American College of Rheumatology/EULAR Remission Criteria for Rheumatoid Arthritis: 2022 Revision

Development and internal-external cross-validation of a patient-reported definition for acute calcium pyrophosphate crystal arthritis

OBJECTIVE

To develop and validate a patient-reported definition of acute calcium pyrophosphate (CPP) crystal arthritis in people with crystal-proven CPP deposition (CPPD) disease.

METHODS

Consecutive patients with crystal-proven CPPD disease from seven centres across four countries were enrolled in a cross-sectional study. In each centre, patient-reported outcomes on the features of acute CPP crystal arthritis were collected. The expert opinion of an independent rheumatologist was the reference standard. We developed definitions based on multivariable logistic regression model with backward selection of predictors and classification and regression tree (CART) approaches.

RESULTS

Two hundred and forty-six patients [mean age 73.2 years (s.d. 10.7), 65.9% female] were enrolled. At the time of the assessment, acute CPP crystal arthritis was diagnosed in 96/246 (39.0%) participants.Patient-reported joint warmth, patient-reported joint swelling, time from pain onset to peak, and self-reported acute CPP crystal inflammatory arthritis were included in the multivariable logistic model. This model had good discrimination (optimism-adjusted c-index: 0.92; 95% CI: 0.89, 0.95) and calibration (optimism-adjusted calibration slope: 0.95; 95% CI: 0.71, 1.19; optimism-adjusted calibration-in-the-large: 0.005; 95% CI: -0.37, 0.37) in the internal validation. Probability threshold ≥0.53 had sensitivity of 0.83 (95% CI: 0.74, 0.90) and specificity of 0.86 (95% CI: 0.79, 0.91). Performances were similar in the internal-external cross-validation. The CART identified patient-reported acute CPP crystal inflammatory arthritis, followed by joint swelling and joint warmth as the most informative variables for ascertaining acute CPP crystal arthritis [sensitivity 0.83 (95% CI: 0.72, 0.91) and specificity 0.83 (95% CI: 0.74, 0.90)].

CONCLUSION

We developed and initially validated easy-to-use patient-reported definitions for acute CPP crystal arthritis for use in clinical trials and observational research in CPPD.

Assessment of ChatGPT's adherence to EULAR diagnostic criteria and therapeutic protocols for rheumatoid arthritis at two distinct time points, 14 days apart, utilizing binary and multiple-choice inquiries

OBJECTIVES

Artificial intelligence (AI) possesses considerable promise in healthcare to offer decision help in particular domains, including rheumatoid arthritis (RA). This study assesses the adherence of the advanced AI model ChatGPT-v4 to the European League Against Rheumatism (EULAR) recommendations.

METHODS

The research employed a 100-item questionnaire consisting of true/false and multiple-choice formats, accompanied with real-world clinical scenarios developed concurrently with EULAR in the therapy of RA. Inquiries addressed diagnostic criteria, therapeutic alternatives, and follow-up procedures. Two rheumatologists assessed the ChatGPT for accuracy, consistency, and comprehensiveness utilizing a 6-point Likert scale.

RESULTS

Evaluation occurred at baseline and on day 14. AI rectified the majority of errors at baseline in the paired questions. It did not advance on specific responses. One of the two previously incongruent responses remained unaltered, while the other was rectified. The 48 originally congruent responses rose to 49 on day 14. In binary questions, AI exhibited greater coherence than in multiple-choice questions. At baseline, 43 (86%) of the multiple-choice items were answered correctly. Upon reevaluation, 42 (84%) were found to be accurate. One response was erroneous on day 14. Three of the seven initially erroneous responses remained unaltered. Four erroneous responses were later rectified.

CONCLUSION

ChatGPT demonstrated efficacy in addressing binary and multiple-choice questions formulated according to EULAR guidelines for RA. The findings validated that AI can serve as a clinical support instrument in RA. It demonstrated that AI can be enhanced. AI attained accuracy in objective information and promptly rectified the error. Key Points • AI in healthcare: The integration of artificial intelligence, specifically ChatGPT-v4, in clinical practice aims to enhance decision-making in RA by adhering to EULAR recommendations for diagnosis, treatment, and follow-up. • Inter-rater reliability: High agreement levels were noted among the evaluators, with Cohen's kappa coefficients of 0.92 for binary questions and 0.94 for multiple-choice questions. • AI learning dynamics: The study reveals that ChatGPT showed improvement in understanding and answering more complex questions over time, unlike findings in previous studies where AI struggled with consistency. • Implications for clinical practice: The findings support the growing role of AI as a reliable tool in rheumatology, suggesting potential for personalized, evidence-based patient care.

Nocturnal baricitinib administration leads to rapid drug responses in rheumatoid arthritis: a multicenter non-randomized controlled study

BACKGROUND

Inflammatory cytokine levels exhibit a circadian rhythm in sera, peaking from late night to early morning in patients with rheumatoid arthritis (RA). This cytokine kinetics is a recognized therapeutic target. This clinical study aimed to evaluate the effectiveness of night-time baricitinib administration based on cytokine secretion.

METHODS

In this 52-week multicenter non-randomized controlled study, 122 patients with RA were assigned to four groups: baricitinib 2 mg morning (BAR2MORN), 2 mg evening (BAR2EVE), 4 mg morning (BAR4MORN), or 4 mg evening (BAR4EVE). The primary endpoint was assessed using the 20% improvement in the American College of Rheumatology criteria (ACR20) at week 12. The secondary endpoints were ACR20/50/70 and changes in the clinical disease activity index (CDAI) through 52 weeks. The results were evaluated using the propensity score inverse probability of treatment weighted to reduce selection bias in patient background.

RESULTS

BAR4EVE resulted in better primary endpoint improvement than BAR4MORN (78.2 vs. 43.3%; p < 0.001). No difference in improvement was observed in the primary endpoint between BAR2EVE and BAR2MORN (75.5 vs. 60.6%; p = 0.10). However, BAR2EVE demonstrated higher ACR20 at weeks 4, 24, and 52 and ACR50 at weeks 4 and 12 than BAR2MORN. BAR4EVE demonstrated higher ACR20/50 at weeks 4, 8, and 12 and ACR70 at weeks 8, 12, and 24 than BAR4MORN. CDAI changes were significantly reduced in BAR4EVE than in BAR4MORN at weeks 4 and 8.

