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Wientjes MHM, Ulijn E, Kievit W, Landewé RBM, Meek I, den Broeder N, van Herwaarden N, van den Bemt BJF, Verhoef LM, den Broeder AA. The added value of predictive biomarkers in treat-to-target strategies for rheumatoid arthritis patients: a conceptual modelling study. Rheumatology (Oxford) 2023; 62:2700-2706. [PMID: 36538875 DOI: 10.1093/rheumatology/keac709] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 12/13/2022] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVES To quantify the additional value of a hypothetical biomarker predicting response to treatment for RA regarding efficacy and costs by using a modelling design. METHODS A Markov model was built comparing a usual care T2T strategy with a biomarker-steered strategy for RA patients starting biologic therapy. Outcome measures include time spent in remission or low disease activity (LDA) and costs. Four additional scenario analyses were performed by varying biomarker or clinical care characteristics: (i) costs of the biomarker; (ii) sensitivity and specificity of the biomarker; (iii) proportion of eligible patients tapering; and (iv) medication costs. RESULTS In the base model, patients spent 2.9 months extra in LDA or remission in the biomarker strategy compared with usual care T2T over 48 months. Total costs were €43 301 and €42 568 for, respectively, the usual care and biomarker strategy, and treatment costs accounted for 91% of total costs in both scenarios. Cost savings were driven due to patients in the biomarker strategy experiencing remission or LDA earlier, and starting tapering sooner. Cost-effectiveness was not so much driven by costs or test characteristics of the biomarker (scenario 1/2), but rather by the level of early and proactive tapering and drug costs (scenarios 3/4). CONCLUSIONS The use of a biomarker for prediction of response to b/tsDMARD treatment in RA can be of added value to current treat-to-target clinical care. However, gains in efficacy are modest and cost gains are depending on a combination of early proactive tapering and high medication costs.
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Affiliation(s)
- Maike H M Wientjes
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Evy Ulijn
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Wietske Kievit
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert B M Landewé
- Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Clinical Immunology Center, Amsterdam, The Netherlands
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Inger Meek
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Noortje van Herwaarden
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
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2
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ÇAPKIN E. Musculoskeletal ultrasonography in rheumatic diseases. Turk J Med Sci 2023; 53:1537-1551. [PMID: 38813491 PMCID: PMC10760546 DOI: 10.55730/1300-0144.5723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 12/12/2023] [Accepted: 07/20/2023] [Indexed: 05/31/2024] Open
Abstract
Ultrasonography is an imaging technique based on sound waves used for the evaluation of soft tissues. Sound waves have been used for a long time in nonmedical fields, including military defense systems, radar systems, and detection of icebergs. Technological advances resulted in new techniques becoming available for medical imaging, including ultrasonography, magnetic resonance imaging, and computed tomography. Nowadays, the use of imaging has become a gold standard protocol in the diagnosis of many diseases, and recently developed diagnosis and therapy options provide more efficient treatment of rheumatic diseases. Thus, it has become possible to prevent structural damage and disability in patients with rheumatic disease. Musculoskeletal ultrasonography is becoming a preferred imaging technique for rheumatic diseases, as it has many advantages. Among its advantages are being inexpensive, being radiation-free, having a dynamic image capacity, helping to detect disease activity, and helping with early detection and diagnosis of structural damage. This review summarizes the use of ultrasonography in rheumatic diseases.
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Affiliation(s)
- Erhan ÇAPKIN
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Karadeniz Technical University, Farabi Hospital, Trabzon,
Turkiye
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3
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Subhas N, Wu F, Fox MG, Nacey N, Aslam F, Blankenbaker DG, Caracciolo JT, DeJoseph DA, Frick MA, Jawetz ST, Said N, Sandstrom CK, Sharma A, Stensby JD, Walker EA, Chang EY. ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update. J Am Coll Radiol 2023; 20:S20-S32. [PMID: 37236743 DOI: 10.1016/j.jacr.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings among the various types of arthritis. This document provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Fangbai Wu
- Research Author, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Michael G Fox
- Program Director and Panel Chair, Mayo Clinic Arizona, Phoenix, Arizona
| | - Nicholas Nacey
- Panel Vice-Chair, University of Virginia Health System, Charlottesville, Virginia
| | - Fawad Aslam
- Mayo Clinic, Scottsdale, Arizona, Rheumatologist
| | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jamie T Caracciolo
- Section Head, Musculoskeletal Imaging, Moffitt Cancer Center and University of South Florida Morsani College of Medicine, Tampa, Florida; and Chair, MSK-RADS (Bone) Committee
| | | | - Matthew A Frick
- Chair of Education, Department of Radiology, Chair of Musculoskeletal Imaging, Mayo Clinic, Rochester, Minnesota
| | | | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
| | - Claire K Sandstrom
- University of Washington Medical Center, Seattle, Washington; Committee on Emergency Radiology-GSER
| | - Akash Sharma
- Mayo Clinic, Jacksonville, Florida; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Eric Y Chang
- Specialty Chair, VA San Diego Healthcare System, San Diego, California
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4
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Liu H, Chen S, Huang C, Zheng Q, Ye Y, Ye Z, Lyu G. Longitudinal Changes in Knee Joint Synovial Vascularity in a Rabbit Model of Rheumatoid Arthritis: Quantification Using Power Doppler Ultrasound and Contrast-Enhanced Ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2430-2441. [PMID: 33958258 DOI: 10.1016/j.ultrasmedbio.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 02/24/2021] [Accepted: 03/16/2021] [Indexed: 06/12/2023]
Abstract
We studied a rabbit model of rheumatoid arthritis (RA) to examine the time course of changes in synovial neovascularization based on quantitative power Doppler ultrasound and contrast-enhanced ultrasound (CEUS). Twenty-five male New Zealand rabbits were in the ovalbumin-induced arthritis (OIA) group, and 5 were in the control group. Both rear knee joints of all rabbits were examined using conventional US and CEUS over 16 weeks. The knee synoviums of OIA rabbits were sampled by US-guided biopsy, and expression of CD31 and vascular endothelial growth factor (VEGF) was determined by immunohistochemistry. The correlation of joint damage based on multimodal US with microvessel density (CD31 positivity) and VEGF expression at different times was analyzed. OIA rabbits had increased synovial expression of CD31 and VEGF from weeks 6 to 12 (p < 0.01). During the early stage of CEUS enhancement, "dot enhancement" was more common at weeks 6 and 8, and "stripe enhancement" was more common at weeks 12 and 16 (p < 0.05). There were significant positive correlations of synovial CD31 and VEGF expression with power Doppler image grade, CEUS grade and peak intensity (p < 0.05 for all). Thus, OIA rabbits mimicked early-stage RA at 6 to 8 weeks, middle-stage RA at 8 to 12 weeks and late-stage RA at 12 to 16 weeks. Power Doppler image grade, CEUS grade and peak intensity, especially when combined with CD31 expression data, accurately characterized the extent of synovial vascularization in a rabbit model of RA. Increased vascularity based on CEUS may have value for the early diagnosis of RA.
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Affiliation(s)
- Hui Liu
- Department of Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuqiang Chen
- Department of Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Chao Huang
- Department of Nuclear Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qing Zheng
- Department of Hematology and Rheumatology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yuhong Ye
- Department of Pathology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhen Ye
- Department of Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Guorong Lyu
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China; Department of Clinical Medicine, Quanzhou Medical College, Quanzhou, China.
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5
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Ranganath VK, Hammer HB, McQueen FM. Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI. Best Pract Res Clin Rheumatol 2020; 34:101593. [PMID: 32988757 DOI: 10.1016/j.berh.2020.101593] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.
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Affiliation(s)
- Veena K Ranganath
- University of California, David Geffen School of Medicine, Los Angeles, USA.
| | - Hilde B Hammer
- Diakonhjemmet Hospital and University of Oslo, Oslo, Norway
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6
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Smith E, Azzopardi C, Thaker S, Botchu R, Gupta H. Power Doppler in musculoskeletal ultrasound: uses, pitfalls and principles to overcome its shortcomings. J Ultrasound 2020; 24:151-156. [PMID: 32683646 DOI: 10.1007/s40477-020-00489-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/05/2020] [Indexed: 11/26/2022] Open
Abstract
Power Doppler (PD) is used widely in musculoskeletal ultrasound, especially in the assessment of structures for evidence of inflammation and in evaluating soft tissue neoplasms. We reinforce and delineate the three cardinal principles of optimising PD assessment in order to avoid false positive or false negative results; namely (1) Optimal gain settings (2) Adequate transducer pressure, and (3) Proper patient/anatomical structure-of-interest positioning with complete tissue relaxation.
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Affiliation(s)
- E Smith
- Department of Musculoskeletal Radiology, The Royal Orthopedic Hospital, Bristol Road South, Northfield, Birmingham, UK
| | - C Azzopardi
- Department of Musculoskeletal Radiology, The Royal Orthopedic Hospital, Bristol Road South, Northfield, Birmingham, UK
| | - S Thaker
- Department of Radiology, Kettering General Hospital, Kettering, UK
| | - R Botchu
- Department of Musculoskeletal Radiology, The Royal Orthopedic Hospital, Bristol Road South, Northfield, Birmingham, UK.
| | - H Gupta
- Department of Musculoskeletal Imaging, Leeds Teaching Hospital, Leeds, UK
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7
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Coras R, Sturchio GA, Bru MB, Fernandez AS, Farietta S, Badia SC, Diez BR, de Agustín de Oro JJ. Analysis of the correlation between disease activity score 28 and its ultrasonographic equivalent in rheumatoid arthritis patients. Eur J Rheumatol 2020; 7:118-123. [PMID: 32716834 PMCID: PMC7431356 DOI: 10.5152/eurjrheum.2020.20038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/24/2020] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVE To study the differences between disease activity score 28 (DAS28) index and an ultrasound (US) approach using index echographic disease activity score (ECODAS). METHODS This was a cross-sectional study in patients diagnosed with rheumatoid arthritis (RA). Demographic, clinical, and laboratory data were collected. We created a US index (ECODAS) evaluating the joints with synovitis using gray scale US (GSUS) and power Doppler US (PDUS) and calculated the formula of DAS28 index with both variables substituting tender joint for GSUS and swollen joint for PDUS (ECODAS1) and vice versa (ECODAS2). RESULTS A total of 58 patients (65.5% women and 34.5% men) were included in the study. There was no significant difference between the 2 US indexes. We obtained a Pearson's correlation coefficient (Pearson's r) of 0.56 (p<0.00001) between DAS28 and ECODAS1 and of 0.57 (p<0.00001) between DAS28 and ECODAS2, respectively. However, for patients with a high disease activity [DAS28>5.1, tender joint count (TJC, high)], the correlation was poor (0.18) and ECODAS indexes were significantly lower (p=0.001). The correlation increased (0.86, p<0.001) when we excluded the tender joints and the joints with GS-positive synovitis in both the scores. CONCLUSION US reduces the bias in the evaluation of patients with RA with a high value in DAS28 index. We found a clear difference between DAS and ECODAS when TJC was high. The results suggest that joint tenderness reported by the patient is not a good reflection of inflammation. More studies are needed to find a new combined clinical and sonographic index that would better assess the disease activity in patients with RA.
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Affiliation(s)
- Roxana Coras
- Unit of Rheumatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Mireia Barceló Bru
- Unit of Rheumatology, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Sandra Farietta
- Unit of Rheumatology, Vall d'Hebron University Hospital, Barcelona, Spain
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8
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Irby A, Gutierrez J, Chamberlin C, Thomas SJ, Rosen AB. Clinical management of tendinopathy: A systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments. Scand J Med Sci Sports 2020; 30:1810-1826. [PMID: 32484976 DOI: 10.1111/sms.13734] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 05/18/2020] [Accepted: 05/25/2020] [Indexed: 12/11/2022]
Abstract
While the pathoetiology is disputed, a wide array of treatments is available to treat tendinopathy. The most common treatments found in the literature include therapeutic modalities, exercise protocols, and surgical interventions; however, their effectiveness remains ambiguous. The purpose of this study was to perform a systematic review of systematic reviews to determine the ability of therapeutic interventions to improve pain and dysfunction in patients with tendinopathy regardless of type or location. Five databases were searched for systematic reviews containing only randomized control trials to determine the effectiveness of treatments for tendinopathies based on pain and patient-reported outcomes. Systematic reviews were assessed via the Assessment of Multiple Systematic Reviews (AMSTAR) for methodological quality. From the database search, 3,295 articles were found, 107 passed the initial inclusion criteria. After further review, 25 systematic reviews were included in the final qualitative analysis. The AMSTAR scores were relatively high (8.8 ± 1.0) across the 25 systematic reviews. Eccentric exercises were the most common and consistently effective treatment for tendinopathy across systematic reviews. Low-level laser therapy and extracorporeal shockwave therapy demonstrated moderate effectiveness, while platelet-rich plasma injections demonstrated inconclusive evidence on their ability to decrease tendinopathy-related pain and improve function. Corticosteroids also showed some effectiveness for short-term pain, but for the long-term use deemed ineffective and at times contraindicated. Regarding surgical options, minimally invasive procedures were more effective compared to open surgical interventions. When treating tendinopathy regardless of location, eccentric exercises were the best treatment option to improve tendinopathy-related pain and improve self-reported function.
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Affiliation(s)
- Alyssa Irby
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska, USA
| | - Jacqueline Gutierrez
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska, USA
| | - Claressa Chamberlin
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska, USA
| | - Stephen J Thomas
- Department of Health and Rehabilitation Sciences, Temple University, Philadelphia, Pennsylvania, USA
| | - Adam B Rosen
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska, USA
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9
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First in man study of [ 18F]fluoro-PEG-folate PET: a novel macrophage imaging technique to visualize rheumatoid arthritis. Sci Rep 2020; 10:1047. [PMID: 31974480 PMCID: PMC6978456 DOI: 10.1038/s41598-020-57841-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/18/2019] [Indexed: 01/26/2023] Open
Abstract
Non-invasive imaging of arthritis activity in rheumatoid arthritis (RA) patients using macrophage PET holds promise for early diagnosis and therapeutic response monitoring. Previously obtained results with macrophage tracer (R)-[11C]PK11195 were encouraging, but the imaging signal could be further improved by reduction of background uptake. Recently, the novel macrophage tracer [18F]fluoro-PEG-folate was developed. This tracer showed excellent targeting of the folate receptor β on activated macrophages in synovial tissue in a preclinical arthritic rat model. We performed three substudies to investigate the biodistribution, potential for imaging arthritis and kinetic properties of [18F]fluoro-PEG-folate in RA patients. Firstly, biodistribution demonstrated fast clearance of [18F]fluoro-PEG-folate from heart and blood vessels and no dose limiting uptake in organs. Secondly, [18F]fluoro-PEG-folate showed uptake in arthritic joints with significantly lower background and hence significantly higher target-to-background ratios as compared to reference macrophage tracer (R)-[11C]PK11195. Lastly, dynamic scanning demonstrated fast tracer uptake in affected joints, reaching a plateau after 1 minute, co-existing with a rapid blood clearance. In conclusion, this first in man study demonstrates the potential of [18F]fluoro-PEG-folate to image arthritis activity in RA with favourable imaging characteristics of rapid clearance and low background uptake, that allow for detection of inflammatory activity in the whole body.
