Treat-to-target (T2T) recommendations for gout

OBJECTIVES

The treat-to-target (T2T) concept has been applied successfully in several inflammatory rheumatic diseases. Gout is a chronic disease with a high burden of pain and inflammation. Because the pathogenesis of gout is strongly related to serum urate levels, gout may be an ideal disease in which to apply a T2T approach. Our aim was to develop international T2T recommendations for patients with gout.

METHODS

A committee of experts with experience in gout agreed upon potential targets and outcomes, which was the basis for the systematic literature search. Eleven rheumatologists, one cardiologist, one nephrologist, one general practitioner and one patient met in October 2015 to develop T2T recommendations based on the available scientific evidence. Levels of evidence, strength of recommendations and levels of agreement were derived.

RESULTS

Although no randomised trial was identified in which a comparison with standard treatment or an evaluation of a T2T approach had been performed in patients with gout, indirect evidence was provided to focus on targets such as normalisation of serum urate levels. The expert group developed four overarching principles and nine T2T recommendations. They considered dissolution of crystals and prevention of flares to be fundamental; patient education, ensuring adherence to medications and monitoring of serum urate levels were also considered to be of major importance.

CONCLUSIONS

This is the first application of the T2T approach developed for gout. Since no publication reports a trial comparing treatment strategies for gout, highly credible overarching principles and level D expert recommendations were created and agreed upon.

2016 updated EULAR evidence-based recommendations for the management of gout

Background

New drugs and new evidence concerning the use of established treatments have become available since the publication of the first European League Against Rheumatism (EULAR) recommendations for the management of gout, in 2006. This situation has prompted a systematic review and update of the 2006 recommendations.

Methods

The EULAR task force consisted of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients and 3 experts in epidemiology/methodology from 12 European countries. A systematic review of the literature concerning all aspects of gout treatments was performed. Subsequently, recommendations were formulated by use of a Delphi consensus approach.

Results

Three overarching principles and 11 key recommendations were generated. For the treatment of flare, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), oral or intra-articular steroids or a combination are recommended. In patients with frequent flare and contraindications to colchicine, NSAIDs and corticosteroids, an interleukin-1 blocker should be considered. In addition to education and a non-pharmacological management approach, urate-lowering therapy (ULT) should be considered from the first presentation of the disease, and serum uric acid (SUA) levels should be maintained at<6 mg/dL (360 µmol/L) and <5 mg/dL (300 µmol/L) in those with severe gout. Allopurinol is recommended as first-line ULT and its dosage should be adjusted according to renal function. If the SUA target cannot be achieved with allopurinol, then febuxostat, a uricosuric or combining a xanthine oxidase inhibitor with a uricosuric should be considered. For patients with refractory gout, pegloticase is recommended.

Conclusions

These recommendations aim to inform physicians and patients about the non-pharmacological and pharmacological treatments for gout and to provide the best strategies to achieve the predefined urate target to cure the disease.

The OA Trial Bank: meta-analysis of individual patient data from knee and hip osteoarthritis trials show that patients with severe pain exhibit greater benefit from intra-articular glucocorticoids

OBJECTIVE

To evaluate the efficacy of intra-articular (IA) glucocorticoids for knee or hip osteoarthritis (OA) in specific subgroups of patients with severe pain and inflammatory signs using individual patient data (IPD) from existing trials.

DESIGN

Randomized trials evaluating one or more IA glucocorticoid preparation in patients with knee or hip OA, published from 1995 up to June 2012 were selected from the literature. IPD obtained from original trials included patient and disease characteristics and outcomes measured. The primary outcome was pain severity at short-term follow-up (up to 4 weeks). The subgroup factors assessed included severe pain (≥70 points, 0-100 scale) and signs of inflammation (dichotomized in present or not) at baseline. Multilevel regression analyses were applied to estimate the magnitude of the effects in the subgroups with the individuals nested within each study.

RESULTS

Seven out of 43 published randomized clinical trials (n = 620) were included. Patients with severe baseline pain had a significantly larger reduction in short-term pain, but not in mid- and long-term pain, compared to those with less severe pain at baseline (Mean Difference 13.91; 95% Confidence Interval 1.50-26.31) when receiving IA glucocorticoid injection compared to placebo. No statistical significant interaction effects were found between inflammatory signs and IA glucocorticoid injections compared to placebo and to tidal irrigation at all follow-up points.

