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Barth K, Gill H, Singh N. Long-term safety of biologic and targeted synthetic disease modifying drugs in rheumatology. Curr Opin Rheumatol 2024; 36:113-119. [PMID: 38126228 PMCID: PMC10836640 DOI: 10.1097/bor.0000000000000995] [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] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW The landscape for treatment of rheumatic diseases is ever evolving, with several new drugs recently approved across diseases and more in the pipeline. This timely review aims to highlight the latest literature on long-term safety profiles of salient established and emerging biologic (b) and targeted synthetic (ts) disease modifying antirheumatic drugs (DMARDs). RECENT FINDINGS The risk of infection remains elevated with the use of most b and tsDMARDs, with specifically risk of hepatitis B reactivation with rituximab and zoster infection with JAK inhibitors (JAKi). The results of the ORAL surveillance trial led to new black box warnings for JAKi and evoked critical risk-benefit discussions surrounding JAKi and DMARDs overall. SUMMARY Such well conducted trials are needed to gather long term comparative safety data of DMARDs. In the interim, real world observational studies also have a role to play in our understanding of long-term drug safety, provided that detailed attention is paid to minimize biases inherent in observational studies.
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Affiliation(s)
- Kaia Barth
- Fellow, Division of Rheumatology, University of Washington, Seattle, USA
| | - Harsimrat Gill
- Medical Student, Department of Medicine, University of Washington, Seattle, USA
| | - Namrata Singh
- Assistant Professor, Division of Rheumatology, University of Washington, Seattle, USA
- Adjunct Assistant Professor, Department of Epidemiology, University of Washington, Seattle, USA
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Cinar C, Dogan YE, Harman H, Yurttutmus Z, Bagatir N, Doran M, Öneş K. Comparison of Hand-Wrist Findings of Rheumatoid Arthritis Patients According to the Use of Synthetic and Biological Disease-Modifying Antirheumatic Drugs ( DMARDs): A Clinical, Radiographic, and Ultrasonographic Study. Cureus 2023; 15:e46876. [PMID: 37954693 PMCID: PMC10638456 DOI: 10.7759/cureus.46876] [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] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE The aim of this study is to evaluate the hand-wrist findings in patients with rheumatoid arthritis (RA) using synthetic and a combination of synthetic and biological disease-modifying antirheumatic drugs (DMARDs) in terms of ultrasonographic, clinical, and radiographic data. METHODS The study is designed as a cross-sectional study, and 31 RA patients followed up in the rheumatology outpatient clinic were enrolled. Nineteen patients were using only synthetic DMARDs, and 12 patients were using a combination of synthetic and biological DMARDs. The clinical data of each patient were recorded simultaneously. Disease Activity Score-28 (DAS-28) was used for the assessment of disease activation, and the Health Assessment Questionnaire (HAQ) score was used for the evaluation of general health status. Bilateral proximal interphalangeal (PIP), metacarpophalangeal (MCP) joints, and the radiocarpal, ulnocarpal, and midcarpal joints of the patients were examined by ultrasonography (US). The Sharp-van der Heijde modified score was used to determine the radiographic damage. RESULTS There was no significant difference between the two groups in terms of demographic data, clinical findings, ESR, and CRP. When the groups were compared in terms of right and left PIP, MCP, and radiocarpal, ulnocarpal, and midcarpal synovitis grade total scores, no significant difference was found between the two groups. Radiographic total joint space scores were significantly lower in the group receiving only synthetic DMARD treatment (p=0.047) and 25-OH vitamin D levels were significantly higher (p=0.008). CONCLUSION This study revealed that there was no significant difference between groups except radiographic total joint space scores.
