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Kedra J, Dieudé P, Giboin C, Marotte H, Salliot C, Schaeverbeke T, Perdriger A, Soubrier M, Morel J, Constantin A, Dernis E, Royant V, Salmon JH, Pham T, Gottenberg JE, Pertuiset E, Dougados M, Devauchelle-Pensec V, Gaudin P, Cormier G, Goupille P, Mariette X, Berenbaum F, Alcaix D, Rouidi SA, Berthelot JM, Monnier A, Piroth C, Lioté F, Goëb V, Gaujoux-Viala C, Chary-Valckenaere I, Hajage D, Tubach F, Fautrel B. Towards the Lowest Efficacious Dose: Results From a Multicenter Noninferiority Randomized Open-Label Controlled Trial Assessing Tocilizumab or Abatacept Injection Spacing in Rheumatoid Arthritis in Remission. Arthritis Rheumatol 2024; 76:541-552. [PMID: 37942714 DOI: 10.1002/art.42752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 10/18/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE We assess the clinical and structural impact at two years of progressively spacing tocilizumab (TCZ) or abatacept (ABA) injections versus maintenance at full dose in patients with rheumatoid arthritis in sustained remission. METHODS This multicenter open-label noninferiority (NI) randomized clinical trial included patients with established rheumatoid arthritis in sustained remission receiving ABA or TCZ at a stable dose. Patients were randomized to treatment maintenance (M) at full dose (M-arm) or progressive injection spacing (S) driven by the Disease Activity Score in 28 joints every 3 months up to biologics discontinuation (S-arm). The primary end point was the evolution of disease activity according to the Disease Activity Score in 44 joints during the 2-year follow-up analyzed per protocol with a linear mixed-effects model, evaluated by an NI test based on the one-sided 95% confidence interval (95% CI) of the slope difference (NI margin 0.25). Other end points were flare incidence and structural damage progression. RESULTS Overall, 202 of the 233 patients included were considered for per protocol analysis (90 in S-arm and 112 in M-arm). At the end of follow-up, 16.2% of the patients in the S-arm could discontinue their biologic disease-modifying antirheumatic drug, 46.9% tapered the dose and 36.9% returned to a full dose. NI was not demonstrated for the primary outcome, with a slope difference of 0.10 (95% CI 0.10-0.31) between the two arms. NI was not demonstrated for flare incidence (difference 42.6%, 95% CI 30.0-55.1) or rate of structural damage progression at two years (difference 13.9%, 95% CI -6.7 to 34.4). CONCLUSION The Towards the Lowest Efficacious Dose trial failed to demonstrate NI for the proposed ABA or TCZ tapering strategy.
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Affiliation(s)
- Joanna Kedra
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Philippe Dieudé
- Université de Paris Cité, INSERM UMR 1152 and Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Caroline Giboin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Hubert Marotte
- Université Jean Monnet Saint-Étienne, Centre Hospitalier Universitaire de Saint-Etienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Étienne, France
| | | | | | | | - Martin Soubrier
- Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Jacques Morel
- Montpellier University Hospital and University of Montpellier, INSRM, CNRS, Montpellier, France
| | - Arnaud Constantin
- Pierre-Paul Riquet University Hospital, Toulouse III - Paul Sabatier University, and INSERM UMR 1291, Purpan University Hospital, Toulouse, France
| | | | | | - Jean-Hugues Salmon
- University of Reims Champagne-Ardenne, Faculty of Medicine, UR 3797 and Maison Blanche Hospital, Reims University Hospitals, Reims, France
| | - Thao Pham
- Sainte-Marguerite Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | | | | | - Maxime Dougados
- University of Paris, Hôpital Cochin. AP-HP, INSERM U1153, pôle de recherche et d'enseignement supérieur Sorbonne Paris-Cité, Paris, France
| | | | | | | | | | - Xavier Mariette
- Université Paris-Saclay, Hôpital Bicêtre, AP-HP, INSERM UMR1184, Le Kremlin Bicêtre, France
| | - Francis Berenbaum
- Sorbonne University-INSERM Centre De Recherche scientifique Saint-Antoine, AP-HP Saint-Antoine Hospital, Paris, France
| | | | | | | | | | | | - Frédéric Lioté
- Université de Paris and INSERM UMR1132 Bioscar (Centre Viggo Petersen), Hôpital Lariboisière, AP-HP, Paris, France
| | - Vincent Goëb
- University Hospital of Amiens, Université de Picardie Jules Verne, Amiens, France
| | - Cécile Gaujoux-Viala
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, University of Montpellier, INSERM, Centre Hospitalier Universitaire de Nîmes, Montpellier, France
| | | | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Bruno Fautrel
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
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Suzuki T, Ohshima M, Suzuki A. Magnetic resonance imaging including bone erosion may be useful for predicting disease flares in patients with rheumatoid arthritis: A hypothesis. Int J Rheum Dis 2023; 26:2559-2562. [PMID: 37847067 DOI: 10.1111/1756-185x.14941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/06/2023] [Accepted: 10/01/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Takeshi Suzuki
- Department of Rheumatology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Miho Ohshima
- Department of Rheumatology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Akitake Suzuki
- Department of Rheumatology, Mitsui Memorial Hospital, Tokyo, Japan
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Dong W, Hu X, Wu C, Wang G, Fang Y, Shi L, Nie X. Efficacy, safety, and cost-effectiveness of therapeutic drug monitoring (TDM) for TNF inhibitor therapy in rheumatic disease: A systematic review and meta-analysis. Semin Arthritis Rheum 2023; 63:152302. [PMID: 37951128 DOI: 10.1016/j.semarthrit.2023.152302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/13/2023]
Abstract
OBJECTIVE The benefits of TDM-guided TNFi therapy in patients with rheumatic disease was still controversial. This systematic review and meta-analysis was conducted to explore if the TDM-guided TNFi therapy is superior to empirical-guided therapy. METHODS We systematically searched PubMed, Web of Science, Cochrane Library, and EMBASE databases for articles published between database inception and October 05, 2023. Studies reporting endpoints in TDM-guided TNFi therapy and empirical therapy were included. Results would be presented in risk ratio (RR) and mean difference, with 95 % confidence interval (CI) reported. This study is registered with PROSPERO (CRD42022353956). RESULTS A total of 14 studies (eight RCTs and six cohort studies) involving 2427 patients were included in this meta-analysis. In the scenario of response prediction, compared with empirical-guided therapy, TDM-guided TNFi therapy had association with higher treat-to-target rates (RR 1.30, 95 % CI 1.02-1.65, P=0.03, I2=79 %), more specifically, higher low disease activity rates (RR 2.11, 95 % CI 1.22-3.66, P=0.007, I2=61 %), but no difference in clinical remission rates (RR 0.98,95 % CI 0.87-1.11, P=0.75, I2=0 %). In the scenario of dose reduction prediction, lower relapse rates (RR 0.73, 95 % CI 0.65-0.82, P <0.00001, I2=0 %) were observed compared with empirical-guided dose reduction strategy, but no difference (RR 1.24, 95 % CI 0.85-1.80, P=0.27, I2=57 %) between TDM-guided dose reduction and standard-dosing therapy. No significant difference was observed in change of disease activity score, mean disease activity score, radiographic progression, and safety. And TDM-guided therapy was associated with reduced cost per patient per year calculated as the total accumulated sum of therapy cost. CONCLUSION TDM-guided TNFi therapy was associated with increased rates of low disease activity and decreased risks of relapse, and may save cost compared with empirical-guided therapy in patients with rheumatic disease. But this does not mean that the use of TDM-guided TNFi therapy can be advocated, because there is no difference in clinical remission rates and many other outcomes. More researches, especially randomized clinical trials are needed to verify this conclusion in the future.
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Affiliation(s)
- Wenliang Dong
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; Clinical Trial Institution, Peking University People's Hospital, Beijing 101109, China
| | - Xiaowen Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Caiying Wu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Gengchen Wang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Yi Fang
- Clinical Trial Institution, Peking University People's Hospital, Beijing 101109, China.
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; International Research Center for Medicinal Administration, Peking University, Beijing 100191, China.
| | - Xiaoyan Nie
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; International Research Center for Medicinal Administration, Peking University, Beijing 100191, China.
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Ward MM, Madanchi N, Yazdanyar A, Shah NR, Constantinescu F. Prevalence and predictors of sustained remission/low disease activity after discontinuation of induction or maintenance treatment with tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic and scoping review. Arthritis Res Ther 2023; 25:222. [PMID: 37986101 PMCID: PMC10659063 DOI: 10.1186/s13075-023-03199-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND To determine the prevalence of sustained remission/low disease activity (LDA) in patients with rheumatoid arthritis (RA) after discontinuation of tumor necrosis factor inhibitors (TNFi), separately in induction treatment and maintenance treatment studies, and to identify predictors of successful discontinuation. METHODS We performed a systematic literature review of studies published from 2005 to May 2022 that reported outcomes after TNFi discontinuation among patients in remission/LDA. We computed prevalences of successful discontinuation by induction or maintenance treatment, remission criterion, and follow-up time. We performed a scoping review of predictors of successful discontinuation. RESULTS Twenty-two induction-withdrawal studies were identified. In pooled analyses, 58% (95% confidence interval (CI) 45, 70) had DAS28 < 3.2 (9 studies), 52% (95% CI 35, 69) had DAS28 < 2.6 (9 studies), and 40% (95% CI 18, 64) had SDAI ≤ 3.3 (4 studies) at 37-52 weeks after discontinuation. Among patients who continued TNFi, 62 to 85% maintained remission. Twenty-two studies of maintenance treatment discontinuation were also identified. At 37-52 weeks after TNFi discontinuation, 48% (95% CI 38, 59) had DAS28 < 3.2 (10 studies), and 47% (95% CI 33, 62) had DAS28 < 2.6 (6 studies). Heterogeneity among studies was high. Data on predictors in induction-withdrawal studies were limited. In both treatment scenarios, longer duration of RA was most consistently associated with less successful discontinuation. CONCLUSIONS Approximately one-half of patients with RA remain in remission/LDA for up to 1 year after TNFi discontinuation, with slightly higher proportions in induction-withdrawal settings than with maintenance treatment discontinuation.
