Real-world comparative effectiveness and safety of tofacitinib and baricitinib in patients with rheumatoid arthritis

OBJECTIVE

To compare the efficacy and safety of tofacitinib and baricitinib in patients with RA in a real-world setting.

METHODS

A total of 242 patients with RA who were treated with tofacitinib (n = 161) or baricitinib (n = 81) were enrolled. We evaluated efficacy and safety between tofacitinib and baricitinib using multivariable analyses to avoid confounding. Their clinical disease activity and AEs were evaluated for 24 weeks.

RESULTS

The mean (SD) DAS28-ESR change from baseline to 24 weeks was 1.57 (1.55) (tofacitinib) and 1.46 (1.36) (baricitinib). There was no significant difference in the clinical response between the two groups (adjusted mean difference, 0.04; 95% CI, -0.35 to 0.28). The efficacy was not significantly changed in the patients without concomitant MTX use in both groups, but the concomitant MTX use showed better clinical efficacy in the cases of baricitinib treatment. In both groups, the most common AE was herpes zoster infection, and the AE rates were similar between the two groups. However, the predictive factors contributing to clinical response as revealed by a multivariable logistic analysis differed. The concomitant oral steroid use was independently associated with the achievement of DAS-low disease activity in the tofacitinib group, whereas in the baricitinib group, the number of biological and/or targeted synthetic DMARDs previously used was associated.

CONCLUSIONS

Our findings indicate that tofacitinib and baricitinib had comparable continuing efficacies and safety profiles. However, there is a possibility that the influence of clinical characteristics on the treatment response differs. The comparison provides useful information to the optimal use of JAK inhibitors in real-world settings.

Comparison of the quantitative measurement of 18F-FDG PET/CT and histopathological findings in IgG4-related disease

OBJECTIVES

To investigate the utility of 18F-FDG PET/CT in the diagnostic procedure of IgG4-related disease (IgG4-RD), we analysed the association between quantitative method of 18F-FDG PET/CT and histological findings.

METHODS

Twenty-one patients with IgG4-RD in whom 18F-FDG PET/CT was performed at the time of diagnosis were enrolled. Tissue biopsy was performed at 24 sites in 21 patients. To perform quantitative analysis of 18F-FDG PET/CT imaging, the highest standardised uptake value (SUV) of the pixels (SUVmax) and the average SUV (SUVmean) within the biopsied lesion were measured. The SUVmean of the liver was also measured as a reference.

RESULTS

The mean age at diagnosis was 64.6±11.9 years, and the median serum IgG4 level was 650 mg/dl. Histological findings were consistent with IgG4-RD (histopathology-positive) at 19 out of 24 sites. Although there was no significant difference in the values of SUVmax between histopathology-positive and histopathology-negative tissues, the values of SUVmean were significantly higher in the histopathology-positive tissue (4.98 and 3.54, respectively p<0.05). The values of SUVmean/liver were also higher in the histopathology-positive tissue (2.17 and 1.52, respectively p<0.05). To establish a cut-off value of SUVmean to determine which of multiple lesions should be biopsied, a ROC curve was constructed. ROC curve analysis indicated SUVmean=4.07 or SUVmean/liver=1.66 as a cut-off value.

CONCLUSIONS

Our present study suggested that quantitative analysis of 18F-FDG-PET/CT imaging might be useful for selecting the biopsy site in IgG4-RD. The calculation of SUVmean, not of SUVmax, is important for evaluating IgG4-RD-related lesions in 18F-FDG PET/CT imaging.

Ultrasound efficacy of targeted-synthetic disease-modifying anti-rheumatic drug treatment in rheumatoid arthritis: a multicenter prospective cohort study in Japan

OBJECTIVE

This study investigated the effectiveness of treatment with Janus kinase (JAK) inhibitors in rheumatoid arthritis (RA) assessed by ultrasonography (US) activity, and the influence of patient characteristics and previous treatments.

