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Rombach I, Tucker L, Tillett W, Jadon D, Watson M, Francis A, Sinomati Y, Dutton SJ, Coates LC. Clinical effectiveness of symptomatic therapy compared with standard step-up care for the treatment of low-impact psoriatic oligoarthritis: the two-arm parallel group randomised POISE feasibility study. Ther Adv Musculoskelet Dis 2022; 13:1759720X211057668. [PMID: 35035537 PMCID: PMC8756359 DOI: 10.1177/1759720x211057668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction In psoriatic arthritis (PsA), treatment recommendations support first-line use of disease-modifying antirheumatic drugs (DMARDs). There are few treatment strategy trials, and no previous studies have investigated tailored treatment choice by disease severity. Studies in oligoarthritis (<5 inflamed joints) are limited but have suggested that some can be managed without DMARDs, preventing unnecessary side effects. This study aimed to assess the feasibility and acceptability of a study comparing standard DMARD treatment against symptomatic therapy in patients with mild psoriatic oligoarthritis. Methods This trial was embedded within the MONITOR-PsA cohort, which uses a Trials Within Cohorts (TWiCs) design. Patients with newly diagnosed psoriatic oligoarthritis, with low disease activity (PASDAS ⩽ 3.2) and the absence of poor prognostic factors [C reactive protein (CRP) < 5 mg/dL, HAQ < 1, no radiographic erosions] were randomised open-label to either standard care with 'step-up' DMARD therapy or to symptomatic therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and local corticosteroid injections to inflamed joints. Key outcomes were the proportion of eligible cohort patients, consent and study completion rate. Results Over the 15-month study period, only one eligible patient was randomised. Although oligoarthritis patients represented 45% of patients in this early PsA cohort, the majority did not have mild disease (24% raised CRP, 51% moderate disease activity, 13% radiographic damage and/or poor function). Of those meeting trial inclusion criteria, many patients refused treatment in the observational cohort prior to an invitation into the trial as they did not wish to be treated with DMARDs. Conclusion The study was not feasible as designed. Oligoarthritis represents around half of initial PsA presentations, but the majority starting therapy have high-impact disease. A small proportion have mild oligoarticular disease but many are not keen on treatment with DMARDs, given the potential side effects of these medications. Further research is needed to support evidence-based treatment in this subgroup. Trial registration number - ClinicalTrials.gov (NCT03797872) and EudraCT (2018-001085-42).
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Affiliation(s)
- Ines Rombach
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Laura Tucker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - William Tillett
- Royal National Hospital for Rheumatic Diseases, Bath, UK; Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Deepak Jadon
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Marion Watson
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anne Francis
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Yvonne Sinomati
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Laura C Coates
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
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Hegde A, Mangal V, Vasdev V, Singh K, Bhanu K. Pure peripheral spondyloarthritis, is it exceedingly rare? A real-world experience from an Indian tertiary care hospital. JOURNAL OF MARINE MEDICAL SOCIETY 2022. [DOI: 10.4103/jmms.jmms_117_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rombach I, Tillett W, Jadon D, Tucker L, Watson M, Francis A, Sinomati Y, Eldridge L, Dritsaki M, Dutton SJ, Al-Mossawi H, Gullick N, Thompson B, Coates LC. Treating to target in psoriatic arthritis: assessing real-world outcomes and optimising therapeutic strategy for adults with psoriatic arthritis-study protocol for the MONITOR-PsA study, a trials within cohorts study design. Trials 2021; 22:185. [PMID: 33663566 PMCID: PMC7931500 DOI: 10.1186/s13063-021-05142-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/20/2021] [Indexed: 11/15/2022] Open
Abstract