CONCLUSION

Chronotherapy targeting cytokine secretion resulted in rapid drug response, proposing a new potential application for JAK inhibitors.

TRIAL REGISTRATION

UMIN000040094, July 1, 2020.

In early rheumatoid arthritis, comorbidities do not explain the increased risk of failure to reach remission in patients with obesity

OBJECTIVE

To examine whether obesity and/or overweight are independently associated with an increased risk of remission failure in patients with early rheumatoid arthritis (RA), treated with methotrexate as first disease-modifying antirheumatic drug, or if the previously reported associations could be explained by underlying comorbidities and lifestyle factors.

METHODS

For patients included in the Epidemiological Investigation of Rheumatoid Arthritis (EIRA) study 2006-2018 initiating methotrexate monotherapy (n=1285), we captured data on body mass index, comorbidities and disease activity from EIRA and through linkage to nationwide Swedish clinical and quality registers. The primary outcome was failure to reach 28-joint Disease Activity Score (DAS28) remission at 3 and 6 months. Secondary outcomes included Boolean, Simplified Disease Activity Index and Clinical Disease Activity Index remission and their individual components. We estimated the relative risk (RR) of remission failure in patients with obesity and overweight compared with normal weight using modified Poisson regression, adjusting for potential confounders.

RESULTS

After 6 months, 64% (n=98/153) of patients with obesity, 52% (n=171/326) with overweight and 48% (n=210/433) with normal weight failed to reach DAS28 remission, with an RR of 1.33 (95% CI 1.14 to 1.55) for patients with obesity after adjustment for age and sex. The increased risk of remission failure in patients with obesity remained after further adjustment for seropositivity, educational level, smoking, alcohol use, physical activity, calendar period, glucocorticoid treatment and comorbidities (RR=1.27, 95% CI 1.08 to 1.50). No significant association was observed for patients with overweight. The results were similar for the secondary outcomes and after 3 months.

CONCLUSION

Obesity is a risk factor for remission failure in early RA, independent of comorbid conditions.

Clinical predictors of flare and drug-free remission in rheumatoid arthritis: preliminary results from the prospective BIO-FLARE experimental medicine study

OBJECTIVES

Huge advances in rheumatoid arthritis (RA) treatment mean an increasing number of patients now achieve disease remission. However, long-term treatments can carry side effects and associated financial costs. In addition, some patients still experience painful and debilitating disease flares, the mechanisms of which are poorly understood. High rates of flare and a lack of effective prediction tools can limit attempts at treatment withdrawal. The BIOlogical Factors that Limit sustAined Remission in rhEumatoid arthritis (BIO-FLARE) experimental medicine study was designed to study flare and remission immunobiology. Here, we present the clinical outcomes and predictors of drug-free remission and flare, and develop a prediction model to estimate flare risk.

DESIGN, SETTING AND PARTICIPANTS

BIO-FLARE was a multicentre, prospective, single-arm, open-label experimental medicine study conducted across seven National Health Service Trusts in the UK. Participants had established RA in clinical remission (disease activity score in 28 joints with C reactive protein (DAS28-CRP)<2.4) and were receiving methotrexate, sulfasalazine or hydroxychloroquine (monotherapy or combination).

INTERVENTIONS

The intervention was disease-modifying anti-rheumatic drug cessation, followed by observation for 24 weeks or until flare, with clinical and immune monitoring.

OUTCOME MEASURES

The primary outcome measure was the proportion of participants experiencing a confirmed flare, defined as DAS28-CRP≥3.2 or DAS28-CRP≥2.4 twice within 2 weeks, and time to flare. Exploratory predictive modelling was also performed using multivariable Cox regression to understand risk factors for flare.

RESULTS

121 participants were recruited between September 2018 and December 2020. Flare rate by week 24 was 52.3% (95% CI 43.0 to 61.7), with a median (IQR) time to flare of 63 (41-96) days. Female sex, baseline methotrexate use, anti-citrullinated peptide antibody level and rheumatoid factor level were associated with flare. An exploratory prediction model incorporating these variables allowed estimation of flare risk, with acceptable classification (C index 0.709) and good calibration performance.

CONCLUSION

The rate of flare was approximately 50%. Several baseline clinical parameters were associated with flare. The BIO-FLARE study design provides a robust experimental medicine model for studying flare and remission immunobiology.

TRIAL REGISTRATION NUMBER

ISRCTN registry 16371380.

Promoting Prevention and Targeting Remission of Asthma: A EUFOREA Consensus Statement on Raising the Bar in Asthma Care

Asthma is a common, multifaceted respiratory disease with a major impact on quality of life. Despite increased insights into mechanisms underlying various asthma phenotypes and endotypes and the availability of targeted biologic treatment options, the disease remains uncontrolled in a substantial proportion of patients with risk of exacerbations, requiring systemic corticosteroids, and with progressive disease. Current international guidelines advocate for a personalized management approach to patients with uncontrolled severe asthma. The European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) asthma expert panel was convened to discuss strategies to optimize asthma care and to prevent systemic corticosteroid overuse and disease progression. In this meeting report, we summarize current concepts and recommendations and provide a rationale to implement personalized asthma management at earlier stages of the disease. The ultimate goal is to move away from the current one-size-fits-most concept, which focuses on a symptom-driven treatment strategy, and shift toward a phenotype- and endotype-targeted approach aimed at curbing the disease course by improving clinical outcomes and preserving health-related quality of life. Herein, we provide a consensus view on asthma care that advocates a holistic approach and highlight some unmet needs to be addressed in future clinical trials and population studies.

Physiotherapy and occupational therapy in rheumatoid arthritis: Bridging functional and comorbidity gaps

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease affecting a significant portion of the global population. Despite advancements in pharmacological treatments, the management of RA remains complex, particularly in regard to comorbidities such as cardiovascular disease and osteoporosis. Physiotherapy (PT) and occupational therapy (OT) are non-pharmacological approaches that play a critical role in the management of RA. This review explores the impact of PT and OT in improving joint function, reducing pain and fatigue, and enhancing the overall quality of life in RA patients. It also addresses the role of these therapies in managing RA-related comorbidities, with an emphasis on exercise therapy, manual techniques, patient education and emerging digital interventions. Evidence supports the inclusion of tailored exercise regimens, such as cardiorespiratory training, resistance exercises and neuromotor activities, as vital components of RA management. By incorporating PT and OT, healthcare providers can better address the multifaceted needs of RA patients, complementing pharmacological treatments and improving long-term outcomes.

