analysis. Results Nineteen CCP+ at-risk individuals (10 women; age range 35-70 years) participated. Three overarching themes were identified: being CCP+ at risk; aiming to prevent RA; and influencers of engagement. Participants described distress related to symptoms and uncertainty about disease progression. Many participants had concerns about medication side effects. In contrast, most participants expressed willingness to make lifestyle changes with the aim of preventing RA. Engagement with preventive measures was influenced by symptom severity, personal risk level, co-morbidities, experiences of taking other medications/supplements, knowledge of RA, risk factors and medications, and perceived effort. Three types of participants were identified from the data: proactive preventers, change considerers and fearful avoiders. Overall orientation to health behaviours also impacted the attitude towards preventing RA. Conclusion Findings could inform recruitment and retention in RA prevention research and promote uptake of preventive interventions in clinical practice.
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Affiliation(s)
- Lara S Chapman
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Stefan Serban
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | | | | | - Simon Pini
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Gul H, Di Matteo A, Anioke I, Shuweidhi F, Mankia K, Ponchel F, Emery P. Predicting Flare in Patients With Rheumatoid Arthritis in Biologic Induced Remission, on Tapering, and on Stable Therapy. ACR Open Rheumatol 2024. [PMID: 38411023 DOI: 10.1002/acr2.11656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 01/02/2024] [Accepted: 01/11/2024] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVE The tapering of biologic disease-modifying antirheumatic drug (b-DMARD) therapy for patients with rheumatoid arthritis (RA) in stable remission is frequently undertaken, but specific guidance on how to successfully taper is lacking. The objective of this study is to identify predictors of flare in patients in stable b-DMARD-induced clinical remission, who did or did not follow structured b-DMARD tapering. METHODS Patients with RA receiving b-DMARD treatment who had achieved sustained remission according to a Disease Activity Score in 28 joints using the C-reactive protein level (DAS28-CRP) <2.6 for ≥6 months were offered tapering. Clinical, ultrasound (US) (total power Doppler [PD]/grayscale abnormalities), CD4+ T cell subsets, and patient-reported outcomes (PROs) were collected at inclusion. The primary endpoint was the occurrence of flare (loss of DAS28-CRP remission) over 12 months. Logistic regression analyses identified predictors of flare. Dichotomization into high/low-risk groups was based on 80% specificity using the area under the receiving operator curve (AUROC). RESULTS Of 63 patients choosing tapering, 23 (37%) flared compared with 12 of 60 (20%) on stable treatment (P = 0.043). All patients who flared regained remission upon reinstating treatment. In the tapering group, flare was associated with lower regulatory T cell (Treg) (P < 0.0001) and higher CRP levels (P < 0.0001), erythrocyte sedimentation rate (P < 0.035), and inflammation-related cells (IRCs) (P = 0.054); stepwise modeling selected Tregs (odds ratio [OR] = 0.350, P = 0.004), IRCs (OR = 1.871, P = 0.007), and CRP level (OR = 1.577, P = 0.004) with 81.7% accuracy and AUROC = 0.890. In the continued therapy group, modeling retained the tender joint count, total PD, and visual analog scale pain score, with 82.1% accuracy and AUROC = 0.899. Most patients in the study were considered low risk of flare (80 of 123 patients [65%]). Only 5 of 37 (13.5%) of the low-risk patients who tapered flared, which was notable compared with the continued therapy group (20% flare). CONCLUSION Flare on tapering b-DMARDs was predicted by lower Tregs and elevated inflammation biomarkers (IRCs/CRP level); flare on continued b-DMARDs was associated with raised pain parameters and US inflammation. Knowledge of these biomarkers should improve outcomes by targeted selection for tapering, and by increased monitoring of those on continued therapy predicted to flare.
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Affiliation(s)
| | - Andrea Di Matteo
- University of Leeds and National Institute for Health and Care Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Kulveer Mankia
- University of Leeds and National Institute for Health and Care Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Paul Emery
- University of Leeds and National Institute for Health and Care Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Hemgren C, Martinsson K, Rooney C, Wetterö J, Mankia K, Emery P, Kastbom A. Elevated Serum Levels of Zonulin Family Peptides in Anticitrullinated Protein Antibody-Positive At-Risk Individuals Without Arthritis. J Rheumatol 2024; 51:134-138. [PMID: 38302186 DOI: 10.3899/jrheum.2023-0160] [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] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Recent advances imply that early events triggering rheumatoid arthritis (RA) occur at mucosal surfaces. We aimed to evaluate whether intestinal permeability is altered in patients at increased risk of RA, and/or predicts the development of clinical arthritis, by measuring serum zonulin family peptides (ZFP) levels, which are shown to reflect intestinal barrier integrity. METHODS Two independent prospective observational cohorts were studied, including subjects with musculoskeletal symptoms and anticitrullinated protein antibodies (ACPA), but without clinical arthritis at baseline. In Sweden, 82 such at-risk patients were compared to 100 age-matched healthy blood donors. In the UK, 307 at-risk patients were compared to 100 ACPA-negative symptomatic controls. ZFP was measured in baseline sera by enzyme-linked immunoassays. RESULTS In the Swedish at-risk cohort, ZFP levels were significantly increased in patients compared to controls (mean 41.4 vs 33.6 ng/mL, P < 0.001) and Cox regression analysis showed prognostic value of ZFP for arthritis development (hazard ratio [HZ] 1.04 per ng/mL ZFP increase, 95% CI 1.01-1.07, P = 0.02). Elevated ZFP levels among ACPA-positive at-risk patients compared to symptomatic ACPA-negative controls were confirmed in the UK at-risk cohort (mean 69.7 vs 36.0 ng/mL, P < 0.001), but baseline ZFP were not associated with arthritis development (HR 1.00 per ng/mL ZFP increase, 95% CI 1.00-1.01, P = 0.30). CONCLUSION Serum ZFP levels are elevated in ACPA-positive at-risk patients when compared to both healthy blood donors and symptomatic ACPA-negative controls. Thus, gut barrier function may be of importance in RA-associated autoimmunity. A possible prognostic value of serum ZFP merits further investigation, preferably in larger prospective cohorts.
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Affiliation(s)
- Cecilia Hemgren
- C. Hemgren, MD, Department of Internal Medicine, Division of Rheumatology, Ryhov Hospital, Jönköping, Sweden;
| | - Klara Martinsson
- K. Martinsson, PhD, J. Wetterö, PhD, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Christopher Rooney
- C. Rooney, MD, K. Mankia, MD, PhD, P. Emery, MD, PhD, Leeds NIHR Biomedical Research Centre, LTHT, and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Jonas Wetterö
- K. Martinsson, PhD, J. Wetterö, PhD, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kulveer Mankia
- C. Rooney, MD, K. Mankia, MD, PhD, P. Emery, MD, PhD, Leeds NIHR Biomedical Research Centre, LTHT, and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Paul Emery
- C. Rooney, MD, K. Mankia, MD, PhD, P. Emery, MD, PhD, Leeds NIHR Biomedical Research Centre, LTHT, and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Alf Kastbom
- A. Kastbom, MD, PhD, Department of Biomedical and Clinical Sciences, Linköping University, and Department of Rheumatology, Linköping University Hospital, Linköping, Sweden
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Garcia-Montoya L, Kang J, Duquenne L, Di Matteo A, Nam JL, Harnden K, Chowdhury R, Mankia K, Emery P. Factors associated with resolution of ultrasound subclinical synovitis in anti-CCP-positive individuals with musculoskeletal symptoms: a UK prospective cohort study. Lancet Rheumatol 2024; 6:e72-e80. [PMID: 38267105 DOI: 10.1016/s2665-9913(23)00305-3] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Subclinical synovitis occurs in a third of individuals at risk of rheumatoid arthritis. The objective of this study was to assess the reversibility of subclinical synovitis in individuals at risk of rheumatoid arthritis who are positive for anti-cyclic citrullinated peptide (CCP) antibody with musculoskeletal symptoms and investigate factors associated with its resolution within 12 months. METHODS We conducted a single-centre, prospective, cohort study in the UK, recruiting individuals aged 18 years or older who were anti-CCP-positive with a new non-specific musculoskeletal symptom but no clinical synovitis. Referrals were made through primary or secondary care. Participants attended a baseline visit, which included a clinical assessment, blood tests, patient questionnaires, and a musculoskeletal ultrasound scan (ie, of wrists and metacarpophalangeal, proximal interphalangeal, and metatarsophalangeal joints), and then follow-up visits every 3 months for the first year, with a repeat ultrasound scan every 12 months. Participants with subclinical synovitis (ie, grey scale ≥1 and power Doppler ≥1) in at least one joint at baseline were selected for this analysis. Investigation of good prognostic factors by 12 months was done first using univariable analysis to identify significant factors in participants with no missing data. Then receiver operating characteristic (ROC) curves were used to establish the optimal cutoffs for significant continuous variables. Finally, a modified Poisson regression approach was performed to identify the best prediction model and was adjusted for confounders, using data from all participants, with missing values imputed. This study is registered with ClinicalTrials.gov, NCT02012764. FINDINGS Between June 30, 2008, and Feb 24, 2020, 451 participants consented to participate in the CCP study and 122 (27%) individuals had subclinical synovitis at baseline, of whom 90 (74%) had data available at 12 months. Mean age was 54·1 years (SD 12·5), and 63 (70%) of 90 participants were women and 27 (30%) were men. Subclinical synovitis resolved in 43 (48%) of 90 participants, whereas subclinical synovitis persisted in 47 (52%) participants, 27 (57%) of whom developed clinical synovitis within 12 months. In the multivariable analysis, low anti-CCP titre (relative risk [RR] 1·52, 95% CI 1·04-2·22), negative rheumatoid factor (1·54, 0·92-2·58), subclinical synovitis in only one joint (1·62, 1·04-2·50), and an erythrocyte sedimentation rate of 15 mm/h or lower (1·82, 1·15-2·87) were predictors of subclinical synovitis resolution within 12 months (ie, good prognostic factors). ROC curve showed an area under the curve of 0·84 (95% CI 0·76-0·92; p<0·0001). Resolution occurred in seven (100%) of seven participants with all four factors present, and in only one (7%) of 14 participants with none of the factors present. INTERPRETATION In individuals who were anti-CCP-positive, subclinical synovitis disappeared in approximately half of the participants by 12 months and was associated with the presence of good prognostic factors. Subclinical synovitis should be interpreted in the context of these additional factors. FUNDING National Institute for Health Research Leeds Biomedical Research Centre.
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Affiliation(s)
- Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Rotherham General Hospital, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Jing Kang
- School of Dentistry, University of Leeds, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Harnden
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rahaymin Chowdhury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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8
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Di Matteo A, De Lorenzis E, Duquenne L, Nam JL, Leticia GM, Harnden K, Chowdhury R, Wakefield RJ, Emery P, Mankia K. Ultrasound in anti-CCP+ at-risk individuals without clinical synovitis: development of a novel 6-joint protocol for feasible risk prediction. Rheumatology (Oxford) 2023:kead570. [PMID: 37934127 DOI: 10.1093/rheumatology/kead570] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/05/2023] [Accepted: 10/14/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVES To investigate, in anti-cyclic citrullinated peptide antibody positive individuals with musculoskeletal symptoms but no clinical synovitis (CCP+ at-risk), the additional value of ultrasound (US) for the prediction of inflammatory arthritis (IA). Furthermore, to define a concise US protocol for feasible risk prediction. METHODS Demographic and clinical data were collected in 417 CCP+ at-risk (Leeds CCP cohort) with a baseline US scan assessing synovitis and bone erosions in 36 joints, and a follow-up duration ≥24 months. Multivariable binary regression models for IA development at 24 months evaluated routine clinical variables associated with IA alone ("clinical" model) and combined with a 36-joint US scanning protocol ("clinical-US extended" model). A "clinical-US short" model was developed. RESULTS At 24 months, 92/417 (22.1%) CCP+ at-risk developed IA (median time: 7 months, IQR : 3-12). The "clinical-US extended" model performed better than the "clinical" model (AUC 0.788 vs AUC 0.731 respectively, p< 0.001) with an odds ratio for IA development of 3.18 (95% IC 1.80-5.63) for US synovitis and 2.54 (95% IC 1.21-5.37) for bone erosions. The "clinical-US short" model, which retained the wrists, knees and MTP5 joints, performed better (AUC 0.782) than the "clinical" model (p< 0.001) and similarly (difference in Akaike information criteria <2) to the "clinical-US extended" model. CONCLUSIONS US provides valuable information for predicting progression to IA in CCP+ individuals both alone and in addition to clinical variables. US synovitis was associated with a threefold increase risk of IA development. A concise US protocol of 6 joints provides clinically feasible risk prediction in CCP+ at-risk.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enrico De Lorenzis
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino-Gemelli IRCSS, Rome, Italy
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Garcia-Montoya Leticia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Harnden
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rahaymin Chowdhury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Anioke I, Duquenne L, Parmar R, Mankia K, Shuweihdi F, Emery P, Ponchel F. Lymphocyte subset phenotyping for the prediction of progression to inflammatory arthritis in anti-citrullinated-peptide antibody-positive at-risk individuals. Rheumatology (Oxford) 2023:kead466. [PMID: 37676828 DOI: 10.1093/rheumatology/kead466] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/09/2023] Open
Abstract
OBJECTIVES Inflammatory arthritis (IA) is considered the last stage of a disease continuum, where features of systemic autoimmunity can appear years before clinical synovitis. Time to progression to IA varies considerably between at-risk individuals, therefore the identification of biomarkers predictive of progression is of major importance. We previously reported on the value of three CD4+T-cell subsets as biomarkers of progression. Here, we aim to establish the value of 18 lymphocyte subsets (LS) for predicting progression to IA. METHODS Participants were recruited based on a new musculoskeletal complaint and being positive for anti-citrullinated-peptide Antibody. Progression (over 10 years) was defined as the development of clinical synovitis. LS analysis was performed for lymphocyte lineages, naïve/memory subsets, inflammation-related cells (IRC), and regulatory cells (Treg/B-reg). Modelling used Logistic/Cox regressions. RESULTS Of 210 patients included, 93 (44%) progressed to IA, 41/93 (44%) within 12 months (rapid progressors). 5/18 LS were associated with progression (Treg/CD4-naïve/IRC (adjusted p < 0.0001), CD8 (p = 0.021), B-reg (p = 0.015)) and 3 trends (NK-cells/memory-B-cells/plasmablasts).Unsupervised hierarchical clustering using these 8 subsets segregated 3 clusters of patients, one cluster being enriched (63/109(58%)) and one poor (10/45(22%)) in progressors.Combining all clinical and LS variables, forward logistic regression predicted progression with accuracy=85.7% and AUC=0.911, selecting smoking/Rheumatoid-Factor/HLA-Shared-Epitope/Tender-Joint-Count-78 and Treg/CD4-naive/CD8/NK-cells/B-reg/plasmablasts.To predict rapid progression, a Cox regression was performed resulting in a model combining smoking/rheumatoid factor and IRC/CD4-naïve/Treg/NK-cells/CD8+T-cells (AUC=0.794). CONCLUSION Overall, progression was predicted by specific LS, suggesting potential triggers for events leading to the development of IA, while rapid progression was associated with a different set of subsets.