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Affiliation(s)
- Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 10CRC, Room 4-1339, 10 Center Drive, Bethesda, MD, 20892-1468, USA.
| | - Nima Madanchi
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Current address: Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA, USA
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Current address: Division of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nehal R Shah
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Lillegraven S, Paulshus Sundlisæter N, Aga AB, Sexton J, Olsen IC, Lexberg ÅS, Madland TM, Fremstad H, Høili CA, Bakland G, Spada C, Haukeland H, Hansen IM, Moholt E, Uhlig T, Solomon DH, van der Heijde D, Kvien TK, Haavardsholm EA. Effect of tapered versus stable treatment with tumour necrosis factor inhibitors on disease flares in patients with rheumatoid arthritis in remission: a randomised, open label, non-inferiority trial. Ann Rheum Dis 2023; 82:1394-1403. [PMID: 37607809 PMCID: PMC10579188 DOI: 10.1136/ard-2023-224476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Many patients with rheumatoid arthritis (RA) require treatment with tumour necrosis factor inhibitor (TNFi) to reach remission. It is debated whether tapering of TNFi to discontinuation should be considered in sustained remission. The aim of ARCTIC REWIND TNFi was to assess the effect of tapering TNFi to withdrawal compared with stable treatment on the risk of disease activity flares in patients with RA in remission ≥1 year. METHODS This randomised, open-label, non-inferiority trial was undertaken at nine Norwegian rheumatology departments. Patients with RA in remission ≥12 months on stable TNFi therapy were allocated by computer-based block-randomisation to tapering to discontinuation of TNFi or stable TNFi. Conventional synthetic disease-modifying antirheumatic co-medication was unchanged. The primary endpoint was disease flare during the 12-month study period (non-inferiority margin 20%), assessed in the per-protocol population. RESULTS Between June 2013 and January 2019, 99 patients were enrolled and 92 received the allocated treatment strategy. Eighty-four patients were included in the per-protocol population. In the tapering TNFi group, 27/43 (63%) experienced a flare during 12 months, compared with 2/41 (5%) in the stable TNFi group; risk difference (95% CI) 58% (42% to 74%). The tapering strategy was not non-inferior to continued stable treatment. The number of total/serious adverse events was 49/3 in the tapering group, 57/2 in the stable group. CONCLUSION In patients with RA in remission for more than 1 year while using TNFi, an increase in flare rate was reported in those who tapered TNFi to discontinuation. However, most regained remission after reinstatement of full-dose treatment. TRIAL REGISTRATION NUMBERS EudraCT: 2012-005275-14 and clinicaltrials.gov: NCT01881308.
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Affiliation(s)
- Siri Lillegraven
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Nina Paulshus Sundlisæter
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Anna-Birgitte Aga
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Joseph Sexton
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Inge Christoffer Olsen
- Department of Research Support for Clinical Trials, Oslo University Hospital, Oslo, Norway
| | | | - Tor Magne Madland
- Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - Hallvard Fremstad
- Department of Rheumatology, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | | | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of North Norway, Tromsø, Norway
| | - Cristina Spada
- Department of Rheumatology, Revmatismesykehuset AS, Lillehammer, Norway
| | - Hilde Haukeland
- Department of Rheumatology, Martina Hansens Hospital, Sandvika, Norway
| | | | - Ellen Moholt
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
| | - Till Uhlig
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Daniel H Solomon
- Division of Rheumatology, Division of Pharmacoepidemiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Désirée van der Heijde
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tore K Kvien
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Espen A Haavardsholm
- REMEDY Center for treatment of Rheumatic and Musculoskeletal Diseases, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Chen F, Lang Y, Geng S, Wang X, Lu L, Ye S, Zhang L, Li T. The effective threshold dose of etanercept in patients with methotrexate-resistant rheumatoid arthritis. Clin Rheumatol 2023; 42:2777-2786. [PMID: 37415053 PMCID: PMC10497429 DOI: 10.1007/s10067-023-06659-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/17/2023] [Accepted: 06/01/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION The therapy of rheumatoid arthritis (RA) was advanced by biological agents, yet costly. This study aims to identify the effective threshold dose of etanercept (ENT) and cost-effectiveness in methotrexate (MTX)-resistant RA in real world. METHODS Eligible patients had an inadequate response (DAS28-ESR > 3.2) to initial MTX monotherapy, and subsequently received etanercept. The effective cut-off value of cumulative dose was identified to maintain remission response (DAS28-ESR < 2.6) at month 24 by using restricted cubic splines. Remission rate, low disease activity (LDA) rate, glucocorticoid exposure, safety, and cost-effectiveness were compared between the saturated and non-saturated dose groups divided by the cut-off dose. RESULTS Seventy-eight (14.2%) of 549 enrolled patients were eligible, and 72 patients completed follow-up. The 2-year cumulative cut-off dose that maintained remission response at 24 months was 1975 mg. And the recommended threshold dosing strategy of etanercept was twice weekly (BIW) for the first 6 months, every week (QW) for the next 6 months, and every 2 weeks (Q2W) and every month (QM) for the second year. Greater net changes in DAS28-ESR score were observed in the ENT saturated dose group than in the non-saturated dose group (average change 0.569, 95%CI 0.236-0.901, p = 0.001). The proportion of patients achieving remission (27.8% vs 72.2%, p < 0.001) and LDA (58.3% vs 83.3%, p = 0.020) in the non-saturated group was both significantly lower than that in the saturated group at 24 months. The incremental cost-effectiveness ratio of the saturated group referred to the non-saturated group was 5791.2 $/QALY. CONCLUSIONS In refractory RA patients, the effective cumulative cut-off dose of etanercept for sustained remission at 24 months was calculated as 1975 mg, and receiving saturated dose was more effective and cost-effective than with non-saturated dose. Key Points • The effective cumulative cut-off dose of etanercept for sustained remission at 24 months in RA patients is calculated as 1975 mg. • Receiving saturated dose of etanercept is more effective and cost-effective than with non-saturated dose in refractory RA patients.
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Affiliation(s)
- Fangfang Chen
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Yitian Lang
- Department of Pharmacy, Huangpu Branch, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shikai Geng
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaodong Wang
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Liangjing Lu
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Shuang Ye
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Le Zhang
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Ting Li
- Department of Rheumatology, Ren Ji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.
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van Esveld L, Cox JM, Kuijper TM, Bosch TM, Weel-Koenders AE. Cost-utility analysis of tapering strategies of biologicals in rheumatoid arthritis patients in the Netherlands. Ann Rheum Dis 2023; 82:1296-1306. [PMID: 37423648 DOI: 10.1136/ard-2023-224190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/21/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Current guidelines recommend tapering biological disease-modifying antirheumatoid drugs (bDMARDs) in rheumatoid arthritis (RA) if the disease is under control. However, guidelines on tapering are lacking. Assessing cost-effectiveness of different tapering strategies might provide broader input for creating guidelines on how to taper bDMARDs in patients with RA. The aim of this study is to evaluate the long-term cost-effectiveness from a societal perspective of bDMARD tapering strategies in Dutch patients with RA, namely 50% dose reduction (tapering), discontinuation and a 50% dose reduction followed by discontinuation (de-escalation). METHODS Using a societal perspective, a Markov model with a life-time horizon of 30 years was used to simulate 3-monthly transitions between Disease Activity 28 (DAS28)-defined health states of remission (<2.6), low disease activity (2.63.2). Transition probabilities were estimated through literature search and random effects pooling. Incremental costs, incremental quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs) and incremental net monetary benefits for each tapering strategy were compared with continuation. Deterministic, probabilistic sensitivity analyses and multiple scenario analyses were performed. RESULTS After 30 years, the ICERs were €115 157/QALY lost, €74 226/QALY lost and €67 137/QALY lost for tapering, de-escalation and discontinuation, respectively; mainly driven by bDMARD cost savings and a 72.8% probability of a loss in quality of life. This corresponds to a 76.1%, 64.3% and 60.1% probability of tapering, de-escalation and discontinuation being cost-effective, provided a willingness-to-accept threshold of €50 000/QALY lost. CONCLUSIONS Based on these analyses, the 50% tapering approach saved the highest cost per QALY lost.
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Affiliation(s)
| | - Juul M Cox
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Tessa M Bosch
- Hospital Pharmacy, Maasstad Hospital, Rotterdam, The Netherlands
- Clinical Pharmacology and Toxicology, MaasstadLab Maasstad Hospital, Rotterdam, The Netherlands
| | - Angelique Eam Weel-Koenders
- Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Kubo S, Miyazaki Y, Amano K, Matsui K, Kameda H, Inoue Y, Nakayamada S, Ogura T, Kaneko Y, Yamaoka K, Tanaka Y. Sustained remission following the discontinuation of tofacitinib in patients with rheumatoid arthritis (XANADU study): an open-label randomised study. RMD Open 2023; 9:rmdopen-2023-003029. [PMID: 37185309 PMCID: PMC10152036 DOI: 10.1136/rmdopen-2023-003029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE To investigate sustained remission following the discontinuation of tofacitinib in patients with rheumatoid arthritis. METHODS Patients who had an inadequate response to methotrexate (MTX) with or without biological disease-modifying antirheumatic drugs were randomly divided into two groups at baseline, and tofacitinib treatment in combination with MTX was administered to both groups. Either MTX or tofacitinib was then withdrawn if patients achieved Clinical Disease Activity Index remission at week 52. The primary outcome was the proportion of patients who sustained clinical remission at week 104. RESULTS A total of 113 patients participated in this study. Among them, a total of 48 patients achieved remission at week 52. After discontinuation of tofacitinib, only 29.2% (7/24) of patients remained remission, while 50.0% (10/20) of patients, which was numerically higher but not statistically significant, sustained remission after MTX discontinuation. A greater proportion of bio-naïve patients achieved remission at week 52 and sustained low disease activity with tofacitinib discontinuation at week 104. Additionally, the patients who were able to discontinue tofacitinib without flares had lower rheumatoid factor (p=0.04) and lower anti-cyclic citrullinated peptide antibody (p=0.051) before discontinuation of tofacitinib. No severe adverse events were recorded after discontinuation of tofacitinib or MTX. In patients who relapsed after tofacitinib discontinuation, 71.4% achieved remission with resumption of tofacitinib. CONCLUSIONS This study implies that a blanket cessation of tofacitinib may not be suitable for all patients, given that 58% of the participants experienced relapse. However, the withdrawal of tofacitinib is unlikely to result in the acquisition of treatment-resistance.
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Affiliation(s)
- Satoshi Kubo
- Department of Molecular Targeted Therapies, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Yusuke Miyazaki
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Centre, Saitama Medical University, Saitama, Japan
| | - Kiyoshi Matsui
- Division of Allergology and Rheumatology, Department of Diabetes Endocrinology and Clinical Immunology, Hyogo Medical University, Hyogo, Japan
| | - Hideto Kameda
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yoshino Inoue
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
| | - Takehisa Ogura
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health Japan, Kitakyushu, Japan
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9
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Ruwaard J, L' Ami MJ, Kneepkens EL, Krieckaert C, Nurmohamed MT, Hooijberg F, van Kuijk A, van Denderen JC, Burgemeister L, Rispens T, Boers M, Wolbink GJ. Interval prolongation of etanercept in rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis: a randomized controlled trial. Scand J Rheumatol 2023; 52:129-136. [PMID: 35234569 DOI: 10.1080/03009742.2022.2028364] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The majority of patients with a rheumatic disease treated with etanercept may be overexposed. Data regarding etanercept tapering are scarce, particularly in psoriatic arthritis (PsA) and ankylosing spondylitis (AS). We compared extending the dose interval to continuation of the standard dose and studied the success rate of etanercept discontinuation. Etanercept concentrations were measured throughout the study. METHOD 160 patients with rheumatoid arthritis (RA), PsA, or AS with sustained minimal disease activity (MDA) were enrolled in this 18-month, open-label, randomized controlled trial. The intervention group doubled the dosing interval at baseline and discontinued etanercept 6 months later. The control group continued the standard dose for 6 months and doubled the dosing-interval thereafter. The primary outcome was the proportion of patients maintaining MDA at 6 month follow-up. RESULTS At 6 months, MDA status was maintained in 47 patients (63%) in the intervention group and 56 (74%) in the control group (p = 0.15), with comparable results in all rheumatic diseases. And median etanercept concentrations decreased from 1.50 µg/mL (interquartile range 1.06- 2.65) to 0.46 µg/mL (0.28-0.92). In total, 40% discontinued etanercept successfully with maintained MDA for at least 6 months. CONCLUSION Etanercept tapering can be done without losing efficacy in RA, PsA, and AS patients in sustained MDA. A substantial proportion of patients could stop etanercept for at least 6 months. In many patients, low drug concentrations proved sufficient to control disease activity. However, the risk of minor and major flares is substantial, even in patients continuing standard dosing.