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10
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Different Original and Biosimilar TNF Inhibitors Similarly Reduce Joint Destruction in Rheumatoid Arthritis-A Network Meta-Analysis of 36 Randomized Controlled Trials. Int J Mol Sci 2019; 20:ijms20184350. [PMID: 31491879 PMCID: PMC6770755 DOI: 10.3390/ijms20184350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/24/2019] [Accepted: 08/29/2019] [Indexed: 11/17/2022] Open
Abstract
The effect of five approved tumour necrosis factor inhibitors (TNFi: infliximab, etanercept, adalimumab, certolizumab, and golimumab) on joint destruction in rheumatoid arthritis (RA) have been compared versus methotrexate (MTX) in randomized controlled trials (RCTs) but have not been compared directly to each other or to an otherwise untreated placebo control. The present analysis compares effects of standard doses, high doses, and low doses of TNFis on radiographic joint destruction in RA and relate these effects to MTX and placebo by means of a Bayesian network meta-analysis. We identified 31 RCTs of the effect of TNFis on joint destruction and 5 RCTs with controls, which indirectly could link otherwise untreated placebo controls to the TNFi treatments in the network. The previously untested comparison with placebo was performed to estimate not only the effect relative to another drug, but also the absolute attainable effect. Compared to placebo there was a highly significant inhibitory effect on joint destruction of infliximab, etanercept, adalimumab, certolizumab, and golimumab, which was about 0.9% per year as monotherapy and about 1.2% per year when combined with MTX. Although significantly better than MTX and placebo, golimumab seemed inferior to the remaining TNFis. There was no difference between original reference drugs (Remicade, Enbrel) and the almost identical copy drugs (biosimilars).
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11
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Ellegaard K, von Bülow C, Røpke A, Bartholdy C, Hansen IS, Rifbjerg-Madsen S, Henriksen M, Wæhrens EE. Hand exercise for women with rheumatoid arthritis and decreased hand function: an exploratory randomized controlled trial. Arthritis Res Ther 2019; 21:158. [PMID: 31242937 PMCID: PMC6595578 DOI: 10.1186/s13075-019-1924-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/22/2019] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND People with hand-related rheumatoid arthritis (RA) experience problems performing activities of daily living (ADL). Compensatory strategies to improve ADL ability have shown effective. Similarly, hand exercise has shown effect on pain, grip strength, and self-reported ability. A combination has shown positive effects based on self-report, but self-report and observation provide distinct information about ADL. The purpose of this study was to examine whether hand exercise as add on to compensatory intervention (CIP) will improve observed ADL ability in RA. METHODS Women (n = 55) with hand-related RA were randomized to CIPEXERCISE (intervention) or CIP only (control). CIP is focused on joint protection, assistive devices, and alternative ways of performing AD. The hand-exercise program addressed range of motion and muscle strength. Primary outcome was change in observed ADL motor ability measured by the Assessment of Motor and Process Skills (AMPS). Baseline measures were repeated after 8 weeks. RESULTS Improvements in ADL motor ability in CIPEXERCISE (mean change = 0.24 logits; 95% CI = 0.09 to 0.39) and CIPCONTROL (mean change =0.20 logits; 95% CI = 0.05 to 0.35) were statistically significant, with no differences between groups (mean difference = 0.04 logits; 95% CI = - 0.16 to 0.25). Thirteen (46.4%) participants in the CIPEXERCISE and 12 (44.4%) in the CIPCONTROL obtained clinically relevant improvements (≥ 0.30 logits) in ADL motor ability; this group difference was not significant (z = 0.15; p = 0.88). CONCLUSION Adding hand exercise to a compensatory intervention did not yield additional benefits in women with hand-related RA. The study was approved by the ethics committee 14th of April 2014 (H-3-2014-025) and registered at ClinicalTrials.gov 16th of May 2014 (NCT02140866).
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Affiliation(s)
- Karen Ellegaard
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.
| | - Cecilie von Bülow
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.,The Research Initiative for Activity Studies and Occupational Therapy, General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Alice Røpke
- Metropolitan University College, Institute for Occupational Therapy and Physiotherapy, Copenhagen, Denmark
| | - Cecilie Bartholdy
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.,Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Inge Skovby Hansen
- Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Signe Rifbjerg-Madsen
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark
| | - Marius Henriksen
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.,Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Eva Ejlersen Wæhrens
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, Nordre Fasanvej 57, DK-2000, Copenhagen F, Denmark.,The Research Initiative for Activity Studies and Occupational Therapy, General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Archer R, Hock E, Hamilton J, Stevens J, Essat M, Poku E, Clowes M, Pandor A, Stevenson M. Assessing prognosis and prediction of treatment response in early rheumatoid arthritis: systematic reviews. Health Technol Assess 2019; 22:1-294. [PMID: 30501821 DOI: 10.3310/hta22660] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic, debilitating disease associated with reduced quality of life and substantial costs. It is unclear which tests and assessment tools allow the best assessment of prognosis in people with early RA and whether or not variables predict the response of patients to different drug treatments. OBJECTIVE To systematically review evidence on the use of selected tests and assessment tools in patients with early RA (1) in the evaluation of a prognosis (review 1) and (2) as predictive markers of treatment response (review 2). DATA SOURCES Electronic databases (e.g. MEDLINE, EMBASE, The Cochrane Library, Web of Science Conference Proceedings; searched to September 2016), registers, key websites, hand-searching of reference lists of included studies and key systematic reviews and contact with experts. STUDY SELECTION Review 1 - primary studies on the development, external validation and impact of clinical prediction models for selected outcomes in adult early RA patients. Review 2 - primary studies on the interaction between selected baseline covariates and treatment (conventional and biological disease-modifying antirheumatic drugs) on salient outcomes in adult early RA patients. RESULTS Review 1 - 22 model development studies and one combined model development/external validation study reporting 39 clinical prediction models were included. Five external validation studies evaluating eight clinical prediction models for radiographic joint damage were also included. c-statistics from internal validation ranged from 0.63 to 0.87 for radiographic progression (different definitions, six studies) and 0.78 to 0.82 for the Health Assessment Questionnaire (HAQ). Predictive performance in external validations varied considerably. Three models [(1) Active controlled Study of Patients receiving Infliximab for the treatment of Rheumatoid arthritis of Early onset (ASPIRE) C-reactive protein (ASPIRE CRP), (2) ASPIRE erythrocyte sedimentation rate (ASPIRE ESR) and (3) Behandelings Strategie (BeSt)] were externally validated using the same outcome definition in more than one population. Results of the random-effects meta-analysis suggested substantial uncertainty in the expected predictive performance of models in a new sample of patients. Review 2 - 12 studies were identified. Covariates examined included anti-citrullinated protein/peptide anti-body (ACPA) status, smoking status, erosions, rheumatoid factor status, C-reactive protein level, erythrocyte sedimentation rate, swollen joint count (SJC), body mass index and vascularity of synovium on power Doppler ultrasound (PDUS). Outcomes examined included erosions/radiographic progression, disease activity, physical function and Disease Activity Score-28 remission. There was statistical evidence to suggest that ACPA status, SJC and PDUS status at baseline may be treatment effect modifiers, but not necessarily that they are prognostic of response for all treatments. Most of the results were subject to considerable uncertainty and were not statistically significant. LIMITATIONS The meta-analysis in review 1 was limited by the availability of only a small number of external validation studies. Studies rarely investigated the interaction between predictors and treatment. SUGGESTED RESEARCH PRIORITIES Collaborative research (including the use of individual participant data) is needed to further develop and externally validate the clinical prediction models. The clinical prediction models should be validated with respect to individual treatments. Future assessments of treatment by covariate interactions should follow good statistical practice. CONCLUSIONS Review 1 - uncertainty remains over the optimal prediction model(s) for use in clinical practice. Review 2 - in general, there was insufficient evidence that the effect of treatment depended on baseline characteristics. STUDY REGISTRATION This study is registered as PROSPERO CRD42016042402. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Rachel Archer
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Munira Essat
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Sweet K, Dasgupta B, de Vries D, Gourley I, Hsu B, Loza MJ, Taylor PC. Sirukumab and adalimumab reduce power Doppler ultrasound signal in patients with rheumatoid arthritis by 4 weeks in a phase III trial. Ann Rheum Dis 2019; 78:1439-1441. [PMID: 31018960 DOI: 10.1136/annrheumdis-2019-215183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/26/2019] [Accepted: 04/11/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Kristen Sweet
- Janssen Research & Development, Spring House, Pennsylvania, USA
| | | | - Dick de Vries
- Janssen Research & Development, Ambler, Pennsylvania, USA
| | - Ian Gourley
- Janssen Research & Development, Ambler, Pennsylvania, USA
| | - Benjamin Hsu
- Janssen Research & Development, Ambler, Pennsylvania, USA
| | - Matthew J Loza
- Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK
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14
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Nozaki Y, Ri J, Sakai K, Shiga T, Inoue A, Nagare Y, Funauchi M, Matsumura I. Prediction of therapeutic responses with ultrasonography in RA patients treated with an anti-TNF drug: a retrospective cohort study. Immunol Med 2019; 41:129-135. [PMID: 30618341 DOI: 10.1080/25785826.2018.1531192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE Ultrasound (US) is more sensitive and reliable than a clinical examination, and is better correlated with the disease activity in rheumatoid arthritis (RA). We conducted the present study to assess the value of US as a screening tool to predict therapeutic responses in RA patients treated with anti-tumor necrosis factor (TNF) drugs. METHODS We retrospectively analyzed the cases of 86 consecutive RA patients who were classified by their DAS28-CRP scores at the 54th week. We assessed two US findings (i.e., the synovial hypertrophy index [SHI] and synovial vascularization) by grey-scale imaging and the Doppler synovitis index (DSI). RESULTS When we applied cut-off points determined by a ROC curve analysis, patients with a lower total SHI (≤34) or DSI (≤7) at baseline were significantly more likely to reach remission (44 patients, 51.2%) as shown by the DAS28-CRP at 54 weeks. On the basis of these cut-off values, we dichotomized all variables and performed a logistic regression analysis using the 54-weeks data; the only predictive factors of remission with anti-TNF therapy were the patients' baseline DAS28-CRP ≤2.7 as low disease activity/remission, and the SHI. CONCLUSION An ultrasound assessment would be a highly useful predictor of the achievement of clinical remission.
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Affiliation(s)
- Yuji Nozaki
- a Department of Hematology and Rheumatology , Kindai University School of Medicine , Osaka , Japan
| | - Jinhai Ri
- a Department of Hematology and Rheumatology , Kindai University School of Medicine , Osaka , Japan
| | - Kenji Sakai
- a Department of Hematology and Rheumatology , Kindai University School of Medicine , Osaka , Japan
| | - Toshihiko Shiga
- a Department of Hematology and Rheumatology , Kindai University School of Medicine , Osaka , Japan
| | - Asuka Inoue
- a Department of Hematology and Rheumatology , Kindai University School of Medicine , Osaka , Japan
| | - Yasuaki Nagare
- a Department of Hematology and Rheumatology , Kindai University School of Medicine , Osaka , Japan
| | - Masanori Funauchi
- a Department of Hematology and Rheumatology , Kindai University School of Medicine , Osaka , Japan
| | - Itaru Matsumura
- a Department of Hematology and Rheumatology , Kindai University School of Medicine , Osaka , Japan
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Is synovial hypertrophy without Doppler activity sensitive to change? Post-hoc analysis from a rheumatoid arthritis ultrasound study. Arthritis Res Ther 2018; 20:224. [PMID: 30285845 PMCID: PMC6235232 DOI: 10.1186/s13075-018-1709-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/28/2018] [Indexed: 11/17/2022] Open
Abstract
Background To explore to what extent synovial hypertrophy in joints without Doppler activity is a sign of active disease, we investigated the sensitivity to change of synovial hypertrophy without Doppler activity during biological disease-modifying antirheumatic drug (bDMARD) treatment in rheumatoid arthritis (RA) patients. Method RA patients initiating or switching bDMARD treatment had ultrasound (US) performed on 36 joints at baseline, and at 3 and 6 months. Synovial hypertrophy by grayscale US and Doppler activity were graded separately from 0 to 3 at the joint level for all time points. Changes in synovial hypertrophy in joints without Doppler activity during treatment were assessed and compared with changes in synovial hypertrophy in joints with Doppler activity. Results We included 151 patients (82.8% women, 80.1% seropositive for anticyclic citrullinated peptide) with a mean ± standard deviation age of 51.4 ± 13.2 years, a disease duration of 9.9 ± 7.9 years, and baseline Disease Activity Score 28-joint count C-reactive peptide (DAS28-CRP) of 4.14 ± 1.32. At baseline, 44.8% of all joints examined (n = 5225) had synovial hypertrophy ≥ 1 and 50.7% of these had synovial hypertrophy without Doppler activity. The improvement in synovial hypertrophy was similar in joints with and without Doppler activity but, when adjusting for the baseline score of synovial hypertrophy, joints with synovial hypertrophy without Doppler had a higher tendency towards a decrease than joints with synovial hypertrophy with Doppler activity independent of grade (3 months: p < 0.0001; 6 months: p = 0.0003). Conclusion Joints with synovial hypertrophy without Doppler activity improve during treatment, independent of the grade. Thus, SH without Doppler activity is not a sign of inactive disease. These findings indicate that joints with synovial hypertrophy without Doppler activity should also be taken in to account when assessing disease activity by US.
