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Patel AV, Morgan SL, Green R, Danila MI, Merriman TR, Wanzeck K, Ahmed H, Gaffo AL. Vitamin B12 status and hyperhomocysteinemia in patients with Rheumatoid arthritis treated with methotrexate and folic acid. Am J Med Sci 2024:S0002-9629(24)01147-9. [PMID: 38561045 DOI: 10.1016/j.amjms.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 03/04/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is an inflammatory arthritis in which the immune system targets synovial joints. Methotrexate serves as the mainstay of treatment for RA due to its efficacy. However, patients treated with methotrexate are uniquely at risk for vitamin B12 deficiency and hyperhomocysteinemia due to coincident disease risk factors and the fact that methotrexate use is associated with malabsorption. The objective of this study was to assess for vitamin B12 deficiency among patients with RA treated with methotrexate and folic acid. METHODS This cross-sectional study included 50 patients with RA treated with methotrexate and folic acid and 49 patients with RA treated with other therapies. Patients were matched by age, sex, race, renal function, and disease activity. We compared plasma vitamin B12, methylmalonic acid, and homocysteine levels between these two groups utilizing quantitative and categorical analyses. RESULTS Thirty-seven (74 %) RA patients on methotrexate and folic acid had elevated plasma homocysteine levels compared with only 27 (55 %) RA patients receiving other therapies (P < 0.05). The proportion of patients with low vitamin B12 and high methylmalonic acid levels did not differ between the two groups. CONCLUSIONS Our data show high plasma homocysteine levels among RA patients treated with methotrexate and folic acid. While plasma vitamin B12 levels were similar between the two groups, high plasma homocysteine is also a sensitive marker of vitamin B12 deficiency. Additional studies should evaluate for the presence of clinical features of vitamin B12 deficiency and hyperhomocysteinemia among RA patients treated with methotrexate and folic acid.
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Affiliation(s)
- Aakash V Patel
- Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Sarah L Morgan
- Division of Rheumatology and Clinical Immunology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California Davis, Davis, CA, United States of America
| | - Maria I Danila
- Division of Rheumatology and Clinical Immunology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tony R Merriman
- Division of Rheumatology and Clinical Immunology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Keith Wanzeck
- Division of Rheumatology and Clinical Immunology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hamdy Ahmed
- Division of Rheumatology, University of South Alabama, Mobile, AL, United States of America
| | - Angelo L Gaffo
- Division of Rheumatology and Clinical Immunology, University of Alabama at Birmingham and Birmingham VA Medical Center, Birmingham, AL, United States of America.
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Guo P, Huang C, Yang Q, Zhong G, Zhang J, Qiu M, Zeng R, Gou K, Zhang C, Qu Y. Advances in Formulations of Microneedle System for Rheumatoid Arthritis Treatment. Int J Nanomedicine 2023; 18:7759-7784. [PMID: 38144510 PMCID: PMC10743780 DOI: 10.2147/ijn.s435251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 12/26/2023] Open
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic joint inflammation, eventually leading to severe disability and premature death. At present, the treatment of RA is mainly to reduce inflammation, swelling, and pain. Commonly used drugs are non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and disease-modifying anti-rheumatic drugs (DMARDs). These drugs lack specificity and require long-term, high-dose administration, which can cause serious adverse effects. In addition, the oral, intravenous, and intra-articular injections will reduce patient compliance, resulting in high cost and low bioavailability. Due to these limitations, microneedles (MNs) have emerged as a new strategy to efficiently localize the drugs in inflamed joints for the treatment of RA. MNs can overcome the cuticle barrier of the skin without stimulating nerves and blood vessels. Which can increase patient compliance, improve bioavailability, and avoid systemic circulation. This review summarizes and evaluates the application of MNs in RA, especially dissolving MNs (DMNs). We encourage the use of MNs to treat RA, by describing the general properties of MNs, materials, preparation technology, drug release mechanism, and advantages. Furthermore, we discussed the biological safety, development prospects, and future challenges of MNs, hoping to provide a new strategy for the treatment of RA.
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Affiliation(s)
- Peng Guo
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, People’s Republic of China
| | - Chi Huang
- Department of Pharmacy, Jiang’an Hospital of Traditional Chinese Medicine, Yibin, 644200, People’s Republic of China
| | - Qin Yang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, People’s Republic of China
| | - Guofeng Zhong
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, People’s Republic of China
| | - Junbo Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, People’s Republic of China
| | - Mengyu Qiu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, People’s Republic of China
| | - Rui Zeng
- Institute of Tibetan Plateau, Southwest Minzu University, Chengdu, 610225, People’s Republic of China
| | - Kaijun Gou
- Institute of Tibetan Plateau, Southwest Minzu University, Chengdu, 610225, People’s Republic of China
| | - Chen Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, People’s Republic of China
| | - Yan Qu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, People’s Republic of China
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Zhao W, Zheng L, Yang J, Ma Z, Tao X, Wang Q. Dissolving microneedle patch-assisted transdermal delivery of methotrexate improve the therapeutic efficacy of rheumatoid arthritis. Drug Deliv 2023; 30:121-132. [PMID: 36533887 PMCID: PMC9769132 DOI: 10.1080/10717544.2022.2157518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Methotrexate (MTX) is a first-line treatment for rheumatoid arthritis (RA), but its clinical use is greatly limited by the adverse effects and poor patient compliance caused by traditional oral administration or injection. In recent years, some transdermal drug delivery systems have received considerable attention due to overcoming these shortcomings. In this study, we developed dissolving microneedle patch (DMNP) for transdermal delivery of MTX to treat RA safely and effectively. The morphology, mechanical strength, skin insertion, drug content, in vitro transdermal delivery, and other properties of DMNP were characterized. Meanwhile, the adjuvant-induced arthritis model of rats was established to investigate the therapeutic effect of MTX-loaded DMNP in vivo. The results showed that the microneedles had excellent morphology with neat array and complete needles, good puncture performance and mechanical strength, and rapid intradermal dissolution rate. In vitro transdermal delivery results indicated that microneedles could significantly increase drug transdermal permeation compared with the cream group. The pharmacological study showed that MTX-loaded DMNP significantly alleviated paw swelling, inhibit inflammatory response via downregulating the levels of TNF-α and IL-1β, relieved synovium destruction with less cartilage erosion, and slowed the progression of RA in AIA rats. Besides, DMNP presented better therapeutic performance than cream or intragastric administration at the same dosage of MTX. In conclusion, the MTX-loaded dissolving microneedle patch has advantages of safety, convenience, and high efficacy over conventional administrations, laying a foundation for the transdermal drug delivery system treatment of rheumatoid arthritis.
