Maintenance of low disease activity and remission with etanercept-disease-modifying antirheumatic drug (DMARD) combination therapy compared with treatment with DMARDs alone in Latin American patients with active rheumatoid arthritis: Subset analysis of a randomized trial

BACKGROUND

Current guidelines on the treatment of rheumatoid arthritis (RA) recommend early therapy targeting the achievement of low disease activity (LDA) or clinical remission. Little published information is available on the success of this treatment strategy in Latin America. In a subset analysis of patients from Latin America, we compared efficacy maintenance with etanercept 50 mg once weekly (ETN50) versus placebo (PBO), on a background of methotrexate (MTX) ± other non-biologic, disease-modifying antirheumatic drugs, in patients with moderate-to-severe RA who had achieved LDA with ETN50.

METHODS

In the Treat-to-Target trial, adult patients with active RA nonresponsive to MTX were treated with ETN50 for 24 weeks (Period 1). Patients achieving LDA were randomized to receive ETN50 or PBO for 28 additional weeks (Period 2). The proportion of patients maintaining LDA at week 52 and other efficacy and quality-of-life measures were assessed. Descriptive statistics are presented using last observation carried forward imputation of data.

RESULTS

Of the 64 patients from Latin America treated in Period 1, 61 (95.3%) achieved LDA. Among patients receiving ETN50, 13/34 remained in LDA and 6/14 maintained remission at week 52 versus 6/27 and 4/10 patients receiving PBO. The median time to flare was 113 days and 33 days for the ETN50 and PBO groups, respectively. In the overall population, adverse events were reported in 37% and 43%, serious adverse events in 1% and 4%, and serious infections in 0% and 2% of patients in the ETN50 and PBO groups, respectively.

CONCLUSIONS

In patients with RA from Latin America, continuing treatment with ETN50 after achieving LDA appears to result in a higher proportion of patients maintaining LDA and remission compared with switching to PBO. CLINICALTRIALS.

GOV REGISTRATION

NCT01578850.

Tofacitinib, an oral Janus kinase inhibitor, in patients from Brazil with rheumatoid arthritis: Pooled efficacy and safety analyses

BACKGROUND

Tofacitinib is an oral Janus kinase inhibitor for the treatment of rheumatoid arthritis (RA). Efficacy and safety of tofacitinib in Brazilian patients from Phase 2 (P2) and Phase 3 (P3) global studies of up to 24 months' duration were evaluated.

METHODS

Data were pooled from Brazilian patients with RA and an inadequate response to conventional synthetic or biologic disease-modifying antirheumatic drugs enrolled in P2/P3 tofacitinib studies who received tofacitinib 5 or 10 mg twice daily (BID), or placebo, as monotherapy or in combination with methotrexate. Efficacy, safety, and patient-reported outcomes were assessed over 24 months.

RESULTS

Patients (226) from Brazil were treated in tofacitinib global P2/P3 studies. At Month 3, there were improvements in American College of Rheumatology 20/50/70 response rates, Disease Activity Score in 28 joints, erythrocyte sedimentation rate, and Health Assessment Questionnaire-Disability Index scores with both tofacitinib doses. Improvements from baseline in pain, fatigue, and health-related quality of life with tofacitinib 5 and 10 mg BID were reported. Efficacy improvements were sustained up to Month 24. The most frequent class of adverse events was infections and infestations. No cases of tuberculosis or other opportunistic infections were reported.

CONCLUSION

In a Brazilian subpopulation of patients with RA, tofacitinib reduced disease signs and symptoms and improved physical function up to Month 24, with a safety profile consistent with findings from global studies.

Effect of Glucocorticoids on the Clinical and Radiographic Efficacy of Tofacitinib in Patients with Rheumatoid Arthritis: A Posthoc Analysis of Data from 6 Phase III Studies

Objective.

Tofacitinib has been investigated for the treatment of rheumatoid arthritis (RA) in phase III studies in which concomitant glucocorticoids (GC) were allowed. We analyzed the effect of GC use on efficacy outcomes in patients with RA receiving tofacitinib and/or methotrexate (MTX) or conventional synthetic disease-modifying antirheumatic drugs (csDMARD) in these studies.