Roads to remission: evolving treatment concepts in type 2 inflammatory diseases

Non-communicable diseases (NCDs) characterised by type 2 inflammation, including asthma, allergic rhinitis, chronic rhinosinusitis with nasal polyps, atopic dermatitis, food allergies and eosinophilic esophagitis, are increasing in prevalence worldwide. Currently, there is a major paradigm shift in the management of these diseases, towards the concept of disease modification and the treatment goal remission, regardless of severity and age. Remission as a treatment goal in chronic inflammatory NCDs was first introduced in rheumatoid arthritis, and then adopted in other non-type 2 inflammatory diseases. Among diseases with type 2 Inflammation, this concept is novel and currently most advanced in asthma. This new paradigm has been developed based on a better understanding of the pathophysiology of type 2 inflammation and the advent of highly effective drugs selectively interfering with type 2 pathways. Here, we review the evolution of the new remission concepts in type 2 inflammatory diseases and discuss associated challenges and future research needs.

Funding

None.

Impact of Short-Term Integrated Yoga Therapy Intervention on Systemic Inflammatory Markers and Quality of Life in Rheumatoid Arthritis Patients: A Randomized Controlled Trial

Background

Rheumatoid arthritis (RA) is an autoimmune disease with prolonged dysregulation of pro- and anti-inflammatory immune pathways resulting in chronic inflammation, which alters the functional status and quality of life. The present study aimed to assess the short-term effect of yoga therapy on systemic inflammatory markers and quality of life among RA patients.

Methods

The study included one hundred RA patients aged 18-60 years and randomized into yoga (n = 50) and control (n = 50) groups. A structured yoga therapy was given for 12 weeks along with their regular disease-modifying antirheumatic medications (DMARDs). During the study period, all the participants were allowed to continue their daily lifestyle and diet.

Results

After 12 weeks of intervention, the yoga group reported a significant decrease in interleukin-6 (IL 6) (P < .001), C-reactive protein (CRP) (P < .01), rheumatoid factor (RA factor) (P = .02), and erythrocyte sedimentation rate (ESR) (P = .05), compared to the control group. Furthermore, compared to the control group, yoga participants showed significant improvement in functional status and disease activity, which included the assessment of DAS-28 (to assess the disease activity) (P < .001), patient global assessment (P < .001), and reduced Visual Analogue Scale (VAS) score (pain intensity assessment) (P < .01). The secondary outcome was the quality of life (SF-36 questionnaire), which showed significant improvement post-intervention (P = .05).

Conclusion

The present study has demonstrated that short-term yoga therapy could lower systemic inflammatory markers by maintaining immune homeostasis to improve the functional status and quality of life in RA patients.

Cost-effectiveness analysis of tofacitinib for the treatment of moderate to severe rheumatoid arthritis: a systematic review and meta-analysis

BACKGROUND

As rheumatoid arthritis (RA) is a chronic and progressive disease that requires lifelong therapeutic intervention, it represents a considerable economic burden on those affected. This study investigated whether tofacitinib is a cost-effective therapeutic alternative to other DMARDs for treating moderate-to-severe RA.

RESEARCH DESIGN AND METHODS

All economic evaluation studies of tofacitinib compared to other DMARDs were identified. Using random-effects meta-analysis, we pooled incremental net benefit (INB) in (purchasing power parity) adjusted US$ with 95% confidence intervals. The modified economic evaluation bias checklist and Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) instrument for quality appraisal were used. The subgroup analysis was done based on the comparator regimen.

RESULTS

Of the selected 11 studies, the number of studies from high-, upper-middle- and lower-middle-income countries was 7, 3, and 1, respectively. The subgroup analysis showed that tofacitinib with an INB of 19,180 US$ [95% CI, -34520 to -3840; p-value = 0.01] was not statistically cost-effective compared with cDMARDs (p-value > 0.0001). Compared to other DMARDs, the estimated pooled INB of tofacitinib was US$ 7260 [95% CI, 3030 to 11,480; p-value < 0.001], but there was substantial heterogeneity among the included studies, and the observed publication bias.

CONCLUSION

While tofacitinib shows potential as a cost-effective treatment, tailored economic evaluations are needed to account for the diverse and evolving contexts of RA treatment.

REGISTRATION

PROSPERO: CRD42023405970.

Poor prognostic factors independently impact remission and treatment escalation in rheumatoid arthritis regardless of disease activity: A nationwide prospective cohort study

OBJECTIVE

To elucidate the impact of poor prognostic factors (PPFs) in daily practice on achieving remission and the requirement for biologic or targeted synthetic DMARDs (b/tsDMARDs) in a large Korean cohort of patients with rheumatoid arthritis (RA).

METHODS

Using the KORean Observational study Network for Arthritis (KORONA) database, patients with RA were categorized into three groups based on the number of PPFs (0-1, 2, or≥3): the presence of functional limitation, extra-articular disease, seropositivity, and bone erosions. Factors related to achieving remission and to initiating b/tsDMARDs were evaluated using Cox proportional hazard regression analyses after adjusting confounders.

RESULTS

Among 5076 patients with RA, group L (PPF≤1), group M (PPFs 2), and group H (PPFs≥3) were 1788 (35.2%), 2027 (39.9%), and 1261 (24.9%), respectively. Group H had higher disease activity and worse patient-reported outcomes than groups L and M. Among moderately-to-highly active patients at baseline, group H was significantly less likely to attain point (hazard ratio [HR]=0.55, 95% confidence interval [CI] 0.38-0.79) and sustained (HR=0.45, 95% CI 0.21-0.99) Boolean-based remission in 5-year. Groups M (HR=1.47, 95% CI 1.10-1.96) and H (HR=1.69, 95% CI 1.22-2.32) had an increased risk of escalation to b/tsDMARDs, compared to group L among b/tsDMARDs-naïve patients at baseline.