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Affiliation(s)
- Weiman Zhao
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Lijie Zheng
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Jianhui Yang
- School of Pharmacy, Anhui Medical University, Hefei, China
| | - Zihui Ma
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Xinyi Tao
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Qingqing Wang
- School of Pharmacy, Bengbu Medical College, Bengbu, China,Engineering Research Center for Biochemical Pharmaceuticals of Anhui Province, Bengbu Medical College, Bengbu, China,CONTACT Qingqing Wang School of Pharmacy, Bengbu Medical College, Bengbu 233030, China
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4
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Myasoedova E. Predicting treatment response to methotrexate: are we closer to solving the enigma? Rheumatology (Oxford) 2023:kead622. [PMID: 38019954 DOI: 10.1093/rheumatology/kead622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/18/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Elena Myasoedova
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
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5
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Tan JM, Reeve E, Fraser L, Proudman SM, Wiese MD. Barriers and Enablers in the Use of Parenteral Methotrexate in Rheumatoid Arthritis Patients: A Scoping Review. Arthritis Care Res (Hoboken) 2023; 75:2306-2315. [PMID: 37128818 DOI: 10.1002/acr.25141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/22/2023] [Accepted: 04/27/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Methotrexate (MTX) is effective in controlling disease activity in rheumatoid arthritis (RA). Parenteral MTX may have benefits over oral MTX, but it is rarely used in practice. To better understand this low usage rate, it is necessary to explore the barriers and enablers of therapy from the perspective of RA patients. The objectives of this scoping review were to describe RA patients' perspectives on the barriers and enablers in the use of parenteral MTX and to identify the research gaps in this field. METHODS The search was performed in Medline, Embase, Scopus, and Cochrane Library from inception to May 2021. Data synthesis was conducted using the Theoretical Framework of Acceptability. This scoping review included any type of study that explored the use of parenteral MTX by adult RA patients from the patients' perspective, written in English. RESULTS Fifteen studies were included; findings related to the constructs "affective attitude," "burden," "intervention coherence," and "self-efficacy" were explored the most, while some were rarely ("opportunity cost" and "perceived effectiveness") or not ("ethicality") reported. RA patients were generally satisfied with MTX injections ("affective attitude"). From the burden construct, the requirement for dexterity for administering MTX by injection was considered a barrier, whereas the lack of significant pain from MTX injection was considered an enabler. CONCLUSION The findings suggested that patients generally preferred parenteral MTX formulations with attributes that facilitate self-administration. However, much of the identified research focused on prefilled pen devices, and significant gaps were identified, such as a lack of qualitative research.
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Affiliation(s)
- Jiun Ming Tan
- University of South Australia, Adelaide, South Australia, Australia
| | - Emily Reeve
- Monash University, Parkville, Victoria, Australia, and University of South Australia, Adelaide, Australia
| | - Lauren Fraser
- University of South Australia, Adelaide, South Australia, Australia
| | - Susanna M Proudman
- Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Michael D Wiese
- University of South Australia, Adelaide, South Australia, Australia
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6
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Pardey N, Zeidler J, Nellenschulte TF, Stahmeyer JT, Hoeper K, Witte T. [Methotrexate treatment before use of biologics in rheumatoid arthritis : Analysis of guideline compliance]. Z Rheumatol 2023; 82:573-579. [PMID: 34545429 PMCID: PMC10495498 DOI: 10.1007/s00393-021-01086-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND With the introduction of biologics the treatment landscape for patients with rheumatoid arthritis (RA) has rapidly expanded; however, according to German and European treatment guidelines the use of biologic disease-modifying antirheumatic drugs (bDMARD) is only indicated after insufficient response under methotrexate (MTX) doses of at least 20 mg/week (first-line treatment). The aim of the study was to analyze the guideline compliance of MTX prescription in the outpatient sector prior to treatment with biologics. MATERIAL AND METHODS Claims data from the AOK Lower Saxony from 2013 to 2016 were provided for all insured patients with a diagnosis of RA and bDMARD prescription during the study period. Within a patient-specific observational period of 180 days prior to the first bDMARD prescription, the maximum prescribed MTX dosage was examined. RESULTS Data from 90 incident and 315 prevalent RA patients were analyzed. A maximum MTX prescription of < 20 mg/week was observed in 60.0% of incident patients and in 67.0% of prevalent patients. Men had a higher mean MTX maximum dose (17.1 ± 4.8 mg) than women (14.9 ± 5.0 mg; p < 0.0001). Of the study population 29.6% received oral only prescriptions during the observational period. In 12.4% of patients a switch to parenteral administration was made. DISCUSSION Targeted use of the full spectrum of therapies provided prior to initiation of bDMARD treatment may contribute to cost-effective RA care. This study showed indications for potential deficits in outpatient MTX prescription practice and can raise awareness for efficient treatment.
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Affiliation(s)
- Nicolas Pardey
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Otto-Brenner-Str. 7, 30159, Hannover, Deutschland.
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Otto-Brenner-Str. 7, 30159, Hannover, Deutschland
| | | | - Jona T Stahmeyer
- Stabsbereich Versorgungsforschung, AOK Niedersachsen, Hannover, Deutschland
| | - Kirsten Hoeper
- Klinik für Rheumatologie und Immunologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Torsten Witte
- Klinik für Rheumatologie und Immunologie, Medizinische Hochschule Hannover, Hannover, Deutschland
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Turk MA, McDermott S, Zhang W, Cai B, Love BL, Hollis N. Associations Between Opioid Prescriptions and Use of Hospital-Based Services Among US Adults with Longstanding Physical Disability or Inflammatory Conditions Compared to Other Adults in the Medical Expenditure Panel Survey, 2010-2015. J Pain Res 2023; 16:1949-1960. [PMID: 37312833 PMCID: PMC10259593 DOI: 10.2147/jpr.s400264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/24/2023] [Indexed: 06/15/2023] Open
Abstract
Purpose To investigate the association of filling opioid prescriptions with healthcare service utilization among a nationally representative sample of adults with disability. Materials and Methods The Medical Expenditure Panel Survey (MEPS) for 2010-2015, Panels 15-19, was used to identify adults who were prescribed opioids during each two-year period. We examined the data for associations between opioid prescription filling and the number of emergency department (ED) visits and hospitalizations. The participants were grouped as those with inflammatory conditions or with longstanding physical disability, and a comparison group of those without these conditions. Results and conclusions Opioid prescription filling differed among adults with inflammatory conditions and longstanding physical disability compared to the comparison group (44.93% and 40.70% vs 18.10%, respectively). For both groups of people with disability, the relative rates for an ED visit or hospitalization were significantly higher for those who filled an opioid prescription, compared to adults with the same conditions who did not fill an opioid prescription. People with a longstanding physical disability who filled an opioid prescription had the highest rate ratio of ED use and hospitalization. Results from this investigation demonstrate that opioid prescription filling among persons with inflammatory conditions and longstanding physical disabilities is associated with higher rates of ED visits and hospitalizations.