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Leblond A, Pezet S, Trouvin AP, Elhai M, Gonzalez V, Allanore Y, Avouac J. Linking systemic angiogenic markers to synovial vascularization in rheumatoid arthritis. PLoS One 2018; 13:e0203607. [PMID: 30188942 PMCID: PMC6126858 DOI: 10.1371/journal.pone.0203607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/03/2018] [Indexed: 12/20/2022] Open
Abstract
Background Neoangiogenesis is a crucial event to promote the development of the hyperplasic proliferative pathologic synovium in Rheumatoid arthritis (RA). Ultrasound (US) is sensitive for detection of power Doppler (PD) vascularization. Objective To explore the associations between a set of complementary circulating angiogenic markers and a comprehensive US assessment in patients with RA. Patients and methods Serum levels of eight angiogenic markers were measured by quantitative ELISAs in a total of 125 patients with RA, who were all systematically assessed in parallel by PDUS, performed on 32 joints. Results Serum levels of soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1) and Tie-2 were more likely to be increased in patients with synovial hyperemia detected on at least one joint (Power Doppler grade ≥1). sVCAM-1, Tie-2 and Angiostatin concentrations gradually increased together with the grade of the semiquantitative PDUS scale and concentrations of these three markers were markedly increased in patients with moderate to marked hyperemia (Power Doppler grade 2 and 3). Levels of sVCAM-1, Tie-2, and Angiostatin correlated with a global arthritis sum score, defined by the sum of the semiquantitative PDUS scores for all joints examined. Levels of Tie-2 and Placenta Growth Factor (PlGF) were associated with PDUS features indicating residual disease activity. Conclusion Our results support the relevance of measuring serum levels of vascular markers to evaluate the intensity and extent of synovial vascularization. Angiogenic markers, and particularly Tie-2, could be a valuable surrogate of active synovitis and their place in relation to PDUS in clinical practice deserve further investigation.
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Affiliation(s)
- Agathe Leblond
- Université Paris Descartes, Sorbonne Paris Cité, INSERM U1016 and CNRS UMR8104, Institut Cochin, Paris, France
| | - Sonia Pezet
- Université Paris Descartes, Sorbonne Paris Cité, INSERM U1016 and CNRS UMR8104, Institut Cochin, Paris, France
| | - Anne Priscille Trouvin
- Université Paris Descartes, Sorbonne Paris Cité, Service de Rhumatologie A, Hôpital Cochin, Paris, France
| | - Muriel Elhai
- Université Paris Descartes, Sorbonne Paris Cité, INSERM U1016 and CNRS UMR8104, Institut Cochin, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Service de Rhumatologie A, Hôpital Cochin, Paris, France
| | - Virginie Gonzalez
- Université Paris Descartes, Sorbonne Paris Cité, INSERM U1016 and CNRS UMR8104, Institut Cochin, Paris, France
| | - Yannick Allanore
- Université Paris Descartes, Sorbonne Paris Cité, INSERM U1016 and CNRS UMR8104, Institut Cochin, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Service de Rhumatologie A, Hôpital Cochin, Paris, France
| | - Jérôme Avouac
- Université Paris Descartes, Sorbonne Paris Cité, INSERM U1016 and CNRS UMR8104, Institut Cochin, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Service de Rhumatologie A, Hôpital Cochin, Paris, France
- * E-mail:
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Chen JH, Huang KC, Huang CC, Lai HM, Chou WY, Chen YC. High power Doppler ultrasound score is associated with the risk of triangular fibrocartilage complex (TFCC) tears in severe rheumatoid arthritis. J Investig Med 2018; 67:327-330. [PMID: 30158166 PMCID: PMC6581084 DOI: 10.1136/jim-2018-000821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2018] [Indexed: 11/26/2022]
Abstract
In the distal radioulnar joint, the triangular fibrocartilage complex (TFCC) is an important stabilizer and are frequently found in patients with rheumatoid arthritis (RA) with wrist pain. This study was designed to predict TFCC tears using high-resolution ultrasound in severe RA. We retrospectively reviewed patients with severe RA. MRI and ultrasound were performed at baseline and after 1 year of follow-up. TFCC tears were recorded. The predictive factors for TFCC tears were analyzed by logistic regression. During the 1-year follow-up period, 54 patients were enrolled (42 females and 12 males), of whom 21 (38.9%) developed TFCC tears. The body mass index was 22.81±2.59 kg/m2 in the TFCC tear group compared with 23.61±2.76 kg/m2 in the non-tear group (p=0.136). The mean age was 55.14±9.54 years in the TFCC tear group compared with 56.45±14.04 years in the non-tear group (p=0.596). The tear group had a higher Disease Activity Score in 28 joints (DAS28) (6.36±0.47 vs 5.58±0.65, p=0.011) and higher power Doppler (PD) ultrasound score at the dorsal radiocarpal joint (1.90±1.30 vs 1.33±0.99, p=0.011) than the non-tear group. We found that high DAS28 (OR 2.96, 95% CI 1.95 to 4.50; p=0.001) and higher baseline PD score (OR 1.51, 95% CI 1.07 to 2.14; p=0.019) were significantly associated with a higher risk of TFCC tears by logistic regression. So we conclude a higher wrist PD score in severe RA predicted future TFCC tears. Therefore, we suggest to use PD score in such patients to monitor the risk of future TFCC tears.
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Affiliation(s)
- Jen-Hung Chen
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chung-Cheng Huang
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Han-Ming Lai
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wen-Yi Chou
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Chou Chen
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Sarzi-Puttini P, Filippucci E, Adami S, Meroni PL, Batticciotto A, Idolazzi L, De Lucia O, Talavera P, Kumke T, Grassi W. Clinical, Ultrasound, and Predictability Outcomes Following Certolizumab Pegol Treatment (with Methotrexate) in Patients with Moderate-to-Severe Rheumatoid Arthritis: 52-Week Results from the CZP-SPEED Study. Adv Ther 2018; 35:1153-1168. [PMID: 30043210 PMCID: PMC6096970 DOI: 10.1007/s12325-018-0751-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Indexed: 12/12/2022]
Abstract
Introduction To assess the impact of certolizumab pegol (CZP) treatment on clinical, patient-reported, and musculoskeletal ultrasound outcomes and to determine the treatment response time point most predictive of long-term outcomes in Italian patients with rheumatoid arthritis (RA). Methods CZP-SPEED (NCT01443364) was a 52-week, open-label, prospective, interventional, multicenter study. Biologic-naïve patients with moderate-to-severe active RA, who had failed at least one DMARD treatment, received CZP (400 mg at weeks 0, 2, and 4, then 200 mg every 2 weeks) concomitantly with methotrexate. The primary objective was to identify the time point of clinical response {decrease in 28-joint Disease Activity Score [DAS28(ESR)] ≥ 1.2} most predictive of a clinical response at week 52. Additional clinical and patient-reported outcomes were measured. Power Doppler (PD) ultrasound was used to assess synovial effusion, synovial proliferation, PD signal, cartilage damage, and bone erosion according to international guidelines. Results A total of 132 patients were enrolled and received CZP; 91/132 (69%) completed to week 52. Predicted 52-week responses for early responders (week 2 onwards) were between 65% and 70%. Rapid improvements in joint cavity widening and PD signal were observed to week 8 and maintained to week 52. Cartilage damage and bone erosion were stable over 52 weeks. No new safety signals were identified. Conclusion In Italian CZP-treated patients with moderate-to-severe RA, week 12 clinical responses may be predictive of long-term response at week 52. Rapid improvements in clinical, patient-reported, and musculoskeletal ultrasound outcomes were maintained to week 52. These data may aid rheumatologists to make earlier treatment decisions. Trial Registration ClinicalTrials.gov identifier, NCT01443364. Funding UCB Pharma. Electronic supplementary material The online version of this article (10.1007/s12325-018-0751-8) contains supplementary material, which is available to authorized users.
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Simpson E, Hock E, Stevenson M, Wong R, Dracup N, Wailoo A, Conaghan P, Estrach C, Edwards C, Wakefield R. What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-258. [PMID: 29712616 PMCID: PMC5949573 DOI: 10.3310/hta22200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US). OBJECTIVE To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness. DATA SOURCES Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015. REVIEW METHODS A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken. MATHEMATICAL MODEL A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated. RESULTS Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used. LIMITATIONS Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed. CONCLUSION Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017216. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Philip Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
| | - Cristina Estrach
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christopher Edwards
- National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| | - Richard Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
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Chen YC, Su FM, Hsu SW, Chen JF, Cheng TT, Lai HM, Chiu WC. Predictor of Hand Radiological Progression in Patients With Rheumatoid Arthritis Receiving TNF Antagonist Therapy by Change in Grayscale Synovitis-A Preliminary Study. J Clin Rheumatol 2017; 23:73-76. [PMID: 28212115 PMCID: PMC5325254 DOI: 10.1097/rhu.0000000000000516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives This prospective study aimed to compare synovial ultrasound scores to conventional measures (DAS28, CRP levels) in predicting radiographic progression in patients with rheumatoid arthritis under TNF antagonist therapy. Methods Patients with RA who received TNF antagonist therapy were enrolled, all of whom underwent clinical, laboratory, and ultrasonographic assessments with grayscale and power Doppler assessments of bilateral elbows (anterior and posterior recess), wrists (dorsal, palmar, and ulnar aspects), second and third MCP joints (dorsal and palmar recess), and PIP II and III (dorsal and palmar) at baseline and at 1, 3 months. Hand radiographic damage was evaluated using van der Heijde modified Total Sharp Score (TSS) at baseline and 12 months. Results Thirty-two patients (384 joints, 832 synovial sites) continued the same treatment regimen for 12 months and completed the study, 41.6% of whom showed radiographic progression during the study period. Baseline DAS28 (P = 0.123), CRP level (P = 0.177), grayscale synovitis (P = 0.092), and power Doppler synovitis (P = 0.120) could not predict radiological damage in the TNF antagonist therapy group. However, ΔTSS was significantly related to changes in grayscale synovitis between baseline and 1 month (P = 0.011), but not at 3 months (P = 0.591), and was not related to changes in the power Doppler score at 1 (P = 0.634) and 3 months (P = 0.298). Conclusions Our data confirm that delayed improvement in grayscale synovitis between baseline and 1 month more accurately reflects 1-year radiological damage than conventional measures such as DAS28 score and CRP level. Therefore, we recommend serial ultrasound follow-up of patients with RA receiving TNF antagonist therapy.
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Affiliation(s)
- Ying-Chou Chen
- From the Departments of *Rheumatology, and †Department of Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Allen JC, Thumboo J, Lye WK, Conaghan PG, Chew LC, Tan YK. Novel joint selection methods can reduce sample size for rheumatoid arthritis clinical trials with ultrasound endpoints. Int J Rheum Dis 2017; 21:693-698. [PMID: 28971583 DOI: 10.1111/1756-185x.13185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether novel methods of selecting joints through (i) ultrasonography (individualized-ultrasound [IUS] method), or (ii) ultrasonography and clinical examination (individualized-composite-ultrasound [ICUS] method) translate into smaller rheumatoid arthritis (RA) clinical trial sample sizes when compared to existing methods utilizing predetermined joint sites for ultrasonography. METHODS Cohen's effect size (ES) was estimated (ES^) and a 95% CI (ES^L, ES^U) calculated on a mean change in 3-month total inflammatory score for each method. Corresponding 95% CIs [nL(ES^U), nU(ES^L)] were obtained on a post hoc sample size reflecting the uncertainty in ES^. Sample size calculations were based on a one-sample t-test as the patient numbers needed to provide 80% power at α = 0.05 to reject a null hypothesis H0 : ES = 0 versus alternative hypotheses H1 : ES = ES^, ES = ES^L and ES = ES^U. We aimed to provide point and interval estimates on projected sample sizes for future studies reflecting the uncertainty in our study ES^S. RESULTS Twenty-four treated RA patients were followed up for 3 months. Utilizing the 12-joint approach and existing methods, the post hoc sample size (95% CI) was 22 (10-245). Corresponding sample sizes using ICUS and IUS were 11 (7-40) and 11 (6-38), respectively. Utilizing a seven-joint approach, the corresponding sample sizes using ICUS and IUS methods were nine (6-24) and 11 (6-35), respectively. CONCLUSIONS Our pilot study suggests that sample size for RA clinical trials with ultrasound endpoints may be reduced using the novel methods, providing justification for larger studies to confirm these observations.
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Affiliation(s)
- John C Allen
- Office of Clinical Sciences, Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Weng Kit Lye
- Office of Clinical Sciences, Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Li-Ching Chew
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - York Kiat Tan
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
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D'Agostino MA, Terslev L, Aegerter P, Backhaus M, Balint P, Bruyn GA, Filippucci E, Grassi W, Iagnocco A, Jousse-Joulin S, Kane D, Naredo E, Schmidt W, Szkudlarek M, Conaghan PG, Wakefield RJ. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce -Part 1: definition and development of a standardised, consensus-based scoring system. RMD Open 2017; 3:e000428. [PMID: 28948983 PMCID: PMC5597799 DOI: 10.1136/rmdopen-2016-000428] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/04/2017] [Accepted: 04/24/2017] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To develop a consensus-based ultrasound (US) definition and quantification system for synovitis in rheumatoid arthritis (RA). METHODS A multistep, iterative approach was used to: (1) evaluate the baseline agreement on defining and scoring synovitis according to the usual practice of different sonographers, using both grey-scale (GS) (synovial hypertrophy (SH) and effusion) and power Doppler (PD), by reading static images and scanning patients with RA and (2) evaluate the influence of both the definition and acquisition technique on reliability followed by a Delphi exercise to obtain consensus definitions for synovitis, elementary components and scoring system. RESULTS Baseline reliability was highly variable but better for static than dynamic images that were directly acquired and immediately scored. Using static images, intrareader and inter-reader reliability for scoring PD were excellent for both binary and semiquantitative (SQ) grading but GS showed greater variability for both scoring systems (κ ranges: -0.05 to 1 and 0.59 to 0.92, respectively). In patient-based exercise, both intraobserver and interobserver reliability were variable and the mean κ coefficients did not reach 0.50 for any of the components. The second step resulted in refinement of the preliminary Outcome Measures in Rheumatology synovitis definition by including the presence of both hypoechoic SH and PD signal and the development of a SQ severity score, depending on both the amount of PD and the volume and appearance of SH. CONCLUSION A multistep consensus-based process has produced a standardised US definition and quantification system for RA synovitis including combined and individual SH and PD components. Further evaluation is required to understand its performance before application in clinical trials.
