Juvenile idiopathic arthritis: from aetiopathogenesis to therapeutic approaches

Juvenile idiopathic arthritis (JIA) is the most common paediatric rheumatological disorder and is classified by subtype according to International League of Associations for Rheumatology criteria. Depending on the number of joints affected, presence of extra-articular manifestations, systemic symptoms, serology and genetic factors, JIA is divided into oligoarticular, polyarticular, systemic, psoriatic, enthesitis-related and undifferentiated arthritis. This review provides an overview of advances in understanding of JIA pathogenesis focusing on aetiology, histopathology, immunological changes associated with disease activity, and best treatment options. Greater understanding of JIA as a collective of complex inflammatory diseases is discussed within the context of therapeutic interventions, including traditional non-biologic and up-to-date biologic disease-modifying anti-rheumatic drugs. Whilst the advent of advanced therapeutics has improved clinical outcomes, a considerable number of patients remain unresponsive to treatment, emphasising the need for further understanding of disease progression and remission to support stratification of patients to treatment pathways.

Tofacitinib 5 mg Twice Daily in Patients with Rheumatoid Arthritis and Inadequate Response to Disease-Modifying Antirheumatic Drugs: A Comprehensive Review of Phase 3 Efficacy and Safety

BACKGROUND

Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). We performed a comprehensive review of phase 3 studies of tofacitinib 5 mg twice daily (BID) (approved dose in many countries) in patients with moderate to severe RA and inadequate response to prior disease-modifying antirheumatic drugs.

METHODS

A search of PubMed and ClinicalTrials.gov identified 5 studies: ORAL Solo (NCT00814307), ORAL Sync (NCT00856544), ORAL Standard (included adalimumab 40 mg once every 2 weeks; NCT00853385), ORAL Scan (NCT00847613), and ORAL Step (NCT00960440). Efficacy and safety data for tofacitinib 5 mg BID, placebo, and adalimumab were analyzed.

RESULTS

Across the 5 studies, 1216 patients received tofacitinib 5 mg BID, 681 received placebo, and 204 received adalimumab. At month 3, tofacitinib demonstrated significantly higher 20%, 50%, and 70% improvement in American College of Rheumatology response criteria (ACR20, ACR50, and ACR70, respectively) response rates, greater improvement in Health Assessment Questionnaire-Disability Index, and a higher proportion of Disease Activity Score-defined remission than placebo. Frequencies of adverse events (AEs), serious AEs, and discontinuations due to AEs were similar for tofacitinib and placebo at month 3; serious infection events were more frequent for tofacitinib. In ORAL Standard, although not powered for formal comparisons, tofacitinib and adalimumab had numerically similar efficacy and AEs; serious AEs and serious infection events were more frequent with tofacitinib.

CONCLUSIONS

Tofacitinib 5 mg BID reduced RA signs and symptoms and improved physical function versus placebo in patients with inadequate response to prior disease-modifying antirheumatic drugs. Tofacitinib 5 mg BID had a consistent, manageable safety profile across studies, with no new safety signals identified.

First-line disease-modifying drugs in relapsing-remitting multiple sclerosis: an Italian real-life multicenter study on persistence

OBJECTIVE

The introduction of oral disease-modifying drugs (DMDs) in addition to the available, injectable, ones for relapsing-remitting multiple sclerosis (RRMS) could be expected to improve medication persistence due to a greater acceptability of the route of administration. The aim of the study was to compare the proportion of patients discontinuing injectable DMDs (interferon beta 1a/1b, pegylated interferon, glatiramer acetate) with those discontinuing oral DMDs (dimethylfumarate and teriflunomide) during an observation period of at least 12 months. Secondary aims were to compare the time to discontinuation and the reasons for discontinuation between the two groups and to explore the demographic and clinical factors associated with DMD discontinuation.

METHODS

In this prospective, multi-center, real-life observational study, patients commencing any first-line DMD between 1 January 2015 and 31 July 2016 were enrolled and followed up for at least 12 months or until the drug was discontinued.

RESULTS

Of the 520 included patients, 262 (49.6%) started an injectable and 258 (50.4%) an oral DMD. There was no difference in the proportion of patients on oral (n = 62, 24%) or on injectable (n = 60, 23%) DMDs discontinuing treatment, the most frequent reason being adverse events/side-effects. Higher baseline Expanded Disability Status Scale (EDSS) scores and younger age increased the odds of treatment withdrawal. Time to treatment discontinuation was not different between the two groups and was not influenced by the initiated DMD (oral versus injectable), even after adjustment for baseline differences.