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Affiliation(s)
- Margaret A Turk
- Department of Physical Medicine and Rehabilitation, State University of New York (SUNY) Upstate Medical University, Syracuse, NY, USA
| | - Suzanne McDermott
- Department of Environmental, Occupational, and Geospatial Health Sciences, CUNY Graduate School of Public Health & Health Policy, New York, NY, USA
| | - Wanfang Zhang
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Bo Cai
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Bryan L Love
- Department of Clinical Pharmacy and Outcome Science, University of South Carolina College of Pharmacy, Columbia, SC, USA
| | - NaTasha Hollis
- Disability and Health Promotion Branch, Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
- U.S Public Health Service, Atlanta, GA, USA
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8
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van de Meeberg MM, Hebing RCF, Nurmohamed MT, Fidder HH, Heymans MW, Bouma G, de Bruin-Weller MS, Tekstra J, van den Bemt B, de Jonge R, Bulatović Ćalasan M. A meta-analysis of methotrexate polyglutamates in relation to efficacy and toxicity of methotrexate in inflammatory arthritis, colitis and dermatitis. Br J Clin Pharmacol 2023; 89:61-79. [PMID: 36326810 PMCID: PMC10099850 DOI: 10.1111/bcp.15579] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/14/2022] [Accepted: 10/25/2022] [Indexed: 11/05/2022] Open
Abstract
AIMS In immune-mediated inflammatory diseases (IMIDs), early symptom control is a key therapeutic goal. Methotrexate (MTX) is the first-line treatment across IMIDs. However, MTX is underutilized and suboptimally dosed, partly due to the inability of making individualized treatment decisions through therapeutic drug monitoring (TDM). To implement TDM in clinical practice, establishing a relationship between drug concentration and disease activity is paramount. In this meta-analysis, we investigated the relationship between concentrations of MTX polyglutamates (MTX-PG) in erythrocytes and efficacy as well as toxicity across IMIDs. METHODS Studies analysing MTX-PG in relation to disease activity and/or toxicity were included for inflammatory arthritis (rheumatoid [RA] and juvenile idiopathic arthritis [JIA]), inflammatory bowel disease (Crohn's and ulcerative colitis) and dermatitis (psoriasis and atopic dermatitis). Meta-analyses were performed resulting in several summary effect measures: regression coefficient (β), correlation coefficient and mean difference (of MTX-PG in responders vs. nonresponders) for IMIDs separately and collectively. RESULTS Twenty-five studies were included. In RA and JIA, higher MTX-PG was significantly associated with lower disease activity at 3 months (β: -0.002; 95% confidence interval [CI]: -0.004 to -0.001) and after 4 months of MTX use (β: -0.003; 95% CI: -0.005 to -0.002). Similarly, higher MTX-PG correlated with lower disease activity in psoriasis (R: -0.82; 95% CI: -0.976 to -0.102). Higher MTX-PG was observed in RA, JIA and psoriasis responders (mean difference: 5.2 nmol/L MTX-PGtotal ; P < .01). CONCLUSION We showed that higher concentrations of erythrocyte MTX-PG were associated with lower disease activity in RA, JIA and psoriasis. These findings are an important step towards implementation of TDM for MTX treatment across IMIDs.
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Affiliation(s)
- Maartje M van de Meeberg
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, The Netherlands
| | - Renske C F Hebing
- Amsterdam Rheumatology and Immunology Center, Reade, Rheumatology, Amsterdam, The Netherlands
| | - Michael T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, Reade, Rheumatology, Amsterdam, The Netherlands
| | - Herma H Fidder
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, The Netherlands
| | | | - Janneke Tekstra
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bart van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Pharmacy, RadboudUMC, Nijmegen, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, The Netherlands
| | - Maja Bulatović Ćalasan
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department of Clinical Chemistry, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Research Institute, Amsterdam, The Netherlands
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9
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Lambert J, Sandhu H, Kean E, Xavier T, Brokman A, Steckler Z, Park L, Stromberg A. A strategy to identify event specific hospitalizations in large health claims databases. BMC Health Serv Res 2022; 22:705. [PMID: 35619126 PMCID: PMC9133593 DOI: 10.1186/s12913-022-08107-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health insurance claims data offer a unique opportunity to study disease distribution on a large scale. Challenges arise in the process of accurately analyzing these raw data. One important challenge to overcome is the accurate classification of study outcomes. For example, using claims data, there is no clear way of classifying hospitalizations due to a specific event. This is because of the inherent disjointedness and lack of context that typically come with raw claims data. METHODS In this paper, we propose a framework for classifying hospitalizations due to a specific event. We then tested this framework in a private health insurance claims database (Symphony) with approximately 4 million US adults who tested positive with COVID-19 between March and December 2020. Our claims specific COVID-19 related hospitalizations proportion is then compared to nationally reported rates from the Centers for Disease Control by age. RESULTS Across all ages (18 +) the total percentage of Symphony patients who met our definition of hospitalized due to COVID-19 was 7.3% which was similar to the CDC's estimate of 7.5%. By age group, defined by the CDC, our estimates vs. the CDC's estimates were 18-49: 2.7% vs. 3%, 50-64: 8.2% vs. 9.2%, and 65 + : 14.6% vs. 28.1%. CONCLUSIONS The proposed methodology is a rigorous way to define event specific hospitalizations in claims data. This methodology can be extended to many different types of events and used on a variety of different types of claims databases.
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Affiliation(s)
- Joshua Lambert
- College of Nursing, University of Cincinnati, Procter Hall, Cincinnati, OH, 45219, USA.
| | - Harpal Sandhu
- Department of Bioengineering, University of Louisville Speed School of Engineering, Eastern Pkwy, Louisville, USA
| | - Emily Kean
- College of Nursing, University of Cincinnati, Procter Hall, Cincinnati, OH, 45219, USA
| | - Teenu Xavier
- College of Nursing, University of Cincinnati, Procter Hall, Cincinnati, OH, 45219, USA
| | - Aviv Brokman
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, USA
| | - Zachary Steckler
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, USA
| | - Lee Park
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, USA
| | - Arnold Stromberg
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, USA
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10
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Chakraborty S, Gupta NV, Sastri KT, M S, Chand P, Kumar H, M. Osmani RA, Gowda DV, Jaind V. Current progressions in transdermal drug delivery systems for management of rheumatoid and osteoarthritis: A comprehensive review. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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Nornberg AB, Martins CC, Cervi VF, Sari MHM, Cruz L, Luchese C, Wilhelm EA, Fajardo AR. Transdermal release of methotrexate by cationic starch/poly(vinyl alcohol)-based films as an approach for rheumatoid arthritis treatment. Int J Pharm 2022; 611:121285. [PMID: 34774696 DOI: 10.1016/j.ijpharm.2021.121285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/25/2021] [Accepted: 11/07/2021] [Indexed: 12/24/2022]
Abstract
Methotrexate (MTX) is a common drug used for rheumatoid arthritis (RA) treatment; however, a series of adverse effects associated with its oral or subcutaneous administration is reported. Transdermal delivery of MTX is an alternative to abate these issues, and the use of drug delivery systems (DDS) based on polymeric films presents an impressive potential for this finality. Based on this, in this study, we report the preparation of films made by cationic starch (CSt), poly(vinyl alcohol) (PVA), and chondroitin sulfate (ChS) to incorporate and release MTX, as well as the in vivo evaluation in model of rheumatoid arthritis in mice. CSt/PVA and CSt/PVA/ChS-based films (with and without MTX) were prepared using a simple protocol under mild conditions. The films loaded with 5 w/w-% of MTX exhibited appreciable drug loading efficiency and distribution. The MTX permeation through the layers of porcine skin demonstrated that most of the drug permeated was detected in the medium, suggesting that the formulation can provide a systemic absorption of the MTX. In vivo studies performed in an arthritis-induced model in mice demonstrated that the MTX-loaded films were able to treat and attenuate the symptoms and the biochemical alterations related to RA (inflammatory process, oxidative stress, and nociceptive behaviors). Besides, the pharmacological activity of MTX transdermally delivery by the CSt/PVA and CSt/PVA/ChS films was comparable to the MTX orally administered. Based on these results, it can be inferred that both films are prominent materials for incorporation and transdermal delivery of MTX in a practical and non-invasive manner.
