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Brown AD, Fisher L, Curtis HJ, Wiedemann M, Hulme WJ, Speed V, Hopcroft LEM, Cunningham C, Costello RE, Galloway JB, Russell MD, Bechman K, Kurt Z, Croker R, Wood C, Walker AJ, Schaffer AL, Bacon SCJ, Mehrkar A, Hickman G, Bates C, Cockburn J, Parry J, Hester F, Harper S, Goldacre B, MacKenna B. OpenSAFELY: The impact of COVID-19 on azathioprine, leflunomide and methotrexate monitoring, and factors associated with change in monitoring rate. Br J Clin Pharmacol 2024. [PMID: 38589944 DOI: 10.1111/bcp.16062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/10/2024] Open
Abstract
AIMS The COVID-19 pandemic created unprecedented pressure on healthcare services. This study investigates whether disease-modifying antirheumatic drug (DMARD) safety monitoring was affected during the COVID-19 pandemic. METHODS A population-based cohort study was conducted using the OpenSAFELY platform to access electronic health record data from 24.2 million patients registered at general practices using TPP's SystmOne software. Patients were included for further analysis if prescribed azathioprine, leflunomide or methotrexate between November 2019 and July 2022. Outcomes were assessed as monthly trends and variation between various sociodemographic and clinical groups for adherence with standard safety monitoring recommendations. RESULTS An acute increase in the rate of missed monitoring occurred across the study population (+12.4 percentage points) when lockdown measures were implemented in March 2020. This increase was more pronounced for some patient groups (70-79 year-olds: +13.7 percentage points; females: +12.8 percentage points), regions (North West: +17.0 percentage points), medications (leflunomide: +20.7 percentage points) and monitoring tests (blood pressure: +24.5 percentage points). Missed monitoring rates decreased substantially for all groups by July 2022. Consistent differences were observed in overall missed monitoring rates between several groups throughout the study. CONCLUSION DMARD monitoring rates temporarily deteriorated during the COVID-19 pandemic. Deterioration coincided with the onset of lockdown measures, with monitoring rates recovering rapidly as lockdown measures were eased. Differences observed in monitoring rates between medications, tests, regions and patient groups highlight opportunities to tackle potential inequalities in the provision or uptake of monitoring services. Further research should evaluate the causes of the differences identified between groups.
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Affiliation(s)
- Andrew D Brown
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Louis Fisher
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Helen J Curtis
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Milan Wiedemann
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - William J Hulme
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Victoria Speed
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Lisa E M Hopcroft
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Christine Cunningham
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | | | | | - Mark D Russell
- Centre for Rheumatic Diseases, King's College London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, UK
| | - Zeyneb Kurt
- Northumbria University, Newcastle upon Tyne, UK
| | - Richard Croker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Chris Wood
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Alex J Walker
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Andrea L Schaffer
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Seb C J Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - George Hickman
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | | | | | | | | | | | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
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Zhao SS, Baker MC, Galloway JB. IL-6 receptor inhibition and risk of sarcoidosis: a Mendelian randomization study. Rheumatology (Oxford) 2024; 63:e118-e119. [PMID: 37975855 PMCID: PMC10986795 DOI: 10.1093/rheumatology/kead613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Sizheng Steven Zhao
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Science, School of Biological Sciences, Faculty of Biological Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Matthew C Baker
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
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Russell MD, Yang Z, Walter B, Alveyn E, Bechman K, Miracle A, Nagra D, Adas MA, Norton S, Cope AP, Langan SM, Galloway JB. The influence of safety warnings on the prescribing of JAK inhibitors. Lancet Rheumatol 2024; 6:e138-e139. [PMID: 38310922 DOI: 10.1016/s2665-9913(24)00002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/21/2023] [Accepted: 01/04/2024] [Indexed: 02/06/2024]
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK.
| | - Zijing Yang
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Ben Walter
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Edward Alveyn
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Aitana Miracle
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Deepak Nagra
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
| | - Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London SE5 9RJ, UK
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Arumalla N, Chan CKD, Gibson M, Man YL, Adas MA, Norton S, Galloway JB, Garrood T. The Clinical Impact of Electronic Patient-Reported Outcome Measures in the Remote Monitoring of Inflammatory Arthritis: A Systematic Review and Meta-analysis. Arthritis Rheumatol 2023; 75:1892-1903. [PMID: 37204273 DOI: 10.1002/art.42559] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 04/28/2023] [Accepted: 05/05/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The inflammatory arthritides (IAs) make up a significant proportion of conditions followed up in rheumatology clinics. These patients require regular monitoring, but this is increasingly difficult with rising patient numbers and demand on clinics. Our objective is to evaluate the clinical impact of electronic patient-reported outcome measures (ePROMs) as a digital remote-monitoring intervention on disease activity, treatment decisions, and health care resource use in patients with IA. METHODS Five databases (MEDLINE, Embase, PubMed, Cochrane Library, and Web of Science) were searched, with randomized controlled trials and (nonrandomized) controlled clinical trials included, and meta-analysis and forest plots conducted for each outcome. Risk of bias was assessed using the Risk of Bias-2 tool and Risk of Bias in Nonrandomized Studies of Interventions. RESULTS Eight studies were included with a total of 4,473 patients, with seven studies assessing patients with rheumatoid arthritis. Compared with control, the disease activity in the ePROM group was lower (standardized mean difference [SMD] -0.15; 95% confidence interval [CI] -0.27 to -0.03) and rates of remission/low disease activity were higher (odds ratio1.65; 95% CI 1.02-2.68), but five of eight studies provided additional combined interventions (e.g., disease education). Fewer face to face visits were needed in the remote ePROM group (SMD -0.93; 95% CI -2.14-0.28). CONCLUSION Most studies were at high risk of bias with significant heterogeneity in design, but our results suggest there is an advantage in using ePROM monitoring in patients with IAs, with the potential for reduction in health care resource use without detrimental impact in disease outcomes.
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Affiliation(s)
| | | | | | - Yik L Man
- Lewisham and Greenwich NHS Trust, London, UK
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Russell MD, Ameyaw-Kyeremeh L, Dell'Accio F, Lapham H, Head N, Stovin C, Patel V, Clarke BD, Nagra D, Alveyn E, Adas MA, Bechman K, de la Puente MA, Ellis B, Byrne C, Patel R, Rutherford AI, Cantle F, Norton S, Roddy E, Hudson J, Cope AP, Galloway JB. Implementing treat-to-target urate-lowering therapy during hospitalisations for gout flares. Rheumatology (Oxford) 2023:kead574. [PMID: 37929968 DOI: 10.1093/rheumatology/kead574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/25/2023] [Accepted: 08/13/2023] [Indexed: 11/07/2023] Open
Abstract
OBJECTIVES To evaluate a strategy designed to optimise care and increase uptake of urate-lowering therapy (ULT) during hospitalisations for gout flares. METHODS We conducted a prospective cohort study to evaluate a strategy that combined optimal in-hospital gout management with a nurse-led, follow-up appointment, followed by handover to primary care. Outcomes, including ULT initiation, urate target attainment, and re-hospitalisation rates, were compared between patients hospitalised for flares in the 12 months post-implementation and a retrospective cohort of hospitalised patients from 12 months pre-implementation. RESULTS 119 and 108 patients, respectively, were hospitalised for gout flares in the 12 months pre- and post-implementation. For patients with 6-month follow-up data available (n = 94 and n = 97, respectively), the proportion newly initiated on ULT increased from 49.2% pre-implementation to 92.3% post-implementation (age/sex-adjusted odds ratio (aOR) 11.5; 95% confidence interval (CI) 4.36-30.5; p < 0.001). After implementation, more patients achieved a serum urate ≤360 micromol/L within 6 months of discharge (10.6% pre-implementation vs. 26.8% post-implementation; aOR 3.04; 95% CI 1.36-6.78; p = 0.007). The proportion of patients re-hospitalised for flares was 14.9% pre-implementation vs. 9.3% post-implementation (aOR 0.53, 95% CI 0.22 to 1.32; p = 0.18). CONCLUSION Over 90% of patients were initiated on ULT after implementing a strategy to optimise hospital gout care. Despite increased initiation of ULT during flares, recurrent hospitalisations were not more frequent following implementation. Significant relative improvements in urate target attainment were observed post-implementation; however, for the majority of hospitalised gout patients to achieve urate targets, closer primary-secondary care integration is still needed.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Louise Ameyaw-Kyeremeh
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Flora Dell'Accio
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Heather Lapham
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Natalie Head
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Christopher Stovin
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Vishit Patel
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Benjamin D Clarke
- Benjamin Clarke, Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Deepak Nagra
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Edward Alveyn
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - María A de la Puente
- Department of Psychology, Health Psychology Section, Institute of Psychiatry, Psychology, & Neuroscience, King's College London, London, United Kingdom
| | - Benjamin Ellis
- Department of Rheumatology, Imperial College Healthcare NHS Foundation Trust, London, United Kingdom
| | - Corrine Byrne
- Pharmacy Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Rina Patel
- Pharmacy Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Andrew I Rutherford
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Fleur Cantle
- Department of Emergency Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - Edward Roddy
- School of Medicine, Keele University, Keele, United Kingdom
| | - Joanna Hudson
- Department of Psychology, Health Psychology Section, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, United Kingdom
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6
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Russell MD, Massey J, Roddy E, MacKenna B, Bacon S, Goldacre B, Andrews CD, Hickman G, Mehrkar A, Mahto A, Rutherford AI, Patel S, Adas MA, Alveyn E, Nagra D, Bechman K, Ledingham JM, Hudson J, Norton S, Cope AP, Galloway JB. Gout incidence and management during the COVID-19 pandemic in England, UK: a nationwide observational study using OpenSAFELY. Lancet Rheumatol 2023; 5:e622-e632. [PMID: 38251486 DOI: 10.1016/s2665-9913(23)00206-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Gout is the most prevalent inflammatory arthritis, yet one of the worst managed. Our objective was to assess how the COVID-19 pandemic impacted incidence and quality of care for people with gout in England, UK. METHODS With the approval of National Health Service England, we did a population-level cohort study using primary care and hospital electronic health record data for 17·9 million adults registered with general practices using TPP health record software, via the OpenSAFELY platform. The study period was from March 1, 2015, to Feb 28, 2023. Individuals aged 18-110 years were defined as having incident gout if they were assigned index diagnostic codes for gout, were registered with TPP practices in England for at least 12 months before diagnosis, did not receive prescriptions for urate-lowering therapy more than 30 days before diagnosis, and had not been admitted to hospital or attended an emergency department for gout flares more than 30 days before diagnosis. Outcomes assessed were incidence and prevalence of people with recorded gout diagnoses, incidence of gout hospitalisations, initiation of urate-lowering therapy, and attainment of serum urate targets (≤360 μmol/L). FINDINGS From a reference population of 17 865 145 adults, 246 695 individuals were diagnosed with incident gout. The mean age of individuals with incident gout was 61·3 years (SD 16·2). 66 265 (26·9%) of 246 695 individuals were female, 180 430 (73·1%) were male, and 189 035 (90·9%) of 208 050 individuals with available ethnicity data were White. Incident gout diagnoses decreased by 30·9% in the year beginning March, 2020, compared with the preceding year (1·23 diagnoses vs 1·78 diagnoses per 1000 adults). Gout prevalence was 3·07% in 2015-16, and 3·21% in 2022-23. Gout hospitalisations decreased by 30·1% in the year commencing March, 2020, compared with the preceding year (9·6 admissions vs 13·7 admissions per 100 000 adults). Of 228 095 people with incident gout and available follow-up, 66 560 (29·2%) were prescribed urate-lowering therapy within 6 months. Of 65 305 individuals who initiated urate-lowering therapy with available follow-up, 16 790 (25·7%) attained a serum urate concentration of 360 μmol/L or less within 6 months of urate-lowering therapy initiation. In interrupted time-series analyses, urate-lowering therapy prescribing improved modestly during the pandemic, compared with pre-pandemic, whereas urate target attainment was similar. INTERPRETATION Using gout as an exemplar disease, we showed the complexity of how health care was impacted during the COVID-19 pandemic. We observed a reduction in gout diagnoses but no effect on treatment metrics. We showed how country-wide, routinely collected data can be used to map disease epidemiology and monitor care quality. FUNDING None.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK.
| | - Jon Massey
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Seb Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Colm D Andrews
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - George Hickman
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Arti Mahto
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Andrew I Rutherford
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Samir Patel
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Edward Alveyn
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Deepak Nagra
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Joanna M Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Joanna Hudson
- Department of Psychology, Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
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Lauper K, Kearsley-Fleet L, Galloway JB, Watson KD, Hyrich KL, Lunt M. Evaluation of serious infections, including Mycobacterium tuberculosis, during treatment with biologic disease-modifying antirheumatic drugs: does line of therapy matter? Rheumatology (Oxford) 2023:kead515. [PMID: 37758229 DOI: 10.1093/rheumatology/kead515] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/15/2023] [Accepted: 09/06/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate if and how the incidence of serious infection (SI) and active tuberculosis (TB) differ among seven biological disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) considering the line of therapy. METHODS Patients with RA from the British Society for Rheumatology Biologics Register-RA cohort who initiated etanercept, certolizumab, infliximab, adalimumab, abatacept, rituximab, or tocilizumab from the first to fifth line of therapy were included. Follow-up extended up to three years. Primary outcome was SI, secondary outcome was TB. Event rates were calculated and compared using Cox proportional-hazards, controlling for confounding with inverse probability of treatment weights. Comparisons were made overall and stratified by line of therapy. Sensitivity analysis restricted to all treatment courses from 2009 (tocilizumab availability) until end of study (2018). RESULTS Among 33 897 treatment courses (62 513 patient-years) the incidence of SI was 4.4/100 patient-years (95%CI 4.2-4.5). After adjustment, hazards ratios (HR) of SI were slightly higher with adalimumab and infliximab compared with etanercept. However, no clear pattern was observed when stratifying by line of therapy, in terms of incidence rate or hazards ratio. Sensitivity analyses showed similar HR among these treatments. Regarding TB, all 49 cases occurred during the first three lines of treatment and rarely since 2009. CONCLUSION The risk of serious infections does not appear to be influenced by the line of therapy in patients with RA. However, the risk of tuberculosis seems to be more frequent during the initial lines of treatment or prior to 2009.