CONCLUSION

The route of administration alone (i.e. oral versus injectable) was not a significant predictor of persistence with first-line DMDs in RRMS.

Rheumatoid Arthritis: Common Questions About Diagnosis and Management

Rheumatoid arthritis is the most commonly diagnosed systemic inflammatory arthritis, with a lifetime prevalence of up to 1% worldwide. Women, smokers, and those with a family history of the disease are most often affected. Rheumatoid arthritis should be considered if there is at least one joint with definite swelling that is not better explained by another disease. In a patient with inflammatory arthritis, the presence of a rheumatoid factor and/or anti-citrullinated protein antibody, elevated C-reactive protein level, or elevated erythrocyte sedimentation rate is consistent with a diagnosis of rheumatoid arthritis. Rheumatoid arthritis may impact organs other than the joints, including lungs, skin, and eyes. Rapid diagnosis of rheumatoid arthritis allows for earlier treatment with disease-modifying antirheumatic drugs, which is associated with better outcomes. The goal of therapy is to initiate early medical treatment to achieve disease remission or the lowest disease activity possible. Methotrexate is typically the first-line agent for rheumatoid arthritis. Additional disease-modifying antirheumatic drugs or biologic agents should be added if disease activity persists. Comorbid conditions, including hepatitis B or C or tuberculosis infections, must be considered when choosing medical treatments. Although rheumatoid arthritis is often a chronic disease, some patients can taper and discontinue medications and remain in long-term remission.

To stop the erosion of hope: the DMARD category and the place of semantics in modern rheumatology

The category of disease-modifying anti-rheumatic drugs (DMARDs) emerged in the 1970s to describe drugs capable of altering the long-term destructive course of arthritis. It became a core concept in rheumatology’s reorientation towards pharmaceuticals in the late twentieth century. By examining the earliest use of the term “disease-modifying” in scientific publications, this paper identifies the drugs that the category described when it first emerged. Leaning on systematic reviews of each of these drugs towards the end of their career in rheumatology, it then establishes that posterity would not recognize any of these early DMARDs as capable of altering the long-term course of the disease. The notion of disease-modifying drugs was thus originally used to categorize drugs that were not disease-modifying. Instead of interpreting this inconsistency as an anomaly, the paper argues that the DMARD category may have gained currency because it allowed a number of actors to respond pragmatically to an ongoing crisis in the pharmacological approach to treating arthritis. The term offered to conjure prospects of disease-modifying effects regardless of drugsʼ actual capacities, and thus to semantically solve the tensions between needs and means that characterized rheumatology at the time. While shedding light on a pivotal moment in the history of rheumatology, the paper also models an approach to understanding drug categories as meaning-making mechanisms by which people can mediate the sometimes uneasy connections that exist between medical practice and science.

Efficacy and Safety of Intravenous Immunoglobulin Treatment in Refractory Behcet's Disease with Different Organ Involvement: A Case Series

Behçet's disease (BD) is a multi-systemic disorder of unknown etiology characterized by relapsing oral-genital ulcers, uveitis, and involvement of the articular, gastrointestinal, neurologic, and vascular systems. The choice of treatment is based on the severity of systemic involvement, clinical presentation and the site affected, and includes corticosteroids, azathioprine, interferon, cyclophosphamide, methotrexate or tumor necrosis factor-alpha and interleukin-1 blockers. We present a case series of four refractory BD patients successfully treated with intravenous immunoglobulins (IVIG). All patients fulfilled International Study Group criteria. The patients' mean age was 38.75 ± 12.09 years and mean disease duration 10.25 ± 8.5 years. Human leukocyte antigen B51 was positive in two of four patients. In addition to oral aphthosis, all patients suffered from genital ulcers and cutaneous BD-related manifestations; central nervous system involvement and arthralgia were found in two patients. Peripheral nervous system, gastrointestinal and eye involvement occurred in 25% of cases. In all patients, previously treated according to EULAR recommendations without reaching satisfactory results, IVIG induced immediate and sustained response over time without incurring any side effects. We propose IVIG administration as an additional effective and safe treatment option in patients with severe and resistant BD.