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Affiliation(s)
- Andressa B Nornberg
- Laboratório de Tecnologia e Desenvolvimento de Compósitos e Materiais Poliméricos (LaCoPol), Universidade Federal de Pelotas (UFPel), Campus Capão do Leão s/n, 96010-900 Pelotas-RS, Brazil
| | - Carolina C Martins
- Laboratório de Pesquisa em Farmacologia Bioquímica (LaFarBio), Universidade Federal de Pelotas (UFPel), Campus Capão do Leão, 96010-900 Pelotas-RS, Brazil
| | - Verônica F Cervi
- Laboratório de Tecnologia Farmacêutica, Centro de Ciências da Saúde, Departamento de Farmácia Industrial, Universidade Federal de Santa Maria (UFSM), 97105-900 Santa Maria-RS, Brazil
| | - Marcel H M Sari
- Laboratório de Tecnologia Farmacêutica, Centro de Ciências da Saúde, Departamento de Farmácia Industrial, Universidade Federal de Santa Maria (UFSM), 97105-900 Santa Maria-RS, Brazil
| | - Letícia Cruz
- Laboratório de Tecnologia Farmacêutica, Centro de Ciências da Saúde, Departamento de Farmácia Industrial, Universidade Federal de Santa Maria (UFSM), 97105-900 Santa Maria-RS, Brazil
| | - Cristiane Luchese
- Laboratório de Pesquisa em Farmacologia Bioquímica (LaFarBio), Universidade Federal de Pelotas (UFPel), Campus Capão do Leão, 96010-900 Pelotas-RS, Brazil
| | - Ethel A Wilhelm
- Laboratório de Pesquisa em Farmacologia Bioquímica (LaFarBio), Universidade Federal de Pelotas (UFPel), Campus Capão do Leão, 96010-900 Pelotas-RS, Brazil.
| | - André R Fajardo
- Laboratório de Tecnologia e Desenvolvimento de Compósitos e Materiais Poliméricos (LaCoPol), Universidade Federal de Pelotas (UFPel), Campus Capão do Leão s/n, 96010-900 Pelotas-RS, Brazil.
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12
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Curtis JR, Nebesky JM, de Bock E, de la Loge C, Arnould B, Davey R, Devenport J, Pethö-Schramm A. Development and validation of the Methotrexate Experience Questionnaire, a new methotrexate oral treatment adherence tool in rheumatoid arthritis. J Patient Rep Outcomes 2021; 5:69. [PMID: 34373947 PMCID: PMC8353039 DOI: 10.1186/s41687-021-00339-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023] Open
Abstract
Objective Despite the development of new biologic therapies, methotrexate (MTX) remains the preferred initial disease-modifying anti-rheumatic drug to treat rheumatoid arthritis (RA). Adherence to disease-modifying anti-rheumatic drugs is suspected to be highly variable potentially leading to reduced treatment effectiveness. This work aimed to develop and validate the Methotrexate Experience Questionnaire (MEQ), a tool to identify and characterize non-adherence to oral MTX. Methods MEQ development included a literature review and qualitative interviews with RA patients and physicians in the United States. A retrospective, cross-sectional study using data from Optimum Patient Care Research Database, a large primary care database of electronic medical records in the United Kingdom, was conducted to finalize the MEQ and evaluate its psychometric properties. Results Three hundred seven e-consented subjects (66% women, mean age of 65 years) completed the MEQ remotely, and were included in this analysis. Item-convergent and divergent validity were generally supportive of the construct validity of the MEQ and Cronbach’s alpha of 0.87 supported its reliability. The MEQ Total score presented statistically significant correlations of small to medium size with all selected concurrent scales, as expected; the highest correlation was obtained between the general acceptance score of ACCEPT and the MEQ Total score (0.55, p < 0.001). Known-groups validity was demonstrated as a logical pattern of higher MEQ scores was obtained for patients considered adherent with both the 6- and 12-month Proportion of Days Covered (mean MEQ total score 82.7 for 12-month PDC ≥ 80% against 76.3 for 12-month PDC < 80%, p< 0.0001). Additionally, a pattern of lower MEQ scores was obtained for patients with more severe disease assessed with Routine Assessment of Patient Index Data 3. Conclusion The 24-item MEQ is a reliable and valid instrument to assess the adherence of RA patients taking MTX, potentially improving over historical refill rate metrics by providing insights into the individual reasons for lack of adherence. This information should facilitate clinician-patient discussions and help inform treatment decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s41687-021-00339-5.
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Affiliation(s)
- Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, FOT 802, 510 20th Street South, Birmingham, AL, 35294, USA.
| | | | | | | | | | | | - Jenny Devenport
- Pharmaceuticals Division, F. Hoffmann-La Roche, Basel, Switzerland
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13
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Muller IB, Lin M, Lems WF, Ter Wee MM, Wojtuszkiewicz A, Nurmohamed MT, Cloos J, Assaraf YG, Jansen G, de Jonge R. Association of altered folylpolyglutamate synthetase pre-mRNA splicing with methotrexate unresponsiveness in early rheumatoid arthritis. Rheumatology (Oxford) 2021; 60:1273-1281. [PMID: 32940699 PMCID: PMC7937028 DOI: 10.1093/rheumatology/keaa428] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 05/23/2020] [Indexed: 02/06/2023] Open
Abstract
Objectives An efficient pharmacological response to MTX treatment in RA patients relies on the retention and accumulation of intracellular MTX-polyglutamates catalysed by the enzyme folylpolyglutamate synthetase (FPGS). We recently identified a partial retention of FPGS intron 8 (8PR) as a prominent splice variant conferring FPGS dysfunction and decreased MTX polyglutamylation in acute lymphoblastic leukaemia. Here, we explored the association between FPGS 8PR levels and lack of MTX responsiveness in RA patients. Methods Thirty-six patients undergoing MTX treatment were enrolled from the Combinatie behandeling Reumatoide Artritis (COBRA)-light trial. RNA was isolated from blood samples at baseline, 13 weeks and 26 weeks of therapy, from patients in either COBRA-light (n = 21) or COBRA (n = 15) treatment arms. RT-qPCR analysis was used to assess RNA levels of FPGS 8PR over wild-type FPGS (8WT). Results In the COBRA-light treatment arm, higher baseline ratios of 8PR/8WT were significantly associated with higher 44-joint disease activity score (DAS44) at 13 and 26 weeks. Higher baseline ratios of 8PR/8WT also trended towards not obtaining low disease activity (DAS <1.6) and becoming a EULAR non-responder at 13 and 26 weeks. In the COBRA-treatment arm, a significant association was observed between high baseline 8PR/8WT ratios and higher DAS44 score at 26 weeks. Higher 8PR/8WT ratios were associated with non-response at week 26 based on both low disease activity and EULAR criteria. Conclusion This study is the first to associate alterations in FPGS pre-mRNA splicing levels with reduced responsiveness to MTX treatment in RA patients. Trial registration ISRCTN55552928.