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Affiliation(s)
- Cigdem Cinar
- Department of Interventional Physiatry, Biruni University, Istanbul, TUR
| | - Yunus Emre Dogan
- Department of Physiotherapy, Istanbul Physical Therapy and Rehabilitation Health Application and Research Center, Istanbul, TUR
| | - Halil Harman
- Department of Rheumatology, Kanuni Sultan Suleyman Health Application and Research Center, Istanbul, TUR
| | - Zeynep Yurttutmus
- Department of Physiotherapy, Istanbul Physical Therapy and Rehabilitation Health Application and Research Center, Istanbul, TUR
| | - Nazire Bagatir
- Department of Physiotherapy, Istanbul Physical Therapy and Rehabilitation Health Application and Research Center, Istanbul, TUR
| | - Muhsin Doran
- Department of Physiotherapy, Yalvac Public Hospital, Istanbul, TUR
| | - Kadriye Öneş
- Department of Physiotherapy, Istanbul Physical Therapy and Rehabilitation Health Application and Research Center, İstanbul, TUR
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Pang M, Sun Z, Zhang H. Biologic DMARDs and targeted synthetic DMARDs and the risk of all-cause mortality in rheumatoid arthritis: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e29838. [PMID: 35960132 PMCID: PMC9371573 DOI: 10.1097/md.0000000000029838] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The aim of this study was to perform a meta-analysis to compare the risk of all-cause mortality between biological/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) and non-b/tsDMARDs involving patients with rheumatoid arthritis (RA). METHODS We performed a systematic review of articles published up to August 2021 using electronic databases. We included studies that reported all-cause mortality in RA patients and compared b/tsDMARDs and non-b/tsDMARDs. RESULTS We included a total of 77 studies involving 64,428 patients. These comprised 44,227 patients treated with b/tsDMARDs and 20,201 treated with non-b/tsDMARDs. The occurrence of all-cause mortality was the primary outcome. The risk of all-cause mortality between the 2 treatments was not significantly different (relative risk = 1.08; 95% confidence interval = 0.98-1.19). However, subgroup analyses showed significant increase in risks of mortality in anti-TNFs users with RA compared with non-b/tsDMARDs (relative risk = 1.47, 95% confidence interval = 1.02-2.12). No significant differences were found after subgroup analyses based on other molecules involved and study duration. CONCLUSION In comparison with non-b/tsDMARDs, our results suggest that antitumor necrosis factor therapy is associated with observed increased risks of mortality and further investigation is needed.
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Affiliation(s)
- Mengduan Pang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Dalian Medical University, Shahekou District, Dalian, China
| | - Zhe Sun
- Department of Thoracic Surgery, The First Affiliated Hospital of Dalian Medical University, Shahekou District, Dalian, China
| | - Hongfeng Zhang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Dalian Medical University, Shahekou District, Dalian, China
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Gros C, Mariaggi AA, Meritet JF, André E, Boisson M, Combier A, Descamps E, Frantz C, Wanono S, Morel J, Avouac J, Rozenberg F, Miceli-Richard C, Fogel O. Évaluation systématique de la réponse humorale contre le SARS-CoV-2 dans une cohorte française de 283 patients atteints d’un rhumatisme inflammatoire chronique ☆. Rev Rhum Ed Fr 2022; 89:405-411. [PMID: 35530370 PMCID: PMC9059432 DOI: 10.1016/j.rhum.2022.04.010] [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] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 12/14/2022]
Abstract
Objectifs Estimer la séroprévalence de l’infection par le SARS-CoV-2 chez les patients atteints de rhumatisme inflammatoire chronique et préciser la proportion de formes asymptomatiques et symptomatiques de COVID-19. Méthodes Nous avons réalisé un dépistage systématique de l’infection à COVID-19 parmi les patients atteints de spondyloarthrite (SpA, n = 143) et de polyarthrite rhumatoïde (PR, n = 140) suivis en hôpital de jour de rhumatologie à l’hôpital Cochin à Paris entre juin et août 2020. Pour chaque patient, un test sérologique détectant les IgG dirigées contre la protéine nucléocapside N (anti-N) et, pour certains patients, contre la protéine Spike (anti-S) du SARS-CoV 2, était réalisé. Nous avons effectué une analyse descriptive des données. Résultats Durant la période de juin à août 2020, la séroprévalence (IgG anti-N) du SARS-CoV-2 dans notre population était de 2,83 % (8/283 patients) sans distinction entre les patients atteints de PR et de SpA (2,14 % et 3,5 % respectivement). Sur les 283 patients, 11 ont eu un diagnostic d’infection à SARS-CoV-2 (3,8 %). Parmi ces 11 patients, 2 patients ont fait une forme asymptomatique de COVID-19 (18 %) dont le diagnostic a été confirmé sur la positivité de la sérologie anti-S. Sur les 283 patients, 85 % étaient sous biothérapie, principalement sous Rituximab (RTX) (n = 44) et Infliximab (IFX) (n = 136). Conclusion La séroprévalence du SARS-CoV-2 chez les patients atteints de rhumatismes inflammatoires chroniques, principalement sous biothérapie, était de 2,83 %. Parmi les patients infectés, 18 % étaient asymptomatiques. La stratégie associant interrogatoire des patients et sérologie anti-N est performante pour dépister les infections à SARS-CoV-2.