Methods.

Our posthoc analysis included data from 6 phase III studies (NCT01039688; NCT00814307; NCT00847613; NCT00853385; NCT00856544; NCT00960440). MTX-naive patients or patients with inadequate response to csDMARD or biological DMARD received tofacitinib 5 or 10 mg twice daily alone or with csDMARD, with or without concomitant GC. Patients receiving GC (≤ 10 mg/day prednisone or equivalent) before enrollment maintained a stable dose throughout. Endpoints included the American College of Rheumatology (ACR) 20/50/70 response rates, rates of Clinical Disease Activity Index (CDAI)-defined low disease activity (LDA; CDAI ≤ 10) and remission (CDAI ≤ 2.8), and changes from baseline in CDAI, 28-joint count Disease Activity Score (DAS28-4)–erythrocyte sedimentation rate (ESR), Health Assessment Questionnaire–Disability Index (HAQ-DI), pain visual analog scale (VAS), and modified total Sharp score.

Results.

Of 3200 tofacitinib-treated patients, 1258 (39.3%) received tofacitinib monotherapy and 1942 (60.7%) received tofacitinib plus csDMARD; 1767 (55.2%) received concomitant GC. ACR20/50/70 response rates, rates of CDAI LDA and remission, and improvements in CDAI, DAS28-4-ESR, HAQ-DI, and pain VAS with tofacitinib were generally similar with or without GC in monotherapy and combination therapy studies. GC use did not appear to affect radiographic progression in tofacitinib-treated MTX-naive patients. MTX plus GC appeared to inhibit radiographic progression to a numerically greater degree than MTX alone.

Conclusion.

Concomitant use of GC with tofacitinib did not appear to affect clinical or radiographic efficacy. MTX plus GC showed a trend to inhibit radiographic progression to a greater degree than MTX alone.

Differences in understanding and application of 1987 ACR criteria for rheumatoid arthritis and 1991 ESSG criteria for spondylarthropathy. A pilot survey

OBJECTIVES

To determine areas of agreement and disagreement among experts in the interpretation of the published criteria for RA (ACR) and spondylarthropathies ( ESSG).

METHODS

Thirty-two experts (16 from France and 16 from 10 other countries) replied anonymously to a mailed questionnaire.

RESULTS

Tenosynovitis and 'sausage-like' painless swelling of the toes were considered as criteria for RA by 18 and 14 experts, respectively. The definition of symmetry differed widely among experts (symmetry of only one group of joints was sufficient for 13). Twenty-five experts considered erosions of other joints than the wrists and fingers as a criterion for RA, 17 thought that fulfilment of criteria could be achieved cumulatively, and 19 would appreciate clarifications of the current criteria. Among possible clarifications for RA, it was frequently recommended that morning stiffness and nodules be eliminated and that new marker antibodies, X-rays of the feet, and exclusion criteria be added. Twenty-three of the 29 experts who gave an opinion (79%) agreed with the notion of SP in the absence of axial signs and sacroiliitis, 26/31 (84%) indicated that a patient can have both RA and SP, and 19/30 (63%) thought that RA and SP could be regarded as syndromes more than diseases. Only 5/32 experts relied more on the criteria than on their clinical judgement in diagnosing RA.

CONCLUSIONS

There would seem to be a needfor the optimisation of RA and ESSG criteria, particularly within the context of early arthritis.

Lessons from an international survey of paper cases of 10 real patients from an early arthritis clinic. CRI (Club Rhumatismes et Inflammation) Group

OBJECTIVE

To determine how experts would classify 10 early-arthritis cases (7 atypical) and to study discrepancies in diagnoses relative to ACR criteria for rheumatoid arthritis (RA) or ESSG criteria for spondyloarthropathy (SpA).

METHODS

Ten real cases (5 met ACR criteria for RA, 6 ESSG criteria for SpA, 3 both and 2 neither) followed for 28.5 +/- 4.8 months were sent as paper cases to 20 international and 12 French experts. Each expert selected a diagnosis among 8 possible choices and rated it on a 0-10 confidence scale. For each case, 3 analog scales (0-100 mm) were used to indicate the probability of RA, SpA or undifferentiated arthritis (UA).