Hypertension and diabetes significantly enhance the risk of cardiovascular disease in patients with psoriatic arthritis

OBJECTIVES

New evidence has lightened the linkage between psoriatic arthritis (PsA) and the development of atherosclerosis and cardiovascular disease (CVD). We aimed to describe the prevalence of cardiovascular events and associated risk factors among patients with PsA.

METHODS

Retrospective evaluation of medical records from consecutive PsA patients who fulfilled the CASPAR criteria for PsA attending a specialised spondyloarthritis clinic at a single referral centre. CVD was defined based on the occurrence of coronary artery disease (CAD) or cerebrovascular ischaemic disease events.

RESULTS

We evaluated 158 PsA patients, 48.7% females and 51.3% males, aged 53.7±13.9 yrs. Mean PsA duration was 13.7±8.9 yrs and polyarticular subtype affected 66 (42%) patients. According to drug therapy, 85 (54%) were using NSAIDs and 21 (13%) low-dose prednisone; 32 (20%) were on anti-TNF agents, 94 (60%) metothrexate, 18 (11%) leflunomide, 13 (8%) sulfasalazine, 5 (3%) other immunossupressors and 4 (2.5%) were on chloroquine. Over half patients (87, 55%) had arterial hypertension (AH); 51 (32%) had dyslipidaemia (DLP), 38 (29%) hypertriglyceridemia and 36 (23%) diabetes mellitus (DM). Lipid profile was similar for both genders with mean total cholesterol= 186.5±38.6mg/dl, LDL=112.3±30.6 mg/dl, HDL= 47.89±14.6 and triglycerides= 127.4± 65.6 mg/dl. Of note, 14% PsA patients have had CVD, namely cerebrovascular or coronary heart disease. Sex, age, disease duration, joint involvement subtype, disease activity, CRP and lipid levels were similar among patients with and without CVD. The prevalence of AH (95% vs. 45%, p<0.001), DLP (75% vs. 27.7%, p<0.001) and DM (60% vs. 19%, p<0.001) were significantly greater in PsA patients who have had CVD compared to those without CVD, conferring an odds ratio of 21.0 for AH and of 5.4 for DM.

CONCLUSIONS

The high prevalence of CVD in PsA patients is influenced by increased AH and DM. Hence early recognition and specific treatment is mandatory in order to reduce the risk for CVD, avoiding early morbidity and mortality.

Racial disparities in treatment preferences for rheumatoid arthritis

BACKGROUND

Data suggest that differences in patient preferences may account for racial disparities in the use of medical interventions. Racial disparities have also been noted in outcomes and the delivery of healthcare services in chronic disease. Whether treatment preferences in chronic disease differ by race is not known.

METHODS

We elicited treatment preferences for aggressive therapy in patients with rheumatoid arthritis who identified themselves as being black or white.

RESULTS

One hundred fifty consecutive eligible patients were invited to participate. Of these, 136 subjects completed the interview. In unadjusted analysis, 51% of white participants preferred aggressive therapy compared with 16% of blacks (P < 0.0001). Subjects who were married and reported having at least some college education had stronger preferences for aggressive therapy compared with their respective counterparts. After adjusting for covariates, race remained the strongest predictor of aggressive therapy examined in this study [adjusted odds ratio (95% confidence interval) = 11.2 (1.9-64.9)].

CONCLUSIONS

In this study, fewer black patients preferred aggressive treatment compared with white patients with similar disease severity. These results have important clinical implications because use of aggressive treatment improves both short- and long-term outcomes in rheumatoid arthritis. Efforts to improve patient education and physician communication should be made to ensure that all patients have an accurate understanding of the benefits, as well as risks, associated with the best available treatment options.

Management of patients with rheumatoid arthritis

Rheumatoid arthritis is a chronic inflammatory disease, which mainly affects the peripheral joints. Nurses are integral to the care of patients with this disease. This article discusses the role of the rheumatology nurse in the management of patients with this disabling condition.