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Affiliation(s)
- Clothilde Gros
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Alice-Andrée Mariaggi
- Université Paris Descartes, service de virologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Jean-François Meritet
- Université Paris Descartes, service de virologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Emma André
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Margaux Boisson
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Alice Combier
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Elise Descamps
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Camelia Frantz
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Sarah Wanono
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Jacques Morel
- Service de rhumatologie, CHU et Université de Montpellier, France
| | - Jérôme Avouac
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Flore Rozenberg
- Université Paris Descartes, service de virologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Corinne Miceli-Richard
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France,Unité Mixte AP–HP/Institut Pasteur, Institut Pasteur, unité immunorégulation, Paris, France,Auteur correspondant
| | - Olivier Fogel
- Université Paris Descartes, service de rhumatologie, hôpital Cochin, AP–HP, 27, rue du Faubourg Saint Jacques, 75014, Paris, France
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Chowdhury T, Dutta J, Noel P, Islam R, Gonzalez-Peltier G, Azad S, Shankar M, Rayapureddy AK, Deb Roy P, Gousy N, Hassan KN. An Overview on Causes of Nonadherence in the Treatment of Rheumatoid Arthritis: Its Effect on Mortality and Ways to Improve Adherence. Cureus 2022; 14:e24520. [PMID: 35651472 PMCID: PMC9136714 DOI: 10.7759/cureus.24520] [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] [Accepted: 04/26/2022] [Indexed: 11/05/2022] Open
Abstract
Rheumatoid arthritis is one of the most prevalent musculoskeletal disorders that, when insufficiently treated, results in detrimental sequelae including joint damage and reduced quality of life. Poor patient adherence to medication is a significant blockade to effective management. The purpose of this review is to highlight and discuss the factors responsible for defiance of antirheumatic medication and ways to overcome these barriers. Education level, health literacy, cohabitation status, multi-morbidities, complicated drug regimen, intermittent co-payments, prescribed regimen adverse effects, and cognitive impairment are a few among many common barrier factors leading to poorer outcomes in rheumatoid arthritis. While there is an abundance of inhibitory factors leading to worsening disease progression, they each can be easily dealt with an effective approach at the beginning or during the treatment course to ensure a better outcome.
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Affiliation(s)
- Tutul Chowdhury
- Internal Medicine, One Brooklyn Health System, Brooklyn, USA
| | - Jui Dutta
- Medicine, Comilla Medical College, New York City, USA
| | - Pharlin Noel
- Surgery, Mount Sinai South Nassau Hospital, Oceanside, USA
| | - Ratul Islam
- Medicine, American University of Antigua, New York City, USA
| | | | - Samzorna Azad
- Medicine, American University of Antigua, New York City, USA
| | - Malavika Shankar
- Internal Medicine, One Brooklyn Health System, New York City, USA
| | | | | | - Nicole Gousy
- Medicine, American University of Antigua, New York City, USA
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Hussain A, Gondal M, Abdallah N, Yousuf H, Iqbal M. Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO): An Interesting Clinical Syndrome. Cureus 2020; 12:e10184. [PMID: 32905195 PMCID: PMC7465995 DOI: 10.7759/cureus.10184] [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] [Indexed: 11/13/2022] Open
Abstract
Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare disorder that classically involves the musculoskeletal system, i.e. bone, joint and skin. The exact pathogenesis of this syndrome is unknown. However, autoimmunity, infections, immune malfunction and genetic factors are attributed to its pathophysiology. Bone and joint involvements are the hallmark of SAPHO syndrome and not necessarily require cutaneous involvement at the time of diagnosis. X-ray of the affected joints could show osteitis with sclerosis. Anterior chest wall involvement particularly ''bullhead appearance'' seen on bone scan is a striking feature of the syndrome. Erythrocyte sedimentation rate (ESR) is usually elevated amongst the majority of patients. Diagnosis of SAPHO is always challenging and often delayed because of a multitude of symptoms. The mainstay of treatment is control of pain and inflammation with both non-steroidal anti-inflammatory drugs (NSAIDs) and rescue courses of systemic steroids. If failed to control symptoms with first-line agents and in those with severe disease, disease-modifying anti-inflammatory drugs (DMARDs) may be needed eventually. Despite a chronic inflammatory condition, it remains stable in the majority of cases. Here in this case report, we reiterate the importance of early recognition, timely diagnosis and prompt treatment initiation.
