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Sepriano A, Ramiro S, Landewé R, van der Heijde D, Ohrndorf S, FitzGerald O, Backhaus M, Larché M, Homik J, Saraux A, Hammer HB, Terslev L, Østergaard M, Burmester G, Combe B, Dougados M, Hitchon C, Boire G, Lambert RG, Dadashova R, Paschke J, Hutchings EJ, Maksymowych WP. Adding ultrasound to treat-to-target shows no benefit in achieving clinical remission nor in slowing radiographic progression in rheumatoid arthritis: results from a multicenter prospective cohort. Clin Rheumatol 2024:10.1007/s10067-024-06978-5. [PMID: 38684600 DOI: 10.1007/s10067-024-06978-5] [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: 02/14/2024] [Revised: 04/11/2024] [Accepted: 04/22/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE To assess whether using ultrasound (US) in addition to clinical information versus only clinical information in a treat-to-target (T2T) strategy leads to more clinical remission and to less radiographic progression in RA. METHODS Patients with RA from the 2-year prospective BIODAM cohort were included. Clinical and US data (US7-score) were collected every 3 months and hands and feet radiographs every 6 months. At each visit, it was decided whether patients were treated according to the clinical definition of T2T with DAS44 remission as benchmark (T2T-DAS44). T2T-DAS44 was correctly applied if: (i) DAS44 remission had been achieved or (ii) if not, treatment was intensified. A T2T strategy also considering US data (T2T-DAS44-US) was correctly applied if: (i) both DAS44 and US remission (synovitis-score < 2, Doppler-score = 0) were present; or (ii) if not, treatment was intensified. The effect of T2T-DAS44-US on attaining clinical remission and on change in Sharp-van der Heijde score compared to T2T-DAS44 was analysed. RESULTS A total of 1016 visits of 128 patients were included. T2T-DAS44 was correctly followed in 24% of visits and T2T-DAS44-US in 41%. DAS44 < 1.6 was achieved in 39% of visits. Compared to T2T-DAS44, using the T2T-DAS44-US strategy resulted in a 41% lower likelihood of DAS44 remission [OR (95% CI): 0.59 (0.40;0.87)] and had no effect on radiographic progression [β(95% CI): 0.11 (- 0.16;0.39)] assessed at various intervals up to 12 months later. CONCLUSION Our results do not suggest a benefit of using the US7-score in addition to clinical information as a T2T benchmark compared to clinical information alone. Key Points • Ultrasound has a valuable role in diagnostic evaluation of rheumatoid arthritis, but it is unclear whether adding ultrasound to the clinical assessment in a treat-to-target (T2T) strategy leads to more patients achieving remission and reduction in radiographic progression. • Our data from a real-world study demonstrated that adding information from ultrasound to the clinical assessment in a T2T strategy led to a lower rather than a higher likelihood of obtaining clinical remission as compared to using only clinical assessment. • Our data demonstrated that adding ultrasound data to a T2T strategy based only on clinical assessment did not offer additional protection against radiographic progression in patients with RA. • Adding US to a T2T strategy based on clinical assessment led to far more treatment intensifications (with consequences for costs and exposure to adverse events) without yielding a meaningful clinical benefit.
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Affiliation(s)
- Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Zuyderland Medical Center, Heerlen, The Netherlands
| | - Robert Landewé
- Zuyderland Medical Center, Heerlen, The Netherlands
- Amsterdam University Medical Center (ARC), Amsterdam, The Netherlands
| | | | - Sarah Ohrndorf
- Department of Internal Medicine - Rheumatology and Clinical Immunology, Academic Hospital of Charité - Universitätsmedizin Berlin, Parkklinik Weissensee, Berlin, Germany
| | - Olivier FitzGerald
- Department of Rheumatology, St. Vincent's University Hospital, Dublin, Ireland
- Conway Institute for Biomolecular Research, University College Dublin, Dublin, Ireland
| | - Marina Backhaus
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maggie Larché
- Divisions of Rheumatology and Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Joanne Homik
- Department of Medicine, University of Alberta, 568 Heritage Medical Research Building, Edmonton, T6G 2S2, Canada
| | - Alain Saraux
- LBAI, U1227, University of Brest, Inserm; CHRU Brest, F-29200, Brest, France
| | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bernard Combe
- Departement de Rhumatologie, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Maxime Dougados
- Rheumatology Department, Paris Descartes University, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Carol Hitchon
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Gilles Boire
- Division of Rheumatology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie - CHUS), Université de Sherbrooke, Québec, Canada
| | - Robert G Lambert
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
- Medical Imaging Consultants, Edmonton, Canada
| | | | | | | | - Walter P Maksymowych
- Department of Medicine, University of Alberta, 568 Heritage Medical Research Building, Edmonton, T6G 2S2, Canada.
- CARE ARTHRITIS LTD, Edmonton, Canada.
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Labinsky H, May S, Boy K, von Rohr S, Grahammer M, Kuhn S, Rojas-Restrepo J, Vogt E, Heinze M, Schett G, Muehlensiepen F, Knitza J. Evaluation of a hybrid telehealth care pathway for patients with axial spondyloarthritis including self-sampling at home: results of a longitudinal proof-of-concept mixed-methods study (TeleSpactive). Rheumatol Int 2024:10.1007/s00296-024-05581-w. [PMID: 38602534 DOI: 10.1007/s00296-024-05581-w] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 04/12/2024]
Abstract
Patients with axial spondyloarthritis (axSpA) require close monitoring to achieve the goal of sustained disease remission. Telehealth can facilitate continuous care while relieving scarce healthcare resources. In a mixed-methods proof-of-concept study, we investigated a hybrid telehealth care axSpA pathway in patients with stable disease over 6 months. Patients used a medical app to document disease activity (BASDAI and PtGA bi-weekly, flare questionnaire weekly). To enable a remote ASDAS-CRP (TELE-ASDAS-CRP), patients used a capillary self-sampling device at home. Monitoring results were discussed and a decision was reached via shared decision-making whether a pre-planned 3-month on-site appointment (T3) was necessary. Ten patients completed the study, and eight patients also completed additional telephone interviews. Questionnaire adherence was high; BASDAI (82.3%), flares (74.8%) and all patients successfully completed the TELE-ASDAS-CRP for the T3 evaluation. At T3, 9/10 patients were in remission or low disease activity and all patients declined the offer of an optional T3 on-site appointment. Patient acceptance of all study components was high with a net promoter score (NPS) of +50% (mean NPS 8.8 ± 1.5) for self-sampling, +70% (mean NPS 9.0 ± 1.6) for the electronic questionnaires and +90% for the T3 teleconsultation (mean NPS 9.7 ± 0.6). In interviews, patients reported benefits such as a better overview of their condition, ease of use of telehealth tools, greater autonomy, and, most importantly, travel time savings. To our knowledge, this is the first study to investigate a hybrid approach to follow-up axSpA patients including self-sampling. The positive results observed in this scalable proof-of-concept study warrant a larger confirmatory study.
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Affiliation(s)
- Hannah Labinsky
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany.
- Department of Internal Medicine 2, Rheumatology/Clinical Immunology, University Hospital Würzburg, Oberdürrbacher Straße 6, Würzburg, Germany.
| | - Susann May
- Center for Health Services Research, Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Katharina Boy
- Center for Health Services Research, Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Sophie von Rohr
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Manuel Grahammer
- Center for Health Services Research, Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Abaton GmbH, Berlin, Germany
| | - Sebastian Kuhn
- Institute for Digital Medicine, University Hospital of Giessen and Marburg, Marburg, Germany
| | | | | | - Martin Heinze
- Center for Health Services Research, Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Department of Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Hospital Rüdersdorf, Rüdersdorf, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Department of Internal Medicine 2, Rheumatology/Clinical Immunology, University Hospital Würzburg, Oberdürrbacher Straße 6, Würzburg, Germany
| | - Felix Muehlensiepen
- Center for Health Services Research, Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- AGEIS, Université Grenoble Alpes, Grenoble, France
| | - Johannes Knitza
- Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Department of Internal Medicine 2, Rheumatology/Clinical Immunology, University Hospital Würzburg, Oberdürrbacher Straße 6, Würzburg, Germany
- AGEIS, Université Grenoble Alpes, Grenoble, France
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Smith EMD, Aggarwal A, Ainsworth J, Al-Abadi E, Avcin T, Bortey L, Burnham J, Ciurtin C, Hedrich CM, Kamphuis S, Lambert L, Levy DM, Lewandowski L, Maxwell N, Morand E, Özen S, Pain CE, Ravelli A, Saad Magalhaes C, Pilkington C, Schonenberg-Meinema D, Scott C, Tullus K, Beresford MW. Defining remission in childhood-onset lupus: PReS-endorsed consensus definitions by an international task force. Clin Immunol 2024; 263:110214. [PMID: 38604255 DOI: 10.1016/j.clim.2024.110214] [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: 01/23/2024] [Revised: 03/30/2024] [Accepted: 04/07/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To derive childhood-onset SLE (cSLE) specific remission definitions for future treat-to-target (T2T) trials, observational studies, and clinical practice. METHODS The cSLE International T2T Task Force conducted Delphi surveys exploring paediatric perspectives on adult-onset SLE remission targets. A modified nominal group technique was used to discuss, refine, and agree on the cSLE remission target criteria. RESULTS The Task Force proposed two definitions of remission: 'cSLE clinical remission on steroids (cCR)' and 'cSLE clinical remission off steroids (cCR-0)'. The common criteria are: (1) Clinical-SLEDAI-2 K = 0; (2) PGA score < 0.5 (0-3 scale); (4) stable antimalarials, immunosuppressive, and biologic therapy (changes due to side-effects, adherence, weight, or when building up to target dose allowed). Criterion (3) in cCR is the prednisolone dose ≤0.1 mg/kg/day (maximum 5 mg/day), whereas in cCR-0 it is zero. CONCLUSIONS cSLE definitions of remission have been proposed, maintaining sufficient alignment with the adult-SLE definition to facilitate life-course research.
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Affiliation(s)
- E M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - A Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - J Ainsworth
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - E Al-Abadi
- Department of Paediatric Rheumatology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - T Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Slovenia
| | - L Bortey
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - J Burnham
- Department of Pediatric Rheumatology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - C Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Division of Medicine, University College London, UK
| | - C M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - S Kamphuis
- Department of Pediatric Rheumatology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - L Lambert
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - D M Levy
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - L Lewandowski
- Lupus Genomics and Global Health Disparities Unit, Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - N Maxwell
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - E Morand
- Centre for Inflammatory Diseases, Monash University, Melbourne, Australia
| | - S Özen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - C E Pain
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - A Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
| | - C Saad Magalhaes
- Paediatric Rheumatology Division, Botucatu Medical School, Sao Paulo State, University (UNESP), Sao Paulo, Brazil
| | - C Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - D Schonenberg-Meinema
- Department of Pediatric Immunology, Rheumatology and Infectious diseases, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - C Scott
- Department of Pediatric Rheumatology, University of Cape Town, Cape Town, South Africa
| | - K Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - M W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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Armstrong A, González-Cantero A, Khattri S, Muzy G, Malatestinic WN, Lampropoulou A, Feely M, See SK, Mert C, Blauvelt A. Comparing Achievement of National Psoriasis Foundation Treatment Targets among Patients with Plaque Psoriasis Treated with Ixekizumab versus Other Biologics in Clinical and Real-World Studies. Dermatol Ther (Heidelb) 2024; 14:933-952. [PMID: 38521874 PMCID: PMC11052751 DOI: 10.1007/s13555-024-01136-w] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 02/29/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION The National Psoriasis Foundation (NPF) recommends evaluating patient response to treatment at week 12, with a target response of ≤ 1% body surface area (BSA) affected by plaque psoriasis and an acceptable response of BSA ≤ 3% or ≥ 75% improvement. This post hoc analysis compared the achievement of NPF target and acceptable responses for ixekizumab (IXE) versus other biologics. METHODS Outcomes were evaluated at week 12 for patients with moderate-to-severe plaque psoriasis from four head-to-head randomized clinical trials (RCTs; UNCOVER-2, UNCOVER-3, IXORA-R, and IXORA-S) and one real-world prospective observational study (Psoriasis Study of Health Outcomes; PSoHO). RCT patients were treated with IXE or etanercept (ETN; UNCOVER-2/3), guselkumab (GUS; IXORA-R), or ustekinumab (UST; IXORA-S). PSoHO patients were treated with anti-interleukin (IL)-17A biologics (IXE, secukinumab, SEC) and other approved biologics for the treatment of plaque psoriasis. Patients with missing outcomes were imputed as non-responder imputation. For RCT data, statistical comparisons between treatment groups were performed using Fisher's exact test with no multiplicity adjustments. For real-world data, adjusted comparative analyses were performed using frequentist model averaging (FMA) and reported as odds ratio (OR). RESULTS Across the four head-to-head clinical trials analyzed, significantly higher proportions of patients achieved target and acceptable responses at week 12 with IXE versus ETN, GUS, or UST. Likewise, the proportion of PSoHO patients achieving target and acceptable response at week 12 was higher with IXE compared with other individual biologics. Adjusted comparative analyses showed that IXE had significantly greater odds of target and acceptable response at week 12 versus SEC, GUS, risankizumab (RIS), adalimumab (ADA), UST, and tildrakizumab (TILD) and numerically greater odds of target and acceptable response at week 12 versus brodalumab (BROD). CONCLUSION Across both clinical studies and real-world settings, more patients treated with IXE achieved NPF target and acceptable responses at week 12 compared with those treated with other biologics. TRIAL REGISTRATION UNCOVER-2 (NCT01597245); UNCOVER-3 (NCT01646177); IXORA-R (NCT03573323); IXORA-S (NCT02561806); PSoHO (EUPAS24207).
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Affiliation(s)
| | - Alvaro González-Cantero
- Ramón y Cajal University Hospital, Madrid, Spain
- Faculty of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | | | | | | | | | - Meghan Feely
- Mount Sinai Hospital, New York, NY, USA
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Can Mert
- HaaPACS GmbH, Schriesheim, Germany
| | - Andrew Blauvelt
- Oregon Medical Research Center, 9495 SW Locust St., Suite G, Portland, OR, 97223, USA.