Background The Tight Control of psoriatic arthritis (TICOPA) trial confirmed improved clinical outcomes with a treat to target (T2T) strategy in psoriatic arthritis (PsA). This consisted of 4-weekly review and escalation of ‘step up’ therapy (single disease modifying therapy (DMARD), combination DMARDs and then biologics) based on remission criteria. Based on this, a T2T approach is supported by European PsA treatment recommendations. However, it is not commonly implemented in routine care primarily due to feasibility and cost concerns. In the TICOPA trial, the same treatment regime was used for all participants regardless of their disease profile. Despite the recognition of PsA as a highly heterogeneous condition, no studies have tailored which drugs are used depending on disease severity. The cohort will establish real world outcomes for the T2T approach in PsA and also form the basis of a trials within cohorts (TWiCs) design to test alternative therapeutic approaches within embedded clinical trials providing an evidence base for treatment strategy in PsA. Methods The Multicentre Observational Initiative in Treat to target Outcomes in Psoriatic Arthritis (MONITOR-PsA) cohort will apply a T2T approach within routine care. It will recruit newly diagnosed adult patients with PsA starting systemic therapies. The cohort is observational allowing routine therapeutic care within NHS clinics but a T2T approach will be supported when monitoring treatment within the cohort. Eligible participants will be adults (≥18 years) with active PsA with ≥ 1 tender or swollen joints or enthesis who have not previously had treatment with DMARDs for articular disease. Discussion This study is the first TWiC designed to support a fully powered randomised drug trial. The results from the observational cohort will be compared with those observed in the TICOPA trial investigating the clinical effectiveness and health care costs of the pragmatic T2T approach. Nested trials will provide definitive RCT evidence establishing the optimal management of PsA within the T2T approach. The TWiCs design allows robust generalizability to routine healthcare, avoids disappointment bias, aids recruitment and in future will allow assessment of longer-term outcomes. Trial registration ClinicalTrials.gov NCT03531073. Retrospectively registered on 21 May 2018.
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Affiliation(s)
- Ines Rombach
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - William Tillett
- Royal National Hospital for Rheumatic Diseases, Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Deepak Jadon
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Laura Tucker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marion Watson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Yvonne Sinomati
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Hussein Al-Mossawi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicola Gullick
- Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ben Thompson
- Department of Rheumatology, Musculoskeletal Unit, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
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Carron P, De Craemer AS, Van den Bosch F. Peripheral spondyloarthritis: a neglected entity-state of the art. RMD Open 2020; 6:e001136. [PMID: 32385142 PMCID: PMC7299516 DOI: 10.1136/rmdopen-2019-001136] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023] Open
Abstract
Peripheral spondyloarthritis (pSpA) refers to a number of seemingly different spondyloarthritis subsets in which psoriatic arthritis (PsA) is the most common, and symptoms of arthritis, enthesitis or dactylitis predominate the clinical presentation. Although formal classification criteria for pSpA have been introduced in 2011, only a minority of epidemiological and clinical studies addressed this clinical entity as a separate disease. Moreover, research on outcome measures and treatment modalities in pSpA has been mainly focused on PsA. Subsequently, all biological treatments are off-label in patients with non-psoriatic pSpA. Its neglected status has important implications for clinical practice since the emerging group of early-diagnosed non-psoriatic pSpA patients remains poorly characterised and lacks specific treatment recommendations. This review summarises what is currently known regarding pSpA in terms of epidemiology, clinical presentation, diagnosis and therapeutic approach.
