Efficacy and Safety of Opinercept Tumor Necrosis Factor Inhibitor Therapy for Drug-Refractory Rheumatoid Arthritis: A Randomized Clinical Trial

Objectives

This study aims to evaluate the efficacy and safety profile of opinercept for rheumatoid arthritis (RA) patients undergoing disease- modifying anti-rheumatic drugs (DMARDs) therapy.

Patients and methods

A total of 98 patients with active RA (17 males, 81 females; mean age 58.6±12.2 years; range, 24.3 to 85.3 years) were randomized into opinercept plus DMARDs (OD group) or placebo plus DMARDs (PD group), in a 24-week treatment period. Primary outcome was American College of Rheumatology score (ACR20) at week 24. Other exploratory endpoints included ACR50, ACR70 and disease activity score-28 (DAS28) at week 12 and 24, tender/swollen joint counts, pain, Health Assessment Questionnaire-Disability Index, erythrocyte sedimentation rate, and C-reactive protein level. Incidence of adverse events (AEs), vital signs and physical findings, and laboratory test results were also evaluated.

Results

Patients in OD group showed significantly higher achievement percentage of ACR20 at week 24 than the PD group (76.6% vs. 30.3%, p<0.001). The evaluation of DAS28 was significantly improved in OD patients compared to PD patients at weeks 12 and 24. Most of the occurred AEs were mild or moderate and considered unrelated to study treatments.

Conclusion

Opinercept concurrent with DMARDs was superior to DMARDs alone in slowing RA progression and ameliorating symptoms, with well- tolerated and acceptable safety profile.

Management of gout and hyperuricemia: Multidisciplinary consensus in Taiwan

Gout is an inflammatory disease manifested by the deposition of monosodium urate (MSU) crystals in joints, cartilage, synovial bursa, tendons or soft tissues. Gout is not a new disease, which was first documented nearly 5,000 years ago. The prevalence of gout has increased globally in recent years, imposing great disease burden worldwide. Moreover, gout or hyperuricemia is clearly associated with a variety of comorbidities, including cardiovascular diseases, chronic kidney disease, urolithiasis, metabolic syndrome, diabetes mellitus, thyroid dysfunction, and psoriasis. To prevent acute arthritis attacks and complications, earlier use of pharmacotherapeutic treatment should be considered, and patients with hyperuricemia and previous episodes of acute gouty arthritis should receive long-term urate-lowering treatment. Urate-lowering drugs should be used during the inter-critical and chronic stages to prevent recurrent gout attacks, which may elicit gradual resolution of tophi. The goal of urate-lowering therapy should aim to maintain serum uric acid (sUA) level <6.0 mg/dL. For patients with tophi, the initial goal can be set at lowering sUA to <5.0 mg/dL to promote tophi dissolution. The goal of this consensus paper was to improve gout and hyperuricemia management at a more comprehensive level. The content of this consensus paper was developed based on local epidemiology and current clinical practice, as well as consensuses from two multidisciplinary meetings and recommendations from Taiwan Guideline for the Management of Gout and Hyperuricemia.

Differences between juvenile-onset ankylosing spondylitis and adult-onset ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic inflammatory disease, which involves the spine, peripheral joints and entheses. Juvenile-onset ankylosing spondylitis (JAS) affects children under the age of 16 years. JAS has been noted to present as clinical courses different from those of adult-onset ankylosing spondylitis (AAS). Therefore, the purpose of the present study was to compare the possible risk factors, clinical manifestations, laboratory markers, radiological changes, and functional outcome between these 2 patient groups.

METHODS

AS patients were enrolled from the rheumatologic clinic of a tertiary medical center from January 1 to June 30 in 2006. The demographic data, clinical symptoms/signs, Bath AS indices, HLA-B27, inflammatory markers, radiological findings, and treatment history were acquired with questionnaires, clinical evaluation, and chart review. The differences between JAS and AAS patients were evaluated and analyzed.