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Ortolan A, Lorenzin M, Cozzi G, Scagnellato L, Favero M, Striani G, Vio S, Scapin V, De Conti G, Doria A, Ramonda R. Treat-to-target in real-life psoriatic arthritis patients: achieving minimal disease activity with bDMARDs/tsDMARDs and potential barriers. Semin Arthritis Rheum 2023; 62:152237. [PMID: 37453183 DOI: 10.1016/j.semarthrit.2023.152237] [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] [Received: 04/02/2023] [Revised: 06/10/2023] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE (1) to describe the frequency of minimal disease activity (MDA) in a real-life psoriatic arthritis (PsA) cohort, (2) to longitudinally explore predictors of MDA; (3) to examine frequency and predictors of low disease activity (LDA) in patients with axial involvement (axPsA). METHODS consecutive PsA patients in stable biological/targeted-synthetic Disease-Modifying Anti-Rheumatic Drugs (bDMARDs/tDMARDs) who attended our center were enrolled. Disease activity indices, including MDA and ankylosing spondylitis disease activity score-LDA (ASDAS-LDA) for axPsA, were evaluated at baseline and every 6 months, up to 36 months or bDMARDs/tsDMARDs discontinuation. Patients' history, BMI, comorbidities - including osteoarthritis (OA) and fibromyalgia - were collected. Variables were compared between patients who achieved sustained MDA and those who did not. Multivariable generalized estimating equation (GEE) models were built to identify predictors of MDA and ASDAS-LDA over time. Data were expressed as beta coefficient (95%CI). RESULTS 104 patients were enrolled, 54% males, mean age 55.7 years; 52% had axPsA. Across all evaluations, 52-61% reached MDA, and 17-24% achieved ASDAS-LDA. AxPsA, fibromyalgia, OA and BMI≥35 were less frequently observed in patients with sustained MDA. The GEE model confirmed the following factors were significantly and independently associated with MDA: age (Beta=-0.05), bDMARDs/tsDMARDs duration (Beta=+0.31), axPsA (Beta=-1.07), fibromyalgia (Beta=-3.35), OA (Beta=-1.87), BMI≥35 (Beta=-2.53). Age (Beta=-0.01), fibromyalgia (Beta=-2.03) and OA (Beta=-1.30) were also independently associated with ASDAS-LDA. CONCLUSIONS MDA is an attainable target in real-life. AxPsA represents a difficult-to-treat subset. Sustained MDA depends on disease features (axPsA) as well as patients' characteristics (e.g. age, bDMARDs/tDMARDs duration, comorbidities).
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Affiliation(s)
- Augusta Ortolan
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Mariagrazia Lorenzin
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Giacomo Cozzi
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Laura Scagnellato
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Marta Favero
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy; Internal Medicine I, Cà Foncello Hospital, Treviso 31100, Italy
| | - Giovanni Striani
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Stefania Vio
- Internal Medicine I, Cà Foncello Hospital, Treviso 31100, Italy
| | - Vanna Scapin
- Internal Medicine I, Cà Foncello Hospital, Treviso 31100, Italy
| | | | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy; Radiology Unit, University of Padova, Padova, Italy.
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Bessette L, Haraoui B, Rampakakis E, Dembowy J, Trépanier MO, Pope J. Effectiveness of a treat-to-target strategy in patients with moderate to severely active rheumatoid arthritis treated with abatacept. Arthritis Res Ther 2023; 25:183. [PMID: 37759330 PMCID: PMC10537125 DOI: 10.1186/s13075-023-03151-2] [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: 04/14/2023] [Accepted: 08/27/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND To compare a treat-to-target (T2T) approach and routine care (RC) in adults with active to severely active rheumatoid arthritis (RA) initiating subcutaneous abatacept. METHODS A 12-month cluster-randomized trial in active RA patients treated with abatacept was conducted. Physicians were randomized to RC or T2T with a primary endpoint of achieving sustained Clinical Disease Activity Index (CDAI) low disease activity (LDA) at two consecutive assessments approximately 3 months apart. Additional outcomes included Simple Disease Activity Index (SDAI), Disease Activity Score 28-CRP (DAS28-CRP), Routine Assessment of Patient Index Data 3 (RAPID3), and the Health Assessment Questionnaire-Disability Index (HAQ-DI). Time to achieve therapeutic endpoints was assessed with survival analysis. RESULTS Among the 284 enrolled patients, 130 were in the T2T group and 154 in RC. Primary endpoint was achieved by 36.9% and 40.3% of patients in T2T and RC groups, respectively. No significant between-group differences were observed in the odds of achieving secondary outcomes, except for a higher likelihood of CDAI LDA in the T2T group vs. RC (odds ratio [95% confidence interval]: 1.33 [1.03-1.71], p = 0.0263). Compared with RC, patients in the T2T group achieved SDAI remission significantly faster (Kaplan-Meier-estimated mean [standard error]: 14.0 [0.6] vs. 19.3 [0.8] months, p = 0.0428) with a trend toward faster achievement of CDAI LDA/remission, DAS28-CRP remission, and HAQ-DI minimum clinically important difference. CONCLUSIONS Patients managed per T2T and those under RC experienced significant improvements in RA disease activity at 12 months of abatacept treatment. T2T was associated with higher odds of CDAI LDA and a shorter time to achieving therapeutic endpoints. TRIAL REGISTRATION Name of the registry: ClinicalTrials.gov. TRIAL REGISTRATIONS NCT03274141 . Date of registration: September 6, 2017.
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Affiliation(s)
- Louis Bessette
- Department of Medicine, Laval University, Quebec, QC, Canada
| | - Boulos Haraoui
- Centre Hospitalier de L'Université de Montréal, Montreal, Québec, Canada
| | - Emmanouil Rampakakis
- Department of Pediatrics, McGill University, Montreal, Canada
- JSS Medical Research, Montreal, Canada
| | | | | | - Janet Pope
- Division of Rheumatology, Department of Medicine, Western University, 268 Grosvenor Street, London, ON, N6A 4V2, Canada.
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Ehlers L, Rolfes E, Lieber M, Müller D, Lainka E, Gohar F, Klaus G, Girschick H, Hörstermann J, Kümmerle-Deschner J, Brunner J, Palm-Beden K, Tenbrock K, von Wrangel L, Faßhauer M, Blank N, Trauzeddel R, von Stuckrad ASL, Higgins S, Welzel T, Lutz T, Hentgen V, Foell D, Wittkowski H, Kallinich T. Treat-to-target strategies for the management of familial Mediterranean Fever in children. Pediatr Rheumatol Online J 2023; 21:108. [PMID: 37752496 PMCID: PMC10521475 DOI: 10.1186/s12969-023-00875-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 08/11/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND The objective of this initiative was to develop a treat-to-target (T2T) approach for the management of patients with Familial Mediterranean Fever (FMF), including the definition of a complex treatment target, and establish strategies that improve patient care and long-term outcome. METHODS An initial set of statements as well as a flow chart visualising the proposed concept was developed. To adapt the preliminary statements to the current state of knowledge, a systematic literature search was performed and the modified statements were subject to a Delphi approach. To ensure the applicability of the statements in daily practice, an online survey was conducted among paediatric rheumatologists in Germany. In addition, data from the national AID-NET registry were analysed with respect to therapeutic response. RESULTS This T2T initiative yielded a total of 26 statements guiding FMF management with respect to diagnosis, treatment targets, treatment strategies and monitoring. The online survey identified cut-off values for inflammatory markers indicating treatment intensification and appropriate measures in case of colchicine intolerance or non-adherence. The analysis of data derived from the national AID-NET showed that colchicine therapy was successfully terminated in 61% of patients (27 out of 44) with heterozygous MEFV mutations. Multidimensional treatment targets incorporating objective and subjective reported outcome measures were developed. These provide the basis for stratifying patients into the following treatment paths: continue colchicine, persisting attacks / inflammation, colchicine intolerance, persisting arthritis, colchicine reduction and adjustment/reduction of biologics. CONCLUSIONS The proposed consensus treatment plan for the management of FMF incorporates multidimensional targets allowing transparent treatment decisions, which will promote personalised disease management and increase adherence to therapy.
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Affiliation(s)
- Lisa Ehlers
- Department of Paediatric Pulmonology, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Elisabeth Rolfes
- Department of Paediatric Pulmonology, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Mareike Lieber
- Department of Paediatric Pulmonology, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dominik Müller
- Department of Paediatrics, Division of Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Elke Lainka
- Department of Paediatrics II, University Hospital Essen, Children's Hospital, Essen, Germany
| | - Faekah Gohar
- Clinic of Paediatric and Adolescent Rheumatology, St. Josef-Stift Sendenhorst, Northwest German Center for Rheumatology, Sendenhorst, Germany
| | - Günter Klaus
- KfH Center of Paediatric Nephrology, Department of Paediatric Nephrology, Marburg, Germany
| | - Hermann Girschick
- Vivantes Klinikum Friedrichshain, Children's Hospital, Berlin, Germany
| | - Jana Hörstermann
- Deutsches Rheuma-Forschungszentrum (DRFZ), An Institute of the Leibniz Association, Berlin, Germany
| | - Jasmin Kümmerle-Deschner
- Autoinflammation Reference Center Tübingen (arcT), Division of Paediatric Rheumatology, Department of Paediatrics, University Hospital Tübingen, Tübingen, Germany
| | - Jürgen Brunner
- Department of Paediatrics, Medical University Innsbruck, Danube Private University, Innsbruck, Krems, Austria
| | - Katharina Palm-Beden
- Clinic of Paediatric and Adolescent Rheumatology, St. Josef-Stift Sendenhorst, Northwest German Center for Rheumatology, Sendenhorst, Germany
| | - Klaus Tenbrock
- Department of Paediatric Pneumology, Allergology and Immunology, RWTH Aachen, Aachen, Germany
| | | | - Maria Faßhauer
- ImmunoDeficiencyCenter Leipzig (IDCL), Hospital St. Georg GmbH Leipzig, Academic Teaching Hospital of the University of Leipzig, Leipzig, Germany
| | - Norbert Blank
- Department of Hematology, Oncology and Rheumatology, Internal Medicine V, University Hospital of Heidelberg, Heidelberg, Germany
| | - Ralf Trauzeddel
- Department of Paediatrics, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Anne Sae Lim von Stuckrad
- Department of Paediatric Pulmonology, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sonja Higgins
- Paediatric medical practice Hürthpark, Hürth, Germany
| | - Tatjana Welzel
- Autoinflammation Reference Center Tübingen (arcT), Division of Paediatric Rheumatology, Department of Paediatrics, University Hospital Tübingen, Tübingen, Germany
- Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University Basel, Basel, Switzerland
| | - Thomas Lutz
- Center for Rheumatology, Paediatric Rheumatology, Heidelberg, Germany
| | - Véronique Hentgen
- Department of Paediatrics, National Reference Center for Auto-inflammatory Diseases and Amyloidosis, CEREMAIA, Versailles Hospital, Versailles, France
| | - Dirk Foell
- Department of Paediatric Rheumatology and Immunology, University Hospital Münster, Münster, Germany
| | - Helmut Wittkowski
- Department of Paediatric Rheumatology and Immunology, University Hospital Münster, Münster, Germany
| | - Tilmann Kallinich
- Department of Paediatric Pulmonology, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
- Deutsches Rheuma-Forschungszentrum (DRFZ), An Institute of the Leibniz Association, Berlin, Germany.
- Berlin Institute of Health (BIH), Berlin, Germany.
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Koppejan H, Beyrend G, Hameetman M, Abdelaal T, Toes REM, van Gaalen FA. Spondyloarthritis mass cytometry immuno-monitoring: a proof of concept study in the tight-control and treat-to target TiCoSpA trial. Clin Rheumatol 2023; 42:2387-2396. [PMID: 37306812 PMCID: PMC10412466 DOI: 10.1007/s10067-023-06637-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Mass cytometry (MC) immunoprofiling allows high-parameter phenotyping of immune cells. We set to investigate the potential of MC immuno-monitoring of axial spondyloarthritis (axSpA) patients enrolled in the Tight Control SpondyloArthritis (TiCoSpA) trial. METHODS Fresh, longitudinal PBMCs samples (baseline, 24, and 48 weeks) from 9 early, untreated axSpA patients and 7 HLA-B27+ controls were analyzed using a 35-marker panel. Data were subjected to HSNE dimension reduction and Gaussian mean shift clustering (Cytosplore), followed by Cytofast analysis. Linear discriminant analyzer (LDA), based on initial HSNE clustering, was applied onto week 24 and 48 samples. RESULTS Unsupervised analysis yielded a clear separation of baseline patients and controls including a significant difference in 9 T cell, B cell, and monocyte clusters (cl), indicating disrupted immune homeostasis. Decrease in disease activity (ASDAS score; median 1.7, range 0.6-3.2) from baseline to week 48 matched significant changes over time in five clusters: cl10 CD4 Tnai cells median 4.7 to 0.02%, cl37 CD4 Tem cells median 0.13 to 8.28%, cl8 CD4 Tcm cells median 3.2 to 0.02%, cl39 B cells median 0.12 to 2.56%, and cl5 CD38+ B cells median 2.52 to 0.64% (all p<0.05). CONCLUSIONS Our results showed that a decrease in disease activity in axSpA coincided with normalization of peripheral T- and B-cell frequency abnormalities. This proof of concept study shows the value of MC immuno-monitoring in clinical trials and longitudinal studies in axSpA. MC immunophenotyping on a larger, multi-center scale is likely to provide crucial new insights in the effect of anti-inflammatory treatment and thereby the pathogenesis of inflammatory rheumatic diseases. Key Points • Longitudinal immuno-monitoring of axSpA patients through mass cytometry indicates that normalization of immune cell compartments coincides with decrease in disease activity. • Our proof of concept study confirms the value of immune-monitoring utilizing mass cytometry.
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Affiliation(s)
- Hester Koppejan
- Department of Rheumatology, Leiden University Medical Center, PO box 9600 (Zone C1-R), Albinusdreef 2, 2233, ZA, Leiden, The Netherlands.
| | - Guillaume Beyrend
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjolijn Hameetman
- Department of Rheumatology, Leiden University Medical Center, PO box 9600 (Zone C1-R), Albinusdreef 2, 2233, ZA, Leiden, The Netherlands
- Flow Core Facility, Leiden University Medical Center, Leiden, The Netherlands
| | - Tamim Abdelaal
- Department of Radiology, Leiden University Medical Center, Leiden, Leiden, The Netherlands
- Faculty of Engineering, Systems and Biomedical Engineering Department, Cairo University, Cairo, Egypt
- Delft Bioinformatics Lab, Delft University of Technology, Delft, The Netherlands
| | - René E M Toes
- Department of Rheumatology, Leiden University Medical Center, PO box 9600 (Zone C1-R), Albinusdreef 2, 2233, ZA, Leiden, The Netherlands
| | - Floris A van Gaalen
- Department of Rheumatology, Leiden University Medical Center, PO box 9600 (Zone C1-R), Albinusdreef 2, 2233, ZA, Leiden, The Netherlands
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Smith EMD, Aggarwal A, Ainsworth J, Al-Abadi E, Avcin T, Bortey L, Burnham J, Ciurtin C, Hedrich CM, Kamphuis S, Lambert L, Levy DM, Lewandowski L, Maxwell N, Morand E, Ozen S, Pain CE, Ravelli A, Saad Magalhaes C, Pilkington C, Schonenberg-Meinema D, Scott C, Tullus K, Beresford MW. PReS-endorsed international childhood lupus T2T task force definition of childhood lupus low disease activity state (cLLDAS). Clin Immunol 2023; 250:109296. [PMID: 36934849 PMCID: PMC10500564 DOI: 10.1016/j.clim.2023.109296] [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: 01/10/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVE To achieve a consensus-based definition of Low Disease Activity (LDA) for use in cSLE trials. METHODS The International cSLE T2T Task Force, comprising of paediatric rheumatologists/nephrologists, and adult rheumatologists undertook a series of Delphi surveys/consensus meetings to discuss, refine, and vote upon cSLE LDA criteria. RESULTS The Task Force agreed that LDA should be based upon the adult-SLE Lupus Low Disease Activity State definition (LLDAS), with modifications to make it applicable to cSLE (cLLDAS). They agreed upon five cLLDAS criteria: (1) SLE Disease Activity Index (SLEDAI)-2 K ≤4, with no activity in major organ systems; (2) no new features of lupus disease activity compared with the last assessment; (3) Physician Global Assessment score of ≤1 (0-3 scale); (4) prednisolone dose of ≤0.15 mg/kg/day, 7.5 mg/day/maximum; while on (5) stable antimalarials, immunosuppressives, and biologics. CONCLUSIONS A cSLE-appropriate definition of cLLDAS has been generated, maintaining alignment with the adult-SLE definition to promote life-course research.