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Affiliation(s)
- Philippe Carron
- Rheumatology, University Hospital Ghent, Ghent, Belgium
- VIB Center for Inflammation Research, Ghent, Belgium
| | - Ann-Sophie De Craemer
- Rheumatology, University Hospital Ghent, Ghent, Belgium
- VIB Center for Inflammation Research, Ghent, Belgium
| | - Filip Van den Bosch
- Rheumatology, University Hospital Ghent, Ghent, Belgium
- VIB Center for Inflammation Research, Ghent, Belgium
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Lopez-Olivo MA, Kakpovbia-Eshareturi V, des Bordes JK, Barbo A, Christensen R, Suarez-Almazor ME. Treating Early Undifferentiated Arthritis: A Systematic Review and Meta-Analysis of Direct and Indirect Trial Evidence. Arthritis Care Res (Hoboken) 2018; 70:1355-1365. [DOI: 10.1002/acr.23474] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 11/14/2017] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | - Andrea Barbo
- University of Texas MD Anderson Cancer Center; Houston
| | - Robin Christensen
- Parker Institute, Bispebjerg and Frederiksberg Hospitals; Copenhagen Denmark
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Burmester GR, Pope JE. Novel treatment strategies in rheumatoid arthritis. Lancet 2017; 389:2338-2348. [PMID: 28612748 DOI: 10.1016/s0140-6736(17)31491-5] [Citation(s) in RCA: 622] [Impact Index Per Article: 88.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/27/2017] [Accepted: 05/03/2017] [Indexed: 02/06/2023]
Abstract
New treatment strategies have substantially changed the course of rheumatoid arthritis. Many patients can achieve remission if the disease is recognised early and is treated promptly and continuously; however, some individuals do not respond adequately to treatment. Rapid diagnosis and a treat-to-target approach with tight monitoring and control, can increase the likelihood of remission in patients with rheumatoid arthritis. In this Series paper, we describe new insights into the management of rheumatoid arthritis with targeted therapy approaches using classic and novel medications, and outline the potential effects of precision medicine in this challenging disease. Articles are included that investigate the treat-to-target approach, which includes adding or de-escalating treatment. Rheumatoid arthritis treatment is impeded by delayed diagnosis, problematic access to specialists, and difficulties adhering to treat-to-target principles. Clinical management goals in rheumatoid arthritis include enabling rapid access to optimum diagnosis and care and the well informed use of multiple treatments approved for this disease.
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Affiliation(s)
- Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Berlin, Germany.
| | - Janet E Pope
- Division of Rheumatology, St Joseph's Hospital, Western University, London, ON, Canada
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Buch MH, Hensor EMA, Rakieh C, Freeston JE, Middleton E, Horton S, Das S, Peterfy C, Tan AL, Wakefield RJ, Emery P. Abatacept reduces disease activity and ultrasound power Doppler in ACPA-negative undifferentiated arthritis: a proof-of-concept clinical and imaging study. Rheumatology (Oxford) 2016; 56:58-67. [DOI: 10.1093/rheumatology/kew357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/18/2016] [Indexed: 11/14/2022] Open
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Heimans L, Akdemir G, Boer KVCWD, Goekoop-Ruiterman YP, Molenaar ET, van Groenendael JHLM, Peeters AJ, Steup-Beekman GM, Lard LR, de Sonnaville PBJ, Grillet BAM, Huizinga TWJ, Allaart CF. Two-year results of disease activity score (DAS)-remission-steered treatment strategies aiming at drug-free remission in early arthritis patients (the IMPROVED-study). Arthritis Res Ther 2016; 18:23. [PMID: 26794605 PMCID: PMC4721018 DOI: 10.1186/s13075-015-0912-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/29/2015] [Indexed: 12/11/2022] Open
Abstract