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Affiliation(s)
- Innocent Anioke
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Department of Medical Laboratory Sciences, University of Nigeria, Nigeria
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rekha Parmar
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Farag Shuweihdi
- Leeds Institute of Health Sciences. University of Leeds, School of Medicine
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Frederique Ponchel
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Martinsson K, Di Matteo A, Öhman C, Johansson A, Svärd A, Mankia K, Emery P, Kastbom A. Antibodies to leukotoxin A from the periodontal pathogen Aggregatibacter actinomycetemcomitans in patients at an increased risk of rheumatoid arthritis. Front Med (Lausanne) 2023; 10:1176165. [PMID: 37601773 PMCID: PMC10435988 DOI: 10.3389/fmed.2023.1176165] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/10/2023] [Indexed: 08/22/2023] Open
Abstract
Objectives Periodontitis and underlying bacteria have been linked to the development of rheumatoid arthritis (RA). One suggested pathogen is Aggregatibacter actinomycetemcomitans (A.a.), which expresses leukotoxin A (LtxA) that can citrullinate human proteins, providing a possible trigger for the production of anti-citrullinated protein antibodies (ACPA). In this study, we seek to determine the presence of antibodies toward LtxA in patients at risk of developing RA. Methods Two prospective observational patient cohorts (one Swedish and one British) with symptomatic at-risk patients were studied. Anti-LtxA antibodies were analyzed by a cell-based neutralization assay in baseline serum and compared to 100 Swedish blood donors that served as controls. Results Serum anti-LtxA levels or positivity did not differ between patients and blood donors. In the British cohort, anti-LtxA was more prevalent among ACPA-positive arthralgia patients compared with ACPA-negative arthralgia cases (24% vs. 13%, p < 0.0001). In the Swedish at-risk cohort, anti-LtxA positive patients were at increased risk of progression to arthritis (hazard ratio (HR) 2.10, 95% CI 1.04-4.20), but this was not confirmed in the UK at-risk cohort (HR 0.99, CI 0.60-1.65). Conclusion Serum anti-LtxA is not elevated before RA diagnosis, and associations with disease progression and ACPA levels differ between populations. Other features of the oral microbiome should be explored in upcoming periodontitis-related RA research.
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Affiliation(s)
- Klara Martinsson
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Andrea Di Matteo
- Leeds Musculoskeletal Biomedical Research Unit, LTHT and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Carina Öhman
- Department of Odontology, Umeå University, Umeå, Sweden
| | | | - Anna Svärd
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Center for Clinical Research Dalarna, Uppsala University, Uppsala, Sweden
| | - Kulveer Mankia
- Leeds Musculoskeletal Biomedical Research Unit, LTHT and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Paul Emery
- Leeds Musculoskeletal Biomedical Research Unit, LTHT and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Alf Kastbom
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Rheumatology, Linköping University Hospital, Linköping, Sweden
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11
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Duquenne L, Hensor EM, Wilson M, Garcia-Montoya L, Nam JL, Wu J, Harnden K, Anioke IC, Di Matteo A, Chowdhury R, Sidhu N, Ponchel F, Mankia K, Emery P. Predicting Inflammatory Arthritis in At-Risk Persons: Development of Scores for Risk Stratification. Ann Intern Med 2023; 176:1027-1036. [PMID: 37523695 DOI: 10.7326/m23-0272] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Inflammatory arthritis (IA) is an immune-related condition defined by the presence of clinical synovitis. Its most common form is rheumatoid arthritis. OBJECTIVE To develop scores for predicting IA in at-risk persons using multidimensional biomarkers. DESIGN Prospective observational cohort study. SETTING Single-center, Leeds, United Kingdom. PARTICIPANTS Persons with new musculoskeletal symptoms, a positive test result for anticitrullinated protein antibodies, and no clinical synovitis and followed for 48 weeks or more or until IA occurred. MEASUREMENTS A simple score was developed using logistic regression, and a comprehensive score was developed using the least absolute shrinkage and selection operator Cox proportional hazards regression. Internal validation with bootstrapping was estimated, and a decision curve analysis was done. RESULTS Of 455 participants, 32.5% (148 of 455) developed IA, and 15.4% (70 of 455) developed it within 1 year. The simple score identified 249 low-risk participants with a false negative rate of 5% (and 206 high-risk participants with a false-positive rate of 72%). The comprehensive score identified 119 high-risk participants with a false-positive rate of 29% (and 336 low-risk participants with a false-negative rate of 19%); 40% of high-risk participants developed IA within 1 year and 71% within 5 years. LIMITATIONS External validation is required. Recruitment occurred over 13 years, with lower rates of IA in later years. There was geographic variation in laboratory testing and recruitment availability. CONCLUSION The simple score identified persons at low risk for IA who were less likely to need secondary care. The comprehensive score identified high-risk persons who could benefit from risk stratification and preventive measures. Both scores may be useful in clinical care and should also be useful in clinical trials. PRIMARY FUNDING SOURCE National Institute for Health and Care Research Leeds Biomedical Research Centre.
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Affiliation(s)
- Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Elizabeth M Hensor
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Michelle Wilson
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Jianhua Wu
- Leeds Institute for Data Analytics, University of Leeds, Leeds, and Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom (J.W.)
| | - Kate Harnden
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Innocent Chidi Anioke
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom, and Department of Medical Laboratory Sciences, University of Nigeria, Nigeria (I.C.A.)
| | - Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Rahaymin Chowdhury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Navkiran Sidhu
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Frederique Ponchel
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom (F.P.)
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds, United Kingdom (L.D., E.M.H., M.W., L.G., J.L.N., K.H., A.D.M., R.C., N.S., K.M., P.E.)
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12
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Topiwala A, Mankia K, Bell S, Webb A, Ebmeier KP, Howard I, Wang C, Alfaro-Almagro F, Miller K, Burgess S, Smith S, Nichols TE. Association of gout with brain reserve and vulnerability to neurodegenerative disease. Nat Commun 2023; 14:2844. [PMID: 37202397 PMCID: PMC10195870 DOI: 10.1038/s41467-023-38602-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 12/12/2022] [Accepted: 05/09/2023] [Indexed: 05/20/2023] Open
Abstract
Studies of neurodegenerative disease risk in gout are contradictory. Relationships with neuroimaging markers of brain structure, which may offer insights, are uncertain. Here we investigated associations between gout, brain structure, and neurodegenerative disease incidence. Gout patients had smaller global and regional brain volumes and markers of higher brain iron, using both observational and genetic approaches. Participants with gout also had higher incidence of all-cause dementia, Parkinson's disease, and probable essential tremor. Risks were strongly time dependent, whereby associations with incident dementia were highest in the first 3 years after gout diagnosis. These findings suggest gout is causally related to several measures of brain structure. Lower brain reserve amongst gout patients may explain their higher vulnerability to multiple neurodegenerative diseases. Motor and cognitive impairments may affect gout patients, particularly in early years after diagnosis.
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Affiliation(s)
- Anya Topiwala
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK.
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Steven Bell
- Department of Clinical Neurosciences, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Alastair Webb
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Klaus P Ebmeier
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Isobel Howard
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
| | - Chaoyue Wang
- Wellcome Centre for Integrative Neuroimaging (WIN FMRIB), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- SJTU-Ruijin-UIH Institute for Medical Imaging Technology, Shanghai, China
| | - Fidel Alfaro-Almagro
- Wellcome Centre for Integrative Neuroimaging (WIN FMRIB), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Karla Miller
- Wellcome Centre for Integrative Neuroimaging (WIN FMRIB), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Stephen Burgess
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Smith
- Wellcome Centre for Integrative Neuroimaging (WIN FMRIB), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Thomas E Nichols
- Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK
- Wellcome Centre for Integrative Neuroimaging (WIN FMRIB), Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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13
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Chapman LS, Vinall-Collier K, Siddle HJ, Mustufvi Z, Mankia K, Serban S. 'It surprised me a lot that there is a link': a qualitative study of the acceptability of periodontal treatment for individuals at risk of rheumatoid arthritis. RMD Open 2023; 9:rmdopen-2023-003099. [PMID: 37156573 PMCID: PMC10174022 DOI: 10.1136/rmdopen-2023-003099] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/06/2023] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVES Current evidence suggests that periodontal disease could be a causal risk factor for rheumatoid arthritis (RA) onset and progression. Earlier periodontal intervention in individuals at risk of RA could provide a unique opportunity to prevent or delay the onset of RA. This study aimed to explore the acceptability of periodontal treatment as a measure to potentially prevent RA among at-risk individuals and healthcare professionals. METHODS Semistructured interviews were conducted with anti-CCP positive at-risk individuals (CCP+ at risk) and a range of healthcare professionals. At-risk participant data were analysed using reflexive thematic analysis; subsequent coding of healthcare professional data was deductive, based on a preidentified set of constructs. RESULTS Nineteen CCP+ at-risk and 11 healthcare professionals participated. Three themes (six subthemes) were identified: (1) understanding risk (knowledge of shared at-risk factors; information and communication); (2) oral health perceptions and experiences (personal challenges and opportunities for dental intervention and oral health maintenance; external barriers) and (3) oral health treatment and maintenance (making oral health changes with the aim of preventing RA; acceptability of participation in periodontal research). CONCLUSIONS Periodontal disease is common in individuals at risk of RA, but the impact of poor oral health may not be well understood. Oral health information should be tailored to the individual. CCP+ at-risk participants and healthcare professionals identified seeking dental treatment can be hindered by dental phobia, treatment costs or inability to access dentists. While CCP+ at-risk individuals may be reluctant to take preventive medications, a clinical trial involving preventive periodontal treatment is potentially acceptable.
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Affiliation(s)
- Lara S Chapman
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Karen Vinall-Collier
- Department of Dental Public Health, School of Dentistry, University of Leeds, Leeds, UK
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Zhain Mustufvi
- Department of Dental Public Health, School of Dentistry, University of Leeds, Leeds, UK
| | - K Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Stefan Serban
- Department of Dental Public Health, School of Dentistry, University of Leeds, Leeds, UK
- Public Health Directorate, NHS England North West Region, Manchester, UK
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Siddle HJ, Bradley SH, Anderson AM, Mankia K, Emery P, Richards SH. Opportunities and challenges in early diagnosis of rheumatoid arthritis in general practice. Br J Gen Pract 2023; 73:152-154. [PMID: 36997210 PMCID: PMC10049595 DOI: 10.3399/bjgp23x732321] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Affiliation(s)
- Heidi J Siddle
- Health Education England (HEE)/National Institute for Health and Care Research (NIHR) Senior Clinical Lecturer, Associate Professor, and Consultant Podiatrist, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | | | - Anna M Anderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds; Consultant Rheumatologist, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds; Consultant Rheumatologist, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Suzanne H Richards
- Professor of Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds
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15
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Gul HL, Di Matteo A, Mankia K, Wu J, Ponchel F, Emery P. Can biomarkers predict successful tapering of conventional disease-modifying therapy in rheumatoid arthritis patients in stable remission? Clin Exp Rheumatol 2023; 41:126-136. [PMID: 35699062 DOI: 10.55563/clinexprheumatol/m7ljv8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/19/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Specific guidelines for managing RA patients in clinical remission for ≥6 months on cs-DMARDs are lacking. Tapering of treatment is encouraged, however, without validated biomarkers for success. We aimed to assess the rate of sustained remission after 12 months in patients who either (i) followed structured cs-DMARD tapering or (ii) continued therapy, focusing on the added value of biomarkers as predictors of outcome. METHODS RA patients fulfilling 3v-DAS28CRP<2.6 for ≥6 months on stable cs-DMARD therapy were included. Patients were offered structured tapering, with 117 accepting tapering and 83 continuing therapy. Clinical, ultrasound, immunological (T-cell subsets) and patient-reported outcome (PRO) data were collected. The primary endpoint was the proportion of patients in sustained remission without relapse after 12 months. Regression analyses were used to identify predictors of sustained remission. RESULTS Of those who tapered, 64% remained in clinical remission after 12 months compared with 80% (p=0.018) of patients on stable treatment. In the tapering group, higher levels of CRP, TJC, % inflammation-related T-cell (IRC) and PROs were associated with flare (all p<0.05), with a trend for total PD (p=0.066). A model predicting sustained remission retained RAQoL, total PD and IRC (85% accuracy, AUROC=0.893, p<0.0001). In the non-tapering group, higher CRP, ESR, SJC and shorter disease duration (all p<0.05) were associated with flare, with no parameter able to predict sustained remission. CONCLUSIONS In the tapering group, the combination of clinical, PRO, US and T-cell parameters demonstrated added value for predicting sustained remission compared with clinical parameters alone. These data may inform best tapering practice.
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Affiliation(s)
- Hanna L Gul
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK
| | - Jianhua Wu
- Leeds Dental Institute, The University of Leeds, UK
| | - Frederique Ponchel
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, UK.
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Ponchel F, Duquenne L, Xie X, Corscadden D, Shuweihdi F, Mankia K, Trouw LA, Emery P. Added value of multiple autoantibody testing for predicting progression to inflammatory arthritis in at-risk individuals. RMD Open 2022; 8:rmdopen-2022-002512. [PMID: 36535711 PMCID: PMC9764647 DOI: 10.1136/rmdopen-2022-002512] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/22/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Predicting progression to clinical arthritis in individuals at-risk of developing rheumatoid arthritis is a prerequisite to developing stratification groups for prevention strategies. Selecting accurate predictive criteria is the critical step to define the population at-risk. While positivity for anti-citrullinated protein antibodies (ACPA) remains the main recruitment biomarker, positivity for other autoantibodies (AutoAbs) identified before the onset of symptoms, may provide additional predictive accuracy for stratification. OBJECTIVE To perform a multiple AutoAbs analysis for both the prediction and the time of progression to inflammatory arthritis (IA). METHODS 392 individuals were recruited based on a new musculoskeletal complaint and positivity for ACPA or rheumatoid factor (RF). ELISAs were performed for ACPA, RF, anti-nuclear Ab, anti-carbamylated protein (anti-CarP) and anti-collagen AutoAbs. Logistic and COX regression were used for analysis. RESULTS Progression to IA was observed in 125/392 (32%) of cases, of which 78 progressed within 12 months. The AutoAbs ACPA, RF, anti-CarP were individually associated with progression (p<0.0001) and improved prediction when combined with demographic/clinical data (Accuracy >77%; area under the curve (AUC) >0.789), compared with prediction using only demographic/clinical data (72.9%, AUC=0.760). Multiple AutoAbs testing provided added value, with +6.4% accuracy for number of positive AutoAbs (AUC=0.852); +5.4% accuracy for AutoAbs levels (ACPA/anti-CarP, AUC=0.832); and +6.2% accuracy for risk-groups based on high/low levels (ACPA/RF/anti-CarP, AUC=0.837). Time to imminent progression was best predicted using ACPA/anti-CarP levels (AUC=0.779), while the number of positive AutoAbs was/status/risk were as good (AUC=0.778). CONCLUSION We confirm added value of multiple AutoAbs testing for identifying progressors to clinical disease, allowing more specific stratification for intervention studies.