RESULTS

A total of 169 patients (142 males, 27 females) were included, comprising 47 JAS and 122 AAS patients. The ages of onset were 12.8 +/- 2.7 years and 25.0 +/- 7.4 years for JAS and AAS, respectively. They had similar gender distribution, years of delay to diagnosis and disease duration. A substantial proportion of our patients (40.4% of JAS and 34.4% of AAS) had physical trauma in the 1 month before disease onset. Also, 22.7% of JAS patients had intense physical training, while 25.2% of AAS patients did heavy work during the period. The first manifestation of JAS was mainly peripheral enthesopathy or arthritis, but axial symptoms in most AAS. More JAS patients had peripheral enthesopathies and arthritis on any occasion. Although there was a trend of higher score in Bath AS Disease Activity Index (BASDAI), Bath AS Metrology Index (BASMI) and Physician's Global Assessment (PGA) score, JAS patients had a comparable Bath AS Functional Index (BASFI) and Bath AS Patient's Global Assessment (BAS-G) as AAS patients. As to the laboratory and radiological tests, JAS patients had higher levels of C-reactive protein and erythrocyte sedimentation rate, and more radiographic changes of hip joints.

CONCLUSION

JAS and AAS patients had distinct presentations. JAS presented more peripheral enthesopathies and arthritis at disease onset and at any time of the course. If treated effectively, JAS will not lead to a worse functional outcome than AAS. Therefore, it is mandatory to diagnose and treat JAS as early as possible.

Soluble triggering receptor expressed on myeloid cell-1 (sTREM-1): a new mediator involved in early ankylosing spondylitis

OBJECTIVE

To investigate the possible role of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in ankylosing spondylitis (AS).

METHODS

Serum sTREM-1 levels were measured in 80 patients with AS and 30 healthy controls, and synovial fluid (SF) sTREM-1 levels were tested in 6 AS patients using ELISA. Demographic data were collected, and patient's disease activity (BASDAI), functional ability (BASFI), and global assessment (BAS-G) were evaluated. We also tested erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and IgA in these patients.

RESULTS

Serum sTREM-1 levels were detectable (definition, > or = 15 pg/ml) in 31.3% (25/80) of the AS patients, as compared to only 10% (3/30) of healthy controls (p = 0.027). SF sTREM-1 levels were detectable (> or = 15 pg/ml) in 83% (5/6) of the AS patients. The detectable rate of sTREM-1 in SF was significantly higher than in serum (p = 0.018). Disease duration was shorter in AS patients with "higher" serum sTREM-1 levels (> or = 30 pg/ml) versus those with "lower" levels (< 30 pg/ml) [mean (SD), 4.3 (3.7) vs 8.6 (7.8) yrs, p = 0.036], but the differences between these 2 groups of patients were not evident based on results of BASDAI, BASFI, BAS-G, ESR, CRP, or IgA levels. Of note, serum sTREM-1 levels inversely correlated with disease duration (r = -0.433, p = 0.03) in the 25 AS patients with detectable sTREM-1 levels.

CONCLUSION

sTREM-1 seems to be a new mediator involved in patients with AS, particularly in the early stages of disease.

Human leukocyte antigen and clinical and demographic characteristics in psoriatic arthritis and psoriasis in Chinese patients

OBJECTIVE

Psoriasis and psoriatic arthritis (PsA) are interrelated disorders. To date, no study has compared the differences of genes between patients with PsA and psoriasis and healthy controls in a Chinese population. We conducted a retrospective study to determine the human leukocyte antigen (HLA) -A, -B, -Cw, -DR, and -DQ alleles in Chinese patients with PsA and psoriasis.

METHODS

HLA studies were performed using polymerase chain reaction sequence-specific oligonucleotide (PCR-SSO) genotyping methods in 91 patients with PsA and 80 with psoriasis and 75 controls. Age at disease onset, sex, disease duration, enthesitis, and uveitis were also analyzed.

RESULTS

Among the patients with PsA and psoriasis, the frequency of HLA-B27 was significantly higher in PsA and HLA-A*30, -Cw*06, -DR*07 in psoriasis compared with controls. In contrast, HLA-B*58 was more common in controls than in PsA and psoriasis groups, and the prevalence of HLA-DR*17 was significantly higher in controls than in those with psoriasis. Comparing PsA and psoriasis, the prevalence of HLA-B*27 and HLA-Cw*12 were more common in PsA patients, while the prevalence of HLA-DR*07 was higher in those with psoriasis (p < 0.05). Among PsA patients, the association between HLA-B*27 and axial joint involvement and uveitis was significant (p < 0.05).