Background Early suppression of disease activity in (rheumatoid) arthritis (RA) patients may result in drug-free remission and prevent damage. We assessed 2-year clinical and radiological outcomes of two disease activity score (DAS)-remission-steered treatment strategies in early arthritis patients. Methods Patients (n = 610) with early RA or undifferentiated arthritis (UA) were treated with methotrexate (MTX) and tapered high dose of prednisone. Patients in early remission (44/53 joints DAS <1.6) after 4 months tapered and stopped medication. Patients who did not achieve early DAS-remission were randomized to either MTX plus hydroxychloroquine plus sulphasalazine plus low dose prednisone (arm 1) or to MTX + adalimumab (arm 2). At four-monthly intervals, medication was tapered and stopped if DAS was <1.6 but restarted, increased or switched if DAS was ≥1.6. Proportions of (drug-free) DAS-remission (DFR) after 2 years and Sharp-van der Heijde scores (SHS) were analyzed separately for the treatment strategies and patients with RA and UA. Results After 2 years, 301/610 (49 %) patients were in DAS-remission and 131/610 (21 %) in DFR. In the early remission group 241/387 patients (62 %) were in DAS-remission and 111/387 (29 %) DFR. In arm 1 22/83 (27 %) and in arm 2 24/78 (31 %) were in DAS-remission, and 6/83 (7 %) and 7/78 (9 %), respectively, were in DFR. RA and UA patients achieved DAS-remission in comparable percentages (RA: 234/479 (49 %), UA: 64/122 (52 %), p = 0.25). More UA patients achieved DFR (41/122 (34 %)) compared to RA patients (89/479 (19 %), p<0.001). Mean (SD) DAS over time was 1.74 (0.58) across all patients, and median (IQR) SHS progression was 0 (0–0). Conclusions After 2 years remission-steered treatment in early RA and UA patients, DAS-remission and DFR percentages were relatively low. Patients who achieved early remission more often achieved (drug-free) remission after 2 years than patients who needed additional treatment steps in the randomization arms, and more UA than RA patients achieved DFR. Overall, disease activity and radiologic damage progression in all patients were well suppressed. Trial registration http://www.controlled-trials.com/ISRCTN11916566 Registered 07/11/2006 and EudraCT number 2006-06186-16 Registered 16/07/2007. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0912-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lotte Heimans
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
| | - Gülşah Akdemir
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
| | - Kirsten V C Wevers-de Boer
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
| | | | | | | | - Andreas J Peeters
- Department of Rheumatology, Reinier de Graaf Gasthuis, Delft, The Netherlands.
| | | | - Leroy R Lard
- Department of Rheumatology, MCH Antoniushove, Leidschendam, The Netherlands.
| | | | | | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, P.O. BOX 9600, Leiden, 2300 RC, The Netherlands.
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van Beers-Tas MH, Turk SA, van Schaardenburg D. How does established rheumatoid arthritis develop, and are there possibilities for prevention? Best Pract Res Clin Rheumatol 2015; 29:527-42. [PMID: 26697764 DOI: 10.1016/j.berh.2015.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Established rheumatoid arthritis (RA) is a chronic state with more or less joint damage and inflammation, which persists after a phase of early arthritis. Autoimmunity is the main determinant of persistence. Although the autoimmune response is already fully developed in the phase of early arthritis, targeted treatment within the first months produces better results than delayed treatment. Prevention of established RA currently depends on the success of remission-targeted treatment of early disease. Early recognition is aided by the new criteria for RA. Further improvement may be possible by even earlier recognition and treatment in the at-risk phase. This requires the improvement of prediction models and strategies, and more intervention studies. Such interventions should also be directed at modifiable risk factors such as smoking and obesity. The incidence of RA has declined for decades in parallel with the decrease of smoking rates; however, a recent increase has occurred that is associated with obesity.
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Affiliation(s)
- Marian H van Beers-Tas
- Amsterdam Rheumatology and Immunology Center, Reade, Doctor Jan van Breemenstraat 2, 1056 AB Amsterdam, The Netherlands.
| | - Samina A Turk
- Amsterdam Rheumatology and Immunology Center, Reade, Doctor Jan van Breemenstraat 2, 1056 AB Amsterdam, The Netherlands.
| | - Dirkjan van Schaardenburg
- Amsterdam Rheumatology and Immunology Center, Reade and Academic Medical Center, Amsterdam, The Netherlands.