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Affiliation(s)
- Frederique Ponchel
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Xuanxiao Xie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Diane Corscadden
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Farag Shuweihdi
- Leeds Institute of Health Sciences, Faculty of Medicine, University of Leeds, Leeds, UK
| | - K Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - L A Trouw
- Department of Immunology, Leiden University Medical Center, Leiden, Netherlands
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK,Leeds NIHR Biomedical Research Centre, Leeds Teaching Hospitals Trust, Leeds, UK
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Taylor CA, Watson RA, Tong O, Ye W, Nassiri I, Gilchrist JJ, de Los Aires AV, Sharma PK, Koturan S, Cooper RA, Woodcock VK, Jungkurth E, Shine B, Coupe N, Payne MJ, Church DN, Naranbhai V, Groha S, Emery P, Mankia K, Freedman ML, Choueiri TK, Middleton MR, Gusev A, Fairfax BP. IL7 genetic variation and toxicity to immune checkpoint blockade in patients with melanoma. Nat Med 2022; 28:2592-2600. [PMID: 36526722 PMCID: PMC9800275 DOI: 10.1038/s41591-022-02095-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 10/18/2022] [Indexed: 12/23/2022]
Abstract
Treatment with immune checkpoint blockade (ICB) frequently triggers immune-related adverse events (irAEs), causing considerable morbidity. In 214 patients receiving ICB for melanoma, we observed increased severe irAE risk in minor allele carriers of rs16906115, intronic to IL7. We found that rs16906115 forms a B cell-specific expression quantitative trait locus (eQTL) to IL7 in patients. Patients carrying the risk allele demonstrate increased pre-treatment B cell IL7 expression, which independently associates with irAE risk, divergent immunoglobulin expression and more B cell receptor mutations. Consistent with the role of IL-7 in T cell development, risk allele carriers have distinct ICB-induced CD8+ T cell subset responses, skewing of T cell clonality and greater proportional repertoire occupancy by large clones. Finally, analysis of TCGA data suggests that risk allele carriers independently have improved melanoma survival. These observations highlight key roles for B cells and IL-7 in both ICB response and toxicity and clinical outcomes in melanoma.
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Affiliation(s)
- Chelsea A Taylor
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - Robert A Watson
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Orion Tong
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - Weiyu Ye
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - Isar Nassiri
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - James J Gilchrist
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Paediatrics, University of Oxford, Oxford, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Alba Verge de Los Aires
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - Piyush Kumar Sharma
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - Surya Koturan
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - Rosalin A Cooper
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - Victoria K Woodcock
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Elsita Jungkurth
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Department of Oncology, University of Oxford, Oxford, UK
| | - Brian Shine
- Department of Clinical Biochemistry, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Nicholas Coupe
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Miranda J Payne
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - David N Church
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Vivek Naranbhai
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
- Center for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Stefan Groha
- Department of Medical Oncology, Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of Harvard & MIT, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew L Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard & MIT, Cambridge, MA, USA
| | - Toni K Choueiri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard & MIT, Cambridge, MA, USA
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark R Middleton
- Department of Oncology, University of Oxford, Oxford, UK
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alexander Gusev
- Department of Medical Oncology, Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of Harvard & MIT, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Genetics, Brigham and Women's Hospital, Boston, MA, USA
| | - Benjamin P Fairfax
- MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK.
- Department of Oncology, University of Oxford, Oxford, UK.
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK.
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Harnden K, Di Matteo A, Mankia K. When and how should we use imaging in individuals at risk of rheumatoid arthritis? Front Med (Lausanne) 2022; 9:1058510. [PMID: 36507546 PMCID: PMC9726914 DOI: 10.3389/fmed.2022.1058510] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
In recent years rheumatologists have begun to shift focus from early rheumatoid arthritis (RA) to studying individuals at risk of developing the disease. It is now possible to use blood, clinical and imaging biomarkers to identify those at risk of progression before the onset of clinical synovitis. The use of imaging, in particular ultrasound (US) and magnetic resonance imaging (MRI), has become much more widespread in individuals at-risk of RA. Numerous studies have demonstrated that imaging can help us understand RA pathogenesis as well as identifying individuals at high risk of progression. In addition, imaging techniques are becoming more sophisticated with newer imaging modalities such as high-resolution peripheral quantitative computed tomography (HR-pQRCT), nuclear imaging and whole body-MRI (WB-MRI) starting to emerge. Imaging studies in at risk individuals are heterogeneous in nature due to the different at-risk populations, imaging modalities and protocols used. This review will explore the available imaging modalities and the rationale for their use in the main populations at risk of RA.
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van Duren BH, Wignall A, Goodman S, Hewitt C, Mankia K, Pandit H. The Effect of Perioperative Biologic Disease-Modifying Anti-Rheumatic Drugs on the Risk of Postoperative Complications: Surgical Site Infection, Delayed Wound Healing, and Disease Flares Following Orthopaedic Surgical Procedures. J Bone Joint Surg Am 2022; 104:1116-1126. [PMID: 35175994 DOI: 10.2106/jbjs.21.00811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Biologic disease-modifying anti-rheumatic drugs (bDMARDs) are effective in treating inflammatory diseases and have been increasingly utilized over the past decade. Patients who receive bDMARDs have been shown to be at an increased risk for surgical site infection following surgical procedures. The severe consequences of infection following orthopaedic surgery have led to the practice of withholding bDMARDs perioperatively; however, there has been no definitive evidence showing a clear benefit of withholding the use of bDMARDs, and in doing so, patients may be at an increased risk for higher disease activity. As such, the purpose of the present study was to compare the risk of infection, delayed wound healing, and disease flares associated with the use of bDMARDs in patients undergoing orthopaedic surgical procedures. METHODS We performed a systematic literature search of MEDLINE, Embase, and PubMed CENTRAL databases for studies comparing continuing and withholding the use of bDMARDs in patients undergoing orthopaedic procedures. Inclusion criteria were established following the PICO (Population, Intervention, Comparison, and Outcomes) approach: Population = patients who underwent orthopaedic surgical procedures and who were taking bDMARDs. Intervention = withholding the use of bDMARDs. Comparator = continuing the use of bDMARDs. Outcomes = surgical site infection, delayed wound healing, and disease flares. Article titles and abstracts were screened prior to review of the full text. Overall odds ratios (ORs) and associated 95% confidence intervals (CIs) for pooled effects were calculated. RESULTS Eleven studies met the inclusion criteria, providing data for 7,344 patients, including 2,385 patients who continued and 4,959 who withheld their bDMARDs perioperatively. Continuing bDMARDs was associated with a significantly lower risk of disease flares (OR, 0.22; 95% CI, 0.05 to 0.95; p = 0.04) and nonsignificant increases in surgical site infections (OR, 1.11; 95% CI, 0.82 to 1.49; p = 0.49) and wound complications (OR, 2.16; 95% CI, 0.48 to 9.85; p = 0.32). CONCLUSIONS The present systematic review highlights the limited evidence supporting the current practice of stopping bDMARDs perioperatively. These findings suggest that patients may not be at an increased risk for developing infection or wound complications if bDMARDs are continued but are at an increased risk for disease flare if bDMARDs are withheld. However, our conclusions are limited by the retrospective and heterogenous nature of the data, and possibly by a lack of study power. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bernard H van Duren
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Alice Wignall
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Susan Goodman
- Weill Cornell Medicine, New York, NY.,Integrative Rheumatology and Orthopedics Center of Excellence, Combined Arthritis Program, Hospital for Special Surgery, New York, NY
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, United Kingdom
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Hemant Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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20
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Duquenne L, Harnden K, Garcia-Montoya L, Sidhu N, Nam J, Mankia K, Emery P. POS0527 ANTI-CCP POSITIVE INDIVIDUALS AT RISK OF PROGRESSION TO INFLAMMATORY ARTHRITIS: WHAT HAPPENS TO BIOMARKERS PRIOR TO PROGRESSION? Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.1454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundAlthough many predictors of progression to inflammatory arthritis (IA) have been identified at first visit in individuals at risk of developing IA, their fluctuation during follow-up is largely unknown.ObjectivesTo describe the changes in relevant biomarkers, which precede arthritis development in anti-CCP positive at risk individuals.MethodsIn a single centre prospective observational cohort of anti-CCP positive individuals with new musculoskeletal symptoms but without clinical arthritis, 394 individuals with at least 3 available longitudinal datapoints including first, second and last records (progression excluded), were selected. Data on anti-CCP2 antibodies (CCP2), rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), early morning stiffness duration (EMS), tender joint count on examination (TJC28), health assessment questionnaire (HAQ), absence from work in the last 3 months (sick days), and ultrasound power Doppler signal (PD) grade ≥ 1 in small joints, were assessed. Mixed model analysis on repeated measures (MANOVA) were performed, missing data were not imputed.ResultsOf the 394 selected individuals, 82 (21%) progressed to IA. In those who progressed, last visit was at a mean (SD) of 6.1 (8) months prior to progression, and total follow-up duration was 33.7 months (26.7) versus 46.5 months (30.2) for those who did not.Within group analysis:in the progressor group there was a significant increase in the value of biomarkers at the visit prior progression for CCP2 +, RF +, EMS, HAQ, and the number of joints with a PD grade ≥ 1 (Figure 1, Table 1). For sick days from work prior last visit, the increase was non-significant.Table 1.Mixed model ANOVA on repeated measures: pairwise comparisonBiomarkerMean (SD)at last visitAnalysis between groupsAnalysis within groupsP-value between groups at last visitP-value between second and last visit within the progressor groupP-value between second and last visit within non- progressor groupWithin subject effectCCP2NP: 71 (108)p<0.001P=0.008P=1.000F(2/257)=3P: 169 (131)Pŋ2= 0.017P=0.077RFNP: 37 (73)P<0.001P=0.012P=0.973F(2/304)=15P: 185 (180)Pŋ2= 0.084P<0.001ESRNP: 11 (9)p<0.001P=1.000P=0.614F(2/580)=0.1P: 22 (21)Pŋ2< 0.001P=0.877EMSNP: 26 (68)P=0.010P=0.006P=1.000F(2/710)=4Pŋ2= 0.018P:58 (120)P=0.011TJC28NP: 0.5 (1.5)P<0.001P=1.000P<0.001F(2/784)=10P: 3 (5.5)Pŋ2< 0.025P<0.001Number of joints PD ≥1NP: 0.7 (2)P=0.020P=0.001P=0.055F(2/318)=4P: 1 (2)Pŋ2= 0.025P=0.014HAQNP: 0.5 (0.6)P=0.105P=0.016P=1.000F(2/494)=2.5P: 0.7 (0.8)Pŋ2= 0.0.009P=0.086Number of sick daysNP: 2 (6)P=0.204P=0.457P=0.492F(2/360)=4(Between visit 1 and 3: p=0.042)Pŋ2= 0.021 P=0.021P: 4 (13)NP: Non progressors, P: progressors, Pŋ2: Partial ŋ2+ for these results the assumption of homogeneity of variance was violated, as assessed by Levene’s test for equality of variances.In the non-progressor group, only TJC28 and sick days showed significant decrease between first and last visit.Between groups analysis showed significant differences at last visit for the following biomarkers -CCP2 +, RF +, ESR, EMS, TJC28, and number of joints PD grade ≥ 1. The difference in HAQ and sick days was non-significant (Figure 1, Table 1). A significant difference was also shown in all visits for CCP2 + and RF +, and at the second visit for TJC28.For PD grade ≥ 1, differences at last visit within progressor group and between groups were only significant after selection of last visits < 3 months before progression.ConclusionThese results show for the first time significant changes in relevant biomarkers prior to progression to IA with individual biomarkers having different trajectories. Clinical markers (EMS, TJC28, and HAQ) and ultrasound changed late, whilst immunological (CCP2 and RF values) and inflammation biomarkers (ESR) were different from baseline. These data provide valuable information for longitudinal monitoring of biomarkers, further analysis will show if these changes have predictive value for imminent progression to IA.Disclosure of InterestsLaurence Duquenne: None declared, Kate Harnden: None declared, Leticia Garcia-Montoya: None declared, Navkiran Sidhu: None declared, Jacqueline Nam: None declared, Kulveer Mankia Speakers bureau: AbbVie, Lilly, UCB, Grant/research support from: Gilead, Lilly, Paul Emery Speakers bureau: AbbVie, Gilead, Lilly, Novartis, Consultant of: BMS, AbbVie, MSD, Pfizer, Novartis, Roche, Grant/research support from: Abbvie, BMS, Lilly, Samsung.
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21
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Mustufvi Z, Twigg J, Kerry J, Chesterman J, Pavitt S, Tugnait A, Mankia K. Does periodontal treatment improve rheumatoid arthritis disease activity? A systematic review. Rheumatol Adv Pract 2022; 6:rkac061. [PMID: 35993013 PMCID: PMC9390064 DOI: 10.1093/rap/rkac061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/10/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
The association of periodontal disease in people diagnosed with RA is emerging as an important driver of the RA autoimmune response. Screening for and treating periodontal disease might benefit people with RA. We performed a systematic literature review to investigate the effect of periodontal treatment on RA disease activity.
Methods
Medline/PubMed, Embase and Cochrane databases were searched. Studies investigating the effect of periodontal treatment on various RA disease activity measures were included. The quality of included studies was assessed. Data were grouped and analysed according to RA disease outcome measures, and a narrative synthesis was performed.
Results
We identified a total of 21 studies, of which 11 were of non-randomized experimental design trials and 10 were randomized controlled trials. The quality of the studies ranged from low to serious/critical levels of bias. RA DAS-28 was the primary outcome for most studies. A total of 9 out of 17 studies reported a significant intra-group change in DAS-28. Three studies demonstrated a significant intra-group improvement in ACPA level after non-surgical periodontal treatment. Other RA biomarkers showed high levels of variability at baseline and after periodontal treatment.
Conclusion
There is some evidence to suggest that periodontal treatment improves RA disease activity in the short term, as measured by DAS-28. Further high-quality studies with longer durations of follow-up are needed. The selection of the study population, periodontal interventions, biomarkers and outcome measures should all be considered when designing future studies. There is a need for well-balanced subject groups with prespecified disease characteristics.