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Affiliation(s)
- Kim Lauper
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Division of Rheumatology, Geneva University Hospitals and Geneva Centre for Inflammation Research, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Lianne Kearsley-Fleet
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - James B Galloway
- Centre of Rheumatic Disease, King's College London, London, United Kingdom
| | - Kath D Watson
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Centre of Rheumatic Disease, King's College London, London, United Kingdom
| | - Mark Lunt
- Centre for Epidemiology Versus Arthritis, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Adas MA, Russell MD, Cook E, Alveyn E, Hannah J, Balachandran S, Oyebanjo S, Amlani-Hatcher P, Ledingham J, Norton S, Galloway JB. COVID-19 admissions and mortality in patients with early inflammatory arthritis: results from a UK national cohort. Rheumatology (Oxford) 2023; 62:2979-2988. [PMID: 36645234 PMCID: PMC10473194 DOI: 10.1093/rheumatology/kead018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/24/2022] [Accepted: 01/03/2023] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To describe the risks and predictors of coronavirus disease 2019 (COVID-19) hospitalization and mortality among patients with early inflammatory arthritis (EIA), recruited to the National Early Inflammatory Arthritis Audit (NEIAA). METHODS NEIAA is an observational cohort. We included adults with EIA from Feb 2020 to May 2021. Outcomes of interest were hospitalization and death due to COVID-19, using NHS Digital linkage. Cox proportional hazards were used to calculate hazard ratios for outcomes according to initial treatment strategy, with adjustment for confounders. RESULTS From 14 127 patients with EIA, there were 143 hospitalizations and 47 deaths due to COVID-19, with incidence rates per 100 person-years of 0.93 (95% CI 0.79, 1.10) for hospitalization and 0.30 (95% CI 0.23, 0.40) for death. Increasing age, male gender, comorbidities and ex-smoking were associated with increased risk of worse COVID-19 outcomes. Higher baseline DAS28 was not associated with COVID-19 admissions [confounder adjusted hazard ratio (aHR) 1.10; 95% CI 0.97, 1.24] or mortality (aHR 1.11; 95% CI 0.90, 1.37). Seropositivity was not associated with either outcome. Higher symptom burden on patient-reported measures predicted worse COVID-19 outcomes. In unadjusted models, CS associated with COVID-19 death (HR 2.29; 95% CI 1.02, 5.13), and SSZ monotherapy associated with COVID-19 admission (HR 1.92; 95% CI 1.04, 3.56). In adjusted models, associations for CS and SSZ were not statistically significant. CONCLUSION Patient characteristics have stronger associations with COVID-19 than the initial treatment strategy in patients with EIA. An important limitation is that we have not looked at treatment changes over time.
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Affiliation(s)
- Maryam A Adas
- Centre for Rheumatic Disease, King’s College London, London, UK
| | - Mark D Russell
- Centre for Rheumatic Disease, King’s College London, London, UK
| | - Emma Cook
- Centre for Rheumatic Disease, King’s College London, London, UK
| | - Edward Alveyn
- Centre for Rheumatic Disease, King’s College London, London, UK
| | - Jennifer Hannah
- Centre for Rheumatic Disease, King’s College London, London, UK
| | | | | | | | - Joanna Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sam Norton
- Centre for Rheumatic Disease, King’s College London, London, UK
- Psychology Department, Institute for Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
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Bechman K, Russell MD, Galloway JB. Predicting COVID-19 vaccination response in populations who are immunosuppressed. Lancet Rheumatol 2023; 5:e431-e432. [PMID: 38251570 DOI: 10.1016/s2665-9913(23)00185-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Katie Bechman
- Centre for Rheumatic Diseases, King's College London SE5 9RJ, UK
| | - Mark D Russell
- Centre for Rheumatic Diseases, King's College London SE5 9RJ, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London SE5 9RJ, UK.
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10
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Russell MD, Stovin C, Alveyn E, Adeyemi O, Chan CKD, Patel V, Adas MA, Atzeni F, Ng KKH, Rutherford AI, Norton S, Cope AP, Galloway JB. JAK inhibitors and the risk of malignancy: a meta-analysis across disease indications. Ann Rheum Dis 2023; 82:1059-1067. [PMID: 37247942 PMCID: PMC10359573 DOI: 10.1136/ard-2023-224049] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/25/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To estimate the association of Janus kinase inhibitors (JAKi) with the incidence of malignancy, compared with placebo, tumour necrosis factor (TNF)-α inhibitors (TNFi) and methotrexate. METHODS Systematic searches of databases were performed, to December 2022, to identify phase II/III/IV randomised clinical trials (RCTs) and long-term extension (LTE) studies of JAKi (tofacitinib, baricitinib, upadacitinib, filgotinib, peficitinib) compared with placebo, TNFi or methotrexate, in adults with rheumatoid arthritis, psoriatic arthritis, psoriasis, axial spondyloarthritis, inflammatory bowel disease or atopic dermatitis. Network and pairwise meta-analyses were performed to estimate incidence rate ratios (IRRs) for malignancy between JAKi and comparators. Bias was assessed using the Cochrane Risk of Bias-2 tool. RESULTS In 62 eligible RCTs and 16 LTE studies, there were 82 366 person-years of exposure to JAKi, 2924 to placebo, 7909 to TNFi and 1074 to methotrexate. The overall malignancy incidence rate was 1.15 per 100 person-years in RCTs, and 1.26 per 100 person-years across combined RCT and LTE data. In network meta-analyses, the incidence of all malignancies including non-melanomatous skin cancers (NMSCs) was not significantly different between JAKi and placebo (IRR 0.71; 95% CI 0.44 to 1.15) or between JAKi and methotrexate (IRR 0.77; 95% CI 0.35 to 1.68). Compared with TNFi, however, JAKi were associated with an increased incidence of malignancy (IRR 1.50; 95% CI 1.16 to 1.94). Findings were consistent when analysing NMSC only and when analysing combined RCT/LTE data. CONCLUSIONS JAKi were associated with a higher incidence of malignancy compared with TNFi but not placebo or methotrexate. Cancers were rare events in all comparisons. PROSPERO REGISTRATION NUMBER CRD42022362630.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | | | - Edward Alveyn
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Olukemi Adeyemi
- Centre for Rheumatic Diseases, King's College London, London, UK
| | | | - Vishit Patel
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Fabiola Atzeni
- Rheumatology Unit, University of Messina, Messina, Italy
| | - Kenrick K H Ng
- Department of Medical Oncology, University College London, London, UK
| | | | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
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11
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Russell MD, Roddy E, Rutherford AI, Ellis B, Norton S, Douiri A, Gulliford MC, Cope AP, Galloway JB. Treat-to-target urate-lowering therapy and hospitalizations for gout: results from a nationwide cohort study in England. Rheumatology (Oxford) 2023; 62:2426-2434. [PMID: 36355461 PMCID: PMC10321109 DOI: 10.1093/rheumatology/keac638] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/03/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE To investigate associations between treat-to-target urate-lowering therapy (ULT) and hospitalizations for gout. METHODS Using linked Clinical Practice Research Datalink and NHS Digital Hospital Episode Statistics data, we described the incidence and timing of hospitalizations for flares in people with index gout diagnoses in England from 2004-2020. Using Cox proportional hazards and propensity models, we investigated associations between ULT initiation, serum urate target attainment, colchicine prophylaxis, and the risk of hospitalizations for gout. RESULTS Of 292 270 people with incident gout, 7719 (2.64%) had one or more hospitalizations for gout, with an incidence rate of 4.64 hospitalizations per 1000 person-years (95% CI 4.54, 4.73). There was an associated increased risk of hospitalizations within the first 6 months after ULT initiation, when compared with people who did not initiate ULT [adjusted Hazard Ratio (aHR) 4.54; 95% CI 3.70, 5.58; P < 0.001]. Hospitalizations did not differ significantly between people prescribed vs not prescribed colchicine prophylaxis in fully adjusted models. From 12 months after initiation, ULT associated with a reduced risk of hospitalizations (aHR 0.77; 95% CI 0.71, 0.83; P < 0.001). In ULT initiators, attainment of a serum urate <360 micromol/l within 12 months of initiation associated with a reduced risk of hospitalizations (aHR 0.57; 95% CI 0.49, 0.67; P < 0.001) when compared with people initiating ULT but not attaining this target. CONCLUSION ULT associates with an increased risk of hospitalizations within the first 6 months of initiation but reduces hospitalizations in the long term, particularly when serum urate targets are achieved.
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Affiliation(s)
- Mark D Russell
- Correspondence to: Mark D. Russell, Centre for Rheumatic Diseases, Weston Education Centre, King’s College London, 10 Cutcombe Road, London SE5 9RJ, UK. E-mail:
| | | | - Andrew I Rutherford
- Department of Rheumatology, King’s College Hospital NHS Foundation Trust, London, UK
| | - Benjamin Ellis
- Department of Rheumatology, Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King’s College London, London, UK
| | - Abdel Douiri
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Martin C Gulliford
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King’s College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King’s College London, London, UK
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12
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Nagra D, Russell MD, Alveyn E, Birring SS, Elias D, Balachandran S, Galloway JB. Diagnosing Camurati-Engelmann disease-the age of whole-exome sequencing. Rheumatology (Oxford) 2023; 62:e221-e222. [PMID: 36519831 PMCID: PMC10321082 DOI: 10.1093/rheumatology/keac670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2022] [Indexed: 07/20/2023] Open
Affiliation(s)
- Deepak Nagra
- Correspondence to: Deepak Nagra, Centre for Rheumatic Diseases, Weston Education Centre, King’s College London, 10 Cutcombe Road, London SE5 9RJ, UK. E-mail:
| | - Mark D Russell
- Centre for Rheumatic Diseases, King’s College London, London, UK
| | - Edward Alveyn
- Centre for Rheumatic Diseases, King’s College London, London, UK
| | | | - David Elias
- King’s College Hospital NHS Foundation Trust, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, King’s College London, London, UK
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13
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Quirke-McFarlane S, Weinman J, Cook ES, Yiu ZZN, Dand N, Langan SM, Bechman K, Tsakok T, Mason KJ, McAteer H, Meynell F, Coker B, Vincent A, Urmston D, Vesty A, Kelly J, Lancelot C, Moorhead L, Barbosa IA, Bachelez H, Capon F, Contreras CR, De La Cruz C, Di Meglio P, Gisondi P, Jullien D, Lambert J, Naldi L, Puig L, Spuls P, Torres T, Warren RB, Waweru H, Galloway JB, Griffiths CEM, Barker JN, Norton S, Smith CH, Mahil SK. Non-adherence to systemic immune-modifying therapy in people with psoriasis during the COVID-19 pandemic: findings from a global cross-sectional survey. Br J Dermatol 2022; 188:610-617. [PMID: 36763806 DOI: 10.1093/bjd/ljac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/04/2022] [Accepted: 12/17/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Non-adherence to immune-modifying therapy is a complex behaviour which, before the COVID-19 pandemic, was shown to be associated with mental health disorders in people with immune-mediated diseases. The COVID-19 pandemic has led to a rise in the global prevalence of anxiety and depression, and limited data exist on the association between mental health and non-adherence to immune modifying therapy during the pandemic. OBJECTIVES To assess the extent of and reasons underlying non-adherence to systemic immune-modifying therapy during the COVID-19 pandemic in individuals with psoriasis, and the association between mental health and non-adherence. METHODS Online self-report surveys (PsoProtectMe), including validated screens for anxiety and depression, were completed globally during the first year of the pandemic. We assessed the association between anxiety or depression and non-adherence to systemic immune-modifying therapy using binomial logistic regression, adjusting for potential cofounders (age, sex, ethnicity, comorbidity), and country of residence. RESULTS Of 3980 participants from 77 countries, 1611 (40.5%) were prescribed a systemic immune-modifying therapy. Of these, 408 (25.3%) reported non-adherence during the pandemic, most commonly due to concerns about their immunity. In the unadjusted model, a positive anxiety screen was associated with non-adherence to systemic immune-modifying therapy (OR 1.36, 95%CI 1.07-1.76). Specifically, anxiety was associated with non-adherence to targeted therapy (OR 1.41, 95%CI 1.01-1.96) but not standard systemic therapy (OR 1.16, 95%CI 0.81-1.67). In the adjusted model, although the directions of the effects remained, anxiety was not significantly associated with non-adherence to overall systemic (OR 1.20, 95%CI 0.92-1.56) or targeted (OR 1.33, 95%CI 0.94-1.89) immune-modifying therapy. A positive depression screen was not strongly associated with non-adherence to systemic immune-modifying therapy in the unadjusted (OR 1.22, 95% CI 0.94-1.57) or adjusted models (OR 1.14, 95% CI 0.87-1.49). CONCLUSION These data indicate substantial non-adherence to immune-modifying therapy in people with psoriasis during the pandemic, with attenuation of the association with mental health after adjusting for confounders. Future research in larger populations should further explore pandemic-specific drivers of treatment non-adherence. Clear communication of the reassuring findings from population-based research regarding immune-modifying therapy-associated adverse COVID-19 risks to people with psoriasis is essential, to optimise adherence and disease outcomes.
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Affiliation(s)
- Sophia Quirke-McFarlane
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK.,School of Psychology, University of Surrey, UK
| | - John Weinman
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Emma S Cook
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Zenas Z N Yiu
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Nick Dand
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sinead M Langan
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,Faculty of Epidemiology, and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Teresa Tsakok
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Kayleigh J Mason
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK.,School of Medicine, Keele University, Keele, UK
| | | | - Freya Meynell
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Bolaji Coker
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Alexandra Vincent
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | | | | | - Jade Kelly
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | | | - Lucy Moorhead
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Ines A Barbosa
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Herve Bachelez
- Department of Dermatology, AP-HP Hôpital Saint-Louis, Paris, France.,INSERM U1163, Imagine Institute for Human Genetic Diseases, Université de Paris, Paris, France
| | - Francesca Capon
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Claudia R Contreras
- Catedra de Dermatologia, Hospital de Clinicas, Facultad de Ciencias Medicas, Universidad Nacional de Asuncion, Paraguay
| | | | - Paola Di Meglio
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Paolo Gisondi
- Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - Denis Jullien
- Department of Dermatology, Edouard Herriot Hospital, Hospices Civils de Lyon, University of Lyon, Lyon, France.,Groupe de recherche sur le psoriasis (GrPso) de la Société française de dermatologie, Paris, France
| | - Jo Lambert
- Department of Dermatology, Ghent University, Ghent, Belgium
| | | | - Lluís Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Catalonia, Spain
| | - Phyllis Spuls
- Department of Dermatology, Amsterdam Public Health/Infection and Immunology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Tiago Torres
- Department of Dermatology, Centro Hospitalar do Porto, Portugal
| | - Richard B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Hoseah Waweru
- International Federation of Psoriasis Associations, France
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Christopher E M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - Jonathan N Barker
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Sam Norton
- Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Catherine H Smith
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Satveer K Mahil
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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14
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Mukherji P, Adas MA, Clarke B, Galloway JB, Mulvey T, Norton S, Turner J, Russell MD, Lempp H, Li S. Changing trends in ethnicity and academic performance: observational cohort data from a UK medical school. BMJ Open 2022; 12:e066886. [PMID: 36521901 PMCID: PMC9756189 DOI: 10.1136/bmjopen-2022-066886] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Quantify differential attainment by ethnicity in undergraduate medical assessments and evaluate whether institutional efforts to reduce the attainment gap have had impact. DESIGN Observational cohort study. SETTING A single UK MBBS medical programme. PARTICIPANTS Pseudonymised data of adults aged ≥18 years enrolled in one of the UK MBBS medical programmes between 2012 and 2018. Ethnicity was self-declared during enrolment as White, Asian, Black, mixed and other. MAIN OUTCOME MEASURE Module mark (distinction, merit, pass, fail) graded according to a variety of assessments, including single best answer examinations, objective structured clinical examinations and coursework submissions. All modular assessments are graded as a percentage. Logistic regression models were used to calculate relative risk ratio to study the association between ethnicity and attainment gap over a calendar and scholastic year. Models were adjusted for age, gender, social deprivation and scholastic year of study. RESULTS 3714 student records were included. In the sample, 2134 students (57%) were non-white. The proportion of non-white students increased from 2007 (49%) to 2018 (70%). Mean age was 18 (IQR 18-21) and 56.6% were females. Higher proportion of non-white students 218 (24.8%) were from more deprived backgrounds versus white 76 (14.8%). Compared with non-white, there were no significant differences in the proportion of students failing assessments. However, white students were more likely to achieve merit (relative risk ratio 1.29 (95% CI 1.08 to 1.45)) or distinction (1.69 (95% CI 1.37 to 2.08)). Differences in attainment gap have remained unchanged over time, and for black students, attainment gap grew between their first and final year of study. CONCLUSION A similar proportion (97%) of non-white and white students had a passing score, but attainment gap for higher grades persists over years despite widespread efforts in medical schools to diminish the attainment gap linked to ethnicity. Our findings are from a single institution, thus affecting generalisability.