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Huynh D, Kavanaugh A. Psoriatic arthritis: current therapy and future approaches. Rheumatology (Oxford) 2014; 54:20-8. [DOI: 10.1093/rheumatology/keu237] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Tarner IH, Albrecht K, Fleck M, Gromnica-Ihle E, Keyßer G, Köhler L, Kötter I, Krüger K, Kuipers J, Nüßlein H, Rubbert-Roth A, Wollenhaupt J, Schneider M, Manger B, Müller-Ladner U. [Evidence-based recommendations for the management of undifferentiated peripheral inflammatory arthritis (UPIA). The German perspective on the international 3e initiative]. Z Rheumatol 2014; 73:363-73. [PMID: 24590079 DOI: 10.1007/s00393-013-1249-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Peripheral arthritis is the most common presenting complaint in clinical rheumatology. Unequivocal identification of the underlying entity can be difficult, particularly at an early stage. Such cases are commonly referred to as undifferentiated peripheral inflammatory arthritis (UPIA). Since evidence-based recommendations for the clinical management of UPIA are lacking, this international 3e initiative convened 697 rheumatologists from 17 countries to develop appropriate recommendations. METHODS Based on a systematic literature research in Medline, EMBASE, Cochrane Library, and the ACR/EULAR abstracts of 2007/2008, 10 multinational recommendations were developed by 3 rounds of a Delphi process. In Germany, a national group of experts worked on 3 additional recommendations using the same method. The recommendations were discussed among the members of the 3e initiative and the degree of consensus was analyzed as well as the potential impact of the recommendations on clinical practice. RESULTS A total of 39,756 references were identified, of which 250 were systematically reviewed for the development of 10 multinational recommendations concerning differential diagnosis, diagnostic and prognostic value of clinical assessments, laboratory tests and imaging techniques, and monitoring of UPIA. In addition, 3 national recommendations on the diagnostic and prognostic value of a response to anti-inflammatory therapy on the analysis of synovial fluid and on enthesitis were developed by the German experts based on 35 out of 5542 references. CONCLUSIONS The article translates the 2011 published original paper of the international 3e initiative (Machado et al., Ann Rheum Dis 70:15-24, 2011) and reports the methods and results of the national vote and the additional 3 national recommendations.
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Affiliation(s)
- I H Tarner
- Abt. für Rheumatologie, Klinische Immunologie, Osteologie und Physikalische Medizin,Kerckhoff-Klinik, Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Gießen, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland
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Efficacy of Anti-TNF Agents as Adjunctive Therapy for Knee Synovitis Refractory to Disease-Modifying Antirheumatic Drugs in Patients with Peripheral Spondyloarthritis. ISRN RHEUMATOLOGY 2013; 2013:907085. [PMID: 23840963 PMCID: PMC3693177 DOI: 10.1155/2013/907085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/26/2013] [Indexed: 11/18/2022]
Abstract
Our aim was to evaluate the effectiveness of tumour necrosis factor (TNF) inhibitors as add-on therapy for knee synovitis that did not respond to disease-modifying antirheumatic drugs (DMARDs) and other standard treatments in patients with peripheral spondyloarthritis (SpA). We retrospectively studied 27 SpA patients, in whom an anti-TNF agent was added for active peripheral arthritis with knee synovitis refractory to DMARDs and treatment with low-dose oral corticosteroids and/or nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular (IA) corticosteroids. As response of knee synovitis, were considered the absence of swelling, tenderness, and decreased range of movement in the clinical examination, after 4 months of anti-TNF therapy. In twenty-four (88.9%) of the patients there was response of knee synovitis. No statistical differences in gender (P = 0.53), age (P = 0.88), disease subtype (P = 0.22), and pattern of arthritis (P = 0.20) between knee synovitis responders and nonresponders were found. Fourteen patients managed to stop DMARD therapy and six, all of whom were initially on DMARDs combination, to decrease the number of DMARDs to one, maintaining simultaneously the response of knee synovitis. Our results imply a beneficial effect of adjunctive anti-TNF therapy on knee synovitis not responding to DMARDs and other standard treatments in patients with peripheral SpA.