METHOD

This prospective study assessed 60 treatment initiations among 53 Japanese patients diagnosed with RA who underwent treatment with JAK inhibitors during June 2013 to February 2020. Of the 53 patients, seven patients were enrolled in duplicate because they were treated with two different JAK inhibitors at different periods. For each case, the improvement rate on the power Doppler (PD) score was assessed at 6 month follow-up. Median improvement rate of PD score was used to classify cases as either US responders or non-responders, and patient characteristics were compared between the two groups.

RESULTS

All indicators of clinical disease activity and US activity showed a significant improvement at 3 months compared with baseline. Although the JAK inhibitor-cycler group and the interleukin-6 (IL-6) inhibitor inadequate response (IR) group tended to show a later improvement for US activity, all indicators of clinical disease activity and US activity showed a significant improvement at 6 months compared with baseline for both groups. Multivariate analysis showed that concomitant methotrexate use and an IR to the previous biologic or targeted-synthetic disease-modifying anti-rheumatic drug (b/tsDMARD) treatment were independently and significantly associated with US responders.

CONCLUSION

Use of a JAK inhibitor in combination with methotrexate and an absence of IR to any previous b/tsDMARDs demonstrated superior effectiveness for patients with RA.

Phytogrowth-inhibitory and antibacterial activities of 2,5-dihydroxy-1,4-dithiane and its derivatives

2,5-Dihydroxy-1,4-dithiane (I) and its derivatives (II-IV) showed rather marked inhibitory activities on the growth of the roots of two plant species. All compounds tested had phytogrowth-inhibitory activities. These compounds markedly inhibited the growth of the two plant species at the concentration of 1.0 x 10(-3) M. Seeds of Brassica rapa treated with 2,5-dihydroxy-2,5-dimethyl-1,4-dithiane (III) and its diacetate (IV) at the same concentration failed to germinate. Among these compounds, IV showed the most potent inhibitory activity on the two plant species. The radicles of both plant species treated with these compounds at concentrations higher than 1.0 x 10(-4) M showed negative geotropism, even though germination occurred. The compounds except for 2,5-diacetoxy-1,4-dithiane (II) also had antibacterial activities. In particular, III had rather marked antibacterial activity and its minimal inhibitory concentration (MIC) for Staphylococcus aureus IFO-3060 and Escherichia coli IFO-12734 was 4.0 micrograms/ml.

Clinical manifestations in anti-Ro52/SS-A antibody-seropositive patients with Sjögren's syndrome

Background: The relationship between anti-Ro52/SS-A antibody (anti-Ro52) and the clinical manifestations of Sjögren's syndrome (SS) has not been fully clarified. We determined the clinical factors relevant to SS patients with anti-Ro52.Methods: We conducted a retrospective study of 149 subjects suspicious for SS and 50 healthy control subjects. We analyzed items of the American-European Consensus Group (AECG) criteria and the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI).Results: SS was documented in 115 subjects. Anti-Ro52 was observed in 70 SS patients. Anti-Ro52 positivity showed a significantly higher association with anti-Ro60 positivity than with anti-centromere antibody (ACA) positivity (p < 0.05). Regarding the difference in the anti-Ro52 concentration, we observed six significantly relevant components: two AECG components and four non-AECG components. The anti-Ro52 concentration well-discriminated three clinical factors (ROC AUC >0.75), i.e., ACA seropositivity, ESSDAI score ≥1, and RF, and it moderately discriminated high serum IgG, focus score ≥1, and anti-La/SS-B antibody seropositivity (ROC AUC >0.7). A linear relationship between the ESSDAI score and the anti-Ro52 concentration was observed.Conclusion: A significant association between clinical factors (including the ESSDAI) and the anti-Ro52 concentration were revealed. Anti-Ro52 was more highly associated with anti-Ro60 positivity than with ACA positivity.

Reexamination of the conditions for processing and storing of blood for plasma renin assay

Reexamination of conditions for processing and storing blood for plasma renin assay confirmed that plasma can be stored at -20 degrees C for at least 4 weeks without significant changes in active renin level. The active renin concentration is increased by storage at 4 degrees C because of conversion from inactive renin.