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Affiliation(s)
| | - Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Benjamin Clarke
- Postgraduate Medical & Dental Education Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Thomas Mulvey
- Clinical Education Department, King's College London, London, UK
| | - Sam Norton
- Psychology Department, Insitute of Psychiatry, King's College London, London, UK
| | - Jonathan Turner
- Clinical Education Department, King's College London, London, UK
| | - Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Shuangyu Li
- Division of Medical Education, King's College London, London, UK
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15
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Russell MD, Galloway JB, Andrews CD, MacKenna B, Goldacre B, Mehrkar A, Curtis HJ, Butler-Cole B, O'Dwyer T, Qureshi S, Ledingham JM, Mahto A, Rutherford AI, Adas MA, Alveyn E, Norton S, Cope AP, Bechman K. Incidence and management of inflammatory arthritis in England before and during the COVID-19 pandemic: a population-level cohort study using OpenSAFELY. Lancet Rheumatol 2022; 4:e853-e863. [PMID: 36447940 PMCID: PMC9691150 DOI: 10.1016/s2665-9913(22)00305-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The impact of the COVID-19 pandemic on the incidence and management of inflammatory arthritis is not understood. Routinely captured data in secure platforms, such as OpenSAFELY, offer unique opportunities to understand how care for patients with inflammatory arthritis was impacted upon by the pandemic. Our objective was to use OpenSAFELY to assess the effects of the pandemic on diagnostic incidence and care delivery for inflammatory arthritis in England and to replicate key metrics from the National Early Inflammatory Arthritis Audit. Methods In this population-level cohort study, we used primary care and hospital data for 17·7 million adults registered with general practices using TPP health record software, to explore the following outcomes between April 1, 2019, and March 31, 2022: (1) incidence of inflammatory arthritis diagnoses (rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and undifferentiated inflammatory arthritis) recorded in primary care; (2) time to first rheumatology assessment; (3) time to first prescription of a disease-modifying antirheumatic drug (DMARD) in primary care; and (4) choice of first DMARD. Findings Among 17 683 500 adults, there were 31 280 incident inflammatory arthritis diagnoses recorded between April 1, 2019, and March 31, 2022. The mean age of diagnosed patients was 55·4 years (SD 16·6), 18 615 (59·5%) were female, 12 665 (40·5%) were male, and 22 925 (88·3%) of 25 960 with available ethnicity data were White. New inflammatory arthritis diagnoses decreased by 20·3% in the year commencing April, 2020, relative to the preceding year (5·1 vs 6·4 diagnoses per 10 000 adults). The median time to first rheumatology assessment was shorter during the pandemic (18 days; IQR 8-35) than before (21 days; 9-41). The proportion of patients prescribed DMARDs in primary care was similar before and during the pandemic; however, during the pandemic, fewer people were prescribed methotrexate or leflunomide, and more were prescribed sulfasalazine or hydroxychloroquine. Interpretation Inflammatory arthritis diagnoses decreased markedly during the early phase of the pandemic. The impact on rheumatology assessment times and DMARD prescribing in primary care was less marked than might have been anticipated. This study demonstrates the feasibility of using routinely captured, near real-time data in the secure OpenSAFELY platform to benchmark care quality on a national scale, without the need for manual data collection. Funding None.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Colm D Andrews
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Helen J Curtis
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Butler-Cole
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Thomas O'Dwyer
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sumera Qureshi
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Joanna M Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Arti Mahto
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Andrew I Rutherford
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Edward Alveyn
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
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16
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Bechman K, Cook ES, Dand N, Yiu ZZ, Tsakok T, Meynell F, Coker B, Vincent A, Bachelez H, Barbosa I, Brown MA, Capon F, Contreras CR, De La Cruz C, Meglio PD, Gisondi P, Jullien D, Kelly J, Lambert J, Lancelot C, Langan SM, Mason KJ, McAteer H, Moorhead L, Naldi L, Norton S, Puig L, Spuls PI, Torres T, Urmston D, Vesty A, Warren RB, Waweru H, Weinman J, Griffiths CE, Barker JN, Smith CH, Galloway JB, Mahil SK. Vaccine hesitancy and access to psoriasis care during the COVID-19 pandemic: findings from a global patient-reported cross-sectional survey. Br J Dermatol 2022; 187:254-256. [PMID: 35104366 PMCID: PMC9545500 DOI: 10.1111/bjd.21042] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/10/2022] [Accepted: 01/30/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Katie Bechman
- Centre for Rheumatic DiseasesKing’s College LondonLondonUK
| | - Emma S. Cook
- Centre for Rheumatic DiseasesKing’s College LondonLondonUK
| | - Nick Dand
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences and MedicineKing’s College LondonLondonUK
- Health Data Research UKLondonUK
| | - Zenas Z.N. Yiu
- Dermatology CentreSalford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research CentreManchesterUK
| | - Teresa Tsakok
- St John’s Institute of DermatologyGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | - Freya Meynell
- St John’s Institute of DermatologyGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | - Bolaji Coker
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | - Alexandra Vincent
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | - Herve Bachelez
- Department of DermatologyAP‐HP Hôpital Saint‐LouisParisFrance
- INSERM U1163, Imagine Institute for Human Genetic Diseases, Université de ParisParisFrance
| | - Ines Barbosa
- St John’s Institute of DermatologyGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | - Matthew A. Brown
- Centre for Rheumatic DiseasesKing’s College LondonLondonUK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | - Francesca Capon
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences and MedicineKing’s College LondonLondonUK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | - Claudia R. Contreras
- Catedra de DermatologiaHospital de Clinicas, Facultad de Ciencias Medicas, Universidad Nacional de AsuncionParaguay
| | | | - Paola Di Meglio
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & MedicineKing’s College LondonLondonUK
| | - Paolo Gisondi
- Section of Dermatology and VenereologyUniversity of VeronaVeronaItaly
| | - Denis Jullien
- Department of DermatologyEdouard Herriot Hospital, Hospices Civils de Lyon, University of LyonLyonFrance
- Groupe de recherche sur le psoriasis (GrPso) de la Société Française de dermatologieParisFrance
| | - Jade Kelly
- Dermatology CentreSalford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research CentreManchesterUK
| | - Jo Lambert
- Department of DermatologyGhent UniversityGhentBelgium
| | | | - Sinead M. Langan
- St John’s Institute of DermatologyGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
- Faculty of Epidemiology, and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Kayleigh J. Mason
- Dermatology CentreSalford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research CentreManchesterUK
- School of MedicineKeele UniversityKeeleUK
| | | | - Lucy Moorhead
- St John’s Institute of DermatologyGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | | | - Sam Norton
- Psychology DepartmentInstitute of Psychiatry, Psychology and Neuroscience, King’s College LondonUK
| | - Lluís Puig
- Department of DermatologyHospital de la Santa Creu i Sant Pau, Universitat Autònoma de BarcelonaBarcelonaCataloniaSpain
| | - Phyllis I. Spuls
- Department of DermatologyAmsterdam Public Health/Infection and Immunology, Amsterdam University Medical CentersLocation AMCAmsterdamthe Netherlands
| | - Tiago Torres
- Department of DermatologyCentro Hospitalar do PortoPortugal
| | | | | | - Richard B. Warren
- Dermatology CentreSalford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research CentreManchesterUK
| | | | - John Weinman
- School of Cancer and Pharmaceutical SciencesKing’s College LondonLondonUK
| | - Christopher E.M. Griffiths
- Dermatology CentreSalford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research CentreManchesterUK
| | - Jonathan N. Barker
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & MedicineKing’s College LondonLondonUK
| | - Catherine H. Smith
- St John’s Institute of DermatologyGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
| | | | - Satveer K. Mahil
- St John’s Institute of DermatologyGuy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College LondonLondonUK
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17
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Adas MA, Norton S, Balachandran S, Alveyn E, Russell MD, Esterine T, Amlani-Hatcher P, Oyebanjo S, Lempp H, Ledingham J, Kumar K, Galloway JB, Dubey S. Worse outcomes linked to ethnicity for early inflammatory arthritis in England and Wales: a national cohort study. Rheumatology (Oxford) 2022; 62:169-180. [PMID: 35536178 PMCID: PMC9788810 DOI: 10.1093/rheumatology/keac266] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/01/2022] [Accepted: 04/19/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To assess variability in care quality and treatment outcomes across ethnicities in early inflammatory arthritis (EIA). METHODS We conducted an observational cohort study in England and Wales from May 2018 to March 2020, including patients with a suspected/confirmed EIA diagnosis. Care quality was assessed against six metrics defined by national guidelines. Clinical outcomes were measured using DAS28. Outcomes between ethnic groups ('White', 'Black', 'Asian', 'Mixed', 'Other') were compared, and adjusted for confounders. RESULTS A total of 35 807 eligible patients were analysed. Of those, 30 643 (85.6%) were White and 5164 (14.6%) were from ethnic minorities: 1035 (2.8%) Black; 2617 (7.3%) Asian; 238 (0.6%) Mixed; 1274 (3.5%) Other. In total, 12 955 patients had confirmed EIA, of whom 11 315 were White and 1640 were from ethnic minorities: 314 (2.4%) Black; 927 (7.1%) Asian; 70 (0.5%) Mixed; 329 (2.5%) Other. A total of 14 803 patients were assessed by rheumatology within three weeks, and 5642 started treatment within six weeks of referral. There were no significant differences by ethnicity. Ethnic minority patients had lower odds of disease remission at three months [adjusted odds ratio 0.79 (95% CI: 0.65, 0.96)] relative to White patients. Ethnic minorities were significantly less likely to receive initial treatment withMTX[0.68 (0.52, 0.90)] or with glucocorticoids [0.63 (0.49, 0.80)]. CONCLUSION We demonstrate that some ethnic minorities are less likely to achieve disease remission in three months following EIA diagnosis. This is not explained by delays in referral or time to treatment. Our data highlight the need for investigation into the possible drivers of these inequitable outcomes and reappraisal of EIA management pathways.
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Affiliation(s)
| | | | | | - Edward Alveyn
- Centre for Rheumatic Disease, Department of Inflammatory Biology
| | - Mark D Russell
- Centre for Rheumatic Disease, Department of Inflammatory Biology
| | | | | | | | - Heidi Lempp
- Centre for Rheumatic Disease, Department of Inflammatory Biology
| | - Joanna Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth
| | - Kanta Kumar
- Institute of Clinical Sciences, University of Birmingham, Birmingham
| | - James B Galloway
- Correspondence to: James Galloway, Weston Education Centre, 10 Cutcombe Road, SE5 9RJ London, UK. E-mail:
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18
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Russell MD, Rutherford AI, Ellis B, Norton S, Douiri A, Gulliford MC, Cope AP, Galloway JB. Management of gout following 2016/2017 European (EULAR) and British (BSR) guidelines: An interrupted time-series analysis in the United Kingdom. Lancet Reg Health Eur 2022; 18:100416. [PMID: 35814340 PMCID: PMC9257653 DOI: 10.1016/j.lanepe.2022.100416] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Following studies reporting sub-optimal gout management, European (EULAR) and British (BSR) guidelines were updated to encourage the prescription of urate-lowering therapy (ULT) with a treat-to-target approach. We investigated whether ULT initiation and urate target attainment has improved following publication of these guidelines, and assessed predictors of these outcomes. Methods We used the Clinical Practice Research Datalink to assess attainment of the following outcomes in people (n = 129,972) with index gout diagnoses in the UK from 2004-2020: i) initiation of ULT; ii) serum urate ≤360 µmol/L and ≤300 µmol/L; iii) treat-to-target urate monitoring. Interrupted time-series analyses were used to compare trends in outcomes before and after updated EULAR and BSR management guidelines, published in 2016 and 2017, respectively. Predictors of ULT initiation and urate target attainment were modelled using logistic regression and Cox proportional hazards. Findings 37,529 (28.9%) of 129,972 people with newly-diagnosed gout had ULT initiated within 12 months. ULT initiation improved modestly over the study period, from 26.8% for those diagnosed in 2004 to 36.6% in 2019 and 34.7% in 2020. Of people diagnosed in 2020 with a serum urate performed within 12 months, 17.1% attained a urate ≤300 µmol/L, while 36.0% attained a urate ≤360 µmol/L. 18.9% received treat-to-target urate monitoring. No significant improvements in ULT initiation or urate target attainment were observed after updated BSR or EULAR management guidance, relative to before. Comorbidities, including chronic kidney disease (CKD), heart failure and obesity, and diuretic use associated with increased odds of ULT initiation but decreased odds of attaining urate targets within 12 months: CKD (adjusted OR 1.61 for ULT initiation, 95% CI 1.55 to 1.67; adjusted OR 0.51 for urate ≤300 µmol/L, 95% CI 0.48 to 0.55; both p < 0.001); heart failure (adjusted OR 1.56 for ULT initiation, 95% CI 1.48 to 1.64; adjusted OR 0.85 for urate ≤300 µmol/L, 95% CI 0.76 to 0.95; both p < 0.001); obesity (adjusted OR 1.32 for ULT initiation, 95% CI 1.29 to 1.36; adjusted OR 0.61 for urate ≤300 µmol/L, 95% CI 0.58 to 0.65; both p < 0.001); and diuretic use (adjusted OR 1.49 for ULT initiation, 95% CI 1.44 to 1.55; adjusted OR 0.61 for urate ≤300 µmol/L, 95% CI 0.57 to 0.66; both p < 0.001). Interpretation Initiation of ULT and attainment of urate targets remain poor for people diagnosed with gout in the UK, despite updated management guidelines. If the evidence-practice gap in gout management is to be bridged, strategies to implement best practice care are needed. Funding National Institute for Health Research.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, SE5 9RJ, UK
- Corresponding author at: Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London, SE5 9RJ, UK.
| | - Andrew I Rutherford
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Benjamin Ellis
- Department of Rheumatology, Imperial College Healthcare NHS Foundation Trust, London
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, SE5 9RJ, UK
| | - Abdel Douiri
- School of Population Health and Environmental Sciences, King's College London, SE1 1UL, UK
| | - Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, SE1 1UL, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, SE5 9RJ, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, SE5 9RJ, UK
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19
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Adas MA, Russell MD, Cook E, Alveyn E, Oyebanjo S, Amlani-Hatcher P, Ledingham J, Galloway JB. OA04 COVID-19 admissions and mortality in patients with early inflammatory arthritis: results from a national cohort. Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac132.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Aims
Patients with inflammatory arthritis were identified as a potentially vulnerable group during the COVID-19 pandemic, with recommendations from the UK government to shield. We set out to describe the risks of COVID-19 according to initial treatment strategy amongst patients recruited to the National Early Inflammatory Arthritis Audit (NEIAA).