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Affiliation(s)
- Maria-Antonietta D'Agostino
- Department of Rheumatology, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt, France.,INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Montigny le Bretonneaux, France
| | - Lene Terslev
- Centre of Rheumatology and Spine Diseases, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Philippe Aegerter
- Département de Santé Publique, AP-HP, Hôpital Ambroise Paré, Unité de Recherche Clinique, Boulogne-Billancourt, France.,INSERM, VIMA U1168, Villejuif, UFR Simone Veil, Versailles-Saint-Quentin University, Montigny le Bretonneaux, France
| | - Marina Backhaus
- Rheumatologie und Klinische Immunologie, Park-Klinik Weissensee, Berlin, Germany
| | - Peter Balint
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - George A Bruyn
- Department of Rheumatology, MC Groep Hospitals, Lelystad, Netherlands
| | - Emilio Filippucci
- Clinica Reumatologica, Università Politecnica delle Marche, Jesi, Italy
| | - Walter Grassi
- Clinica Reumatologica, Università Politecnica delle Marche, Jesi, Italy
| | | | - Sandrine Jousse-Joulin
- Department of Rheumatology, CHRU de Brest, Brest cedex, France.,EA2216, INSERM ESPRI, ERI29, Laboratoire d'Immunologie, Université de Brest, LabEx IGO, Brest cedex, France
| | - David Kane
- Department of Rheumatology, Trinity College, Dublin, Ireland
| | - Esperanza Naredo
- Rheumatology and Joint Bone Research Unit, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain
| | - Wolfgang Schmidt
- Medical Centre for Rheumatology, Immanuel Krankenhaus, Berlin, Germany
| | - Marcin Szkudlarek
- Department of Rheumatology, University of Copenhagen Hospital, Køge, Denmark
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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23
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Singh JA, Hossain A, Mudano AS, Tanjong Ghogomu E, Suarez‐Almazor ME, Buchbinder R, Maxwell LJ, Tugwell P, Wells GA. Biologics or tofacitinib for people with rheumatoid arthritis naive to methotrexate: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2017; 5:CD012657. [PMID: 28481462 PMCID: PMC6481641 DOI: 10.1002/14651858.cd012657] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Biologic disease-modifying anti-rheumatic drugs (biologics) are highly effective in treating rheumatoid arthritis (RA), however there are few head-to-head biologic comparison studies. We performed a systematic review, a standard meta-analysis and a network meta-analysis (NMA) to update the 2009 Cochrane Overview. This review is focused on the adults with RA who are naive to methotrexate (MTX) that is, receiving their first disease-modifying agent. OBJECTIVES To compare the benefits and harms of biologics (abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab) and small molecule tofacitinib versus comparator (methotrexate (MTX)/other DMARDs) in people with RA who are naive to methotrexate. METHODS In June 2015 we searched for randomized controlled trials (RCTs) in CENTRAL, MEDLINE and Embase; and trials registers. We used standard Cochrane methods. We calculated odds ratios (OR) and mean differences (MD) along with 95% confidence intervals (CI) for traditional meta-analyses and 95% credible intervals (CrI) using a Bayesian mixed treatment comparisons approach for network meta-analysis (NMA). We converted OR to risk ratios (RR) for ease of interpretation. We also present results in absolute measures as risk difference (RD) and number needed to treat for an additional beneficial or harmful outcome (NNTB/H). MAIN RESULTS Nineteen RCTs with 6485 participants met inclusion criteria (including five studies from the original 2009 review), and data were available for four TNF biologics (adalimumab (six studies; 1851 participants), etanercept (three studies; 678 participants), golimumab (one study; 637 participants) and infliximab (seven studies; 1363 participants)) and two non-TNF biologics (abatacept (one study; 509 participants) and rituximab (one study; 748 participants)).Less than 50% of the studies were judged to be at low risk of bias for allocation sequence generation, allocation concealment and blinding, 21% were at low risk for selective reporting, 53% had low risk of bias for attrition and 89% had low risk of bias for major baseline imbalance. Three trials used biologic monotherapy, that is, without MTX. There were no trials with placebo-only comparators and no trials of tofacitinib. Trial duration ranged from 6 to 24 months. Half of the trials contained participants with early RA (less than two years' duration) and the other half included participants with established RA (2 to 10 years). Biologic + MTX versus active comparator (MTX (17 trials (6344 participants)/MTX + methylprednisolone 2 trials (141 participants))In traditional meta-analyses, there was moderate-quality evidence downgraded for inconsistency that biologics with MTX were associated with statistically significant and clinically meaningful benefit versus comparator as demonstrated by ACR50 (American College of Rheumatology scale) and RA remission rates. For ACR50, biologics with MTX showed a risk ratio (RR) of 1.40 (95% CI 1.30 to 1.49), absolute difference of 16% (95% CI 13% to 20%) and NNTB = 7 (95% CI 6 to 8). For RA remission rates, biologics with MTX showed a RR of 1.62 (95% CI 1.33 to 1.98), absolute difference of 15% (95% CI 11% to 19%) and NNTB = 5 (95% CI 6 to 7). Biologics with MTX were also associated with a statistically significant, but not clinically meaningful, benefit in physical function (moderate-quality evidence downgraded for inconsistency), with an improvement of HAQ scores of -0.10 (95% CI -0.16 to -0.04 on a 0 to 3 scale), absolute difference -3.3% (95% CI -5.3% to -1.3%) and NNTB = 4 (95% CI 2 to 15).We did not observe evidence of differences between biologics with MTX compared to MTX for radiographic progression (low-quality evidence, downgraded for imprecision and inconsistency) or serious adverse events (moderate-quality evidence, downgraded for imprecision). Based on low-quality evidence, results were inconclusive for withdrawals due to adverse events (RR of 1.32, but 95% confidence interval included possibility of important harm, 0.89 to 1.97). Results for cancer were also inconclusive (Peto OR 0.71, 95% CI 0.38 to 1.33) and downgraded to low-quality evidence for serious imprecision. Biologic without MTX versus active comparator (MTX 3 trials (866 participants)There was no evidence of statistically significant or clinically important differences for ACR50, HAQ, remission, (moderate-quality evidence for these benefits, downgraded for imprecision), withdrawals due to adverse events,and serious adverse events (low-quality evidence for these harms, downgraded for serious imprecision). All studies were for TNF biologic monotherapy and none for non-TNF biologic monotherapy. Radiographic progression was not measured. AUTHORS' CONCLUSIONS In MTX-naive RA participants, there was moderate-quality evidence that, compared with MTX alone, biologics with MTX was associated with absolute and relative clinically meaningful benefits in three of the efficacy outcomes (ACR50, HAQ scores, and RA remission rates). A benefit regarding less radiographic progression with biologics with MTX was not evident (low-quality evidence). We found moderate- to low-quality evidence that biologic therapy with MTX was not associated with any higher risk of serious adverse events compared with MTX, but results were inconclusive for withdrawals due to adverse events and cancer to 24 months.TNF biologic monotherapy did not differ statistically significantly or clinically meaningfully from MTX for any of the outcomes (moderate-quality evidence), and no data were available for non-TNF biologic monotherapy.We conclude that biologic with MTX use in MTX-naive populations is beneficial and that there is little/inconclusive evidence of harms. More data are needed for tofacitinib, radiographic progression and harms in this patient population to fully assess comparative efficacy and safety.
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Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical CenterDepartment of MedicineFaculty Office Tower 805B510 20th Street SouthBirminghamALUSA35294
| | - Alomgir Hossain
- University of Ottawa Heart InstituteCardiovascular Research Methods Centre40 Ruskin StreetRoom H‐2265OttawaONCanadaK1Y 4W7
| | - Amy S Mudano
- University of Alabama at BirminghamDepartment of Medicine ‐ RheumatologyBirminghamUSA
| | | | - Maria E Suarez‐Almazor
- The University of Texas, MD Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology, Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Lara J Maxwell
- Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital ‐ General CampusCentre for Practice‐Changing Research (CPCR)501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
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Singh JA, Hossain A, Tanjong Ghogomu E, Mudano AS, Maxwell LJ, Buchbinder R, Lopez‐Olivo MA, Suarez‐Almazor ME, Tugwell P, Wells GA. Biologics or tofacitinib for people with rheumatoid arthritis unsuccessfully treated with biologics: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2017; 3:CD012591. [PMID: 28282491 PMCID: PMC6472522 DOI: 10.1002/14651858.cd012591] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Biologic disease-modifying anti-rheumatic drugs (DMARDs: referred to as biologics) are effective in treating rheumatoid arthritis (RA), however there are few head-to-head comparison studies. Our systematic review, standard meta-analysis and network meta-analysis (NMA) updates the 2009 Cochrane overview, 'Biologics for rheumatoid arthritis (RA)' and adds new data. This review is focused on biologic or tofacitinib therapy in people with RA who had previously been treated unsuccessfully with biologics. OBJECTIVES To compare the benefits and harms of biologics (abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab) and small molecule tofacitinib versus comparator (placebo or methotrexate (MTX)/other DMARDs) in people with RA, previously unsuccessfully treated with biologics. METHODS On 22 June 2015 we searched for randomized controlled trials (RCTs) in CENTRAL, MEDLINE, and Embase; and trials registries (WHO trials register, Clinicaltrials.gov). We carried out article selection, data extraction, and risk of bias and GRADE assessments in duplicate. We calculated direct estimates with 95% confidence intervals (CI) using standard meta-analysis. We used a Bayesian mixed treatment comparison (MTC) approach for NMA estimates with 95% credible intervals (CrI). We converted odds ratios (OR) to risk ratios (RR) for ease of understanding. We have also presented results in absolute measures as risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB). Outcomes measured included four benefits (ACR50, function measured by Health Assessment Questionnaire (HAQ) score, remission defined as DAS < 1.6 or DAS28 < 2.6, slowing of radiographic progression) and three harms (withdrawals due to adverse events, serious adverse events, and cancer). MAIN RESULTS This update includes nine new RCTs for a total of 12 RCTs that included 3364 participants. The comparator was placebo only in three RCTs (548 participants), MTX or other traditional DMARD in six RCTs (2468 participants), and another biologic in three RCTs (348 participants). Data were available for four tumor necrosis factor (TNF)-biologics: (certolizumab pegol (1 study; 37 participants), etanercept (3 studies; 348 participants), golimumab (1 study; 461 participants), infliximab (1 study; 27 participants)), three non-TNF biologics (abatacept (3 studies; 632 participants), rituximab (2 studies; 1019 participants), and tocilizumab (2 studies; 589 participants)); there was only one study for tofacitinib (399 participants). The majority of the trials (10/12) lasted less than 12 months.We judged 33% of the studies at low risk of bias for allocation sequence generation, allocation concealment and blinding, 25% had low risk of bias for attrition, 92% were at unclear risk for selective reporting; and 92% had low risk of bias for major baseline imbalance. We downgraded the quality of the evidence for most outcomes to moderate or low due to study limitations, heterogeneity, or rarity of direct comparator trials. Biologic monotherapy versus placeboCompared to placebo, biologics were associated with clinically meaningful and statistically significant improvement in RA as demonstrated by higher ACR50 and RA remission rates. RR was 4.10 for ACR50 (95% CI 1.97 to 8.55; moderate-quality evidence); absolute benefit RD 14% (95% CI 6% to 21%); and NNTB = 8 (95% CI 4 to 23). RR for RA remission was 13.51 (95% CI 1.85 to 98.45, one study available; moderate-quality evidence); absolute benefit RD 9% (95% CI 5% to 13%); and NNTB = 11 (95% CI 3 to 136). Results for withdrawals due to adverse events and serious adverse events did not show any statistically significant or clinically meaningful differences. There were no studies available for analysis for function measured by HAQ, radiographic progression, or cancer outcomes. There were not enough data for any of the outcomes to look at subgroups. Biologic + MTX versus active comparator (MTX/other traditional DMARDs)Compared to MTX/other traditional DMARDs, biologic + MTX was associated with a clinically meaningful and statistically significant improvement in ACR50, function measured by HAQ, and RA remission rates in direct comparisons. RR for ACR50 was 4.07 (95% CI 2.76 to 5.99; high-quality evidence); absolute benefit RD 16% (10% to 21%); NNTB = 7 (95% CI 5 to 11). HAQ scores showed an improvement with a mean difference (MD) of 0.29 (95% CI 0.21 to 0.36; high-quality evidence); absolute benefit RD 9.7% improvement (95% CI 7% to 12%); and NNTB = 5 (95% CI 4 to 7). Remission rates showed an improved RR of 20.73 (95% CI 4.13 to 104.16; moderate-quality evidence); absolute benefit RD 10% (95% CI 8% to 13%); and NNTB = 17 (95% CI 4 to 96), among the biologic + MTX group compared to MTX/other DMARDs. There were no studies for radiographic progression. Results were not clinically meaningful or statistically significantly different for withdrawals due to adverse events or serious adverse events, and were inconclusive for cancer. Tofacitinib monotherapy versus placeboThere were no published data. Tofacitinib + MTX versus active comparator (MTX)In one study, compared to MTX, tofacitinib + MTX was associated with a clinically meaningful and statistically significant improvement in ACR50 (RR 3.24; 95% CI 1.78 to 5.89; absolute benefit RD 19% (95% CI 12% to 26%); NNTB = 6 (95% CI 3 to 14); moderate-quality evidence), and function measured by HAQ, MD 0.27 improvement (95% CI 0.14 to 0.39); absolute benefit RD 9% (95% CI 4.7% to 13%), NNTB = 5 (95% CI 4 to 10); high-quality evidence). RA remission rates were not statistically significantly different but the observed difference may be clinically meaningful (RR 15.44 (95% CI 0.93 to 256.1; high-quality evidence); absolute benefit RD 6% (95% CI 3% to 9%); NNTB could not be calculated. There were no studies for radiographic progression. There were no statistically significant or clinically meaningful differences for withdrawals due to adverse events and serious adverse events, and results were inconclusive for cancer. AUTHORS' CONCLUSIONS Biologic (with or without MTX) or tofacitinib (with MTX) use was associated with clinically meaningful and statistically significant benefits (ACR50, HAQ, remission) compared to placebo or an active comparator (MTX/other traditional DMARDs) among people with RA previously unsuccessfully treated with biologics.No studies examined radiographic progression. Results were not clinically meaningful or statistically significant for withdrawals due to adverse events and serious adverse events, and were inconclusive for cancer.