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Affiliation(s)
- Ali Hussain
- Acute Medicine, Pinderfields General Hospital, Wakefield, GBR
| | - Mohsin Gondal
- Cardiology, The Mid Yorkshire Hospitals NHS Trust, Wakefield, GBR
| | - Nizar Abdallah
- Endocrinology, Diabetes and Metabolism, Pinderfields General Hospital, Wakefield, GBR
| | - Hira Yousuf
- Oncology, Pinderfields General Hospital, Wakefield, GBR
| | - Mubashar Iqbal
- Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, GBR
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7
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Benucci M, Damiani A, Infantino M, Manfredi M, Quartuccio L. Médicaments rhumatologiques pour le traitement de l’infection par le COVID-19 ☆. Rev Rhum Ed Fr 2020; 87:150-152. [PMID: 32355446 PMCID: PMC7181992 DOI: 10.1016/j.rhum.2020.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Maurizio Benucci
- Rheumatology Unit, Azienda Sanitaria USL-Toscana Centro, Hospital S. Giovanni di Dio, Via Torregalli 3, 50143 Florence, Italy
| | - Arianna Damiani
- Rheumatology Unit, Azienda Sanitaria USL-Toscana Centro, Hospital S. Giovanni di Dio, Via Torregalli 3, 50143 Florence, Italy
| | - Maria Infantino
- Immunology and Allergology Laboratory Hospital S.Giovanni di Dio, Azienda USL-Toscana Centro, Florence, Italy
| | - Mariangela Manfredi
- Immunology and Allergology Laboratory Hospital S.Giovanni di Dio, Azienda USL-Toscana Centro, Florence, Italy
| | - Luca Quartuccio
- Clinic of Rheumatology, Department of Medicine (DAME), ASUFC, Udine, Italy
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Kim SK, Kwak SG, Choe JY. Association between biologic disease modifying anti-rheumatic drugs and incident hypertension in patients with rheumatoid arthritis: Results from prospective nationwide KOBIO Registry. Medicine (Baltimore) 2020; 99:e19415. [PMID: 32118795 PMCID: PMC7478791 DOI: 10.1097/md.0000000000019415] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
There has been some debate between biologic disease modifying anti-rheumatic drugs (bDMARDs) treatment and hypertension (HTN) in rheumatoid arthritis (RA). The aim of this study was to determine the effect of bDMARDs on the development of HTN in patients with RA.A total of 996 patients eligible for analysis were recruited from the Korean College of Rheumatology Biologics & Targeted Therapy (KOBIO) registry from 2012 to 2018. The bDMARDs were tumor necrosis factor (TNF) inhibitors, abatacept, and tocilizumab. The cDMARDs included methotrexate, hydroxychloroquine, and leflunomide. The incidence rate and 95% confidence interval of HTN were estimated using the Kaplan-Meier method. Hazard ratio (HR) of risk factors associated with hypertension was assessed by cox proportional hazard model analysis.Among the 996 patients, 62 patients (6.2%) were newly diagnosed with HTN. There were differences in incidence rate of HTN among conventional DMARDs (cDMARDs), TNF inhibitors, tocilizumab, and abatacept during the follow-up period (P = .015). Kaplan-Meier analysis showed that there was a significant difference in incident HTN only between cDMARDs and tocilizumab (P = .001). Systolic blood pressure and positive rheumatoid factor were associated with development of HTN (HR = 1.049, P = .016 and HR = 1.386, P = .010, respectively). Cox proportional hazard model analysis showed no difference in the development of HTN between bDMARDs and cDMARDs in RA.This study showed that bDMARDs treatment might not increase risk of incident HTN in patients with RA, compared to cDMARDs.