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Affiliation(s)
| | | | - Joel Kerry
- Library and Information Service, Leeds Teaching Hospitals NHS Trust
| | | | - Sue Pavitt
- School of Dentistry, University of Leeds
| | | | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds , Leeds, UK
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22
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Shukla R, Levy R, Ho P, Mankia K, Wakefield RJ, Emery P, Buch MH. P214 Classifiable early RA shows heterogeneous imaging features and potential means of stratification. Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac133.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background/Aims
Synovitis and tenosynovitis (TS) are key findings seen in patients with rheumatoid arthritis (RA) on musculoskeletal ultrasound (MSUS). Both power Doppler TS (PDTS) and power Doppler synovitis (PDUS) have also been reported in preclinical-RA. We aimed to describe the prevalence of PDTS and PDUS in a treatment-naïve, new-onset RA trial cohort and their association with clinical and disease activity data.
Methods
The VEDERA (Very early Etanercept and Methotrexate versus Methotrexate with/without Delayed Etanercept in RA) trial recruited 120 treatment-naïve, new-onset RA patients fulfilling ACR-EULAR 2010 classification criteria with at least moderate DAS28-ESR to either first-line etanercept + methotrexate (ETN+MTX) or methotrexate treat-to-target (MTX-TT), and included clinical and dominant hand (MCP 1-5, wrist, flexor tendons 1-5 and extensor carpii ulnaris tendon) MSUS assessments. Joint Grey scale (GS), PDUS and PDTS were assessed semi-quantitatively and converted to dichotomous scale (absent = total score 0; present = total score ≥ 1). Patients were categorised in one of four groups based on presence of PDUS and/or PDTS: no PDUS or PDTS (PDUS-PDTS-), PDTS alone (PDUS-PDTS+), PDUS alone (PDUS+PDTS-) and both PDUS and PDTS (PDUS+PDTS+). Clinical and GS features are described for these groups.
Results
At time of diagnosis, 17% (20/120) were PDUS-PDTS-, 16% (19/120) PDUS-PDTS+, 15% (18/120) PDUS+PDTS- and 53% (63/120) PDUS+PDTS+. Table 1 details demographic, clinical and disease activity data.
GS was present in 60% (12/20) and 74% (14/19) of PDUS-PDTS- and PDUS-PDTS+ groups respectively, while all patients with PDUS + (PDUS+PDTS- and PDUS+PDTS+ groups) demonstrated GS (table 1). The PDUS+PDTS+ group had the shortest symptom duration. PDUS-PDTS- group had lower DAS28ESR, tender/swollen joint counts (28 joints), CRP and pain. The two groups with PDTS + (with/without PDUS) had higher visual analogue pain scores.
Conclusion
Heterogeneous imaging features of classifiable, new-onset RA likely reflect different rates of progress along the continuum and presentation, and timing in capturing PDUS and PDTS. Severe clinical and imaging features associate with more rapid presentation. A minor proportion show no clear features of PDUS or GS yet are classifiable as RA indicating other contributors to diagnosis. MSUS features may offer a means of stratifying patients and tailoring treatment approaches.
Disclosure
R. Shukla: None. R. Levy: None. P. Ho: None. K. Mankia: None. R.J. Wakefield: None. P. Emery: None. M.H. Buch: None.
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Affiliation(s)
- Rudresh Shukla
- Centre for Musculoskeletal Research, University of Manchester, MANCHESTER, UNITED KINGDOM
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UNITED KINGDOM
| | - Roxanne Levy
- University of Manchester, University of Manchester, MANCHESTER, UNITED KINGDOM
| | - Pauline Ho
- Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, MANCHESTER, UNITED KINGDOM
| | - Kulveer Mankia
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UNITED KINGDOM
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UNITED KINGDOM
| | - Richard J Wakefield
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UNITED KINGDOM
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UNITED KINGDOM
| | - Paul Emery
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UNITED KINGDOM
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UNITED KINGDOM
| | - Maya H Buch
- Centre for Musculoskeletal Research, University of Manchester, MANCHESTER, UNITED KINGDOM
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UNITED KINGDOM
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23
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Saleem B, Ross RL, Bissell LA, Aslam A, Mankia K, Duquenne L, Corsadden D, Carter C, Hughes P, Nadat FA, Mulipa P, Lobb M, Clarke B, Mbara K, Morton R, Dibb S, Chowdhury R, Newton D, Pike A, Kakkar V, Savic S, DelGaldo F, Emery P. Effectiveness of SARS-CoV-2 vaccination in patients with rheumatoid arthritis (RA) on DMARDs: as determined by antibody and T cell responses. RMD Open 2022; 8:rmdopen-2021-002050. [PMID: 35365569 PMCID: PMC8977455 DOI: 10.1136/rmdopen-2021-002050] [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] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/16/2022] [Indexed: 01/11/2023] Open
Abstract
Objectives To assess antibody and T cell responses to SARS-CoV-2 vaccination in patients with rheumatoid arthritis (RA) on disease-modifying antirheumatic drugs (DMARDs). Methods This prospective study recruited 100 patients with RA on a variety of DMARDs for antibody and T cell analysis, pre-vaccination and 4 weeks post-vaccination. Positive antibody response was defined as sera IgG binding to ≥1 antigen. Those that remained seronegative after first vaccination were retested 4 weeks after second vaccination; and if still seronegative after vaccination three. A T cell response was defined an ELISpot count of ≥7 interferon (IFN)γ-positive cells when exposed to spike antigens. Type I IFN activity was determined using the luminex multiplex assay IFN score. Results After vaccine one, in patients without prior SARS-CoV-2 exposure, 37/83 (45%) developed vaccine-specific antibody responses, 44/83 (53%) vaccine-specific T cell responses and 64/83 (77%) developed either antibody or T cell responses. Reduced seroconversion was seen with abatacept, rituximab (RTX) and those on concomitant methotrexate (MTX) compared to 100% for healthy controls (p<0.001). Better seroconversion occurred with anti-tumour necrosis factor (TNF) versus RTX (p=0.012) and with age ≤50 (p=0.012). Pre-vaccine SARS-CoV-2 exposure was associated with higher quantitative seroconversion (≥3 antibodies) (p<0.001). In the subgroup of non-seroconverters, a second vaccination produced seroconversion in 54% (19/35), and after a third in 20% (2/10). IFN score analysis showed no change post-vaccine. Conclusion Patients with RA on DMARDs have reduced vaccine responses, particularly on certain DMARDs, with improvement on subsequent vaccinations but with approximately 10% still seronegative after three doses.
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Affiliation(s)
- Benazir Saleem
- Rheumatology, Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Rebecca L Ross
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,Rheumatology, Leeds Biomedical Research Centre, Leeds, UK
| | - Lesley-Anne Bissell
- Rheumatology, Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Aamir Aslam
- Rheumatology, Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,Rheumatology, Leeds Biomedical Research Centre, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,Rheumatology, Leeds Biomedical Research Centre, Leeds, UK
| | - Diane Corsadden
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Clive Carter
- Transplant and Cellular Immunology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Pam Hughes
- Transplant and Cellular Immunology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Fatima A Nadat
- Transplant and Cellular Immunology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Panji Mulipa
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Mark Lobb
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Brendan Clarke
- Transplant and Cellular Immunology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Katie Mbara
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Ruth Morton
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Sophie Dibb
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Rahaymin Chowdhury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Darren Newton
- Institute of Medical Research at St James's University Hospital, University of Leeds, Leeds, UK
| | - Alexandra Pike
- Institute of Medical Research at St James's University Hospital, University of Leeds, Leeds, UK
| | - Vishal Kakkar
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Sinisia Savic
- Transplant and Cellular Immunology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Francesco DelGaldo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,Rheumatology, Leeds Biomedical Research Centre, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK.,Rheumatology, Leeds Biomedical Research Centre, Leeds, UK
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24
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Garcia-Montoya L, Nam JL, Duquenne L, Villota-Eraso C, Di Matteo A, Hartley C, Mankia K, Emery P. Prioritising referrals of individuals at-risk of RA: guidance based on results of a 10-year national primary care observational study. Arthritis Res Ther 2022; 24:26. [PMID: 35042555 PMCID: PMC8767684 DOI: 10.1186/s13075-022-02717-w] [Citation(s) in RCA: 1] [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: 07/25/2021] [Accepted: 01/03/2022] [Indexed: 12/04/2022] Open
Abstract
Background Musculoskeletal (MSK) symptoms are among the commonest reasons for primary care assessments; however, few individuals will be diagnosed with an inflammatory arthritis (IA) within the following year. The purpose of this study was to investigate, in individuals with new MSK symptoms, the association between patient factors and risk of progression to IA, in order to optimise primary care referrals to rheumatology. Methods Individuals ≥16 years old with new non-specific MSK symptoms and no clinical synovitis were recruited by primary care across the UK from July 2007 until May 2019. Those testing positive for the anti-CCP2 assay (anti-CCP+) were invited to Leeds for follow-up. Subjects with a negative result (anti-CCP−) were sent a 1-year questionnaire, and general practitioners were contacted to confirm whether the individual had been diagnosed with an IA by a rheumatologist. Predictors for progression were assessed using multivariable regression analysis. Results Six thousand seven hundred eighty individuals were recruited: 3% were anti-CCP+, of whom 45% progressed to IA, predominantly rheumatoid arthritis. Anti-CCP+ participants with high antibody levels had an odds ratio (OR) for progression to IA of 9.42 [P < 0.001, 95% CI (3.13–28.30)], hand pain, OR 2.74 [P = 0.043, 95% CI (1.03–7.27)] and foot pain, OR 4.10 [P = 0.003, 95% CI (1.59–10.54)]. In low-level anti-CCP+ individuals, absence of pain in hands or feet had a negative predictive value of 96% for progression to IA. One-year follow-up data were available for 5640 anti-CCP− individuals, of whom 53 were diagnosed with IA (0.93%). Pain in hands, OR 2.51 [P = 0.018, 95% CI (1.17–5.39)] or knees, OR 3.03 [P = 0.003, 95% CI (1.47–6.25)] were associated with development of IA within 12 months. Conclusions This is the largest prospective primary care study of individuals at risk of IA, and the first one to prospectively investigate the outcome of MSK symptoms in a large anti-CCP− cohort. High anti-CCP levels and pain in hands/feet indicated an increased likelihood of progression to IA. In patients with low anti-CCP level and no pain in the hands/feet, progression is unlikely. In anti-CCP− patients, those with hand or knee pain were at increased risk of progression. This study demonstrates that routinely available tests and joint symptoms provide useful discrimination that may be used to prioritise referrals to rheumatology and avoid a delayed diagnosis. Trial registration NCT, NCT02012764. Registered 25 January 2007. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02717-w.
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Affiliation(s)
- Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, LS7 4SA, UK.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, LS7 4SA, UK.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, LS7 4SA, UK.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Catalina Villota-Eraso
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, LS7 4SA, UK.,Universidad de La Sabana, Department of Rheumatology, Chía, Colombia
| | - Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, LS7 4SA, UK.,Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Polytechnic University of Marche, Jesi, Ancona, Italy
| | - Collette Hartley
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, LS7 4SA, UK.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, LS7 4SA, UK.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, LS7 4SA, UK. .,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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25
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Di Matteo A, Duquenne L, Cipolletta E, Nam JL, Garcia-Montoya L, Wakefield RJ, Mahler M, Mankia K, Emery P. Ultrasound subclinical synovitis in anti-CCP+ at-risk individuals with MSK symptoms: an important and predictable stage in the RA continuum. Rheumatology (Oxford) 2021; 61:3192-3200. [PMID: 34849610 PMCID: PMC9348771 DOI: 10.1093/rheumatology/keab862] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 07/28/2021] [Revised: 11/11/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives To investigate whether anti-CCP2-positive at-risk individuals with musculoskeletal (MSK) symptoms but without clinical synovitis (CCP2+ at-risk) develop US subclinical synovitis before inflammatory arthritis and if US subclinical synovitis can be predicted. Methods First, US scans of CCP2+ at-risk individuals who developed inflammatory arthritis (‘progressors’) were reviewed for subclinical synovitis prior to inflammatory arthritis development. Patients in whom the pre-progression US scan was negative but the scan was conducted >6 months before progression were excluded. Subsequently, regression analyses were performed to identify predictors of US synovitis in CCP2+ at-risk individuals without baseline US abnormalities who had one or more longitudinal US scan and a complete dataset. Results US subclinical synovitis was detected in one or more scan in 75 of 97 progressors (77.3%) {median time to inflammatory arthritis development from first evidence of US synovitis 26.5 weeks [interquartile range (IQR) 7–60]}, in whom one or more scan was available, excluding those with a negative scan >6 months from inflammatory arthritis development (n = 38). In 220 CCP2+ at-risk individuals with normal baseline US scans, who had one or more longitudinal US scan and a complete dataset, US synovitis was detected in 69/220 (31.4%) [median time to first developing US synovitis 56.4 weeks (IQR 33.0–112.0)]. In the multivariable analysis, only anti-CCP3 antibodies were predictive for the development of US synovitis [odds ratio 4.75 (95% CI 1.97, 11.46); P < 0.01]. Conclusions In anti-CCP2+ at-risk individuals, a stage of subclinical synovitis usually precedes the development of inflammatory arthritis. Anti-CCP2+/CCP3+ individuals without clinical or US subclinical synovitis may represent the optimal window of opportunity for intervention to prevent joint disease.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Polytechnic University of Marche, Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Jesi, Ancona, Italy
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Edoardo Cipolletta
- Polytechnic University of Marche, Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Jesi, Ancona, Italy
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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26
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Siddle HJ, Chapman LS, Mankia K, Zăbălan C, Kouloumas M, Raza K, Falahee M, Kerry J, Kerschbaumer A, Aletaha D, Emery P, Richards SH. Perceptions and experiences of individuals at-risk of rheumatoid arthritis (RA) knowing about their risk of developing RA and being offered preventive treatment: systematic review and thematic synthesis of qualitative studies. Ann Rheum Dis 2021; 81:159-168. [PMID: 34750103 PMCID: PMC8762008 DOI: 10.1136/annrheumdis-2021-221160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 07/16/2021] [Accepted: 10/07/2021] [Indexed: 11/04/2022]
Abstract
Objectives There is increasing interest in identifying individuals at-risk of rheumatoid arthritis (RA) and initiating early treatment to prevent or delay the onset of arthritis. We aimed to describe the perceptions and experiences of at-risk individuals and to inform the conduct of clinical trials and studies, and clinical practice. Methods A systematic review and thematic synthesis of qualitative studies was conducted. Two review authors independently screened studies for inclusion, appraised their methodological quality using the Critical Appraisal Skills Programme checklist and assessed confidence in the findings using the Grading of Recommendations Assessment, Development and Evaluation–Confidence in Evidence from Reviews of Qualitative Research approach. Results Seven studies involving 115 individuals at-risk of developing RA were included. Three major themes (seven subthemes) were identified: understanding the risk of developing RA (knowledge of RA and identification of potential risk factors); preventive interventions to reduce the risk of developing RA (understanding the value and role of preventive interventions, and engagement with preventive interventions); and perceptions of predictive testing for RA (benefits of predictive testing, decision to undertake predictive testing and concerns about predictive testing). Moderate confidence in most review findings was evident. Conclusion While there are clear benefits in informing individuals at-risk of RA about their risk following predictive testing and offering preventive treatment, there are potential barriers to engagement, intensified by the burden of uncertainty. Identification of the optimum approaches for presenting risk information, including the risks and benefits of engaging with preventive interventions, is urgently needed to support individuals at-risk of RA in their decision making. PROSPERO registration number CRD42021236034.