CONCLUSION

Certain HLA alleles are found in Chinese patients with psoriasis (HLA-A*30, -Cw*06, -DR*07) and PsA (HLA-B*27). Psoriasis patients with the HLA-B*27 and/or -Cw*12 may have higher risk of developing PsA. Ours is the first study to assess the genetic role of HLA in patients with psoriasis and PsA in a Chinese population.

Temporomandibular joint disorders in patients with rheumatoid arthritis

BACKGROUND

Temporomandibular joint disorders (TMD) are not uncommon in patients with rheumatoid arthritis (RA). However, the extent of involvement and its clinical relevance have not been well characterized. This study evaluated the correlation between the severity of RA-related TMD and RA, as well as determined the potential predictors for early identification and management of TMD in RA patients.

METHODS

We sequentially recruited 56 adult RA patients from our Arthritis Clinic. TMD and RA were surveyed, clinically by questionnaires and physical examinations, and radiologically by tomography in TMD and conventional radiography in RA. The patients were stratified into no, mild and severe TMD groups according to the physical and tomographic examinations. The correlation of the severity of TMD and RA were evaluated. The relative importance of relevant predictors of severe TMD was analyzed by a logistic regression model.

RESULTS

Physical and radiologic temporomandibular joint abnormalities were found to be highly prevalent (85.7% and 74.5%) in these patients, and the occurrence increased to as much as 92.9% when the 2 data sets were combined. More than half of the patients had severe TMD presenting with debilitating symptoms or with a significant degree of bony destruction. The severity of TMD was variably correlated with RA severity. The score of hand-joint space narrowing was found to be the most influential predictor of severe TMD by logistic regression analysis.

CONCLUSION

There was a high prevalence of TMD in RA patients. The severity of TMD variably correlated with RA severity. Clinically, a high score of hand-joint space narrowing may serve as an early indicator of RA patients at risk of severe TMD. This may facilitate early management and prevent the functional impairment of the temporomandibular joint.

Human leukocyte antigens in undifferentiated spondyloarthritis

OBJECTIVES

Undifferentiated spondyloarthritis (USpA) is a major member of the spondyloarthritis family. Ankylosing spondylitis (AS), the prototype of the family, is a largely genetic disease, with human leukocyte antigens (HLA)-B27 being the essential gene. Other genes in the HLA region have also been implicated. The purpose of this study was to identify the alleles of the HLA-A, -B, -C, -DR, and -DQ, which are present at higher frequencies in USpA patients compared with an ethnically matched control population.

METHODS

Sixty-three Taiwanese patients with USpA were compared with 75 matched healthy controls. HLA typing was performed by polymerase chain reaction-sequence specific oligo-nucleotide genotyping.

RESULTS

The frequencies of HLA-B27, -B60, -C3, and -DR12 were strikingly higher in USpA patients compared with healthy subjects, with odds ratios of 75.4, 14.0, 9.6, and 7.0, respectively. When USpA patients with axial involvement were compared with those with peripheral arthritis, the following were more marginally frequent in those with axial involvement: HLA-B27 and -DR12 (odds ratios, 4.0 and 4.0, respectively). There was no association of HLA typing with other variables, including enthesitis, uveitis, erythrocyte sedimentation rate, and serum C-reactive protein. Interestingly, in 12 HLA-B27-negative USpA patients, HLA-B60, -C3, and -DR12 were more frequent compared with controls (odds ratios, 35, 16.2, and 8.1, respectively).

CONCLUSIONS

Similar to AS, USpA is also linked to HLA-B27. A linkage to other HLA alleles observed here, even in our HLA-B27-negative USpA patients, strongly suggests that USpA in general is a genetic disease.