[Management of patients with rheumatoid arthritis]

Recent years have shown considerable advances in the understanding of pathophysiology and clinical course of patients with rheumatoid arthritis. We now know that there is preclinical disease. Autoantibodies precede clinical symptoms and erosive disease can be seen in patients as early as at the beginning of the symptoms. Clinical progress has come from a better recognition of the natural history of disease. Outcome measures were developed and validated, allowing innovative trial design. Therapy must aim at achieving clinical remission, reversal from destructive to nondestructive arthritis and even healing of erosions. Such aim necessitates early diagnosis of disease and aggressive treatment. Regular assessment of the disease state should be performed. For disease assessment validated tools should be used. The search for new therapies is ongoing. Studies indicate there is a considerable window of opportunity in very early rheumatoid arthritis. If we can use this window of opportunity with an efficient therapeutic strategy we should be able to change the course of disease or even achieve long term remission.

Management of rheumatoid arthritis

The past few years have witnessed a major change in the approach to the treatment of rheumatoid arthritis. The present focus is on early recognition and prompt treatment with disease-modifying antirheumatic drugs of which methotrexate continues to be the drug of choice. Leflunomide is an important recent addition to the list of available drugs. The use of combinations of disease-modifying antirheumatic drugs is gaining wide acceptance. A better understanding of the pathobiology of rheumatoid arthritis has led to the development of targeted therapies such as tumour necrosis factor blockers. There are robust data to show the clinical utility of tumour necrosis factor blockers in patients with rheumatoid arthritis.

A case study on rheumatoid arthritis

At a time when many managed care organizations increasingly shift costs to patients through tiered formularies and widening copay differentials, biologic agents represent a significant clinical and financial challenge unlikely to be managed optimally with tiered formularies and greater patient cost sharing. The information discussed in this article is intended for healthcare professionals involved with rheumatoid arthritis therapy, including but not limited to physicians in both the inpatient and outpatient setting, and for other managed care professionals, including medical directors, pharmacy directors, long-term care decision makers, nurses, pharmacists, and case managers.

[Treatment of arthroses in the elderly patient]

BACKGROUND

Elderly subjects with osteoarthritis are treated with analgesic drugs, non-steroidal antiinflammatory drugs (NSAID) and intra-articular corticosteroid injections as well as symptomatic slow acting drugs in osteoarthritis (Sy-SADOA).

BASIC REGIMENS

Initial treatment for osteoarthritis pain should be paracetamol, followed by NSAID if necessary, especially in the elderly, because of their adverse effects.

EFFICACY

Sy-SADOA are effective on pain and function with a persistent effect, allowing the reduction of analgesic and NSAID dosage.

[Disease modifying anti-rheumatic drugs(DMARDs)]

Several kinds of disease modifying anti-rheumatic drugs (DMARDs) can be utilized for the treatment of patients with rheumatoid arthritis (RA) to expect the prevention of joint damage progression and the improvement of quality of life. However, the methodology for the use of DMARDs is still controversial. On the basis of our prospective study, earlier introduction of DMARDs can be more efficient for the suppression of active disease. Thus, for the patients with more than three swollen joints, high ESR and CRP, immediate prescription of DMARD is recommended. And if these situation will not change even 6 months after starting the therapy, we should make all possible efforts to lead patients into remission using DMARD or corticosteroids, which would prevent patients from disability of joint function and thus would improve the quality of life of patients with early RA.

Rheumatology. Part 2: The role of medication

Rheumatoid arthritis is a chronic, long-term inflammatory disease. Symptom relief can be achieved with analgesia and NSAIDs. The only way to influence its progress is by administering disease-modifying anti-rheumatic drugs.

Recommendations for the registration of drugs used in the treatment of rheumatoid arthritis. Group for the Respect of Ethics and Excellence in Science (GREES): rheumatoid arthritis section

Rheumatoid arthritis (RA) is the commonest form of chronic inflammatory joint disease and a major target for symptom-modifying and disease-modifying drug therapy. New approaches to the treatment of RA using biological agents targeted to cellular receptors, cytokines and other mediators of inflammation, together with the availability of new methods of outcome assessment, make it timely to reconsider the classification of anti-rheumatic drugs and the requirements for the registration of new drug entities. Under the auspices of GREES (Group for the Respect of Ethics and Excellence in Science), a European Working Group of clinicians with experience in rheumatology, scientists and representatives from industry and national drug licensing authorities have formulated recommendations for the requirements for registration of anti-rheumatic drugs designed for symptom modification, structural modification and the suppression of inflammation, with particular emphasis placed on quality of life assessment by generic and disease-specific validated methods. This paper outlines the group's advice for pre-clinical testing, and Phase I, Phase II and Phase III trials to allow licences to be granted for each indication, while recognizing that a single drug may have reason to be approved under several headings.