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Affiliation(s)
- Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Lara S Chapman
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | | | | | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Marie Falahee
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Joel Kerry
- Library and Information Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
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van Duren BH, Wignall A, Rangan A, Coates L, Pandit H, Mankia K. To stop or not to stop: what should we be doing with biologic DMARDs when patients undergo orthopaedic surgery? Rheumatol Adv Pract 2021; 5:rkab057. [PMID: 34622125 PMCID: PMC8493102 DOI: 10.1093/rap/rkab057] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/02/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Bernard H van Duren
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Alice Wignall
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford
| | - Laura Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford
| | - Hemant Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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28
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Mustufvi Z, Serban S, Chesterman J, Mankia K. Should We Be Screening for and Treating Periodontal Disease in Individuals Who Are at Risk of Rheumatoid Arthritis? Healthcare (Basel) 2021; 9:1326. [PMID: 34683006 PMCID: PMC8544588 DOI: 10.3390/healthcare9101326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/06/2021] [Revised: 09/24/2021] [Accepted: 09/30/2021] [Indexed: 12/21/2022] Open
Abstract
There is increasing evidence supporting an association between periodontal disease (PD) and rheumatoid arthritis (RA), both mechanistically and clinically. Trials have shown that treating PD in people with RA may improve RA disease activity. Patients with musculoskeletal symptoms without arthritis, who test positive for cyclic-citrullinated protein antibodies, are at risk of RA (CCP+ at-risk), with seropositivity preceding arthritis onset by months or years. Importantly, there is evidence to suggest that periodontal inflammation may precede joint inflammation in CCP+ at-risk and, therefore, this could be a trigger for RA. There has been increased research interest in RA prevention and the phenotyping of the pre-RA disease phase. This review will examine the merits of identifying individuals who are CCP+ at-risk and performing screening for PD. In addition, we discuss how PD should be treated once identified. Finally, the review will consider future research needed to advance our understanding of this disease association.
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Affiliation(s)
- Zhain Mustufvi
- Leeds Teaching Hospitals NHS Trust, National Institute for Health Research, School of Dentistry, University of Leeds, Leeds LS2 9LU, UK
| | - Stefan Serban
- School of Dentistry, University of Leeds, Leeds LS2 9LU, UK;
| | - James Chesterman
- Leeds Dental Institute, Leeds Teaching Hospitals NHS Trust, Worsley Building, Clarendon Way, Leeds LS2 9LU, UK;
| | - Kulveer Mankia
- National Institute for Health Research Biomedical Research Centre, Chapel Allerton Hospital, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapeltown Road, Leeds LS7 4SA, UK;
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29
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Mankia K, Siddle HJ, Kerschbaumer A, Alpizar Rodriguez D, Catrina AI, Cañete JD, Cope AP, Daien CI, Deane KD, El Gabalawy H, Finckh A, Holers VM, Koloumas M, Ometto F, Raza K, Zabalan C, van der Helm-van Mil A, van Schaardenburg D, Aletaha D, Emery P. EULAR points to consider for conducting clinical trials and observational studies in individuals at risk of rheumatoid arthritis. Ann Rheum Dis 2021; 80:1286-1298. [PMID: 34362746 PMCID: PMC8458095 DOI: 10.1136/annrheumdis-2021-220884] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 06/02/2021] [Accepted: 07/24/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Despite growing interest, there is no guidance or consensus on how to conduct clinical trials and observational studies in populations at risk of rheumatoid arthritis (RA). METHODS An European League Against Rheumatism (EULAR) task force formulated four research questions to be addressed by systematic literature review (SLR). The SLR results informed consensus statements. One overarching principle, 10 points to consider (PTC) and a research agenda were proposed. Task force members rated their level of agreement (1-10) for each PTC. RESULTS Epidemiological and demographic characteristics should be measured in all clinical trials and studies in at-risk individuals. Different at-risk populations, identified according to clinical presentation, were defined: asymptomatic, musculoskeletal symptoms without arthritis and early clinical arthritis. Study end-points should include the development of subclinical inflammation on imaging, clinical arthritis, RA and subsequent achievement of arthritis remission. Risk factors should be assessed at baseline and re-evaluated where appropriate; they include genetic markers and autoantibody profiling and additionally clinical symptoms and subclinical inflammation on imaging in those with symptoms and/or clinical arthritis. Trials should address the effect of the intervention on risk factors, as well as progression to clinical arthritis or RA. In patients with early clinical arthritis, pharmacological intervention has the potential to prevent RA development. Participants' knowledge of their RA risk may inform their decision to participate; information should be provided using an individually tailored approach. CONCLUSION These consensus statements provide data-driven guidance for rheumatologists, health professionals and investigators conducting clinical trials and observational studies in individuals at risk of RA.
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Affiliation(s)
- Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Andreas Kerschbaumer
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | | | - Juan D Cañete
- Department of Rheumatology, Arthritis Unit, Hospital Clinic and IDIBAPS, Barcelona, Spain
| | - Andrew P Cope
- Faculty of Life Sciences and Medicine, Centre for Rheumatic Diseases, King's College London, London, UK
| | - Claire Immediato Daien
- Department of Rheumatology, CHU de Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS UMR, Montpellier, France
| | - Kevin D Deane
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hani El Gabalawy
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Axel Finckh
- Division of Rheumatology, University of Geneva, Geneva, Switzerland
| | - V Michael Holers
- Division of Rheumatology, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Francesca Ometto
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Karim Raza
- Centre for Musculoskeletal Ageing Research and Research into Inflammatory Arthritis, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dirkjan van Schaardenburg
- Department of Rheumatology, Academic Medical Center, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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30
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Mankia K, Siddle H, Di Matteo A, Alpízar-Rodríguez D, Kerry J, Kerschbaumer A, Aletaha D, Emery P. A core set of risk factors in individuals at risk of rheumatoid arthritis: a systematic literature review informing the EULAR points to consider for conducting clinical trials and observational studies in individuals at risk of rheumatoid arthritis. RMD Open 2021; 7:rmdopen-2021-001768. [PMID: 34531306 PMCID: PMC8449955 DOI: 10.1136/rmdopen-2021-001768] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 06/10/2021] [Accepted: 09/01/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There is significant interest in determining risk factors in individuals at risk of rheumatoid arthritis (RA). A core set of risk factors for clinical arthritis development has not been defined. METHODS A literature search and systematic literature review (SLR) was conducted to identify risk factors in individuals at risk of RA using Medline, Embase, PubMed and Central databases. RESULTS 3854 articles were identified by the literature search. After screening of titles, 138 abstracts were reviewed and 96 articles finally included. Fifty-three articles included data on risk factors including autoantibodies, subclinical inflammation on imaging, clinical features, serum and cellular biomarkers and genetic markers. Risk factors were dependent on the at-risk population. There was good evidence for serum anticitrullinated protein antibodies (ACPA) levels, as risk factors for arthritis in all at-risk populations (n=13 articles). Subclinical inflammation on ultrasound (n=12) and MRI (n=6) was reported as a risk factor in multiple studies in at-risk individuals with musculoskeletal (MSK) symptoms and undifferentiated arthritis (UA). Clinical features were reported as a risk factor in at-risk individuals with MSK symptoms and UA (n=13). Other risk factors, including serum and cellular markers were less frequently reported. CONCLUSIONS Risk factors for arthritis development in RA are specific to the at-risk population. Serum ACPA confers risk in all populations; subclinical inflammation on imaging and clinical features confer risk in at-risk individuals with MSK symptoms. This SLR informed the EULAR taskforce for points to consider on conducting clinical trials and studies in individuals at risk of RA.
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Affiliation(s)
- Kulveer Mankia
- Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK .,Department of Rheumatology, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Heidi Siddle
- Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Andrea Di Matteo
- Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Clinica Reumatologica, Universita Politecnica delle Marche, Ancona, Italy
| | | | - Joel Kerry
- Library and Information Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andreas Kerschbaumer
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Paul Emery
- Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Department of Rheumatology, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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31
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Di Matteo A, Mankia K, Nam JL, Cipolletta E, Garcia-Montoya L, Duquenne L, Rowbotham E, Emery P. In anti-CCP+ at-risk individuals, radiographic bone erosions are uncommon and are not associated with the development of clinical arthritis. Rheumatology (Oxford) 2021; 60:3156-3164. [PMID: 33415335 DOI: 10.1093/rheumatology/keaa761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 07/10/2020] [Revised: 10/08/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To investigate the prevalence, distribution and predictive value for the development of inflammatory arthritis (IA) of conventional radiography (CR) bone erosions (BE) in anti-CCP positive (CCP+) at-risk individuals with musculoskeletal (MSK) symptoms but without clinical synovitis. METHODS Baseline CR of the hands and feet of 418 CCP+ at-risk individuals were analysed. The presence of US-BE was explored in the anatomical areas in which CR-BE were reported. Hands and feet CR at the time of progression were analysed in a subset of individuals who developed IA (73/123, 59.3%). Logistic regression analyses were performed to calculate the predictive value of baseline CR-BE for the development of IA in 394 CCP+ individuals with ≥1 follow-up visit. RESULTS BE were detected in 17/418 (4.1%) CCP+ at-risk individuals (median Simple Erosions Narrowing Score-BE = 2.0, IQR: 1.0-2.0; median Sharp van der Heijde score-BE = 4.0, IQR: 3.0-8.5), most frequently in the foot joints (11/17, 64.7% individuals). A total of 123/394 (31.2%) CCP+ at-risk individuals developed IA; 7/17 (41.2%) with, and 116/377 (30.8%) without BE on CR (P = 0.37). US-BE were found in 4/7 (57.1%) individuals with CR-BE who developed IA, but only in 1/10 (10.0%) who did not. At the time of progression, new BE were detected in 4/73 (5.5%) CCP+ individuals on repeated CR. In the regression analyses, baseline CR-BE were not predictive for the development of IA. CONCLUSIONS In CCP+ at-risk individuals with MSK symptoms, CR-detected BE are uncommon and do not predict the development of IA.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, 'Carlo Urbani' Hospital, Ancona, Italy
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edoardo Cipolletta
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, 'Carlo Urbani' Hospital, Ancona, Italy
| | - Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emma Rowbotham
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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32
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Rooney CM, Mankia K, Mitra S, Moura IB, Emery P, Wilcox MH. Perturbations of the gut microbiome in anti-CCP positive individuals at risk of developing rheumatoid arthritis. Rheumatology (Oxford) 2021; 60:3380-3387. [PMID: 33313854 DOI: 10.1093/rheumatology/keaa792] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 07/07/2020] [Revised: 10/15/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Individuals with newly diagnosed RA have a distinct microbiome when compared with healthy controls. However, little is known as to when these microbiome perturbations begin. Using a prospective at-risk cohort of individuals positive for anti-citrullinated protein (anti-CCP) antibody with new onset musculoskeletal symptoms, but without clinical arthritis, we investigated for the presence of a gut dysbiosis before the onset of RA. METHODS The gut microbiota of 25 anti-CCP positive individuals without clinical synovitis were sequenced targeting the V4 region of the 16S rRNA gene. Using a publicly available database, a control population of 44 individuals, approximately matched in age, gender, diet and ethnicity was selected for comparison, using the same sequencing methodology. Median interval between sample collection and progression to RA was 188 days. Taxonomic analysis was performed using QIIME and MEGAN, and statistical analysis using R software. RESULTS There were significant differences (P =0.01) at family level in gut microbiomes of anti-CCP positive individuals vs controls. The anti-CCP positive population had an overabundance of Lachnospiraceae, Helicobacteraceae, Ruminococcaceae, Erysipelotrichaceae and Bifidobacteriaceae, among others. Five individuals progressed to RA between sample collection and analysis. Clustering of the progressor population was observed on a phylogenetic network created using a probabilistic similarity index (Goodall's index). CONCLUSIONS Anti-CCP positive at-risk individuals without clinical synovitis appear to have a distinct gut microbiome compared with healthy controls. Phylogenetic clustering was observed in individuals who progressed to RA, suggesting that distinct taxa are associated with the development of RA many months before its onset.
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Affiliation(s)
- Christopher M Rooney
- Leeds Institute of Medical Research, University of Leeds, Leeds General Infirmary, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
| | - Suparna Mitra
- Leeds Institute of Medical Research, University of Leeds, Leeds General Infirmary, Leeds, UK
| | - Ines B Moura
- Leeds Institute of Medical Research, University of Leeds, Leeds General Infirmary, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
| | - Mark H Wilcox
- Leeds Institute of Medical Research, University of Leeds, Leeds General Infirmary, Leeds, UK
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Wouters F, Maurits MP, van Boheemen L, Verstappen M, Mankia K, Matthijssen XME, Dorjée AL, Emery P, Knevel R, van Schaardenburg D, Toes REM, van der Helm-van Mil AHM. Determining in which pre-arthritis stage HLA-shared epitope alleles and smoking exert their effect on the development of rheumatoid arthritis. Ann Rheum Dis 2021; 81:48-55. [PMID: 34285049 DOI: 10.1136/annrheumdis-2021-220546] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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] [Received: 04/12/2021] [Accepted: 07/07/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The human leukocyte antigen-shared epitope (HLA-SE) alleles and smoking are the most prominent genetic and environmental risk factors for rheumatoid arthritis (RA). However, at which pre-arthritis stage (asymptomatic/symptomatic) they exert their effect is unknown. We aimed to determine whether HLA-SE and smoking are involved in the onset of autoantibody positivity, symptoms (clinically suspect arthralgia (CSA)) and/or progression to clinical arthritis. METHODS We performed meta-analyses on results from the literature on associations of HLA-SE and smoking with anti-citrullinated protein antibodies (ACPAs) in the asymptomatic population. Next, we studied associations of HLA-SE and smoking with autoantibody positivity at CSA onset and with progression to clinical inflammatory arthritis (IA) during follow-up. Associations in ACPA-positive patients with CSA were validated in meta-analyses with other arthralgia cohorts. Analyses were repeated for rheumatoid factor (RF), anti-carbamylated protein antibodies (anti-CarP) and anti-acetylated protein antibodies (AAPA). RESULTS Meta-analyses showed that HLA-SE is not associated with ACPA positivity in the asymptomatic population (OR 1.06 (95% CI:0.69 to 1.64)), whereas smoking was associated (OR 1.37 (95% CI: 1.15 to 1.63)). At CSA onset, both HLA-SE and smoking associated with ACPA positivity (OR 2.08 (95% CI: 1.24 to 3.49), OR 2.41 (95% CI: 1.31 to 4.43)). During follow-up, HLA-SE associated with IA development (HR 1.86 (95% CI: 1.23 to 2.82)), in contrast to smoking. This was confirmed in meta-analyses in ACPA-positive arthralgia (HR 1.52 (95% CI: 1.08 to 2.15)). HLA-SE and smoking were not associated with RF, anti-CarP or AAPA-positivity at CSA onset. Longitudinally, AAPA associated with IA development independent from ACPA and RF (HR 1.79 (95% CI: 1.02 to 3.16)), anti-CarP did not. CONCLUSIONS HLA-SE and smoking act at different stages: smoking confers risk for ACPA and symptom development, whereas HLA-SE mediates symptom and IA development. These data enhance the understanding of the timing of the key risk factors in the development of RA.