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Affiliation(s)
- E M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - A Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - J Ainsworth
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - E Al-Abadi
- Department of Paediatric Rheumatology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - T Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center Ljubljana, Slovenia
| | - L Bortey
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - J Burnham
- Department of Pediatric Rheumatology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - C Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis, Division of Medicine, University College London, UK
| | - C M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - S Kamphuis
- Department of Pediatric Rheumatology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - L Lambert
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - D M Levy
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - L Lewandowski
- Lupus Genomics and Global Health Disparities Unit, Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - N Maxwell
- TARGET Lupus Public Patient Involvement and Engagement Group, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - E Morand
- Centre for Inflammatory Diseases, Monash University, Melbourne, Australia
| | - S Ozen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - C E Pain
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - A Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
| | - C Saad Magalhaes
- Department of Pediatric Rheumatology, Botucatu Medical School, Sao Paulo State University, Sao Paulo, Brazil
| | - C Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - D Schonenberg-Meinema
- Department of Pediatric Immunology, Rheumatology and Infectious diseases, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - C Scott
- Clinical Research Centre, Department of Pediatric Rheumatology, University of Cape Town, Cape Town, South Africa
| | - K Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - M W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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10
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Maksymowych WP, Inman RD, Bessette L, Rahman P, Rampakakis E, Asin-Milan O, Rachich M, Marrache AM, Lehman AJ. Sustained low functional impairment in axial spondyloarthritis (axSpA): which are the primary outcomes that should be targeted to achieve this? Arthritis Res Ther 2023; 25:70. [PMID: 37118833 PMCID: PMC10148455 DOI: 10.1186/s13075-023-03055-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/20/2023] [Indexed: 04/30/2023] Open
Abstract
OBJECTIVES To (i) determine whether sustained disease activity states, as measured by Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS), impact function, and (ii) evaluate characteristics predicting sustained low functional impairment in a prospective axial spondyloarthritis (axSpA) cohort. METHODS Biologic Treatment Registry Across Canada (BioTRAC) was a multi-center, prospective registry that collected real-world data on axSpA patients receiving infliximab or golimumab between 2006 and 2017. Generalized estimating equations (GEE) were used to test baseline characteristics, treatment, and duration (at 6 and 12 months vs. only at 6 or 12 months vs. neither) of low BASDAI (< 3), ASDAS-inactive disease (ID)(< 1.3), and ASDAS-low disease activity (LDA) in predicting sustained low Bath Ankylosing Spondylitis Functional Index (BASFI)(< 3) between 12 and 18 months. The adjusted impact of achieving low disease state at 6 and/or 12 months on BASFI at 18 months was analyzed by generalized linear models. RESULTS Eight hundred ten patients were enrolled. 33.7%, 13.4%, and 24.7% achieved sustained low BASDAI, ASDAS-ID, and ASDAS-LDA, respectively. In univariable GEE of baseline variables, age and baseline BASDAI, BASFI, and ASDAS significantly predicted sustained low BASFI. In multivariable GEE, sustained low BASDAI (p < 0.001), low BASDAI only at 6 or 12 months (p = 0.001), and baseline BASFI (p < 0.001) were the only predictors of sustained low BASFI. Sustained ASDAS-ID (p = 0.040) and ASDAS-LDA (p < 0.001) were also predictors when forced into the model. Similar results were obtained when evaluating the BASFI score at 18 months. CONCLUSION Sustained BASDAI < 3 may be a valid and feasible target for a treat-to-target strategy in axSpA having function as treatment goal.
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Affiliation(s)
- Walter P Maksymowych
- Department of Medicine, Division of Rheumatology, University of Alberta, 568 Heritage Medical Research Building, T6G 2S2, Edmonton, Canada.
- CARE Arthritis, Edmonton, Canada.
| | - Robert D Inman
- Schroeder Arthritis Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Louis Bessette
- Department of Medicine, Université Laval, Quebec, QC, Canada
| | - Proton Rahman
- Faculty of Medicine, Memorial University, St John's, NL, Canada
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Han Y, Huang S. Nanomedicine is more than a supporting role in rheumatoid arthritis therapy. J Control Release 2023; 356:142-161. [PMID: 36863691 DOI: 10.1016/j.jconrel.2023.02.035] [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: 12/03/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/04/2023]
Abstract
Rheumatoid arthritis(RA) is an autoimmune disorder that affects the joints. Various medications successfully alleviate the symptoms of RA in clinical. Still, few therapy strategies can cure RA, especially when joint destruction begins, and there is currently no effective bone-protective treatment to reverse the articular damage. Furthermore, the RA medications now used in clinical practice accompany various adverse side effects. Nanotechnology can improve the pharmacokinetics of traditional anti-RA drugs and therapeutic precision through targeting modification. Although the clinical application of nanomedicines for RA is in its infancy, preclinical research is rising. Current anti-RA nano-drug studies mainly focus on the following: drug delivery systems, nanomedicines with anti-inflammatory and anti-arthritic properties, biomimetic design with better biocompatibility and therapeutic features, and nanoparticle-dominated energy conversion therapies. These therapies have shown promising therapeutic benefits in animal models, indicating that nanomedicines are a potential solution to the current bottleneck in RA treatment. This review will summarize the present state of anti-RA nano-drug research.
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Affiliation(s)
- Yu Han
- Department of Orthopedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China.
| | - Shilei Huang
- Department of Orthopedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
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Caballero T, Lleonart-Bellfill R, Pedrosa M, Ferrer L, Guilarte M. Expert review and consensus on the t2t management of hereditary angioedema: from the scientific evidence to clinical practice. J Investig Allergol Clin Immunol 2023:0. [PMID: 36811842 DOI: 10.18176/jiaci.0875] [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] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Hereditary angioedema with C1 inhibitor deficiency (HAE-C1INH) is a rare disease characterized by swelling episodes. It affects quality of life (QoL) and can be lethal, when involving upper airways. Treatment is individualized, with therapeutic options including on-demand treatment (ODT), and short- and long-term prophylaxis (STP, LTP). However, available guidelines are not always clear about treatment selection, its goals or assessment of goal achievement. OBJECTIVE To review the available evidence for the management of HAE-C1INH and build a Spanish expert consensus to steer HAE-C1INH management towards a treat-to-target (T2T) approach, while addressing some of the unclear aspects of the Spanish guidelines. METHODS We reviewed the literature on the management of HAE-C1INH with a T2T approach, focusing on: 1) treatment selection and goals; and 2) available tools to assess goal achievement. We discussed the literature based on clinical experience and drew up 45 statements on undefined management aspects. A panel of 53 HAE experts validated the statements through a two-round Delphi process. RESULTS The goals for ODT and STP are minimizing the morbidity and mortality of attacks, and preventing attacks caused by known triggers, respectively, while the main goal of LTP is to decrease the rate, severity and duration of attacks. Furthermore, when prescribing, clinicians should consider the reduction in adverse events, while increasing patient QoL and satisfaction. Appropriate instruments for assessing goal achievement have also been indicated. CONCLUSIONS We provide recommendations on previously unclear aspects of HAE-C1INH management with ODT, STP and LTP, focusing particularly on clinical and patient-oriented goals.
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Affiliation(s)
- T Caballero
- Allergy Department, Hospital Universitario La Paz, IdiPAZ Group 44, CIBERER U754, Madrid, Spain
| | - R Lleonart-Bellfill
- Allergology Service, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Spain.,Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - M Pedrosa
- Allergy Department, Hospital Universitario La Paz, IdiPAZ Group 44, CIBERER U754, Madrid, Spain
| | - L Ferrer
- Hospital Clínico Universitario "Lozano Blesa", Zaragoza, Spain
| | - M Guilarte
- Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain.,RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL)
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13
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Cherrez-Ojeda I, Robles-Velasco K, Thomsen SF, Ramon GD, Sánchez J, Bernstein JA, Hidalgo B. Challenges in the Use of the Treat-to-Target Strategy in Atopic Dermatitis in Latin America: A Case Series Review. Dermatol Ther (Heidelb) 2023; 13:661-72. [PMID: 36709473 DOI: 10.1007/s13555-023-00890-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/12/2023] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Atopic dermatitis (AD) is a chronic, relapsing-remitting illness. In moderate-to-severe instances, recommendations urge patient-centered systemic therapy. Existing standards lack long-term treatment success requirements. A treat-to-target methodology was proposed for systemic therapy patients that requires global improvements to prompt decisions about treatment. METHODS We conducted an observational study between May 2021 and June 2022 in three Ecuadorian patients with severe AD who were treated with dupilumab to assess the clinical evolution and behavior of the subdomains evaluated by clinimetric tools. RESULTS Patients A and C satisfied disease-domain response criteria to dupilumab at 12 and 24 weeks, but B did not complete the algorithm objectives. Nonetheless, patient A improved AD severity, itching, bleeding, desquamation, sleep, daily activities, mood, emotions, sexual troubles, clothing, and sports subdomains. Patient B experienced reduced symptomatology, AD aggravation, daily activities impact, and work/study impairment. Patient C improved from severe to mild desquamation, itching, exudate, lichenification, and rough/dry skin. Sleep, shame, and study subdomains improved the most. CONCLUSION We provide a new operational construct for analyzing current patient-reported outcome measures (PROMs) and clinician-reported outcome measures (CROMs) based on subdomains to widen our understanding of the state of disease activity and make clinical decisions when the treat-to-target strategy is not attained.
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Fragoulis GE, Bertsias G, Bodaghi B, Gul A, van Laar J, Mumcu G, Saadoun D, Tugal-Tutkun I, Hatemi G, Sfikakis PP. Treat to target in Behcet's disease: Should we follow the paradigm of other systemic rheumatic diseases? Clin Immunol 2023; 246:109186. [PMID: 36410686 DOI: 10.1016/j.clim.2022.109186] [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: 10/17/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
During the last decades the efficacy of biologic agents, mainly of anti-TNFs, in controlling the activity of serious manifestations of Behcet's Disease (BD) has been established. On the other hand, the clinical heterogeneity of BD has precluded the validation of a widely-accepted composite index for disease assessment and for target disease-state definitions, such as low disease activity and remission, and the testing of their implementation in clinical practice. Therefore, in contrast to other systemic rheumatic diseases, a treat-to-target strategy has not yet been developed in BD. There are several challenges towards this approach, including standardization of outcome measures for assessing the disease activity in each-affected organ and construction of a composite disease activity index. The challenges for the development of a treat-to-target strategy and possible solutions are discussed in this position paper, which stemmed from a round table discussion that took place in the 19th International Conference on BD.
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Affiliation(s)
- George E Fragoulis
- Joint Rheumatology Program and First Department of Propaedeutic and Internal Medicine, National & Kapodistrian University of Athens Medical School, Athens, Greece
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete Medical School, Heraklion, Greece
| | - Bahram Bodaghi
- Dept of Ophthalmology, IHU FOReSIGHT, Sorbonne University, APHP, Paris, France
| | - Ahmet Gul
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Turkey
| | - Jan van Laar
- Departments of Internal Medicine and Immunology, Division Clinical Immunology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Gonca Mumcu
- Department of Health Management, Faculty of Health Sciences, Marmara University, Istanbul, Turkey
| | - David Saadoun
- Sorbonne Université, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, National reference center for autoinflammatory diseases and for rare systemic autoimmune diseases, F-75013 Paris, France
| | - Ilknur Tugal-Tutkun
- Istanbul University, Istanbul Faculty of Medicine, Department of Ophthalmology, Istanbul, Turkey; Eye Protection Foundation Bayrampasa Eye Hospital, Istanbul, Turkey
| | - Gulen Hatemi
- Department of Internal Medicine, Division of Rheumatology, Cerrahpaşa School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey; Behçet's Disease Research Center, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Petros P Sfikakis
- Joint Rheumatology Program and First Department of Propaedeutic and Internal Medicine, National & Kapodistrian University of Athens Medical School, Athens, Greece.
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Abstract
PURPOSE OF REVIEW Ulcerative colitis (UC) is a chronic disease with an increasing incidence. Recent guidelines emphasize treating toward objective targets, requiring the use of effective, steroid-sparing therapies. This review summarizes the safety and efficacy data of available therapies as well comparative effectiveness studies in order to help the reader make rational treatment decisions. RECENT FINDINGS Following the approval of tumor necrosis factor alpha antagonists, we have seen recent regulatory approval of several additional biologic and small molecule agents from several therapeutic classes (integrin antagonists, interleukin 12/23 antagonists, Janus kinase inhibitors, and sphingosine-1-phosphate receptor antagonists) for UC. Randomized, controlled trials, real-world analyses, and network meta-analyses have investigated the comparative safety and efficacy of these therapies in order to help clinicians better position these therapies in clinical practice. Numerous agents are now approved for the treatment of UC. This evidence-based review will help the reader understand the important factors weighing into treatment decisions for patients with UC and enable patient education and discussion with a focus on a shared decision-making approach.
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Affiliation(s)
- Amneet Hans
- Jill Roberts Center for Inflammatory Bowel Disease, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA
| | - Robert Battat
- Division of Gastroenterology and Hepatology, Centre Hospitalier de L'Université de Montréal (CHUM), University of Montreal, Quebec, Montreal, Canada
| | - Dana J Lukin
- Jill Roberts Center for Inflammatory Bowel Disease, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA.
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16
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Doumen M, Pazmino S, Bertrand D, Westhovens R, Verschueren P. Glucocorticoids in rheumatoid arthritis: Balancing benefits and harm by leveraging the therapeutic window of opportunity. Joint Bone Spine 2022; 90:105491. [PMID: 36410680 DOI: 10.1016/j.jbspin.2022.105491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/21/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022]
Abstract
Glucocorticoids have been available since the early 1950s and have since become an integral part of the management of rheumatoid arthritis (RA). Due to their rapid effect, glucocorticoids have an appealing profile for treating flares or as "bridging" agents in early RA. The efficacy of glucocorticoids to treat RA has been well established, both to control disease activity and to delay the progression of joint damage. However, despite their benefits, glucocorticoids have equally well-known adverse effects. It is generally accepted that long-term use of glucocorticoids, particularly at higher doses, is not advisable, and recent guidelines for the management of RA therefore either recommend against the use of glucocorticoids or suggest using them only as bridging therapy. Perceptions on the harmful effects of glucocorticoids remain, although mainly based on observational studies. Prolonged glucocorticoid therapy at low doses is still highly prevalent in clinical practice, but recent data suggest a rather favourable risk-benefit balance for this strategy, even in senior patients. Balancing the benefits and risks of treating RA with glucocorticoids thus remains a somewhat controversial topic. This narrative review outlines the historical and current position of glucocorticoids in the management of RA, while summarising recent evidence on their beneficial and detrimental effects. Furthermore, practical strategies for the current use and tapering of glucocorticoids in RA are formulated.