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Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical CenterDepartment of MedicineFaculty Office Tower 805B510 20th Street SouthBirminghamALUSA35294
| | - Alomgir Hossain
- University of Ottawa Heart InstituteCardiovascular Research Methods Centre40 Ruskin StreetRoom H‐2265OttawaONCanadaK1Y 4W7
| | | | - Amy S Mudano
- University of Alabama at BirminghamDepartment of Medicine ‐ RheumatologyBirminghamUSA
| | - Lara J Maxwell
- Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital ‐ General CampusCentre for Practice‐Changing Research (CPCR)501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical Epidemiology, Cabrini HospitalSuite 41, Cabrini Medical Centre183 Wattletree RoadMalvernVictoriaAustralia3144
| | - Maria Angeles Lopez‐Olivo
- The University of Texas, M.D. Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | - Maria E Suarez‐Almazor
- The University of Texas, M.D. Anderson Cancer CenterDepartment of General Internal Medicine1515 Holcombe BlvdUnit 1465HoustonTexasUSA77030
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
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Závada J, Hánová P, Hurňáková J, Szczuková L, Uher M, Forejtová Š, Klein M, Mann H, Olejárová M, Růžičková O, Šléglová O, Hejduk K, Pavelka K. The relationship between synovitis quantified by an ultrasound 7-joint inflammation score and physical disability in rheumatoid arthritis - a cohort study. Arthritis Res Ther 2017; 19:5. [PMID: 28086960 PMCID: PMC5237153 DOI: 10.1186/s13075-016-1208-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/09/2016] [Indexed: 12/30/2022] Open
Abstract
Background Restoring normal physical functioning is a major therapeutic aim in the management of rheumatoid arthritis (RA). It is unknown, whether the extent of synovial inflammation quantified by musculoskeletal ultrasound (US) can predict current or future capacity for physical functioning. To answer this question we investigated the longitudinal relationship between physical function assessed by the health assessment questionnaire (HAQ) and the German 7-joint ultrasound score (US7S) in a prospective cohort of patients with RA. Methods Patients with RA (n = 185 (46 with incident and 139 with prevalent disease) were followed for 30.9 ± 9.1 months. Baseline and annual assessments comprised the disease activity score in 28 joints (DAS28), HAQ and US7S. The US7S includes semiquantitative measurements of synovitis assessed by greyscale (GS) and power Doppler (PD) in seven joints of the clinically dominant hand and foot, which are then aggregated in PD and GS synovitis sum-scores (PDsynSS and GSsynSS). A linear mixed-effect model was used to assess the longitudinal relationship between GSsynSS, PDsynSS and HAQ. We used standard and time-lag models to explore the association between HAQ, and GSsynSS, PDsynSS and DAS28 measured at the same time or at the previous visit 12 months ago, respectively. Results When the standard model was applied, in univariate analyses HAQ score was positively associated with GSsynSS and PDsynSS with β coefficients significantly higher in incident than in prevalent disease. In multivariate analysis both synSSs were individually no longer significant predictors of HAQ score. When using the time-lag model, after adjustment for the previous DAS28 or HAQ score, both PDsynSS and GSsynSS were significantly and negatively associated with the current HAQ. Conclusions US7 PD and GS synovitis sum-scores alone were positively associated with current functional status reflected by the HAQ in patients with RA, and this relationship was stronger in patients with early disease. When combined with the DAS28 or HAQ, US7 PD and GS synovitis sum-scores were predictive of the change in HAQ score over one year. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1208-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jakub Závada
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic.
| | - Petra Hánová
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Jana Hurňáková
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Lenka Szczuková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michal Uher
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Šárka Forejtová
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Martin Klein
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Herman Mann
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Marta Olejárová
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Olga Růžičková
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Olga Šléglová
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Karel Hejduk
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
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26
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Gandjbakhch F, Granger B, Freund R, Foltz V, Jousse-Joulin S, Devauchelle V, Afshar M, Albert JD, Bailly F, Constant E, Biale L, Milin M, Couderc M, Denarie D, Fradin A, Martaille V, Pierreisnard A, Poursac N, Saraux A, Fautrel B. Multireader assessment as an alternative to reference assessment to improve the detection of radiographic progression in a large longitudinal cohort of rheumatoid arthritis (ESPOIR). RMD Open 2017; 3:e000343. [PMID: 28123779 PMCID: PMC5237761 DOI: 10.1136/rmdopen-2016-000343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Structural damage progression is a major outcome in rheumatoid arthritis (RA). Its evaluation and follow-up in trials should involve radiographic scoring by 1 or 2 readers (reference assessment), which is challenging in large longitudinal cohorts with multiple assessments. OBJECTIVES To compare the reproducibility of multireader and reference assessment to improve the feasibility of detecting radiographic progression in a large cohort of patients with early arthritis (ESPOIR). METHODS We used 3 sessions to train 12 rheumatologists in radiographic scoring by the van der Heijde-modified Sharp score (SHS). Multireader scoring was based on 10 trained-reader assessments, each reader scoring a random sample of 1/5 of all available radiographs (for double scoring for each X-ray set) for patients included in the ESPOIR cohort with complete radiographic data at M0 and M60. Reference scoring was performed by 2 experienced readers. Scoring was performed blindly to clinical data, with radiographs in chronological order. We compared multireader and reference assessments by intraclass correlation coefficients (ICCs) for SHS and significant radiographic progression (SRP). RESULTS The intrareader and inter-reader reproducibility for trained assessors increased during the training sessions (ICC 0.79 to 0.94 and 0.76 to 0.92), respectively. For the 524 patients included, agreement between multireader and reference assessment of SHS progression between M0 and M60 and SRP assessment were almost perfect, ICC (0.88 (95% CI 0.82 to 0.93)) and (0.99 (95% CI 0.99 to 0.99)), respectively. CONCLUSIONS Multireader assessment of radiographic structural damage progression is comparable to reference assessment and could be used to improve the feasibility of radiographic scoring in large longitudinal cohort with numerous X-ray evaluations.
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Affiliation(s)
- Frederique Gandjbakhch
- Department of Rheumatology, APHP, CHU Pitie-Salpetriere, Paris, France; Paris 6 University, GRC-UPMC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| | - Benjamin Granger
- Paris 6 University, GRC-UPMC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France; Department of Statistics, CHU Pitie Salpetriere, APHP, Paris, France
| | - Romain Freund
- Department of Rheumatology, APHP, CHU Pitie-Salpetriere, Paris, France; Paris 6 University, GRC-UPMC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| | - Violaine Foltz
- Department of Rheumatology, APHP, CHU Pitie-Salpetriere, Paris, France; Paris 6 University, GRC-UPMC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| | | | | | - Mona Afshar
- Department of Rheumatology , Hopital Jean Verdier , Bondy , France
| | | | - Florian Bailly
- Department of Rheumatology, APHP, CHU Pitie-Salpetriere, Paris, France; Paris 6 University, GRC-UPMC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| | - Elodie Constant
- Department of Rheumatology , CHU Saint Etienne , Saint Etienne , France
| | - Lisa Biale
- Department of Rheumatology , Hopital Begin , Saint Mande , France
| | - Morgane Milin
- Department of Rheumatology , CHU la Cavale Blanche , Brest , France
| | - Marion Couderc
- Department of Rheumatology , CHU Clermont Ferrand , Clermont Ferrand , France
| | - Delphine Denarie
- Department of Rheumatology , CHU Saint Etienne , Saint Etienne , France
| | - Anne Fradin
- Department of Rheumatology , CHU Poitiers , Poitiers , France
| | | | - Audrey Pierreisnard
- Department of Rheumatology, APHP, CHU Pitie-Salpetriere, Paris, France; Paris 6 University, GRC-UPMC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| | - Nicolas Poursac
- Department of Rheumatology , CHU Bordeaux , Bordeaux , France
| | - Alain Saraux
- Department of Rheumatology , CHU la Cavale Blanche , Brest , France
| | - Bruno Fautrel
- Department of Rheumatology, APHP, CHU Pitie-Salpetriere, Paris, France; Paris 6 University, GRC-UPMC 08, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
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Fleischmann R, Tongbram V, van Vollenhoven R, Tang DH, Chung J, Collier D, Urs S, Ndirangu K, Wells G, Pope J. Systematic review and network meta-analysis of the efficacy and safety of tumour necrosis factor inhibitor-methotrexate combination therapy versus triple therapy in rheumatoid arthritis. RMD Open 2017; 3:e000371. [PMID: 28123782 PMCID: PMC5237767 DOI: 10.1136/rmdopen-2016-000371] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/18/2016] [Accepted: 11/28/2016] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Clinical trials have not consistently demonstrated differences between tumour necrosis factor inhibitor (TNFi) plus methotrexate and triple therapy (methotrexate plus hydroxychloroquine plus sulfasalazine) in rheumatoid arthritis (RA). The study objective was to estimate the efficacy, radiographic benefits, safety and patient-reported outcomes of TNFi-methotrexate versus triple therapy in patients with RA. METHODS A systematic review and network meta-analysis (NMA) of randomised controlled trials of TNFi-methotrexate or triple therapy as one of the treatment arms in patients with an inadequate response to or who were naive to methotrexate was conducted. American College of Rheumatology 70% response criteria (ACR70) at 6 months was the prespecified primary endpoint to evaluate depth of response. Data from direct and indirect comparisons between TNFi-methotrexate and triple therapy were pooled and quantitatively analysed using fixed-effects and random-effects Bayesian models. RESULTS We analysed 33 studies in patients with inadequate response to methotrexate and 19 in patients naive to methotrexate. In inadequate responders, triple therapy was associated with lower odds of achieving ACR70 at 6 months compared with TNFi-methotrexate (OR 0.35, 95% credible interval (CrI) 0.19 to 0.64). Most secondary endpoints tended to favour TNFi-methotrexate in terms of OR direction; however, no clear increased likelihood of achieving these endpoints was observed for either therapy. The odds of infection were lower with triple therapy than with TNFi-methotrexate (OR 0.08, 95% CrI 0.00 to 0.57). There were no differences observed between the two regimens in patients naive to methotrexate. CONCLUSIONS In this NMA, triple therapy was associated with 65% lower odds of achieving ACR70 at 6 months compared with TNFi-methotrexate in patients with inadequate response to methotrexate. Although secondary endpoints numerically favoured TNFi-methotrexate, no clear differences were observed. The odds of infection were greater with TNFi-methotrexate. No differences were observed for patients naive to methotrexate. These results may help inform care of patients who fail methotrexate first-line therapy.
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Affiliation(s)
- Roy Fleischmann
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Metroplex Clinical Research Center, Dallas, Texas, USA
| | | | | | - Derek H Tang
- Amgen Inc., Thousand Oaks, California, USA
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
| | | | | | - Shilpa Urs
- Oxford Outcomes, ICON plc, Morristown, New Jersey, USA
- Doctors’ Hospital of Michigan, Pontiac, Michigan, USA
| | | | - George Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Janet Pope
- Department of Rheumatology, St. Joseph's Health Care, London, Ontario, Canada
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Chen HH. The Third Eye of the Rheumatologist: Applications of Musculoskeletal Ultrasound in Rheumatic Diseases. J Med Ultrasound 2017; 25:4-8. [PMID: 30065447 PMCID: PMC6029281 DOI: 10.1016/j.jmu.2017.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 02/24/2017] [Indexed: 11/23/2022] Open
Abstract
Rheumatologists manage patients with rheumatic diseases, which are of a wide range of musculoskeletal pathologies. Without clarification of the exact location of pathologies and the degree of inflammation, rheumatologists may have an incorrect assessment, leading to inappropriate management. In everyday practice, physical examination is limited by its sensitivity and power of assessment. Musculoskeletal ultrasonography (MSUS) is inexpensive, readily available, and allows side-by-side image comparisons. Thus, during the past 10 years, MSUS has become the “third eye” of the rheumatologist, in that it allows more detailed examination of muscles, bones, and joints, just as the stethoscope provides further details about the respiratory and circulatory systems. We briefly introduce how rheumatologists in Taiwan use MSUS for the diagnosis and treatment for rheumatic diseases.
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Affiliation(s)
- Hsin-Hua Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung City, Taiwan, ROC
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Hull DN, Cooksley H, Chokshi S, Williams RO, Abraham S, Taylor PC. Increase in circulating Th17 cells during anti-TNF therapy is associated with ultrasonographic improvement of synovitis in rheumatoid arthritis. Arthritis Res Ther 2016; 18:303. [PMID: 28010726 PMCID: PMC5180397 DOI: 10.1186/s13075-016-1197-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 11/28/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Anti-TNF agents have revolutionised rheumatoid arthritis (RA) treatment; however, a third of patients fail to achieve therapeutic responses. Unexpectedly, studies in murine and human arthritis have indicated that anti-TNF treatment can increase circulating T helper 17 (Th17) cells, but the relationship to treatment response is unclear. To identify immune correlates of anti-TNF treatment response, we conducted a longitudinal study using clinical, ultrasound and T cell assessments. METHODS Patients with RA (n = 25) were studied at protocol visits during the initial 12 weeks of anti-TNF treatment. Improvement in the disease activity score of 28 joints (DAS28) >1.2 defined treatment responders (n = 16) and non-responders (n = 9). Changes in synovial thickening and vascularity of 10 metacarpophalangeal joints were quantitatively assessed by grey scale and power Doppler ultrasound. The frequency of circulating Th17 cells was determined by IL17 enzyme-linked immunospot assay (Elispot) and flow cytometry (fluorescence-activated cell sorting (FACS)). RESULTS The frequency of circulating IL17-producing cells increased significantly 12 weeks after anti-TNF initiation (Elispot median (range) specific spot forming cells (spSFC)/106 360 (280-645) vs 632 (367 - 1167), p = 0.003). The increase in CD4 + IL17+ cells at 12 weeks was confirmed by FACS (median (range) %, 0.7 (0.5-0.9) vs 1.05 (0.6-1.3); p = 0.01). The increase in circulating Th17 cells inversely correlated with reduction in synovial vascularity (r = -0.68, p = 0.007) and thickening (r = -0.39; p = 0.04). Higher frequencies of circulating Th17 cells at baseline were associated with poorer anti-TNF treatment response defined by ultrasonographic measures. CONCLUSIONS These results demonstrate a link between changes in circulating Th17 cells with resolution of ultrasonographic features of synovial inflammation and vascularity during anti-TNF treatment. The findings may reflect redistribution of Th17 cells from inflamed joints or TNF-driven regulation of Th17 cell production. TRIAL REGISTRATION ClinicalTrials.gov: NCT01060098 . Registered 29 January 2010.
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Affiliation(s)
- Dobrina N Hull
- Department of Medicine, Imperial College London, London, UK.,Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - Helen Cooksley
- Institute of Hepatology, The Foundation for Liver Research, 111 Coldharbour Lane, London, SE5 9NT, UK
| | - Shilpa Chokshi
- Institute of Hepatology, The Foundation for Liver Research, 111 Coldharbour Lane, London, SE5 9NT, UK
| | - Richard O Williams
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - Sonya Abraham
- Department of Medicine, Imperial College London, London, UK
| | - Peter C Taylor
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Headington, Oxford, OX3 7LD, UK.