CONCLUSION

Achieving remission was particularly challenging for group H, and more patients in groups M and H initiated b/tsDMARDS during the 5-year observation period. Therefore, the presence of PPFs≥3 significantly influences both patients' outcomes and clinician's treatment decisions regardless of disease activity.

Integrating different perspectives to define a concept of comprehensive remission in rheumatoid arthritis: The SUMAR project

INTRODUCTION AND OBJECTIVES

The SUMAR project aimed to establish a consensus on the concept of remission in patients with rheumatoid arthritis (RA) that takes into account the different perspectives of patients, health care professionals and health care managers.

MATERIALS AND METHODS

The scientific committee comprised a rheumatologist who acted as a national coordinator, 4 rheumatologists, 1 primary care physician, 1 nurse, 2 hospital pharmacists, 2 health care managers and 1 member of a patient advocacy group. The study was undertaken from 2020 to 2021 in three phases: (1) analysis of several perspectives on remission in RA with the participation of 275 patients, 160 rheumatologists and 31 health care managers; (2) an integrative definition of remission, which included two multidisciplinary workshops with 11 and 12 participants; and (3) extension and dissemination with up to 200 participants in 7 regional multidisciplinary meetings.

RESULTS

The concept of remission in the different settings and by the different stakeholders was heterogeneous. It was agreed that, in addition to inflammatory activity, remission should include pain and functionality as well as the duration of remission. For the participants, the definition of remission varied depending on the clinical scenario, without or with structural damage, seeking to "normalize" the outcomes in the former and avoid progression in the latter. The implementation of the concept of comprehensive remission was considered less feasible, and the main barriers to implementation were the lack of time for consultation and the variability in information technology systems across the different autonomous communities.

DISCUSSION AND CONCLUSIONS

This definition of remission is not only based on the concept of the presence or absence of inflammatory activity based on existing indexes, but also includes variables directly reported by the patient that are related to their health and quality of life.

Approaches and outcomes of adalimumab discontinuation in patients with well-controlled inflammatory arthritis: a systematic search and review

OBJECTIVE

This systematic search and review aimed to evaluate the available literature on discontinuation of adalimumab and other tumor necrosis factor inhibitors (TNFi) for patients with well-controlled chronic inflammatory arthritides.

METHODS

We conducted a publication search on adalimumab discontinuation from 2000-2023 using PubMed, CINAHL, EMBASE, and Cochrane Library. Included studies evaluated adalimumab discontinuation approaches, tapering schemes, and outcomes including successful discontinuation and recapture after flare, in patients with well-controlled disease. Studies included evaluated rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and juvenile idiopathic arthritis (JIA).

RESULTS

Forty-nine studies were included. Studies evaluating adalimumab alone were limited, and many reported TNFi outcomes as a single entity. Studies on rheumatoid arthritis (RA) (32, 8 RCTs) reported flare rates from 33-87%. Flares with medication tapering were slightly lower than with abrupt stop, and successful recapture was generally high (80-100%). Studies on spondyloarthropathy (12, 4 RCTs), focused on tapering, noting lower flare rates in tapering rather than abruptly stopping, and high recapture rates (~ 90%). Studies on JIA (5) were observational and demonstrated modestly lower flare rates with tapering (17-63%) versus abrupt stopping (28-82%). There was notable variability in study design, follow-up duration, specificity for TNFi results, and controlled pediatric studies.

CONCLUSION

The literature evaluating adalimumab and other TNFi discontinuation, flare rates, and recapture success within the inflammatory arthritis population demonstrated less flare when medications were tapered, over abrupt stop in the RA, spondyloarthropathy, and JIA populations. When medications were restarted after flare, recapture of well-controlled disease was generally high in RA and spondyloarthropathy, and generally favorable in JIA.

Olokizumab plus methotrexate: safety and efficacy over 106 weeks of treatment

OBJECTIVE

To report long-term safety and tolerability of olokizumab (OKZ) in combination with methotrexate (MTX) in subjects with active rheumatoid arthritis (RA), using pooled data from three randomised clinical trials (RCT) followed by open-label extension (OLE) study.

METHODS

Cumulative data from three phase 3 core trials and their OLE were analysed. Safety variables assessed included treatment-emergent adverse events (AEs), serious AEs (SAEs), AEs of special interest and laboratory results. Efficacy assessments included ACR20/50/70 responses, Disease Activity Score 28 (C-reactive protein) <3.2, CDAI remission and low disease activity (LDA), SDAI remission and LDA, HAQ-DI decrease of 0.22 unit and Boolean 2.0 remission.

RESULTS

A total of 2304 patients received OKZ in combination with MTX either once every 2 weeks or once every 4 weeks. Event rates per 100 patient-years in OKZ every 2 weeks and OKZ every 4 weeks, respectively, were 9.57 and 9.13 for SAEs; 2.95 and 2.34 for serious infections; 0.09 and 0.05 for gastrointestinal perforations; 0.58 and 0.83 for major adverse cardiovascular events; and 0.45 and 0.50 for malignancies. No increase in the rate of any AE was observed over 106 weeks of treatment. The evaluation of laboratory variables demonstrated the expected changes, like neutropenia, elevation of liver enzymes and blood lipids. Clinical response rates remained stable during the OLE.

CONCLUSION

The long-term safety and tolerability of OKZ in combination with MTX remained stable. The efficacy of OKZ was maintained through week 106. These findings support OKZ as a treatment option for patients with active RA.

Application of disease activity index in rheumatoid arthritis management in Korea

Effective management of rheumatoid arthritis (RA) necessitates the accurate measurement of disease activity using a treat-to-target strategy established as a cornerstone approach. Disease activity assessment tools such as the Disease Activity Score in 28 joints (DAS28), Simplified Disease Activity Index, Clinical Disease Activity Index, and Routine Assessment of Patient Index Data 3 have been internationally validated and recognised. In Korea, the government initiated a quality assessment program mandating routine measurement of DAS28 to ensure high-quality RA management. However, whether the DAS28 is the most suitable disease activity measurement tool in the Korean clinical environment is a topic worth considering. In this review, we comprehensively examined disease activity measurement tools and their performance in the Korean context. We also propose a new strategy for measuring RA disease activity, tailored to the different situations encountered by physicians in routine clinical practice. This review may contribute to the improvement of the quality of care for patients with RA in Korea.