CONCLUSIONS

This IPD meta-analysis demonstrates that patients with severe knee pain at baseline derive more benefit from IA glucocorticoid injection at short-term follow-up than those with less severe pain at baseline.

Molecular profiling of advanced biliary cancer: Lost in translation from bench to bedside

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Background: Advanced Biliary Cancer (ABC) is a collection of diseases which carry poor prognosis, and many patients derive limited benefit from chemotherapy. Identification of molecular drivers of ABC may help to predict treatment response and direct development of targeted therapy. Methods: Formalin fixed paraffin embedded (FFPE) tissue form patients with ABC treated at Princess Margaret Cancer Centre was analysed by MassARRAY Sequenom panel (23 genes, 279 mutations), or by next general sequencing (NGS) using Proton or Illumina MiSeq TruSeq Amplicon Cancer Panel (48 genes, 212 amplicons, ≥500x coverage). Clinicopathologic and treatment data were collected from electronic health records. Results: Of 112 tested patients, 16 had insufficient DNA, and 96 had data for analysis: 13 with ampullary cancer (AC), 19 with hilar/distal bile duct (DBD), 43 with gallbladder (GBC), and 21 with intrahepatic (IHC). 13 patients had Sequenom testing, 85 had NGS with Miseq or Proton. 127 mutations were identified in 60 patients, 36 had no mutations detected: 23 in AC, 54 in GBC, 24 in IHC, 26 in DBD. The most frequent mutations were in TP53 (34%) and KRAS (20%). TP53 and SMAD4 mutations appeared most common in GBC, BRAF and KRAS mutations were most common in AC, and IDH1 and FGFR2mutations were seen only in IHC. 14 patients (15%) had a mutation for which targeted treatment could be applied. Conclusions: Profiling of patients with ABC is feasible and can identify some molecular drivers, with different tumour sites demonstrating distinct biological patterns. Only a limited number of patients are shown to have clinically relevant mutations with current NGS techniques, suggesting additional techniques (whole genome/RNA sequencing) may be required to fully characterise these diseases and identify new therapeutic targets. [Table: see text]

Long-term responders to palliative chemotherapy for advanced biliary tract cancer

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Background: Standard palliative chemotherapy (PC) in patients (pts) with Advanced Biliary Tract Cancer (ABTC) since publication of ABC-02 study in 2010 is cisplatin/gemcitabine (cis/gem), with median overall survival (OS) of 11.7 months. Prior to this, institutional standard was gemcitabine/fluoropyrimidine combination. From the ABC-02 study, 8 cycles of PC is standard. Some pts benefit from continuing PC longer than 8 cycles. Methods: Pts treated for ABTC in Princess Margaret Cancer Centre between 06/1987 and 09/2015, receiving > 8 cycles of PC were included for analysis. Data was collected on demographics, clinicopathologic features, PC regimen, toxicities, and survival. Results: Of 553 pts who received PC, 119 pts met inclusion criteria of PC > 8 cycles. Median age was 60 (range 27-80). Site of tumour was ampullary in 11, distal bile duct in 14, gallbladder in 28, intrahepatic in 37, perihilar in 26, and unspecified in 3 pts. 61 (51%) required biliary stenting. 30 (25%) had definitive surgical resection at diagnosis, while 89 (75%) presented with ABTC. First-line PC regimens were cis/gem in 44 and gemcitabine/capecitabine in 62. Other regimens included gemcitabine and 5-fluorouracil alone or combined. Median time on first line PC was 10 months, with median of 12 cycles (range 9-47). 22 pts (19%) had treatment breaks > 8 weeks then restarted same PC. Any tumour shrinkage was seen in 73 pts (61%). The majority of pts discontinued PC due to disease progression (69), however 16 stopped due to toxicity such as thrombocytopenia, neutropenia, fatigue and neuropathy. At time of analysis, 103 pts had progressive disease, with median progression free survival of 11.8 months. 51 and 21 pts received second and third line chemotherapy, respectively. 27 pts are alive; median OS for the whole group was 22 months (95%CI 18.7-27.3 months). Conclusions: A cohort of ABTC pts continued to derive benefit from chemotherapy beyond 8 cycles, with median OS considerably greater than that seen in clinical trials. Toxicities were mostly manageable, with treatment breaks from PC for relief of side-effects observed. Further exploration of factors prognostic and predictive for continued benefit from PC will be explored and updated at presentation.