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Affiliation(s)
- Seong-Kyu Kim
- Division of Rheumatology, Department of Internal Medicine
| | - Sang Gyu Kwak
- Department of Medical Statistics, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Jung-Yoon Choe
- Division of Rheumatology, Department of Internal Medicine
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McCulley CB, Barton JL, Cannon GW, Sauer BC, Teng CC, George MD, Caplan L, England BR, Mikuls TR, Baker JF. Body mass index and persistence of conventional DMARDs and TNF inhibitors in rheumatoid arthritis. Clin Exp Rheumatol 2019; 37:422-428. [PMID: 30418120 PMCID: PMC7836911] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/02/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Obese patients with rheumatoid arthritis (RA) may be more likely to discontinue therapy than non-obese patients, possibly signifying a more refractory phenotype. The purpose of this study was to examine the association between body mass index (BMI) and discontinuation rates for different RA treatments accounting for confounding factors. METHODS Veterans Affairs administrative databases were used to define initial courses of methotrexate (MTX), hydroxychloroquine, sulfasalazine, prednisone, and self-injectable tumour necrosis factor inhibitors (TNFi). Discontinuation was defined as a lapse in drug refill >90 days. Using overweight BMI (25-30 kg/m2) as the referent group, multivariable Cox proportional hazards models were used to evaluate associations between BMI category and time to treatment discontinuation. RESULTS There were 46,970 initial RA treatment courses identified from 2005-2014 among 23,669 Veterans with RA. In multivariable models, severe obesity (BMI >35 kg/m2), compared to overweight BMI, was not associated with treatment discontinuation with the exception of prednisone [HR 1.10 (1.04, 1.17) p<0.001]. Patients with low (<20 kg/m2) and normal BMI (20-25 kg/m2) were more likely to discontinue MTX, TNFi, and HCQ compared to overweight patients. Other factors associated with earlier MTX and/or TNFi discontinuation included female sex, black race, greater comorbidity, depression, malignancy, congestive heart failure, current smoking, and more recent calendar year. CONCLUSIONS Obesity was not associated with therapy discontinuation among veterans with RA after accounting for confounding factors, suggesting that obesity is not a biological mediator of more refractory disease. Conversely, low BMI, comorbidity, and depression were identified as important predictors of drug discontinuation.
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Affiliation(s)
- Caroline B McCulley
- VA Portland Health Care System; Oregon Health & Science University, OR, USA.
| | - Jennifer L Barton
- VA Portland Health Care System; Oregon Health & Science University, OR, USA
| | - Grant W Cannon
- VA Salt Lake City Healthcare System; University of Utah; Salt Lake City VA Medical Center (IDEAS 2.0) University of Utah, Division of Epidemiology, Team VERITAS, OR, USA
| | - Brian C Sauer
- VA Salt Lake City Healthcare System; University of Utah; Salt Lake City VA Medical Center (IDEAS 2.0) University of Utah, Division of Epidemiology, Team VERITAS, OR, USA
| | - Chia Chen Teng
- VA Salt Lake City Healthcare System; University of Utah; Salt Lake City VA Medical Center (IDEAS 2.0) University of Utah, Division of Epidemiology, Team VERITAS, OR, USA
| | - Michael D George
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Liron Caplan
- Department of Medicine, Rocky Mountain VA Medical Center, Aurora, CO, USA
| | - Bryant R England
- VA Nebraska-Western Iowa Health Care Center and the University of Nebraska Medical Center, Omaha, NE, USA
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Health Care Center and the University of Nebraska Medical Center, Omaha, NE, USA
| | - Joshua F Baker
- Division of Rheumatology, University of Pennsylvania, Philadelphia, and Corporal Michael C. Crescenz VA Medical Center, Philadelphia, PA, USA
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Abstract
PURPOSE OF REVIEW Patients with rheumatoid arthritis are at increased risk of infection after surgery. Recent literature has provided more data and updated guidelines to guide the management of immunosuppression in the perioperative period. RECENT FINDINGS Studies over the past few years have confirmed that patients with rheumatoid arthritis are at increased risk of infection after surgery. Patients treated with biologics are at greater risk of postoperative infection, but this risk might be explained by the comorbidities and greater disease severity often seen in these patients. Recent observational studies have suggested that interruption of biologic therapies before surgery may not be associated with better outcomes. Glucocorticoids, however, have consistently been found to be risk factors for infection. Recent guidelines from the American College of Rheumatology/American Association of Hip and Knee Surgeons recommend continuing conventional disease-modifying drugs and holding biologics for one dosing interval before surgery. SUMMARY Prolonged interruption of conventional and biologic therapies before surgery does not appear to substantially reduce infection risk. Guidelines now recommend continuing conventional DMARDs and holding biologics for just one dosing interval before surgery. Glucocorticoids are strongly associated with the risk of postoperative infection and should be minimized before surgery.