Association of acute anterior uveitis with disease activity, functional ability and physical mobility in patients with ankylosing spondylitis: a cross-sectional study of Chinese patients in Taiwan

Acute anterior uveitis (AAU) is the most frequently extra-articular manifestation of ankylosing spondylitis (AS). To investigate whether AAU has an association with disease activity, functional ability and physical mobility in AS patients, 146 Chinese AS patients in Taiwan were enrolled in a cross-sectional study. These patients fulfilled the 1984 modified New York criteria and visited the Outpatient Department of the Veterans General Hospital-Taipei from April 2004 to July 2005. Patients completed questionnaires assessing disease activity [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)], functional ability [Bath Ankylosing Spondylitis Functional Index (BASFI)] and patient's global assessment [Bath Ankylosing Spondylitis Patient Global Score (BAS-G)]. Meanwhile, physical examinations were performed, including Schober test, finger-to-floor, lateral spinal flexion, occiput-to-wall and chest expansion. The history of AAU was accepted only if diagnosed by an ophthalmologist. The prevalence of AAU in this Chinese AS cohort was 15.8% (23/146). Patients with AAU had a significantly higher BASDAI than those without [absolute differences=0.96, 95% confidence intervals (CI): 0.35-1.88]. Additionally, patients with AAU had significantly increased BASFI than those without (absolute differences=1.46, 95% CI: 0.33-2.59). Moreover, there was advanced limitation of physical motility in patients with AAU, including finger-to-floor, occiput-to-wall distances and Schober test, (95% CI: 3.89-16.95 and p=0.046, respectively). Disease duration mildly correlated with BASFI (r=0.24, p=0.003) but not with BASDAI (p=0.838). There was no difference of disease duration between patients with and without AAU (p=0.343). These results suggested that the presence of AAU in AS patients may be associated with higher disease activity, poor functional ability and advanced physical impairment.

Spatial and temporal distribution in density and biomass of two Pseudodiaptomus species (Copepoda: Calanoida) in the Caeté river estuary (Amazon region - North of Brazil)

Spatial and temporal density and biomass distribution of the planktonic copepods Pseudodiaptomus richardi and P. acutus along a salinity gradient were investigated in the Caeté River Estuary (North-Brazil) in June and December, 1998 (dry season) and in February and May, 1999 (rainy season). Copepod biomass was estimated using regression parameters based on the relation of dry weight and body length (prosome) of adult organisms. The Caeté River Estuary was characterized by high spatial and temporal variations in salinity (0.8-37.2‰). Exponential length-weight relationships were observed for both Pseudodiaptomus species. Density and biomass values oscillated between 0.28-46.18 ind. m-3 and 0.0022-0.3507 mg DW. m-3 for P. richardi; and between 0.01-17.02 ind. m-3 and 0.0005-0.7181 mg DW. m-3 for P. acutus. The results showed that the contribution of P. richardi for the secondary production in the Caeté River Estuary is more important in the limnetic zone than in other zones where euhaline-polyhaline regimes were predominant. However, it was not possible to observe a clear pattern of spatial and temporal distribution for P. acutus.

Double-blind, randomised, comparative trial of etodolac SR versus diclofenac in the treatment of osteoarthritis of the knee

A multi-centre, double-blind, randomised parallel-group study was conducted to compare the efficacy and safety between etodolac SR and diclofenac in treating patients with osteoarthritis of the knee. Thirty-two patients receiving etodolac SR (400 mg/day) and 32 patients receiving diclofenac (100 mg/day) were included for analyses. After receiving the study treatment, etodolac SR and diclofenac were shown to produce comparable improvement in pain relief as measured by a 10-cm visual analogue scale. There was no statistically significant difference observed between groups for the degree of functional impairment or the amount of paracetamol taken. The etodolac SR treatment group showed fewer incidents of adverse event. In addition, fewer gastrointestinal symptoms were observed in the etodolac SR treatment group. A statistically higher percentage of etodolac SR-treated patients were better tolerated to the study treatment compared with the diclofenac-treated patients. Etodolac SR-treated patients also took fewer antacids than the diclofenac-treated patients during the treatment period. In conclusion, etodolac SR is an effective treatment with fewer side-effects than diclofenac for patients with osteoarthritis of the knee.