Do changes in prescription practice in patients with rheumatoid arthritis treated with biological agents affect treatment response and adherence to therapy? Results from the nationwide Danish DANBIO Registry

BACKGROUND

Prescription practice for tumour necrosis factor alpha (TNFalpha) inhibitors has changed towards treating patients with lower disease activity.

OBJECTIVE

To determine the trend in treatment response in cohorts of patients with rheumatoid arthritis who started TNFalpha inhibitor treatment between 2000 and 2005.

METHODS

1813 patients with RA starting treatment with biological agents in 2000-5 were registered prospectively in the nationwide DANBIO Registry. Baseline disease activity and 12 months' treatment responses were determined in cohorts based on start year (2000/1; 2002; 2003; 2004; 2005).

RESULTS

Despite decreasing baseline disease activity from the 2000/2001 cohort to 2005 cohort (28-joint count Disease Activity Score (DAS28): from 5.9 to 5.3 (p<0.001)), the 12 months' DAS improvement increased from 1.8 units (2000/2001 cohort) to 2.2 units (2005 cohort) (p<0.001). The fraction with good EULAR response increased from 28% (2000/2001 cohort) to 50% (2005 cohort); the fraction with no response decreased from 29% (2000/2001 cohort) to 16% (2005 cohort). ACR20/50/70 response rates increased from 53%/31%/13% (2000/2001 cohort) to 69%/51%/30% (2005 cohort). After correction for withdrawals, treatment responses were lower, but patterns unchanged. One-year drug survival was for the 2000/2001 cohort: 73%, 2002: 62%, 2003: 67%, 2004: 70%, 2005: 69%.

CONCLUSION

From 2000 to 2005, significantly improved treatment responses to TNF inhibitors were seen in clinical practice despite decreasing baseline disease activity levels. This lends support to the less stringent prescription practice towards treating patients with lower disease activity that has been observed in several countries.

Do rheumatoid arthritis patients in clinical practice benefit from switching from infliximab to a second tumor necrosis factor alpha inhibitor?

OBJECTIVE

To investigate the efficacy of switching to a second biological drug in rheumatoid arthritis (RA) patients.

METHODS

Since 2000, Danish RA patients (n = 1021) receiving biological therapy have been registered in the nationwide DANBIO database. The first and second treatment series of patients, who switched therapy before 2005 (n = 235), were analysed for their reasons for switching, Disease Activity Score 28 (DAS28), DAS28 improvement, European League against Rheumatology (EULAR) response and drug survival. Most patients switched from infliximab to etanercept or adalimumab.

RESULTS

Median survivals for switchers' first/second treatment were 37/92 weeks (all patients' first treatment 119 weeks). Reasons for switching were lack of efficacy (LOE; 109 patients), adverse events (AE; 72), other reasons (54). If patients experienced AE to the first drug, 15% had AE to the second. Median DAS28 improvements in first/second treatment at 3 months were: LOE switchers 1.1/1.6; AE switchers 1.5/0.8. In LOE switchers, a good/moderate EULAR response was more prevalent during the second treatment course than during the first (63% versus 54%, p = 0.02). AE switchers achieved similar EULAR responses to both treatments (59% versus 50%, p = 0.38).

CONCLUSION

LOE switchers had a better clinical response to the second treatment. AE switchers responded equally well to both treatments, with a low risk of discontinuing the second drug as a result of AE. Drug survival of the switchers' second biological therapy was higher than of the first, but lower than that of non-switchers. No difference between various sequences of drugs were found. Danish post-marketing data thus support that RA patients may benefit from switching biological therapy.

[Epidural glucocorticoid injection in lumbago sciatica]

Within the past decades, epidural steroid injections have been used in the treatment of severe low back pain and sciatica. In reviewing papers for this article an effort is made to concentrate on those that meet commonly accepted research design criteria, such as being blinded, randomized and prospective. The risks and the advantages of the procedure are discussed. Some of the studies report an efficient reduction in low back pain and sciatica for a longer period. Risks of more serious complications are low using the right technique. However, the results are to some extent conflicting. Future correctly designed studies are necessary to clarify whether the injection should be a supplement to the established treatment of low back pain and sciatica.