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Yoshida K, Nishioka M, Matsushima S, Joh K, Oto Y, Yoshiga M, Otani K, Ito H, Hirai K, Furuya K, Ukichi T, Noda K, Kingetsu I, Kurosaka D. Brief Report: Power Doppler Ultrasonography for Detection of Increased Vascularity in the Fascia: A Potential Early Diagnostic Tool in Fasciitis of Dermatomyositis. Arthritis Rheumatol 2016; 68:2986-2991. [DOI: 10.1002/art.39798] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 06/21/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Ken Yoshida
- Jikei University School of Medicine; Tokyo Japan
| | | | | | - Kensuke Joh
- Tohoku University Graduate School of Medicine; Sendai Japan
| | - Yosuke Oto
- Jikei University School of Medicine; Tokyo Japan
| | | | | | - Haruyasu Ito
- Jikei University School of Medicine; Tokyo Japan
| | | | | | - Taro Ukichi
- Jikei University School of Medicine; Tokyo Japan
| | - Kentaro Noda
- Jikei University School of Medicine; Tokyo Japan
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D'Agostino MA, Haavardsholm EA, van der Laken CJ. Diagnosis and management of rheumatoid arthritis; What is the current role of established and new imaging techniques in clinical practice? Best Pract Res Clin Rheumatol 2016; 30:586-607. [PMID: 27931956 DOI: 10.1016/j.berh.2016.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 10/19/2016] [Indexed: 01/05/2023]
Abstract
Ultrasound and magnetic resonance imaging (MRI) have become established imaging techniques for the management of rheumatoid arthritis. Several publications have pointed out the advantages of these techniques for a more complete evaluation of the inflammation and structural damage at joint level. Recently new imaging techniques as the positron emission tomography (PET) associated with computed tomography (CT) or MRI scan, and the optical imaging have been introduced in the panorama. This article presents the advantages and limitations of each imaging techniques in light with the recent publications.
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Affiliation(s)
- Maria Antonietta D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, 92100, Boulogne-Billancourt, France; INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France.
| | - Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vindern, 0319, Oslo, Norway
| | - Conny J van der Laken
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center - Location VU University Medical Center, Amsterdam, The Netherlands
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Singh JA, Hossain A, Tanjong Ghogomu E, Mudano AS, Tugwell P, Wells GA. Biologic or tofacitinib monotherapy for rheumatoid arthritis in people with traditional disease-modifying anti-rheumatic drug (DMARD) failure: a Cochrane Systematic Review and network meta-analysis (NMA). Cochrane Database Syst Rev 2016; 11:CD012437. [PMID: 27855242 PMCID: PMC6469573 DOI: 10.1002/14651858.cd012437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We performed a systematic review, a standard meta-analysis and network meta-analysis (NMA), which updates the 2009 Cochrane Overview, 'Biologics for rheumatoid arthritis (RA)'. This review is focused on biologic monotherapy in people with RA in whom treatment with traditional disease-modifying anti-rheumatic drugs (DMARDs) including methotrexate (MTX) had failed (MTX/other DMARD-experienced). OBJECTIVES To assess the benefits and harms of biologic monotherapy (includes anti-tumor necrosis factor (TNF) (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab) or non-TNF (abatacept, anakinra, rituximab, tocilizumab)) or tofacitinib monotherapy (oral small molecule) versus comparator (placebo or MTX/other DMARDs) in adults with RA who were MTX/other DMARD-experienced. METHODS We searched for randomized controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2015, Issue 6, June), MEDLINE (via OVID 1946 to June 2015), and Embase (via OVID 1947 to June 2015). Article selection, data extraction and risk of bias and GRADE assessments were done in duplicate. We calculated direct estimates with 95% confidence intervals (CI) using standard meta-analysis. We used a Bayesian mixed treatment comparisons (MTC) approach for NMA estimates with 95% credible intervals (CrI). We converted odds ratios (OR) to risk ratios (RR) for ease of understanding. We calculated absolute measures as risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB). MAIN RESULTS This update includes 40 new RCTs for a total of 46 RCTs, of which 41 studies with 14,049 participants provided data. The comparator was placebo in 16 RCTs (4,532 patients), MTX or other DMARD in 13 RCTs (5,602 patients), and another biologic in 12 RCTs (3,915 patients). Monotherapy versus placeboBased on moderate-quality direct evidence, biologic monotherapy (without concurrent MTX/other DMARDs) was associated with a clinically meaningful and statistically significant improvement in American College of Rheumatology score (ACR50) and physical function, as measured by the Health Assessment Questionnaire (HAQ) versus placebo. RR was 4.68 for ACR50 (95% CI, 2.93 to 7.48); absolute benefit RD 23% (95% CI, 18% to 29%); and NNTB = 5 (95% CI, 3 to 8). The mean difference (MD) was -0.32 for HAQ (95% CI, -0.42 to -0.23; a negative sign represents greater HAQ improvement); absolute benefit of -10.7% (95% CI, -14% to -7.7%); and NNTB = 4 (95% CI, 3 to 5). Direct and NMA estimates for TNF biologic, non-TNF biologic or tofacitinib monotherapy showed similar results for ACR50 , downgraded to moderate-quality evidence. Direct and NMA estimates for TNF biologic, anakinra or tofacitinib monotherapy showed a similar results for HAQ versus placebo with mostly moderate quality evidence.Based on moderate-quality direct evidence, biologic monotherapy was associated with a clinically meaningful and statistically significant greater proportion of disease remission versus placebo with RR 1.12 (95% CI 1.03 to 1.22); absolute benefit 10% (95% CI, 3% to 17%; NNTB = 10 (95% CI, 8 to 21)).Based on low-quality direct evidence, results for biologic monotherapy for withdrawals due to adverse events and serious adverse events were inconclusive, with wide confidence intervals encompassing the null effect and evidence of an important increase. The direct estimate for TNF monotherapy for withdrawals due to adverse events showed a clinically meaningful and statistically significant result with RR 2.02 (95% CI, 1.08 to 3.78), absolute benefit RD 3% (95% CI,1% to 4%), based on moderate-quality evidence. The NMA estimates for TNF biologic, non-TNF biologic, anakinra, or tofacitinib monotherapy for withdrawals due to adverse events and for serious adverse events were all inconclusive and downgraded to low-quality evidence. Monotherapy versus active comparator (MTX/other DMARDs)Based on direct evidence of moderate quality, biologic monotherapy (without concurrent MTX/other DMARDs) was associated with a clinically meaningful and statistically significant improvement in ACR50 and HAQ scores versus MTX/other DMARDs with a RR of 1.54 (95% CI, 1.14 to 2.08); absolute benefit 13% (95% CI, 2% to 23%), NNTB = 7 (95% CI, 4 to 26) and a mean difference in HAQ of -0.27 (95% CI, -0.40 to -0.14); absolute benefit of -9% (95% CI, -13.3% to -4.7%), NNTB = 2 (95% CI, 2 to 4). Direct and NMA estimates for TNF monotherapy and NMA estimate for non-TNF biologic monotherapy for ACR50 showed similar results, based on moderate-quality evidence. Direct and NMA estimates for non-TNF biologic monotherapy, but not TNF monotherapy, showed similar HAQ improvements , based on mostly moderate-quality evidence.There were no statistically significant or clinically meaningful differences for direct estimates of biologic monotherapy versus active comparator for RA disease remission. NMA estimates showed a statistically significant and clinically meaningful difference versus active comparator for TNF monotherapy (absolute improvement 7% (95% CI, 2% to 14%)) and non-TNF monotherapy (absolute improvement 19% (95% CrI, 7% to 36%)), both downgraded to moderate quality.Based on moderate-quality direct evidence from a single study, radiographic progression (scale 0 to 448) was statistically significantly reduced in those on biologic monotherapy versus active comparator, MD -4.34 (95% CI, -7.56 to -1.12), though the absolute reduction was small, -0.97% (95% CI, -1.69% to -0.25%). We are not sure of the clinical relevance of this reduction.Direct and NMA evidence (downgraded to low quality), showed inconclusive results for withdrawals due to adverse events, serious adverse events and cancer, with wide confidence intervals encompassing the null effect and evidence of an important increase. AUTHORS' CONCLUSIONS Based mostly on RCTs of six to 12-month duration in people with RA who had previously experienced and failed treatment with MTX/other DMARDs, biologic monotherapy improved ACR50, function and RA remission rates compared to placebo or MTX/other DMARDs.Radiographic progression was reduced versus active comparator, although the clinical significance was unclear.Results were inconclusive for whether biologic monotherapy was associated with an increased risk of withdrawals due to adverse events, serious adverse events or cancer, versus placebo (no data on cancer) or MTX/other DMARDs.
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Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical CenterDepartment of MedicineFaculty Office Tower 805B510 20th Street SouthBirminghamALUSA35294
| | - Alomgir Hossain
- University of Ottawa Heart InstituteCardiovascular Research Methods Centre40 Ruskin StreetRoom H‐2265OttawaONCanadaK1Y 4W7
| | | | - Amy S Mudano
- University of Alabama at BirminghamDepartment of Medicine ‐ RheumatologyBirminghamUSA
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
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Rezaei H, Af Klint E, Hammer HB, Terslev L, D'Agostino MA, Kisten Y, Arnaud L. Analysis of correlation and causes for discrepancy between quantitative and semi-quantitative Doppler scores in synovitis in rheumatoid arthritis. Rheumatology (Oxford) 2016; 56:255-262. [PMID: 28123118 PMCID: PMC5410929 DOI: 10.1093/rheumatology/kew385] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/19/2016] [Indexed: 01/09/2023] Open
Abstract
Objectives. The aim of this study was to evaluate the association between two semi-quantitative Doppler US scoring systems (SQS), and the quantitative scoring (QS) of Doppler pixel count. Methods. Adult patients with RA and inadequate clinical response to anti-rheumatic therapy were examined with musculoskeletal US (MSUS). Dorsal MSUS of the wrists, MCP and MTP 2–5 were performed. MSUS images with sign of synovitis were collected and the QS was measured. Five assessors blinded to the QS evaluated the images independently, according to either SQS method. Association between QS and SQS was studied using correlations and multilevel models taking into account the clustering of ratings at the rater, patient and joint levels. Results. Analysis of the 1190 ratings revealed a strong correlation (ρ = 0.89, P < 0.0001) and significant associations (P < 0.0001) between QS and SQS. Correlations between QS and SQS according to Szkudlarek et al. (ρ = 0.87, P < 0.0001) or Hammer et al. (ρ = 0.91, P < 0.0001) were similar. A total of 239 (20.1%) images were given a SQS grade that did not match that expected based on initial QS, using pre-defined cut-offs. Main explanations for discrepancies were different perceived region of interest (40.7%) and Doppler pixel count near cut-offs between SQS grades (32.3%). Conclusion. We showed that both SQS methods correlated well with QS to assess synovitis, but SQS methods are intrinsically limited when the Doppler pixel count is close to the cut-offs between the SQS grades. Analysis discrepancies between these methods may help further revision of criteria used to assess disease activity with MSUS in RA.
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Affiliation(s)
- Hamed Rezaei
- Department of Rheumatology, institute of medicine, Karolinska University Hospital .,Unit of Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institutet, Stockholm, Sweden
| | - Erik Af Klint
- Unit of Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institutet, Stockholm, Sweden
| | | | - Lene Terslev
- Center for Rheumatology and Spine Disease, Copenhagen, Denmark, Rigshospitalet
| | - Maria Antonietta D'Agostino
- APHP, Hôpital Ambroise Paré, Rheumatology Department, Boulogne-Billancourt, INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines
| | - Yogan Kisten
- Department of Rheumatology, institute of medicine, Karolinska University Hospital
| | - Laurent Arnaud
- Department of Rheumatology, institute of medicine, Karolinska University Hospital
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Wu HY, Filer A, Styles I, Dehghani H. Development of a multi-wavelength diffuse optical tomography system for early diagnosis of rheumatoid arthritis: simulation, phantoms and healthy human studies. BIOMEDICAL OPTICS EXPRESS 2016; 7:4769-4786. [PMID: 27896015 PMCID: PMC5119615 DOI: 10.1364/boe.7.004769] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/30/2016] [Accepted: 07/22/2016] [Indexed: 05/21/2023]
Abstract
A multi-wavelength diffuse optical tomography (DOT) system has been developed to directly extract physiological information, such as total haemoglobin concentration, from tissue in human hand joints. Novel methods for 3D surface imaging and spectrally constrained image reconstruction are introduced and their potential application to imaging of rheumatoid arthritis is discussed. Results are presented from simulation studies as well as experiments using phantoms and data from imaging of three healthy volunteers. The image features are recovered partially for phantom data using transmission measurements only. Images that reveal joint regions and surrounding features within the hand are shown to co-register with co-acquired ultrasound images which are shown to be related to total haemoglobin concentration.
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Affiliation(s)
- Hao Yang Wu
- The Centre for Physical Sciences of Imaging in Biomedical Sciences (PSIBS), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Andrew Filer
- The Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Iain Styles
- The Centre for Physical Sciences of Imaging in Biomedical Sciences (PSIBS), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- School of Computer Science, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Hamid Dehghani
- The Centre for Physical Sciences of Imaging in Biomedical Sciences (PSIBS), University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- School of Computer Science, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Han J, Geng Y, Deng X, Zhang Z. Subclinical Synovitis Assessed by Ultrasound Predicts Flare and Progressive Bone Erosion in Rheumatoid Arthritis Patients with Clinical Remission: A Systematic Review and Metaanalysis. J Rheumatol 2016; 43:2010-2018. [PMID: 27803342 DOI: 10.3899/jrheum.160193] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Subclinical synovitis can be detected by ultrasound in patients with rheumatoid arthritis (RA) who are in clinical remission. We aimed to confirm its predictive value for flare and progressive bone erosion. METHODS A systematic literature search was performed in Pubmed, Web of Science, Embase, and Cochrane Library on September 7, 2014. Baseline clinical and ultrasonographic characteristics were collected. Methodological quality was assessed. Pooled OR were calculated using Mantel-Haenszel model. We explored the source of heterogeneity through subgroup analysis and completed a cumulative metaanalysis. RESULTS Thirteen articles were included (8 with flare, 4 with bone erosion, 1 with both flare and bone erosion). Metaanalysis revealed an association between power Doppler (PD) positivity and the risk of flare (OR 4.52, 95% CI 2.61-7.84, p < 0.00001, I2 = 21%), the risk of progressive bone erosion on patient level (OR 12.80, 95% CI 1.29-126.81, p = 0.03, I2 = 52%) and the risk of progressive bone erosion on joint level (OR 11.85, 95% CI 5.01-28.03, p < 0.00001, I2 = 0%). Further subgroup analysis showed a higher risk of flare in patients with a study period < 1 year (OR 19.98 vs 3.41). No significant differences were observed in the subgroup analysis in duration of remission, disease duration, and medications. Moreover, cumulative metaanalysis indicated the validation and an increasing accuracy of PD positivity in predicting flare since 2012. CONCLUSION Ultrasound-detected subclinical synovitis can predict the risk of flare and progressive bone erosion in RA patients with clinical remission. Additionally, the flare of RA tends to occur within a followup of 1 year.