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Affiliation(s)
- J Ruwaard
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - M J L' Ami
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - E L Kneepkens
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Clm Krieckaert
- Department of Rheumatology, Amsterdam UMC
- Vrije Universiteit, Amsterdam, The Netherlands
| | - M T Nurmohamed
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.,Department of Rheumatology, Amsterdam UMC
- Vrije Universiteit, Amsterdam, The Netherlands
| | - F Hooijberg
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Awr van Kuijk
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - J C van Denderen
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - L Burgemeister
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - T Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Center, Amsterdam, The Netherlands
| | - M Boers
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.,Department of Rheumatology, Amsterdam UMC
- Vrije Universiteit, Amsterdam, The Netherlands.,Department of Epidemiology and Data Science, Amsterdam UMC
- Vrije Universiteit, Amsterdam, The Netherlands
| | - G J Wolbink
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands.,Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Center, Amsterdam, The Netherlands
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10
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Wang M, Xue Y, Du F, Ma L, Lu LJ, Jiang L, Tao YL, Yang C, Shi H, Liu H, Cheng X, Ye J, Su Y, Zhao D, Dai SM, Teng J, Hu Q. Continuation, reduction, or withdrawal of tofacitinib in patients with rheumatoid arthritis achieving sustained disease control: a multicenter, open-label, randomized controlled trial. Chin Med J (Engl) 2023; 136:331-340. [PMID: 36848153 PMCID: PMC10106157 DOI: 10.1097/cm9.0000000000002561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA), a chronic systemic autoimmune disease, is characterized by synovitis and progressive damage to the bone and cartilage of the joints, leading to disability and reduced quality of life. This study was a randomized clinical trial comparing the outcomes between withdrawal and dose reduction of tofacitinib in patients with RA who achieved sustained disease control. METHODS The study was designed as a multicenter, open-label, randomized controlled trial. Eligible patients who were taking tofacitinib (5 mg twice daily) and had achieved sustained RA remission or low disease activity (disease activity score in 28 joints [DAS28] ≤3.2) for at least 3 months were enrolled at six centers in Shanghai, China. Patients were randomly assigned (1:1:1) to one of three treatment groups: continuation of tofacitinib (5 mg twice daily); reduction in tofacitinib dose (5 mg daily); and withdrawal of tofacitinib. Efficacy and safety were assessed up to 6 months. RESULTS Overall, 122 eligible patients were enrolled, with 41 in the continuation group, 42 in the dose-reduction group, and 39 in the withdrawal group. After 6 months, the percentage of patients with a DAS28-erythrocyte sedimentation rate (ESR) of <3.2 was significantly lower in the withdrawal group than that in the reduction and continuation groups (20.5%, 64.3%, and 95.1%, respectively; P < 0.0001 for both comparisons). The average flare-free time was 5.8 months for the continuation group, 4.7 months for the dose reduction group, and 2.4 months for the withdrawal group. CONCLUSION Withdrawal of tofacitinib in patients with RA with stable disease control resulted in a rapid and significant loss of efficacy, while standard or reduced doses of tofacitinib maintained a favorable state. TRIAL REGISTRATION Chictr.org, ChiCTR2000039799.
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Affiliation(s)
- Mengyan Wang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yu Xue
- Department of Rheumatology and Immunology, Huashan Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Fang Du
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| | - Lili Ma
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Liang-jing Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yi-Li Tao
- Department of Rheumatology and Immunology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Honglei Liu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiaobing Cheng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Junna Ye
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yutong Su
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dongbao Zhao
- Department of Rheumatology and Immunology, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Sheng-Ming Dai
- Department of Rheumatology and Immunology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200233, China
| | - Jialin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Qiongyi Hu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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11
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Curtis JR, Stolshek B, Emery P, Haraoui B, Karis E, Kricorian G, Collier DH, Yen PK, Bykerk VP. Effects of Disease-Worsening Following Withdrawal of Etanercept or Methotrexate on Patient-Reported Outcomes in Patients With Rheumatoid Arthritis: Results From the SEAM-RA Trial. J Clin Rheumatol 2023; 29:16-22. [PMID: 36459119 PMCID: PMC9803379 DOI: 10.1097/rhu.0000000000001893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND/OBJECTIVE The effect of treatment withdrawal on patient-reported outcomes (PROs) in patients with rheumatoid arthritis (RA) whose disease is in sustained remission has not been well described. This analysis aimed to compare PRO changes in patients with RA following medication withdrawal and disease worsening. METHODS SEAM-RA (Study of Etanercept and Methotrexate in Combination or as Monotherapy in Subjects With Rheumatoid Arthritis) was a phase 3, multicenter, randomized withdrawal, double-blind controlled study in patients with RA taking methotrexate plus etanercept and in remission (Simple Disease Activity Index ≤3.3). Patient's Global Assessment of Disease Activity, Patient's Assessment of Joint Pain, Health Assessment Questionnaire-Disability Index, and 36-Item Short-Form Health Survey were evaluated for 48 weeks following methotrexate or etanercept withdrawal. Treatment differences for patients with versus without disease worsening were evaluated using a 2-sample t test for continuous end points and log-rank test for time-to-event end points. RESULTS Of 253 patients, 121 experienced disease worsening and 132 did not. All PRO scores were similar to those of a general population at baseline and deteriorated over time across the study population. The PtGA and Patient's Assessment of Joint Pain values deteriorated less in those on etanercept monotherapy compared with methotrexate monotherapy. More patients with versus without disease worsening experienced deterioration that was greater than the minimal clinically important difference (MCID) for all PROs tested. In patients with disease worsening, PtGA deterioration more than the MCID preceded Simple Disease Activity Index disease worsening. CONCLUSIONS Etanercept monotherapy showed benefit over methotrexate in maintaining PRO scores. Patients with disease worsening experienced a more rapid worsening of PtGA beyond the MCID versus patients without disease worsening.Categories: autoinflammatory disease, biological therapy, DMARDs, rheumatoid arthritis.
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Affiliation(s)
- Jeffrey R. Curtis
- From the Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, University of Leeds, Leeds, United Kingdom
| | - Boulos Haraoui
- Centre Hospitalier de I'Université de Montréal, Montréal, Quebec, Canada
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12
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Smolen JS, Landewé RBM, Bergstra SA, Kerschbaumer A, Sepriano A, Aletaha D, Caporali R, Edwards CJ, Hyrich KL, Pope JE, de Souza S, Stamm TA, Takeuchi T, Verschueren P, Winthrop KL, Balsa A, Bathon JM, Buch MH, Burmester GR, Buttgereit F, Cardiel MH, Chatzidionysiou K, Codreanu C, Cutolo M, den Broeder AA, El Aoufy K, Finckh A, Fonseca JE, Gottenberg JE, Haavardsholm EA, Iagnocco A, Lauper K, Li Z, McInnes IB, Mysler EF, Nash P, Poor G, Ristic GG, Rivellese F, Rubbert-Roth A, Schulze-Koops H, Stoilov N, Strangfeld A, van der Helm-van Mil A, van Duuren E, Vliet Vlieland TPM, Westhovens R, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis 2023; 82:3-18. [PMID: 36357155 DOI: 10.1136/ard-2022-223356] [Citation(s) in RCA: 312] [Impact Index Per Article: 312.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/21/2022] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Robert B M Landewé
- Division of Clinical Immunology and Rheumatology, Amsterdam University Medical Center & Zuyderland Medical Center Heerlen, Heerlen, The Netherlands
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Roberto Caporali
- Milan & Department of Rheumatology, ASST PINI-CTO, University of Milan, Milan, Italy
| | - Christopher John Edwards
- MSK Research Unit, NIHR Southampton Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Kimme L Hyrich
- Centre for Epidemiology Versus Arthritis, Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre. Manchester University NHS Trust, University of Manchester, Manchester, UK
| | - Janet E Pope
- Western University, Schulich School of Medicine & Dentistry, London, Ontario, Canada
| | - Savia de Souza
- EULAR Patient Research Partner Network, Zurich, Switzerland
| | - Tanja A Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Keio University School of Medicine, Tokyo and Saitama Medical University, Saitama, Japan
| | | | | | - Alejandro Balsa
- Servicio de Reumatologia, Hospital Universitario La Paz, Universidad Autonoma de Madrid, Madrid, Spain
| | - Joan M Bathon
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Maya H Buch
- Centre for Musculoskeletal Research, Division of Musculoskeletal & Dermatological Sciences, Faculty of Biology, Medicine & Health and NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Hospital, Berlin, Germany
| | | | - Katerina Chatzidionysiou
- Department of Medicine Solna, Karolinska Institutet, Rheumatology Division, Karolinska University Hospital, Stockholm, Sweden
| | - Catalin Codreanu
- Center for Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Division of Rheumatology DiMI, Department of Internal Medicine and Medical Specialties, University of Genova IRCCS, San Martino Polyclinic Hospital, Genoa, Italy
| | | | - Khadija El Aoufy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Axel Finckh
- Division of Rheumatology, Department of Medicine, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - João Eurico Fonseca
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Center, and Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | - Espen A Haavardsholm
- Center for treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital and University of Oslo, Oslo, Norway
| | - Annamaria Iagnocco
- Academic Rheumatology Centre - AO Mauriziano Torino, Cattedra di Reumatologia - Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Turin, Italy
| | - Kim Lauper
- Division of Rheumatology, Department of Medicine, Geneva University Hospitals & Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Iain B McInnes
- College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Peter Nash
- School of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Gyula Poor
- National Institute of Musculoskeletal Disorders, Semmelweis University Medical School, Budapest, Hungary
| | - Gorica G Ristic
- Department of Rheumatology and Clinical Immunology and Medical Faculty of the Military Medical Academy, The University of Defense in Belgrade, Belgrade, Serbia
| | - Felice Rivellese
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, London, UK
| | - Andrea Rubbert-Roth
- Division of Rheumatology and Clinical Immunology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, Ludwig Maximilians University of Munich, Munich, Germany
| | - Nikolay Stoilov
- Department of Rheumatology, Faculty of Medicine, University Hospital "St. Ivan Rilski", Medical University of Sofia, Sofia, Bulgaria
| | - Anja Strangfeld
- Department of Medicine Solna, Karolinska Institutet, Rheumatology Division, Karolinska University Hospital, Stockholm, Sweden.,Programme Area of Epidemiology and Health Services Research, German Rheumatism Research Centre, Berlin, Germany
| | | | - Elsa van Duuren
- The Sefako Makgatho Health Science University, Pretoria, South Africa
| | - Theodora P M Vliet Vlieland
- Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, The Netherlands
| | - René Westhovens
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
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13
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The Impact of b/tsDMARD Dose Reduction on Chronic Hepatitis B in Rheumatoid Arthritis Patients: A Two-Center Long-Term Safety Analysis. J Clin Med 2022; 12:jcm12010086. [PMID: 36614890 PMCID: PMC9821696 DOI: 10.3390/jcm12010086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND We aimed to investigate the change of hepatitis B virus (HBV) viral loads and HBV reactivation (HBVr) in rheumatoid arthritis (RA) patients after tapering the dose of biological/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs). METHODS This two-center analysis retrospectively investigated the virological and biochemical evidence of HBVr in RA patients who underwent b/tsDMARD dose reduction. Serum levels of viral loads were determined using real-time PCR. Serum levels of alanine transaminase (ALT) were determined using spectrophotometry. RESULTS Among a total of 40 HBsAg+ RA patients who tapered b/tsDMARDs, 14 (35%) used tocilizumab; 12 (30%) used tumor necrosis factor (TNF)-α inhibitors; and the rest used either abatacept or tofacitinib. We found that patients who had detectable HBV DNA before tapering achieved a one-log reduction in HBV DNA levels, in contrast to the findings in the other 12 patients who did not taper b/tsDMARDs (no change in HBV DNA levels with time). The incidence of HBVr (increased viral loads with hepatitis) was 4.62 (95%CI: 2.08, 10.28) and 2.26 (95%CI: 0.56, 9.02) events per 100 person-years before and after b/tsDMARD tapering, respectively. CONCLUSIONS The HBV viral load decreased after the tapering of b/tsDMARDs in RA patients with detectable HBV DNA. Dose reduction in b/tsDMARDs might be beneficial.