Methods
NEIAA is an observational cohort design. It includes adults in England with a new diagnosis of inflammatory arthritis between May 2018 and March 2021. The outcomes of interest were death due to COVID-19 (COVID-19 stated on a death certificate) and hospitalisation due to COVID-19 (primary admission reason or nosocomial acquisition), identified using NHS Digital linkage. Cox proportional hazards models were used to calculate hazard ratios, with adjustment for patient factors (age, gender, smoking status, comorbidity) and disease factors (seropositivity, disease severity (DAS28), patient-reported disability (HAQ) and functional impact (MSK-HQ)) recorded at baseline. Individuals were considered at risk from February 2020 or date of diagnosis (whichever was later) and censored at a COVID-19 event, May 2021 or death (whichever was sooner).
Results
14,127 patients were included. Mean age was 57 (+/-16); 62% were female. Smoking status: 19% current; 29% ex-smokers. Comorbidities: 19% hypertension; 9% diabetes; and 9% lung disease. Overall, 20% had two or more comorbidities. Rheumatoid Factor or CCP antibodies were positive in 56%. At presentation, mean scores were 4.6 (+/-1.5) for DAS28, 1.1 (+/-0.7) for HAQ and 25 (+/-11) for MSK-HQ. Initial DMARD therapy was known for 13,682/14,127 patients; methotrexate was most common (54%), then hydroxychloroquine (23%) and sulfasalazine (11%). There were 143 COVID-19 hospital admissions and 47 deaths, corresponding to incidence rates per 100 person-years for hospitalisation: 0.94 (95% CI: 0.79-1.10) and death: 0.31 (95% CI: 0.23-0.41). Increasing age, male gender, diabetes, hypertension, lung disease and smoking status all predicted COVID-19 events. Higher baseline DAS28 predicted COVID-19 admission (HR 1.24 (95% CI: 1.10-1.39)) and mortality (HR 1.33 (95% CI: 1.09-1.63)). Higher HAQ predicted both COVID-19 admission and death. Seropositivity was not a significant predictor of any COVID-19 event, nor was MSK-HQ. Unadjusted, corticosteroids associated with COVID-19 death (HR 2.29 (95% CI: 1.02-5.13)), and sulfasalazine monotherapy associated with COVID-19 admission (HR 1.93 (95% CI: 1.04-3.56)). In adjusted models, associations for corticosteroids and sulfasalazine were no longer significant. Only age, smoking status, and comorbidities independently predicted COVID-19 events.
Conclusion
The burden of COVID-19 amongst early arthritis patients was substantial during the pandemic. Patient characteristics and rheumatoid disease severity at diagnosis appear to be the more important predictors of COVID-19 events than initial treatment strategy. An important limitation is that we have not looked at treatment changes over time, and must acknowledge that many patients, especially those recruited in 2019, may have changed therapy prior to the pandemic.
Disclosure
M.A. Adas: None. M.D. Russell: Grants/research support; has received speaker fees and educational grants from Janssen, Lilly, Menarini, Pfizer and UCB. E. Cook: None. E. Alveyn: None. S. Oyebanjo: None. P. Amlani-Hatcher: None. J. Ledingham: Other; is a BSR trustee. J.B. Galloway: Honoraria; has received honoraria from AbbVie, Celgene, Chugai, Gilead, Janssen, Eli Lilly, Pfizer, Roche and UCB.
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Affiliation(s)
- Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London, UNITED KINGDOM
| | - Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UNITED KINGDOM
| | - Emma Cook
- Centre for Rheumatic Diseases, King's College London, London, UNITED KINGDOM
| | - Edward Alveyn
- Centre for Rheumatic Diseases, King's College London, London, UNITED KINGDOM
| | - Sarah Oyebanjo
- British society of Rheumatology, NEIAA, London, UNITED KINGDOM
| | - Paul Amlani-Hatcher
- British Society for Rheumatology, NEIAA Patient Panel, London, UNITED KINGDOM
| | - Joanna Ledingham
- Rheumatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UNITED KINGDOM
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UNITED KINGDOM
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20
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Russell MD, Nagra D, Clarke BD, Balachandran S, Buazon A, Boalch A, Bechman K, Adas MA, Alveyn EG, Rutherford AI, Galloway JB. Hospitalizations for acute gout: process mapping the inpatient journey and identifying predictors of admission. J Rheumatol 2022; 49:725-730. [DOI: 10.3899/jrheum.211203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2022] [Indexed: 11/22/2022]
Abstract
Objective To identify predictors of admission following emergency attendances for gout flares, and describe barriers to optimal inpatient gout care. Methods Emergency department (ED) attendances and hospital admissions with primary diagnoses of gout were analyzed at two UK-based hospitals between 1st January 2017 and 31st December 2020. Demographic and clinical predictors of ED disposition (admission or discharge) and re-attendance for gout flares were identified using logistic regression and survival models, respectively. Case-note reviews (n=59), stakeholder meetings and process mapping were performed to capture detailed information on gout management and identify strategies to optimize care. Results Of 1,220 emergency attendances for gout flares, 23.5% required hospitalization (median length of stay: 3.6 days). Recurrent attendances for flares occurred in 10.4% of patients during the study period. In multivariate logistic regression models, significant predictors of admission from ED were older age, overnight ED arrival time, higher serum urate, higher CRP and higher total white cell count at presentation. Detailed case-note reviews showed that only 22.6% of patients with pre-existing gout were receiving urate-lowering therapy (ULT) at presentation. Initial diagnostic uncertainty was common, yet rheumatology input and synovial aspirates were rarely obtained. By six months post-discharge, 43.6% were receiving ULT; however, few patients had treat-to-target dose optimization, and only 9.1% achieved a urate ≤360 micromol/L. Conclusion We identified multiple predictors of hospitalization for acute gout. Prescription of ULT and treat-to-target optimization following hospitalization remain inadequate, and must be improved if admissions are to be prevented.
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21
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Hannah JR, Ali SS, Nagra D, Adas MA, Buazon AD, Galloway JB, Gordon PA. Skeletal muscles and Covid-19: a systematic review of rhabdomyolysis and myositis in SARS-CoV-2 infection. Clin Exp Rheumatol 2022; 40:329-338. [PMID: 35225218 DOI: 10.55563/clinexprheumatol/mkfmxt] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Myalgia is a widely publicised feature of Covid-19, but severe muscle injury can occur. This systematic review summarises relevant evidence for skeletal muscle involvement in Covid-19. METHODS A systematic search of OVID and Medline databases was conducted on 16/3/2021 and updated on 28/10/2021 to identify case reports or observational studies relating to skeletal muscle manifestations of Covid-19 (PROSPERO: CRD42020198637). Data from rhabdomyolysis case reports were combined and summary descriptive statistics calculated. Data relating to other manifestations were analysed for narrative review. RESULTS 1920 articles were identified. From these, 61 case reports/series met inclusion criteria, covering 86 rhabdomyolysis cases. Median age of rhabdomyolysis patients was 50 years, (range 6-89). 49% had either hypertension, diabetes mellitus or obesity. 77% were male. Symptoms included myalgia (74%), fever (69%), cough (59%), dyspnoea (68%). Median peak CK was 15,783U/L. 28% required intravenous haemofiltration and 36% underwent mechanical ventilation. 62% recovered to discharge and 30% died. Dyspnoea, elevated CRP and need for intravenous haemofiltration increased risk of fatal outcome. Additional articles relating to skeletal muscular pathologies include 6 possible concomitant diagnoses or relapses of idiopathic inflammatory myopathies and 10 reports of viral-induced muscle injuries without rhabdomyolysis. Localised myositis and rhabdomyolysis with SARS-CoV-2 vaccination have been reported. CONCLUSIONS Rhabdomyolysis is an infrequent but important complication of Covid-19. Increased mortality was associated with a high CRP, renal replacement therapy and dyspnoea. The idiopathic inflammatory myopathies (IIM) may have viral environmental triggers. However, to date the limited number of case reports do not confirm an association with Covid-19.
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Affiliation(s)
- Jennifer R Hannah
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, and Centre for Rheumatic Disease, King's College London, UK.
| | - Saadia Sasha Ali
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
| | - Deepak Nagra
- Centre for Rheumatic Disease, King's College London, UK
| | - Maryam A Adas
- Centre for Rheumatic Disease, King's College London, UK
| | | | | | - Patrick A Gordon
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, London, UK
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22
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Bechman K, Yates M, Mann K, Nagra D, Smith LJ, Rutherford AI, Patel A, Periselneris J, Walder D, Dobson RJB, Kraljevic Z, Teo JHT, Bernal W, Barker R, Galloway JB, Norton S. Inpatient COVID-19 mortality has reduced over time: Results from an observational cohort. PLoS One 2022; 17:e0261142. [PMID: 35025917 PMCID: PMC8757902 DOI: 10.1371/journal.pone.0261142] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 11/24/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The Covid-19 pandemic in the United Kingdom has seen two waves; the first starting in March 2020 and the second in late October 2020. It is not known whether outcomes for those admitted with severe Covid were different in the first and second waves. METHODS The study population comprised all patients admitted to a 1,500-bed London Hospital Trust between March 2020 and March 2021, who tested positive for Covid-19 by PCR within 3-days of admissions. Primary outcome was death within 28-days of admission. Socio-demographics (age, sex, ethnicity), hypertension, diabetes, obesity, baseline physiological observations, CRP, neutrophil, chest x-ray abnormality, remdesivir and dexamethasone were incorporated as co-variates. Proportional subhazards models compared mortality risk between wave 1 and wave 2. Cox-proportional hazard model with propensity score adjustment were used to compare mortality in patients prescribed remdesivir and dexamethasone. RESULTS There were 3,949 COVID-19 admissions, 3,195 hospital discharges and 733 deaths. There were notable differences in age, ethnicity, comorbidities, and admission disease severity between wave 1 and wave 2. Twenty-eight-day mortality was higher during wave 1 (26.1% versus 13.1%). Mortality risk adjusted for co-variates was significantly lower in wave 2 compared to wave 1 [adjSHR 0.49 (0.37, 0.65) p<0.001]. Analysis of treatment impact did not show statistically different effects of remdesivir [HR 0.84 (95%CI 0.65, 1.08), p = 0.17] or dexamethasone [HR 0.97 (95%CI 0.70, 1.35) p = 0.87]. CONCLUSION There has been substantial improvements in COVID-19 mortality in the second wave, even accounting for demographics, comorbidity, and disease severity. Neither dexamethasone nor remdesivir appeared to be key explanatory factors, although there may be unmeasured confounding present.
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Affiliation(s)
- Katie Bechman
- Centre for Rheumatic Diseases, King’s College London, London, United Kingdom
- * E-mail:
| | - Mark Yates
- Centre for Rheumatic Diseases, King’s College London, London, United Kingdom
| | - Kirsty Mann
- Centre for Rheumatic Diseases, King’s College London, London, United Kingdom
| | - Deepak Nagra
- Centre for Rheumatic Diseases, King’s College London, London, United Kingdom
| | - Laura-Jane Smith
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Amit Patel
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - David Walder
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Richard J. B. Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London, London, United Kingdom
- Health Data Research UK London, University College London, London, United Kingdom
| | - Zeljko Kraljevic
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - James H. T. Teo
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - William Bernal
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
- School of Immunology and Microbial Sciences, King’s College London, London, United Kingdom
| | - Richard Barker
- Centre for Rheumatic Diseases, King’s College London, London, United Kingdom
| | - James B. Galloway
- Centre for Rheumatic Diseases, King’s College London, London, United Kingdom
| | - Sam Norton
- Centre for Rheumatic Diseases, King’s College London, London, United Kingdom
- Psychology Department, King’s College London, London, United Kingdom
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23
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Mahil SK, Bechman K, Raharja A, Domingo-Vila C, Baudry D, Brown MA, Cope AP, Dasandi T, Graham C, Khan H, Lechmere T, Malim MH, Meynell F, Pollock E, Sychowska K, Barker JN, Norton S, Galloway JB, Doores KJ, Tree T, Smith CH. Humoral and cellular immunogenicity to a second dose of COVID-19 vaccine BNT162b2 in people receiving methotrexate or targeted immunosuppression: a longitudinal cohort study. Lancet Rheumatol 2022; 4:e42-e52. [PMID: 34778846 PMCID: PMC8577228 DOI: 10.1016/s2665-9913(21)00333-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND COVID-19 vaccines have robust immunogenicity in the general population. However, data for individuals with immune-mediated inflammatory diseases who are taking immunosuppressants remains scarce. Our previously published cohort study showed that methotrexate, but not targeted biologics, impaired functional humoral immunity to a single dose of COVID-19 vaccine BNT162b2 (Pfizer-BioNTech), whereas cellular responses were similar. Here, we aimed to assess immune responses following the second dose. METHODS In this longitudinal cohort study, we recruited individuals with psoriasis who were receiving methotrexate or targeted biological monotherapy (ie, tumour necrosis factor [TNF] inhibitors, interleukin [IL]-17 inhibitors, or IL-23 inhibitors) from a specialist psoriasis centre serving London and South-East England. The healthy control cohort were volunteers without psoriasis, not receiving immunosuppression. Immunogenicity was evaluated immediately before, on day 28 after the first BNT162b2 vaccination and on day 14 after the second dose (administered according to an extended interval regimen). Here, we report immune responses following the second dose. The primary outcomes were humoral immunity to the SARS-CoV-2 spike glycoprotein, defined as titres of total spike-specific IgG and of neutralising antibody to wild-type, alpha (B.1.1.7), and delta (B.1.617.2) SARS-CoV-2 variants, and cellular immunity defined as spike-specific T-cell responses (including numbers of cells producing interferon-γ, IL-2, IL-21). FINDINGS Between Jan 14 and April 4, 2021, 121 individuals were recruited, and data were available for 82 participants after the second vaccination. The study population included patients with psoriasis receiving methotrexate (n=14), TNF inhibitors (n=19), IL-17 inhibitors (n=14), IL-23 inhibitors (n=20), and 15 healthy controls, who had received both vaccine doses. The median age of the study population was 44 years (IQR 33-52), with 43 (52%) males and 71 (87%) participants of White ethnicity. All participants had detectable spike-specific antibodies following the second dose, and all groups (methotrexate, targeted biologics, and healthy controls) demonstrated similar neutralising antibody titres against wild-type, alpha, and delta variants. By contrast, a lower proportion of participants on methotrexate (eight [62%] of 13, 95% CI 32-86) and targeted biologics (37 [74%] of 50, 60-85; p=0·38) had detectable T-cell responses following the second vaccine dose, compared with controls (14 [100%] of 14, 77-100; p=0·022). There was no difference in the magnitude of T-cell responses between patients receiving methotrexate (median cytokine-secreting cells per 106 cells 160 [IQR 10-625]), targeted biologics (169 [25-503], p=0·56), and controls (185 [133-328], p=0·41). INTERPRETATION Functional humoral immunity (ie, neutralising antibody responses) at 14 days following a second dose of BNT162b2 was not impaired by methotrexate or targeted biologics. A proportion of patients on immunosuppression did not have detectable T-cell responses following the second dose. The longevity of vaccine-elicited antibody responses is unknown in this population. FUNDING NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London; The Psoriasis Association.