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Affiliation(s)
- Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium.
| | - Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium
| | - Rene Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven, Leuven, Belgium; Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
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17
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Elliott RS, Taylor E, Ainsworth J, Preston J, Smith EMDS. Improving communication of the concept of 'treat-to target' in childhood lupus: a public and patient (PPI) engagement project involving children and young people. BMC Rheumatol 2022; 6:69. [PMID: 36242078 PMCID: PMC9578343 DOI: 10.1186/s41927-022-00300-z] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A treat-to-target (T2T) approach, where treatment is escalated until a specific target is achieved, and re-escalated if the target is lost, has been proposed as a strategy to improve Childhood Systemic Lupus Erythematosus (cSLE) outcomes. Previous studies involving children and young people (CYP) have identified that the concept of T2T can be difficult to understand by CYP and their families. We aimed to explore the views of CYP participating in existing public and patient involvement (PPI) groups in relation to a proposed animation that is being developed to explain the concept of T2T to CYP who will be eligible for a future cSLE T2T trial. METHODS An illustrated animation storyboard was developed on PowerPoint, to be used alongside a contemporaneous voiceover to simulate the animation for CYP participating in three existing CYP PPI groups (GenerationR, Lupus UK, and YOUR RHEUM). Mixed methods were used to generate CYP feedback on the resource, including on-line surveys and qualitative topic-guided discussion, noting CYP suggestions for improvement. Changes were made iteratively to the resources. Pre/post workshop questionnaires to assess the impact of the resource on their understanding of T2T were completed anonymously. RESULTS 40 CYP were consulted; 16/40 (40%) from GenerationR (median age 15-years [IQR 12-15]), 12/40 (30%) from Lupus UK (median age 27-years [IQR 22-30]), and 12/40 (30%) from YOUR RHEUM (median age 17-years [IQR 16-21]). 62% of respondents had an underlying rheumatic condition. Pre-workshop median participant understanding of T2T was 2/10 [IQR 1-4], on a 1-10 scale (1 = "no understanding at all", 10 = "completely confident in my understanding"). After viewing the resource, participant understanding improved to a median of 9/10 [IQR 8-10], p < 0.0001). Overall, participants felt that the animation greatly improved their understanding of the concept of T2T, making several suggestions for improvement. CONCLUSION Involvement of CYP in research is crucial to help improve the design/delivery of studies, ensuring relevance to CYP and their families. This manuscript demonstrates the involvement of CYP in the development of an animation that will be integral to a future clinical trial, helping to describe the T2T approach in a comprehensible way to eligible CYP and their families, supporting study recruitment.
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Affiliation(s)
- R S Elliott
- School of Medicine, University of Liverpool, Liverpool, UK
| | - E Taylor
- School of Medicine, University of Liverpool, Liverpool, UK
| | - J Ainsworth
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - J Preston
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - E M D S Smith
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK. .,Department of Paediatric Rheumatology, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Samões B, Zen M, Abelha-Aleixo J, Gatto M, Doria A. Caveats and pitfalls in defining low disease activity in systemic lupus erythematosus. Autoimmun Rev 2022; 21:103165. [PMID: 35931316 DOI: 10.1016/j.autrev.2022.103165] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/31/2022] [Indexed: 11/02/2022]
Abstract
The treat-to-target strategy has been recently suggested in the management of Systemic Lupus Erythematosus (SLE). Lupus Low Disease Activity State (LLDAS) and Definitions Of Remission In SLE (DORIS) remission were outlined as two concentric targets. The achievement of LLDAS was shown to be associated with lower frequency of SLE flare, decreased damage progression, better quality of life, and reduced mortality. In addition, LLDAS has successfully been tested in post-hoc analyses of a number of randomized controlled trials. However, it has been recently underlined that LLDAS includes a high proportion of patients in remission, raising the question if these endpoints are sufficiently distinct to consider their separation clinically relevant. Some studies suggest that the protective effect of LLDAS on damage might be due to the inclusion of patients who are in remission. Notably, clinical low disease activity (LDA) seems to be uncommon in SLE due to the relapsing-remitting pattern of the disease, in which low level of activity only occurs transiently. Moreover, since the domains included in LLDAS have several limitations, such as the use of a binomial disease activity index, the exclusion of some mild manifestations and the consideration of items subjected to variability (physician global assessment and glucocorticoids dose), not all patients in LDA are adequately represented by LLDAS.
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Affiliation(s)
- Beatriz Samões
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Margherita Zen
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| | - Joana Abelha-Aleixo
- Rheumatology Department, Centro Hospitalar de Vila Nova de Gaia e Espinho, Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
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Gondo G, Mosca M, Hong J, Maverakis E, Merola JF, Armstrong AW, Bhutani T, Bell SJ, Liao W. Demographic and Clinical Factors Associated with Patient-Reported Remission in Psoriatic Arthritis. Dermatol Ther (Heidelb) 2022; 12:1885-1895. [PMID: 35864377 PMCID: PMC9357585 DOI: 10.1007/s13555-022-00770-6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Achievement of remission in psoriatic arthritis is a key goal for patients and clinicians, yet definitions of remission may vary. Previous efforts have utilized multidomain measures such as minimal disease activity that assess the status of joints, skin, and function to determine current level of psoriatic arthritis (PsA) disease activity. The goal of this study is to identify factors associated with patient-reported psoriatic arthritis remission. Methods The National Psoriasis Foundation conducted a cross-sectional study using an online survey of a random stratified sample of 1570 individuals with psoriatic disease in the USA. Participants were asked about a provider diagnosis of psoriasis and/or psoriatic arthritis, comorbid conditions, and psoriatic arthritis impact and disease activity, and demographic questions. All participants reporting a physician-given diagnosis of psoriatic arthritis were asked if they felt their psoriatic arthritis was in remission (“Do you feel your psoriatic arthritis is in remission?” Yes/No/Unsure) and, if so, length of remission. Individuals with psoriasis and psoriatic arthritis reporting a body surface area impacted by psoriasis 3% or less were asked if they felt their psoriasis was in remission. Psoriatic arthritis disease activity and impact was assessed using the nine-question Psoriatic Arthritis Impact of Disease (PsAID-9) instrument and a global PsA-related quality of life question. PsAID-9 scores ≤ 4 were used to indicate acceptable disease state. Multivariate logistic regression was used to identify factors associated with patient-perceived PsA remission. Results Of 834 participants with PsA, including 76 (4.8%) with PsA without skin involvement ever, 144 (17.3%) felt their psoriatic arthritis was in remission, with an average remission duration of 43 months. Of those in remission, 116 (78.4%) reported currently using a treatment for their PsA, with most (75.7%) reporting using a biologic therapy for their PsA in the past 12 months. Multivariate logistic regression revealed that patient-perceived psoriatic arthritis remission was independently associated with experiencing acceptable disease state (PsAID-9 ≤ 4), perception of psoriasis remission, lower impact of PsA on global quality of life, and non-white race. Age, sex, body mass index, or biologic use in the last 12 months were not associated with patient-reported PsA remission. Conclusion Overall, patient perception of PsA remission was most strongly associated with patient-reported psoriasis remission.
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Affiliation(s)
- George Gondo
- National Psoriasis Foundation, Portland, OR, USA
| | - Megan Mosca
- University of California at San Francisco, San Francisco, CA, USA
| | - Julie Hong
- University of California at San Francisco, San Francisco, CA, USA
| | | | - Joseph F Merola
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Tina Bhutani
- University of California at San Francisco, San Francisco, CA, USA
| | - Stacie J Bell
- Opsis Health/Global Nutrition Project, Golden, CO, USA
| | - Wilson Liao
- University of California at San Francisco, San Francisco, CA, USA.
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20
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Gergely M, Deepak P. Tools for the Diagnosis and Management of Crohn's Disease. Gastroenterol Clin North Am 2022; 51:213-239. [PMID: 35595412 DOI: 10.1016/j.gtc.2021.12.003] [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] [Indexed: 02/21/2023]
Abstract
Numerous tools have emerged over recent decades to aid in the increasingly complex management of patients with Crohn's disease (CD) beyond endoscopy, including video capsule endoscopy, magnetic resonance enterography, computed tomography enterography, a variety of biomarkers, and even wearable biosensors and smartphone applications. These tools have allowed for a more sophisticated and less invasive complementary approach to the evaluation of disease activity and treatment response in patients with CD. This article details the characteristics, practical application, and limitations of these various modalities and discusses how updated guidelines are now incorporating many of them into a treat-to-target strategy.
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Affiliation(s)
- Maté Gergely
- Division of Gastroenterology, Inflammatory Bowel Diseases Center, Washington University School of Medicine, 600 South Euclid Avenue, Campus Box 8124, Saint Louis, MO 63110, USA
| | - Parakkal Deepak
- Division of Gastroenterology, Inflammatory Bowel Diseases Center, Washington University School of Medicine, 600 South Euclid Avenue, Campus Box 8124, Saint Louis, MO 63110, USA.
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21
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Zhao JL, Liu X, Nan Li J, Ru Liu M, Rottier E, Zhao Y, Zeng XF. Implementation of the treat-to-target approach and treatment satisfaction in patients with rheumatoid arthritis: perspectives of Chinese rheumatologists. Clin Rheumatol 2022; 41:2659-2668. [PMID: 35579773 DOI: 10.1007/s10067-022-06187-y] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 03/30/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the implementation of treat-to-target (T2T) and treatment satisfaction from Chinese rheumatologists' perspectives. METHODS This retrospective analysis of a cross-sectional database collected from rheumatologists and their adult patients with RA in China using Adelphi Real World Disease Specific Programme™ methodology. Multivariate logistic regression models were used to evaluate factors associated with T2T use, achievement of T2T goals, and physician treatment satisfaction. RESULTS Sixty physicians provided data for 600 patients, of whom 39.0% (234/600) were being treated using T2T, and 64.9% (366/564) had achieved their T2T goal. Physicians were satisfied with treatment in 74.3% (445/599) of patients. Patients with a higher pain score were more likely to be managed using T2T (odds ratio (OR) 1.25; p = 0.017), but less likely to have achieved the T2T goal (OR 0.76; p = 0.004). T2T use was more likely if patients had a longer time since diagnosis (> 2 vs ≤ 2 years; OR 1.61; p = 0.031) or received targeted synthetic or biologic disease-modifying antirheumatic drugs (tsDMARDs or bDMARDs; OR 6.90; p < 0.001). T2T goal achievement was more likely for patients with higher body mass index (≥ 24 vs < 24 kg/m2; OR 2.73; p = 0.001) or full-time employment (OR 2.11; p = 0.005). Physician treatment satisfaction was more likely if the T2T goal was achieved (OR 4.78; p < 0.001) or tsDMARDs or bDMARDs were used (OR 2.58; p = 0.017), and less likely if pain scores were higher (OR 0.79; p = 0.019). CONCLUSIONS T2T implementation in China is suboptimal. Our findings provide insight into T2T implementation and physician treatment satisfaction, supporting T2T use in Chinese RA clinical practice. Key Points • T2T implementation in China is currently suboptimal. • Patients with greater pain were more likely to be managed using T2T but were less likely to have achieved their T2T goals. • Physician treatment satisfaction was associated with T2T goal achievement.
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Affiliation(s)
- Jiu Liang Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China. .,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China. .,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China. .,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Xin Liu
- Lilly China Drug Development and Medical Affairs Center, Eli Lilly and Company, Shanghai, China
| | - Jin Nan Li
- Lilly China Drug Development and Medical Affairs Center, Eli Lilly and Company, Shanghai, China
| | - Meng Ru Liu
- Lilly China Drug Development and Medical Affairs Center, Eli Lilly and Company, Shanghai, China
| | - Elke Rottier
- Autoimmune Franchise, Adelphi Real World, Bollington, Cheshire, UK
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiao Feng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, Beijing, China.,State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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22
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Menzies-Gow A, Hoyte FL, Price DB, Cohen D, Barker P, Kreindler J, Jison M, Brooks CL, Papeleu P, Katial R. Clinical Remission in Severe Asthma: A Pooled Post Hoc Analysis of the Patient Journey with Benralizumab. Adv Ther 2022; 39:2065-2084. [PMID: 35287231 PMCID: PMC9056458 DOI: 10.1007/s12325-022-02098-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [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: 02/01/2022] [Accepted: 02/18/2022] [Indexed: 12/29/2022]
Abstract
Introduction Consensus definitions for clinical remission and super-response were recently established for severe asthma. Benralizumab is an interleukin-5 (IL-5) receptor α-directed monoclonal antibody for severe, uncontrolled asthma; efficacy and safety were demonstrated in previous pivotal phase 3 trials (SIROCCO, CALIMA, ZONDA). This analysis applied a composite remission definition to characterize individual responses to benralizumab after 6 and 12 months. Methods In previous phase 3 studies, eligible patients were those with severe, uncontrolled asthma receiving medium- or high-dosage inhaled corticosteroids plus long-acting β2-agonists. This post hoc analysis included patients randomized to the approved benralizumab dose and not receiving oral corticosteroids (OCS) at baseline (SIROCCO/CALIMA) or OCS ≤ 12.5 mg per day (ZONDA). Individual remission components were zero exacerbations; zero OCS use; Asthma Control Questionnaire-6 (ACQ-6) score < 1.5 or ≤ 0.75; and pre-bronchodilator forced expiratory volume in 1 s (FEV1) increase ≥ 100 mL; clinical remission incorporated zero exacerbations, zero OCS use, ACQ-6 score ≤ 0.75, and pre-bronchodilator FEV1 increase ≥ 100 mL after 6 or 12 months. Results Overall, 609 patients (N = 301 and N = 308) and 586 patients (N = 293 and N = 293) receiving benralizumab in SIROCCO and CALIMA were included at 6 and 12 months, respectively; 40 ZONDA patients were included after 6 months. In SIROCCO/CALIMA, similar to 6-month findings, approx. 83% and approx. 49% receiving benralizumab, and 77% and 37% on placebo achieved ≥ 2 and ≥ 3 remission components after 12 months; 14.5% (85/586) on benralizumab and 7.7% (48/620) on placebo achieved clinical remission at 12 months. Among ZONDA patients, 75% and approx. 48% on benralizumab and 35% and 20% on placebo achieved ≥ 2 and ≥ 3 remission components at 6 months, respectively; 22.5% (9/40) on benralizumab and 7.5% on placebo achieved clinical remission. Conclusions This analysis demonstrates clinical remission is achievable by targeting the underlying drivers of inflammation. Precision medicines can help shift treatment paradigms toward treat-to-target, with clinical remission as the ultimate therapeutic goal in severe asthma. Clinical trial registration SIROCCO (NCT01928771); CALIMA (NCT01914757); ZONDA (NCT02075255). Dr. Andrew Menzies-Gow Discusses a Post Hoc Analysis of Clinical Remission in Severe Asthma with Benralizumab
Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02098-1. Widely accepted definitions for disease remission are already established for the treatment of rheumatoid arthritis, ulcerative colitis, and cancer, among others. Two separate expert groups recently collaborated to discuss clinical remission/super-response to treatment in patients with severe asthma. Both groups developed separate, yet similar ways to determine whether a patient should be considered “in remission.” In this study, we used the results from three previous trials (SIROCCO, CALIMA, and ZONDA) that were conducted to assess a therapy called benralizumab in patients with severe asthma to identify patients who met some or all of the criteria for disease remission in severe asthma. These criteria included zero asthma exacerbations; zero oral steroid (OCS) use; asthma control score; and improvement in lung function. Across all three trials, about three quarters of the patients achieved two or more remission components and about half achieved three or more remission components after 6 months of treatment; furthermore, these rates were generally similar to the numbers of patients who achieved two or more components and three or more components of remission after 12 months of treatment. Overall, 15–23% of patients achieved clinical remission in 6 months, and approximately 15% achieved remission within 12 months. The results show that biologic therapies like benralizumab help improve the symptoms of severe asthma and allow patients to achieve disease remission.