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14
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Terslev L, Ostergaard M, Georgiadis S, Brahe CH, Ellegaard K, Dohn UM, Fana V, Møller T, Juul L, Huynh TK, Krabbe S, Ornbjerg LM, Glinatsi D, Røgind H, Hansen A, Nørregaard J, Jacobsen S, Jensen DV, Manilo N, Asmussen K, Boesen M, Rastiemadabadi Z, Morsel-Carlsen L, Møller JM, Krogh NS, Hetland ML. Flare during tapering of biological DMARDs in patients with rheumatoid arthritis in routine care: characteristics and predictors. RMD Open 2022; 8:rmdopen-2022-002796. [PMID: 36549857 PMCID: PMC9791469 DOI: 10.1136/rmdopen-2022-002796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To identify predictors of flare in a 2-year follow-up study of patients with rheumatoid arthritis (RA) in sustained clinical remission tapering towards withdrawal of biological disease-modifying anti-rheumatic drugs (bDMARDs). METHODS Sustained clinical remission was defined as Disease Activity Score for 28 joints (DAS28)-C reactive protein (CRP) ≤2.6 without radiographic progression for >1 year. bDMARDs were tapered according to a mandatory clinical guideline to two-thirds of standard dose at baseline, half of dose at week 16 and discontinuation at week 32. Prospective assessments for 2 years included clinical evaluation, conventional radiography, ultrasound and MRI for signs of inflammation and bone changes. Flare was defined as DAS28-CRP ≥2.6 with ∆DAS28-CRP ≥1.2 from baseline. Baseline predictors of flare were assessed by logistic regression analyses. RESULTS Of 142 included patients, 121 (85%) flared during follow-up of which 86% regained remission within 24 weeks after flare. Patients that flared were more often rheumatoid factor positive, had tried more bDMARDs and had higher baseline ultrasound synovitis sum scores than those not flaring. For patients on standard dose, predictors of flare within 16 weeks after reduction to two-thirds of standard dose were baseline MRI-osteitis (OR 1.16; 95% CI 1.03 to 1.33; p=0.014), gender (female) (OR 6.71; 95% CI 1.68 to 46.12; p=0.005) and disease duration (OR 1.06; 95% CI 1.01 to 1.11; p=0.020). Baseline predictors for flare within 2 years were ultrasound grey scale synovitis sum score (OR 1.19; 95% CI 1.02 to 1.44; p=0.020) and number of previous bDMARDs (OR 4.07; 95% CI 1.35 to 24.72; p=0.007). CONCLUSION The majority of real-world patients with RA tapering bDMARDs flared during tapering, with the majority regaining remission after stepwise dose increase. Demographic and imaging parameters (MR-osteitis/ultrasound greyscale synovitis) were independent predictors of immediate flare and flare overall and may be of importance for clinical decision-making in patients eligible for tapering.
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Affiliation(s)
- L Terslev
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Ostergaard
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Stylianos Georgiadis
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Cecilie Heegaard Brahe
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Karen Ellegaard
- The Parker Institute, Bispebjerg og Frederiksberg Hospital, Frederiksberg, Denmark
| | - UM Dohn
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Viktoria Fana
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Torsten Møller
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Lars Juul
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Tuan Khai Huynh
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Holte Rheumatology Clinic, Capital Region, Holte, Denmark
| | - Simon Krabbe
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - L M Ornbjerg
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Daniel Glinatsi
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Rheumatology, Skaraborg Hospital Skövde, Skovde, Sweden
| | - Henrik Røgind
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Annette Hansen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Jesper Nørregaard
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Søren Jacobsen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dorte V Jensen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Danbio Registry, Glostrup, Denmark
| | - Natalia Manilo
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Karsten Asmussen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Mikael Boesen
- Department of Radiology, Bispebjerg and Frederiksberg University Hospitals, Copenhagen, Denmark
| | | | - Lone Morsel-Carlsen
- Department of Radiology, Bispebjerg and Frederiksberg University Hospitals, Copenhagen, Denmark
| | | | | | - Merete Lund Hetland
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Glostrup, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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15
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Braverman G, Bridges SL, Moreland LW. Tapering biologic DMARDs in rheumatoid arthritis. Curr Opin Pharmacol 2022; 67:102308. [PMID: 36274358 DOI: 10.1016/j.coph.2022.102308] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/20/2022] [Indexed: 01/25/2023]
Abstract
With the arrival of biologics and the shift toward treat-to-target therapy, the possibility of a sustained clinical response has become an achievable goal for many patients with rheumatoid arthritis (RA). Although biologics have revolutionized the treatment of RA, they are costly, potentially inconvenient, and carry risks of side effects. Whether they can or should be tapered in patients with tight disease control is a matter of clinical uncertainty. The major international rheumatology professional societies have all issued guidelines on this question, but across recommendations, consensus is lacking on how and when to consider therapy de-escalation. Recent evidence suggests that sustained remission or low disease activity is more attainable with dose reduction as opposed to outright discontinuation of biologic therapy, and certain predictors of successful taper have begun to be described. This article will (1) summarize the current evidence base for biologic tapering in RA, (2) outline real-world outcomes findings, (3) review important contextual factors relevant to therapy de-escalation, such as cost-effectiveness considerations and patient perspectives, and (4) conclude by summarizing current guidelines.
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Affiliation(s)
- Genna Braverman
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA; Department of Medicine, Division of Rheumatology, Weill Cornell Medicine, New York, NY, USA.
| | - S Louis Bridges
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA; Department of Medicine, Division of Rheumatology, Weill Cornell Medicine, New York, NY, USA
| | - Larry W Moreland
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, USA
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16
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Sakashita E, Nagatani K, Endo H, Minota S. Serum level of IFNβ distinguishes early from late relapses after biologics withdrawal in rheumatoid arthritis. Sci Rep 2022; 12:16547. [PMID: 36192530 PMCID: PMC9529916 DOI: 10.1038/s41598-022-21160-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 09/23/2022] [Indexed: 11/14/2022] Open
Abstract
Since the advent of biological disease modifying anti-rheumatic drugs (bDMARDs) in the treatment of rheumatoid arthritis (RA), most RA patients receiving such drugs have achieved remission at the expense of cost and infection risk. After bDMARDs are withdrawn, a substantial proportion of patients would have relapses even if they were in complete remission. In our previous report, relapse prediction could be made at the time of bDMARD withdrawal by measuring the serum levels of five cytokines. We report herein that, among 73 cytokines examined, serum levels of only interferon β (IFNβ) at the time of bDMARD withdrawal could predict early relapse (within 5 months) in patients who were categorized to relapse by the five cytokines in our previous report, with a cut-off value of 3.38 in log2 and AUC of 0.833. High serum levels of IFNβ in the early-relapse group remained high until actual relapse occurred. Therefore, patients who relapse early might be biochemically different from those who relapse late or do not relapse at all. We recommend that patients who are predicted to relapse early continue bDMARDs even if they are in complete remission. This finding contributes to shared decision-making regarding how and when bDMARDs should be discontinued.
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Affiliation(s)
- Eiji Sakashita
- Department of Biochemistry, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Katsuya Nagatani
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 3290498, Japan
| | - Hitoshi Endo
- Department of Biochemistry, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Seiji Minota
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 3290498, Japan.
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17
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Zhao J, Zhou W, Wu Y, Yan X, Yang L, Zhang Z. Efficacy, safety, and cost-effectiveness of triple therapy in preventing relapse in rheumatoid arthritis: A randomized controlled trial (ESCoRT study). Chin Med J (Engl) 2022; 135:2200-2209. [PMID: 36525606 PMCID: PMC9771172 DOI: 10.1097/cm9.0000000000002336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Biological agents, such as tumor necrosis factor inhibitors (TNFi), have been widely used in rheumatoid arthritis (RA) patients and greatly improved goal achievement. The aim of this study was to investigate whether conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) combination was better in reducing relapse than methotrexate (MTX) monotherapy, and more cost-effective than continuing TNFi plus MTX in RA patients who achieved low disease activity (LDA) with TNFi and MTX therapy. METHODS RA patients who failed to csDMARDs received an induction therapy of MTX plus TNFi for maximally 12 weeks. Those achieving LDA in 12 weeks were randomly assigned at a 1:1:1 ratio into three groups: (A) adding hydroxychloroquine and sulfasalazine for the first 12 weeks and then discontinuing TNFi for the following 48 weeks; (B) maintaining TNFi and MTX for 60 weeks; and (C) maintaining TNFi and MTX for the first 12 weeks and then discontinuing TNFi for the following 48 weeks. The primary outcome was relapse. RESULTS A total of 117 patients were enrolled for induction therapy and 67 patients who achieved LDA within 12 weeks were randomized, with 24, 21, and 22 patients in groups A, B, and C, respectively. The relapse rates of groups A and B during the entire 60 weeks were comparable [10/22 (45.5%) vs. 7/20 (35.0%), χ2 = 0.475, P = 0.491], however, significantly lower than that of group C [10/22 (45.5%) vs. 17/20 (85.0%), χ2 = 5.517, P = 0.019; 7/20 (35.0%) vs. 17/20 (85.0%), χ2 = 11.035, P = 0.004, respectively]. Taking RMB 100,000 Yuan as the threshold of willingness to pay, compared to MTX monotherapy (group C), both TNFi maintenance and triple csDMARDs therapies were cost-effective, but triple csDMARDs therapy was better. CONCLUSION For RA patients who have achieved LDA with TNFi and MTX, csDMARDs triple therapy was a cost-effective option in favor of reducing relapse. TRIAL REGISTRATION ClinicalTrials.gov, NCT02320630.