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Affiliation(s)
- Satveer K Mahil
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- St John's Institute of Dermatology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Antony Raharja
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Clara Domingo-Vila
- Department of Immunobiology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - David Baudry
- St John's Institute of Dermatology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Matthew A Brown
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Tejus Dasandi
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Carl Graham
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Hataf Khan
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Thomas Lechmere
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Michael H Malim
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Freya Meynell
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Emily Pollock
- Department of Immunobiology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kamila Sychowska
- Department of Immunobiology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jonathan N Barker
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- St John's Institute of Dermatology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sam Norton
- Psychology Department, Institute for Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie J Doores
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Timothy Tree
- Department of Immunobiology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Catherine H Smith
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- St John's Institute of Dermatology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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24
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Abstract
Introduction Janus Kinase inhibitors (JAKi) have shown to be highly effective in the treatment of immune-mediated inflammatory diseases. As with all immunomodulatory therapies, careful assessment of any treatment-associated infection risk is essential to inform clinical decision-making. Areas covered We summarize current literature on infection rates among the licensed JAKi using published phase II/III trial results, post-licensing and registry data. Expert opinion licensed JAKi show increased risk of infection across the class compared to placebo, most commonly affecting respiratory and urinary tracts, nasopharynx and skin. This risk is dose-dependent. Risks are similar at licensed JAKi doses to that seen with biologic therapies. The risk is compounded by other risk factors for infection, such as age and steroid co-prescription. Herpes zoster reactivation is more common with JAKi compared to other targeted immune modulation, making screening for varicella exposure and vaccination in appropriate cohorts an advisable strategy. Crucially, these small risk increases must be balanced against the known harms (including infection) of uncontrolled autoimmune disease. JAKi are a safe and potentially transformative treatment when used for appropriately selected patients.
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Affiliation(s)
- Maryam A Adas
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK.,Department of Physiology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Edward Alveyn
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Emma Cook
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Rheumatology, Countess of Chester Hospital Nhs Foundation Trust, Chester, UK
| | - James B Galloway
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Katie Bechman
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
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25
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Bechman K, Galloway JB. Response to letter to editor (AR-21-1598) - Nonserious infections, Respiratory virus. Arthritis Rheumatol 2021; 74:729. [PMID: 34807511 DOI: 10.1002/art.42028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Katie Bechman
- Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, Kings College London, United Kingdom
| | - James B Galloway
- Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, Kings College London, United Kingdom
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26
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Russell MD, Coath F, Yates M, Bechman K, Norton S, Galloway JB, Ledingham J, Sengupta R, Gaffney K. Corrigendum to: Diagnostic delay is common for patients with axial spondyloarthritis: results from the National Early Inflammatory Arthritis Audit. Rheumatology (Oxford) 2021; 61:881. [PMID: 34718438 PMCID: PMC8824426 DOI: 10.1093/rheumatology/keab665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London
| | - Fiona Coath
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich
| | - Mark Yates
- Centre for Rheumatic Diseases, King's College London, London
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London
| | | | - Joanna Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth
| | - Raj Sengupta
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich
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27
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Yates M, Ledingham JM, Hatcher PA, Adas M, Hewitt S, Bartlett-Pestell S, Rampes S, Norton S, Galloway JB. Disease activity and its predictors in early inflammatory arthritis: findings from a national cohort. Rheumatology (Oxford) 2021; 60:4811-4820. [PMID: 33537759 PMCID: PMC8487309 DOI: 10.1093/rheumatology/keab107] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/25/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We set out to characterize patient factors that predict disease activity during the first year of treatment for early inflammatory arthritis (EIA). METHODS We used an observational cohort study design, extracting data from a national clinical audit. All NHS organizations providing secondary rheumatology care in England and Wales were eligible to take part, with recruitment from 215/218 (99%) clinical commissioning groups (CCGs)/Health Boards. Participants were >16 years old and newly diagnosed with RA pattern EIA between May 2018 and May 2019. Demographic details collected at baseline included age, gender, ethnicity, work status and postcode, which was converted to an area level measure of socioeconomic position (SEP). Disease activity scores (DAS28) were collected at baseline, three and 12 months follow-up. RESULTS A total of 7455 participants were included in analyses. Significant levels of CCG/Health board variation could not be robustly identified from mixed effects modelling. Gender and SEP were predictors of low disease activity at baseline, three and 12 months follow-up. Mapping of margins identified a gradient for SEP, whereby those with higher degrees of deprivation had higher disease activity. Black, Asian and Minority Ethnic patients had lower odds of remission at three months follow-up. CONCLUSION Patient factors (gender, SEP, ethnicity) predict disease activity. The rheumatology community should galvanise to improve access to services for all members of society. More data are required to characterize area level variation in disease activity.
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Affiliation(s)
- Mark Yates
- Centre for Rheumatic Diseases, King's College London
| | | | | | - Maryam Adas
- Centre for Rheumatic Diseases, King's College London
| | | | | | - Sanketh Rampes
- King's College London, Faculty of Life Sciences and Medicine
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London.,Department of Rheumatology, King's College London, UK
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28
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Adas MA, Allen VB, Yates M, Bechman K, Clarke BD, Russell MD, Rutherford AI, Cope AP, Norton S, Galloway JB. A systematic review and network meta-analysis of the safety of early interventional treatments in rheumatoid arthritis. Rheumatology (Oxford) 2021; 60:4450-4462. [PMID: 34003970 PMCID: PMC8487311 DOI: 10.1093/rheumatology/keab429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/29/2021] [Accepted: 05/06/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives To evaluate the safety of treatment strategies in patients with early RA. Methods Systematic searches of MEDLINE, EMBASE and PubMed were conducted up to September 2020. Double-blind randomized controlled trials (RCTs) of licensed treatments conducted on completely naïve or MTX-naïve RA patients were included. Long-term extension studies, post-hoc and pooled analyses and RCTs with no comparator arm were excluded. Serious adverse events, serious infections and non-serious adverse events were extracted from all RCTs, and event rates in intervention and comparator arms were compared using meta-analysis and network meta-analysis (NMA). Results From an initial search of 3423 studies, 20 were included, involving 9202 patients. From the meta-analysis, the pooled incidence rates per 1000 patient-years for serious adverse events were 69.8 (95% CI: 64.9, 74.8), serious infections 18.9 (95% CI: 16.2, 21.6) and non-serious adverse events 1048.2 (95% CI: 1027.5, 1068.9). NMA showed that serious adverse event rates were higher with biologic monotherapy than with MTX monotherapy, rate ratio 1.39 (95% CI: 1.12, 1.73). Biologic monotherapy rates were higher than those for MTX and steroid therapy, rate ratio 3.22 (95% CI: 1.47, 7.07). Biologic monotherapy had a higher adverse event rate than biologic combination therapy, rate ratio 1.26 (95% CI: 1.02, 1.54). NMA showed no significant difference between strategies with respect to serious infections and non-serious adverse events rates. Conclusion The study revealed the different risk profiles for various early RA treatment strategies. Observed differences were overall small, and in contrast to the findings of established RA studies, steroid-based regimens did not emerge as more harmful.
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Affiliation(s)
- Maryam A Adas
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Victoria B Allen
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | | | - Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | | | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
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29
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Mahil SK, Bechman K, Raharja A, Domingo-Vila C, Baudry D, Brown MA, Cope AP, Dasandi T, Graham C, Lechmere T, Malim MH, Meynell F, Pollock E, Seow J, Sychowska K, Barker JN, Norton S, Galloway JB, Doores KJ, Tree TIM, Smith CH. The effect of methotrexate and targeted immunosuppression on humoral and cellular immune responses to the COVID-19 vaccine BNT162b2: a cohort study. Lancet Rheumatol 2021; 3:e627-e637. [PMID: 34258590 PMCID: PMC8266273 DOI: 10.1016/s2665-9913(21)00212-5] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients on therapeutic immunosuppressants for immune-mediated inflammatory diseases were excluded from COVID-19 vaccine trials. We therefore aimed to evaluate humoral and cellular immune responses to COVID-19 vaccine BNT162b2 (Pfizer-BioNTech) in patients taking methotrexate and commonly used targeted biological therapies, compared with healthy controls. Given the roll-out of extended interval vaccination programmes to maximise population coverage, we present findings after the first dose. METHODS In this cohort study, we recruited consecutive patients with a dermatologist-confirmed diagnosis of psoriasis who were receiving methotrexate or targeted biological monotherapy (tumour necrosis factor [TNF] inhibitors, interleukin [IL]-17 inhibitors, or IL-23 inhibitors) from a specialist psoriasis centre serving London and South East England. Consecutive volunteers without psoriasis and not receiving systemic immunosuppression who presented for vaccination at Guy's and St Thomas' NHS Foundation Trust (London, UK) were included as the healthy control cohort. All participants had to be eligible to receive the BNT162b2 vaccine. Immunogenicity was evaluated immediately before and on day 28 (±2 days) after vaccination. The primary outcomes were humoral immunity to the SARS-CoV-2 spike glycoprotein, defined as neutralising antibody responses to wild-type SARS-CoV-2, and spike-specific T-cell responses (including interferon-γ, IL-2, and IL-21) 28 days after vaccination. FINDINGS Between Jan 14 and April 4, 2021, 84 patients with psoriasis (17 on methotrexate, 27 on TNF inhibitors, 15 on IL-17 inhibitors, and 25 on IL-23 inhibitors) and 17 healthy controls were included. The study population had a median age of 43 years (IQR 31-52), with 56 (55%) males, 45 (45%) females, and 85 (84%) participants of White ethnicity. Seroconversion rates were lower in patients receiving immunosuppressants (60 [78%; 95% CI 67-87] of 77) than in controls (17 [100%; 80-100] of 17), with the lowest rate in those receiving methotrexate (seven [47%; 21-73] of 15). Neutralising activity against wild-type SARS-CoV-2 was significantly lower in patients receiving methotrexate (median 50% inhibitory dilution 129 [IQR 40-236]) than in controls (317 [213-487], p=0·0032), but was preserved in those receiving targeted biologics (269 [141-418]). Neutralising titres against the B.1.1.7 variant were similarly low in all participants. Cellular immune responses were induced in all groups, and were not attenuated in patients receiving methotrexate or targeted biologics compared with controls. INTERPRETATION Functional humoral immunity to a single dose of BNT162b2 is impaired by methotrexate but not by targeted biologics, whereas cellular responses are preserved. Seroconversion alone might not adequately reflect vaccine immunogenicity in individuals with immune-mediated inflammatory diseases receiving therapeutic immunosuppression. Real-world pharmacovigilance studies will determine how these findings reflect clinical effectiveness. FUNDING UK National Institute for Health Research.
