Short interruptions of TNF-inhibitor treatment can be associated with treatment failure in patients with immune-mediated diseases

INTRODUCTION

The prevalence of immune-mediated diseases has increased in the past decades and despite the use of biological treatments all patients do not achieve remission. The aim of this study was to characterise the reasons for short interruptions during treatment with two commonly used TNF-inhibitors infliximab and adalimumab and to analyse the possible effects of the interruptions on immunisation and switching the treatment.

MATERIAL AND METHODS

This case-control study was based on retrospective analyses of patient records and a questionnaire survey to clinicians. A total of 370 patients (194 immunised cases and 172 non-immunised controls, 4 excluded) were enrolled from eight hospitals around Finland. Eleven different diagnoses were represented, and the largest patient groups were those with inflammatory bowel or rheumatic diseases.

RESULTS

Treatment interruptions were associated with immunisation in patients using infliximab (p < .001) or adalimumab (p < .000001). Patients with treatment interruptions were more likely to have been treated with more than one biological agent compared to those without treatment interruptions. This was particularly prominent among patients with a rheumatic disease (p < .00001). The most frequent reason for a treatment interruption among the cases was an infection, whereas among the control patients it was remission. The median length of one interruption was one month (interquartile range 1-3 months).

CONCLUSION

Our results suggest that the interruptions of the treatment with TNF-inhibitors expose patients to immunisation and increase the need for drug switching. These findings stress the importance of careful judgement of the need for a short interruption in the biological treatment in clinical work, especially during non-severe infections.

Survival and safety of infliximab bio-original and infliximab biosimilar (CT-P13) in usual rheumatology care

OBJECTIVES

Reports to-date indicate similarity between infliximab biosimilar (IB) and infliximab bio-original (IO) in clinical efficacy and safety. This study examines the survival of IB and IO using routinely collected data over a 2-year period.

METHODS

Routinely collected clinical data inputted directly in an electronic database at a large rheumatology centre were analysed. Adult patients taking IO or IB for any rheumatological diagnosis were included. Kaplan-Meier survival analyses were used to examine IB and IO survival, with a sub-group analysis among those starting infliximab from 2008 onwards.

RESULTS

Out of 395 patients analysed, 53% (n=209) were female; the majority had rheumatoid arthritis (31%) followed by spondyloarthritis (28%). Ninety-nine patients had IB as the first infliximab drug. Patients who started on IB vs. IO as their first infliximab product, had better survival over the first 2 years (log rank=0.001). Discontinuation due to inefficacy was much commoner in IO versus IB users (18 vs. 5%). In patients switching from IO to IB, drug survival was better versus those receiving IB as the first infliximab drug (log rank=0.073).

CONCLUSIONS

IB was well-tolerated and comparable to IO, with no additional safety signals identified. The results suggest superior survival of IB over IO over the first 2 years.

Early Remission Is a Realistic Target in a Majority of Patients with DMARD-naive Rheumatoid Arthritis

Objective.

We analyzed remission rates at 3 and 12 months in patients with rheumatoid arthritis (RA) who were naive for disease-modifying antirheumatic drugs (DMARD) and who were treated in a Finnish rheumatology clinic from 2008 to 2011. We compared remission rates and drug treatments between patients with RA and patients with undifferentiated arthritis (UA).

Methods.

Data from all DMARD-naive RA and UA patients from the healthcare district were collected using software that includes demographic and clinical characteristics, disease activity, medications, and patient-reported outcomes. Our rheumatology clinic applies the treat-to-target principle, electronic monitoring of patients, and multidisciplinary care.

Results.

Out of 409 patients, 406 had data for classification by the 2010 RA criteria of the American College of Rheumatology/European League Against Rheumatism. A total of 68% were female, and mean age (SD) was 58 (16) years. Respectively, 56%, 60%, and 68% were positive for anticyclic citrullinated peptide antibodies (anti-CCP), rheumatoid factor (RF), and RF/anti-CCP, and 19% had erosive disease. The median (interquartile range) duration of symptoms was 6 (4–12) months. A total of 310 were classified as RA and 96 as UA. The patients with UA were younger, had better functional status and lower disease activity, and were more often seronegative than the patients with RA. The 28-joint Disease Activity Score (3 variables) remission rates of RA and UA patients at 3 months were 67% and 58% (p = 0.13), and at 12 months, 71% and 79%, respectively (p = 0.16). Sustained remission was observed in 57%/56% of RA/UA patients. Patients with RA used more conventional synthetic DMARD combinations than did patients with UA. None used biological DMARD at 3 months, and only 2.7%/1.1% of the patients (RA/UA) used them at 12 months (p = 0.36).

Conclusion.

Remarkably high remission rates are achievable in real-world DMARD-naive patients with RA or UA.

Similar clinical outcomes in rheumatoid arthritis with more versus less expensive treatment strategies. Observational data from two rheumatology clinics

OBJECTIVES

Selection of efficacious medications for rheumatoid arthritis (RA) has tremendously increased over a decade including new costly biologic agents and inexpensive conventional anti-rheumatic drugs, used in combinations for more efficacy. Treatments aim at remission or at least low disease activity. Our objective was to study whether treatment target is reached and to what cost, in patients with RA in two Nordic rheumatology clinics.

METHODS

Cross sectional observational clinical data of all patients with RA seen in 2010 in two Nordic county hospital rheumatology units: Kristiansand, Norway and Jyväskylä, Finland, which both serve a population of about 275,000. Measures included patient demographic measures, clinical characteristics, disease activity, functional status, and treatments. Annual costs of medications to the society were calculated per 100 patients, using an assumption that a patient is taking current medications for one year.