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Affiliation(s)
- Juan Zhao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing 100034, China
| | - Wei Zhou
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing 100034, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute (PUCRI), Beijing 100083, China
| | - Xiaoyan Yan
- Peking University Clinical Research Institute (PUCRI), Beijing 100083, China
| | - Li Yang
- Peking University School of Public Health, Beijing 100083, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing 100034, China
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18
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Shin K, Kwon HM, Kim MJ, Yoon MJ, Chai HG, Kang SW, Park W, Park SH, Suh CH, Kim HA, Lee SG, Lee CK, Bae SC, Park YB, Song YW. Two-year clinical outcomes after discontinuation of long-term golimumab therapy in Korean patients with rheumatoid arthritis. Korean J Intern Med 2022; 37:1061-1069. [PMID: 34883551 PMCID: PMC9449209 DOI: 10.3904/kjim.2021.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/15/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The aim of this study was to investigate long-term post-discontinuation outcomes in patients with rheumatoid arthritis (RA) who had been treated with tumor necrosis factor-α inhibitors (TNF-αi) which was then discontinued. METHODS Sixty Korean patients with RA who participated in a 5-year GO-BEFORE and GO-FORWARD extension trials were included in this retrospective study. Golimumab was deliberately discontinued after the extension study (baseline). Patients were then followed by their rheumatologists. We reviewed their medical records for 2 years (max 28 months) following golimumab discontinuation. Patients were divided into a maintained benefit (MB) group and a loss-of-benefit (LB) group based on treatment pattern after golimumab discontinuation. The LB group included patients whose conventional disease-modifying antirheumatic drug(s) were stepped-up or added/switched (SC) and those who restarted biologic therapy (RB). RESULTS The mean age of patients at baseline was 56.5 years and 55 (91.7%) were females. At the end of follow-up, 23 (38.3%) patients remained in the MB group. In the LB group, 75.7% and 24.3% were assigned into SC and RB subgroups, respectively. Fifty percent of patients lost MB after 23.3 months. Demographics and clinical variables at baseline were comparable between MB and LB groups except for age, C-reactive protein level, and corticosteroid use. Restarting biologic therapy was associated with swollen joint count (adjusted hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.01 to 3.55) and disease duration (adjusted HR, 1.12; 95% CI, 1.02 to 1.23) at baseline. CONCLUSION Treatment strategies after discontinuing TNF-αi are needed to better maintain disease control and quality of life of patients with RA.
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Affiliation(s)
- Kichul Shin
- Division of Rheumatology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Hyun Mi Kwon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Min Jung Kim
- Division of Rheumatology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul,
Korea
| | - Myung Jae Yoon
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Hyun Gyung Chai
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
| | - Seong-Wook Kang
- Division of Rheumatology, Chungnam National University Hospital, Daejeon,
Korea
| | - Won Park
- Division of Rheumatology, Inha University Hospital, Incheon,
Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Chang Hee Suh
- Division of Rheumatology, Ajou University Hospital, Suwon,
Korea
| | - Hyun Ah Kim
- Division of Rheumatology, Hallym University Sacred Heart Hospital, Anyang,
Korea
| | - Seung-Geun Lee
- Division of Rheumatology, Pusan National University Hospital, Busan,
Korea
| | - Choong Ki Lee
- Division of Rheumatology, Yeungnam University Medical Center, Daegu,
Korea
| | - Sang-Cheol Bae
- Division of Rheumatology, Hanyang University Seoul Hospital, Seoul,
Korea
| | - Yong-Beom Park
- Division of Rheumatology, Severance Hospital, Yonsei University College of Medicine, Seoul,
Korea
| | - Yeong Wook Song
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine, Medical Research Center, Seoul National University, Seoul,
Korea
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19
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Birkner B, Rech J, Edelmann E, Verheyen F, Schett G, Stargardt T. Patient-individual tapering of DMARDs in rheumatoid arthritis patients in a real-world setting. Rheumatology (Oxford) 2022; 62:1476-1484. [PMID: 35980267 DOI: 10.1093/rheumatology/keac472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 07/17/2022] [Accepted: 07/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We aim to provide real-world evidence on the effectiveness of patient-individual tapering of DMARDs for patients with rheumatoid arthritis (RA) in daily clinical practice using medical records and claims data. METHODS We utilize data obtained through a controlled prospective cohort study in Germany conducted from July 2018 to March 2021. Participants consist of RA patients in sustained remission (>6 months) who were eligible for tapering at enrolment. Patients treated with individual tapering based on shared decision making (n = 200) are compared with patients without any dose-reduction (n = 237). The risk of loss of remission and the risk of flare is assessed with risk-adjusted Kaplan-Meier estimators and Cox-Regressions. We evaluate differences in costs one year before and after baseline based on claims data for the subgroup of patients insured at one major sickness fund in Germany (n = 76). RESULTS The risk of flare (HR 0.88 95%-CI: 0.59-1.30) or loss of remission (HR 1.04 95%-CI: 0.73, 1.49) was not statistically different between the individual tapering group and the continuation group. Minor increases of disease activity and decreases of quality of life were observed 12 months after baseline, again with no statistically significant difference. Drug costs decreased by 1,017€in the individual tapering group while increased by 1,151€in the continuation group (p< 0.01). CONCLUSION Individual tapering of DMARDs does not increase the average risk of experiencing flares or loss of remission. Encouraging rheumatologists and patients to apply tapering in shared decision may be a feasible approach to allow individualisation of treatment in RA.
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Affiliation(s)
- Benjamin Birkner
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Hamburg, Germany
| | - Jürgen Rech
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Tom Stargardt
- Hamburg Center for Health Economics (HCHE), Universität Hamburg, Hamburg, Germany
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20
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Kashiwado Y, Kiyohara C, Kimoto Y, Nagano S, Sawabe T, Oryoji K, Mizuki S, Nishizaka H, Yoshizawa S, Yoshizawa S, Tsuru T, Inoue Y, Ueda N, Ota SI, Suenaga Y, Miyamura T, Tada Y, Niiro H, Akashi K, Horiuchi T. Clinical course of patients with rheumatoid arthritis who continue or discontinue biologic therapy after hospitalization for infection: a retrospective observational study. Arthritis Res Ther 2022; 24:131. [PMID: 35650638 PMCID: PMC9158270 DOI: 10.1186/s13075-022-02820-y] [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: 08/30/2021] [Accepted: 05/21/2022] [Indexed: 05/31/2023] Open
Abstract
Background To analyse the subsequent clinical course of patients with rheumatoid arthritis (RA) who either continued or discontinued biologic agents after hospitalization for infections. Methods We retrospectively reviewed the clinical records of 230 RA patients with 307 hospitalizations for infections under biologic therapy between September 2008 and May 2014 in 15 institutions for up to 18 months after discharge. The risks of RA flares and subsequent hospitalizations for infections from 61 days to 18 months after discharge were evaluated. Results Survival analyses indicated that patients who continued biologic therapy had a significantly lower risk of RA flares (31.4% vs. 60.6%, P < 0.01) and a slightly lower risk of subsequent infections (28.7% vs. 34.5%, P = 0.37). Multivariate analysis showed that discontinuation of biologic therapy, diabetes, and a history of hospitalization for infection under biologic therapy were associated with RA flares. Oral steroid therapy equivalent to prednisolone 5 mg/day or more and chronic renal dysfunction were independent risk factors for subsequent hospitalizations for infections. Conclusions Discontinuation of biologic therapy after hospitalization for infections may result in RA flares. Continuation of biologic therapy is preferable, particularly in patients without immunodeficiency. Supplementary Information The online version contains supplementary material available at 10.1186/s13075-022-02820-y.
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Affiliation(s)
- Yusuke Kashiwado
- Department of Internal Medicine, Kyushu University Beppu Hospital, 4546 Tsurumibaru, Beppu, Oita, 874-0838, Japan
| | - Chikako Kiyohara
- Department of Preventive Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasutaka Kimoto
- Department of Internal Medicine, Kyushu University Beppu Hospital, 4546 Tsurumibaru, Beppu, Oita, 874-0838, Japan
| | - Shuji Nagano
- Department of Rheumatology, Aso Iizuka Hospital, Iizuka, Japan
| | - Takuya Sawabe
- Department of Rheumatology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Kensuke Oryoji
- The Center for Rheumatic Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shinichi Mizuki
- The Center for Rheumatic Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Hiroaki Nishizaka
- Department of Rheumatology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Seiji Yoshizawa
- Department of Rheumatology, Hamanomachi Hospital, Fukuoka, Japan
| | - Shigeru Yoshizawa
- Department of Rheumatology, National Hospital Organization Fukuoka Hospital, Fukuoka, Japan
| | - Tomomi Tsuru
- Department of Rheumatology, Med.Co. LTA PS Clinic, Fukuoka, Japan
| | - Yasushi Inoue
- Department of Rheumatology, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Naoyasu Ueda
- Department of Rheumatology and Infection, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Shun-Ichiro Ota
- Department of Rheumatology, Internal medicine and connective tissue disorders, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Yasuo Suenaga
- Department of Rheumatology, Beppu Medical Center, NHO, Beppu, Japan
| | - Tomoya Miyamura
- Department of Internal Medicine and Rheumatology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Yoshifumi Tada
- Department of Rheumatology, Saga University Hospital, Saga, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, 4546 Tsurumibaru, Beppu, Oita, 874-0838, Japan.
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21
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He B, Li Y, Luo WW, Cheng X, Xiang HR, Zhang QZ, He J, Peng WX. The Risk of Adverse Effects of TNF-α Inhibitors in Patients With Rheumatoid Arthritis: A Network Meta-Analysis. Front Immunol 2022; 13:814429. [PMID: 35250992 PMCID: PMC8888889 DOI: 10.3389/fimmu.2022.814429] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/24/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives To evaluate the safety of each anti-TNF therapy for patients with rheumatoid arthritis (RA) and then make the best choice in clinical practice. Methods We searched PUBMED, EMBASE, and the Cochrane Library. The deadline for retrieval is August 2021. The ORs, Confidence Intervals (CIs), and p values were calculated by STATA.16.0 software for assessment. Result 72 RCTs involving 28332 subjects were included. AEs were more common with adalimumab combined disease-modifying anti-rheumatic drugs (DMARDs) compared with placebo (OR = 1.60, 95% CI: 1.06, 2.42), DMARDs (1.28, 95% CI: 1.08, 1.52), etanercept combined DMARDs (1.32, 95% CI: 1.03, 1.67); certolizumab combined DMARDs compared with placebo (1.63, 95% CI: 1.07, 2.46), DMARDs (1.30, 95% CI: 1.10, 1.54), etanercept combined DMARDs (1.34, 95% CI: 1.05, 1.70). In SAEs, comparisons between treatments showed adalimumab (0.20, 95% CI: 0.07, 0.59), etanercept combined DMARDs (0.39, 95% CI: 0.15, 0.96), golimumab (0.19, 95% CI: 0.05, 0.77), infliximab (0.15, 95% CI: 0.03,0.71) decreased the risk of SAEs compared with golimumab combined DMARDs. In infections, comparisons between treatments showed adalimumab combined DMARDs (0.59, 95% CI: 0.37, 0.95), etanercept (0.49, 95% CI: 0.28, 0.88), etanercept combined DMARDs (0.56, 95% CI: 0.35, 0.91), golimumab combined DMARDs (0.51, 95% CI: 0.31, 0.83) decreased the risk of infections compared with infliximab combined DMARDs. No evidence indicated that the use of TNF-α inhibitors influenced the risk of serious infections, malignant tumors. Conclusion In conclusion, we regard etanercept monotherapy as the optimal choice for RA patients in clinical practice when the efficacy is similar. Conversely, certolizumab + DMARDs therapy is not recommended. Systematic Review Registration identifier PROSPERO CRD42021276176.