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Affiliation(s)
- Ittai B Muller
- Department of Clinical Chemistry, Amsterdam, The Netherlands
| | - Marry Lin
- Department of Clinical Chemistry, Amsterdam, The Netherlands
| | - Willem F Lems
- Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Marieke M Ter Wee
- Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Anna Wojtuszkiewicz
- Department of Hematology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Michael T Nurmohamed
- Amsterdam Rheumatology and Immunology Center, location Reade, Amsterdam, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Yehuda G Assaraf
- The Fred Wyszkowski Cancer Research Laboratory, Department of Biology, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gerrit Jansen
- Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam, The Netherlands
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14
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Jain S, Dhir V, Aggarwal A, Gupta R, Leishangthem B, Naidu S, Khullar A, Maurya S, Dhawan V, Sharma SK, Sharma A, Jain S. Comparison of two dose escalation strategies of methotrexate in active rheumatoid arthritis: a multicentre, parallel group, randomised controlled trial. Ann Rheum Dis 2021; 80:1376-1384. [PMID: 34112656 DOI: 10.1136/annrheumdis-2021-220512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/25/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES There are no head-to-head trials of different dose escalation strategies of methotrexate (MTX) in RA. We compared the efficacy, safety and tolerability of 'usual' (5 mg every 4 weeks) versus 'fast' (5 mg every 2 weeks) escalation of oral MTX. METHODS This multicentre, open-label (assessor blinded) RCT included patients 18-55 years of age having active RA with disease duration <5 years, and not on DMARDs. Patients were randomized 1:1 into usual or fast escalation groups, both groups starting MTX at 15 mg/week till a maximum of 25 mg/week. Primary outcome was EULAR good response at 16 weeks, secondary outcomes were ΔDAS28 and adverse effects (AE). Analyses were intention-to-treat. RESULTS 178 patients with mean DAS28-CRP of 5.4(1.1) were randomized to usual (n=89) or fast escalation groups (n=89). At 16 weeks, there was no difference in good EULAR response in the usual (28.1%) or fast escalation (22.5%) groups (p=0.8). There was no difference in mean ΔDAS28-CRP at 8 weeks (-0.9, -0.8, p=0.72) or 16 weeks (-1.3, -1.3, p=0.98). Even at 24 weeks (extended follow-up), responses were similar. There were no inter-group differences in ΔHAQ, or MTX-polyglutamates 1-3 levels at 8 or 16 weeks. Gastrointestinal AE were higher in the fast escalation group over initial 8 weeks (27%, 40%, p=0.048), but not over 16 weeks. There was no difference in cytopenias, transaminitis, or drug discontinuation/dose reduction between the groups. No serious AE were seen. CONCLUSION A faster MTX escalation strategy in RA was not more efficacious over 16-24 weeks, and did not significantly increase AE, except higher gastrointestinal AE initially. TRIAL REGISTRATION NUMBER CTRI/2018/12/016549.
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Affiliation(s)
- Siddharth Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ranjan Gupta
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India
| | - Bidyalaxmi Leishangthem
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Naidu
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aastha Khullar
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Supriya Maurya
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Veena Dhawan
- Department of Experimental Medicine and Biotechnology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shefali Khanna Sharma
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Tornero Molina J, López Robledillo JC, Casamira Ruiz N. Potential Benefits of the Self-Administration of Subcutaneous Methotrexate with Autoinjector Devices for Patients: A Review. DRUG HEALTHCARE AND PATIENT SAFETY 2021; 13:81-94. [PMID: 33824602 PMCID: PMC8018568 DOI: 10.2147/dhps.s290771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/02/2021] [Indexed: 11/30/2022]
Abstract
The role of patient adherence in improving the efficacy of any treatment is widely accepted, as well as its impact in optimizing the use of healthcare resources and associated costs. Adherence is particularly affected in chronic conditions, such as rheumatoid arthritis (RA), requiring long-term therapies and a commitment of the patient to manage his/her disease. Methotrexate (MTX) is one of the mainstays of treatment for several immune-mediated inflammatory joint and skin diseases, especially RA. The use of parenteral MTX, particularly when administered as a subcutaneous (SC) injection, has recently raised a great interest to overcome the limitations of oral MTX. For addressing this issue, new optimized self-injection systems have been developed to improve the ease of use of SC MTX. Increasing evidence shows how patients tend to opt for autoinjectors over prefilled syringes or conventional syringes in terms of easiness of use, preference and satisfaction, regardless of whether the treatment is a biologic or MTX. Additionally, positive views and beliefs of patients about treatment may contribute to increasing expectations of effectiveness and treatment adherence. Similarly, the implementation of prefilled pens in clinical practice might be a way to facilitate and simplify the self-injection of SC MTX delivery, optimizing adherence and treatment outcomes as a consequence. This article aimed to review the available literature data on the use of MTX autoinjectors and their impact on treatment adherence and patients’ perceptions.
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16
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Zhang L, Chen F, Geng S, Wang X, Gu L, Lang Y, Li T, Ye S. Methotrexate (MTX) Plus Hydroxychloroquine versus MTX Plus Leflunomide in Patients with MTX-Resistant Active Rheumatoid Arthritis: A 2-Year Cohort Study in Real World. J Inflamm Res 2020; 13:1141-1150. [PMID: 33376379 PMCID: PMC7755368 DOI: 10.2147/jir.s282249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/18/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose To compare the efficacy, safety, and cost-effectiveness of methotrexate (MTX) plus hydroxychloroquine (HCQ) vs MTX plus leflunomide (LEF) in established rheumatoid arthritis (RA) with inadequate response to MTX monotherapy in a real-world Chinese cohort. Patients and Methods A prospective RA cohort (n=549) was screened with eligible patients who had inadequate response (disease activity score in 28 joints using erythrocyte sedimentation rate, DAS28-ESR>3.2) to initial MTX monotherapy and subsequently received either MTX+HCQ or MTX+LEF. Propensity score matching (PSM) was applied to adjust the possible baseline confounders between two groups. The primary outcome was the proportion of patients achieving first remission (DAS28-ESR<2.6) during follow-up by log rank test. Secondary outcomes were changes of DAS28, glucocorticoids (GCs) exposure, safety, cost-effectiveness, sustained remission, and low disease activity (LDA) rate after 24-month follow-up. Results Overall, 222 eligible patients were subjected to the aforementioned two treatment protocols (MTX+HCQ, n=102; MTX+LEF, n=120). After PSM adjustment, 97 patients in each group were analyzed. A higher remission rate was observed in the MTX+HCQ group than in the MTX+LEF group (70.1% vs 56.7%, P=0.048). The median time to remission was 11 and 16 months in the two groups, respectively. At the endpoint, more patients achieved remission (46.8% vs 32.5%, P=0.063) and maintained sustained LDA in the HCQ group (53.2% vs 38.6%, P=0.062) and also more patients withdrew GCs in this group (32% vs 16.7%, P=0.053) than those in the LEF group. Safety profiles were non-alarming, with no significant difference between the two groups. The incremental cost-effectiveness ratio yielded by MTX+HCQ over MTX+LEF was $1,111.8 per quality-adjusted life-year (QALY), within the cost-effective threshold set as the per capita gross domestic product (GDP) of China. Conclusion The MTX+HCQ combination was seemingly superior to MTX+LEF in a real-world cohort of Chinese RA patients with inadequate response to methotrexate monotherapy in respect of the efficacy and cost-effectiveness.