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Affiliation(s)
- Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton Hospital, Sydney St, London, SW3 6NP, UK.
- Harefield Hospital, Harefield, Uxbridge, UK.
| | - Flavia L Hoyte
- Division of Allergy and Clinical Immunology, Department of Medicine, National Jewish Health, Denver, CO, USA
| | - David B Price
- Observational and Pragmatic Research Institute, Midview City, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - David Cohen
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD, USA
| | - Peter Barker
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD, USA
| | - James Kreindler
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD, USA
| | - Maria Jison
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD, USA
| | | | | | - Rohit Katial
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD, USA
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Abstract
Gout is the most common inflammatory arthritis in the United States. Gouty arthritis is associated with significant morbidity and mortality and is the result of chronic hyperuricemia. Gout is effectively managed and potentially cured by decreasing the overall urate burden with serum urate-lowering therapy. When serum urate is maintained at less than 6.0 mg/dL, urate deposition is resolved, and gout can be cured. Unfortunately, because of less than optimal physician monitoring and dose escalation, many patients do not achieve these urate levels.
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Affiliation(s)
- Sarah F Keller
- Department of Rheumatic & Immunologic Diseases, The Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44915, USA.
| | - Brian F Mandell
- Department of Rheumatic & Immunologic Diseases, The Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44915, USA
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Gondo G, Hadeler E, Brownstone N, Maverakis E, Merola JF, Armstrong AW, Bhutani T, Bell SJ, Liao W. Demographic and Clinical Factors Associated with Patient-Reported Remission in Psoriasis. Dermatol Ther (Heidelb) 2022; 12:753-760. [PMID: 35254634 PMCID: PMC8941001 DOI: 10.1007/s13555-022-00692-3] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/08/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Achievement of remission in psoriasis is a key goal for patients and providers, yet definitions of remission may vary. Some treat-to-target initiatives in psoriasis have focused on degree of skin involvement, while others have also incorporated quality of life (QoL) measures. The goal of this study is to identify factors associated with patient-reported psoriasis remission. Methods The National Psoriasis Foundation conducted a survey of a random stratified sample of 1570 individuals with psoriatic disease in the USA. The survey contained questions regarding provider diagnosis of psoriasis and/or psoriatic arthritis, as well as comorbid conditions and participant demographics. Psoriasis severity was assessed using the Patient Report of Extent of Psoriasis Involvement (PREPI), a validated self-reported measure of body surface area (BSA). Dermatologic-related quality of life was assessed using the Dermatology Life Quality Index (DLQI). Individuals reporting BSA ≤ 3% were asked if they believed their psoriasis was in remission. Multivariate logistic regression was used to identify factors associated with remission. Results Of 930 participants reporting BSA ≤ 3%, 479 (51.7%) believed their psoriasis was in remission, with an average remission duration of 31 months. Of those in remission, 79.1% reported current treatment. Multivariate regression revealed that psoriasis remission was independently associated with female sex, lower BSA, less impairment in the Dermatology Life Quality Index and global QoL, biologic use, and concomitant diagnosis of psoriatic arthritis. There was no association with age, race, body mass index, or number of comorbidities. Conclusion Overall, patient perception of psoriasis remission was not solely associated with BSA, but also with sex, quality of life, and treatment type.
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Affiliation(s)
- George Gondo
- National Psoriasis Foundation, Portland, OR, USA
| | - Edward Hadeler
- University of California at San Francisco, San Francisco, CA, USA
| | | | | | - Joseph F Merola
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Tina Bhutani
- University of California at San Francisco, San Francisco, CA, USA
| | - Stacie J Bell
- Opsis Health/Global Nutrition Project, Colorado, USA
| | - Wilson Liao
- University of California at San Francisco, San Francisco, CA, USA.
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25
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Parodis I, Tamirou F, Houssiau FA. Treat-to-Target in Lupus Nephritis. What is the Role of the Repeat Kidney Biopsy? Arch Immunol Ther Exp (Warsz) 2022; 70:8. [PMID: 35147824 PMCID: PMC8837511 DOI: 10.1007/s00005-022-00646-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 08/07/2021] [Accepted: 10/12/2021] [Indexed: 01/14/2023]
Abstract
Kidney involvement, termed lupus nephritis (LN), develops in 35-60% of patients with systemic lupus erythematosus, often early during the disease course. When not treated promptly and efficiently, LN may lead to rapid and severe loss of kidney function, being the reason why it is considered one of the most severe lupus manifestations. Despite improved pharmacotherapy, 5-20% of LN patients develop end-stage kidney disease within ten years from the LN diagnosis. While the principal ground of LN therapy is prevention of renal function worsening, resembling a race against nephron loss, consensual agreement upon outcome measures and clinically meaningful short- and long-term targets of LN therapy have yet to be determined. Literature points to the importance of inclusion of tissue-based approaches in the determination of those targets, and evidence accumulates regarding the importance of per-protocol repeat kidney biopsies in the evaluation of the initial phase of therapy and prediction of long-term renal prognosis. The latter leads to the hypothesis that the information gleaned from repeat biopsies may contribute to optimised therapeutic decision making, and, therefore, increased probability to attain complete renal response in the short term, and a more favourable renal prognosis within a longer prospect. The multinational project ReBioLup was recently designed to serve as a key contributor to form evidence about the role of per-protocol repeat biopsies in a randomised fashion and aspires to unify the global LN community towards improved kidney and patient survival.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, 171 76, Stockholm, Sweden. .,Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Farah Tamirou
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Rheumatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Frédéric A Houssiau
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Rheumatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Hao Y, Oon S, Ji L, Gao D, Fan Y, Geng Y, Zhang X, Li G, Morand EF, Nikpour M, Zhang Z. Determinants and protective associations of the lupus low disease activity state in a prospective Chinese cohort. Clin Rheumatol 2022; 41:357-366. [PMID: 34595670 PMCID: PMC8782788 DOI: 10.1007/s10067-021-05940-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the frequency and determinants of achieving the lupus low disease activity state (LLDAS), and the effect of LLDAS attainment on disease flare and damage accrual in a prospective, single-center cohort of Chinese lupus patients. METHODS Baseline and follow-up data from consecutive patients at the Peking University First Hospital were collected from January 2017 to June 2020. RESULTS A total of 185 patients were enrolled, with median (range) disease duration at enrolment of 2.3 (0.8-7.7) years, and median follow-up of 2.2 (1.0-2.9) years. By the end of the study, 139 (75.1%) patients had achieved LLDAS at least once; 82 (44.3%) patients achieved LLDAS for ≥ 50% of observations. Multivariable logistic regression analysis showed that 24-h urinary total protein (UTP; per g) (OR = 0.447, 95%CI [0.207-0.968], p = 0.041), serum creatinine (Scr; per 10 µmol/L) (OR = 0.72, 95%CI [0.52-0.99], p = 0.040), and C3 level (per 100 mg/L) (OR = 1.60, 95%CI [1.18-2.17], p = 0.003) at recruitment had independent negative associations with achieving LLDAS for ≥ 50% of observations. Kaplan-Meier analyses showed a significant reduction in flare rate with increased proportion of time in LLDAS. Attainment of LLDAS in at least 50% of observations was an independent protective factor for damage accrual (OR = 0.19, 95%CI [0.04-0.99], p = 0.049). CONCLUSIONS In this prospective Chinese cohort, LLDAS was an attainable goal in clinical practice. Nephritis-related markers (UTP and Scr) and C3 level at recruitment negatively influenced achievement of LLDAS. LLDAS achievement was significantly protective from flare and damage accrual. KEY POINTS • Low disease activity status (LLDAS) is an achievable target during SLE treatment in China. Urine protein, serum creatinine, and C3 level at recruitment independently affect LLDAS achievement in this group of Chinese lupus patients. • As a treatment target, LLDAS achievement has a highly protective effect for preventing flare and damage accrual, especially in case of achieving LLDAS for ≥ 50% of observations. • The present results further highlight the practical significance of treat-to-target principle in SLE management (T2T/SLE) and the needs for promoting the application of T2T/SLE in clinical practice as well as exploring the concrete implement strategy.
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Affiliation(s)
- Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
- The University of Melbourne Department of Medicine at St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Shereen Oon
- The University of Melbourne Department of Medicine at St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- Department of Rheumatology, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | - Dai Gao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | - Yong Fan
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | | | - Xiaohui Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | - Guangtao Li
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China
| | - Eric F Morand
- Monash University, Faculty of Medicine, Nursing and Health Sciences, Melbourne, Australia
| | - Mandana Nikpour
- The University of Melbourne Department of Medicine at St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- Department of Rheumatology, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - ZhuoLi Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, 8 Xishiku St, Beijing, 100034, People's Republic of China.
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Krüger K. [Innovative strategies for treatment of rheumatoid arthritis]. Z Rheumatol 2022. [PMID: 34997270 DOI: 10.1007/s00393-021-01144-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 10/19/2022]
Abstract
Besides excellent guidelines and newly developed highly effective drugs, evidence-based strategic use of these new drugs has especially contributed to enormous advances in rheumatoid arthritis treatment, apparent especially since 2000. Currently, the treat-to-target (T2T) strategy has proven to be the most successful in several studies and systematic reviews. The target is to achieve remission, which should be reached and sustained for an optimal outcome (i.e. stable over a long time period). If the initial disease-modifying antirheumatic drug (DMARD) treatment fails, the best strategy for continuing treatment is controversial, with swap or switch being open to debate (change within a class of drugs or change in the mechanism of action). Recent studies seem to indicate that switching to another mechanism of action is the most successful approach. A hotly discussed topic is the question whether DMARD treatment can or should be tapered when sustained remission has been achieved? Many patients wish for a reduction of drugs in cases of stable remission; however, the stable disease control might become destabilized by tapering. The main priority is the reduction or tapering of glucocorticoid treatment. When the decision for reduction of DMARD treatment is made together with the patient, a complete cessation bears a high risk of a flare, therefore, a careful step by step reduction of DMARD treatment should be preferred. In the case of a running combination, the question whether the conventional DMARD (mostly methotrexate), the biological (b)DMARD or targeted synthetic (ts)DMARD should be reduced first, must be decided on an individual basis. Most patients prefer to first reduce methotrexate and transfer to a monotherapy.
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Ostor AJ, Sawant R, Qi CZ, Wu A, Nagy O, Betts KA. Value of Remission in Patients with Rheumatoid Arthritis: A Targeted Review. Adv Ther 2022; 39:75-93. [PMID: 34787822 DOI: 10.1007/s12325-021-01946-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/01/2021] [Indexed: 11/03/2022]
Abstract
The treat-to-target strategy, which defines clinical remission as the primary therapeutic goal for rheumatoid arthritis (RA), is a widely recommended treatment approach in clinical guidelines. Achieving remission has been associated with improved clinical outcomes, quality of life, and productivity. These benefits are likely to translate to reduced economic burden in terms of lower healthcare costs and resource utilization. As such, a literature review was conducted to better understand the economic value of remission. Despite the large heterogeneity found in RA-related economic outcomes across studies, patients in remission consistently had lower direct medical and indirect costs, less healthcare resource utilization, and greater productivity compared to those without remission. Remission was associated with 19–52% savings in direct medical costs and 37–75% savings in indirect costs. The economic value of remission should thus be considered in economic analyses of RA therapies to inform treatment and reimbursement decisions.
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Assunção H, Jesus D, Larosa M, Henriques C, Matos A, Le Guern V, Rubiño F, da Silva JAP, Rua-Figueroa I, Costedoat-Chalumeau N, Doria A, Inês LS. Definition of Low Disease Activity State based on the SLE-DAS: Derivation and validation in a multicentre real-life cohort. Rheumatology (Oxford) 2021; 61:3309-3316. [PMID: 34864894 DOI: 10.1093/rheumatology/keab895] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 09/21/2021] [Revised: 11/23/2021] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To derive and validate a definition of low disease activity (LDA) for systemic lupus erythematosus (SLE) based on the SLE Disease Activity Score (SLE-DAS), in a real-life multicentre cohort of SLE patients. METHODS Derivation was conducted using data from a monocentric cohort of SLE (Portugal), and validation was performed in a multicentre cohort (Italy, France, and Spain). The Lupus Low Disease Activity State (LLDAS) was used as comparator. We applied receiver operating characteristics (ROC) curve analysis against the LLDAS to determine the cut-off of SLE-DAS for LDA using bootstrap methodology. In a second step, we tested a definition of SLE-DAS LDA that included: (i) the statistically derived SLE-DAS upper threshold for LDA, and (ii) prednisone dose ≤7.5 mg/day. In the multicentre validation cohort, we assessed the classification performance of this SLE-DAS LDA definition. RESULTS We included 774 patients, 300 in the derivation and 474 in the validation cohorts, respectively. In the derivation cohort, the optimal cut-off to identify patients in LLDAS was SLE-DAS ≤2.48, presenting an area under the curve (AUC) of 0.965 (95%CI 0.935-0.994). When applied to the multicentre validation cohort, the SLE-DAS LDA definition showed a sensitivity of 97.1% and a specificity of 97.7% for LLDAS and an almost perfect agreement (Cohen's Kappa =0.933; p< 0.001). McNemar's test found no significant differences between the two definitions (p= 0.092). CONCLUSION The SLE-DAS LDA is a validated, accurate, and easy-to-use definition for classifying SLE patients in LDA state.
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Affiliation(s)
- Helena Assunção
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra
| | - Diogo Jesus
- Rheumatology Department, Centro Hospitalar de Leiria. Leiria, Portugal.,Faculty of Health Sciences, University of Beira Interior. Covilhã, Portugal
| | | | - Carla Henriques
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal.,Centre for Mathematics, University of Coimbra, Coimbra, Portugal
| | - Ana Matos
- School of Technology and Management, Polytechnic Institute of Viseu, Viseu, Portugal.,CISeD-Research Centre in Digital Services, Polytechnic of Viseu, Portugal
| | - Véronique Le Guern
- APHP, Internal Medicine Department, Cochin Hospital, Paris, France; Université de Paris, Paris, France
| | - Francisco Rubiño
- Rheumatology Department, Doctor Negrín University Hospital, Las Palmas de Gran Canaria, Spain
| | - José A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Iñigo Rua-Figueroa
- Rheumatology Department, Doctor Negrín University Hospital, Las Palmas de Gran Canaria, Spain
| | | | - Andrea Doria
- Division of Rheumatology, University of Padova, Padova, Italy
| | - Luís S Inês
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra.,Faculty of Health Sciences, University of Beira Interior. Covilhã, Portugal
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Al Rayes H, Alazmi M, Attar S, Alderaan K, Alghamdi M, Alghanim N, Alhazmi A, Alkhadhrawi N, Almohideb M, Alzahrani Z, Bedaiwi M, Halabi H. Consensus-based recommendations on the diagnosis, referral and clinical management of patients with psoriatic arthritis. Rheumatol Int 2021; 42:391-401. [PMID: 34716785 DOI: 10.1007/s00296-021-05029-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/08/2021] [Indexed: 12/15/2022]
Abstract
Psoriatic arthritis (PsA) is a highly heterogeneous disease with complex manifestations. Limited understanding of the disease and non-availability of local guidelines pose challenges in the management of PsA in Saudi Arabia. Therefore, this expert consensus is aimed to provide recommendations on the management of patients with PsA, including referral pathway, definition of remission and treat-to-target (T2T) approach. A Delphi technique of consensus development was used involving an expert panel comprised of 10 rheumatologists, one dermatologist and one family physician. Based on the review of available published evidence and the opinions of clinical experts, key recommendations were developed. A consensus was achieved in defining the following: management guideline adaptable for Saudi Arabia, most useful screening tool, laboratory investigations, imaging tests and criteria for referring suspected PsA patients to a rheumatologist. In addition, an agreement was achieved in defining the T2T strategy and remission for the clinical management of PsA. Overall, these recommendations provide an evidence-based framework for the management of PsA patients in Saudi Arabia.