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Affiliation(s)
| | - Joshua F. Baker
- University of Pennsylvania, Division of Rheumatology
- Philadelphia Veterans Affairs Medical Center, Division of Rheumatology
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Persson MSM, Sarmanova A, Doherty M, Zhang W. Conventional and biologic disease-modifying anti-rheumatic drugs for osteoarthritis: a meta-analysis of randomized controlled trials. Rheumatology (Oxford) 2018; 57:1830-1837. [PMID: 29917100 PMCID: PMC6199417 DOI: 10.1093/rheumatology/key131] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 01/19/2018] [Revised: 04/11/2018] [Indexed: 12/14/2022] Open
Abstract
Objectives The role of inflammation in OA is controversial and it is unclear whether suppressing inflammation with conventional or biologic DMARDs is effective. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to compare DMARDs with placebo in participants with symptomatic OA. Methods Databases (Medline, Embase, Allied and Complementary Medicine Database, Web of Science and Cochrane Library), conference abstracts and ClinicalTrials.gov were searched to end of November 2017 for placebo-controlled RCTs of DMARDs, including biologics, in symptomatic OA. Pain data at treatment peak time point were extracted and combined using a random-effects meta-analysis. Markers of inflammation and adverse events were extracted and reviewed. Risk of bias assessment was conducted using Cochrane's tool. Results Eleven RCTs (1205 participants) were meta-analysed, including six for conventional DMARDs (757 participants) and five for biologics (448 participants). Overall, DMARDs were statistically superior to placebo [effect size (ES) = 0.18, 95% CI: 0.03, 0.34], although the difference was not clinically significant (0.5 ES threshold). Furthermore, no statistically significant differences were observed in sub-analysis of high-quality trials (ES = 0.11, 95% CI : -0.06, 0.28), biologics (ES = 0.16, 95% CI: -0.02, 0.34) or conventional DMARDs (ES = 0.24, 95% CI: -0.05, 0.54). No difference was found between erosive vs non-erosive hand OA, hand vs knee OA or anti-IL1 vs anti-TNF biologics. Conclusion DMARDs did not offer clinically significant pain relief above placebo in OA. This poor efficacy indicates that inflammation may not be a prime driver for OA pain.
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Affiliation(s)
- Monica S M Persson
- Academic Rheumatology, Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK
| | - Aliya Sarmanova
- Academic Rheumatology, Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK
| | - Michael Doherty
- Academic Rheumatology, Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK
| | - Weiya Zhang
- Academic Rheumatology, Arthritis Research UK Pain Centre, University of Nottingham, Nottingham, UK
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Clowse MEB, Eudy AM, Kiernan E, Williams MR, Bermas B, Chakravarty E, Sammaritano LR, Chambers CD, Buyon J. The prevention, screening and treatment of congenital heart block from neonatal lupus: a survey of provider practices. Rheumatology (Oxford) 2018; 57:v9-v17. [PMID: 30137589 PMCID: PMC6099126 DOI: 10.1093/rheumatology/key141] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/20/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To survey an international sample of providers to determine their current practices for the prevention, screening, and treatment of congenital heart block (CHB) due to maternal Ro/SSA antibodies. Methods A survey was designed by the organizing committee of the 9th International Conference of Reproduction, Pregnancy and Rheumatic Diseases. It was sent to attendants of the conference and authors of recent publications or abstracts at ACR 2012, 2013 or 2014 on rheumatic diseases and pregnancy. Results In anti-Ro/SSA positive women, 80% of 49 respondents recommended screening by serial fetal echocardiogram (ECHO), with most starting at week 16 (59%) and stopping at week 28 (25%), although the time to stop varied widely. For women without a prior infant with neonatal lupus, respondents recommend every other week (44%) or weekly (28%) fetal ECHOs. For women with a prior infant with neonatal lupus, 80% recommend weekly fetal ECHOs. To prevent CHB, HCQ was recommended by 67% of respondents and most would start pre-pregnancy (62%). Respondents were asked about medications to treat varying degrees of CHB in a 20-week pregnant, anti-Ro and La positive SLE patient. For first degree, respondents recommended starting dexamethasone (53%) or HCQ (43%). For second degree, respondents recommended starting dexamethasone (88%). For third degree, respondents recommended starting dexamethasone (55%) or IVIg (33%), although 27% would not start treatment. Conclusion Despite the absence of official guidelines, many physicians with a focus on pregnancy and rheumatic disease have developed similar patterns in the screening, prevention and treatment of CHB.