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Affiliation(s)
- Jingjing Han
- From the Department of Geriatrics, and the Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China.,J. Han, MD, Department of Geriatrics, Peking University First Hospital; Y. Geng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; X. Deng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; Z. Zhang, MD, PhD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital
| | - Yan Geng
- From the Department of Geriatrics, and the Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China.,J. Han, MD, Department of Geriatrics, Peking University First Hospital; Y. Geng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; X. Deng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; Z. Zhang, MD, PhD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital
| | - Xuerong Deng
- From the Department of Geriatrics, and the Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China.,J. Han, MD, Department of Geriatrics, Peking University First Hospital; Y. Geng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; X. Deng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; Z. Zhang, MD, PhD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital
| | - Zhuoli Zhang
- From the Department of Geriatrics, and the Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China. .,J. Han, MD, Department of Geriatrics, Peking University First Hospital; Y. Geng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; X. Deng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; Z. Zhang, MD, PhD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital.
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D'Agostino MA, Terslev L, Wakefield R, Østergaard M, Balint P, Naredo E, Iagnocco A, Backhaus M, Grassi W, Emery P. Novel algorithms for the pragmatic use of ultrasound in the management of patients with rheumatoid arthritis: from diagnosis to remission. Ann Rheum Dis 2016; 75:1902-1908. [PMID: 27553213 DOI: 10.1136/annrheumdis-2016-209646] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/31/2016] [Indexed: 12/25/2022]
Abstract
The absence of specific guidance on how to use ultrasound (US) to diagnose and manage patients with inflammatory arthritis, especially with rheumatoid arthritis (RA) has hindered the optimal utilisation of US in clinical practice, potentially limiting its benefits for patient outcomes. In view of this, a group of musculoskeletal US experts formed a working group to consider how this unmet need could be satisfied and to produce guidance (additional to European League against Rheumatism (EULAR) imaging recommendations) to support clinicians in their daily clinical work. This paper describes this process and its outcome, namely five novel algorithms, which identify when US could be used. They are designed to aid diagnosis, to inform assessment of treatment response/disease monitoring and to evaluate stable disease state or remission in patients with suspected or established RA, by providing a pragmatic template for using US at certain time points of the RA management. A research agenda has also been defined for answering unmet clinical needs.
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Affiliation(s)
- Maria Antonietta D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt, France INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines, France Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Richard Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Balint
- Third Rheumatology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Esperanza Naredo
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón and Universidad Complutense, Madrid, Spain
| | - Annamaria Iagnocco
- Ultrasound Unit, Rheumatology Department, Sapienza Università di Roma, Rome, Italy
| | - Marina Backhaus
- Department of Internal Medicine, Rheumatology and Clinical Immunology Academic Hospital of the Charité Berlin, Park-Klinik Weissensee Berlin, Berlin, Germany
| | - Walter Grassi
- Clinica Reumatologica-Scuola di Specializzazione in Reumatologia Università Politecnica delle Marche, Ancona, Italy
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Singh JA, Hossain A, Tanjong Ghogomu E, Kotb A, Christensen R, Mudano AS, Maxwell LJ, Shah NP, Tugwell P, Wells GA. Biologics or tofacitinib for rheumatoid arthritis in incomplete responders to methotrexate or other traditional disease-modifying anti-rheumatic drugs: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2016; 2016:CD012183. [PMID: 27175934 PMCID: PMC7068903 DOI: 10.1002/14651858.cd012183] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This is an update of the 2009 Cochrane overview and network meta-analysis (NMA) of biologics for rheumatoid arthritis (RA). OBJECTIVES To assess the benefits and harms of nine biologics (abatacept, adalimumab, anakinra, certolizumab pegol, etanercept, golimumab, infliximab, rituximab, tocilizumab) and small molecule tofacitinib, versus comparator (MTX, DMARD, placebo (PL), or a combination) in adults with rheumatoid arthritis who have failed to respond to methotrexate (MTX) or other disease-modifying anti-rheumatic drugs (DMARDs), i.e., MTX/DMARD incomplete responders (MTX/DMARD-IR). METHODS We searched for randomized controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (via The Cochrane Library Issue 6, June 2015), MEDLINE (via OVID 1946 to June 2015), and EMBASE (via OVID 1947 to June 2015). Data extraction, risk of bias and GRADE assessments were done in duplicate. We calculated both direct estimates using standard meta-analysis and used Bayesian mixed treatment comparisons approach for NMA estimates to calculate odds ratios (OR) and 95% credible intervals (CrI). We converted OR to risk ratios (RR) which are reported in the abstract for the ease of interpretation. MAIN RESULTS This update included 73 new RCTs for a total of 90 RCTs; 79 RCTs with 32,874 participants provided usable data. Few trials were at high risk of bias for blinding of assessors/participants (13% to 21%), selective reporting (4%) or major baseline imbalance (8%); a large number had unclear risk of bias for random sequence generation (68%) or allocation concealment (74%).Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with a statistically significant and clinically meaningful improvement in ACR50 versus comparator (RR 2.71 (95% confidence interval (CI) 2.36 to 3.10); absolute benefit 24% more patients (95% CI 19% to 29%), number needed to treat for an additional beneficial outcome (NNTB) = 5 (4 to 6). NMA estimates for ACR50 in tumor necrosis factor (TNF) biologic+MTX/DMARD (RR 3.23 (95% credible interval (Crl) 2.75 to 3.79), non-TNF biologic+MTX/DMARD (RR 2.99; 95% Crl 2.36 to 3.74), and anakinra + MTX/DMARD (RR 2.37 (95% Crl 1.00 to 4.70) were similar to the direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with a clinically and statistically important improvement in function measured by the Health Assessment Questionnaire (0 to 3 scale, higher = worse function) with a mean difference (MD) based on direct evidence of -0.25 (95% CI -0.28 to -0.22); absolute benefit of -8.3% (95% CI -9.3% to -7.3%), NNTB = 3 (95% CI 2 to 4). NMA estimates for TNF biologic+MTX/DMARD (absolute benefit, -10.3% (95% Crl -14% to -6.7%) and non-TNF biologic+MTX/DMARD (absolute benefit, -7.3% (95% Crl -13.6% to -0.67%) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), biologic+MTX/DMARD was associated with clinically and statistically significantly greater proportion of participants achieving remission in RA (defined by disease activity score DAS < 1.6 or DAS28 < 2.6) versus comparator (RR 2.81 (95% CI, 2.23 to 3.53); absolute benefit 18% more patients (95% CI 12% to 25%), NNTB = 6 (4 to 9)). NMA estimates for TNF biologic+MTX/DMARD (absolute improvement 17% (95% Crl 11% to 23%)) and non-TNF biologic+MTX/DMARD (absolute improvement 19% (95% Crl 12% to 28%) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for inconsistency), radiographic progression (scale 0 to 448) was statistically significantly reduced in those on biologics + MTX/DMARDs versus comparator, MD -2.61 (95% CI -4.08 to -1.14). The absolute reduction was small, -0.58% (95% CI -0.91% to -0.25%) and we are unsure of the clinical relevance of this reduction. NMA estimates of TNF biologic+MTX/DMARD (absolute reduction -0.67% (95% Crl -1.4% to -0.12%) and non-TNF biologic+MTX/DMARD (absolute reduction, -0.68% (95% Crl -2.36% to 0.92%)) were similar to respective direct estimates.Based on direct evidence of moderate quality (downgraded for imprecision), results for withdrawals due to adverse events were inconclusive, with wide confidence intervals encompassing the null effect and evidence of an important increase in withdrawals, RR 1.11 (95% CI 0.96 to 1.30). The NMA estimates of TNF biologic+MTX/DMARD (RR 1.24 (95% Crl 0.99 to 1.57)) and non-TNF biologic+MTX/DMARD (RR 1.20 (95% Crl 0.87 to 1.67)) were similarly inconclusive and downgraded to low for both imprecision and indirectness.Based on direct evidence of high quality, biologic+MTX/DMARD was associated with clinically significantly increased risk (statistically borderline significant) of serious adverse events on biologic+MTX/DMARD (Peto OR [can be interpreted as RR due to low event rate] 1.12 (95% CI 0.99 to 1.27); absolute risk 1% (0% to 2%), As well, the NMA estimate for TNF biologic+MTX/DMARD (Peto OR 1.20 (95% Crl 1.01 to 1.43)) showed moderate quality evidence of an increase in the risk of serious adverse events. The other two NMA estimates were downgraded to low quality due to imprecision and indirectness and had wide confidence intervals resulting in uncertainty around the estimates: non-TNF biologics + MTX/DMARD: 1.07 (95% Crl 0.89 to 1.29) and anakinra: RR 1.06 (95% Crl 0.65 to 1.75).Based on direct evidence of low quality (downgraded for serious imprecision), results were inconclusive for cancer (Peto OR 1.07 (95% CI 0.68 to 1.68) for all biologic+MTX/DMARD combinations. The NMA estimates of TNF biologic+MTX/DMARD (Peto OR 1.21 (95% Crl 0.63 to 2.38) and non-TNF biologic+MTX/DMARD (Peto OR 0.99 (95% Crl 0.58 to 1.78)) were similarly inconclusive and downgraded to low quality for both imprecision and indirectness.Main results text shows the results for tofacitinib and differences between medications. AUTHORS' CONCLUSIONS Based primarily on RCTs of 6 months' to 12 months' duration, there is moderate quality evidence that the use of biologic+MTX/DMARD in people with rheumatoid arthritis who have failed to respond to MTX or other DMARDs results in clinically important improvement in function and higher ACR50 and remission rates, and increased risk of serious adverse events than the comparator (MTX/DMARD/PL; high quality evidence). Radiographic progression is slowed but its clinical relevance is uncertain. Results were inconclusive for whether biologics + MTX/DMARDs are associated with an increased risk of cancer or withdrawals due to adverse events.
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Affiliation(s)
- Jasvinder A Singh
- Birmingham VA Medical CenterDepartment of MedicineFaculty Office Tower 805B510 20th Street SouthBirminghamALUSA35294
| | - Alomgir Hossain
- University of Ottawa Heart InstituteCardiovascular Research Methods Centre40 Ruskin StreetRoom H‐2265OttawaONCanadaK1Y 4W7
| | | | - Ahmed Kotb
- University of Ottawa Heart InstituteCardiovascular Research Methods Centre40 Ruskin StreetRoom H‐2265OttawaONCanadaK1Y 4W7
| | - Robin Christensen
- Copenhagen University Hospital, Bispebjerg og FrederiksbergMusculoskeletal Statistics Unit, The Parker InstituteNordre Fasanvej 57CopenhagenDenmarkDK‐2000
| | - Amy S Mudano
- University of Alabama at BirminghamDepartment of Medicine ‐ RheumatologyBirminghamUSA
| | - Lara J Maxwell
- Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital ‐ General CampusCentre for Practice‐Changing Research (CPCR)501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Nipam P Shah
- University of Alabama at BirminghamDepartment of Clinical Immunology and RheumatologyFaculty Office Tower, Suite 805, 510 20th Street SouthBirminghamALUSA35294
| | - Peter Tugwell
- Faculty of Medicine, University of OttawaDepartment of MedicineOttawaONCanadaK1H 8M5
| | - George A Wells
- University of OttawaDepartment of Epidemiology and Community MedicineRoom H128140 Ruskin StreetOttawaONCanadaK1Y 4W7
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Ultrasound7 versus ultrasound12 in monitoring the response to infliximab in patients with rheumatoid arthritis. Clin Rheumatol 2016; 35:587-94. [DOI: 10.1007/s10067-016-3176-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 11/28/2015] [Accepted: 01/10/2016] [Indexed: 11/25/2022]
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General applications of ultrasound in rheumatology: why we need it in our daily practice. J Clin Rheumatol 2015; 21:133-43. [PMID: 25807093 DOI: 10.1097/rhu.0000000000000230] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ultrasound (US) is a noninvasive imaging technique that continues to gain interest among rheumatologists because of its undoubted utility for the assessment of a wide range of abnormalities in rheumatic diseases. It also has a great potential to be used at the time of consultation as an extension of the clinical examination.Current data demonstrate that the standard clinical approach could result in an insensitive assessment of some the different aspects of the various rheumatic diseases for which US has become a feasible and effective imaging modality that allows early detection of anatomical changes, careful guidance for the aspiration and/or local treatment, and short- and long-term therapy monitoring at the joint, tendon, enthesis, nail, and skin levels. The spectrum of pathological conditions for which US plays a crucial role continues to increase over time and includes rheumatoid arthritis, spondyloarthropathies, osteoarthritis, crystal-related arthropathies, connective tissue disorders, and vasculitis.It is expected that the inclusion of more longitudinal studies with a larger number of patients and more rigorous methodological approach will undoubtedly provide a better understanding of the significance of the abnormal US findings detected in order to provide the proper diagnostic and/or therapeutic approaches. In this article, we analyze the current potential applications of US in rheumatology and discuss the evidence supporting its use in the daily rheumatologic practice.
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D'Agostino MA, Wakefield RJ, Berner-Hammer H, Vittecoq O, Filippou G, Balint P, Möller I, Iagnocco A, Naredo E, Østergaard M, Boers M, Gaillez C, Van Holder K, Le Bars M. Value of ultrasonography as a marker of early response to abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: results from the APPRAISE study. Ann Rheum Dis 2015; 75:1763-9. [PMID: 26590174 PMCID: PMC5036216 DOI: 10.1136/annrheumdis-2015-207709] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 10/25/2015] [Indexed: 11/24/2022]
Abstract
Objectives To study the responsiveness of a combined power Doppler and greyscale ultrasound (PDUS) score for assessing synovitis in biologic-naïve patients with rheumatoid arthritis (RA) starting abatacept plus methotrexate (MTX). Methods In this open-label, multicentre, single-arm study, patients with RA (MTX inadequate responders) received intravenous abatacept (∼10 mg/kg) plus MTX for 24 weeks. A composite PDUS synovitis score, developed by the Outcome Measures in Rheumatology–European League Against Rheumatism (OMERACT–EULAR)-Ultrasound Task Force, was used to evaluate individual joints. The maximal score of each joint was added into a Global OMERACT–EULAR Synovitis Score (GLOESS) for bilateral metacarpophalangeal joints (MCPs) 2–5 (primary objective). The value of GLOESS containing other joint sets was explored, along with clinical efficacy. Results Eighty-nine patients completed the 24-week treatment period. The earliest PDUS sign of improvement in synovitis was at week 1 (mean change in GLOESS (MCPs 2–5): −0.7 (95% CIs −1.2 to −0.1)), with continuous improvement to week 24. Early improvement was observed in the component scores (power Doppler signal at week 1, synovial hyperplasia at week 2, joint effusion at week 4). Comparable changes were observed for 22 paired joints and minimal joint subsets. Mean Disease Activity Score 28 (C reactive protein) was significantly reduced from weeks 1 to 24, reaching clinical meaningful improvement (change ≥1.2) at week 8. Conclusions In this first international prospective study, the composite PDUS score is responsive to abatacept. GLOESS demonstrated the rapid onset of action of abatacept, regardless of the number of joints examined. Ultrasound is an objective tool to monitor patients with RA under treatment. Trial registration number NCT00767325.