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Affiliation(s)
- Hanan Al Rayes
- Department of Medicine, Prince Sultan Military Medical City, Riyadh, 21577, Saudi Arabia.
| | - Mansour Alazmi
- Department of Rheumatology, Prince Mohammed Medical City, Al Jouf, Saudi Arabia
| | - Suzan Attar
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khaled Alderaan
- Department of Rheumatology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Mushabab Alghamdi
- Department of Rheumatology, University of Bisha, Bisha, Saudi Arabia
| | - Nayef Alghanim
- Department of Rheumatology, King Saud Medical City, Riyadh, Saudi Arabia
| | - Ahmed Alhazmi
- Department of Medicine, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Nadeer Alkhadhrawi
- Department of Family Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammad Almohideb
- Department of Dermatology, King Saud Bin Abdulaziz University for Health Sciences and King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Zeyad Alzahrani
- Department of Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Mohamed Bedaiwi
- Department of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hussein Halabi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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Wendling D, Claudepierre P, Goupille P, Pham T, Prati C. Tight control and treat-to-target in axial spondyloarthritis. Where are we? Joint Bone Spine 2021; 89:105263. [PMID: 34506936 DOI: 10.1016/j.jbspin.2021.105263] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/31/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Daniel Wendling
- Department of rheumatology, CHRU de Besançon, boulevard Fleming, 25030 Besançon, France; EA 4266, EPILAB, université de Franche-Comté, Besançon, France.
| | - Pascal Claudepierre
- EpiDermE, université Paris Est Créteil, 94010 Créteil, France; Service de rhumatologie, hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Philippe Goupille
- Department of rheumatology, CHRU de Tours, Tours, France; EA 7501, GICC, université de Tours, Tours, France
| | - Thao Pham
- Department of rheumatology, Aix Marseille université, CHU Sainte-Marguerite, AP-HM, Marseille, France
| | - Clément Prati
- Department of rheumatology, CHRU de Besançon, boulevard Fleming, 25030 Besançon, France; EA 4267, PEPITE, université de Franche-Comté, FHU INCREASE, Besançon, France
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Al Khoury A, Xiao Y, Golovics PA, Kohen R, Afif W, Wild G, Friedman G, Galiatsatos P, Hilzenrat N, Szilagyi A, Wyse J, Cohen A, Bitton A, Bessissow T, Lakatos PL. Assessing adherence to objective disease monitoring and outcomes with adalimumab in a real-world IBD cohort. Dig Liver Dis 2021; 53:980-6. [PMID: 33640302 DOI: 10.1016/j.dld.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Data suggests that tight objective monitoring may improve clinical outcomes in IBD. AIM To assess the adherence to serial tight objective monitoring(clinical and biomarkers) and its effect on clinical outcomes. METHODS We retrospectively reviewed the chart of 428 consecutive IBD patients started on adalimumab between January 1,2015-January 1,2019 [338 Crohn's disease(CD), 90 ulcerative colitis(UC)]. Clinical symptoms(assessed by Harvey-Bradshaw-Index,partial Mayo),C-Reactive Protein(CRP), and fecal calprotectin(FCAL) assessments were captured at treatment initiation and at 3,6,9, and12 months. Dose optimization and drug sustainability curves were plotted by Kaplan-Meier method. RESULTS Clinical evaluation was available in nearly all patients at 3(CD-UC:95-94%), 6(90-83%), 9(86-85%) and 12(96-89%) months. CRP testing frequency decreased in CD patients over time. Compliance to serial FCAL testing was low. Clinical remission at one-year was higher in patients adherent to early assessment visit at 3 months(p = 0.001 for CD and UC). Adherence to early follow-up resulted in earlier dose optimization in CD and UC patients(pLogrank=0.026 for UC & p = 0.09 for CD). Overall drug sustainability did not differ. CONCLUSION Clinical & CRP, but not FCAL, were frequently assessed in patients starting adalimumab. Adherence to early objective combined follow-up visits resulted in earlier dose optimization, improved one-year clinical outcomes but did not change drug sustainability.
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Segú-Vergés C, Coma M, Kessel C, Smeets S, Foell D, Aldea A. Application of systems biology-based in silico tools to optimize treatment strategy identification in Still's disease. Arthritis Res Ther 2021; 23:126. [PMID: 33892792 PMCID: PMC8063416 DOI: 10.1186/s13075-021-02507-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 08/11/2020] [Accepted: 04/07/2021] [Indexed: 01/06/2023] Open
Abstract
Background Systemic juvenile idiopathic arthritis (sJIA) and adult-onset Still’s disease (AOSD) are manifestations of an autoinflammatory disorder with complex pathophysiology and significant morbidity, together also termed Still’s disease. The objective of the current study is to set in silico models based on systems biology and investigate the optimal treat-to-target strategy for Still’s disease as a proof-of-concept of the modeling approach. Methods Molecular characteristics of Still’s disease and data on biological inhibitors of interleukin (IL)-1 (anakinra, canakinumab), IL-6 (tocilizumab, sarilumab), and glucocorticoids as well as conventional disease-modifying anti-rheumatic drugs (DMARDs, methotrexate) were used to construct in silico mechanisms of action (MoA) models by means of Therapeutic Performance Mapping System (TPMS) technology. TPMS combines artificial neuronal networks, sampling-based methods, and artificial intelligence. Model outcomes were validated with published expression data from sJIA patients. Results Biologicals demonstrated more pathophysiology-directed efficiency than non-biological drugs. IL-1 blockade mainly acts on proteins implicated in the innate immune system, while IL-6 signaling blockade has a weaker effect on innate immunity and rather affects adaptive immune mechanisms. The MoA models showed that in the autoinflammatory/systemic phases of Still’s disease, in which the innate immunity plays a pivotal role, the IL-1β-neutralizing antibody canakinumab is more efficient than the IL-6 receptor-inhibiting antibody tocilizumab. MoA models reproduced 67% of the information obtained from expression data. Conclusions Systems biology-based modeling supported the preferred use of biologics as an immunomodulatory treatment strategy for Still’s disease. Our results reinforce the role for IL-1 blockade on innate immunity regulation, which is critical in systemic autoinflammatory diseases. This further encourages early use on Still’s disease IL-1 blockade to prevent the development of disease or drug-related complications. Further analysis at the clinical level will validate the findings and help determining the timeframe of the window of opportunity for canakinumab treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02507-w.
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Affiliation(s)
- Cristina Segú-Vergés
- Anaxomics Biotech, Carrer Diputació 237, 1°, 1ª, 08007, Barcelona, Catalonia, Spain
| | - Mireia Coma
- Anaxomics Biotech, Carrer Diputació 237, 1°, 1ª, 08007, Barcelona, Catalonia, Spain
| | - Christoph Kessel
- Department of Pediatric Rheumatology & Immunology, University Children's Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Serge Smeets
- Novartis, Haaksbergweg, 1101 BX, Amsterdam, The Netherlands
| | - Dirk Foell
- Department of Pediatric Rheumatology & Immunology, University Children's Hospital, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Anna Aldea
- Novartis, Gran Via de les Corts Catalanes, 764, 08013, Barcelona, Catalonia, Spain.
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Gaujoux-Viala C, Hudry C, Zinovieva E, Herman-Demars H, Flipo RM. MTX optimization or adding bDMARD equally improve disease activity in rheumatoid arthritis: results from the prospective study STRATEGE. Rheumatology (Oxford) 2021; 61:270-280. [PMID: 33774669 PMCID: PMC8742827 DOI: 10.1093/rheumatology/keab274] [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] [Indexed: 11/16/2022] Open
Abstract
Objectives The STRATEGE (Therapeutic Strategy in Patients Treated With Methotrexate for Rheumatoid Arthritis) study aimed to describe treatment strategies in current practice in RA biologic DMARD (bDMARD)-naïve patients with an inadequate response to MTX therapy, and to compare clinical efficacy of the different therapeutic strategies on disease activity after 6 months. Methods The main inclusion criteria of this prospective, observational, multicentre study were confirmed RA diagnosis, treatment by MTX monotherapy and need for therapeutic management modification. Results The 722 patients included had a mean (s.d.) RA duration of 5.3 (6.7) years, a mean DAS28 of 4.0 (1.1); they were all receiving MTX monotherapy, 68% oral, at a mean dose of 15.0 (4.1) mg/week. Two major strategies were identified: (i) MTX monotherapy dose and/or route optimization (72%) and (ii) bDMARD initiation ± MTX (16%). MTX dosing was modified for 70% of patients, maintained (dose and route) for 28% of patients and interrupted for 2%. bDMARDs were started when the MTX mean dose was 17.4 mg/week, 56% parenterally; MTX was maintained concomitantly for 96% of patients. Six-month follow-up results adjusted by propensity score showed that both options were equally successful in improving disease activity and physical function, with 63 and 68% of good-to-moderate EULAR responses, respectively. Conclusion The STRATEGE study shows the importance of initial MTX treatment optimization before initiation of a biological treatment and emphasizes the importance of treat-to-target strategy. Trial registration ClinicalTrials.gov NCT02288520.
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Affiliation(s)
- Cécile Gaujoux-Viala
- Department of Rheumatology, CHU Nîmes, Univ Montpellier, Nîmes, France.,Research Unit INSERM University of Montpellier, IDESP Institute Desbrest of Epidemiology and Public Health, Montpellier, France
| | - Christophe Hudry
- Department of Rheumatology, Hôpital Cochin, AP-HP, Paris, France.,Institut de Rhumatologie, Paris 7, France
| | | | | | - René-Marc Flipo
- Department of Rheumatology, Hôpital Roger Salengro, University of Lille, France
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Wei W, Dougados M, Bernasconi C. Design and analysis considerations for first treatment escalation in clinical trials. Contemp Clin Trials 2021; 104:106369. [PMID: 33781927 DOI: 10.1016/j.cct.2021.106369] [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: 12/28/2020] [Revised: 03/04/2021] [Accepted: 03/23/2021] [Indexed: 11/29/2022]
Abstract
Protocol-mandated, outcome-driven treatment adaptations are common in many types of clinical trials, and a prominent feature of so-called treat-to-target trials. Successive treatment escalation (dosage increase or addition of a drug) if disease activity targets are not reached is a typical design element in these studies. Focusing on the first treatment escalation step, here we address ways of estimating the effect of this outcome-based intervention as well some issues pertaining to the design of such treatment changes in randomized trials. Estimating escalation effects requires to disentangle them from concurrent effects, including persisting effects of the randomized treatment and regression to the mean. A regression-based method and a likelihood ratio test were adapted and assessed in simulations and in data from a recent treat-to-target study in rheumatoid arthritis. In simulations, the procedures were satisfactory in terms of bias and sensitivity with some advantage for the likelihood ratio test. They were able to identify evidence for the escalation effect in the examined study. In summary, both analysis methods are useful, but are sensitive to key assumptions and rely on compliance to the protocol as well as frequent and complete assessments. Furthermore, we examined different treatment escalation designs, including escalation at multiple time points (early escalation). If a longitudinal model for the disease activity is available, we describe how early escalation strategies can decrease the overall disease burden. We provide recommendations for the design of treatment escalation procedures in typical settings.
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Affiliation(s)
- Wei Wei
- Product Development Biometrics, F. Hoffmann-La Roche AG, Basel, Switzerland
| | | | - Corrado Bernasconi
- Product Development Biometrics, F. Hoffmann-La Roche AG, Basel, Switzerland; Neuro-CTU, Department of Neurology, Inselspital and University Bern, Switzerland.
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Rombach I, Tillett W, Jadon D, Tucker L, Watson M, Francis A, Sinomati Y, Eldridge L, Dritsaki M, Dutton SJ, Al-Mossawi H, Gullick N, Thompson B, Coates LC. Treating to target in psoriatic arthritis: assessing real-world outcomes and optimising therapeutic strategy for adults with psoriatic arthritis-study protocol for the MONITOR-PsA study, a trials within cohorts study design. Trials 2021; 22:185. [PMID: 33663566 PMCID: PMC7931500 DOI: 10.1186/s13063-021-05142-7] [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: 11/26/2020] [Accepted: 02/20/2021] [Indexed: 11/15/2022] Open
Abstract
Background The Tight Control of psoriatic arthritis (TICOPA) trial confirmed improved clinical outcomes with a treat to target (T2T) strategy in psoriatic arthritis (PsA). This consisted of 4-weekly review and escalation of ‘step up’ therapy (single disease modifying therapy (DMARD), combination DMARDs and then biologics) based on remission criteria. Based on this, a T2T approach is supported by European PsA treatment recommendations. However, it is not commonly implemented in routine care primarily due to feasibility and cost concerns. In the TICOPA trial, the same treatment regime was used for all participants regardless of their disease profile. Despite the recognition of PsA as a highly heterogeneous condition, no studies have tailored which drugs are used depending on disease severity. The cohort will establish real world outcomes for the T2T approach in PsA and also form the basis of a trials within cohorts (TWiCs) design to test alternative therapeutic approaches within embedded clinical trials providing an evidence base for treatment strategy in PsA. Methods The Multicentre Observational Initiative in Treat to target Outcomes in Psoriatic Arthritis (MONITOR-PsA) cohort will apply a T2T approach within routine care. It will recruit newly diagnosed adult patients with PsA starting systemic therapies. The cohort is observational allowing routine therapeutic care within NHS clinics but a T2T approach will be supported when monitoring treatment within the cohort. Eligible participants will be adults (≥18 years) with active PsA with ≥ 1 tender or swollen joints or enthesis who have not previously had treatment with DMARDs for articular disease. Discussion This study is the first TWiC designed to support a fully powered randomised drug trial. The results from the observational cohort will be compared with those observed in the TICOPA trial investigating the clinical effectiveness and health care costs of the pragmatic T2T approach. Nested trials will provide definitive RCT evidence establishing the optimal management of PsA within the T2T approach. The TWiCs design allows robust generalizability to routine healthcare, avoids disappointment bias, aids recruitment and in future will allow assessment of longer-term outcomes. Trial registration ClinicalTrials.gov NCT03531073. Retrospectively registered on 21 May 2018.
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Affiliation(s)
- Ines Rombach
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - William Tillett
- Royal National Hospital for Rheumatic Diseases, Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Deepak Jadon
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Laura Tucker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marion Watson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Yvonne Sinomati
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Hussein Al-Mossawi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicola Gullick
- Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ben Thompson
- Department of Rheumatology, Musculoskeletal Unit, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
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Abstract
Gout is the most common inflammatory arthritis in the United States. Gouty arthritis is associated with significant morbidity and mortality and is caused by hyperuricemia. Gout is effectively managed and potentially cured by decreasing the overall urate burden with serum urate-lowering therapy. When serum urate is maintained at less than 6.0 mg/dL urate deposition is resolved and gout can be cured. Unfortunately, owing to a lack of physician monitoring and dose escalation the majority of patients do not achieve these urate levels.