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Affiliation(s)
- Satveer K Mahil
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Antony Raharja
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Clara Domingo-Vila
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - David Baudry
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Matthew A Brown
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Tejus Dasandi
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Carl Graham
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Thomas Lechmere
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Michael H Malim
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Freya Meynell
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Emily Pollock
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Jeffery Seow
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Kamila Sychowska
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Jonathan N Barker
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Sam Norton
- Psychology Department, Institute for Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie J Doores
- Department of Infectious Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - Timothy I M Tree
- Department of Immunobiology, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Catherine H Smith
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
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30
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Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. Programme Grants Appl Res 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
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31
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Abstract
Objectives Hospital admissions for gout flares have increased dramatically in recent years, despite widely available, effective medications for the treatment and prevention of flares. We conducted a systematic review to evaluate the effectiveness and implementation of interventions in patients hospitalized for gout flares. Methods A search was conducted in MEDLINE, Embase and the Cochrane library, from database inception to 8 April 2021, using the terms ‘gout’ and ‘hospital’ and their synonyms. Studies were included if they evaluated the effectiveness and/or implementation of interventions during hospital admissions or emergency department attendances for gout flares. Risk of bias assessments were performed for included studies. Results Nineteen articles were included. Most studies were small, retrospective analyses performed in single centres, with concerns for bias. Eleven studies (including five randomized controlled trials) reported improved patient outcomes following pharmacological interventions with known efficacy in gout, including allopurinol, prednisolone, NSAIDs and anakinra. Eight studies reported improved outcomes associated with non-pharmacological interventions: inpatient rheumatology consultation and a hospital gout management protocol. No studies to date have prospectively evaluated strategies designed to prevent re-admissions of patients hospitalized for gout flares. Conclusion There is an urgent need for high-quality, prospective studies of strategies for improving uptake of urate-lowering therapies in hospitalized patients, incorporating prophylaxis against flares and treat-to-target optimization of serum urate levels. Such studies are essential if the epidemic of hospital admissions from this treatable condition is to be countered.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Disease, King's College London, London, UK
| | | | - Edward Roddy
- School of Medicine, Keele University, Keele, UK.,Haywood Academic Rheumatology Centre, Midland Partnership NHS Foundation Trust, Stoke-on-Trent, UK
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32
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Nagra D, Russell MD, Rosmini S, Sado D, Buazon A, Shafi T, Hamlyn E, Sandhu G, Rutherford AI, Galloway JB. A Kawasaki-like illness in an adult with recent SARS-CoV-2 infection. Rheumatol Adv Pract 2021; 5:rkab035. [PMID: 34159291 PMCID: PMC8194598 DOI: 10.1093/rap/rkab035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/10/2021] [Indexed: 01/09/2023] Open
Affiliation(s)
- Deepak Nagra
- Centre for Rheumatic Disease, King's College London
| | | | | | - Daniel Sado
- King's College Hospital NHS Foundation Trust, London, UK
| | - April Buazon
- Centre for Rheumatic Disease, King's College London
| | - Taimur Shafi
- King's College Hospital NHS Foundation Trust, London, UK
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33
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Mahil SK, Yates M, Yiu ZZN, Langan SM, Tsakok T, Dand N, Mason KJ, McAteer H, Meynell F, Coker B, Vincent A, Urmston D, Vesty A, Kelly J, Lancelot C, Moorhead L, Bachelez H, Capon F, Contreras CR, De La Cruz C, Di Meglio P, Gisondi P, Jullien D, Lambert J, Naldi L, Norton S, Puig L, Spuls P, Torres T, Warren RB, Waweru H, Weinman J, Brown MA, Galloway JB, Griffiths CM, Barker JN, Smith CH. Describing the burden of the COVID-19 pandemic in people with psoriasis: findings from a global cross-sectional study. J Eur Acad Dermatol Venereol 2021; 35:e636-e640. [PMID: 34145643 PMCID: PMC8447018 DOI: 10.1111/jdv.17450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S K Mahil
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - M Yates
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,Centre for Rheumatic Diseases, King's College London, London, UK
| | - Z Z N Yiu
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - S M Langan
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,Faculty of Epidemiology, and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - T Tsakok
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - N Dand
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Health Data Research UK, London, UK
| | - K J Mason
- Centre for Rheumatic Diseases, King's College London, London, UK.,School of Medicine, Keele University, Keele, UK
| | - H McAteer
- The Psoriasis Association, Northampton, UK
| | - F Meynell
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - B Coker
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - A Vincent
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - D Urmston
- The Psoriasis Association, Northampton, UK
| | - A Vesty
- The Psoriasis Association, Northampton, UK
| | - J Kelly
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - C Lancelot
- International Federation of Psoriasis Associations (IFPA), Bromma, Sweden
| | - L Moorhead
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - H Bachelez
- Department of Dermatology, AP-HP Hôpital Saint-Louis, Paris, France.,INSERM U1163, Imagine Institute for Human Genetic Diseases, Université de Paris, Paris, France
| | - F Capon
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - C R Contreras
- Catedra de Dermatologia, Hospital de Clinicas, Facultad de Ciencias Medicas, Universidad Nacional de Asuncion, San Lorenzo, Paraguay
| | | | - P Di Meglio
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - P Gisondi
- Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - D Jullien
- Department of Dermatology, Edouard Herriot Hospital, Hospices Civils de Lyon, University of Lyon, Lyon, France.,Groupe de Recherche sur le Psoriasis (GrPso) de la Société Française de Dermatologie, Paris, France
| | - J Lambert
- Department of Dermatology, Ghent University, Ghent, Belgium
| | - L Naldi
- Centro Studi GISED, Bergamo, Italy
| | - S Norton
- Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - L Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - P Spuls
- Department of Dermatology, Amsterdam Public Health/Infection and Immunology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - T Torres
- Department of Dermatology, Centro Hospitalar do Porto, Porto, Portugal
| | - R B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - H Waweru
- International Federation of Psoriasis Associations (IFPA), Bromma, Sweden
| | - J Weinman
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - M A Brown
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,Centre for Rheumatic Diseases, King's College London, London, UK
| | - J B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK.,Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - C M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - J N Barker
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,St John's Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - C H Smith
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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McDonaugh B, Perepelova N, Kellman P, Galloway JB, Rosmini S. Recurrent acute pericarditis diagnosed by extra-cellular volume maps. Eur Heart J 2021; 43:1440-1441. [PMID: 34128054 DOI: 10.1093/eurheartj/ehab341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Benedict McDonaugh
- King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Natalia Perepelova
- King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Peter Kellman
- National Institutes of Health, National Heart, Lung and Blood Institute, 31 Center Dr, Bethesda, MD 20892, USA
| | - James B Galloway
- Centre for Rheumatic Disease, King's College London, Denmark Hill, London SE5 9RS, UK
| | - Stefania Rosmini
- King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
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35
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Bechman K, Dey M, Yates M, Bukhari M, Winthrop K, Galloway JB. The COVID-19 Vaccine Landscape: What a Rheumatologist Needs to Know. J Rheumatol 2021; 48:1201-1204. [PMID: 34074678 DOI: 10.3899/jrheum.210106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Katie Bechman
- K. Bechman, PhD, M. Yates, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, Kings College London, London, UK;
| | - Mrinalini Dey
- M. Dey, MB BChir., Institute of Life Course and Medical Sciences, University of Liverpool, and Rheumatology, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Mark Yates
- K. Bechman, PhD, M. Yates, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, Kings College London, London, UK
| | - Marwan Bukhari
- M. Bukhari, PhD, Rheumatology, Royal Lancaster Infirmary, Lancaster, UK
| | - Kevin Winthrop
- K. Winthrop, MD, MPH, Division of Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - James B Galloway
- K. Bechman, PhD, M. Yates, PhD, J.B. Galloway, PhD, Centre for Rheumatic Diseases, Kings College London, London, UK
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36
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Russell MD, Bukhari M, Shah AM, Galloway JB. Colchicine and the heart: old friends, old foes. Rheumatology (Oxford) 2021; 60:2035-2036. [PMID: 33493309 DOI: 10.1093/rheumatology/keab062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 12/23/2020] [Accepted: 01/14/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London
| | - Marwan Bukhari
- Rheumatology Department, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster
| | - Ajay M Shah
- King's College London British Heart Foundation Centre of Excellence, King's College London, London, UK
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37
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Russell MD, Coath F, Yates M, Bechman K, Norton S, Galloway JB, Ledingham J, Sengupta R, Gaffney K. Diagnostic delay is common for patients with axial spondyloarthritis: results from the National Early Inflammatory Arthritis Audit. Rheumatology (Oxford) 2021; 61:734-742. [PMID: 33982063 PMCID: PMC8824413 DOI: 10.1093/rheumatology/keab428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/10/2021] [Indexed: 01/20/2023] Open
Abstract
Objectives Updated guidelines for patients with axial SpA (axSpA) have sought to reduce diagnostic
delay by raising awareness among clinicians. We used the National Early Inflammatory
Arthritis Audit (NEIAA) to describe baseline characteristics and time to diagnosis for
newly referred patients with axSpA in England and Wales. Methods Analyses were performed on sociodemographic and clinical metrics, including time to
referral and assessment, for axSpA patients (n = 784) recruited to the
NEIAA between May 2018 and March 2020. Comparators were patients recruited to the NEIAA
with RA (n = 9270) or mechanical back pain (MBP;
n = 370) in the same period. Results Symptom duration prior to initial rheumatology assessment was longer in axSpA than RA
patients (P < 0.001) and non-significantly longer in axSpA than MBP
patients (P = 0.062): 79.7% of axSpA patients had symptom durations of
>6 months, compared with 33.7% of RA patients and 76.0% of MBP patients. Following
referral, the median time to initial rheumatology assessment was longer for axSpA than
RA patients (36 vs 24 days; P < 0.001) and similar
to MBP patients (39 days; P = 0.30). Of the subset of patients deemed
eligible for early inflammatory arthritis pathway follow-up, fewer axSpA than RA
patients had disease education provided (77.5% vs 97.8%) and RA
patients reported a better understanding of their condition and treatment. Conclusion Diagnostic delay in axSpA remains a major challenge despite improved disease
understanding and updated referral guidelines. Disease education is provided to fewer
axSpA than RA patients, highlighting the need for specialist clinics and support
programmes for axSpA patients.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Fiona Coath
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Joanna Ledingham
- Rheumatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Raj Sengupta
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Bath, UK
| | - Karl Gaffney
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
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38
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Zakeri R, Pickles A, Carr E, Bean DM, O'Gallagher K, Kraljewic Z, Searle T, Shek A, Galloway JB, Teo JTH, Shah AM, Dobson RJB, Bendayan R. Biological responses to COVID-19: Insights from physiological and blood biomarker profiles. Curr Res Transl Med 2021; 69:103276. [PMID: 33588321 PMCID: PMC7857048 DOI: 10.1016/j.retram.2021.103276] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/05/2021] [Accepted: 01/26/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Understanding the spectrum and course of biological responses to coronavirus disease 2019 (COVID-19) may have important therapeutic implications. We sought to characterise biological responses among patients hospitalised with severe COVID-19 based on serial, routinely collected, physiological and blood biomarker values. METHODS AND FINDINGS We performed a retrospective cohort study of 1335 patients hospitalised with laboratory-confirmed COVID-19 (median age 70 years, 56 % male), between 1st March and 30th April 2020. Latent profile analysis was performed on serial physiological and blood biomarkers. Patient characteristics, comorbidities and rates of death and admission to intensive care, were compared between the latent classes. A five class solution provided the best fit. Class 1 "Typical response" exhibited a moderately elevated and rising C-reactive protein (CRP), stable lymphopaenia, and the lowest rates of 14-day adverse outcomes. Class 2 "Rapid hyperinflammatory response" comprised older patients, with higher admission white cell and neutrophil counts, which declined over time, accompanied by a very high and rising CRP and platelet count, and exibited the highest mortality risk. Class 3 "Progressive inflammatory response" was similar to the typical response except for a higher and rising CRP, though similar mortality rate. Class 4 "Inflammatory response with kidney injury" had prominent lymphopaenia, moderately elevated (and rising) CRP, and severe renal failure. Class 5 "Hyperinflammatory response with kidney injury" comprised older patients, with a very high and rising CRP, and severe renal failure that attenuated over time. Physiological measures did not substantially vary between classes at baseline or early admission. CONCLUSIONS AND RELEVANCE Our identification of five distinct classes of biomarker profiles provides empirical evidence for heterogeneous biological responses to COVID-19. Early hyperinflammatory responses and kidney injury may signify unique pathophysiology that requires targeted therapy.
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Affiliation(s)
- Rosita Zakeri
- King's College London British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine & Sciences, London, SE5 9NU, UK; King's College Hospital NHS Foundation Trust, London, UK
| | - Andrew Pickles
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Ewan Carr
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Daniel M Bean
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Health Data Research UK London, University College London, London, UK
| | - Kevin O'Gallagher
- King's College London British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine & Sciences, London, SE5 9NU, UK
| | - Zeljko Kraljewic
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Tom Searle
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
| | - Anthony Shek
- Department of Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - James T H Teo
- King's College Hospital NHS Foundation Trust, London, UK; Department of Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ajay M Shah
- King's College London British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine & Sciences, London, SE5 9NU, UK; King's College Hospital NHS Foundation Trust, London, UK
| | - Richard J B Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK; Institute of Health Informatics, University College London, London, UK; NIHR Biomedical Research Centre at University College London Hospitals NHS Foundation Trust, London, UK
| | - Rebecca Bendayan
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, London, UK.
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39
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Bechman K, Halai K, Yates M, Norton S, Cope AP, Hyrich KL, Galloway JB. Nonserious Infections in Patients With Rheumatoid Arthritis: Results From the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Arthritis Rheumatol 2021; 73:1800-1809. [PMID: 33844458 DOI: 10.1002/art.41754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/25/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To describe the frequency and predictors of nonserious infections (NSI) and compare incidence across biologic agents within the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis (BSRBR-RA). METHODS The BSRBR-RA is a prospective observational cohort study. An NSI was defined as an infection that did not require hospitalization or intravenous therapy. Infections were captured from clinician questionnaires and patient diaries. Individuals were considered "at risk" from the date of initiation of biologic treatment for up to 3 years. Drug exposure was defined by agent: tumor necrosis factor inhibitor (TNFi), interleukin-6 (IL-6) inhibitor, B cell depletion (rituximab), or conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) alone. A multiple-failure Cox model was used with multivariable adjustment. Missing data were addressed using multiple imputation. RESULTS There were 17,304 NSI in 8,145 patients, with an event rate of 27.0 per person per year (95% confidence interval [95% CI] 26.6-27.4). Increasing age, female sex, comorbidity burden, glucocorticoid therapy, higher Disease Activity Score in 28 joints, and higher Health Assessment Questionnaire disability index were associated with an increased risk of NSI. There was a significant reduction in NSI risk with csDMARDs compared to biologic treatments. Compared to TNFi, IL-6 inhibition and rituximab were associated with a higher NSI risk (adjusted hazard ratio 1.45 [95% CI 1.29-1.63] and adjusted hazard ratio 1.28 [95% CI 1.14-1.45], respectively), while the csDMARD cohort had a lower risk (adjusted hazard ratio 0.64 [95% CI 0.59-0.70]). Within the TNFi class, adalimumab was associated with a higher NSI risk than etanercept (adjusted hazard ratio 1.11 [95% CI 1.05-1.17]). CONCLUSION NSI occur frequently in RA, and predictors mirror those reported with serious infections. All biologics are associated with a greater risk of NSI, with differences observed between agents. While unmeasured confounding must be considered, the magnitude of effect is large, and a relationship between NSI and targeted immunomodulatory therapy likely exists.