American College of Rheumatology and Food and Drug Administration Summit: Summary of the Meeting, May 17-18, 2022

The American College of Rheumatology and the US Food and Drug Administration co-sponsored a public meeting in May 2022 about challenges in the clinical development of drugs for rheumatoid arthritis (RA) and psoriatic arthritis (PsA), focusing on innovative clinical trial designs, outcome measures, and data collection methods. Recommendations include early dose-ranging studies and use of active comparators. Challenges and opportunities in assessing long-term safety by leveraging real-world data from electronic health records (EHRs) and claims data are discussed, along with insights from European registries and the evolving role of real-world evidence and artificial intelligence in regulatory evaluations. Endpoints for assessing disease activity and outcome measures used in RA and PsA trials are explored, emphasizing challenges in defining remission, assessing clinical response, and evaluating structural progression. The need for outcome measures that better reflect treatment targets and the potential of advanced imaging in future trials are highlighted. Challenges with placebo-controlled trials in RA are discussed and use of non-inferiority clinical trial design, in which new drugs are evaluated with active comparators, is proposed. Pragmatic trials in RA and PsA, employing decentralized approaches, are highlighted for their real-world relevance and administrative efficiencies. Strategies for identifying at-risk populations for RA and the challenges of using EHRs and insurance claims data in drug development are discussed. Registry data and digital health technologies show promise in bridging the gap between clinical trials and real-world effectiveness.

Challenges in implementing treat-to-target in rheumatoid arthritis: a perspective from Brazilian rheumatologists

BACKGROUND

Patient management in rheumatoid arthritis (RA) has evolved to a "treat-to-target" (T2T) approach, which entails intensive treatment and regular follow-up with the goal of achieving low levels of disease activity or clinical remission. Even though a T2T approach is endorsed by professional organizations and yields superior outcomes, its implementation remains incomplete. EVEREST (EleVatE care in RhEumatoid arthritiS with Treat-to-target) is a quality-improvement initiative designed to improve the widespread implementation of a personalized T2T strategy and enable patients with RA to reach their full potential for remission. We describe the Brazilian results from the Global T2T Survey, first part of the EVEREST program.

METHODS

Between June and September 2022, we conducted an online survey targeting rheumatologists in Brazil. Our objective was to evaluate the barriers and knowledge gaps hindering the effective implementation of T2T strategies. To achieve this, we employed a set of multiple-choice questions specifically crafted to elicit responses categorized in a structured order.

RESULTS

166 rheumatologists participated in the survey, 51% of them with more than 21 years of experience in rheumatology. Regarding the perceived challenges in the management of RA in clinical practice, the highest percentage of agreement/strong agreement among the participants was related to the contradictory results of disease activity measures (60%). In terms of the main barriers to assess the disease activity in clinical practice, the lack of adherence to treatment and contradictory assessments between patient-reported outcomes and composite measures were indicated by 75% and 59% of the participants, respectively, as a moderate/serious barrier. The most frequently knowledge and skill gaps related to the management of RA pointed out by the participants were on the difficulty to assess patients' health literacy (54% stated to have no more than intermediate knowledge on standardized methods to assess it and 43% no more than intermediate skills on determining the level of health literacy of the patients). In general, the use of tools to support the management of RA patients in clinical practice was indicated to be unusual by the participants. Self-reflection questionnaires, patient education materials and treatment consideration checklists were pointed out as the least frequently used tools (85%, 64% and 62% of the participants stated to use them never, rarely, or only sometimes, respectively).

CONCLUSIONS

Our findings indicate a greater need for design, selection, and uptake of practical strategies to further improve communication between healthcare providers and patients with RA, as well as for promoting well-informed, collaborative decision-making in their care.

Rheumatoid arthritis epidemiology: a nationwide study in Poland

To assess the incidence and prevalence of rheumatoid arthritis (RA) in Poland for the period 2013-2021, total and dependent on gender, age, region and serological status. Information on reported National Health Fund (NHF) health services and reimbursed prescriptions were used, defining an RA patient as a person who had at least two visits in different quarters with ICD-10 code M05 or M06 and at the same time filled at least one reimbursed prescription for a drug whose active substance is methotrexate, sulfasalazine, leflunomide or was treated with biologic disease-modifying anti-rheumatic drugs (bDMRDs) or targeted synthetic DMARDs (tsDMARDs) as part of a drug program financed by the National Health Fund. The nationwide standardised incidence rate of RA in 2021 was 29 persons per 100,000 population (18 per 100,000 population of seropositive vs. 11 per 100,000 population of seronegative RA). The prevalence of RA in Poland in 2021 was 689.0 people per 100,000 population, a total of 0.7% (1.1% in women and 0.3% in men). The incidence of seronegative RA was approximately 38%. The majority of new RA diagnoses were in the sixth and seventh decades of life, irrespective of patients' gender. The results allow RA to be classified as a disease with a significant social impact. A trend of later onset of RA has been observed, which requires special consideration of the needs of patients over 55 years of age.

The steroid-sparing effect of JAK inhibitors across multiple patient populations

Introduction

JAK-inhibitors (JAK-i) represent an effective treatment in Rheumatoid Arthritis (RA) and Psoriatic Arthritis (PsA). Oral glucocorticoids (OGC) are commonly used in combination with JAK-i to reach therapeutic target. We aimed to assess, in a real-life setting, the reduction of OGC dose during JAK-i treatment in active RA and PsA patients.

Methods

We prospectively enrolled 103 patients (88 RA, 15 PsA) treated with JAK-i: 24% bio-naïve (b-naïve), 76% bDMARD-insufficient responders (bDMARD-IR) and 40% difficult to treat (D2T), defined as failure of ≥2 bDMARDs with different mechanism of action. Disease activity (DAS28 and DAPSA, VAS-pain, GH) and OGC dose was collected at baseline and after 3, 6 and 12 months (T3, T6, T12) of treatment.