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Affiliation(s)
- Sarah F Keller
- Department of Rheumatic and Immunologic Diseases, The Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44915, USA.
| | - Brian F Mandell
- Department of Rheumatic and Immunologic Diseases, The Cleveland Clinic, 9500 Euclid Avenue A50, Cleveland, OH 44915, USA
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Terslev L, Brahe CH, Østergaard M, Fana V, Ammitzbøll-Danielsen M, Møller T, Krabbe S, Hetland ML, Døhn UM. Using a DAS28-CRP-steered treat-to-target strategy does not eliminate subclinical inflammation as assessed by ultrasonography in rheumatoid arthritis patients in longstanding clinical remission. Arthritis Res Ther 2021; 23:48. [PMID: 33522948 PMCID: PMC7849184 DOI: 10.1186/s13075-021-02426-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 09/11/2020] [Accepted: 01/19/2021] [Indexed: 12/21/2022] Open
Abstract
Background Subclinical synovitis by ultrasound is a frequent finding in rheumatoid arthritis (RA) patients in remission and has been shown to be related to erosive progression, risk of flare and unsuccessful drug tapering, but it has not been investigated how a DAS28 T2T-steered strategy in routine care affects the presence of subclinical synovitis in RA patients in remission. The aim of the current study was to investigate the presence of ultrasound-detected subclinical inflammation in RA patients in long-term remission receiving either biological or conventional disease-modifying anti-rheumatic drugs (bDMARD/csDMARD) and, finally, to investigate the presence of ultrasound remission using different ultrasound remission criteria. Methods Eighty-seven RA patients (42 patients receiving bDMARD and 45 csDMARD) received DAS28-CRP-steered treatment in routine care and had achieved DAS28-CRP-remission for > 1 year without radiographic progression. Twenty-four joints were scored 0–3 by ultrasound (elbows, wrists, knees, ankles, metacarpophalangeal and metatarsophalangeal joints 2–5) for grey-scale synovial hypertrophy (GS) and colour Doppler activity (CD) using the OMERACT scoring system. Ultrasound remission was defined as strict (GS score = 0 and CD score = 0), semi-strict (GS score < 1 and Doppler score = 0) and Doppler remission (Doppler score = 0). Results No differences between treatment groups were found for GS sum score and Doppler sum score (median (range) 6 (0–19) and 0 (0–12), respectively). A Doppler score > 0 in at least 1 joint was seen in 44%, a GS score > 1 in at least 1 joint in 93% and a GS score > 2 in at least 1 joint in 54% of patients. Strict ultrasound remission was only observed in bDMARD patients (7%; p = 0.01). Thirty-seven per cent were in semi-strict ultrasound remission and 56% in Doppler remission (no significant difference between groups) with similar results across the subgroups of patients who also fulfilled the ACR-EULAR Boolean-, CDAI- and SDAI-remission criteria. Conclusions Ultrasound frequently detected subclinical synovitis in RA patients in longstanding DAS28-remission obtained through a DAS28-CRP-steered strategy. This was independent of treatment and applied ultrasound remission criteria. Strict ultrasound remission was rare.
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Affiliation(s)
- Lene Terslev
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark. .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Cecilie Heegaard Brahe
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Viktoria Fana
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Mads Ammitzbøll-Danielsen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Torsten Møller
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Simon Krabbe
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Uffe Møller Døhn
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Glostrup, Copenhagen, Denmark
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Gisondi P, Talamonti M, Chiricozzi A, Piaserico S, Amerio P, Balato A, Bardazzi F, Calzavara Pinton P, Campanati A, Cattaneo A, Dapavo P, De Simone C, Dini V, Fargnoli MC, Flori ML, Galluzzo M, Guarneri C, Lasagni C, Loconsole F, Lo Schiavo A, Malagoli P, Malara G, Mercuri SR, Musumeci ML, Naldi L, Papini M, Parodi A, Potenza C, Prignano F, Rongioletti F, Stingeni L, Tiberio R, Venturini M, Bianchi L, Costanzo A, Cusano F, Girolomoni G, Offidani AM, Peris K. Treat-to-Target Approach for the Management of Patients with Moderate-to-Severe Plaque Psoriasis: Consensus Recommendations. Dermatol Ther (Heidelb) 2021; 11:235-52. [PMID: 33426634 DOI: 10.1007/s13555-020-00475-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/02/2020] [Indexed: 01/14/2023] Open
Abstract
Introduction Treat-to-target strategies are used in several chronic diseases to improve outcomes. Treatment goals have also been suggested for psoriasis, but there is currently no consensus on targets, and guidance is needed to implement this strategy in clinical practice. The project ‘Treat to Target Italia’ was launched by a scientific board (SB) of 10 psoriasis experts to generate expert consensus recommendations. Methods On the basis of the published literature, their clinical experience, and the results of a survey among Italian dermatologists, the SB identified four relevant topics: (1) clinical remission; (2) quality of life; (3) abrogation of systemic inflammation; (4) safety. They drafted 20 statements addressing these four topics and submitted them to a panel of 28 dermatologists, in a Delphi process, to achieve consensus (greater than 80% agreement). Results Consensus was reached on all statements. Treatment goals defining clinical remission should include a 90% improvement from baseline in the Psoriasis Area and Severity Index (PASI90 response) or an absolute PASI score of less than or equal to 3. Patient’s quality of life and satisfaction are important targets. If PASI targets are achieved, there should be no or very low impact of psoriasis on quality of life [Dermatology Life Quality Index (DLQI) score less than or equal to 3]. If PASI or DLQI goals are not achieved within 3–4 months, treatment should be changed. Abrogation of systemic inflammation may be crucial for preventing or delaying inflammatory comorbidities. Safety is an equally important target as efficacy. Conclusion These 20 consensus statements define the parameters of a treat-to-target strategy for psoriasis in Italy. It is hoped that use of these in the management of patients with psoriasis will improve treatment outcomes and patient health-related quality of life.
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Nekvindová L, Vencovský J, Pavelka K, Horák P, Křístková Z, Závada J. Switching first-line targeted therapy after not reaching low disease activity within 6 months is superior to conservative approach: a propensity score-matched analysis from the ATTRA registry. Arthritis Res Ther 2021; 23:11. [PMID: 33407803 PMCID: PMC7789592 DOI: 10.1186/s13075-020-02393-8] [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: 09/11/2020] [Accepted: 12/13/2020] [Indexed: 01/23/2023] Open
Abstract
Background Treat-to-target (T2T) is a widely accepted strategy for patients with rheumatoid arthritis (RA). It recommends attaining a goal of at least low disease activity (LDA) within 6 months; otherwise, the current therapy should be modified. We aimed to investigate whether switching a first-line targeted therapy (TT) in patients not reaching LDA within 6 months leads to a higher probability of meeting LDA at the 12-month visit in daily clinical practice using data from Czech registry ATTRA. Methods We included patients with RA starting the first-line TT from 1 January 2012 to 31 January 2017 with at least 1-year follow-up. We created four mutually exclusive cohorts based on (1) switching to another TT within the first year and (2) reaching a treatment target (DAS28-ESR ≤ 3.2) at the 6-month visit. The primary outcome was the comparison of odds for reaching remission (REM) or LDA at the 12-month visit between patients switching and not switching TT after not reaching treatment target at 6 months. Before using logistic regression to estimate the odds ratio, we employed the propensity score to match patients at the 6-month visit. Results A total of 1275 patients were eligible for the analysis. Sixty-two patients switched within the first 5 months of the treatment before evaluating treatment response at the 6-month visit (C1); 598 patients reached the treatment target within 6 months of therapy (C2); 124 patients did not reach treatment response at 6-month visit and switched to another therapy (C3), and 491 patients continued with the same treatment despite not reaching LDA at the 6-month visit (C4). We matched 75 patients from cohort C3 and 75 patients from C4 using the propensity score. Patients following the T2T principle (C3) showed 2.8 (95% CI 1.4–5.8; p = 0.005) times increased likelihood of achieving REM/LDA at the 12-month visit compared to patients not following the T2T strategy (C4). Conclusions In daily clinical practice, the application of the T2T strategy is underused. Switching TT after not reaching REM/LDA within the first 6 months leads to a higher probability of achieving REM/LDA in RA patients at the 12-month visit.
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Affiliation(s)
- Lucie Nekvindová
- Institute of Biostatistics and Analyses, Ltd., Brno, Czech Republic.,Institute of Rheumatology, Na Slupi 4, 128 00, Prague, Czech Republic
| | - Jiří Vencovský
- Institute of Rheumatology, Na Slupi 4, 128 00, Prague, Czech Republic.,Department of Rheumatology, First Faculty of Medicine, Prague, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, Na Slupi 4, 128 00, Prague, Czech Republic.,Department of Rheumatology, First Faculty of Medicine, Prague, Czech Republic
| | - Pavel Horák
- Department of Internal Medicine III - Nephrology, Rheumatology, Endocrinology, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Czech Republic.,University Hospital, Olomouc, Czech Republic
| | | | - Jakub Závada
- Institute of Rheumatology, Na Slupi 4, 128 00, Prague, Czech Republic. .,Department of Rheumatology, First Faculty of Medicine, Prague, Czech Republic.
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Thomas T, Casado E, Geusens P, Lems WF, Timoshanko J, Taylor D, Hofbauer LC. Is a treat-to-target strategy in osteoporosis applicable in clinical practice? Consensus among a panel of European experts. Osteoporos Int 2020; 31:2303-2311. [PMID: 32767094 PMCID: PMC7661407 DOI: 10.1007/s00198-020-05569-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 07/24/2020] [Indexed: 02/07/2023]
Abstract
UNLABELLED A panel of European experts was convened to establish consensus on a treat-to-target strategy in osteoporosis. Panellists agreed that the ultimate goals of treating osteoporosis are recovering pre-fracture functional level and reducing subsequent fracture risk; there was consensus that total hip bone mineral density is currently the most appropriate treatment target in clinical practice. INTRODUCTION A modified Delphi approach was convened to establish consensus among European experts on best practice management for patients with fragility fractures and whether a treat-to-target (T2T) strategy is applicable in osteoporosis. METHODS A panel of 12 clinical experts (from eight European countries) voted on 13 final statements relating to a T2T strategy for osteoporosis across three rounds of blinded, remotely conducted electronic surveys (Likert scale: 'strongly disagree', 'disagree', 'unable to answer', 'agree', 'strongly agree'). When panellists disagreed, they were asked how the statement could be adjusted to allow for a positive response, which was used to refine the statement for the following round. Consensus was defined as ≥ 75% agreement with a statement. Panellists were selected by UCB Pharma, which provided financial and logistical support. RESULTS Consensus was reached for 13/13 statements. Panellists agreed that the most important goals for fragility fracture patients are recovery of pre-fracture functional level and reduction of subsequent fracture risk. There was also consensus that a T2T strategy is applicable to osteoporosis and that bone mineral density (BMD) is currently the most clinically appropriate target. With regard to the definition of a specific BMD treatment target and timeframes applicable to T2T in osteoporosis, no clear consensus was reached; panellists emphasised that these would need to be individually determined. CONCLUSIONS According to a panel of European experts, the main goals of fracture management are to recover pre-fracture functional level and reduce fracture risk. Total hip BMD seems to be the most clinically appropriate treatment target within a T2T strategy.
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Affiliation(s)
- T Thomas
- CHU de St-Etienne, INSERM U1059, Université de Lyon, St-Etienne, France
| | - E Casado
- University Hospital Parc Taulí, Sabadell, Spain
| | - P Geusens
- Maastricht University, Maastricht, The Netherlands
- Hasselt University, Hasselt, Belgium
| | - W F Lems
- Amsterdam University Medical Center, location VUmc, Amsterdam, The Netherlands
| | | | | | - L C Hofbauer
- Center for Healthy Aging & Department of Medicine III, Technische Universität Dresden, Dresden, Germany
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Abstract
Still's disease covers a range of disorders from systemic juvenile idiopathic arthritis (SJIA) up to adult onset Still's disease (AOSD). The overlapping clinical features suggest that SJIA and AOSD are different manifestations of a phenotypic continuum in different age stages. Still's disease is clinically characterized by fever, rash, joint involvement, lymphadenopathy and serositis. In this review the more recent pathogenetic model of a biphasic disease course is presented. The initial autoinflammation with predominant dysregulation of innate immunity is the basis of the "window of opportunity" hypothesis for the early use of a cytokine blockade. If the disease is not stopped in this phase, a phenotype change to a disease with destructive arthritis regularly occurs, in which dysregulation of the mechanisms of adaptive immunity plays a special role. The understanding of Still's disease as a biphasic disease enables the monitoring of molecular signatures. At the same time, this opens up perspectives for phase-specific targeted treatment using modern treat-to-target strategies.
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Affiliation(s)
- D Föll
- Klinik für Pädiatrische Rheumatologie und Immunologie, Universitätsklinikum Münster, Domagkstr. 3, 48149, Münster, Deutschland.
| | - H Wittkowski
- Klinik für Pädiatrische Rheumatologie und Immunologie, Universitätsklinikum Münster, Domagkstr. 3, 48149, Münster, Deutschland
| | - C Hinze
- Klinik für Pädiatrische Rheumatologie und Immunologie, Universitätsklinikum Münster, Domagkstr. 3, 48149, Münster, Deutschland
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Watanabe K. Clinical management for small bowel of Crohn's disease in the treat-to-target era: now is the time to optimize treatment based on the dominant lesion. Intest Res 2020; 18:347-354. [PMID: 33131231 PMCID: PMC7609393 DOI: 10.5217/ir.2020.00032] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/08/2020] [Indexed: 02/07/2023] Open
Abstract
A treat-to-target strategy, in which treatment is continuously adjusted according to the results of scheduled objective monitoring, is optimal for patients with Crohn's disease (CD) in the era of biologics. The small bowel is a common site of intractable CD, which may result from multiple strictures or expanding lesions. To improve the prognosis of patients with small bowel CD, lesions should be proactively monitored within the subclinical phase. Objective assessment of small bowel lesions is technically difficult, however, due to the relatively poor correlation between endoscopic activity and clinical symptoms or biomarker titers. The presence of proximal small bowel lesions and asymptomatic "Real Silent CD" must be considered. Endoscopy remains the gold standard to assess these lesions. In clinical practice, the advantages and disadvantages of each imaging modality and biomarker must be carefully weighed for appropriate application and reliable monitoring. The prevalence of small bowel lesions depends on the precision of the imaging modality used for detection. Clinical management should be based on the dominant location of the intestinal lesions rather than classical classification. Optimal strategies for detecting and treating small bowel lesions in patients with CD must be developed utilizing reliable, precise, and objective monitoring.
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Affiliation(s)
- Kenji Watanabe
- Center for Inflammatory Bowel Disease, Division of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
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Nuñez F P, Mahadevan U, Quera R, Bay C, Ibañez P. Treat-to-target approach in the management of inflammatory Bowel disease. Gastroenterol Hepatol 2020; 44:312-319. [PMID: 33070988 DOI: 10.1016/j.gastrohep.2020.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
With the advent of biologic and small molecule therapies, there has been a substantial change in the treatment of inflammatory bowel disease. These advances have had a great impact in preventing disease progression, intestinal damage and, therefore, have contributed to a better quality of life. Discordance between symptom control and mucosal healing has been demonstrated. This has led to the search for new disease control targets. The treat to target strategy, based on expert recommendations and now a randomized controlled trial, has determined that clinical and endoscopic remission should be the goal of therapy. Biomarkers (fecal calprotectin) can be a surrogate target. Although histological healing has shown benefits, there is inadequate evidence and inadequate therapy for that to be a fixed goal at this time. This review will focus on therapeutic goals, according to the evidence currently available, and evaluate strategies to achieve them.