RESULTS

Experts often disagreed about diagnoses (up to 5 different diagnoses for a given case, with a mean of 3.9 per case). Similarly, expert opinions on probabilities for RA and SpA differed widely, with great overlap between confidence for RA, SpA and UA. Fulfilment of ACR or ESSG criteria was poorly related to the experts' diagnosis and evaluation of probabilities for RA and SpA. However, UA was a relatively infrequent choice (19%).

CONCLUSIONS

There was no general consensus about the nosology of early RA and SpA. Classification of atypical early arthritis was not resolved by currently available criteria for RA and SpA. This may have implications for therapy in early disease.

Risk factors for proximal femur osteoporosis in men aged 50 years or older

The objective of this study was to analyze the risk factors for osteoporosis in 325 volunteer men aged 50 years or older. Participants completed questionnaires including demographic and social information, personal medical history, maternal and paternal history of bone fracture after the age of 50 years, smoking habit, alcoholic beverage consumption, calcium intake and present and past physical activities. The individuals were submitted to bone densitometry of the femoral neck and to anthropometric measurements. The chi2 test and multiple logistic regression were used to evaluate the association between the independent variables and the presence of osteoporosis. We concluded that the independent risk factors for osteoporosis were body mass index, present practice of physical/leisure activity (last 12 months), age, present and past smoking habit, no current thiazide diuretic use, white race and maternal history of fracture after the age of 50 years.

Bone mineral density in Brazilian men 50 years and older

Bone mineral density (BMD) in the lumbar spine (LSBMD), femoral neck (FNBMD) and whole body (WBBMD) and whole body tissue composition were evaluated in 288 Brazilian men 50 years and older, 80% white and 20% Mulattoes. Age was inversely correlated with WBBMD (r = -0.20) and FNBMD (r = -0.21) but not with LSBMD (r = 0.03). Body mass index and weight showed a strong positive correlation with WBBMD (r = 0.48 and 0.54), LSBMD (r = 0.37 and 0.45) and FNBMD (r = 0.42 and 0.48). Correlation with height was positive but weaker. No significant bone loss at the lumbar spine level was observed as the population aged. FNBMD and WBBMD decreased significantly only in the last decade (age 70-79) studied. BMD was higher for Brazilian men as compared to Brazilian women at all sites. No significant differences were observed between Brazilian and the US/European male population for BMD in the femoral neck. BMD measured by dual-energy X-ray absorptiometry in South American men is reported here for the first time. A decrease in FNBMD was detected only later in life, with a pattern similar to that described for the US/European male population.

Health status in rheumatoid arthritis: cross cultural evaluation of a Portuguese version of the Arthritis Impact Measurement Scales 2 (BRASIL-AIMS2)

OBJECTIVE

To develop a Portuguese version of the Arthritis Impact Measurement Scales 2 (AIMS2) and to evaluate its measurement properties in Brazilian patients with rheumatoid arthritis (RA).

METHODS

The BRASIL-AIMS2 was developed through the stages of initial translation, back translation, definition of the first Portuguese version, and committee review. Convergent validity was determined by administering the questionnaire to 32 patients with RA and correlating it with several clinical and laboratory variables. Twenty-five of the 32 patients were interviewed 3 times to evaluate test-retest and interobserver reliability.

RESULTS

Six translated questions were replaced due to the lack of cultural equivalence. The mean time of administering the questionnaire was about 30 minutes. The test-retest and interobserver reliability were satisfactory, except for Health Perception, and correlation coefficients ranged from 0.87 to 0.98. The Physical, Symptom, and Role components were statistically correlated with Health Assessment Questionnaire, functional class, morning stiffness, and physician assessed disease activity.

CONCLUSION

The Physical, Symptom, and Role subscales of the BRASIL-AIMS2 may be useful in the evaluation of quality of life in Brazilian patients with RA.

Lack of association between fibromyalgia syndrome and abnormalities in muscle energy metabolism

OBJECTIVE

To compare parameters of muscle energy metabolism in patients with fibromyalgia syndrome (FMS) and sedentary controls.