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Affiliation(s)
- Fenne Wouters
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc P Maurits
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Laurette van Boheemen
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, The Netherlands
| | - Marloes Verstappen
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Annemarie L Dorjée
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rachel Knevel
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirkjan van Schaardenburg
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Reade, Amsterdam, The Netherlands
| | - René E M Toes
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Di Matteo A, Mankia K, Duquenne L, Cipolletta E, Nam J, Garcia-Montoya L, Wakefield R, Mahler M, Emery P. POS0464 IS IT POSSIBLE TO IDENTIFY INDIVIDUALS AT IMMINENT-RISK OF SUB-CLINICAL JOINT INVOLVEMENT? Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.2290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:In anti-CCP antibody (Ab) positive at-risk individuals with MSK symptoms but without clinical synovitis, the detection of ultrasound (US) subclinical inflammation is associated with an increased risk of progression to inflammatory arthritis (IA) 1. Studies suggest that in these at-risk individuals, MSK symptoms develop before subclinical joint inflammation occurs on US. As such, anti-CCP Ab positive individuals with MSK symptoms in the absence of clinical or sub-clinical inflammation may be at the critical time-point for preventive treatments, before joint inflammation occurs and eventually becomes established (i.e., before the ‘second-hit’ in RA pathogenesis); however, identifying these individuals is challenging.Objectives:To identify, in second generation anti-CCP Ab (CCP2+) at-risk individuals with MSK symptoms, but without clinical or sub-clinical synovitis, predictors of US sub-clinical synovitis.Methods:In 186 CCP2+ at-risk individuals with normal baseline US scan (i.e., no synovitis or bone erosions), and a complete dataset, US data were analyzed at 6, 12 months, then annually until occurrence of IA. US synovitis was identified according to the EULAR/OMERACT definitions2. Relevant demographic (age and gender), clinical [early morning stiffness (EMS), tenderness in the small joints of the hands] and serological [anti-CCP2 Ab level, third generation anti-CCP Ab (CCP3) and rheumatoid factor (RF)] data were collected at baseline. Regression analyses, Kaplan-Meier analysis and Log-Rank test were performed.Results:US synovitis was detected in ≥1 longitudinal US scan in 69/186 (37.1%) at-risk individuals (median time to first developing US synovitis: 53 weeks, IQR 27.0-105.8; median number of joints with US synovitis: 2.0, IQR 1.0-2.0). As shown in Table 1, only anti-CCP3 Ab were significantly associated with development of US sub-clinical synovitis in the multi-variable analysis while borderline results were observed with age.Table 1.Regression analyses for the development of US synovitis.Univariable analysisMultivariableanalysisOR (95% CI)p-valueOR (95% CI)p-valueGender (male)1.02 (0.52-2.02)0.95//Age1.03 (1.01-1.06)<0.011.03 (1.00-1.06)0.03Tenderness in the hands0.86 (0.46-1.61)0.64//EMS1.60 (0.87-2.95)0.13//Anti-CCP2 Ab (high titre)2.79 (1.37-5.67)<0.011.20 (0.50-2.89)0.69Anti-CCP3+4.44 (2.28-8.66)<0.013.30 (1.39-7.89)<0.01RF+2.96 (0.46-1.61)0.011.45 (0.68-3.11)0.33CCP2+ individuals with positive anti-CCP3 Ab show a significantly reduced sub-clinical synovitis-free survival rate compared with individuals with negative anti-CCP3 Ab (Figure 1). At 1- and 2-year follow-up, respectively 23.3% and 38.3% of individuals with dual CCP2/CCP3 positivity developed sub-clinical synovitis on longitudinal scans, compared with 8.4% and 13.3% of CCP2+ individuals with negative anti-CCP3 Ab (p=0.01) (Figure 1a).Similar results were observed in the subgroup of high level CCP2+ individuals. At 1- and 2-year follow-up, respectively 24.5% and 39.4% of high level CPP2/anti-CCP3+, but only 6.1% and 15.2% of CCP2+ individuals with negative anti-CCP3 developed sub-clinical synovitis on longitudinal scans (p<0.01) (Figure 1b).Figure 1.Kaplan-Meier analysis shows US sub-clinical synovitis free survival time in CCP2+ at-risk individuals.Conclusion:In anti-CCP2+ at-risk individuals with MSK symptoms, anti-CCP3 antibodies improve prediction of imminent development of subclinical joint inflammation. This may represent the critical time-point for interventions to prevent the onset of joint disease. This is also a unique population for investigating the drivers of joint involvement in the development of RA.References:[1]Duquenne L, et al. The Role of Ultrasound Across the Inflammatory Arthritis Continuum: Focus on “At-Risk” Individuals. 2020.[2]D’Agostino MA, et al. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce — Part 1: definition and development of a standardised, consensus-based scoring system. 2017.Disclosure of Interests:Andrea Di Matteo Grant/research support from: This study was conducted while Andrea Di Matteo was an ARTICULUM Fellow., Kulveer Mankia Speakers bureau: KM reports personal fees from Abbvie, UCB and Eli Lilly (all <$10.000), outside the submitted work., Grant/research support from: Research grants from BMS, Eli Lilly (all <$10.000), Laurence Duquenne: None declared, Edoardo Cipolletta: None declared, Jacqueline Nam: None declared, Leticia Garcia-Montoya: None declared, Richard Wakefield Speakers bureau: RJW has received honoraria from Abbvie, Novartis and GE for ultrasound related educational activities (all <$10.000)., Michael Mahler Employee of: MM is employee of Inova Diagnostics, commercializing CCP3, Paul Emery Speakers bureau: PE reports consultant fees from BMS, AbbVie, Gilead, Galapagos, Lilly, MSD, Pfizer, Novartis, Roche, and Samsung outside the submitted work (all <$10.000)., Grant/research support from: He also reports research grants from UCB, AbbVie, Lilly, Novartis, BMS, Pfizer, MSD and Roche, outside the submitted work. PE is National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) director and BRC funds supported this work. Leticia Garcia-Montoya and Laurence Duquenne are NIHR BRC fellows.
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Garcia-Montoya L, Mankia K, Duquenne L, Nam J, Di Matteo A, Peill J, Mumba E, Emery P. POS0499 WORK ABSENCE DUE TO MUSCULOSKELETAL SYMPTOMS IN PATIENTS AT-RISK OF RHEUMATOID ARTHRITIS IS COMPARABLE TO THOSE WITH ESTABLISHED DISEASE. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.3765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Rheumatoid arthritis (RA) is an established cause of disability and work absence; however, little is known about the impact of musculoskeletal (MSK) symptoms on sick leave in patients at-risk of developing the disease.Objectives:To describe the sick leave of individuals at-risk of RA, compared to patients who had recently been diagnosed with RA, over a 12-month period. Additionally, to investigate baseline predictors for sick leave within the first 12 months.Methods:A prospective observational cohort for individuals at-risk of RA was conducted. A total of 591 consecutive anti-citrullinated protein antibodie positive (ACPA+) individuals, with no clinical synovitis were recruited. A MSK ultrasound scan and a blood test were performed at baseline, and information about employment regime (retired, not in a paid job, part time and full time), days of sick leave and reasons for absences within the previous months were collected every 3 months and analysed at baseline, 6 months, 12 months and at the moment of diagnosis of an inflammatory arthritis (IA) (if the patient had progressed). Subjects who had retired (n=80) were excluded from the analysis.A comparison was made with 114 RA patients from an observational study. Employment information was collected at pre-treatment, 6 months and 1 year after diagnosis.Univariable and logistic regression analyses were performed to assess predictors of work absence due to MSK reasons in the next 12 months from baseline for at-risk individuals.Results:Even though the reasons for unemployment were not available, there were no statistically significant differences between employment rates across the timepoints of the study for the at-risk individuals’ group (p=0.778). A similar pattern was observed in the RA patient group; which also maintained the same employment rates throughout the study (p=0.311) and these were comparable to the at-risk individuals’ (p=0.480).Over 35% of at-risk individuals in paid employment had work absences in the 3 months prior to the baseline visit. Of these 65.5% were due to MSK related issues, meaning 23.2% of the total absences were MSK related. The other reasons for work absence can be seen in table 1. This fell to 12.9% of the total absences at 6 months (which probably reflects clinical intervention) and increased to 38% if the patient progressed to an IA (graph 1).Table 1.REASONS FOR SICK LEAVE AT BASELINE IN INDIVIDUALS AT-RISK OF RA (%)MSK related issues65.5Flu-like symptoms20.1Gastrointestinal issues19.4Stress/anxiety14.4Headaches11.5Infection3.6Fatigue1.4Other3.6The percentage of individuals who took absence from work due to MSK related issues, was similar in both the at risk and RA group, including an initial reduction possibly due to drug intervention (graph 1). However, the median number of days off work 3 months prior baseline, 6 months and 1 year in RA patients tended to be higher than those in the at-risk group (10, 2 and 6 versus 5, 4 and 3 respectively).Several factors were assessed to predict sick leave within 12 months in at-risk individuals: age, gender, smoking status, ACPA, rheumatoid factor (RF), anti-nuclear antibodies (ANA), C-reactive protein (CRP), early morning stiffness, shared epitope, joint pain, joint tenderness and abnormal findings in the ultrasound scan (erosions or power doppler); however, only RF [OR 0.18; p=0.018; 95% CI (0.04-0.84)] and CRP [OR 1.3; p=0.021; 95%CI (1.04-1.60)] were statistically significant in the multivariable analysis.Conclusion:Even though being at-risk of RA is not considered a potential cause of disability, results show that the burden on the workplace, due to MSK related absences, was comparable to subjects diagnosed with RA. Although further investigation is required, initial data suggests that clinical intervention may reduce this burden; which tends to be higher in at-risk individuals with a negative RF and a high CRP.Graph 1.Percentage of individuals who had work absences related to MSK issues 3 months prior to each timepoint.Acknowledgements:H. SinghT. HullandG. John- Leeds Cares -Disclosure of Interests:None declared
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Mankia K, Emery P. Should we aim for personalized prevention in individuals at risk of rheumatoid arthritis? Int J Rheum Dis 2021; 24:621-622. [PMID: 33938140 DOI: 10.1111/1756-185x.14045] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Di Matteo A, Mankia K, Filippucci E, Grassi W, Rowbotham E, Wakefield RJ. Facing the challenges of running a rheumatology-based ultrasound service in the COVID-19 era. Rheumatology (Oxford) 2021; 60:1013-1015. [PMID: 33331890 PMCID: PMC7798732 DOI: 10.1093/rheumatology/keaa844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/18/2020] [Accepted: 11/21/2020] [Indexed: 01/22/2023] Open
Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Polytechnic University of Marche, Jesi, Ancona, Italy
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emilio Filippucci
- Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Polytechnic University of Marche, Jesi, Ancona, Italy
| | - Walter Grassi
- Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Polytechnic University of Marche, Jesi, Ancona, Italy
| | - Emma Rowbotham
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Musculoskeletal Radiology, Chapel Allerton Hospital, Leeds, UK
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Mankia K, Gul H, Emery P. Treating rheumatoid arthritis to an imaging target produces better outcomes, or does it? Rheumatology (Oxford) 2021; 60:3-4. [PMID: 33175981 DOI: 10.1093/rheumatology/keaa659] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds NIHR Biomedical Research Centre, Leeds, UK
| | - Hanna Gul
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds NIHR Biomedical Research Centre, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds NIHR Biomedical Research Centre, Leeds, UK
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Corradini D, Di Matteo A, Emery P, Mankia K. How should we treat palindromic rheumatism? A systematic literature review. Semin Arthritis Rheum 2020; 51:266-277. [PMID: 33401055 DOI: 10.1016/j.semarthrit.2020.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 07/23/2020] [Revised: 10/31/2020] [Accepted: 11/12/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To perform a systematic literature review (SLR) analysing all studies that reported on the efficacy and safety of pharmacological treatments for palindromic rheumatism (PR). METHODS We performed a SLR using PubMed, Embase and Cochrane databases. Three main aspects of PR were considered: treating flares, preventing recurrence of flares (i.e. achieving remission), and preventing progression to RA or to other persistent arthritis. Quality assessment of the studies was performed using the Newcastle-Ottawa Scale (NOS). RESULTS Twenty-seven articles met the inclusion criteria: 6 (22.2%) retrospective studies, 8 (29.6%) longitudinal studies, and 13 (48.1%) case series/case reports. No randomized controlled trials (RCTs) were found. Most of the studies (21/27, 77.7%) had a high risk of bias according to NOS. Non-steroidal anti-inflammatory drugs were the most commonly reported treatments for flares of PR, with variable results. Anti-malarials, such as hydroxychloroquine and chloroquine phosphate, showed efficacy in reducing the frequency of the flares and, to a lesser extent, in preventing progression to RA. There was minimal evidence in support of other conventional/biological disease modifying anti-rheumatic treatments, or corticosteroids. CONCLUSION Although a frequent clinical dilemma for rheumatologists, the pharmacological management of PR has not been thoroughly evaluated, with no RCTs reported. Of all therapies, antimalarials have been the best studied and may be capable of reducing the recurrence of flares. The optimum treatment strategy for PR remains largely undefined and should be evaluated by robust RCTs in well-defined PR cohorts.
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Affiliation(s)
- Davide Corradini
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS7 4SA, United Kingdom; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Jesi, Ancona, Italy
| | - Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS7 4SA, United Kingdom; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Jesi, Ancona, Italy
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS7 4SA, United Kingdom; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS7 4SA, United Kingdom; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
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Duquenne L, Chowdhury R, Mankia K, Emery P. The Role of Ultrasound Across the Inflammatory Arthritis Continuum: Focus on "At-Risk" Individuals. Front Med (Lausanne) 2020; 7:587827. [PMID: 33195348 PMCID: PMC7662561 DOI: 10.3389/fmed.2020.587827] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/12/2020] [Indexed: 02/04/2023] Open
Abstract
In individuals at-risk of developing inflammatory arthritis, the value of an ultrasound (US) scan assessment to predict progression has been demonstrated repeatedly. However, depending on recruitment criteria, these individuals may be at different stages in the arthritis development continuum, therefore representing a heterogeneous population. As a consequence, the predictive value of ultrasound results may differ between cohorts. As other reviews have focused on the challenges in population recruitment or have combined biomarkers predicting value according to one recruitment pathway, we wanted to focus on the sole use of ultrasound assessment and its variation according to population recruitment criteria. In this review, we discuss the use of ultrasound in the different at-risk populations across the inflammatory arthritis disease continuum. This review demonstrates that although some sub-population data is scarce, ultrasound is best predictive in three at-risk populations: those with a positive ACPA test in the context of non-specific MSK symptoms, those with clinically suspect arthralgia and those with palindromic rheumatism. We consider that ultrasound assessment will be a cornerstone in prediction risk modeling and prevention studies of the preclinical phases of IA in the future.