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Affiliation(s)
| | | | | | | | | | | | - Kimme L Hyrich
- Manchester Academic Health Sciences Centre, University of Manchester, NIHR Manchester Biomedical Research Centre, and Manchester University NHS Foundation Trust, Manchester, UK
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40
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Bechman K, Oke A, Yates M, Norton S, Dennison E, Cope AP, Galloway JB. Corrigendum to: Is background methotrexate advantageous in extending TNF inhibitor drug survival in elderly patients with rheumatoid arthritis? An analysis of the British Society for Rheumatology Biologics Register. Rheumatology (Oxford) 2021; 60:2033. [PMID: 33026092 PMCID: PMC8023986 DOI: 10.1093/rheumatology/keaa612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Katie Bechman
- Centre for Rheumatic Diseases, Kings College London, London, UK
| | - Anuoluwapo Oke
- Centre for Rheumatic Diseases, Kings College London, London, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, Kings College London, London, UK
| | - Sam Norton
- Psychology Department, Institute of Psychiatry, Kings College London, London, UK
| | - Elaine Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, Kings College London, London, UK
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41
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Yates M, Mootoo A, Adas M, Bechman K, Rampes S, Patel V, Qureshi S, Cope AP, Norton S, Galloway JB. Venous Thromboembolism Risk With JAK Inhibitors: A Meta-Analysis. Arthritis Rheumatol 2021; 73:779-788. [PMID: 33174384 DOI: 10.1002/art.41580] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/14/2020] [Accepted: 11/23/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE JAK inhibitor therapies are effective treatment options for immune-mediated inflammatory diseases (IMIDs), but their use has been limited by venous thromboembolism (VTE) risk warnings from licensing authorities. We undertook this study to evaluate the VTE risk of JAK inhibitors in patients with IMIDs. METHODS Systematic searches of Medline and Embase databases from inception to September 30, 2020 were conducted. Phase II and phase III double-blind, randomized controlled trials (RCTs) of JAK inhibitors at licensed doses were included in our analyses. RCTs with no placebo arm, long-term extension studies, post hoc analyses, and pooled analyses were excluded. Three researchers independently extracted data on exposure to JAK inhibitors or placebo and VTE events (e.g., pulmonary embolism [PE] and deep vein thrombosis [DVT]) and assessed study quality. RESULTS A total of 42 studies were included, from an initial search that yielded 619. There were 6,542 JAK inhibitor patient exposure years (PEYs) compared to 1,578 placebo PEYs. There were 15 VTE events in the JAK inhibitor group and 4 in the placebo group. The pooled incidence rate ratios (IRRs) of VTE, PE, and DVT in patients receiving JAK inhibitors were 0.68 (95% confidence interval [95% CI] 0.36-1.29), 0.44 (95% CI 0.28-0.70), and 0.59 (95% CI 0.31-1.15), respectively. CONCLUSION This meta-analysis of RCT data defines the VTE risk with JAK inhibitors as a class in IMID patients. The pooled IRRs do not provide evidence that support the current warnings of VTE risk for JAK inhibitors. These findings will aid continued development of clinical guidelines for the use of JAK inhibitors in IMIDs.
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42
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Tharmarajah E, Buazon A, Patel V, Hannah JR, Adas M, Allen VB, Bechman K, Clarke BD, Nagra D, Norton S, Russell MD, Rutherford AI, Yates M, Galloway JB. IL-6 inhibition in the treatment of COVID-19: A meta-analysis and meta-regression. J Infect 2021; 82:178-185. [PMID: 33745918 PMCID: PMC7970418 DOI: 10.1016/j.jinf.2021.03.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/13/2021] [Indexed: 12/29/2022]
Abstract
Objectives Multiple RCTs of interleukin-6 (IL-6) inhibitors in COVID-19 have been published, with conflicting conclusions. We performed a meta-analysis to assess the impact of IL-6 inhibition on mortality from COVID-19, utilising meta-regression to explore differences in study results. Methods Systematic database searches were performed to identify RCTs comparing IL-6 inhibitors (tocilizumab and sarilumab) to placebo or standard of care in adults with COVID-19. Meta-analysis was used to estimate the relative risk of mortality at 28 days between arms, expressed as a risk ratio. Within-study mortality rates were compared, and meta-regression was used to investigate treatment effect modification. Results Data from nine RCTs were included. The combined mortality rate across studies was 19% (95% CI: 18, 20%), ranging from 2% to 31%. The overall risk ratio for 28-day mortality was 0.90 (95% CI: 0.81, 0.99), in favour of benefit for IL-6 inhibition over placebo or standard of care, with low treatment effect heterogeneity: I2 0% (95% CI: 0, 53%). Meta-regression showed no evidence of treatment effect modification by patient characteristics. Trial-specific mortality rates were explained by known patient-level predictors of COVID-19 outcome (male sex, CRP, hypertension), and country-level COVID-19 incidence. Conclusions IL-6 inhibition is associated with clinically meaningful improvements in outcomes for patients admitted with COVID-19. Long-term benefits of IL-6 inhibition, its effectiveness across healthcare systems, and implications for differing standards of care are currently unknown.
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Affiliation(s)
- Emmanuel Tharmarajah
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - April Buazon
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Vishit Patel
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Jennifer R Hannah
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Maryam Adas
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Victoria B Allen
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Katie Bechman
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Benjamin D Clarke
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Deepak Nagra
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Sam Norton
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Mark D Russell
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK.
| | - Andrew I Rutherford
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
| | - James B Galloway
- Centre for Rheumatic Diseases, Weston Education Centre, King's College London, 10 Cutcombe Road, London SE5 9RJ, UK
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43
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White KM, Ivan A, Williams R, Galloway JB, Norton S, Matcham F. Remote Measurement in Rheumatoid Arthritis: Qualitative Analysis of Patient Perspectives. JMIR Form Res 2021; 5:e22473. [PMID: 33687333 PMCID: PMC7988394 DOI: 10.2196/22473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/18/2020] [Accepted: 12/20/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is characterized by recurrent fluctuations in symptoms such as joint pain, swelling, and stiffness. Remote measurement technologies (RMTs) offer the opportunity to track symptoms continuously and in real time; therefore, they may provide a more accurate picture of RA disease activity as a complement to prescheduled general practitioner appointments. Previous research has shown patient interest in remote symptom tracking in RA and has provided evidence for its clinical validity. However, there is a lack of co-design in the current development of systems, and the features of RMTs that best promote optimal engagement remain unclear. OBJECTIVE This study represents the first in a series of work that aims to develop a multiparametric RMT system for symptom tracking in RA. The objective of this study is to determine the important outcomes for disease management in patients with RA and how these can be best captured via remote measurement. METHODS A total of 9 patients (aged 23-77 years; mean 55.78, SD 17.54) with RA were recruited from King's College Hospital to participate in two semistructured focus groups. Both focus group discussions were conducted by a facilitator and a lived-experience researcher. The sessions were recorded, transcribed, independently coded, and analyzed for themes. RESULTS Thematic analysis identified a total of four overarching themes: important symptoms and outcomes in RA, management of RA symptoms, views on the current health care system, and views on the use of RMTs in RA. Mobility and pain were key symptoms to consider for symptom tracking as well as symptom triggers. There is a general consensus that the ability to track fluctuations and transmit such data to clinicians would aid in individual symptom management and the effectiveness of clinical care. Suggestions for visually capturing symptom fluctuations in an app were proposed. CONCLUSIONS The findings support previous work on the acceptability of RMT with RA disease management and address key outcomes for integration into a remote monitoring system for RA self-management and clinical care. Clear recommendations for RMT design are proposed. Future work will aim to take these recommendations into a user testing phase.
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Affiliation(s)
- Katie M White
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Alina Ivan
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Ruth Williams
- Department of Academic Rheumatology, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - James B Galloway
- The Centre for Rheumatic Diseases, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Sam Norton
- The Centre for Rheumatic Diseases, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom.,Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Faith Matcham
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
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44
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D'Cruz RF, Waller MD, Perrin F, Periselneris J, Norton S, Smith LJ, Patrick T, Walder D, Heitmann A, Lee K, Madula R, McNulty W, Macedo P, Lyall R, Warwick G, Galloway JB, Birring SS, Patel A, Patel I, Jolley CJ. Chest radiography is a poor predictor of respiratory symptoms and functional impairment in survivors of severe COVID-19 pneumonia. ERJ Open Res 2021; 7:00655-2020. [PMID: 33575312 PMCID: PMC7585700 DOI: 10.1183/23120541.00655-2020] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 10/07/2020] [Indexed: 12/31/2022] Open
Abstract
Background A standardised approach to assessing COVID-19 survivors has not been established, largely due to the paucity of data on medium- and long-term sequelae. Interval chest radiography is recommended following community-acquired pneumonia; however, its utility in monitoring recovery from COVID-19 pneumonia remains unclear. Methods This was a prospective single-centre observational cohort study. Patients hospitalised with severe COVID-19 pneumonia (admission duration ≥48 h and oxygen requirement ≥40% or critical care admission) underwent face-to-face assessment at 4-6 weeks post-discharge. The primary outcome was radiological resolution of COVID-19 pneumonitis (Radiographic Assessment of Lung Oedema score <5). Secondary outcomes included clinical outcomes, symptom questionnaires, mental health screening (Trauma Screening Questionnaire, seven-item Generalised Anxiety Disorder assessment and nine-item Patient Health Questionnaire) and physiological testing (4-m gait speed (4MGS) and 1-min Sit-to-Stand (STS) tests). Results 119 patients were assessed between June 3, 2020 and July 2, 2020 at median (interquartile range (IQR)) 61 (51-67) days post-discharge: mean±sd age 58.7±14.4 years, median (IQR) body mass index 30.0 (25.9-35.2) kg·m-2, 62% male and 70% ethnic minority. Despite radiographic resolution of pulmonary infiltrates in 87%, modified Medical Research Council Dyspnoea (breathlessness) scale grades were above pre-COVID-19 baseline in 44%, and patients reported persistent fatigue (68%), sleep disturbance (57%) and breathlessness (32%). Screening thresholds were breached for post-traumatic stress disorder (25%), anxiety (22%) and depression (18%). 4MGS was slow (<0.8 m·s-1) in 38% and 35% desaturated by ≥4% during the STS test. Of 56 thoracic computed tomography scans performed, 75% demonstrated COVID-19-related interstitial and/or airways disease. Conclusions Persistent symptoms, adverse mental health outcomes and physiological impairment are common 2 months after severe COVID-19 pneumonia. Follow-up chest radiography is a poor marker of recovery; therefore, holistic face-to-face assessment is recommended to facilitate early recognition and management of post-COVID-19 sequelae.
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Affiliation(s)
- Rebecca F D'Cruz
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Michael D Waller
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK.,Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Felicity Perrin
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Jimstan Periselneris
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Sam Norton
- Centre for Rheumatic Disease, King's College London, London, UK
| | - Laura-Jane Smith
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Tanya Patrick
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - David Walder
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Amadea Heitmann
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Kai Lee
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Rajiv Madula
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - William McNulty
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Patricia Macedo
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Rebecca Lyall
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Geoffrey Warwick
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Surinder S Birring
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK.,Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Amit Patel
- Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Irem Patel
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK.,Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Caroline J Jolley
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK.,Dept of Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
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45
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Bechman K, Oke A, Yates M, Norton S, Dennison E, Cope AP, Galloway JB. Is background methotrexate advantageous in extending TNF inhibitor drug survival in elderly patients with rheumatoid arthritis? An analysis of the British Society for Rheumatology Biologics Register. Rheumatology (Oxford) 2021; 59:2563-2571. [PMID: 31998962 PMCID: PMC7449803 DOI: 10.1093/rheumatology/kez671] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 12/09/2019] [Indexed: 12/16/2022] Open
Abstract
Objective To evaluate drug survival with monotherapy compared with combination therapy with MTX in RA older adults. Methods Patients from the British Society for Rheumatology Biologics Register, a prospective observational cohort, who were biologic naïve and commencing their first TNF inhibitors (TNFi) were included. The cohort was stratified according to age: <75 and ≥75. Cox-proportional hazards models compared the risk of TNFi discontinuation from (i) any-cause, (ii) inefficacy and (iii) adverse events, between patients prescribed TNFi-monotherapy compared with TNFi MTX combination. Results The analysis included 15 700 patients. Ninety-five percent were <75 years old. Comorbidity burden and disease activity were higher in the ≥75 cohort. Fifty-two percent of patients discontinued TNFi therapy during the follow-up period. Persistence with therapy was higher in the <75 cohort. Patients receiving TNFi monotherapy were more likely to discontinue compared with patients receiving concomitant MTX [hazard rate 1.12 (1.06–1.18) P <0.001]. This finding only held true in patients <75 [hazard rate (HR) 1.11 (1.05–1.17) vs ≥75 [HR 1.13 (0.90–1.41)]. Examining TNFi discontinuation by cause revealed patients ≥75 receiving TNFi monotherapy were less likely to discontinue TNFi due to inefficacy [HR 0.66 (0.43–0.99) P=0.04] and more likely to discontinue therapy from adverse events [HR 1.41(1.02–1.96) P =0.04]. These results were supported by the multivariate adjustment in complete case and imputed analyses. Conclusion TNFi monotherapy is associated with increased treatment failure. In older adults, the disadvantage of TNFi monotherapy on drug survival is no longer seen. Patients ≥75 have fewer discontinuations due to inefficacy than adverse events compared with younger patients. This likely reflects greater disposition to toxicity but perhaps also a decline in immunogenicity associated with immunosenescence.
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Affiliation(s)
- Katie Bechman
- Centre for Rheumatic Diseases, Kings College London, LondonUK
| | - Anuoluwapo Oke
- Centre for Rheumatic Diseases, Kings College London, LondonUK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, Kings College London, LondonUK
| | - Sam Norton
- Psychology Department, Institute of Psychiatry, Kings College London, London, UK
| | - Elaine Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, Kings College London, LondonUK
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46
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Buckland MS, Galloway JB, Fhogartaigh CN, Meredith L, Provine NM, Bloor S, Ogbe A, Zelek WM, Smielewska A, Yakovleva A, Mann T, Bergamaschi L, Turner L, Mescia F, Toonen EJM, Hackstein CP, Akther HD, Vieira VA, Ceron-Gutierrez L, Periselneris J, Kiani-Alikhan S, Grigoriadou S, Vaghela D, Lear SE, Török ME, Hamilton WL, Stockton J, Quick J, Nelson P, Hunter M, Coulter TI, Devlin L, Bradley JR, Smith KGC, Ouwehand WH, Estcourt L, Harvala H, Roberts DJ, Wilkinson IB, Screaton N, Loman N, Doffinger R, Lyons PA, Morgan BP, Goodfellow IG, Klenerman P, Lehner PJ, Matheson NJ, Thaventhiran JED. Treatment of COVID-19 with remdesivir in the absence of humoral immunity: a case report. Nat Commun 2020; 11:6385. [PMID: 33318491 PMCID: PMC7736571 DOI: 10.1038/s41467-020-19761-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/27/2020] [Indexed: 12/18/2022] Open
Abstract
The response to the coronavirus disease 2019 (COVID-19) pandemic has been hampered by lack of an effective severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antiviral therapy. Here we report the use of remdesivir in a patient with COVID-19 and the prototypic genetic antibody deficiency X-linked agammaglobulinaemia (XLA). Despite evidence of complement activation and a robust T cell response, the patient developed persistent SARS-CoV-2 pneumonitis, without progressing to multi-organ involvement. This unusual clinical course is consistent with a contribution of antibodies to both viral clearance and progression to severe disease. In the absence of these confounders, we take an experimental medicine approach to examine the in vivo utility of remdesivir. Over two independent courses of treatment, we observe a temporally correlated clinical and virological response, leading to clinical resolution and viral clearance, with no evidence of acquired drug resistance. We therefore provide evidence for the antiviral efficacy of remdesivir in vivo, and its potential benefit in selected patients.