Results

In all the cohort and in b-naïve patients we reported a reduction of OGC dose at all time-points; bDMARD-IR patients were able to reduce OGC dose at T3 and T12; D2T ones only at T3. We reported an improvement of disease activity and withdrawal of OGC as early as three months of therapy, at all time-points, regardless of line of bDMARD treatment.

Conclusion

Chronic OGC may cause detrimental bone, metabolic, cardiovascular side effects and infections; therefore JAK-i steroid-sparing effect may be beneficial for patients in long-term treatment.

Unmet need in rheumatology: reports from the Advances in Targeted Therapies meeting, 2023

The Advances in Targeted Therapies meets annually, convening experts in the field of rheumatology to both provide scientific updates and identify existing scientific gaps within the field. To review the major unmet scientific needs in rheumatology. The 23rd annual Advances in Targeted Therapies meeting convened with more than 100 international basic scientists and clinical researchers in rheumatology, immunology, infectious diseases, epidemiology, molecular biology and other specialties relating to all aspects of immune-mediated inflammatory diseases. We held breakout sessions in five rheumatological disease-specific groups including: rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (axSpa), systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and vasculitis, and osteoarthritis (OA). In each group, experts were asked to identify and prioritise current unmet needs in clinical and translational research. An overarching theme across all disease states is the continued need for clinical trial design innovation with regard to therapeutics, endpoint and disease endotypes. Within RA, unmet needs comprise molecular classification of disease pathogenesis and activity, pre-/early RA strategies, more refined pain profiling and innovative trials designs to deliver on precision medicine. Continued scientific questions within PsA include evaluating the genetic, immunophenotypic, clinical signatures that predict development of PsA in patients with psoriasis, and the evaluation of combination therapies for difficult-to-treat disease. For axSpA, there continues to be the need to understand the role of interleukin-23 (IL-23) in pathogenesis and the genetic relationship of the IL-23-receptor polymorphism with other related systemic inflammatory diseases (eg, inflammatory bowel disease). A major unmet need in the OA field remains the need to develop the ability to reliably phenotype and stratify patients for inclusion in clinical trials. SLE experts identified a number of unmet needs within clinical trial design including the need for allowing endpoints that reflect pharmacodynamic/functional outcomes (eg, inhibition of type I interferon pathway activation; changes in urine biomarkers). Lastly, within SSc and vasculitis, there is a lack of biomarkers that predict response or disease progression, and that allow patients to be stratified for therapies. There remains a strong need to innovate clinical trial design, to identify systemic and tissue-level biomarkers that predict progression or response to therapy, endotype disease, and to continue developing therapies and therapeutic strategies for those with treatment-refractory disease. This document, based on expert consensus, should provide a roadmap for prioritising scientific endeavour in the field of rheumatology.

High-grade synovitis associates with clinical markers and response to therapy in chronic inflammatory arthritis: post hoc analysis of a synovial biomarkers prospective cohort study

Background

Inflammatory arthritis (IAs), such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA), are characterized by the presence of chronic synovitis. The Krenn's synovitis score (KSS), a simple tool detectable by haematoxylin/eosin staining of synovial biopsy samples, allows the discrimination between high-grade and low-grade synovitis. The aim of this study was to identify the clinical associations of KSS and to evaluate the relationship between high-grade synovitis and treatment response in IA patients.

Methods

Clinical, laboratory and ultrasound data were retrieved from RA and PsA patients recruited in the prospective MATRIX cohort study. Inclusion criteria were age≥18 years, RA or PsA diagnosis, and presence of active disease with eligibility to start/modify therapy. Patients underwent ultrasound-guided synovial biopsy of one of the most involved joints before starting/modifying treatment according to treat-to-target strategy. The samples were analysed by an expert pathologist for KSS calculation. Univariable and multivariable logistic regression analyses were performed to evaluate the relationship between KSS and baseline variables. The association between KSS and treatment response at 24 weeks of follow-up was investigated in univariable logistic regression analysis.

Results

53 patients, 34 RA and 19 PsA, completed 24 weeks of follow-up after synovial biopsy. Patients were either treatment naïve (N=6, 11%), csDMARDs-experienced (N=46, 87%) or b/tsDMARDs-experienced (N=20, 38%). Median KSS was 6.00 (Q1-Q3 4.00-7.00) in RA and 4.00 (3.00-6.00) in PsA (p=0.040), and inflammatory infiltrates score was significantly higher in RA than in PsA patients (median 3.00 vs 2.00, p=0.021). In multivariable analysis, synovial effusion in the biopsied joint (OR 9.26, 95%CI 2.12-53.91) and erythrocyte sedimentation rate (ESR) (OR 1.04, 95%CI 1.01-1.08) associated with high KSS. High-grade synovitis significantly associated with a higher probability of achieving DAS28 remission, ACR20/50 response, and Boolean2.0 remission, independently from diagnosis.

Conclusion

Several markers of pro-inflammatory pathways associated with the presence of high-grade synovitis, and patients with higher KSS shared a higher probability of treatment targets achievement in the follow up. The integration of a simple and feasible tool like KSS in the clinical and prognostic stratification of patients with IA might help in intercepting patients with a disease more prone to respond to available treatment paradigms.

Comorbidities and chance of remission in patients with early rheumatoid arthritis receiving methotrexate as first-line therapy: a Swedish observational nationwide study

OBJECTIVES

This study aims to examine whether comorbidities affect the likelihood of reaching primary remission on methotrexate monotherapy as the first disease-modifying antirheumatic drug (DMARD) in early rheumatoid arthritis (RA).

METHODS

We used nationwide Swedish clinical and quality registers to collect RA disease activity measures and comorbidity data for patients diagnosed with RA 2007-2020 (n=11 001). The primary outcome was failure to reach 28-joint Disease Activity Score (DAS28) remission at 3 months. Secondary outcomes included Boolean, Simplified Disease Activity Index/Clinical Disease Activity Index remission, European Alliance of Associations for Rheumatology response and no swollen joint count at 3 and 6 months. For each comorbidity, and for combinations thereof, we calculated adjusted relative risks (RRs) of failure to reach remission, using modified Poisson regression.