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Affiliation(s)
- Bei He
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yun Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wen-Wen Luo
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xuan Cheng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Huai-Rong Xiang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qi-Zhi Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jie He
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wen-Xing Peng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
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22
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De-escalation of Anti-tumor Necrosis Factor Alpha Agents and Reduction in Adverse Effects: A Systematic Review. Biomedicines 2022; 10:biomedicines10051034. [PMID: 35625771 PMCID: PMC9139158 DOI: 10.3390/biomedicines10051034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 12/04/2022] Open
Abstract
Background: The long-term use of anti-TNF-α agents can lead to adverse effects, such as infections and immune-mediated cutaneous reactions. Whether de-escalation by dose reduction or interval lengthening reduces these adverse effects is uncertain. This systematic review aims to compare the incidence of infections and skin manifestations after anti-TNF-α dose de-escalation with standard dosing. Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception to 14 January 2022. Randomized controlled trials (RCTs) and observational studies comparing anti-TNF-α de-escalation strategies with standard dosing among patients with inflammatory conditions, that report on infections, skin manifestations, or both, were included. The risk of bias was assessed with the revised Cochrane risk-of bias tool (RCTs) or the Newcastle–Ottawa scale (non-RCTs). Results: Fourteen RCTs and six observational studies (or 2706 patients) were included. Eight RCTs had low risk of bias or some concerns. Four non-RCTs were of good methodological quality. The studies described patients with axial spondyloarthritis (8 studies, 780 patients), rheumatoid arthritis (7 studies, 1458 patients), psoriasis (3 studies, 332 patients), or inflammatory bowel disease (2 studies, 136 patients). De-escalation strategies included interval lengthening (12 studies, 1317 patients), dose reduction (6 studies, 1130 patients), or both (2 studies, 259 patients). Overall, the occurrence of infections and skin manifestations did not differ between standard treatment and de-escalation. The disappearance of infections or skin manifestations after de-escalation was only reported in two studies. The majority of studies focused on etanercept and adalimumab. Heterogeneity in reporting of infections and skin manifestations precluded meta-analysis. Conclusion: We found that anti-TNF-α de-escalation does not reduce infections or skin reactions. A de-escalation strategy should not be recommended for the sole purpose of reducing drug-related adverse effects. The meticulous documentation of adverse effects is recommended to further address this question. Registration: PROSPERO CRD42021252977.
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23
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Park JW, Kim MJ, Kim HA, Kim JH, Lee EB, Shin K. The Aftermath of Tapering Tocilizumab After Achieving Treatment Target in Patients With Rheumatoid Arthritis: A Nationwide Cohort Study. Front Med (Lausanne) 2022; 9:839206. [PMID: 35211491 PMCID: PMC8860908 DOI: 10.3389/fmed.2022.839206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/17/2022] [Indexed: 01/08/2023] Open
Abstract
Background Although recent guidelines recommend that tapering of biologic disease-modifying anti-rheumatic drugs (bDMARDs) can be considered in patients with rheumatoid arthritis (RA), there has been little evidence supporting the strategy during the non-tumor necrosis factor inhibitor treatment. This study aims to investigate the effectiveness and safety of tapering tocilizumab (TCZ) dose in patients with RA who attain low disease activity (LDA) after TCZ therapy in a nationwide cohort. Methods Data were collected from a nationwide cohort of patients with RA receiving biologic disease-modifying anti-rheumatic drugs in South Korea (KOBIO-RA). This study included 350 patients who were treated with TCZ and achieved Clinical Disease Activity Index-low disease activity (CDAI)-LDA (CDAI ≤ 10) after 1 year of treatment. We performed longitudinal analysis considering clinical data measured at all 1-year intervals for the included patients using the generalized estimating equation. A total of 575 intervals were classified into two groups according to their dose quotient (DQ) of TCZ (tapering group vs. standard-dose group). The main outcome was maintaining CDAI-LDA in the following 1-year interval. Results Tapering TCZ dose strategy was used in 282 (49.0%) intervals with a mean (SD) DQ of 66.0 (15.5) %. Loss of CDAI-LDA occurred in 91 (15.1%) intervals. Multivariable GEE showed that the tapering group was associated with more frequent failure to sustain CDAI-LDA (adjusted OR [95% CI]: 0.57 [0.33–0.99]), which subsequently led to impaired functional status. The likelihood of achieving DAS28-deep remission (DAS28-ESR <1.98) was also significantly lower in the tapering group (adjusted OR 0.68 [0.46–0.99]). CDAI remission was achieved in only 69 (12.0%) of the total intervals, with no significant difference in the proportion of intervals achieving the target between the two groups. Incidence of adverse events was comparable in both groups except for hypercholesterolemia, which was lower in the tapering group. Conclusions Tapering TCZ dose after achieving LDA increases the risk of losing LDA without a significant merit in safety.
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Affiliation(s)
- Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Min Jung Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul Boramae Medical Center, Seoul, South Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Hyun Kim
- Division of Rheumatology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Eun Bong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul Boramae Medical Center, Seoul, South Korea
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24
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Tornero-Molina J, Alperi-López M, Castellví I, de Agustín-de Oro JJ, Escudero A, García-Vicuña R, González-Gay MÁ, Hidalgo C, Rubio E, Sanmartí R, Casamira N, Calvo-Alén J. Experts document on methotrexate use in combined therapy with biological or targeted synthetic disease modifying drugs in patients with rheumatoid arthritis. REUMATOLOGIA CLINICA 2022; 18:33-41. [PMID: 35090610 DOI: 10.1016/j.reumae.2020.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/20/2020] [Indexed: 06/14/2023]
Abstract
OBJECTIVE We aimed to develop recommendations for the management of methotrexate (MTX) when considering the combination with biological (b) or targeted synthetic (ts) disease modifying drugs (DMARDs) in rheumatoid arthritis (RA). METHODS Eleven experts on RA were selected. Two coordinators formulated 13 questions about the combination therapy of MTX with bDMARDs or tsDMARDs. A systematic review was conducted to answer the questions. Inclusion and exclusion criteria were established as well as the search strategies (Medline, Embase and the Cochrane Library were searched up to January 2019). Two reviewers selected the articles and collected data. Simultaneously, EULAR and ACR meeting abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation was established using the Oxford Center for Evidence Based Medicine and the level of agreement with a Delphi. Agreement was established if at least 80% of the experts voted 'yes' (yes/no). RESULTS The systematic review retrieved 513 citations of which 61 were finally included. A total of 10 recommendations were generated, voted and accepted. The level of agreement was very high in all of them and it was achieved in the first Delphi round. Final recommendations cover aspects such as the optimal MTX dosage, tapering strategy or patients' risk management. CONCLUSIONS This document is intended to help clinicians solve usual clinical questions and facilitate decision making when treating RA patients with MTX in combination with bDMARDs or tsDMARDs.
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Affiliation(s)
| | | | - Ivan Castellví
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Alejandro Escudero
- Servicio de Reumatología, Hospital Universitario Reina Sofía, IMIBIC, Córdoba, Spain
| | | | | | - Cristina Hidalgo
- Servicio de Reumatología, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Esteban Rubio
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Raimon Sanmartí
- Servicio de Reumatología, Hospital Universitari Clínic, Barcelona, Spain
| | - Núria Casamira
- Departamento Médico, Laboratorios Gebro Pharma, Barcelona, Spain
| | - Jaime Calvo-Alén
- Servicio de Reumatología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
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25
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Hirose T, Kawaguchi I, Murata T, Atsumi T. Cost-Effectiveness Analysis of Etanercept 25 mg Maintenance Therapy After Treatment with Etanercept 50 mg for Moderate Rheumatoid Arthritis in the PRESERVE Trial in Japan. Value Health Reg Issues 2021; 28:105-111. [PMID: 34923285 DOI: 10.1016/j.vhri.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/23/2021] [Accepted: 06/10/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To use Markov modeling to estimate the cost-effectiveness of treatment with etanercept 25 mg once weekly plus methotrexate (MTX) in Japanese patients with rheumatoid arthritis who had achieved remission or low disease activity with etanercept 50 mg once weekly plus MTX. METHODS Effectiveness data were estimated based on results from a clinical trial (PRESERVE) in patients with rheumatoid arthritis who had achieved remission or low disease activity and who were then randomized to receive etanercept 25 mg plus MTX or placebo plus MTX. A Markov model was established and included flare rates of 21% and 62% in the etanercept 25 mg and placebo groups, respectively. EQ-5D was calculated using an ordinary least-squares model that included the health assessment questionnaire disability index and pain visual analog scale. Worsening of the health assessment questionnaire score over 1 year was estimated to be 0.047 for patients with flare, and when associated with radiographic progression it was estimated to increase by 0.006 and 0.025 in the etanercept 25 mg and placebo groups, respectively. A cycle length of 1 year was applied to calculate the cumulative cost and effectiveness for a 10-year time span. RESULTS Compared with the placebo group, the quality-adjusted life-years for the etanercept 25 mg group was increased by 0.841. The incremental cost-effectiveness ratio was ¥6 173 772. CONCLUSION These results suggest that maintenance treatment with etanercept 25 mg is cost-effective.
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Affiliation(s)
- Tomohiro Hirose
- Immunology & Inflammation Medical Affairs, Pfizer Innovative Health, Pfizer Japan, Tokyo, Japan; Atopy (Allergy) Research Center, Juntendo University School of Medicine, Tokyo, Japan.
| | - Isao Kawaguchi
- Immunology & Inflammation Medical Affairs, Pfizer Innovative Health, Pfizer Japan, Tokyo, Japan
| | | | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Hokkaido University Hospital, Sapporo, Japan
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26
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Hamada K, Oishi K, Murata Y, Hirano T, Matsunaga K. Feasibility of Discontinuing Biologics in Severe Asthma: An Algorithmic Approach. J Asthma Allergy 2021; 14:1463-1471. [PMID: 34908847 PMCID: PMC8665775 DOI: 10.2147/jaa.s340684] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/29/2021] [Indexed: 12/29/2022] Open
Abstract
In severe asthma with type 2 (T2) inflammation, biologics targeting key mediators of T2 inflammation, including interleukin (IL)-5, IL-4/IL-13, and immunoglobulin (Ig)E, remarkably improve the management of severe asthma, providing new insights into the clinical course of asthma such as disease modification and broad modulation of T2 inflammation. Once severe asthma has become a “controllable” condition, the question of discontinuation of biologics arises due to cost and side effects. The studies on discontinuing biologics in asthma demonstrate that some of patients successfully discontinue biologics, indicating that it is a feasible option in a subset of patients. Incorporating the evidence of discontinuation, we propose the criteria for the discontinuation of biologics. Our proposed criteria for the discontinuation of biologics consist of an absence of asthma symptoms (asthma control questionnaire [ACQ] score < 1.5 or asthma control test [ACT] score > 19), no asthma exacerbations, no use of oral corticosteroids, normalized spirometry (forced exhaled volume in 1 second [FEV1] ≥ 80%), suppressed T2 inflammation (blood eosinophil counts < 300 μL and fractional exhaled nitric oxide [FeNO] < 50 ppb), and control of asthma comorbidities. Real-world evidence verified a subset of patients achieving highly well-controlled conditions after use of biologics, namely super-responders, who are candidates for the discontinuation of biologics. If super-responders meet all of the criteria, they are allowed to discontinue biological therapies. Our proposed algorithm may support physicians’ treatment decisions for patients receiving biologics.