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Affiliation(s)
- Paulina Nuñez F
- Division of Gastroenterology, Unversity of Chile, Hospital San Juan de Dios, Santiago, Chile a Division of Gastroenterology, Unversity of Chile, Hospital San Juan de Dios, Santiago, Chile.
| | - Uma Mahadevan
- Division of Gastroenterology, University of California, San Francisco, United States
| | - Rodrigo Quera
- Inflammatory Bowel Disease Program, Gastroenterology Department, Clínica Las Condes, Santiago, Chile
| | - Constanza Bay
- Department of Pediatrics, Pontifical Catholic University of Chile, Santiago, Chile
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Dal Buono A, Roda G, Argollo M, Zacharopoulou E, Peyrin-Biroulet L, Danese S. Treat to target or 'treat to clear' in inflammatory bowel diseases: one step further? Expert Rev Gastroenterol Hepatol 2020; 14:807-817. [PMID: 32762582 DOI: 10.1080/17474124.2020.1804361] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Inflammatory bowel diseases (IBD) are chronic and progressive diseases. Long-term complications are demolitive surgery and colon-rectal cancer. A 'treat to target' strategy, in which the treatment aims to achieve objective outcomes, has already been introduced in the management of chronic conditions as rheumatic diseases. This approach is emerging as suitable for ulcerative colitis and Crohn's disease. Targets are predefined therapeutic goals demonstrated to prevent end-organ dysfunction. An optimization or switch of therapy is considered depending on the target's achievement, with regular monitoring. AREAS COVERED According to the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) indications, mucosal healing and clinical remission are the main targets in IBDs. Histological remission is increasingly being considered as a novel target and has given rise to the new concept of 'disease clearance' which includes clinical, endoscopic and microscopic remission. We aim to review current evidence on the treat-to-target strategy in comparison to a stricter treat-to-clear in the IBD field. EXPERT OPINION Prospective studies on treat-to-target algorithm are sparse; a treat-to-clear approach is desirable but far from adoption in the daily practice and clinical trials. The ultimate goals of a treat-to-clear strategy differ in UC and in CD, including histological healing and transmural healing, respectively.
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Affiliation(s)
- Arianna Dal Buono
- IBD Center, Department of Gastroenterology, Humanitas Clincal and Research Hospital (IRCCS) , Milan, Italy
| | - Giulia Roda
- IBD Center, Department of Gastroenterology, Humanitas Clincal and Research Hospital (IRCCS) , Milan, Italy
| | - Marjorie Argollo
- Gastroenterology, Universidade Federal de São Paulo , São Paulo, Brazil
| | - Eirini Zacharopoulou
- IBD Center, Department of Gastroenterology, Humanitas Clincal and Research Hospital (IRCCS) , Milan, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, University Hospital of Nancy, University of Lorraine , Vandoeuvre-lès-Nancy, France
| | - Silvio Danese
- IBD Center, Department of Gastroenterology, Humanitas Clincal and Research Hospital (IRCCS) , Milan, Italy.,Department of Biomedical Sciences, Humanitas University , Pieve Emanuele, Milan, Italy
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Novella-Navarro M, Cabrera-Alarcon JL, Diaz-Torne C, Aramburu-Muñoz F, Janta I, Ortega de la O MC, Prada-Ojeda A, Sala-Icardo L, Urruticoechea-Arana A, García de la Peña Lefebvre P, Calvo-Aranda E. A treat-to-target approach for gout confers renoprotective effect in patients with chronic kidney disease stage 3. Rheumatol Int 2020; 40:1081-1087. [PMID: 31982955 DOI: 10.1007/s00296-020-04517-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 10/24/2019] [Accepted: 01/11/2020] [Indexed: 12/23/2022]
Abstract
The aim of this study was to assess changes in the estimated glomerular filtration rate (eGFR) in gouty patients with chronic kidney disease (CKD) using a "treat-to-target" (T2T) approach in gout. This multicenter observational retrospective study included patients diagnosed with gout and CKD stage 3 taking xanthine oxidase inhibitors (XOIs) (allopurinol or febuxostat) for at least 12 months. All patients were treated using a T2T strategy according to national gout guidelines to achieve the target levels of serum uric acid (sUA; < 5-6 mg/dl) within 6 months of the first visit. The primary outcome was to assess changes in eGFR. The effects of independent variables were analyzed over eGFR in a linear mixed-effects (LME) model. Fifty patients with gout and CKD stage 3 treated with XOIs with a T2T strategy for 12 months were included. Eighty-two percent of the patients achieved the sUA target during the study period. The improvement seen in eGFR was higher during the first 6 months, showing a median increase of 7.54 ml/min/m2 (SE = 1.25) and trending towards stability over 12 months. For every 1 mg/dl of decrease in sUA, an improvement of 1.5 ml/min/m2 in eGFR was observed (coefficient ± SE: - 1.58 ± 0.26) (p < 0.001) with no differences between type and dosage of XOIs treatment, colchicine administration, age, sex, and smoking status. A reduction in sUA levels using a T2T approach with XOIs at an optimal dose is possible and could help conserve and improve renal function in gouty patients with CKD stage 3.
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Affiliation(s)
- Marta Novella-Navarro
- Rheumatology Department, Hospital Universitario Torrejon de Ardoz, Madrid, Spain.,Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain
| | - Jose Luis Cabrera-Alarcon
- Bioinformatic Unit/GENOXPHOS-Group, Centro Nacional Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Cesar Diaz-Torne
- Rheumatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain
| | | | - Iustina Janta
- Rheumatology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain.,Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain
| | - Maria Carmen Ortega de la O
- Rheumatology Department, Hospital Universitario Infanta Elena, Madrid, Spain.,Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain
| | - Alejandro Prada-Ojeda
- Rheumatology Department, Hospital Universitario Torrejon de Ardoz, Madrid, Spain.,Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain
| | - Luis Sala-Icardo
- Rheumatology Department, Hospital Universitario Torrejon de Ardoz, Madrid, Spain
| | | | | | - Enrique Calvo-Aranda
- Rheumatology Department, Hospital Universitario Infanta Leonor, Avenida Gran Via del Este, 80, 28031, Madrid, Spain. .,Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain.
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Zhao J, Wang Y, Geng Y, Zhang X, Deng X, Ji L, Song Z, Zhang Z. Intensive therapy alleviates subclinical synovitis on ultrasound and disease activity and reduces flare in rheumatoid arthritis patients who have achieved clinical target - a randomized controlled trial. Semin Arthritis Rheum 2020; 50:673-679. [PMID: 32512262 DOI: 10.1016/j.semarthrit.2020.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/17/2020] [Accepted: 05/22/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Whether intensive therapy can alleviate subclinical synovitis and reduce flare in rheumatoid arthritis (RA) patients in clinical remission remains unclear. We designed a 1-year open-labelled, randomized controlled clinical trial to elucidate this question. METHODS RA patients in clinical remission/low disease activity (defined by DAS28-CRP≤ 3.2), however with subclinical synovitis on ultrasound [power Doppler (PD)≥1 and/or gray scale (GS)≥2] were randomized to receive maintenance or intensive treatment at a ratio of 1:1. The primary outcome was the rate of RA relapse (defined by DAS28-CRP>3.2 and an increase≥0.6). The secondary outcomes were changes of PD and GS scores, and clinical disease activity at each visit from baseline. RESULTS 108 patients with 54 in each group were enrolled. During 1-year follow-up, the relapse rate was significantly higher in maintenance group than in intensive group, regardless of all enrolled patients or those in remission [24.1% (13/54) vs. 9.1% (5/54), p=0.039; 26.2% (11/42) vs. 5.3% (2/38), p=0.026, respectively]. Although GS and PD scores were decreased at 12 months in both groups, the decline was more remarkable in intensive group than in maintenance group. The improvement of clinical disease activity score was only observed in intensive group, not maintenance group. Adverse events were comparable between two groups. Abnormal liver function tests were observed in 24 (22%) patients with 16 from intensive group. CONCLUSION Intensive therapy can alleviate subclinical synovitis on ultrasound and clinical disease activity, and prevent relapse in RA patients who have achieved clinical remission or low disease activity, with comparable safety profiles to maintenance therapy. REGISTRATION NUMBER ChiCTR2000029279.
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Affiliation(s)
- Juan Zhao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Yu Wang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Yan Geng
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Xiaohui Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Xuerong Deng
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Zhibo Song
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China.
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Hansmann S, Lainka E, Horneff G, Holzinger D, Rieber N, Jansson AF, Rösen-Wolff A, Erbis G, Prelog M, Brunner J, Benseler SM, Kuemmerle-Deschner JB. Consensus protocols for the diagnosis and management of the hereditary autoinflammatory syndromes CAPS, TRAPS and MKD/HIDS: a German PRO-KIND initiative. Pediatr Rheumatol Online J 2020; 18:17. [PMID: 32066461 PMCID: PMC7027082 DOI: 10.1186/s12969-020-0409-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/03/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Rare autoinflammatory diseases (AIDs) including Cryopyrin-Associated Periodic Syndrome (CAPS), Tumor Necrosis Receptor-Associated Periodic Syndrome (TRAPS) and Mevalonate Kinase Deficiency Syndrome (MKD)/ Hyper-IgD Syndrome (HIDS) are genetically defined and characterized by recurrent fever episodes and inflammatory organ manifestations. Early diagnosis and early start of effective therapies control the inflammation and prevent organ damage. The PRO-KIND initiative of the German Society of Pediatric Rheumatology (GKJR) aims to harmonize the diagnosis and management of children with rheumatic diseases nationally. The task of the PRO-KIND CAPS/TRAPS/MKD/HIDS working group was to develop evidence-based, consensus diagnosis and management protocols including the first AID treat-to-target strategies. METHODS The national CAPS/TRAPS/MKD/HIDS expert working group was established, defined its aims and conducted a comprehensive literature review synthesising the recent (2013 to 2018) published evidence including all available recommendations for diagnosis and management. General and disease-specific statements were anchored in the 2015 SHARE recommendations. An iterative expert review process discussed, adapted and refined these statements. Ultimately the GKJR membership vetted the proposed consensus statements, agreement of 80% was mandatory for inclusion. The approved statements were integrated into three disease specific consensus treatment plans (CTPs). These were developed to enable the implementation of evidence-based, standardized care into clinical practice. RESULTS The CAPS/TRAPS/MKD/HIDS expert working group of 12 German and Austrian paediatric rheumatologists completed the evidence synthesis and modified a total of 38 statements based on the SHARE recommendation framework. In iterative reviews 36 reached the mandatory agreement threshold of 80% in the final GKJR member survey. These included 9 overarching principles and 27 disease-specific statements (7 for CAPS, 11 TRAPS, 9 MKD/HIDS). A diagnostic algorithm was established based on the synthesized evidence. Statements were integrated into diagnosis- and disease activity specific treat-to-target CTPs for CAPS, TRAPS and MKD/HIDS. CONCLUSIONS The PRO-KIND CAPS/TRAPS/MKD/HIDS working group established the first evidence-based, actionable treat-to-target consensus treatment plans for three rare hereditary autoinflammatory diseases. These provide a path to a rapid evaluation, effective control of disease activity and tailored adjustment of therapies. Their implementation will decrease variation in care and optimize health outcomes for children with AID.
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Affiliation(s)
- Sandra Hansmann
- Department of Pediatric Rheumatology, autoinflammation reference centre Tuebingen (arcT), University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Elke Lainka
- Department of Pediatric Rheumatology, University Children's Hospital Essen, Essen, Germany
| | - Gerd Horneff
- Department of Pediatrics, Asklepios Clinic Sankt Augustin GmbH, Sankt Augustin, Germany
| | - Dirk Holzinger
- Department of Pediatric Hematology-Oncology, University of Duisburg-Essen, Essen, Germany
| | - Nikolaus Rieber
- Department of Pediatrics, Kinderklinik Muenchen Schwabing, Klinikum Schwabing, StKM GmbH und Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Pediatrics I, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Annette F Jansson
- Division of Pediatric Rheumatology and Immunology, Dr. von Hauner Children's Hospital, University Hospital Munich, Munich, Germany
| | - Angela Rösen-Wolff
- Department of Pediatrics, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Gabi Erbis
- Department of Pediatric Rheumatology, autoinflammation reference centre Tuebingen (arcT), University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Martina Prelog
- Department of Pediatrics, Pediatric Rheumatology and Special Immunology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Juergen Brunner
- Department of Pediatrics, Medical University Innsbruck, Innsbruck, Austria
| | - Susanne M Benseler
- Department of Pediatric Rheumatology, autoinflammation reference centre Tuebingen (arcT), University Children's Hospital Tuebingen, Tuebingen, Germany
- Rheumatology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Jasmin B Kuemmerle-Deschner
- Department of Pediatric Rheumatology, autoinflammation reference centre Tuebingen (arcT), University Children's Hospital Tuebingen, Tuebingen, Germany.
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Andréu JL, Martín MA, Corominas H, Pérez-Venegas JJ, Román-Ivorra JA, Sánchez-Alonso F, Gil de Miguel Á. Treat-to-target strategy in patients with rheumatoid arthritis: Audit of adherence from real world clinical data. ACTA ACUST UNITED AC 2019; 17:212-214. [PMID: 31882343 DOI: 10.1016/j.reuma.2019.10.006] [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: 10/15/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The current paradigm of the management of rheumatoid arthritis (RA) recommends achieving a state of remission or low disease activity through the treat-to-target strategy. Our study assesses adherence to this strategy. METHOD Patients with RA (ACR-EULAR 2010 criteria) were included. From each centre, 19 patients were randomly selected. Clinical histories (CH) were assessed by independent auditors, checking compliance with predefined quality criteria. The study was approved by ethics committees. RESULTS We included 856 patients (mean age 54 years; 71% women). The use of a combined index (CI) was recorded in 61% of cases. Visits were recorded every 4 weeks using a CI in 4% of CH while attempts were made to achieve remission. Monitoring of disease activity every 6-8 months after reaching the target was recorded in 73% of cases. CONCLUSIONS The implementation of the treat-to-target strategy is barely recorded in patients with RA in routine clinical practice.
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Affiliation(s)
- José-Luis Andréu
- Rheumatology Department, H.U. Puerta de Hierro Majadahonda, Majadahonda, Spain.
| | | | - Héctor Corominas
- Unitat territorial de Reumatologia, Hospital Universitari de Sant Pau & Hospital Dos de Maig, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | | | | | - Ángel Gil de Miguel
- Cátedra de Medicina Preventiva y Salud Pública, Universidad Rey Juan Carlos, Madrid, Spain
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Abstract
Despite evidence that treat-to-target (TTT) approaches lead to better disease outcomes in RA, TTT is not widely implemented in rheumatology clinics in North America. This article discusses the barriers (including access to care, patient and physician factors, and systems issues) to implementing TTT in the clinic, and proposes possible solutions and future research directions.
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Affiliation(s)
- Julia A Ford
- Division of Rheumatology, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Daniel H Solomon
- Division of Rheumatology, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA; Division of Pharmacoepidemiology, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
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