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Wevers-de Boer KVC, Heimans L, Huizinga TWJ, Allaart CF. Drug therapy in undifferentiated arthritis: a systematic literature review. Ann Rheum Dis 2013; 72:1436-44. [DOI: 10.1136/annrheumdis-2012-203165] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Sakellariou GT, Sayegh FE, Anastasilakis AD, Bisbinas I, Kapetanos GA. Disease-modifying anti-rheumatic drugs for refractory severe knee synovitis in patients with peripheral spondyloarthritis: efficacy and predictors of response. Scand J Rheumatol 2013; 42:369-72. [PMID: 23607529 DOI: 10.3109/03009742.2013.777107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES In this study we aimed to evaluate the efficacy of disease-modifying anti-rheumatic drugs (DMARDs) for severe knee synovitis, refractory to low-dose oral corticosteroids and/or non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular (IA) corticosteroid injections, in patients with peripheral spondyloarthritis (SpA). We also examined the association between the clinical response of knee synovitis and demographic and clinical parameters of the studied patients. METHOD Patients with SpA-related arthritis including resistant and severe knee synovitis, defined as the presence of swelling, tenderness, and a decreased range of movement on clinical examination, treated with DMARDs between January 2005 and January 2012 were studied retrospectively. No evidence of knee synovitis was considered a clinical response to DMARDs. RESULTS Forty-five patients [mean age 41.0 ± 1.9 years; 33 (73.3%) males] were studied. In 14 (31.1%) of the patients there was a clinical response of knee synovitis, while the remaining 31 (68.9%) patients were non-responders. Response to DMARD therapy was associated with disease subtype (p = 0.011) and HLA-B27 (p = 0.023) but not with a history of psoriasis (p = 0.067) or age at disease onset (p = 0.054). However, only a history of psoriasis could independently predict the response to DMARDs [adjusted odds ratio (OR) 0.232, p = 0.049]. CONCLUSIONS One-third of the patients with peripheral SpA and severe resistant knee synovitis had a clinical response to DMARD therapy. Disease subtype and HLA-B27 were associated with the response of knee synovitis to DMARDs, but only psoriasis could independently predict this response.
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Affiliation(s)
- G T Sakellariou
- Department of Rheumatology, 424 General Military Hospital , Thessaloniki , Greece
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Bennett AN, Marzo-Ortega H, Tan AL, Hensor EMA, Green M, Emery P, McGonagle D. Ten-year follow-up of SpA-related oligoarthritis involving the knee: the presence of psoriasis but not HLA-B27 or baseline MRI bone oedema predicts outcome. Rheumatology (Oxford) 2012; 51:1099-106. [DOI: 10.1093/rheumatology/ker420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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van Eijk IC, Nielen MMJ, van der Horst-Bruinsma I, Tijhuis GJ, Boers M, Dijkmans BAC, van Schaardenburg D. Aggressive therapy in patients with early arthritis results in similar outcome compared with conventional care: the STREAM randomized trial. Rheumatology (Oxford) 2011; 51:686-94. [PMID: 22166255 PMCID: PMC3306166 DOI: 10.1093/rheumatology/ker355] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective. To compare the effects of aggressive tight control therapy and conventional care on radiographic progression and disease activity in patients with early mild inflammatory arthritis. Methods. Patients with two to five swollen joints, Sharp–van der Heijde radiographic score (SHS) <5 and symptom duration ≤2 years were randomized between two strategies. Patients with a definite non-RA diagnosis were excluded. The protocol of the aggressive group aimed for remission (DAS < 1.6), with consecutive treatment steps: MTX, addition of adalimumab and combination therapy. The conventional care group followed a strategy with traditional DMARDs (no prednisone or biologics) without DAS-based guideline. Outcome measures after 2 years were SHS (primary), remission rate and HAQ score (secondary). Results. Eighty-two patients participated (60% ACPA positive). In the aggressive group (n = 42), 19 patients were treated with adalimumab. In the conventional care group (n = 40), 24 patients started with hydroxychloroquin (HCQ), 2 with sulfasalazine (SSZ) and 14 with MTX. After 2 years, the median SHS increase was 0 [interquartile range (IQR) 0–1.1] and 0.5 (IQR 0–2.5), remission rates were 66 and 49% and HAQ decreased with a mean of −0.09 (0.50) and −0.25 (0.59) in the aggressive and conventional care group, respectively. All comparisons were non-significant. Conclusion. In patients with early arthritis of two to five joints, both aggressive tight-control therapy including adalimumab and conventional therapy resulted in remission rates around 50%, low radiographic damage and excellent functional status after 2 years. However, full disease control including radiographic arrest in all patients remains an elusive target even in moderately active early arthritis. Trial registration. Dutch Trial Register, http://www.trialregister.nl/, NTR 144.