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Affiliation(s)
- Laurence Duquenne
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | | | - Kulveer Mankia
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Paul Emery
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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Cheng Z, Do T, Mankia K, Meade J, Hunt L, Clerehugh V, Speirs A, Tugnait A, Emery P, Devine D. Dysbiosis in the oral microbiomes of anti-CCP positive individuals at risk of developing rheumatoid arthritis. Ann Rheum Dis 2020; 80:162-168. [PMID: 33004333 DOI: 10.1136/annrheumdis-2020-216972] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [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: 01/09/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES An increased prevalence of periodontitis and perturbation of the oral microbiome has been identified in patients with rheumatoid arthritis (RA). The periodontal pathogen Porphyromonas gingivalis may cause local citrullination of proteins, potentially triggering anti-citrullinated protein antibody production. However, it is not known if oral dysbiosis precedes the onset of clinical arthritis. This study comprehensively characterised the oral microbiome in anti-cyclic citrullinated peptide (anti-CCP) positive at-risk individuals without clinical synovitis (CCP+at risk). METHODS Subgingival plaque was collected from periodontally healthy and diseased sites in 48 CCP+at risk, 26 early RA and 32 asymptomatic healthy control (HC) individuals. DNA libraries were sequenced on the Illumina HiSeq 3000 platform. Taxonomic profile and functional capability of the subgingival microbiome were compared between groups. RESULTS At periodontally healthy sites, CCP+at risk individuals had significantly lower microbial richness compared with HC and early RA groups (p=0.004 and 0.021). Microbial community alterations were found at phylum, genus and species levels. A large proportion of the community differed significantly in membership (523 species; 35.6%) and structure (575 species; 39.1%) comparing CCP+at risk and HC groups. Certain core species, including P. gingivalis, had higher relative abundance in the CCP+at risk group. Seventeen clusters of orthologous gene functional units were significantly over-represented in the CCP+at risk group compared with HC (adjusted p value <0.05). CONCLUSION Anti-CCP positive at-risk individuals have dysbiotic subgingival microbiomes and increased abundance of P. gingivalis compared with controls. This supports the hypothesis that the oral microbiome and specifically P. gingivalis are important in RA initiation.
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Affiliation(s)
- Zijian Cheng
- Division of Oral Biology, University of Leeds, School of Dentistry, Leeds, UK.,The Affiliated Stomatology Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.,Key Laboratory of Oral Biomedical Research of Zhejiang Province, Zhejiang University School of Stomatology, Hangzhou, China
| | - Thuy Do
- Division of Oral Biology, University of Leeds, School of Dentistry, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, School of Medicine, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Josephine Meade
- Division of Oral Biology, University of Leeds, School of Dentistry, Leeds, UK
| | - Laura Hunt
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, School of Medicine, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Val Clerehugh
- Division of Restorative Dentistry, University of Leeds, School of Dentistry, Leeds, UK
| | - Alastair Speirs
- Leeds Dental Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Aradhna Tugnait
- Division of Restorative Dentistry, University of Leeds, School of Dentistry, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, School of Medicine, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Deirdre Devine
- Division of Oral Biology, University of Leeds, School of Dentistry, Leeds, UK
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Abstract
Once referred to as “normal commensal flora” the human microbiome plays an integral role between health and disease. The host mucosal surface replete with a multitude of immune cells is a vast arena constantly sensing and responding to antigen presentation and microbial by-products. It is this key role that may allow the microbiome to prime or protect the host from autoimmune disease. Rheumatoid arthritis (RA) is a chronic, disabling inflammatory condition characterized by a complex multifactorial etiology. The presence of certain genetic markers has been proven to increase susceptibility to RA however it does not guarantee disease development. Given low concordance rates demonstrated in monozygotic twin studies there is a clear implication for the involvement of external players in RA pathogenesis. Since the historical description of rheumatoid factor, numerous additional autoantibodies have been described in the sera of RA patients. The presence of anti-cyclic citrullinated protein antibody is now a standard test, and is associated with a more severe disease course. Interestingly these antibodies are detectable in patient’s sera long before the clinical signs of RA occur. The production of autoantibodies is driven by the lack of tolerance of the immune system, and how tolerance is broken is a crucial question for understanding RA development. Here we review current literature on the role of the microbiome in RA development including periodontal, gut and lung mucosa, with particular focus on proposed mechanisms of host microbiome interactions. We discuss the use of Mendelian randomization to assign causality to the microbiome and present considerations for future studies.
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Affiliation(s)
- Cristopher M Rooney
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom.,Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom.,Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
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Di Matteo A, Mankia K, Duquenne L, Mahler M, Corscadden D, Mbara K, Garcia‐Montoya L, Nam JL, Emery P. Third‐Generation Anti–Cyclic Citrullinated Peptide Antibodies Improve Prediction of Clinical Arthritis in Individuals at Risk of Rheumatoid Arthritis. Arthritis Rheumatol 2020; 72:1820-1828. [DOI: 10.1002/art.41402] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/15/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Andrea Di Matteo
- University of Leeds NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust, Leeds, UK, and Polytechnic University of Marche Carlo Urbani Hospital Jesi Italy
| | - Kulveer Mankia
- University of Leeds NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Laurence Duquenne
- University of Leeds NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Michael Mahler
- Inova Diagnostics, Inc. San Diego California United States
| | - Diane Corscadden
- University of Leeds NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Katie Mbara
- University of Leeds NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Leticia Garcia‐Montoya
- University of Leeds NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Jacqueline L. Nam
- University of Leeds NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Paul Emery
- University of Leeds NIHR Leeds Biomedical Research Centre Leeds Teaching Hospitals NHS Trust Leeds UK
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Abstract
PURPOSE OF REVIEW Rheumatoid arthritis (RA) is no longer considered a fixed phenotype but rather a disease continuum. This review outlines the current and potential value of applying ultrasound (US) along this continuum: from the prediction of progression to RA in at-risk individuals, to confirmation of the early diagnosis of RA, as well as the consideration of differential diagnoses, and the use in disease monitoring and defining remission. RECENT FINDINGS In individuals at-risk of RA (i.e., positive autoantibodies with symptoms but without synovitis), US has shown a promising predictive value for the development of clinical arthritis, providing the opportunity to improve risk stratification (and disease prevention) of these individuals. The detection of inflammation on US in patients with early undifferentiated arthritis, in which a definite diagnosis cannot be reached, could predict evolution to persistent arthritis, mostly RA. This, in addition to the US potential ability to identify disease specific patterns for different rheumatic conditions, might facilitate early diagnosis and, therefore, improve the management of patients with RA, or other types of inflammatory arthritides. US has also demonstrated the capability to predict radiographic progression, and relapse risk after treatment discontinuation, in RA patients in remission according to the clinical instruments, raising implications in the management, including therapy discontinuation, of these patients. US has an undeniable value in the management of patients at different stages along the RA continuum. Further research is needed to identify which groups of patients benefit the most from US imaging.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Rheumatology Unit, Carlo Urbani Hospital, Jesi, Ancona, Italy
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Masayuki Azukizawa
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Orthopaedic Surgery, Himeji Medical Center, 68 Honmachi, Himeji, Hyogo, 670-8520, Japan
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Di Matteo A, Mankia K, Wakefield RJ, Emery P. Which joints and what pathological findings should be evaluated on ultrasound in CCP+ at-risk individuals? The fifth MTP joint for bone erosions is a good starting point. Response to: 'Pisotriquetral arthritis: 'forgotten' joint in ultrasound imaging of the wrist' by Becciolini et al. Ann Rheum Dis 2020; 81:e98. [PMID: 32513649 DOI: 10.1136/annrheumdis-2020-218036] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Andrea Di Matteo
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Leeds, UK.,Clinica Reumatologica, Dipartimento di Scienze Cliniche e Molecolari, Universita Politecnica delle Marche, Ancona, Italy
| | - Kulveer Mankia
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Richard J Wakefield
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Paul Emery
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Leeds, UK .,NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
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Garcia-Montoya L, Wigston Z, Burska A, Mankia K, Vital E, Emery P. THU0015 TYPE I INTERFERON SIGNATURE PREDICTS PROGRESSION TO INFLAMMATORY ARTHRITIS IN ACPA+ AT-RISK INDIVIDUALS WITHOUT CLINICAL SYNOVITIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.4981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Interferon (IFN) is known to play a role in the pathogenesis of many autoimmune diseases, among them, rheumatoid arthritis (RA). A study showed that two interferon-stimulated gene expression scores (IFN-Score-A and IFN-Score-B) can be used to predict progression to connective tissue disease (CTD) in at-risk individuals, positive for anti-nuclear antibodies (ANA+) [1]. This validated score could potentially be applied to individuals at-risk of RA.Objectives:To investigate the role of type I IFN in patients at-risk of RA and assess its potential role as a biomarker to predict progression to inflammatory arthritis (IA).Methods:PBMC samples were taken from 36 at-risk individuals positive for anti-citrullinated protein antibodies (ACPA+), with a non-specific musculoskeletal complaint but no clinical synovitis and a normal ultrasound scan at baseline (BL). 17 of them developed IA later on, and had a second sample taken at the moment of progression. The other 19 did not progress and had a second sample taken after 1 year. Expression of IFN stimulated genes was assessed using TaqMan. T-test was used to compare the expression of the genes at the two time points of each individual. Binary logistic regression was used to assess BL predictors of progression. Multivariable analysis was adjusted for confounders such as C-reactive protein (CRP) rheumatoid factor (RF) and ACPA titre.Results:Table 1 shows the list of tested genes. There were no differences in the gene expression of progressors at BL and at the moment of IA diagnosis. Similarly, no differences were found between the non-progressors at BL and after 1 year. Comparing BL samples from progressors and non-progressors, there was a trend to higher expression of IFN-score-B in the progressors (Mann Whitney p=0.055), whereas IFN-score-A was similarly expressed in both groups. This is similar to the results found in a cohort of ANA+ individuals at risk of progressing to CTD [1]. Multivariable analysis showed that IFN-score-B and RF titre were predictive for IA progression with an odds ratio (OR) of 2.18 (p=0.048) and OR 1.01 (p=0.035).Table 1.Interferon stimulated genes and scores A and BGENEIFN scoreGENEIFN scoreCCL8BST2CEACAM1IFI16CXCL10IFIH1GBP1LAMP3IFI27NT5C3BIFI44PHF11IFI44LASERPING1BIFIT1SOCS1IRF7SP100ISG15STAT1RSAD2TAP1XAF1TRIM38UBE2L6UNC93B1Table 2.Baseline characteristics and predictors of progressionConclusion:These exploratory results suggest that IFN changes in IA progressors precede subclinical inflammation on ultrasound. A preliminary risk model shows that IFN-score-B could be useful to predict progression to IA in at-risk of RA individuals; however, these results require validation in a larger at-risk cohort.References:[1]Md Yusof MY. Ann. Rheum. Dis. 2018;77(10):1432-9.Disclosure of Interests:Leticia Garcia-Montoya: None declared, Zoe Wigston: None declared, Agata Burska: None declared, Kulveer Mankia: None declared, Edward Vital Grant/research support from: AstraZeneca, Roche/Genentech, and Sandoz, Consultant of: AstraZeneca, GSK, Roche/Genentech, and Sandoz, Speakers bureau: Becton Dickinson and GSK, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor)