[A case of inflammatory pseudotumor of the lung that extended to involve the mediastinum]

A 17-year-old woman was referred to our hospital because of cough and fever. The chest X-ray films revealed an anterior mediastinal mass shadow. Steroid drugs and antibiotics were administered and the shadow diminished slightly. To confirm diagnosis, open thoracotomy was performed. The tumor was extended to the mediastinum, thymus and heart as well as the right middle lobe and right lower lobe. Microscopic findings of the resected tumor showed proliferation of histiocytes with infiltration by inflammatory cells, lymphocytes and fibrous tissue.

The hypotensive effect and antifungal activity of 3,3'-dihydroxy-alpha,beta-diethyldiphenylethane

3,3'-Dihydroxy-alpha,beta-diethyldiphenylethane (I), an isomer of hexestrol (II), was found to have a strong hypotensive effect on rats and antifungal activity against some pathogenic fungi. The hypotensive effect of I (-100.0 +/- 21.0 mmHg, 10 mg/kg, i.v.) was stronger than that of II (-40.0 +/- 2.60 mmHg, i.v.). Unlike II and other oxystilbene-related compounds already tested, I showed prolonged hypotensive action at the dose of 10 mg/kg, and the blood pressure was not restored to the original level within 20 min. I also showed antifungal activity against all fungi tested (minimal inhibitory concentration: 10-120 micrograms/ml). It should be emphasized that by shifting the phenolic hydroxyl group to m-position, the biological activities were greatly increased.

Current Views on Pathophysiology and Potential Therapeutic Targets in Sjögren's Syndrome: A Review from the Perspective of Viral Infections, Toll-like Receptors, and Long-Noncoding RNAs

Sjögren's syndrome (SS) is a rheumatic disease characterized by sicca and extraglandular symptoms, such as interstitial lung disease and renal tubular acidosis. SS potentially affects the prognosis of patients, especially in cases of complicated extraglandular symptoms; however, only symptomatic therapies against xerophthalmia and xerostomia are currently included in the practice guidelines as recommended therapies for SS. Considering that SS is presumed to be a multifactorial entity caused by genetic and environmental factors, a multidisciplinary approach is necessary to clarify the whole picture of its pathogenesis and to develop disease-specific therapies for SS. This review discusses past achievements and future prospects for pursuing the pathophysiology and therapeutic targets for SS, especially from the perspectives of viral infections, toll-like receptors (TLRs), long-noncoding RNAs (lncRNAs), and related signals. Based on the emerging roles of viral infections, TLRs, long-noncoding RNAs and related signals, antiviral therapy, hydroxychloroquine, and vitamin D may lower the risk of or mitigate SS. Janus-kinase (JAK) inhibitors are also potential novel therapeutic options for several rheumatic diseases involving the JAK-signal transducer and activator of transcription pathways, which are yet to be ascertained in a randomized controlled study targeting SS.

[A study involving early carcinomas of the gall bladder]

In recent years, with the development of diagnostic procedures, the number of cases of early carcinoma of the gall bladder has been seen to gradually increase. In this paper, 8 cases of early gall bladder carcinoma have been evaluated, using a diagnostic approach. Cholecystolithiasis was the complication in 6 cases, and abdominal pain was seen as the most common symptom. Findings by various image diagnoses, such as ultrasonography, DIC, ERCP, and CT scan are described and discussed with a review of literature. Ultrasonography was considered to be the most useful tool for the detection and diagnosis of an early carcinoma of the gall bladder. A survey is thought to be required, involving the cases that have accumulated throughout the entire nation.