RESULTS

In total, 53% (n=4019/7643) failed to reach DAS28 remission after 3 months of methotrexate monotherapy, ranging from 66% (n=25/38) among patients with chronic kidney disease to 48% (n=154/319) in patients with previous cancer. The risk of not reaching DAS28 remission at 3 months (RR adjusted for sex and age) was increased among patients with endocrine (RR 1.08, 95% CI 1.01 to 1.15), gastrointestinal (RR 1.16, 95% CI 1.03 to 1.30), infectious (RR 1.21, 95% CI 1.06 to 1.38), psychiatric (RR 1.24, 95% CI 1.15 to 1.35) and respiratory comorbidities (RR 1.16, 95% CI 1.01 to 1.32). Having three or more comorbidity categories was associated with a 27% higher risk of DAS28 remission failure at 3 months. A similar pattern was observed for the secondary outcomes.

CONCLUSIONS

Comorbidities decrease the chance of reaching remission on methotrexate as DMARD monotherapy in patients with early RA and are important to consider when assessing treatment outcomes.

Systematic Literature Review of Real-World Evidence on Baricitinib for the Treatment of Rheumatoid Arthritis

INTRODUCTION

Baricitinib, an orally available small-molecule inhibitor of Janus kinase (JAK)1 and JAK2, is indicated to treat active moderate-to-severe rheumatoid arthritis (RA).

OBJECTIVE

This systematic review described the real-world clinical characteristics of baricitinib-treated patients with RA, prescription patterns, effectiveness, drug persistence, patient-reported outcomes (PROs; physical function, pain, health-related quality of life [HRQoL]), patient global assessment (PGA), and safety of baricitinib.

METHODS

A PRISMA systematic review of real-world studies was conducted to identify relevant literature published between January 2016 and September 2022 using MEDLINE®, EMBASE®, and evidence-based medicine review databases. Websites or online repositories of the American College of Rheumatology and the European Alliance of Associations for Rheumatology were searched manually to include relevant abstracts from conferences held between January 2016 and November 2022.

RESULTS

A total of 11,472 records were identified by searching online databases. Seventy studies were included in the study, of which 40 were abstracts. Most patients were older (51-71 years), female, and with mean RA duration of 4-19 years. Baricitinib was mostly used after the failure of one or more bDMARDs, and 4 mg dosing was prevalent in patients with RA (range 22-100%). Clinical effectiveness of baricitinib was reported in real-world settings regardless of prior biologic/targeted synthetic disease-modifying antirheumatic drug (DMARD) use and concomitant conventional synthetic DMARD use. Achievement of Clinical Disease Activity Index (CDAI) remission was reported in 8.7-60% of patients at week 12 and CDAI low disease activity (LDA) in 20.2-81.6% at week 24. The proportion of patients attaining Simple Disease Activity Index (SDAI) remission was reported in 12% at week 4 to 45.4% at 24 weeks. Drug persistence was high, similar, or equal to anti-tumor necrosis factor drugs. No new safety signals were identified.

CONCLUSION

Baricitinib demonstrated effectiveness in the real-world setting with a consistent safety profile observed in clinical studies. Better persistence rates for baricitinib compared to bDMARDs with improvement in PROs were reported, although baricitinib-treated patients had RA with poor prognostic characteristics.

The Multimorbidity Web in rheumatoid arthritis

Multimorbidity, the presence of multiple chronic conditions, is highly prevalent in people with RA. An essential characteristic of multimorbidity is the interrelatedness of the different conditions that may develop in a multimorbid person. Recent studies have begun to identify and describe the Multimorbidity Web by elucidating unique multimorbidity patterns in people with RA. The primary multimorbidity patterns in this web are cardiopulmonary, cardiometabolic, and mental health and chronic pain multimorbidity. Once caught in the Multimorbidity Web, the consequences can be devastating, with reduced quality of life, physical function, survival, and treatment responses observed in multimorbid RA persons. The development of effective management and preventive approaches for multimorbidity in people with RA is in its infancy. Determining how best to assess, intervene, and prevent multimorbidity in RA is crucial to optimize long-term outcomes in people with RA.

RheuMetric Quantitative 0 to 10 Physician Estimates of Inflammation, Damage, and Distress in Rheumatoid Arthritis: Validation Against Reference Measures

OBJECTIVE

To analyze a RheuMetric checklist, which includes four feasible physician 0 to 10 scores for DOCGL, inflammation (DOCINF), damage (DOCDAM), and distress (DOCSTR) for criterion and discriminant validity against standard reference measures.

METHODS

A prospective, cross-sectional assessment was performed at one routine care visit at Liverpool Hospital, Sydney, Australia. Rheumatologists recorded DOCGL, DOCINF, DOCDAM, DOCSTR, and 28 joint counts for swelling (SJC), tenderness (TJC), and limited motion/deformity (DJC). Patients completed a multidimensional health assessment questionnaire (MDHAQ), which includes routine assessment of patient index data (RAPID3), fibromyalgia assessment screening tool (FAST4), and MDHAQ depression screen (MDS2). Laboratory tests and radiographic scores were recorded. RheuMetric estimates of inflammation, damage, and distress were compared with reference and other measures using correlations and linear regressions.

RESULTS

In 173 patients with RA, variation in RheuMetric DOCINF was explained significantly by SJC and inversely by disease duration; variation in DOCDAM was explained significantly by DJC, radiographic scores, and physical function; and variation in DOCSTR was explained significantly by fibromyalgia and depression.

CONCLUSION

RheuMetric DOCINF, DOCDAM, and DOCSTR estimates were correlated significantly and specifically with reference measures of inflammation, damage, and distress, documenting criterion and discriminant validity.