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Affiliation(s)
- Izhar C van Eijk
- Jan van Breemen Research Institute/Reade, Dr Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands
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Tillett W, de-Vries C, McHugh NJ. Work disability in psoriatic arthritis: a systematic review. Rheumatology (Oxford) 2011; 51:275-83. [PMID: 21752872 DOI: 10.1093/rheumatology/ker216] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Work disability (WD) is an important functional outcome measure in arthritis. There is a large body of information on WD in rheumatic diseases such as RA and AS; however, until now factors that influence WD in PsA have not been systematically reviewed. Our objective was to perform a systematic and critical review of the current literature on WD and its measurement in PsA. METHODS A systematic literature search was conducted using Medline, Embase and Cochrane databases. The search strategy was supplemented by a manual search of cited articles. All original English language publications in the form of meta-analyses, randomized controlled trials (RCTs), observational studies and publications in abstract form were included. A quality assessment was made of the articles published in full form. RESULTS Nineteen publications (nine in abstract form) were identified. There is intermediate quality evidence that levels of unemployment (20-50%) and WD (16-39%) are high and associated with longer disease duration, worse physical function, high joint count, low educational level, female gender, erosive disease and manual work. There is sparse low-quality evidence that WD is worse in those with PsA than psoriasis alone. CONCLUSIONS Disability at work in those with PsA is high; however, data on its associations are limited by the small number of reports and heterogeneity of data collected. Future work should focus on the validation of WD data collection tools for use in PsA.
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Affiliation(s)
- William Tillett
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath BA11RL, UK.
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The Changing Management of Inflammatory Arthritis. J Clin Rheumatol 2010; 16:403-7. [DOI: 10.1097/rhu.0b013e31820014e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Indications of glucocorticoids in early arthritis and rheumatoid arthritis: Recommendations for clinical practice based on data from the literature and expert opinion. Joint Bone Spine 2010; 77:597-603. [DOI: 10.1016/j.jbspin.2009.12.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 12/10/2009] [Indexed: 11/19/2022]
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Machold KP. Prevention and cure of rheumatoid arthritis: is it possible? Best Pract Res Clin Rheumatol 2010; 24:353-61. [PMID: 20534369 DOI: 10.1016/j.berh.2009.12.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Advances in treatment of rheumatoid arthritis have made it possible to profoundly influence signs and symptoms as well as the course of joint destruction in inflammatory arthritis. Earlier and more efficient treatment appears to significantly improve the prognosis of this disease. Despite these advances, cure (the absence of signs and symptoms without further treatment) is still relatively rare, observable in, at most, 20% of the patients. Remission (or a state of very low disease activity), however, has been observed with intense and individually tailored treatment in up to 75% of patients. The use of structured assessments followed by individual modification of the intensity of treatment aiming for remission leads to better clinical responses and radiological outcomes. It remains to be seen whether earlier and more aggressive treatment of patients with not yet 'fully established' rheumatoid arthritis may succeed in preventing at least some of them from progressing to destructive arthritis.
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Affiliation(s)
- Klaus P Machold
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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Puolakka K, Kautiainen H, Pohjolainen T, Virta L. Rheumatoid arthritis (RA) remains a threat to work productivity: a nationwide register-based incidence study from Finland. Scand J Rheumatol 2010; 39:436-8. [DOI: 10.3109/03009741003674198] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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van Schaardenburg D, Dijkmans BAC. Clinical approaches to early inflammatory arthritis. Nat Rev Rheumatol 2009; 5:627-33. [PMID: 19786990 DOI: 10.1038/nrrheum.2009.203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Several advances have been made in the understanding of the pathogenesis, as well as in the clinical evaluation and treatment, of early inflammatory arthritis. The presence of anti-citrullinated protein antibodies (ACPAs) has emerged as a major new biomarker for use in clinical practice. The presence of ACPAs can be used to divide patients with early arthritis into subsets that are phenotypically similar but have varying pathogenetic and prognostic features. Although the detection of ACPAs is a major development in the diagnosis and prognosis of rheumatoid arthritis (RA), prediction of the outcome of arthritis at the individual level can still be much improved. For patients diagnosed with RA, and who have active polyarthritis, treatment is not dependent on the assessment of prognostic factors, as these patients are best treated with combination therapy; over 40% of these patients achieve remission with such treatment. In patients who present with oligoarthritis, however, management should be based on the assessment of prognostic factors. The success of early treatment of inflammatory arthritis and the recognition of a measurable preclinical phase of RA offer hope that treating the disease before it becomes clinically active might be possible.