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Affiliation(s)
- Matthew S Buckland
- Department of Clinical Immunology, Barts Health, London, UK.
- UCL GOSH Institute of Child Health Division of Infection and Immunity, Section of Cellular and Molecular Immunology, London, UK.
| | - James B Galloway
- Centre for Rheumatic Diseases, King's College London, London, UK
| | | | - Luke Meredith
- Department of Pathology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nicholas M Provine
- Peter Medawar Building for Pathogen Research, South Parks Rd, Oxford, OX1 3SY, UK
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Stuart Bloor
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - Ane Ogbe
- Peter Medawar Building for Pathogen Research, South Parks Rd, Oxford, OX1 3SY, UK
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Wioleta M Zelek
- Systems Immunity Institute and Dementia Research Institute, Cardiff University, Cardiff, UK
| | - Anna Smielewska
- Division of Virology, Department of Pathology, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
- PHE - Public Health England Laboratory, Cambridge. Box 236, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK
| | - Anna Yakovleva
- Department of Pathology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Tiffeney Mann
- Medical Research Council Toxicology Unit, University of Cambridge, Gleeson Building, Tennis Court Road, Cambridge, CB2 1QW, UK
| | - Laura Bergamaschi
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - Lorinda Turner
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - Frederica Mescia
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - Erik J M Toonen
- R&D Department, Hycult Biotechnology, Frontstraat 2A, 5405 PB, Uden, The Netherlands
| | - Carl-Philipp Hackstein
- Peter Medawar Building for Pathogen Research, South Parks Rd, Oxford, OX1 3SY, UK
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Hossain Delowar Akther
- Peter Medawar Building for Pathogen Research, South Parks Rd, Oxford, OX1 3SY, UK
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Vinicius Adriano Vieira
- Peter Medawar Building for Pathogen Research, South Parks Rd, Oxford, OX1 3SY, UK
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Jimstan Periselneris
- Respiratory Department, King's College Hospital NHS Foundation Trust, UK. Department of Clinical Virology, Addenbrookes, UK
| | | | | | - Devan Vaghela
- Department of Infectious Diseases, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Sara E Lear
- Department of Immunology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - M Estée Török
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Department of Microbiology, Cambridge, UK
| | - William L Hamilton
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joanne Stockton
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Josh Quick
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Peter Nelson
- Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Michael Hunter
- Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Tanya I Coulter
- Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
- Regional Immunology Service, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Lisa Devlin
- Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
- Regional Immunology Service, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - John R Bradley
- NIHR BioResource and NIHR Cambridge Biomedical Research Centre, Cambridge Biomedical Campus, Cambridge, UK
| | - Kenneth G C Smith
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - Willem H Ouwehand
- Department of Haematology, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
- NHS Blood and Transplant, Cambridge Biomedical Campus, Cambridge, UK
| | | | | | - David J Roberts
- NHS Blood and Transplant, Oxford, UK
- Radcliffe Department of Medicine and BRC Haematology Theme, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Ian B Wilkinson
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Nicholas Loman
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - Rainer Doffinger
- Respiratory Department, King's College Hospital NHS Foundation Trust, UK. Department of Clinical Virology, Addenbrookes, UK
| | - Paul A Lyons
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - B Paul Morgan
- Systems Immunity Institute and Dementia Research Institute, Cardiff University, Cardiff, UK
| | - Ian G Goodfellow
- Department of Pathology, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Paul Klenerman
- Peter Medawar Building for Pathogen Research, South Parks Rd, Oxford, OX1 3SY, UK
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Paul J Lehner
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
- Department of Infectious Diseases, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Nicholas J Matheson
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK.
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK.
- Department of Infectious Diseases, Cambridge University Hospitals NHS Trust, Cambridge, UK.
- NHS Blood and Transplant, Cambridge Biomedical Campus, Cambridge, UK.
| | - James E D Thaventhiran
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, Cambridge Biomedical Campus, Cambridge, UK.
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK.
- Medical Research Council Toxicology Unit, University of Cambridge, Gleeson Building, Tennis Court Road, Cambridge, CB2 1QW, UK.
- Cancer Research UK Cambridge Institute, Cambridge Biomedical Campus, Cambridge, UK.
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47
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Bechman K, Dalrymple A, Southey-Bassols C, Cope AP, Galloway JB. A systematic review of CXCL13 as a biomarker of disease and treatment response in rheumatoid arthritis. BMC Rheumatol 2020; 4:70. [PMID: 33292827 PMCID: PMC7604968 DOI: 10.1186/s41927-020-00154-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 08/06/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The B cell chemoattractant CXCL13 is a promising biomarker in rheumatoid arthritis (RA), with a plausible role in supporting diagnosis, monitoring disease activity and as a prognostic value. It is a key chemokine driving the formation of lymphoid follicles within the inflamed synovium. The objective of this systematic review was to evaluate the role of CXCL13 as a viable biomarker in RA. METHODS We conducted a systematic literature review of all published cohort and randomised controlled trials evaluating the role of CXCL13 in RA. The primary outcomes were; i) CXCL13 levels in RA patients compared to healthy controls, ii) the correlation between CXCL13 and markers of disease activity, and iii) the association between CXCL13 and treatment response. RESULTS The search produced 278 articles, of which 31 met the inclusion criteria. Of the 12 studies evaluating CXCL13 expression in early or established RA, all reported higher levels than that seen in healthy controls. Twelve of sixteen studies reported a weakly positive correlation between CXCL13 and markers of disease activity including DAS28 and swollen joint count, with rho values between 0.20-0.67. In 2 studies, CXCL13 levels correlated with ultrasonographic evidence of synovitis. Eighteen studies assessed CXCL13 in response to therapeutic intervention. The majority signified a fall in levels in response to treatment including biologics and Janus kinase (JAK) inhibition. In some, this reduction was only seen in treatment responders. High CXCL13 levels predicted failure to achieve disease remission with csDMARDs. The evidence for treatment prediction with biologics was conflicting. CONCLUSION Despite evidence to suggest a role in diagnosing RA and in detecting synovitis, the heterogeneity of studies included in this review limit our ability to draw robust conclusions. At present there are inadequate results to justify the routine use of CXCL13 as a biomarker in RA routine clinical practice.
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Affiliation(s)
- Katie Bechman
- Centre of Rheumatic Diseases, Weston Education Centre, King's College London, Room 3.46, Third Floor, London, SE5 9RJ, UK.
| | - Anthony Dalrymple
- Centre of Rheumatic Diseases, Weston Education Centre, King's College London, Room 3.46, Third Floor, London, SE5 9RJ, UK
| | - Charles Southey-Bassols
- Centre of Rheumatic Diseases, Weston Education Centre, King's College London, Room 3.46, Third Floor, London, SE5 9RJ, UK
| | - Andrew P Cope
- Centre of Rheumatic Diseases, Weston Education Centre, King's College London, Room 3.46, Third Floor, London, SE5 9RJ, UK
| | - James B Galloway
- Centre of Rheumatic Diseases, Weston Education Centre, King's College London, Room 3.46, Third Floor, London, SE5 9RJ, UK
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48
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Ledingham JM, Yates M, Galloway JB. NEIAA: driving EIA service quality in a shifting clinical landscape. Rheumatology (Oxford) 2020; 59:3127-3128. [PMID: 32879979 DOI: 10.1093/rheumatology/keaa423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Mark Yates
- The Centre for Rheumatic Diseases, School of Immunology, Infection & Inflammatory Disease, King's College London, London, UK
| | - James B Galloway
- The Centre for Rheumatic Diseases, School of Immunology, Infection & Inflammatory Disease, King's College London, London, UK
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49
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Cunniffe NG, Gunter SJ, Brown M, Burge SW, Coyle C, De Soyza A, Dymond T, Esmail H, Francis DP, Galloway J, Galloway JB, Gkrania-Klotsas E, Greenaway J, Katritsis G, Kanagaratnam P, Knolle MD, Leonard K, McIntyre ZC, Prudon B, Rampling T, Torok ME, Warne B, Yates M, Matheson NJ, Su L, Villar S, Stewart GD, Toshner M. How achievable are COVID-19 clinical trial recruitment targets? A UK observational cohort study and trials registry analysis. BMJ Open 2020; 10:e044566. [PMID: 33020111 PMCID: PMC7536634 DOI: 10.1136/bmjopen-2020-044566] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To analyse enrolment to interventional trials during the first wave of the COVID-19 pandemic in England and describe the barriers to successful recruitment in the circumstance of a further wave or future pandemics. DESIGN We analysed registered interventional COVID-19 trial data and concurrently did a prospective observational study of hospitalised patients with COVID-19 who were being assessed for eligibility to one of the RECOVERY, C19-ACS or SIMPLE trials. SETTING Interventional COVID-19 trial data were analysed from the clinicaltrials.gov and International Standard Randomized Controlled Trial Number databases on 12 July 2020. The patient cohort was taken from five centres in a respiratory National Institute for Health Research network. Population and modelling data were taken from published reports from the UK government and Medical Research Council Biostatistics Unit. PARTICIPANTS 2082 consecutive admitted patients with laboratory-confirmed SARS-CoV-2 infection from 27 March 2020 were included. MAIN OUTCOME MEASURES Proportions enrolled, and reasons for exclusion from the aforementioned trials. Comparisons of trial recruitment targets with estimated feasible recruitment numbers. RESULTS Analysis of trial registration data for COVID-19 treatment studies enrolling in England showed that by 12 July 2020, 29 142 participants were needed. In the observational study, 430 (20.7%) proceeded to randomisation. 82 (3.9%) declined participation, 699 (33.6%) were excluded on clinical grounds, 363 (17.4%) were medically fit for discharge and 153 (7.3%) were receiving palliative care. With 111 037 people hospitalised with COVID-19 in England by 12 July 2020, we determine that 22 985 people were potentially suitable for trial enrolment. We estimate a UK hospitalisation rate of 2.38%, and that another 1.25 million infections would be required to meet recruitment targets of ongoing trials. CONCLUSIONS Feasible recruitment rates, study design and proliferation of trials can limit the number, and size, that will successfully complete recruitment. We consider that fewer, more appropriately designed trials, prioritising cooperation between centres would maximise productivity in a further wave.
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Affiliation(s)
- Nick G Cunniffe
- Department of Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - Simon J Gunter
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Michael Brown
- Division of Infection, University College London Hospital NHS Trust, London, UK
| | - Sarah W Burge
- Cancer Research UK Urological Malignancies Programme, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Clare Coyle
- Department of Cardiology, Hammersmith Hospitals NHS Trust, London, UK
| | | | - Tom Dymond
- Department of Infection and Inflammation Research, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Hanif Esmail
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
- MRC Clinical Trials Unit, University College London, London, UK
- Institute for Global Health, University College London, London, United Kingdom
| | - Darrel P Francis
- Faculty of Medicine, National Heart & Lung Institute, Imperial College London, London, UK
| | - Jacqui Galloway
- Department of Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | - Jane Greenaway
- Research and Development, North Tees Hospital, Stockton-on-Tees, UK
| | - George Katritsis
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Prapa Kanagaratnam
- Department of Cardiology, St Marys Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Martin D Knolle
- Department of Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kelly Leonard
- Cambridge Urology Translational Research and Clinical Trials Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Zoe C McIntyre
- School of Clinical Medicine, Office for Translational Research, University of Cambridge, Cambridge, UK
| | - Ben Prudon
- Department of Respiratory Medicine, North Tees Hospital, Stockton-on-Tees, UK
| | - Tommy Rampling
- Division of Pathology, University College London Hospital NHS Trust, London, United Kingdom
| | | | - Ben Warne
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Mark Yates
- Centre for Rheumatic Diseases, Kings College London, London, UK
| | - Nicholas J Matheson
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
- NHS Blood and Transplant, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Li Su
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - Sofia Villar
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Cambridge, United Kingdom
| | - Grant D Stewart
- Cancer Research UK Urological Malignancies Programme, Department of Oncology, University of Cambridge, Cambridge, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Mark Toshner
- Department of Medicine, University of Cambridge, Cambridge, UK
- NIHR Respiratory Translational Research Collaboration, Cambridge, UK
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50
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Scott D, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. The clinical effectiveness of intensive management in moderate established rheumatoid arthritis: The titrate trial. Semin Arthritis Rheum 2020; 50:1182-1190. [PMID: 32931984 PMCID: PMC7390769 DOI: 10.1016/j.semarthrit.2020.07.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Many trials have shown that intensive management is effective in patients with early active rheumatoid arthritis (RA). But its benefits are unproven for the large number of RA patients seen in routine care who have established, moderately active RA and are already taking conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs). The TITRATE trial studied whether these patients also benefit from intensive management and, in particular, achieve more remissions. METHODS A 12-month multicentre individually randomised trial compared standard care with monthly intensive management appointments which was delivered by specially trained healthcare professionals and incorporated monthly clinical assessments, medication titration and psychosocial support. The primary outcome was 12-month remission assessed using the Disease Activity Score for 28 joints using ESR (DAS28-ESR). Secondary outcomes included fatigue, disability, harms and healthcare costs. Intention-to-treat multivariable logistic- and linear regression analyses compared treatment arms with multiple imputation used for missing data. RESULTS 459 patients were screened and 335 were randomised (168 intensive management; 167 standard care); 303 (90%) patients provided 12-month outcomes. Intensive management increased DAS28-ESR 12-month remissions compared to standard care (32% vs 18%, p = 0.004). Intensive management also significantly increased remissions using a range of alternative remission criteria and increased patients with DAS28-ESR low disease activity scores. (48% vs 32%, p = 0.005). In addition it substantially reduced fatigue (mean difference -18; 95% CI: -24, -11, p<0.001). There was no evidence that serious adverse events (intensive management =15 vs standard care =11) or other adverse events (114 vs 151) significantly increase with intensive management. INTERPRETATION The trial shows that intensive management incorporating psychosocial support delivered by specially trained healthcare professions is effective in moderately active established RA. More patients achieve remissions, there were greater improvements in fatigue, and there were no more harms.
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Affiliation(s)
- David Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom.
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR, United Kingdom
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Ailsa Bosworth
- National Rheumatoid Arthritis Society (NRAS), Switchback Office Park, Gardner Rd, Maidenhead, SL6 7RJ, United Kingdom
| | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Jackie Sturt
- Department Of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, United Kingdom
| | - Frances M K Williams
- Twin Research & Genetic Epidemiology, School of Life Course Sciences, King's College London, St Thomas' Hospital, London SE1 7EH, United Kingdom
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London Cutcombe Road, London, SE5 9RJ, United Kingdom
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