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Affiliation(s)
- Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Elizabeth Kiernan
- Department of Pediatrics, Division of Dysmorphology and Teratology, University of California San Diego, San Diego, CA
| | - Matthew R Williams
- Pediatric Cardiology and Cardiovascular Surgery, Rady Children's Hospital, University of California San Diego, San Diego, CA
| | - Bonnie Bermas
- Division of Rheumatic Diseases, UT Southwestern, Dallas, TX
| | - Eliza Chakravarty
- Department of Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Lisa R Sammaritano
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
| | | | - Jill Buyon
- Division of Rheumatology, New York University School of Medicine, NY, USA
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Lomholt JJ, Thastum M, Herlin T. Pain experience in children with juvenile idiopathic arthritis treated with anti-TNF agents compared to non-biologic standard treatment. Pediatr Rheumatol Online J 2013; 11:21. [PMID: 23641813 PMCID: PMC3653734 DOI: 10.1186/1546-0096-11-21] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 04/30/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anti-TNF agents have proven efficacy in children with severe juvenile idiopathic arthritis (JIA) who are unresponsive to standard therapy. Therefore pain reduction or elimination could be expected. The aim of this study was to compare the pain experience in children with JIA treated with anti-TNF agents (n = 41) or non-biologic standard treatment (n = 50). METHODS All children completed a 2-week pain diary and, for children treated with anti-TNF agents, measures of pain-coping and pain-specific beliefs. Parents rated the child's level of functional disability. Clinical data were collected from the pediatric rheumatologists. RESULTS No significant differences were found between the anti-TNF group and non-biologic standard treatment group for average pain score, number of children with daily pain reported in the pain diary, or level of functional disability. Significantly more children in the anti-TNF group reported no pain at all. Children undergoing standard treatment had significantly higher disease activity. Significant differences were found between the high pain patients treated with anti-TNF agents and the rest of the anti-TNF group in regards to their pain-specific beliefs of disability and harm, and the pain-coping strategy of catastrophizing. CONCLUSION These results indicate that a great proportion of children treated with anti-TNF agents respond well to the treatment in regards to disease activity and pain, but pain was still a problem for a subgroup of children though they were in remission with biological agents. More focus on pain management is needed.
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Affiliation(s)
| | - Mikael Thastum
- Department of Psychology, Aarhus University, Bartholins Allé 9, Aarhus 8000, Denmark
| | - Troels Herlin
- Department of Pediatrics, Aarhus University Hospital, Brendstrupgaardsvej 100, Aarhus N 8200, Denmark
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Abstract
Inflammatory arthritis involves a diverse range of conditions in which an uncontrolled immune response occurs. A number of advances in assessment, diagnosis and treatment have been made in recent years. Drug therapies used in inflammatory arthritis aim to reduce symptoms and suppress inflammation, joint damage and disability. In rheumatoid arthritis (RA), immunosuppression is used in almost all patients, with an emphasis on early aggressive treatment to achieve clinical remission. This approach is less successful in spondylarthropathies, for which non-steroidal anti-inflammatory drugs remain first-line therapy. The use of biologic therapies has increased dramatically across a range of indications and has resulted in improved outcomes for patients. These agents are associated with an increased risk of infection, particularly tuberculosis in patients receiving tumour necrosis factor inhibitors. Alternative biologics have entered clinical practice for RA in recent years, and clinical trials using these agents, as well as novel non-biologic therapies, are in progress for RA and other conditions.
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Affiliation(s)
- Nicola J Gullick
- Academic Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, London.