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Affiliation(s)
- Kazuki Hamada
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Keiji Oishi
- Department of Medicine and Clinical Science, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Yoriyuki Murata
- Department of Medicine and Clinical Science, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Tsunahiko Hirano
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Ube, Yamaguchi, Japan
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27
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O'Neil LJ, Hu P, Liu Q, Islam MM, Spicer V, Rech J, Hueber A, Anaparti V, Smolik I, El-Gabalawy HS, Schett G, Wilkins JA. Proteomic Approaches to Defining Remission and the Risk of Relapse in Rheumatoid Arthritis. Front Immunol 2021; 12:729681. [PMID: 34867950 PMCID: PMC8636686 DOI: 10.3389/fimmu.2021.729681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 10/20/2021] [Indexed: 12/29/2022] Open
Abstract
Objectives Patients with Rheumatoid Arthritis (RA) are increasingly achieving stable disease remission, yet the mechanisms that govern ongoing clinical disease and subsequent risk of future flare are not well understood. We sought to identify serum proteomic alterations that dictate clinically important features of stable RA, and couple broad-based proteomics with machine learning to predict future flare. Methods We studied baseline serum samples from a cohort of stable RA patients (RETRO, n = 130) in clinical remission (DAS28<2.6) and quantified 1307 serum proteins using the SOMAscan platform. Unsupervised hierarchical clustering and supervised classification were applied to identify proteomic-driven clusters and model biomarkers that were associated with future disease flare after 12 months of follow-up and RA medication withdrawal. Network analysis was used to define pathways that were enriched in proteomic datasets. Results We defined 4 proteomic clusters, with one cluster (Cluster 4) displaying a lower mean DAS28 score (p = 0.03), with DAS28 associating with humoral immune responses and complement activation. Clustering did not clearly predict future risk of flare, however an XGboost machine learning algorithm classified patients who relapsed with an AUC (area under the receiver operating characteristic curve) of 0.80 using only baseline serum proteomics. Conclusions The serum proteome provides a rich dataset to understand stable RA and its clinical heterogeneity. Combining proteomics and machine learning may enable prediction of future RA disease flare in patients with RA who aim to withdrawal therapy.
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Affiliation(s)
- Liam J O'Neil
- Section of Rheumatology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Proteomics and Systems Biology, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada
| | - Pingzhao Hu
- Department of Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, MB, Canada.,Department of Computer Science, University of Manitoba, Winnipeg, MB, Canada
| | - Qian Liu
- Department of Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, MB, Canada.,Department of Computer Science, University of Manitoba, Winnipeg, MB, Canada
| | - Md Mohaiminul Islam
- Department of Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, MB, Canada.,Department of Computer Science, University of Manitoba, Winnipeg, MB, Canada
| | - Victor Spicer
- Manitoba Centre for Proteomics and Systems Biology, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada
| | - Juergen Rech
- Department of Medicine, Friedrich-Alexander University Erlangen-Nuernberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Axel Hueber
- Department of Medicine, Friedrich-Alexander University Erlangen-Nuernberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - Vidyanand Anaparti
- Manitoba Centre for Proteomics and Systems Biology, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada
| | - Irene Smolik
- Section of Rheumatology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hani S El-Gabalawy
- Section of Rheumatology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Proteomics and Systems Biology, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada
| | - Georg Schett
- Department of Medicine, Friedrich-Alexander University Erlangen-Nuernberg and Universitaetsklinikum Erlangen, Erlangen, Germany
| | - John A Wilkins
- Section of Rheumatology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada.,Manitoba Centre for Proteomics and Systems Biology, University of Manitoba and Health Sciences Centre, Winnipeg, MB, Canada
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28
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Uhrenholt L, Christensen R, Dinesen WKH, Liboriussen CH, Andersen SS, Dreyer L, Schlemmer A, Hauge EM, Skrubbeltrang C, Taylor PC, Kristensen S. Risk of flare after tapering or withdrawal of b-/tsDMARDs in patients with RA or axSpA: A systematic review and meta-analysis. Rheumatology (Oxford) 2021; 61:3107-3122. [PMID: 34864896 DOI: 10.1093/rheumatology/keab902] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate flare risk when tapering or withdrawing biological or targeted synthetic disease-modifying antirheumatic drugs (b-/tsDMARDs) compared to continuation in patients with inflammatory arthritis (IA) in sustained remission or low disease activity. METHODS Articles were identified in Cochrane Library, PubMed, EMBASE and Web of Science. Eligible trials were randomised, controlled trials comparing tapering and/or withdrawal of b- and/or tsDMARDs with standard dose in IA. Random-effects meta-analysis was performed with risk ratio (RR), or Peto's Odds Ratio (POR) for sparse events, and 95% confidence intervals (95%CI). RESULTS The meta-analysis comprised 22 trials: 11 assessed tapering and 7 addressed withdrawal (4 assessed both). Only trials with a rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) population were identified. An increased flare risk was demonstrated when b-/tsDMARD tapering was compared to continuation, RR = 1.45 (95%CI: 1.19 to 1.77, I2 = 42.5%), and potentially increased for persistent flare, POR = 1.56 (95%CI: 0.97 to 2.52, I2 = 0%). Comparing tumour necrosis factor inhibitor (TNFi) withdrawal to continuation, a highly increased flare risk (RR = 2.28, 95%CI: 1.78 to 2.93, I2 = 78%) and increased odds of persistent flare (POR = 3.41, 95%CI: 1.91 to 6.09, I2 = 49%) was observed. No clear difference in flare risk between RA or axSpA was observed. CONCLUSION A high risk for flare and persistent flare was demonstrated for TNFi withdrawal whereas an increased risk for flare but not for persistent flare was observed for b-/tsDMARD tapering. Thus, tapering seems to be the more favourable approach. REGISTRATION PROSPERO (CRD42019136905).
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Affiliation(s)
- Line Uhrenholt
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Section for Biostatistics and Evidence-Based Research, Bispebjerg and Frederiksberg Hospital, The Parker Institute, Copenhagen, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, Bispebjerg and Frederiksberg Hospital, The Parker Institute, Copenhagen, Denmark.,Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | | | | | - Stine S Andersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lene Dreyer
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Annette Schlemmer
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Rheumatology, Randers Regional Hospital, Randers, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Conni Skrubbeltrang
- Department of Medical Library, Aalborg University Hospital, Aalborg, Denmark
| | - Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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29
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Tascilar K, Hagen M, Kleyer A, Simon D, Reiser M, Hueber AJ, Manger B, Englbrecht M, Finzel S, Tony HP, Schuch F, Kleinert S, Wendler J, Ronneberger M, Figueiredo CP, Cobra JF, Feuchtenberger M, Fleck M, Manger K, Ochs W, Schmitt-Haendle M, Lorenz HM, Nuesslein H, Alten R, Kruger K, Henes J, Schett G, Rech J. Treatment tapering and stopping in patients with rheumatoid arthritis in stable remission (RETRO): a multicentre, randomised, controlled, open-label, phase 3 trial. THE LANCET. RHEUMATOLOGY 2021; 3:e767-e777. [PMID: 38297524 DOI: 10.1016/s2665-9913(21)00220-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 02/02/2024]
Abstract
BACKGROUND Owing to increasing remission rates, the management of patients with rheumatoid arthritis in sustained remission is of growing interest. The Rheumatoid Arthritis in Ongoing Remission (RETRO) study investigated tapering and withdrawal of disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis in stable remission to test whether remission could be retained without the need to take DMARD therapy despite an absence of symptoms. METHODS RETRO was an investigator-initiated, multicentre, prospective, randomised, controlled, open-label, parallel-group phase 3 trial in patients aged at least 18 years with rheumatoid arthritis for at least 12 months before randomisation who were in sustained Disease Activity Score using 28 joints with erythrocyte sedimentation rate (ESR) remission (score <2·6 units). Eligible patients were recruited consecutively from 14 German hospitals or rheumatology practices and randomly assigned (1:1:1) without stratification and regardless of baseline treatment, using a sequence that was computer-generated by the study statistician, to continue 100% dose DMARD (continue group), taper to 50% dose DMARD (taper group), or 50% dose DMARD for 6 months before stopping DMARDs (stop group). Neither patients nor investigators were masked to the treatment assignment. Patients were assessed every 3 months and screened for disease activity and relapse. The primary endpoint was the proportion of patients in sustained DAS28-ESR remission without relapse at 12 months, analysed using a log-rank test of trend and Cox regression. Analysis by a trained statistician of the primary outcome and safety was done in a modified intention-to-treat population that included participants with non-missing baseline data. This study is completed and closed to new participants and is registered with ClinicalTrials.gov (NCT02779114). FINDINGS Between May 26, 2010, and May 29, 2018, 303 patients were enrolled and allocated to continue (n=100), taper (n=102), or stop DMARDs (n=101). 282 (93%) of 303 patients were analysed (93 [93%] of 100 for continue, 93 [91%] of 102 for taper, and 96 [95%] of 101 for stop). Remission was maintained at 12 months by 81·2% (95% CI 73·3-90·0) in the continue group, 58·6% (49·2-70·0) in the taper group, and 43·3% (34·6-55·5) in the stop group (p=0·0005 with log-rank test for trend). Hazard ratios for relapse were 3·02 (1·69-5·40; p=0.0003) for the taper group and 4·34 (2·48-7·60; p<0.0001)) for the stop group, in comparison with the continue group. The majority of patients who relapsed regained remission after reintroduction of 100% dose DMARDs. Serious adverse events occurred in ten of 93 (11%) patients in the continue group, seven of 93 (8%) patients in taper group, and 13 of 96 (14%) patients in the stop group. None were considered to be related to the intervention. The most frequent type of serious adverse event was injuries or procedural complications (n=9). INTERPRETATION Reducing antirheumatic drugs in patients with rheumatoid arthritis in stable remission is feasible, with maintenance of remission occurring in about half of the patients. Because relapse rates were significantly higher in patients who tapered or stopped antirheumatic drugs than in patients who continued with a 100% dose, such approaches will require tight monitoring of disease activity. However, remission was regained after reintroduction of antirheumatic treatments in most of those who relapsed in this study. These results might help to prevent overtreatment in a substantial number of patients with rheumatoid arthritis. FUNDING None.