Nasal airway resistance in children

Using anterior rhinomanometry, nasal resistance was measured in 397 Japanese children and students, aged 5 to 17 years. Thereafter the relationship between nasal resistance and age, sex, height and weight was studied. The results are as follows: 1. The nasal resistance of children and students significantly decreases with aging and it reaches almost the same as that of an adult at about 16 years of age. This decrease was confirmed statistically. However, the difference of sex was not significant in any age group. 2. There is no significant correlation among total nasal resistance, height and weight. So, it would be concluded that the growth of the frame-work of the nasal cavity does not follow the same course as that of the height or the weight. 3. Between ages 13 and 14, it seems that the nasal resistance increases slightly. The change in nasal resistance during this period may be attributed to unbalance of the growth between the nasal turbinates and the frame-work of the nasal cavity.

Clinical and ultrasound features of difficult-to-treat rheumatoid arthritis: A multicenter RA ultrasound cohort study

OBJECTIVE

The optimal strategy for difficult-to-treat (D2T) rheumatoid arthritis (RA) has not been identified, and the ultrasound characteristics of D2T RA have not been reported. We investigated the clinical characteristics and factors contributing to the outcome in D2T RA in a multicentre RA ultrasound observational cohort.

METHOD

We reviewed 307 Japanese patients diagnosed with RA who underwent treatment with biological and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs). We compared the differences in patient characteristics between the D2T RA and non-D2T RA groups. We examined the factors contributing to a good response [defined as b/tsDMARD continuation and Clinical Disease Activity Index (CDAI) ≤ 10 at 12 months] in the D2T RA patient group.

RESULTS

Forty-three patients (14%) were categorized as D2T RA and the remaining 264 (86%) as non-D2T RA at baseline. The grey-scale (GS) score, disease duration, and CDAI at the initiation of treatment were significantly higher in the D2T RA group than in the non-D2T RA group. In contrast, the power Doppler (PD) score was not significantly different between the two groups. Of the 43 D2T RA patients, 20 achieved a good response. The introduction of CTLA4-Ig (n = 5) was significantly associated with a good response in analysis based on inverse probability weighting with propensity score. GS and PD scores at baseline were not significantly associated with therapeutic response at 12 months in D2T RA patients.

CONCLUSIONS

Patients with D2T RA had high clinical and ultrasound activity and poor responses to treatment with b/tsDMARDs. CTLA4-Ig was associated with a good response at 12 months in D2T RA patients.

[A case of HBs antigen negative hepatocellular carcinoma without liver cirrhosis in a young woman]

A 27-year-old woman, post parturition, was admitted to hospital because of epigastric pain. Ultrasonography and abdominal computerized tomography revealed a giant mass in the left lobe of the liver. Celiac angiography showed a hypervascular mass with irregular vascularity. Serum HBs antigen proved negative. A left hepatic lobectomy was performed in March, 1985. Histology of the tumor revealed the trabecular type of a hepatocellular carcinoma with Edmondson grade 2 atypism, whereas the non-cancerous region of the liver showed chronic inactive hepatitis. This case is presented, because of the rarity of a hepatocellular carcinoma developing in such a young patient. In addition, reported cases of a hepatocellular carcinoma in the young in Japan are reviewed.

[Prevalence rate of allergy to Japanese cedar pollen in Tokyo--from field investigation in 1996 by Tokyo Japanese Cedar Pollen Allergy Measurements and Review Committee]

Prevalence rate of allergy to Japanese cedar pollen was investigated by means of questionnaires and immunological examinations in residents of 3 regions in Tokyo (Akiruno city, Chofu city, and Ota ward). The results were as follows: 1) the prevalence rate of allergy to Japanese cedar pollen in Tokyo was 25.7% in Akiruno city, 21.1% in Chofu city, and 17.7% in Ota ward in 1996; 2) stratification by the age reveal that the prevalence rate was the highest in the age group of 30 to 44, and the group showed prevalence rate of above 40% in Akiruno city; 3) overall prevalence rate of Tokyo was 19.4% in 1996, which was approximately twice as much as that in 1985; 4) increase in prevalence rate in the recent decade was most significant in Akiruno city where the largest number of Japanese cedar pollen was detected in the air, and prevalence rate tended to rise in the young group of 14 or less.