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Duquenne L, Mankia K, Garcia-Montoya L, Nam J, Di Matteo A, Emery P. OP0112 IN INDIVIDUALS AT RISK OF INFLAMMATORY ARTHRITIS, PATIENT REPORTED OUTCOMES DETERIORATE IN THE 12 WEEKS BEFORE PROGRESSION TO CLINICAL DISEASE. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Subjects with clinically significant arthralgia who will eventually develop inflammatory arthritis (IA) had a higher HAQ at baseline (1). Here we investigated the change in patients reported outcomes (PRO) over time in ACPA+ at risk of IA subjects.Objectives:In ACPA+ subjects at risk of developing IA, to analyse the change in PRO results in order to identify an imminent phase of progression.Methods:In a single centre prospective observational cohort, PRO from 109 ACPA+ subjects without clinical arthritis were collected prospectively at 0, 12, 26, 39 weeks; the last time-point was 52 weeks for the individuals who did not progress to IA (non-progressors) or the last visit preceding progression (within 12 weeks) for those who developed IA (progressors). Data on the following PRO were collected: HAQ, “general health” (GH-VAS), “fatigue” (fatigue-VAS), and “global pain” (GP-VAS) using visual analogic scale measures graded 0 to 100. We firstly used mixed models repeated measures ANOVA analysis then included covariates such as gender, shared epitope (SE) (HLA DRB1*01, *04 and/or *10), anti-CCP2 antibody (CCP2) and/or rheumatoid factor (RF) high titre (≥3ULN), and smoking exposure (Ever/Never).Results:All analysis met sphericity assumption. In this selection, 20% of subjects (24/109) developed IA within a median of 77 weeks (Range 37-369.43), non-progressors were followed for a median of 216 weeks (Range 50-590), 74 subjects were SE positive (68%), 81 had a CCP2 and/or RF high titre (74%), and 66 were previous or current smokers (61%).Analysis revealed significant differences between both groups for the last visit, and within the progressor group for the last visit compared to all previous visits regarding the GH-VAS, GP-VAS and HAQ (Table 1, figure 1). Between subject analysis showed a significant influence of GH-VAS and GP-VAS change on progression. Covariate analysis showed a significant influence of previous smoking history on HAQ results (p=0.033, F=2.645 (4,408), Eta = 0.025).Table 1.Mixed Models repeated measuresGeneral HealthGlobal PainHAQFatigueWithin subject effects;VAS change over time depending on group.P= 0.004F(4, 428) = 3.883Partial Eta Square= 0.35P < 0.001F(4, 400) = 5.754Partial Eta Squared = 0.054P = 0.115P = 0.459Pairwise comparison within groupNon-progressors:all p > 0.05Non-progressors:all p > 0.05Non-progressors:all p > 0.05Non-progressors:all p > 0.05Progressors:Time-point 1 to 5:p = 0.010SE = 4.199Time-point 2 to 5:p = 0.001SE = 4.709Time-point 3 to 5:P = 0.001SE = 3.842Time-point 4 to 5:P = 0.043SE = 4.239Progressors:Time-point 1 to 5:p < 0.001SE = 6.172Time-point 2 to 5:p < 0.001SE = 5.518Time-point 3 to 5:P = 0.002SE = 5.246Time-point 4 to 5:P = 0.001SE = 5.333Progressors:Time-point 1 to 5:p = 0.215Time-point 2 to 5:P = 0.036SE = 0.068Time-point 3 to 5:P = 0.040SE = 0.062Time-point 4 to 5:P = 0.017SE = 0.066Progressors:Time-point 1 to 5:p = 0.448Time-point 2 to 5:P =0.292Time-point 3 to 5:P = 0.047SE = 5.421Time-point 4 to 5:P = 0.202Pairwise comparison between groupLast visit:P = 0.009SE = 5.454All other visits:P > 0.05Last visit:P = 0.003SE = 7.082All other visits:P > 0.05Last visit:P = 0.016SE = 0.119All other visits:P > 0.05P-value > 0.05Mauchly’s test of sphericityP = 0.099P = 0.050P = 0.057P = 0.722N (Progressors/total)24/10915/10224/10719/102Figure 1.Repeated measure ANOVA between groupsConclusion:These results show for the first time a significant deterioration in the PRO of general health, global pain, and HAQ weeks just preceding clinical arthritis development. This phase prior progression needs to be thoroughly studied to improve the accuracy of predicting imminent progression.References:[1]Ten Brinck RM et al. Functional limitations in the phase of clinically suspect arthralgia are as serious as in early clinical arthritis; a longitudinal study. RMD open. 2017;3(1):e000419.Disclosure of Interests:Laurence Duquenne: None declared, Kulveer Mankia: None declared, Leticia Garcia-Montoya: None declared, Jacqueline Nam: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor)
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Duquenne L, Nam J, Mankia K, Garcia-Montoya L, DI Matteo A, Emery P. FRI0036 VALIDATION OF RISK SCORES FOR PREDICTING PROGRESSION IN INDIVIDUALS “AT RISK OF RHEUMATOID ARTHRITIS”. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.4368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Composite scores for risk of progression were described in 2015 in a cohort of 100 anti-cyclic citrullinated peptide (anti-CCP) + individuals at risk of developing Inflammatory Arthritis (IA) (1). The first score, designed for primary care, was based on anti-CCP and rheumatoid factor (RF) titres, small joints tenderness and early morning stiffness (EMS). A second score developed for secondary care added power Doppler presence (PD+) and/or at least one allele positive for the shared epitope (SE+).Objectives:To validate previous data by scoring risk factors in a new cohort of 394 individuals.Methods:Individuals at risk of developing IA selected by a positive anti-CCP test and a new musculoskeletal symptom have been followed in a single-centre prospective observational cohort since 2008. The previous risk score was derived from 100 patients. With the same recruitment and follow-up pathways, the next 394 consecutive participants were studied (full data were available for 373 patients for secondary care model). Participants followed for less than 10 weeks without progression were excluded.Results:Participants from both cohorts were similar in terms of age and sex. Although the mean time to progression is comparable, there were significantly more participants with a high titre anti-CCP test in the 2015 cohort (Table 1).Table 1.Patients characteristicsScore20152020N100394Percentage of progression n/N50/100 (50%)82/413 (19.9%)Mean of follow-up before progression to IA (Months (SD))15.35 (15.27)13.50 (12.62)Mean follow-up of non progressors (Months (SD))39.7 (15.82)27.6 (19.75)Mean follow-up duration: all participants (Months (SD))27.7(19.36)24.8 (19.38)High CCP titre83%65%Women72%72%Smoker ever72%50%Age (Mean (SD))51.2 (11.9)50.2 (13.474)Cox multivariable analysis showed similar Hazard Ratios (HR) of progression in both groups (Table 2) confirming the high predictive value of high CCP/RF titre, early morning stiffness duration, power doppler presence and shared epitope. High risk of progression individuals identified by the secondary score were eight times more likely to develop IA (HR = 8.290, CI = 3.763-18.264, p<0.001), 50% of them had progressed at 2 years (Figure 1).Table 2.Multivariable Cox regression analysis of time to progression to inflammatory arthritis.2015 (n=98)2020 (n=394)Primary care modelHRp-valueCIHRp-valueCIHigh anti-CCP or RF titre4.860.0311.16−20.434.96<0.0011.445−3.526EMS≥30min1.860.0391.03−3.372.26<0.0011.445−3.526Small Joints Tenderness1.420.2520.78−2.571.300.2490.832−2.0352015 (n=98)2020 (n=373)Secondary care modelHRp-valueCIHRp-valueCIHigh anti-CCP or RF titre3.040.1470.68−13.63.920.0011.790−8.567EMS≥30min1.560.1670.83−2.922.100.0021.314−3.357Small Joints Tenderness1.540.1780.82−2.881.340.2160.843−2.135PD signal1.920.0331.06−3.502.350.0011.424−3.887Shared epitope1.570.2720.70−3.492.330.0031.333−4.059Figure 1.Probability of IA free survival according to categories of risk in the secondary care model.Conclusion:These data from a new large cohort confirm the validity previous Leeds Risk Scores for Primary and Secondary care, and the fidelity of the risk factors over time to predict progression.References:[1]Rakieh C, Nam JL, Hunt L, Hensor EM, Das S, Bissell LA, et al. Predicting the development of clinical arthritis in anti-CCP positive individuals with non-specific musculoskeletal symptoms: a prospective observational cohort study. Annals of the rheumatic diseases. 2015;74(9):1659-66.Disclosure of Interests:Laurence Duquenne: None declared, Jacqueline Nam: None declared, Kulveer Mankia: None declared, Leticia Garcia-Montoya: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor)
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Mankia K, Mustufvi Z, Kang J, Tugnait A, Letton R, Duquenne L, Speirs A, Clerehugh V, Devine D, Emery P. SAT0045 DISTRIBUTION AND SEVERITY OF PERIODONTITIS PREDICTS PROGRESSION TO INFLAMMATORY ARTHRITIS IN ANTI-CCP POSITIVE AT-RISK INDIVIDUALS WITHOUT CLINICAL SYNOVITIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.5589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:The prevalence of periodontal disease and the citrullinating bacteriumPorphyromonas gingivalisare increased in anti-CCP positive individuals at-risk of rheumatoid arthritis (RA) (1). This suggests periodontal inflammation may have an important role in the initiation and development of RA. Despite significant interest in the role of the periodontium and other mucosal sites in the initiation of RA-related autoimmunity, the influence of mucosal inflammation on progression to inflammatory arthritis (IA) in at-risk individuals remains unclear.Objectives:To investigate the association between periodontitis and progression to inflammatory arthritis in anti-CCP+ at-risk individuals without synovitis.Methods:Anti-CCP positive individuals with musculoskeletal symptoms but no clinical synovitis (CCP+ at-risk) were recruited as part of a national prospective cohort study. Comprehensive periodontal examination was performed at baseline by a dentist; six sites per tooth were assessed for clinical attachment level (CAL), pocket depth (PD) and bleeding on probing (BOP). Periodontal disease sites (PDD) were defined as CAL ≥2mm and PD ≥4mm. The distribution of PDD was classified in line with recent guidelines (2). The severity i.e. total burden of periodontal inflammation, was quantified at patient level using the periodontal inflamed surface area (PISA) index(3). CCP+ at-risk were monitored for progression to IA. Multivariable Cox regression was used to assess the effect of PDD distribution and PISA on progression to IA.Results:126 CCP+ at-risk underwent full periodontal examination and were followed up for median 23.4 months (range 0.6 – 56.8 months). Mean age was 49 years, 86 (68%) were females. At baseline, 42(33%) subjects had no PDD, 51(40%) had localised PDD (<30% teeth with one or more PDD site) and 33 (26%) had generalised PDD (≥ 30% of teeth with one or more PDD site). Mean (SD) PISA for all subjects was 267(319)mm2. 31 subjects (25%) progressed to IA after median of 12.6 months (range 0.6 – 49.5 months). Progression to IA was significantly higher in subjects with localised PDD compared with those without PDD (33% vs 16%, HR (95% CI) 2.45 (1.02, 5.94) p=0.02), figure 1. Interestingly, this association was not seen in subjects with generalised PDD (19% progression, HR 0.68 (0.20, 2.32). In addition, severity (i.e. total burden) of periodontal inflammation (PISA) was not significantly predictive of progression to IA alone (HR 1.001 (0.999-1.002), p=0.08). However, when adjusting for distribution of PDD, PISA was significantly associated with progression to IA (HR 1.0016 (1.0003- 1.003), p=0.00163).Conclusion:Periodontal inflammation predicts progression to IA in CCP+ at-risk individuals without clinical synovitis. The severity (i.e. total burden) of periodontitis appears to be particularly predictive of progression to IA in patients with localised periodontitis. These data suggest periodontitis may be an important factor in the development of RA and provide rationale for periodontal intervention with the aim of arthritis prevention in at-risk individuals.References:[1] Mankia K et al, JAMA Network Open(2019)[2] Caton J et al, J Clin Periodontol(2018)[3] Nesse W et al, J Clin Periodontol(2008)Disclosure of Interests :Kulveer Mankia: None declared, Zhain Mustufvi: None declared, Jing Kang: None declared, Aradhna Tugnait: None declared, Robert Letton: None declared, Laurence Duquenne: None declared, Alastair Speirs: None declared, Val Clerehugh: None declared, Deirdre Devine: None declared, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor)
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DI Matteo A, Mankia K, Duquenne L, Cipolletta E, Wakefield R, Nam J, Garcia-Montoya L, Emery P. FRI0557 IN INDIVIDUALS AT-RISK OF RHEUMATOID ARTHRITIS, ULTRASOUND BONE EROSIONS AT THE V METATARSOPHALANGEAL JOINTS ARE THE MOST PREDICTIVE FOR THE DEVELOPMENT OF CLINICAL ARTHRITIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:While the central role of bone erosions in the pathogenesis and diagnosis of patients with rheumatoid arthritis (RA) is widely recognized, their prevalence, pattern, and relationship with subclinical synovitis in individuals at-risk of RA (positive autoantibodies without clinical arthritis) is not well understood.Objectives:To investigate, in individuals at-risk of RA, the prevalence and distribution of ultrasound (US) bone erosions, their correlation with subclinical synovitis at joint level, and their association with the development of inflammatory arthritis (IA).Methods:Baseline US scans of 2ndgeneration anti-cyclic citrullinated peptide (CCP) positive at-risk subjects with musculoskeletal symptoms (without clinical arthritis) taking part in the Leeds CCP study were analyzed. The presence of bone erosions was evaluated in the classic sites for RA damage: the II and V metacarpophalangeal (MCP) joints, and the V metatarsophalangeal (MTP) joints1. US synovitis was defined as synovial hypertrophy (SH) ≥2 or SH ≥1 + power Doppler signal ≥12. Only subjects with ≥1 follow-up visit were included in the progression analysis (n=400). Progression to IA was defined as the development of clinical synovitis in ≥1 one joint.Results:US bone erosions: prevalence, distribution, and association with subclinical synovitisA total of 2514 joints, in 419 subjects were evaluated.Bone erosions were found in ≥1 joint in 41/419 subjects (9.8%), in 55/2514 joints (2.2%). The prevalence of bone erosions was significantly higher in the V MTP than in the MCP joints (p<0.01). They were detected in 42 V MTP (31 subjects; 7.4%), in 10 II MCP (10 subjects; 2.4%), and in 3 V MCP (3 subjects; 0.7%) joints. US synovitis was detected in 22/55 joints (40%) with bone erosions, in 17/41 subjects (42%). It was found in 48.6% of the V MTP, in 20% of the II MCP and in none of the V MCP joints with bone erosions. A significant correlation between bone erosions and synovitis in the same joint was detected (Cramer’s V=0.22, p<0.01).Seven out of the 55 joints (12.7%) with bone erosions were tender on physical examination: 14.3% of the V MTP, 10% of the II MCP, and none of the V MCP joints.US bone erosions: predicting development of IAA total of 122 subjects (30.5%) developed IA (median follow-up: 301 days, IQR 112-721). The hazard ratios of the US findings for the development of IA (adjusted for age, sex, smoking, anti-CCP and rheumatoid factor titer) are reported in Table 1.Table 1.EverAt 1 yearAt 3 yearsHR (95%CI)P valueHR (95%CI)P valueHR (95%CI)P valuePresence of bone erosion in ≥1 joint (any joint)3.98(1.82-8.7)<0.013.57(1.7-7.5)<0.013.48(1.63-7.4)<0.01- in the II MCP joints2.4(0.52-11.08)0.261.07(0.2-5.76)0.941.67(0.38-7.04)0.5- in the V MCP joints1.37(0.06-31)0.850(N/A)10(N/A)1- in the V MTP joints4.79(1.97-11.63)<0.015.23(2.32-11.8)<0.015.43(2.28-12.92)<0.01Presence of bone erosion and synovitis in the same joint (any joint)3.9(1.19-12.77)0.026.03(2.07-17.55)<0.013.91(1.29-11.85)0.02Presence of bone erosion and synovitis in the same V MTP joint5.08(1.37-18.9)0.027.03(2.28-21.71)<0.014.89(1.48-16.19)<0.01Presence of bone erosion in >1 joint (any joint)10.63(1.87-60.42)<0.015.68(1.66-19.5)<0.017.26(1.67-31.66)<0.01IA free survival rates are showed in Figures 1 and 2.Figure 1.Figure 2.Conclusion:The feet appear to be an early site for damage in individuals at-risk of RA. US bone erosions were mainly detected in asymptomatic joints, but frequently in association with subclinical synovitis. In individuals at-risk of RA, bone erosions in the V MTP joints are more predictive than in the hands (II and V MCP joints) for the development of IA.References:[1] Zayat AS, et al. Ann Rheum Dis. 2015;[2] D’Agostino, et al. RMD Open. 2017;Disclosure of Interests:Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Kulveer Mankia: None declared, Laurence Duquenne: None declared, Edoardo Cipolletta: None declared, Richard Wakefield Speakers bureau: Novartis, Janssen, GE, Jacqueline Nam: None declared, Leticia Garcia-Montoya: None declared, Paul Emery Grant/research support from: AbbVie, Bristol-Myers Squibb, Merck Sharp & Dohme, Pfizer, Roche (all paid to employer), Consultant of: AbbVie (consultant, clinical trials, advisor), Bristol-Myers Squibb (consultant, clinical trials, advisor), Lilly (clinical trials, advisor), Merck Sharp & Dohme (consultant, clinical trials, advisor), Novartis (consultant, clinical trials, advisor), Pfizer (consultant, clinical trials, advisor), Roche (consultant, clinical trials, advisor), Samsung (clinical trials, advisor), Sandoz (clinical trials, advisor), UCB (consultant, clinical trials, advisor)
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