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Affiliation(s)
- Maria-Antonietta D'Agostino
- Service de Rhumatologie, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt, France Laboratoire d'Excellence INFLAMEX, INSERM U1173, Université Paris Ouest-Versailles Saint-Quentin, Saint-Quentin-en-Yvelines, France
| | - Richard J Wakefield
- NIHR Leeds Musculoskeletal Biomedical Research Unit (LMBRU), Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | | | - Olivier Vittecoq
- Department of Rheumatology and CIC-CRB-1404, Inserm U905, Rouen University Hospital, Rouen University, Rouen, France
| | - Georgios Filippou
- Department of Medicine, Surgery and Neurosciences, Rheumatology Section, University of Siena, Siena, Italy
| | - Peter Balint
- 3rd Rheumatology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Ingrid Möller
- Department of Rheumatology, Instituto Poal, Barcelona, Spain
| | - Annamaria Iagnocco
- Rheumatology Unit, Dipartimento Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Roma, Italy
| | - Esperanza Naredo
- Department of Rheumatology, Hospital GU Gregorio Marañón, Madrid, Spain
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, The Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Amsterdam, Netherlands
| | - Corine Gaillez
- Medical Affairs, Bristol-Myers Squibb, Rueil-Malmaison, France
| | - Karina Van Holder
- Global Clinical Operations and Strategy, Bristol-Myers Squibb, Braine-L'Alleud, Belgium
| | - Manuela Le Bars
- Medical Affairs, Bristol-Myers Squibb, Rueil-Malmaison, France
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Grassi W, Okano T, Di Geso L, Filippucci E. Imaging in rheumatoid arthritis: options, uses and optimization. Expert Rev Clin Immunol 2015; 11:1131-46. [DOI: 10.1586/1744666x.2015.1075395] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Baker JF, Tan YK, Conaghan PG. Monitoring in established RA: Role of imaging and soluble biomarkers. Best Pract Res Clin Rheumatol 2015; 29:566-79. [DOI: 10.1016/j.berh.2015.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Amitai I, Werner S, Schicke B, Burmester GR, Minet O, Zabaryło U, Backhaus M, Ohrndorf S. Comparison of Photo Optical Imaging with Musculoskeletal Ultrasound and Clinical Examination in the Assessment of Inflammatory Activity in Proximal Interphalangeal Joints in Rheumatoid Arthritis and Osteoarthritis. J Rheumatol 2015; 42:1595-602. [DOI: 10.3899/jrheum.150098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2015] [Indexed: 11/22/2022]
Abstract
Objective.Lightscan is a novel, rapid, low-cost, easily operated and noninvasive imaging technology used to assess inflammatory activity in proximal interphalangeal (PIP) joints. The results are calculated automatically. To our knowledge, this is the first comparative study of photo optical imaging (POI), with clinical examination (CE), disease activity score at 28 joints (DAS28)-erythrocyte sedimentation rate (ESR), and musculoskeletal ultrasonography (US) in healthy subjects and patients with rheumatoid arthritis (RA) or osteoarthritis (OA).Methods.There were 688 PIP joints of both hands examined in 87 subjects (38 RA, 21 OA, 28 healthy) by Lightscan and compared with CE for clinically swollen and tender joints, DAS28-ESR (only RA), and US.Results.With US as reference, POI had a sensitivity of 74% and a specificity of 93%. In the receiver-operating curve (ROC) analysis, the Lightscan showed a higher sensitivity and specificity [area under the curve (AUC) 0.879] for the distinction of healthy subjects versus patients (OA, RA) than US in greyscale (GSUS; AUC 0.797) and power Doppler (PDUS; AUC 0.67). POI correlated significantly with GSUS (r 0.473, p < 0.01) and PDUS (r 0.486, p < 0.01). The agreement rates between POI and GSUS were up to 79%, between POI and PDUS up to 92%, and between POI and CE up to 66%. POI did not correlate with DAS28-ESR.Conclusion.The Lightscan is a new technology offering sensitive imaging detection of inflammatory changes in subjects with RA and OA with PIP arthritis. POI was more sensitive than CE and correlated significantly to GSUS and PDUS, while presenting a higher sensitivity and specificity for the detection of healthy subjects versus patients (RA, OA) based on the ROC analysis.
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Scott DL, Ibrahim F, Farewell V, O'Keeffe AG, Ma M, Walker D, Heslin M, Patel A, Kingsley G. Randomised controlled trial of tumour necrosis factor inhibitors against combination intensive therapy with conventional disease-modifying antirheumatic drugs in established rheumatoid arthritis: the TACIT trial and associated systematic reviews. Health Technol Assess 2015; 18:i-xxiv, 1-164. [PMID: 25351370 DOI: 10.3310/hta18660] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is initially treated with methotrexate and other disease-modifying antirheumatic drugs (DMARDs). Active RA patients who fail such treatments can receive tumour necrosis factor inhibitors (TNFis), which are effective but expensive. OBJECTIVE We assessed whether or not combination DMARDs (cDMARDs) give equivalent clinical benefits at lower costs in RA patients eligible for TNFis. DESIGN An open-label, 12-month, pragmatic, randomised, multicentre, two-arm trial [Tumour necrosis factor inhibitors Against Combination Intensive Therapy (TACIT)] compared these treatment strategies. We then systematically reviewed all comparable published trials. SETTING The TACIT trial involved 24 English rheumatology clinics. PARTICIPANTS Active RA patients eligible for TNFis. INTERVENTIONS The TACIT trial compared cDMARDs with TNFis plus methotrexate or another DMARD; 6-month non-responders received (a) TNFis if in the cDMARD group; and (b) a second TNFi if in the TNFi group. MAIN OUTCOME MEASURES The Heath Assessment Questionnaire (HAQ) was the primary outcome measure. The European Quality of Life-5 Dimensions (EQ-5D), joint damage, Disease Activity Score for 28 Joints (DAS28), withdrawals and adverse effects were secondary outcome measures. Economic evaluation linked costs, HAQ changes and quality-adjusted life-years (QALYs). RESULTS In total, 432 patients were screened; 104 started on cDMARDs and 101 started on TNFis. The initial demographic and disease assessments were similar between the groups. In total, 16 patients were lost to follow-up (nine in the cDMARD group, seven in the TNFi group) and 42 discontinued their intervention but were followed up (23 in the cDMARD group and 19 in the TNFi group). Intention-to-treat analysis with multiple imputation methods used for missing data showed greater 12-month HAQ score reductions with initial cDMARDs than with initial TNFis [adjusted linear regression coefficient 0.15, 95% confidence interval (CI) -0.003 to 0.31; p = 0.046]. Increases in 12-month EQ-5D scores were greater with initial cDMARDs (adjusted linear regression coefficient -0.11, 95% CI -0.18 to -0.03; p = 0.009) whereas 6-month changes in HAQ and EQ-5D scores and 6- and 12-month changes in joint damage were similar between the initial cDMARD group and the initial TNFi group. Longitudinal analyses (adjusted general estimating equations) showed that the DAS28 was lower in the initial TNFi group in the first 6 months (coefficient -0.63, 95% CI -0.93 to -0.34; p < 0.001) but there were no differences between the groups in months 6-12. In total, 36 patients in the initial cDMARD group and 44 in the initial TNFi group achieved DAS28 remission. The onset of remission did not differ between groups (p = 0.085 on log-rank test). In total, 10 patients in the initial cDMARD group and 18 in the initial TNFi group experienced serious adverse events; stopping therapy because of toxicity occurred in 10 and six patients respectively. Economic evaluation showed that the cDMARD group had similar or better QALY outcomes than TNFi with significantly lower costs at 6 and 12 months. In the systematic reviews we identified 32 trials (including 20-1049 patients) on early RA and 19 trials (including 40-982 patients) on established RA that compared (1) cDMARDs with DMARD monotherapy; (2) TNFis/methotrexate with methotrexate monotherapy; and (3) cDMARDs with TNFis/methotrexate. They showed that cDMARDs and TNFis had similar efficacies and toxicities. CONCLUSIONS Active RA patients who have failed methotrexate and another DMARD achieve equivalent clinical benefits at a lower cost from starting cDMARDs or from starting TNFis (reserving TNFis for non-responders). Only a minority of patients achieve sustained remission with cDMARDs or TNFis; new strategies are needed to maximise the frequency of remission. TRIAL REGISTRATION Current Control Trials ISRCTN37438295. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Department of Rheumatology, King's College London School of Medicine, London, UK
| | - Fowzia Ibrahim
- Department of Rheumatology, King's College London School of Medicine, London, UK
| | - Vern Farewell
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, UK
| | - Aidan G O'Keeffe
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, UK
| | - Margaret Ma
- Department of Rheumatology, King's College London School of Medicine, London, UK
| | - David Walker
- Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Margaret Heslin
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
| | - Anita Patel
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
| | - Gabrielle Kingsley
- Department of Rheumatology, King's College London School of Medicine, London, UK
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Schmidt WA, Schönau V, Reiche BE, Oberdorfer PD, Ohrndorf S, Backhaus M. Grading of ultrasound Doppler signals in synovitis: does it need an update? Rheumatology (Oxford) 2015; 54:1897-903. [DOI: 10.1093/rheumatology/kev205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Indexed: 11/14/2022] Open
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The Role of Power Doppler Ultrasonography as Disease Activity Marker in Rheumatoid Arthritis. DISEASE MARKERS 2015; 2015:325909. [PMID: 26063952 PMCID: PMC4433665 DOI: 10.1155/2015/325909] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 04/07/2015] [Indexed: 11/28/2022]
Abstract
Structural damage in rheumatoid arthritis (RA) occurs early if inflammation is not treated promptly. Treatment targeted to reduce inflammation, in particular, that of synovial inflammation in the joints (synovitis), has been recommended as standard treat-to-target recommendations by rheumatologists. The goal is to achieve disease remission (i.e., no disease activity). Several accepted remission criteria have not always equated to the complete absence of true inflammation. Over the last decade, musculoskeletal ultrasonography has been demonstrated to detect subclinical synovitis not appreciated by routine clinical or laboratory assessments, with the Power Doppler modality allowing clinicians to more readily appreciate true inflammation. Thus, targeting therapy to Power Doppler activity may provide superior outcomes compared with treating to clinical targets alone, making it an attractive marker of disease activity in RA. However, more validation on its true benefits such as its benefits to patients in regard to patient related outcomes and issues with standardized training in acquisition and interpretation of power Doppler findings are required.
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Torp-Pedersen S, Christensen R, Szkudlarek M, Ellegaard K, D'Agostino MA, Iagnocco A, Naredo E, Balint P, Wakefield RJ, Torp-Pedersen A, Terslev L. Power and color Doppler ultrasound settings for inflammatory flow: impact on scoring of disease activity in patients with rheumatoid arthritis. Arthritis Rheumatol 2015; 67:386-95. [PMID: 25370843 DOI: 10.1002/art.38940] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 10/28/2014] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine how settings for power and color Doppler ultrasound sensitivity vary on different high- and intermediate-range ultrasound machines and to evaluate the impact of these changes on Doppler scoring of inflamed joints. METHODS Six different types of ultrasound machines were used. On each machine, the factory setting for superficial musculoskeletal scanning was used unchanged for both color and power Doppler modalities. The settings were then adjusted for increased Doppler sensitivity, and these settings were designated study settings. Eleven patients with rheumatoid arthritis (RA) with wrist involvement were scanned on the 6 machines, each with 4 settings, generating 264 Doppler images for scoring and color quantification. Doppler sensitivity was measured with a quantitative assessment of Doppler activity: color fraction. Higher color fraction indicated higher sensitivity. RESULTS Power Doppler was more sensitive on half of the machines, whereas color Doppler was more sensitive on the other half, using both factory settings and study settings. There was an average increase in Doppler sensitivity, despite modality, of 78% when study settings were applied. Over the 6 machines, 2 Doppler modalities, and 2 settings, the grades for each of 7 of the patients varied between 0 and 3, while the grades for each of the other 4 patients varied between 0 and 2. CONCLUSION The effect of using different machines, Doppler modalities, and settings has a considerable influence on the quantification of inflammation by ultrasound in RA patients, and this must be taken into account in multicenter studies.
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Affiliation(s)
- Søren Torp-Pedersen
- Copenhagen University Hospital, Frederiksberg, Denmark, and Copenhagen University Hospital at Glostrup, Glostrup, Denmark
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Mendonça JA, Yazbek MA, Costallat BL, Gutiérrez M, Bértolo MB. [The modified US7 score in the assessment of synovitis in early rheumatoid arthritis]. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 54:287-94. [PMID: 25627224 DOI: 10.1016/j.rbr.2014.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/19/2014] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the modified US7 score (MUS7 score SYN) in the assessment of patients with early rheumatoid arthritis (ERA). In addition, dorsal and palmar recesses of the wrists as well as of small joints of the hands and feet were examined for the presence of synovitis by means of a global assessment of joints. METHODS The study sample comprised 32 patients treated for arthritis, with an average disease duration of 13 months. An ultrasound machine with high frequency transducer was used. Hands were also X-rayed and analysed by Larsen score. RESULTS Out of the 832 examined joints, synovitis was detected in 173 (20,79%), tenosynovitis in 22 (4,91%), and erosions in 3 (1,56%). Synovitis was predominantly detected in the dorsal recess (73,38%) of MCP and PIP joints, when compared with palmar recess (26%). The presence of synovitis in the joints evaluated correlated with clinical (HAQ-DI, DAS28), laboratory (ACPA, RF, CRP), and ultrasound results (r = 0,37 to r = 0,42; p = 0,04 to p = 0,003). We found correlation of the MUS7 score SYN of the gray scale US or of the power Doppler US with DAS28 (PCR) values (r = 0,38; p = 0,0332), and with CRP results (r = 0,39; p = 0,0280), respectively. CONCLUSION The dorsal recess, the wrist, and small joints can be considered as important sites to detect synovitis by the MUS7 score SYN in patients with ERA.
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Affiliation(s)
- José Alexandre Mendonça
- Departamento de Reumatologia, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brasil.
| | - Michel Alexandre Yazbek
- Departamento de Reumatologia, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brasil
| | | | | | - Manoel Barros Bértolo
- Departamento de Reumatologia, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brasil
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Kane D. Musculoskeletal ultrasound. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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