Disease activity and disease-related factors are drivers of patient global assessment in rheumatoid arthritis: a real-life cross-sectional study

Despite that the Patient Global Assessment (PGA) is widely used for measuring Rheumatoid Arthritis (RA) disease activity to define the remission state of the disease, the primary contributors influencing patients' ratings are still debated. This study aims to determine which clinical, sociodemographic and lifestyle-related contextual factors might be key drivers of PGA in RA. This single-center cross-sectional study recruited 393 consecutive adult RA patients. Median age 60 years, females 306 (77.9%). Data related to disease activity were assessed by using Simplified Disease Activity Index (SDAI), severity by Health Assessment Questionnaire (HAQ), and impact by RA Impact of Disease (RAID). Sociodemographic/lifestyle features were collected. Disease remission was calculated using Boolean-based criteria 1.0 and 2.0. Quantile regression models were used for univariate and multivariate analysis. The remission rate progressively increased from 15% by using SDAI with a Boolean 1.0-based definition to 43.5% using a Boolean 2.0-based remission. Among factors related to disease activity, the use of low-dose corticosteroids, the RAID items pain and sleep difficulties were predictive for worse PGA scores (p = 0.01). Among factors related to disease severity HAQ score and RAID total were independent factors associated with higher median PGA (p = 0.02 and p < 0.001). RAID's physical well-being was related to PGA scores (p = 0.01). An increasing trend in PGA was observed in longstanding diseases (> 15 years). Our results confirmed that there is no unambiguous interpretation of the PGA score. It is a measure related to some disease activity parameters, but it is also influenced by contextual factors related to disease severity and impact. These data highlighted that PGA should have a broad interpretation, thus supporting the proposal of a dual targets (biological and impact) approach to obtain a more accurate estimate of disease activity.

Remission, response, retention and persistence to treatment with disease-modifying agents in patients with rheumatoid arthritis: a study of harmonised Swedish, Danish and Norwegian cohorts

OBJECTIVE

Precision medicine in rheumatoid arthritis (RA) requires a good understanding of treatment outcomes and often collaborative efforts that call for data harmonisation. We aimed to describe how harmonisation across study cohorts can be achieved and investigate how the observed proportions reaching remission vary across remission criteria, study types, disease-modifying antirheumatic drugs (DMARDs) and countries, and how they relate to other treatment outcomes.

METHODS

We used data from eight existing large-scale, clinical RA registers and a pragmatic trial from Sweden, Denmark and Norway. In these, we defined three types of treatment cohorts; methotrexate monotherapy (as first DMARD), tumour necrosis factor inhibitors (TNFi) (as first biological DMARD) and rituximab. We developed a harmonised study protocol defining time points during 36 months of follow-up, collected clinical visit data on treatment response, retention, persistence and six alternative definitions of remission, and investigated how these outcomes differed within and between cohorts, by treatment.

RESULTS

Cohort sizes ranged from ~50 to 22 000 patients with RA. The proportions reaching each outcome varied across outcome metric, but with small to modest variations within and between cohorts, countries and treatment. Retention and persistence rates were high (>50% at 1 year), yet <33% of patients starting methotrexate or TNFi, and only 10% starting rituximab, remained on drug without other DMARDs added and achieved American Congress of Rheumatology/European Alliance of Associations for Rheumatology or Simplified Disease Activity Index remission at 1 year.

CONCLUSION

Harmonisation of data from different RA data sources can be achieved without compromising internal validity or generalisability. The low proportions reaching remission, point to an unmet need for treatment optimisation in RA.

Patient global assessment is elevated by up to 5 of 10 units in patients with inflammatory arthritis who screen positive for fibromyalgia (by FAST4) and/or depression (by MDS2) on a single MDHAQ

BACKGROUND

Patient global assessment (PATGL) is a component of rheumatoid arthritis (RA) and spondyloarthritis (SpA) activity indices, reflecting inflammation in selected clinical trial patients. In routine care, PATGL often may be elevated independently of inflammatory activity by fibromyalgia (FM) and/or depression, leading to complexities in interpretation. A feasible method to screen for FM and/or depression could help to clarify interpretation of high PATGL and index scores, including explanation of apparent limited responses to anti-inflammatory therapies.

PATIENTS AND METHODS

Patients with RA or SpA in routine care in Barcelona, Chicago, and Sydney complete a 2-page multidimensional health assessment questionnaire (MDHAQ) in 5-10 min. The MDHAQ includes PATGL and three indices, RAPID3 (routine assessment of patient index data) to assess clinical status, FAST4 (0-4 fibromyalgia assessment screening tool) and MDS2 (0-2 MDHAQ depression screen). PATGL was compared for each diagnosis at each site and pooled data in FAST4 positive (+) vs negative (-) and/or MDS2+ vs MDS2- patients using medians and median regressions.

RESULTS

Median PATGL was 5.0 in 393 RA and 175 SpA patients; 2.0-3.0 in 305 (58.9%) FAST4-,MDS2- patients, 5.5-6.0 in 71 (13.7%) FAST4-,MDS2+ patients, 7.0-7.5 in 50 (9.7%) FAST4+,MDS2- patients, and 7.0-8.0 in 92 (17.8%) FAST4+,MDS2+ patients. Positive FAST4 and/or MDS2 screens were seen in 41% of patients. Results were similar in RA and SpA at 3 settings on 3 continents.

CONCLUSION

Median 0-10 PATGL varied from 2-3/10 to 5.5-8/10, according to negative vs positive screening for FM and/or depression on a single MDHAQ for busy clinical settings.

EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update

OBJECTIVES

To provide an update of the EULAR rheumatoid arthritis (RA) management recommendations addressing the most recent developments in the field.

METHODS

An international task force was formed and solicited three systematic literature research activities on safety and efficacy of disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs). The new evidence was discussed in light of the last update from 2019. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned to and participants finally voted on the level of agreement with each item.

RESULTS

The task force agreed on 5 overarching principles and 11 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); GCs; biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab including biosimilars), abatacept, rituximab, tocilizumab, sarilumab and targeted synthetic (ts) DMARDs, namely the Janus kinase inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib. Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering in sustained clinical remission is provided. Safety aspects, including risk of major cardiovascular events (MACEs) and malignancies, costs and sequencing of b/tsDMARDs were all considered. Initially, MTX plus GCs is recommended and on insufficient response to this therapy within 3-6 months, treatment should be based on stratification according to risk factors; With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD should be added to the csDMARD; after careful consideration of risks of MACEs, malignancies and/or thromboembolic events tsDMARDs may also be considered in this phase. If the first bDMARD (or tsDMARD) fails, any other bDMARD (from another or the same class) or tsDMARD (considering risks) is recommended. With sustained remission, DMARDs may be tapered but should not be stopped. Levels of evidence and levels of agreement were high for most recommendations.

CONCLUSIONS

These updated EULAR recommendations provide consensus on RA management including safety, effectiveness and cost.