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Affiliation(s)
- Le Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.,Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Fangfang Chen
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Shikai Geng
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaodong Wang
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Liyang Gu
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Yitian Lang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Ting Li
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Shuang Ye
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
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17
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Mahr TA, Lieberman JA, Haselkorn T, Damle V, Ali Y, Chidambaram A, Griffin NM, Sublett JW. Characteristics of Peanut Allergy Diagnosis in a US Health Care Claims Database (2011-2017). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1683-1694.e5. [PMID: 33346150 DOI: 10.1016/j.jaip.2020.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Peanut allergy is the most common food allergy among children. Studies assessing the burden of peanut allergy in a real-world setting are limited. OBJECTIVE To estimate annual incidence and prevalence of peanut allergy cases among children aged 4 to 17 years and assess severe reaction and associated health care utilization rates. METHODS Patient longitudinal data between January 2011 and December 2017 from a geographically and payer-type representative US health care claims database were used. Peanut allergy cases were identified using diagnostic codes and/or services indicating peanut-allergy-associated severe reactions/anaphylaxis. Estimated annual incidence was defined as peanut-allergic births as a proportion of all 1-year-olds and adjusted for less than 100% data set capture, undercoding, patient underpresenting rates, and spontaneous outgrowth. Prevalence was calculated on the basis of incidence. To assess rates of severe reactions to peanut and associated health care utilization, the cohort of 720,490 peanut allergy cases identified in 2011 was evaluated over a 6-year period from 2011 to 2017. RESULTS Annual incidence increased from 1.7% to 5.2% between 2001 and 2017. Estimated prevalence in 4- to 17-year-olds was 1.25 million (2.2%) in 2017. Atopic comorbidities (asthma, 60.8%; atopic dermatitis, 61.7%) and other food allergies (35.3%) were common. Severe reactions (≥1) were observed in more than half (n = 399,806) the patients, and 37.9% were triggered by an accidental exposure. One in 5 patients (n = 144,883) visited the emergency department due to peanut exposure. CONCLUSIONS Claims data suggest that the incidence and prevalence of peanut allergy in the United States may be increasing. Estimated severe reaction rates and health care utilization were high, suggesting that the burden of peanut allergy may be considerable.
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Affiliation(s)
- Todd A Mahr
- Division of Allergy, Asthma, and Immunology, Gundersen Health System, La Crosse, Wis.
| | - Jay A Lieberman
- Department of Pediatrics, Division of Pulmonology, Allergy, & Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | | | - Varsha Damle
- Aimmune Therapeutics, a Nestle Health Science Company, Brisbane, Calif
| | - Yasser Ali
- Aimmune Therapeutics, a Nestle Health Science Company, Brisbane, Calif
| | | | - Noelle M Griffin
- Aimmune Therapeutics, a Nestle Health Science Company, Brisbane, Calif
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18
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Rathbun AM, England BR, Mikuls TR, Ryan AS, Barton JL, Shardell MD, Hochberg MC. Relationship Between Depression and Disease Activity in United States Veterans With Early Rheumatoid Arthritis Receiving Methotrexate. J Rheumatol 2020; 48:813-820. [PMID: 33191277 DOI: 10.3899/jrheum.200743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Depression is common in patients with rheumatoid arthritis (RA), exacerbates disease activity, and may decrease response to first-line disease-modifying antirheumatic drugs. This study aimed to determine if depression affects disease activity among veterans with early RA prescribed methotrexate (MTX). METHODS Participants included veterans enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry with early RA (onset < 2 yrs) prescribed MTX. Depression was assessed at enrollment using the International Classification of Diseases, 9th revision codes (296.2-296.39, 300.4, 311). Disease activity was measured using the Disease Activity Score in 28 joints (DAS28) and other core measures of RA disease activity. Propensity score weights were used to adjust depressed (n = 48) and nondepressed (n = 220) patients on baseline confounders within imputed datasets. Weighted estimating equations were used to assess standardized mean differences in disease activity between depressed and nondepressed patients at 6-month, 1-year, and 2-year follow-ups. RESULTS The analytic sample was composed of 268 veterans with early RA prescribed MTX who were predominantly male (n = 239, 89.2%) and older (62.7 yrs, SD 10.6) than patients with RA in the general population. Adjusted estimates indicated that depression was associated with significantly higher DAS28 at 6 months (β 0.35, 95% CI 0.01-0.68) but not at the 1- or 2-year follow-up. Also, depression was associated with significantly worse pain at 6 months (β 0.39, 95% CI 0.04-0.73) and 1 year (β 0.40, 95% CI 0.04-0.75). CONCLUSION In early RA, depression is associated with greater short-term disease activity during MTX treatment, as well as more persistent and severe pain.
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Affiliation(s)
- Alan M Rathbun
- A.M. Rathbun, PhD, MPH, Department of Epidemiology and Public Health, and Department of Medicine, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland;
| | - Bryant R England
- B.R. England, MD, PhD, T.R. Mikuls, MD, MSPH, VA Nebraska-Western Iowa Health Care System, and Department of Internal Medicine, University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska
| | - Ted R Mikuls
- B.R. England, MD, PhD, T.R. Mikuls, MD, MSPH, VA Nebraska-Western Iowa Health Care System, and Department of Internal Medicine, University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska
| | - Alice S Ryan
- A.S. Ryan, PhD, Department of Medicine, University of Maryland Baltimore, School of Medicine, and VA Maryland Health Care System, Baltimore, Maryland
| | - Jennifer L Barton
- J.L. Barton, MD, MCR, VA Portland Health Care System, and Department of Medicine, Oregon Health & Science University, School of Medicine, Portland, Oregon
| | - Michelle D Shardell
- M.D. Shardell, PhD, Department of Epidemiology and Public Health, University of Maryland Baltimore, School of Medicine, Baltimore, Maryland
| | - Marc C Hochberg
- M.C.Hochberg, MD, MPH, Department of Epidemiology and Public Health, and Department of Medicine, University of Maryland Baltimore, School of Medicine, and VA Maryland Health Care System, Baltimore, Maryland, USA
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Ozen G, Pedro S, Michaud K. The Risk of Cardiovascular Events Associated With Disease-modifying Antirheumatic Drugs in Rheumatoid Arthritis. J Rheumatol 2020; 48:648-655. [PMID: 32801134 DOI: 10.3899/jrheum.200265] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine the comparative effects of biologic disease-modifying antirheumatic drugs (bDMARD) and tofacitinib against conventional synthetic DMARD (csDMARD) on incident cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA). METHODS RA patients with ≥ 1 year of participation in the FORWARD study, from 1998 through 2017, were assessed for incident composite CVD events (myocardial infarction, stroke, heart failure, and CVD-related death validated from hospital/death records). DMARD were categorized into 7 mutually exclusive groups: (1) csDMARD-referent; (2) tumor necrosis factor-α inhibitor (TNFi); (3) abatacept (ABA); (4) rituximab; (5) tocilizumab; (6) anakinra; and (7) tofacitinib. Glucocorticoids (GC) were assessed using a weighted cumulative exposure model, which combines information about duration, intensity, and timing of exposure into a summary measure by using the weighted sum of past oral doses (prednisolone equivalent). Cox proportional hazard models were used to adjust for confounders. RESULTS During median (IQR) 4.0 (1.7-8.0) years of follow-up, 1801 CVD events were identified in 18,754 RA patients. The adjusted model showed CVD risk reduction with TNFi (HR 0.81, 95% CI 0.71-0.93) and ABA (HR 0.50, 95% CI 0.30-0.83) compared to csDMARD. While higher GC exposure as weighted cumulative exposure was associated with increased CVD risk (HR 1.15, 95% CI 1.11-1.19), methotrexate (MTX) use was associated with CVD risk reduction [use vs nonuse HR 0.82, 95% CI 0.74-0.90, and high dose (> 15 mg/week) vs low dose (≤ 15 mg/week) HR 0.83, 95% CI 0.70-0.99]. CONCLUSION ABA and TNFi were associated with decreased risk of CVD compared to csDMARD. Minimizing GC use and optimizing MTX dose may improve cardiovascular outcomes in patients with RA.