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Soriano ER, Rosa J. Update on the treatment of peripheral arthritis in psoriatic arthritis. Curr Rheumatol Rep 2009; 11:270-7. [DOI: 10.1007/s11926-009-0038-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Mjaavatten MD, Haugen AJ, Helgetveit K, Nygaard H, Sidenvall G, Uhlig T, Kvien TK. Pattern of joint involvement and other disease characteristics in 634 patients with arthritis of less than 16 weeks' duration. J Rheumatol 2009; 36:1401-6. [PMID: 19487273 DOI: 10.3899/jrheum.081217] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate the distribution of joint involvement in a cohort of patients with very recent onset arthritis and describe the disease characteristics in these patients. METHODS A very early arthritis clinic (NOR-VEAC) was established as a multicenter study. General practitioners were asked to refer patients presenting with at least 1 swollen joint of maximum 16 weeks' duration. Clinical and laboratory markers were examined. RESULTS We included 634 patients during the first 3 years, with mean (25th-75th percentile) arthritis duration of 30 (11-63) days. Monoarthritis was present in 243 (38.3%) patients, 216 (34.1%) had oligoarthritis, and 175 (27.6%) polyarthritis. Patients with polyarthritis were older, had longer duration of arthritis, and were more frequently anti-cyclic citrullinated peptide antibody and rheumatoid factor-positive. Patients in all 3 joint pattern groups (mono-/oligo-/polyarthritis) reported substantial effect on physical function, pain, and fatigue and had elevated levels of acute-phase reactants. Knee or ankle arthritis was most frequent in patients with mono- and oligoarthritis, whereas small joint involvement was most frequent in patients with polyarthritis. CONCLUSION Patients with recent-onset arthritis report a substantial influence on health status. Mono- and oligoarthritis are at least as frequent as polyarthritis. Polyarthritic patients more frequently exhibit features associated with a worse outcome.
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Disease-modifying antirheumatic drugs other than methotrexate in rheumatoid arthritis and seronegative arthritis. Curr Opin Rheumatol 2008; 20:251-6. [PMID: 18388514 DOI: 10.1097/bor.0b013e3282fb7caa] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To outline recent research findings with nonmethotrexate disease-modifying antirheumatic drugs in rheumatoid arthritis and seronegative arthritis spanning systematic reviews, randomized controlled trials, observational clinical practice trials and assessments of adverse effects. RECENT FINDINGS Systematic reviews show no important differences between methotrexate, leflunomide and sulfasalazine monotherapies; early disease-modifying antirheumatic drug therapy reduces erosive progression. Observational studies show that nonmethotrexate disease-modifying antirheumatic drugs are widely prescribed; their usage has increased in the biologic era. A systemic review also showed patients who failed monotherapy benefited from disease-modifying antirheumatic drug combinations without excess toxicity. Randomized controlled trials of intensive initial disease-modifying antirheumatic drug combinations showed they reduce synovitis and erosive damage, especially when used with steroids. The subsequent sequence of disease-modifying antirheumatic drugs and the value of changing disease-modifying antirheumatic drug monotherapies or stepping-up to combination disease-modifying antirheumatic drugs are, however, unresolved. The adverse risks of nonmethotrexate disease-modifying antirheumatic drugs have been evaluated, including infections and lung disease; patient-related risks seem more important than drug-related risks, though several disease-modifying antirheumatic drugs increase both types of adverse reactions. Two limitations of nonmethotrexate disease-modifying antirheumatic drugs are reduced impact on comorbidities like cardiovascular disease and reduced patient and clinician preferences for these treatments. SUMMARY Nonmethotrexate disease-modifying antirheumatic drugs are effective, relatively well tolerated and widely used. Their role in intensive treatment strategies in early rheumatoid arthritis appears of crucial importance.
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