[Prognostic implications of the ploidy pattern of the nuclear DNA in hepatocellular carcinomas]

The nuclear DNA contents of paraffin-embedded specimens of 41 cases of a hepatocellular carcinoma have been measured by means of flow cytometry. Results have indicated that 25 cases (61%) were diploid and 16 cases (39%) were aneuploid. In the aneuploid cases, the serum AFP level was found to be higher and stage more advanced. We also found that patients with aneuploid tumors had a poorer prognosis than those with diploid tumors, this fact uncovered by means of a Cox's proportional hazard model. In conclusion, the ploidy pattern of the nuclear DNA may serve as a useful prognostic marker for a hepatocellular carcinoma.

[A case of Behçet disease associated with hepatocellular carcinoma]

A 31-year-old man, suffering from Behçet disease, was admitted to our hospital because of a palpable mass in the right hypochondrium. On testing, laboratory data showed an abnormal liver function, positive HBs antigens, and a high AFP level. An abdominal CT and a SCAG revealed large tumors in the liver. The patient died of hepatic failure 6 months after the first admission and an autopsy was performed. At autopsy, hepatocellular carcinomas were found to occupy most of the entire liver. Histologically, the residual liver showed no remarkable changes, such as liver cirrhosis or chronic hepatitis. To date, few cases of Behçet disease complicating a malignant neoplasma have been reported. The possible relationship between Behçet disease and the occurrence of malignant tumors is described with a review of the literature.

Increased Expression of the lncRNA NRON Along With NFATc1/PIM-1 in Labial Salivary Glands of Sjögren's Syndrome Patients

The aim of our study was to analyze the expressions of nuclear factor of activated T cells (NFAT)-related substances including long noncoding RNA NRON which participates in pathophysiology of Sjögren's syndrome (SS), and to assess the histologic findings in individuals with SS. In this study, the expressions of NRON, NFATc1, CD3/CD4, and proviral integration site for Moloney murine leukemia virus (PIM)-1 were examined by in situ hybridization, immunohistochemical analysis, and immunofluorescence in labial salivary glands (LSGs) obtained from 16 patients with SS and five controls. The microcell count method has been applied to calculate the NFATc1-positive area/infiltrating cell area in LSGs, and we compared those results to the infiltrating cell area, focus score, serum immunoglobulin G, and the European League Against Rheumatism Sjögren's Syndrome Disease Activity Index. The NRON expression in the nuclei of cell-infiltration lesions of the SS patients were prominent. The NFATc1 expression was strong in the cytoplasm of infiltrating mononuclear cells and weak in ducts of both SS and controls. In SS, the NFATc1-positive area/infiltrating cell area was positively correlated with the infiltrating cell area and focus score. CD3/CD4 was expressed in infiltrating mononuclear cells, and PIM-1 colocalized with NFATc1 in the cytoplasm. These results suggest NRON along with NFATc1/PIM-1 in SS LSGs might participate in SS pathophysiology.

Anti-centromere antibody positivity is an independent variable associated with salivary gland ultrasonography score in Sjögren's syndrome

Sjögren's syndrome (SS) is an autoimmune disease characterized by periductal lymphocytic infiltration of the salivary and lacrimal glands. SS also exhibits extra-glandular manifestations and specific autoantibodies. Salivary gland ultrasonography (SGUS) is a common procedure used to assess the severity of glandular involvement. However, the association between SGUS and extra-glandular lesions remains poorly understood. This study aimed to identify clinical indices, including disease activity, associated with glandular involvement using SGUS in patients with SS. We included 115 patients with SS and 90 without SS. Patients with SS had significantly higher ultrasonography (US) score than patients without SS. Multivariate analysis revealed focus score, Saxon test positivity, and anti-centromere antibody (ACA) positivity as independent variables associated with the US score in patients with SS. In addition, these results were similar to those obtained in patients with primary SS. Patients with SS and ACA positivity had higher US score and an increased prevalence of hyperechoic bands in the parotid glands and submandibular glands. In conclusion, this study indicated that ACA positivity is associated with the US score in patients with SS. These results suggest that US findings in patients with ACA positivity might show specific changes in the salivary glands, especially fibrosis.