RESULTS

Patient populations from Kristiansand and Jyväskylä were similar according to age, gender, disease duration, and prevalence of RF and CCP. Disease activity was low and patients' functional status well reserved in both clinics. Almost twice as many patients in Kristiansand than in Jyväskylä (33% vs. 17%) used biologic agents. A combination of conventional anti-rheumatic drugs was currently used by <1% of patients in Kristiansand and by 37% of patients in Jyväskylä. Estimated annual costs of medications per 100 patients were €508,000 in Kristiansand and €280,000 in Jyväskylä.

CONCLUSIONS

Treatment target of remission/low disease activity and good functional status can be reached in RA using expensive and less-expensive anti-rheumatic drugs.

Blood-derived gene-expression profiling in unravelling susceptibility to recessive disease

Identification of new disease predisposition genes with chip-based technologies typically requires extensive financial and sample resources. We have recently shown that combining peripheral blood genome and transcriptome (BGT) information in highly selected materials can be a successful low-cost approach to unravelling dominant tumour susceptibility. In this study, we extended our investigations to recessively inherited tumour predisposition, and identified a homozygous germline mutation in the damage-specific DNA binding protein 2 (DDB2) gene in a patient with several facial tumours, for which doctors had been unable to provide a diagnosis. Our results provide proof of principle that BGT is a powerful approach for both dominant and recessive genes. In addition to tumour susceptibility, the method may be useful in characterising genetic defects underlying other disease phenotypes.

Serrated carcinomas form a subclass of colorectal cancer with distinct molecular basis

Serrated colorectal carcinomas (CRCs) are morphologically different from conventional CRCs and have been proposed to follow a distinct pathway of CRC formation. Despite studies of single molecular events in this tumor type, the diagnosis of serrated CRC relies on morphology and the putative unique biological character of these tumors has not been established. Here we show that the gene expression profiling of 37 CRCs separated serrated and conventional CRCs into two distinct branches in unsupervised hierarchical clustering (P-value 7.8 x 10(-7)), and revealed 201 differentially expressed genes representing potential biomarkers for serrated CRC. Immunohistochemistry was utilized to verify the key findings in the 37 CRCs examined by expression profiling, and a separate validation set of 37 serrated and 86 conventional CRCs was examined to evaluate the candidate biomarkers in an extended sample material. Ephrin receptor B2, hypoxia-inducible factor 1-alpha and patched appeared as proteins important for genesis of serrated CRC. This study establishes serrated CRCs as a biologically distinct subclass of CRC and represents a step forward in the molecular classification of these cancers. The study also provides a platform to understand the molecular basis of serrated CRC and in long term may contribute to the development of specific treatment options for this tumor type.

Dust exposure in Finnish foundries

Dust measurements were made in 51 iron, 9 steel, and 8 nonferrous foundries, at which 4,316 foundrymen were working. The sampling lasted at least two entire shifts or work days continuously during various operations in each foundry. The dust samples were collected at fixed sites or in the breathing zones of the workers. The mass concentration was determined by weighing and the respirable dust fraction was separated by liquid sedimentation. The free silica content was determined by X-ray diffraction. In the study a total of 3,188 samples were collected in the foundries and 6,505 determinations were made in the laboratory. The results indicated a definite difference in the dust exposure during various operations. The highest dust exposures were found during furnace, cupola, and pouring ladle repair. During cleaning work, sand mixing, and shake-out operations excessive silica dust concentrations were also measured. The lowest dust concentrations were measured during melting and pouring operations. Moderate dust concentrations were measured during coremaking and molding operations. The results obtained during the same operations of iron and steel foundries were similar. The distribution of the workers into various exposure categories, the content of respirable dust and quartz, the correlation between respirable dust and total dust, and the correlation between respirable silica and total dust concentrations are discussed. Observations concerning dust suppression and control methods are briefly considered.

Effect of foundry size on the dust concentration of different work phases

The dust concentrations of different work phases in iron foundries of different sizes were studied. The results of the total dust measurements made during the Finnish Foundry Project were considered according to the eight main work phases, and the 51 iron foundries were divided into four groups according to the number of foundry workers. The division between the groups at 25, 50, and 100 workers is related to the degree of mechanization in Finnish foundries. The total dust concentration clearly increased in sand making and melting as the size of the foundry increased. The concentration decreased in molding, coremaking, knock-out, and cleaning as the number of workers increased. No significant differences between the foundry groups could be found during casting. The factors affecting the differences in dust concentrations are discussed.

Precision and accuracy of foundry dust exposure estimates from air sampling data

Errors in the sampling methods and in the determination of respirable size quartz in foundry dust have been evaluated and discussed. In general, the total precision of dust sampling and analysis was better than 20%. The term "exposure dose" is introduced and defined. The temporal variation associated with measuring exposure dose is assessed with reference to the use of a log-normal distribution of air sampling results. The logarithmic standard deviations of dust concentrations at fixed sites and jobs are calculated.

Fine structural localization of acetylcholinesterase using acetyl-beta-methylthiocholine and acetylselenocholine as substrates

Acetyl-β-methylthiocho1ine and acetylselenocholine were used as substrates for fine structural demonstration of acetylcholinesterase activity and were compared with acetylthiocholine. Essentially, the same localization of the enzyme activity was found with all of these substrates in the rat spinal cord. Acetyl-β-methylthiocoline proved to be the most specific for acetylcholinesterase in the cytochemical system used and the final product was deposited most rapidly with acetylselenocholine. When the method of Karnovsky and Roots was modified by substituting tartrate for citrate as a chelating agent, a fine crystalline end product was produced and a sharp localization with little evidence of diffusion was obtained. A fixative containing a mixture of formaldehyde and glutaraldehyde proved to be the best in preserving both enzyme activity and ultrastructure. The substrates were tested biochemically and the results substantiate the cytochemical data.