Anticardiolipin antibodies and lipoprotein (a) levels in patients with chronic renal failure treated with dialysis: associations with atherothrombotic disease

The present study evaluated the importance of anticardiolipin antibodies (ACA) and lipoprotein (a) (Lp(a)) as markers of atherothrombotic disease in a retrospective study of patients on maintenance hemodialysis (HD) or peritoneal dialysis (PD). ACA and Lp(a) were measured in 22 patients on PD, and 64 on HD. Three patients were ACA IgM seropositive, whereas none were ACA IgG seropositive. The mean number of previous atherothrombotic events was 2.0 (1-3) in ACA seropositive patients, as compared to 0.7 (0-4) in ACA seronegative patients. The mean Lp(a) level was 56.7 mg/dl (3.0-217.7) in PD patients and 38.8 mg/dl (2.0-255.6) in HD patients (n.s.). Levels of Lp(a) greater than 30 mg/dl were not significantly associated with a history of atherothrombotic events, but all patients who had suffered a myocardial infarction or cerebrovascular insult had Lp(a) levels above 30 mg/dl. We conclude that ACA seropositivity is rare. All ACA seropositive patients had suffered atherothrombotic disease in the current study, whereas all patients with myocardial infarction or cerebrovascular insult had Lp(a) levels above 30 mg/dl.

No signs of Campylobacter jejuni/coli-related antibodies in patients with active ankylosing spondylitis

Twenty-two patients with active ankylosing spondylitis were investigated to assess the levels of specific serum IgG, IgA and IgM titres against Campylobacter jejuni/coli before and during treatment with sulfasalazine. An enzyme-linked immunosorbent assay was used, and the results were compared with the antibody levels in 300 healthy blood donors. Three patients had elevated levels of serum anti-Campylobacter-IgA before treatment, and a two-fold decrease in the antibody titre was observed during treatment. Three patients had elevated anti-Campylobacter-IgG titres before treatment. One of these patients also had elevated anti-Campylobacter-IgA and IgM titres. Elevated IgM titres were not seen in any other patient. The results do not support the hypothesis that C. jejuni/coli plays an important role in the pathogenesis of active AS.

Ankylosing spondylitis--education, employment and invalidity

Two hundred forty-eight patients suffering from ankylosing spondylitis (AS) completed a questionnaire about the social impact of the disease. Of the 84% who replied to the questions about employment status, 118 patients were employed full-time. The ability to manage full-time employment was reduced in 41 patients. Eighty-five patients indicated that they had changed occupation or educational status as a cause of AS; 46 of these later experienced a more progressive course, which reduced their working capacity, and 31 retired as invalids. Despite the long-term morbidity with gradual loss of functional capacity, 85% were still able to work after more than 20 years of illness. If we pay more attention to initial symptoms related to AS, delay in the diagnosis of AS could be decreased and social instability avoided by guidance in education and light occupations.

Ankylosing spondylitis--experience with a self administered questionnaire: an analytical study

A questionnaire drafted by the president of a self help group of patients suffering from ankylosing spondylitis (AS), the Danish Ankylosing Spondylitis Society (DASS), was completed by 179 of 184 (97%) consecutive patients with AS. The following results were found. The diagnosis of AS was delayed an average of 12.6 years for women and 9.5 years for men. No differences were found in age at onset of the disease. A comparison of juvenile and adult onset showed a higher incidence of initial peripheral articular manifestations in patients with juvenile ankylosing spondylitis. Stiffness progressed significantly in both sexes during the illness. Two men still had stiffness localised only to the lumbar spine after more than 20 years of illness. Twenty four of 47 women (51%) and 36/121 (30%) of the men had experienced extra-articular disease. Fifteen of 46 women (33%) and 18/121 (15%) of the men had iritis and conjunctivitis before the diagnosis of AS was established and later, in the course of the illness. The results of this study agreed with those of previous investigations. The advantage of using a questionnaire as a screening test is that many patients may be studied and information brought up to date in a simple and inexpensive way.

[Antibacterial treatment of Campylobacter pylori-associated gastritis and peptic ulcer]

On the basis of possible etiological or pathogenetic significance of Campylobacter pylori for the development, maintenane og recurrence of gastritis and peptic ulceration, a review based on the literature is presented for the sensitivity of the bacteria in vitro and in vivo to antibiotics and preparations employed in the medicinal treatment of gastritis and peptic ulceration. The bacterium is sensitive in vitro to a long series of antibiotics and all of the anti-ulcer agents have, similarly, antibacterial activity in vitro, but, apart from bismuth, only in high concentrations. Among the anti-ulcer agents, only bismuth and, similarly, amoxycillin are capable of eliminating the bacteria from the stomach and this is associated with healing of any gastritis present. Recurrence of infection is observed in more than 50% of the patients after the conclusion of treatment regardless of whether this was antibiotic or bismuth treatment. High in vitro activity of a substance is not synonymous with in vivo activity. A correlation was demonstrated between recurrence of duodenal ulcer and recurrent/persistent infection with Campylobacter pylori. The optimal antibacterial therapeutic strategy is not established and, similarly, no generally accepted indication for specific antimicrobial treatment of Campylobacter pylori associated gastritis or peptic ulceration exists.