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Affiliation(s)
- Gulsen Ozen
- G. Ozen, MD, University of Nebraska Medical Center, Omaha, Nebraska
| | - Sofia Pedro
- S. Pedro, MS, FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Kaleb Michaud
- K. Michaud, PhD, University of Nebraska Medical Center, Omaha, Nebraska, and FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas, USA.
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Development and characterisation of novel poly (vinyl alcohol)/poly (vinyl pyrrolidone)-based hydrogel-forming microneedle arrays for enhanced and sustained transdermal delivery of methotrexate. Int J Pharm 2020; 586:119580. [DOI: 10.1016/j.ijpharm.2020.119580] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 12/11/2022]
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21
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Moura CS, Schieir O, Valois M, Thorne C, Bartlett SJ, Pope JE, Hitchon CA, Boire G, Haraoui B, Hazlewood GS, Keystone EC, Tin D, Bykerk VP, Bernatsky S, Baron M, Bessette L, Colmegna I, Fallavollita S, Haaland D, Haraoui P, Jamal S, Jamal S, Joshi R, Nair B, Panopoulos P, Penney C, Rubin L, Villeneuve E, Zummer M. Treatment Strategies in Early Rheumatoid Arthritis Methotrexate Management: Results From a Prospective Cohort. Arthritis Care Res (Hoboken) 2020; 72:1104-1111. [DOI: 10.1002/acr.23927] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 05/14/2019] [Indexed: 11/08/2022]
Affiliation(s)
| | | | | | - Carter Thorne
- Southlake Regional Health Center Newmarket California USA
| | | | | | | | - Gilles Boire
- Université de Sherbrooke Sherbrooke Quebec Canada
| | - Boulos Haraoui
- Institut de Rhumatologie de Montréal Montreal Quebec Canada
| | - Glen S. Hazlewood
- University of Toronto, Toronto, Ontario, Canada and University of Calgary Calgary Alberta Canada
| | | | - Diane Tin
- Southlake Regional Health Center Newmarket California USA
| | - Vivian P. Bykerk
- Mount Sinai Hospital, Toronto, Ontario, Canada and Hospital for Special Surgery New York
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Li CKH, Baker K, Jones T, Coulson E, Roberts A, Birrell F. Safety and Tolerability of Subcutaneous Methotrexate in Routine Clinical Practice. Arthritis Care Res (Hoboken) 2020; 73:1306-1311. [PMID: 32475009 DOI: 10.1002/acr.24334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/19/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To show the safety and efficacy of subcutaneous (SC) methotrexate (MTX) compared to oral MTX, alternative disease-modifying antirheumatic drugs (DMARDs) monotherapy, biologic monotherapy, and combinations (conventional and biologic combination groups) in routine clinical practice. METHODS Clinical and laboratory data were retrospectively analyzed for rheumatology clinic attendances at a large Northeast England hospital trust between January 2014 and January 2018. Rates of adverse events and stop events (transaminitis [serum alanine aminotransferase level of >80 units/liter] or neutropenia [neutrophil count of <2.0 × 109 /liter]) were calculated, with adjustment for duration of DMARD exposure. RESULTS In the present study, 8,394 patients received DMARDs, with 2,093 patients receiving oral MTX and 949 patients receiving SC MTX. The median dose was 15 mg (interquartile range [IQR] 10-20 mg) for oral MTX, and 20 mg (IQR 15-25 mg) for SC MTX (P < 0.0001). Continuation rates were higher for SC MTX therapy when adjusted for follow-up duration, with a rate ratio (RR) of 1.54 (95% confidence interval [95% CI] 1.40-1.70) (P < 0.0001). For the time period assessed, 2,382 patients experienced 4,358 adverse events, with 1,711 incidents of transaminitis and 2,647 incidents of neutropenia recorded. Significantly fewer adverse events were observed in patients who received SC MTX monotherapy versus those who received biologic and combination DMARD therapies (P < 0.01). Compared to oral MTX, SC MTX was associated with a nonsignificant trend toward lower rates of neutropenia, but only a slightly higher rate of transaminitis (RR 1.26 [95% CI 1.07-1.48]) (P = 0.006), despite significantly higher doses of MTX. CONCLUSION Subcutaneous MTX is safe in routine clinical practice. This is the largest study yet reported on SC MTX and provides observational data that SC MTX is continued longer and better tolerated in patients compared to other therapy groups, especially oral MTX.
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Affiliation(s)
- Christien K H Li
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Kenneth Baker
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Tania Jones
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Elizabeth Coulson
- Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Fraser Birrell
- Translational and Clinical Research Institute, Newcastle University and Northumbria Healthcare NHS Foundation Trust, Newcastle Upon Tyne, UK
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Koduri GM, Mukhtyar C. Why subcutaneous methotrexate should be a prerequisite to biologic use in patients with rheumatoid arthritis. Rheumatology (Oxford) 2020; 58:559-560. [PMID: 29672739 DOI: 10.1093/rheumatology/key097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Gouri M Koduri
- Rheumatology Department, Southend University Hospital NHSFT, Southend-on-Sea, UK
| | - Chetan Mukhtyar
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
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Warum wir parenterales Methotrexat zur Behandlung der rheumatoiden Arthritis empfehlen: eine Erwiderung und Überblick über die Literatur. Z Rheumatol 2019; 78:385-387. [DOI: 10.1007/s00393-019-0628-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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How to Get the Most from Methotrexate (MTX) Treatment for Your Rheumatoid Arthritis Patient?-MTX in the Treat-to-Target Strategy. J Clin Med 2019; 8:jcm8040515. [PMID: 30991730 PMCID: PMC6518419 DOI: 10.3390/jcm8040515] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 02/07/2023] Open
Abstract
Methotrexate (MTX) is a remarkable drug with a key role in the management of rheumatoid arthritis (RA) at every stage of its evolution. Its attributes include good overall efficacy for signs and symptoms, inhibition of structural damage and preservation of function with acceptable and manageable safety, a large dose-titratable range, options for either an oral or parenteral route of administration, and currently unrivalled cost-effectiveness. It has a place as a monotherapy and also as an anchor drug that can be safely used in combination with other conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or used concomitantly with biological DMARDs or targeted synthetic DMARDs. MTX is not without potential issues regarding toxicity, notably hepatotoxicity and bone marrow toxicity, as well as tolerability problems for some, but not all, patients. But many of these issues can be mitigated or managed. In the face of a welcome expansion in available targeted therapies for the treatment of RA, MTX looks set to remain at the foundation of pharmacotherapy for the majority of people living with RA and other inflammatory rheumatic diseases. In this article, we provide an evidence-based discussion as to how to achieve the best outcomes with this versatile drug in the context of a treat-to-target strategy for the management of RA.