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Abstract
Arthritis is the most common extraintestinal manifestation of inflammatory bowel disease (IBD) and can have a significant impact on morbidity and quality of life. IBD-associated arthropathy is considered a subtype of seronegative spondyloarthropathy, with axial, peripheral, or a combination of both joint manifestations. Peripheral arthritis is generally non-erosive and the oligoarticular variant particularly may correlate with intestinal disease activity. Axial arthritis may include inflammatory back pain, sacroiliitis, or ankylosing spondylitis, and is less likely to correlate with gastrointestinal symptoms. While there have been advances in identifying predisposing genetic factors and in elucidating pathophysiology of inflammatory bowel disease, the mechanisms surrounding the development of arthritis in IBD remain unclear. Treatment of inflammatory bowel disease is not always sufficient for control of arthritis. While treatment with biologic agents is promising, there remains a great need for larger, randomized studies to address optimal therapy of IBD associated arthropathy.
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Affiliation(s)
- Sheila L. Arvikar
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
| | - Mark C. Fisher
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
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Doan QV, Chiou CF, Dubois RW. Review of eight pharmacoeconomic studies of the value of biologic DMARDs (adalimumab, etanercept, and infliximab) in the management of rheumatoid arthritis. J Manag Care Pharm 2006; 12:555-69. [PMID: 16981801 PMCID: PMC10437502 DOI: 10.18553/jmcp.2006.12.7.555] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Treatment options for the management of rheumatoid arthritis (RA) have expanded from the traditional disease-modifying antirheumatic drugs (DMARDs) to include the biologic DMARDs that inhibit tumor necrosis factoralpha (TNF-a). OBJECTIVE To assess the medical literature for studies of the economic value of biologic DMARDs, specifically the 3 TNF-a inhibitors (adalimumab, etanercept, and infliximab) used for the management of RA, compared with the traditional DMARDs such as sulfasalazine, antimalarials, penicillamine, gold, methotrexate, azathioprine, leflunomide, and cyclophosphamide. METHODS A comprehensive search of the MEDLINE and HealthSTAR databases was conducted to identify cost-efficacy, cost-effectiveness, or cost-utility studies published in the English language (from 1966 through November 2004). The search terms and/or MeSH (medical subject headings) titles were cost-benefit analysis, rheumatoid arthritis, antirheumatic agents, antineoplastic and immunosuppressive agents. Studies were critically reviewed and quality was assessed using the Quality of Health Economic Studies instrument. Most studies evaluated the use of biologics among RA patients resistant to DMARDs. Studies were assessed with regard to comparators evaluated, measures of efficacy, perspectives, model duration, treatment duration, and discount rate. RESULTS From 180 titles identified, 155 were excluded for the following reasons: 89 because they did not consider the drugs of interest, 15 because the population was not RA, 19 because of having the wrong drugs and population, 22 because they were review articles, and 10 because they were general articles. Twentyfive abstracts were accepted for further review. Of these, 13 abstracts were subsequently selected for full-text review. One of the authors identified a study not indexed in MEDLINE. Ultimately, 2 cost-effectiveness and 6 cost-utility studies were selected for this critical review. One study over 6 months reported that triple therapy with DMARDs (methotrexate-hydroxychloroquine-sulfasalazine) was cost effective for methotrexate-resistant patients, which is consistent with American College of Rheumatology (ACR) guidelines that support the use of triple therapy prior to biologics. The incremental cost-effectiveness ratio (ICER) was $1,500 per patient to achieve an ACR20 response for this triple therapy compared with no second-line agent. Overall, biologic therapies cost considerably more than traditional DMARDs but produced more quality-adjusted life-years (QALYs). Despite differences in design and assumptions, published economic models consistently reported ICERs <50,000 dollars per QALY gained for biologics compared with traditional DMARDs, although ICERs of >100,000 dollars were reported from sensitivity analyses. CONCLUSIONS Clinical guidelines currently recommend the use of biologics as step therapy after failure of traditional DMARDs. Reported ICERs comparing biologics with traditional DMARDs are within a range that is comparable with other accepted medical interventions. The worth of the additional expenditure will ultimately be judged by formulary and policy decision makers because no maximum cost has been defined. Models can be used to inform decision makers, but they must be interpreted and applied carefully. More research is also needed to differentiate the relative economic value of the various biologic agents by therapeutic indication.
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Affiliation(s)
- Quan V Doan
- Cerner LifeSciences, 9100 Wilshire Blvd., Suite 605E, Beverly Hills, CA 90212, USA.
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