Optimisation of the zinc sulphate turbidity test for the determination of immune status

Failure of passive transfer of maternal immunity occurs in calves that fail to absorb sufficient immunoglobulins from ingested colostrum. The zinc sulphate turbidity test has been developed to test bovine neonates for this failure. The specificity of this test has been shown to be less than ideal. The objective was to examine how parameters of the zinc sulphate turbidity test may be manipulated in order to improve its diagnostic accuracy. One hundred and five blood samples were taken from calves of dairy cows receiving various rates of colostrum feeding. The zinc sulphate turbidity test was carried out multiple times on each sample, varying the solution strength, time of reaction and wavelength of light used and the results compared with those of a radial immunodiffusion test, which is the reference method for measuring immunoglobulin concentration in serum. Reducing the time over which the reaction occurs, or increasing the wavelength of light used to read the turbidity, resulted in decreased specificity without improving sensitivity. Increasing the concentration of the zinc sulphate solution used in the test was shown to improve the specificity without decreasing sensitivity. Examination of the cut-off points suggested that a lower cut-off point would improve the performance.

OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hip osteoarthritis

The ability to assess the efficacy and effectiveness of an intervention for the treatment of hip osteoarthritis (OA) requires strong clinical trial methodology. This consensus paper provides recommendations based on a narrative literature review and best judgment of the members of the committee for clinical trials of hip OA. We provide recommendations on clinical trial design, outcome measures, including structural (radiography), and patient and physician global assessments, performance based measures, molecular markers and experimental endpoints including MRI imaging. This information can be utilized by sponsors of trials for new therapeutic agents for hip OA.

OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hand osteoarthritis

Hand osteoarthritis (OA) is a very frequent disease, but yet understudied. However, a lot of works have been published in the past 10 years, and much has been done to better understand its clinical course and structural progression. Despite this new knowledge, few therapeutic trials have been conducted in hand OA. The last OARSI recommendations for the conduct of clinical trials in hand OA dates back to 2006. The present recommendations aimed at updating previous recommendations, by incorporating new data. The purpose of this expert opinion, consensus driven exercise is to provide evidence-based guidance on the design, execution and analysis of clinical trials in hand OA, where published evidence is available, supplemented by expert opinion, where evidence is lacking, to perform clinical trials in hand OA, both for symptom and for structure-modification. They indicate core outcome measurement sets for studies in hand OA, and list the methods and instruments that should be used to measure symptoms or structure. For both symptom- and structure-modification, at least pain, physical function, patient global assessment, HR-QoL, joint activity and hand strength should be assessed. In addition, for structure-modification trials, structural progression should be measured by radiographic changes. We also provide a research agenda listing many unsolved issues that seem to most urgently need to be addressed from the perspective of performing "good" clinical trials in hand OA. These updated OARSI recommendations should allow for better standardizing the conduct of clinical trials in hand OA in the next future.

Inflammation and tuberculosis: host-directed therapies

Tuberculosis (TB) is an airborne infectious disease that kills almost two million individuals every year. Multidrug-resistant (MDR) TB is caused by strains of Mycobacterium tuberculosis (M. tb) resistant to isoniazid and rifampin, the backbone of first-line antitubercular treatment. MDR TB affects an estimated 500,000 new patients annually. Genetic analysis of drug-resistant MDR-TB showed that airborne transmission of undetected and untreated strains played a major role in disease outbreaks. The need for new TB vaccines and faster diagnostics, as well as the development of new drugs, has recently been highlighted. The major problem in terms of current TB research and clinical demands is the increasing number of cases of extensively drug-resistant and 'treatment-refractory' TB. An emerging scenario of adjunct host-directed therapies is intended to target pulmonary TB where inflammatory processes can be deleterious and lead to immune exhaustion. 'Target-organ-saving' strategies may be warranted to prevent damage to infected tissues and achieve focused, clinically relevant and long-lasting anti-M. tb cellular immune responses. Candidates for such interventions may be biological agents or already approved drugs that can be 're-purposed' to interfere with biologically relevant cellular checkpoints. Here, we review current concepts of inflammation in TB disease and discuss candidate pathways for host-directed therapies to achieve better clinical outcomes.