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Muller IB, Hebing RF, Jansen G, Nurmohamed MT, Lems WF, Peters GJ, de Jonge R. Personalized medicine in rheumatoid arthritis: methotrexate polyglutamylation revisited. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2018. [DOI: 10.1080/23808993.2018.1517025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Ittai B. Muller
- Department of Clinical Chemistry, VU University Medical Center, Amsterdam, The Netherlands
| | - Renske F. Hebing
- Reade Research, Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
| | - Gerrit Jansen
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Mike T. Nurmohamed
- Reade Research, Amsterdam Rheumatology and immunology Center, Amsterdam, The Netherlands
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Willem F. Lems
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, Amsterdam, The Netherlands
| | - Godefridus J. Peters
- Department of Medical Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, VU University Medical Center, Amsterdam, The Netherlands
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Moura CA, Moura CG. Methotrexate still works: comment on the articles by Rohr et al and Hirata et al. Arthritis Care Res (Hoboken) 2018; 70:1118. [DOI: 10.1002/acr.23342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Carlos Antonio Moura
- Hospital Santo Antonio; Escola Bahiana de Medicina e Saúde Pública and Universidade Salvador (UNIFACS); Bahia Brazil
| | - Carlos Geraldo Moura
- Hospital Santo Antonio and Escola Bahiana de Medicina e Saúde Pública; Bahia Brazil
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Doshi JA, Li P, Huo H, Pettit AR, Armstrong KA. Association of Patient Out-of-Pocket Costs With Prescription Abandonment and Delay in Fills of Novel Oral Anticancer Agents. J Clin Oncol 2018; 36:476-482. [DOI: 10.1200/jco.2017.74.5091] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The number of novel oral anticancer agents is increasing, but financial barriers may limit access. We examined associations between out-of-pocket (OOP) costs and reduced and/or delayed treatment initiation. Methods This retrospective claims-based study used 2014 to 2015 data from a large, proprietary, integrated database and included Medicare and commercial insurance enrollees with a new, adjudicated prescription for any of 38 oral anticancer agents. We examined rates of claim reversal (failure to purchase approved prescription), delayed initiation (reversal with subsequent fill of same agent within 90 days after adjudication), and abandonment (reversal with no fill of same agent within 90 days after adjudication) for the index oral anticancer agent. We also examined whether patients filled any alternate oral, injectable, or infusible anticancer agent within 90 days. Logistic regressions controlled for sociodemographic, clinical, and treatment characteristics to estimate adjusted rates. Results Among the final sample (N = 38,111), risk-adjusted rates of claim reversal ranged from 13% to 67%, increasing with higher OOP costs. Although the abandonment rate was 18% overall, risk-adjusted rates were higher in greater OOP cost categories (10.0% for ≤ $10 group v 13.5% for $50.01 to $100 group, 31.7% for $100.01 to $500 group, 41.0% for $500.01 to $2,000 group, and 49.4% for > $2,000 group; P < .001 compared with ≤ $10 group). Rates remained similar after accounting for use of alternate oral, injectable, or infusible anticancer agents. Delayed initiation was also more frequent for higher OOP cost categories (3% in ≤ $10 group v 18% in > $2,000 group; P < .001). Sensitivity and subgroup analyses by insurance type, pharmacy type, sex, and indication identified similar associations. Conclusion Higher OOP costs were associated with higher rates of oral prescription abandonment and delayed initiation across cancers. Fiscally sustainable strategies are needed to improve patient access to cancer medications.
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Affiliation(s)
- Jalpa A. Doshi
- Jalpa A. Doshi, Pengxiang Li, Hairong Huo, and Amy R. Pettit, University of Pennsylvania, Philadelphia, PA; and Katrina A. Armstrong, Massachusetts General Hospital, Boston, MA
| | - Pengxiang Li
- Jalpa A. Doshi, Pengxiang Li, Hairong Huo, and Amy R. Pettit, University of Pennsylvania, Philadelphia, PA; and Katrina A. Armstrong, Massachusetts General Hospital, Boston, MA
| | - Hairong Huo
- Jalpa A. Doshi, Pengxiang Li, Hairong Huo, and Amy R. Pettit, University of Pennsylvania, Philadelphia, PA; and Katrina A. Armstrong, Massachusetts General Hospital, Boston, MA
| | - Amy R. Pettit
- Jalpa A. Doshi, Pengxiang Li, Hairong Huo, and Amy R. Pettit, University of Pennsylvania, Philadelphia, PA; and Katrina A. Armstrong, Massachusetts General Hospital, Boston, MA
| | - Katrina A. Armstrong
- Jalpa A. Doshi, Pengxiang Li, Hairong Huo, and Amy R. Pettit, University of Pennsylvania, Philadelphia, PA; and Katrina A. Armstrong, Massachusetts General Hospital, Boston, MA
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Bello AE, Perkins EL, Jay R, Efthimiou P. Recommendations for optimizing methotrexate treatment for patients with rheumatoid arthritis. Open Access Rheumatol 2017; 9:67-79. [PMID: 28435338 PMCID: PMC5386601 DOI: 10.2147/oarrr.s131668] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methotrexate (MTX) remains the cornerstone therapy for patients with rheumatoid arthritis (RA), with well-established safety and efficacy profiles and support in international guidelines. Clinical and radiologic results indicate benefits of MTX monotherapy and combination with other agents, yet patients may not receive optimal dosing, duration, or route of administration to maximize their response to this drug. This review highlights best practices for MTX use in RA patients. First, to improve the response to oral MTX, a high initial dose should be administered followed by rapid titration. Importantly, this approach does not appear to compromise safety or tolerability for patients. Treatment with oral MTX, with appropriate dose titration, then should be continued for at least 6 months (as long as the patient experiences some response to treatment within 3 months) to achieve an accurate assessment of treatment efficacy. If oral MTX treatment fails due to intolerability or inadequate response, the patient may be "rescued" by switching to subcutaneous delivery of MTX. Consideration should also be given to starting with subcutaneous MTX given its favorable bioavailability and pharmacodynamic profile over oral delivery. Either initiation of subcutaneous MTX therapy or switching from oral to subcutaneous administration improves persistence with treatment. Upon transition from oral to subcutaneous delivery, MTX dosage should be maintained, rather than increased, and titration should be performed as needed. Similarly, if another RA treatment is necessary to control the disease, the MTX dosage and route of administration should be maintained, with titration as needed.
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Affiliation(s)
| | | | - Randy Jay
- Arizona Arthritis & Rheumatology Associates, Phoenix, AZ
| | - Petros Efthimiou
- Division of Rheumatology, New York Methodist Hospital, Brooklyn, NY, USA
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