METHODS

Thirteen female FMS patients and 13 female sedentary controls underwent a standardized clinical assessment (including dolorimeter measurements of the upper trapezius and tibialis anterior muscles) and a standardized aerobic fitness test including measurement of maximum oxygen uptake (VO2max). Phosphorus (31P) magnetic resonance spectroscopy studies of the upper trapezius and tibialis anterior muscles were then performed in FMS patients and controls, at rest and during and following a muscle-fatiguing exercise protocol.

RESULTS

FMS patients and controls had similar levels of VO2max and of maximum voluntary contraction (MVC) of the upper trapezius and tibialis anterior muscles. After controlling for VO2max and MVC, measurements of phosphocreatine (PCr), inorganic phosphate (P(i)), and intracellular pH in these muscles were not significantly different in FMS patients versus sedentary controls either at rest, during exercise, or during recovery. In the patients with FMS, no correlation was found between overall or local pain severity and the principal muscle metabolic parameter, PCr/P(i). Inverse correlations between dolorimeter scores at 2 muscle sites and tibialis anterior PCr/P(i) were found both in patients and in controls.

CONCLUSION

This study demonstrates that under the conditions studied, muscle energy metabolism in FMS is no different than that in sedentary controls. These findings do not support the hypothesis that detectable defects in muscle energy metabolism occur in FMS.

Fibromyalgia syndrome in patients infected with human immunodeficiency virus. The Boston City Hospital Clinical AIDS Team

PURPOSE

To prospectively assess rheumatic manifestations of human immunodeficiency virus (HIV) disease in a municipal hospital clinic population in which intravenous drug use was the most common risk factor for HIV infection.

PATIENTS AND METHODS

Patients with documented HIV infection were evaluated for rheumatic disease using a standardized questionnaire and examination. Patients with fibromyalgia were compared with HIV-infected patients without fibromyalgia and with fibromyalgia patients without known risk factors for HIV infection.

RESULTS

Thirty-seven of 140 patients with HIV infection had muskuloskeletal symptoms. Three of these 37 patients had arthritis, but none had Reiter's syndrome or psoriatic arthritis. Thirty (81%) of 37 patients had chronic musculoskeletal symptoms (for 3 months or longer). Twenty of 30 patients with chronic musculoskeletal symptoms had polyarthralgia, and of those, 15 (75%) were found to have either definite or probable fibromyalgia syndrome. Therefore, fibromyalgia syndrome was found in 41% of HIV-infected patients with musculoskeletal symptoms and in approximately 11% of all HIV-infected patients. Fibromyalgia patients with HIV infection had a longer duration of HIV infection (p = 0.01) and more frequently reported past depressed mood (p = 0.001) than HIV-infected patients without fibromyalgia. Compared with 301 patients with fibromyalgia syndrome and no known risk behavior for HIV, known HIV-infected patients with fibromyalgia were more commonly male (p = 0.001) and reported current depressed mood more frequently (p = 0.0001).

CONCLUSION

Few patients with arthritis were noted among HIV-infected patients who had intravenous drug use as risk behavior. By comparison, fibromyalgia syndrome appeared to be a common cause of musculoskeletal symptoms in this patient population.

[Late diagnosis of juvenile dermatomyositis with spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema]

The authors describe a 11 year-old girl that presented eczematous scabies with acute oligoarthritis that subsided in one day. Fourteen months later, she developed a classical juvenile dermatomyositis with spontaneous pneumothorax, pneumomediastinum, subcutaneous emphysema; pulmonary infection due to Pneumocystis carinii had been diagnosed and was attributable to immunosuppressive therapy. Despite the late diagnosis, the rapid disease activity and the multiple complications, clinical and laboratory controls were achieved by the corticotherapy and by an early diagnosis and treatment of complications.

[Recurrent lupus nephritis in kidney transplantation]

A case of recurrent lupus nephritis involving a renal allograft in a 28-year-old woman is described. The transplant was made after 2 years of hemodialysis. The allograft function remained stable for 2 years after the transplant. Clinical course, serologic tests, and renal histopathologic findings at the time of recurrence paralleled those seen in the patient's primary disease. There were no changes of transplant rejection. One year of follow-up shows a stable allograft renal function despite the histological and clinical recurrence of systemic lupus erythematosus.