Development of eosinophilic granulomatosis with polyangiitis during the clinical course of microscopic polyangiitis: A case report

RATIONALE

Eosinophilic granulomatosis with polyangiitis (EGPA) is belongs to the antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) subgroups. EGPA, unlike other subgroups of AAV, including microscopic polyangiitis (MPA) and granulomatosis with polyangiitis, has the unique feature that both ANCA and eosinophilic inflammation are involved in its pathogenesis. Although AAV often relapses, there are currently no reports of EGPA developing during other subgroups of AAV. Herein, we document a case of EGPA that developed during the clinical course of MPA.

PATIENT CONCERNS

A 61-year-old Japanese woman was diagnosed with MPA based on interstitial lung disease and myeloperoxidase-ANCA positivity. After starting immunosuppression therapy, including prednisolone and tacrolimus, she was expected to achieve clinical remission. Nonetheless, she occasionally experienced MPA relapse, which required an increased prednisolone dose, rituximab, intravenous cyclophosphamide, and plasma exchange. Three years after MPA onset, she developed renal amyloidosis; thus, subcutaneous tocilizumab was added to her regimen. Following clinical remission, the administration interval of her subcutaneous tocilizumab therapy was extended and immunosuppressants were discontinued. She then developed bronchial asthma and mild eosinophilia (eosinophilic count: ~1000/μL). Further, a year later, she underwent total hip replacement using a titanium implant. Subsequently, she developed abnormal sensation in both hands, numbness, and muscle weakness, as well as palpable purpura and massive eosinophilia (eosinophilic count: ~8500/μL).

DIAGNOSIS

We diagnosed the patient with EGPA based on 5 items (asthma, multiple mononeuropathies, sinus abnormality, and extravascular eosinophils) of the 1990 American College of Rheumatology classification criteria.

INTERVENTIONS

We administered 400 mg/kg intravenous immunoglobulin for 5 consecutive days, 300 mg mepolizumab subcutaneously every 4 weeks, and 40 mg/day prednisolone following pulsed methylprednisolone therapy (1000 mg/day for 3 consecutive days).

OUTCOMES

After these treatments, the patient's symptoms improved, and eosinophilic count and inflammatory markers declined.

LESSONS

The present case suggests that EGPA can be induced by the development of eosinophilic inflammation in other subgroups of AAV.

The Toll-like Receptor 7-Mediated Ro52 Antigen-Presenting Pathway in the Salivary Gland Epithelial Cells of Sjögren's Syndrome

OBJECTIVE

To investigate whether stimulation with toll-like receptor (TLR) 7 leads to pathways that proceed to tripartite motif-containing protein 21 (TRIM21) or Ro52/SS-A antigen presentation through major histocompatibility complex (MHC) class I in salivary gland epithelial cells (SGECs) from Sjögren's syndrome (SS) patients.

DESIGN AND METHODS

Cultured SGECs from SS patients were stimulated with TLR7 agonist, loxoribine, and interferon-β. Cell lysates immunoprecipitated by anti-MHC class I antibody were analyzed by Western blotting. The immunofluorescence of salivary gland tissue from SS and non-SS subjects and cultured TLR7-stimulated SGECs was examined.

RESULTS

Significantly increased MHC class I expression was observed in SS patients' ducts versus non-SS ducts; no significant difference was detected for ubiquitin. Upregulated MHC class I in the cell membrane and cytoplasm and augmented Ro52 expression were observed in SGECs stimulated with TLR7. The formation of peptide-loading complex (PLC), including tapasin, calreticulin, transporter associated with antigen processing 1, and endoplasmic reticulum-resident protein 57 in labial salivary glands (LSGs) from SS patients, was dominantly observed and colocalized with MHC class I, which was confirmed in TLR7-stimulated SGEC samples.

CONCLUSION

These findings suggest that the TLR7 stimulation of SS patients' SGECs advances the process toward the antigen presentation of TRIM21/Ro52-SS-A via MHC class I.