The design of clinical trials aimed at assessing the DC-ART properties of new molecules in rheumatoid arthritis

Considerations in designing clinical trials of novel molecules are not different from those that should be considered in every rheumatoid arthritis clinical trial. This article raises some critical issues that clinicians have to face in the planning and design of clinical trials for new molecules in rheumatoid arthritis. The most frequent problems are related to outcome measures (core set of endpoints, improvement and remission), patient populations, characteristics of the study design, and economic evaluation. Although some of these issues have been resolved by consensus, further research needs to be carried out to support the use of different measurement techniques. Because clinical trials remain the most powerful investigative instrument for deciding about the benefits of new advances in medical therapy, their design should be based on an appropriate methodology.

Adverse drug reactions and their measurement in the rheumatic diseases

Drugs administered as therapy for rheumatological disorders are a relatively common cause of adverse events. Important data regarding the effects of drugs on patients with rheumatological conditions is being lost or rendered inaccessible because of deficiencies in classification, measurement, and collection methods for adverse drug reactions. A significant number of adverse reactions to drugs will not be known before marketing, and hence vigilance on the part of clinicians and patients in observing and documenting these reactions is paramount in building our knowledge and modifying our practice accordingly. A variety of systems and methods for detecting adverse drug reactions are described, critically evaluated, and compared for cost, potential bias, ethical concerns, and subject recruitment required for necessary statistical power. Systems need to be developed to give access to the wealth of clinical experimental data available in the individual practices of a broad spectrum of clinicians. To facilitate this, representative organizations need to make adverse drug reactions a high priority as well as contributing expertise and finance to database formulation and accessibility.

DC-ART classification: review of relevant clinical studies

The proposed disease controlling antirheumatic therapy (DC-ART) definition requires that the therapy change the course of rheumatoid arthritis (RA) for at least 1 year, evidenced by (1) sustained improvement in physical function, (2) decreased inflammatory synovitis, and (3) slowing or prevention of structural joint damage. Selected studies are reviewed. All studies were at least 1 year in duration, but most did not include all 3 of the DC-ART requirements. In these studies, patients treated with placebo generally had no improvement in inflammatory synovitis and progressive structural joint damage, judged by serial joint radiographs. A minority of studies significantly favored one or another of the available agents (gold injections, D-penicillamine, auranofin, antimalarials, azathioprine, sulfasalazine, methotrexate), but the evidence for any one agent is not convincing. For future DC-ART clinical trials patients with early RA should be studied. A hybrid study design may be useful, combining an initial double blind randomized controlled clinical trial with continuing longterm observation of all withdrawals using specified clinical, radiographic, and self report assessments at regular intervals, and an intent-to-treat analysis comparing longterm response rates of the original control and experimental therapy groups. Responsive subgroups should be sought, their characteristics identified, and their responsiveness confirmed in additional trials limited to the identified subgroup.

DC-ART: the concept

The International League of Associations for Rheumatology (ILAR) and the World Health Organization (WHO) have ratified a new classification of antirheumatic therapy comprising two major categories, as follows: (1) Symptom modifying antirheumatic drugs (SMARD) improve the symptoms and clinical features of inflammatory synovitis; (2) Disease controlling antirheumatic therapy (DC-ART) changes the course of rheumatoid arthritis. The DC-ART category, a new group and a new concept, poses a number of problems and challenges but also generates a basis for setting management objectives for rheumatoid arthritis. It is uncertain whether any of the current SMARD would fulfill the stringent DC-ART criteria.

Guidelines for testing slow acting drugs in osteoarthritis

New compounds appear to improve symptoms of osteoarthritis (OA), and others are putative chondroprotective agents. We suggest experimental designs for studying the effects of these agents in subjects with hip and knee OA. The course of the articular cartilage lesion is the primary outcome measure to be assessed in putative chondroprotective agent trials. Serial radiographic studies suggest that the annual rate of joint space narrowing in patients with hip or knee OA is about 0.25 mm. Other approaches to quantitation of cartilage loss, e.g., radiographic measurement of the area of joint space, ultrasonography, magnetic resonance imaging and fiberoptic arthroscopy (for knee OA) are under investigation.