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Affiliation(s)
- Koray Tascilar
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Melanie Hagen
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Arnd Kleyer
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - David Simon
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Michaela Reiser
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Axel J Hueber
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany; Rheumatology Section, Sozialstiftung Bamberg, Bamberg, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Matthias Englbrecht
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
| | - Stephanie Finzel
- Department of Rheumatology and Clinical Immunology, University of Freiburg, Freiburg, Germany
| | - Hans-Peter Tony
- Department of Internal Medicine 2, University of Wuerzburg, Wuerzburg, Germany
| | | | - Stefan Kleinert
- Department of Internal Medicine 2, University of Wuerzburg, Wuerzburg, Germany; Rheumatology Practice, Erlangen, Germany
| | | | | | - Camille P Figueiredo
- Division of Rheumatology, Faculty of Medicine, Sao Paulo University, Sao Paulo, Brazil
| | | | - Martin Feuchtenberger
- Rheumatology Practice and Department of Internal Medicine 2, Clinic Burghausen, Burghausen, Germany
| | - Martin Fleck
- Department of Internal Medicine I, University of Regensburg, Regensburg, Germany; Asklepios Medical Center Bad Abbach, Bad Abbach, Germany
| | | | | | | | - Hanns-Martin Lorenz
- Department of Internal Medicine V, Division of Rheumatology, University of Heidelberg, Heidelberg, Germany
| | | | | | | | - Joerg Henes
- Department of Internal Medicine 2, University of Tubingen, Tubingen, Germany
| | - Georg Schett
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany.
| | - Juergen Rech
- Department of Internal Medicine 3 and Deutsches Zentrum für Immuntherapie, Friedrich Alexander University Erlangen-Nuremberg and Universitatsklinikum, Erlangen, Germany
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30
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Bertrand D, Stouten V, De Cock D, Pazmino S, Doumen M, de Wergifosse I, Joly J, Badot V, Corluy L, Hoffman I, Taelman V, De Knop K, Geens E, Langenaken C, Lenaerts JL, Lenaerts J, Walschot M, Mannaerts J, Westhovens R, Verschueren P. Tapering of Etanercept is feasible in patients with Rheumatoid Arthritis in sustained remission: a pragmatic randomized controlled trial. Scand J Rheumatol 2021; 51:470-480. [PMID: 34514929 DOI: 10.1080/03009742.2021.1955467] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: In patients with rheumatoid arthritis (RA) in sustained remission, tapering of biological disease-modifying anti-rheumatic drugs can be considered. Tapering has already been investigated, but its feasibility remains to be determined. Therefore, we explored the feasibility of tapering etanercept in RA in a setting close to practice.Method: Patients with RA in 28-joint Disease Activity Score (DAS28) remission (≥ 6 months) and treated with etanercept 50 mg weekly (≥ 1 year) were included in the pragmatic 1 year open-label multicentre randomized controlled TapERA (Tapering Etanercept in Rheumatoid Arthritis) trial. Patients were assigned to continue etanercept weekly or to taper to every other week (EOW). Patients who lost remission [DAS28-C-reactive protein (CRP) ≥ 2.6] were re-escalated to etanercept weekly. The primary outcome was the proportion of patients maintaining DAS28-CRP remission for 6 months.Results: Sixty-six patients were randomized to etanercept weekly (n = 34) or EOW (n = 32). After 6 months, 26/34 patients (76%) in the weekly and 19/32 (59%) in the EOW group maintained disease control (p = 0.136). In the EOW group, 20/32 patients (63%) remained on their tapered treatment during the trial. Two patients reintroduced weekly etanercept themselves. Ten patients were re-escalated to etanercept weekly by the rheumatologist, after a median (interquartile range) interval of 3.0 (2.0-6.0) months. Among these patients, 7/10 regained remission after re-escalation, four of them at the next study visit.Conclusions: Although non-inferiority could not be demonstrated, tapering of etanercept to EOW appeared feasible in patients in sustained remission.
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Affiliation(s)
- D Bertrand
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - V Stouten
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - D De Cock
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - S Pazmino
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - M Doumen
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | | | - J Joly
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - V Badot
- Rheumatology, CHU Brugmann, Brussels, Belgium
| | - L Corluy
- Rheumatology, AZ Herentals, Herentals, Belgium
| | - I Hoffman
- Rheumatology, GZA Sint-Augustinus Antwerpen, Antwerpen, Belgium
| | - V Taelman
- Rheumatology, Heilig Hart Ziekenhuis Leuven, Leuven, Belgium
| | - K De Knop
- Rheumatology, GZA Sint-Augustinus Antwerpen, Antwerpen, Belgium
| | - E Geens
- Rheumatology, ZNA Jan Palfijn Antwerpen, Antwerpen, Belgium
| | | | | | - J Lenaerts
- Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | | | - J Mannaerts
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - R Westhovens
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - P Verschueren
- Skeletal Biology and Engineering Research Center, KU Leuven Department of Development and Regeneration, Leuven, Belgium.,Rheumatology, University Hospitals Leuven, Leuven, Belgium
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31
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Jung SY, Koh JH, Kim KJ, Park YW, Yang HI, Choi SJ, Lee J, Choi CB, Kim WU. Switching from TNFα inhibitor to tacrolimus as maintenance therapy in rheumatoid arthritis after achieving low disease activity with TNFα inhibitors and methotrexate: 24-week result from a non-randomized, prospective, active-controlled trial. Arthritis Res Ther 2021; 23:182. [PMID: 34233727 PMCID: PMC8265052 DOI: 10.1186/s13075-021-02566-z] [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: 02/08/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background Tapering or stopping biological disease-modifying anti-rheumatic drugs has been proposed for patients with rheumatoid arthritis (RA) in remission, but it frequently results in high rates of recurrence. This study evaluates the efficacy and safety of tacrolimus (TAC) as maintenance therapy in patients with established RA in remission after receiving combination therapy with tumor necrosis factor inhibitor (TNFi) and methotrexate (MTX). Methods This 24-week, prospective, open-label trial included patients who received TNFi and MTX at stable doses for ≥24 weeks and had low disease activity (LDA), measured by Disease Activity Score-28 for ≥12 weeks. Patients selected one of two arms: maintenance (TNFi plus MTX) or switched (TAC plus MTX). The primary outcome was the difference in the proportion of patients maintaining LDA at week 24, which was assessed using a logistic regression model. Adverse events were monitored throughout the study period. Results In efficacy analysis, 80 and 34 patients were included in the maintenance and switched arms, respectively. At week 24, LDA was maintained in 99% and 91% of patients in the maintenance and switched arms, respectively (odds ratio, 0.14; 95% confidence interval, 0.01–1.59). Drug-related adverse effects tended to be more common in the switched arm than in the maintenance arm (20.9% versus 7.1%, respectively) but were well-tolerated. Conclusion This controlled study tested a novel treatment strategy of switching from TNFi to TAC in RA patients with sustained LDA, and the findings suggested that TNFi can be replaced with TAC in most patients without the patients experiencing flare-ups for at least 24 weeks. Trial registration Korea CDC CRIS, KCT0005868. Registered 4 February 2021—retrospectively registered Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02566-z.
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Affiliation(s)
- Sang Youn Jung
- Division of Rheumatology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Jung Hee Koh
- Division of Rheumatology, Department of Internal Medicine, Bucheon St. Mary's Hospital, the Catholic University of Korea, Seoul, South Korea
| | - Ki-Jo Kim
- Division of Rheumatology, Department of Internal Medicine, St. Vincent Hospital, the Catholic University of Korea, Seoul, South Korea
| | - Yong-Wook Park
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Hyung-In Yang
- College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Sung Jae Choi
- Division of Rheumatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, South Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Chan-Bum Choi
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Wan-Uk Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St Mary's Hospital, Center for Integrative Rheumatoid Transcriptomics and Dynamics, College of Medicine, the Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, South Korea.
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Wu M, Tao M, Wang Q, Lu X, Yuan H. Fusion proteins of biologic agents in the treatment of rheumatoid arthritis (RA): A network meta-analysis. Medicine (Baltimore) 2021; 100:e26350. [PMID: 34128886 PMCID: PMC8213327 DOI: 10.1097/md.0000000000026350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/01/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To evaluate the efficacy of fusion proteins biologics (Etanercept (ETN), Anakinra (ANA), and Abatacept) combinations in the treatment of rheumatoid arthritis (RA) using network meta-analysis to rank those according to their performance medicines. The performance of these processes is ranked according to the results of the analysis and an explanatory study of the possible results is carried out. METHODS Multiple databases including PubMed, EMBASE, and Cochrane Library were used to identify applicable articles and collect relevant data to analyze using STATA (14.0) software. The literature included in this study was divided into a combination of a placebo, methotrexate (MTX), and an observation group (1 of the 3 drugs). The last search date was December 12, 2019. RESULTS A total of 19 eligible randomized controlled trials of fusion proteins biologics were identified, a total of 1109 papers were included, and the results showed that the ETN + MTX had the highest probability of being the most clinically efficacious intervention, with a surface under the cumulative ranking curve of 91.6, was significantly superior (P < .05). Patients who had received ETN or ETN + MTX or ANA had effective compared with patients who had received placebo (95% CI 1.28%-8.47%; 1.92%-19.18%; 1.06%-10.45%). CONCLUSIONS 1. The combination of ETN and MTX had the highest probability of optimal treatment compared to other drugs and 2. ENT, ENT + MTX, and ANA were effective in the treatment of RA compared to placebo.
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Affiliation(s)
- Mingcai Wu
- Department of Biochemistry and Molecular Biology
| | - Mengjun Tao
- Department of Epidemiology and Biostatistics
| | - Quanhai Wang
- Department of Biochemistry and Molecular Biology
| | - Xiaohua Lu
- Functional experiment and training center, School of Public Health, Wannan Medical College, Wuhu, China
| | - Hui Yuan
- Department of Epidemiology and Biostatistics
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Terslev L, Ostergaard M. Rheumatoid Arthritis Relapse and Remission - Advancing Our Predictive Capability Using Modern Imaging. J Inflamm Res 2021; 14:2547-2555. [PMID: 34163211 PMCID: PMC8215903 DOI: 10.2147/jir.s284405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/27/2021] [Indexed: 01/18/2023] Open
Abstract
Clinical remission has become an achievable target for the majority of patients with rheumatoid arthritis, but subclinical inflammation as assessed by ultrasound and magnetic resonance imaging (MRI) has been demonstrated to be frequent in patients in clinical remission. Subclinical synovitis has been shown to be linked to both subsequent structural damage progression and a risk of flare, demonstrating that subclinical synovitis represents incomplete suppression of inflammation and questions whether it is appropriate only to use clinical composite scores as treatment target in clinical practice. Maintaining a state of remission has proven important as sustained clinical remission impacts long-term outcome regarding joint damage progression, physical function and quality of life. Treating subclinical inflammation has been attempted and has led to more frequent strict clinical remission and better physical function, but also to more adverse events. Thus, an overall benefit of incorporating imaging goals in treat-to-target strategies has not been documented. However, in patients in clinical remission on biological disease-modifying anti-rheumatic drugs, both ultrasound and MRI may aid in the clinical decision regarding whether drug tapering or even discontinuation should be attempted.
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Affiliation(s)
- Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Ostergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Curtis JR, Emery P, Karis E, Haraoui B, Bykerk V, Yen PK, Kricorian G, Chung JB. Etanercept or Methotrexate Withdrawal in Rheumatoid Arthritis Patients in Sustained Remission. Arthritis Rheumatol 2021; 73:759-768. [PMID: 33205906 PMCID: PMC8251940 DOI: 10.1002/art.41589] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/10/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) in whom remission is achieved following combination therapy with methotrexate plus etanercept face an ongoing medication burden. This study was undertaken to investigate whether sustained remission achieved on combination therapy can be maintained with either methotrexate or etanercept monotherapy, as assessed following discontinuation of one or the other medication from the combination. METHODS Of the 371 adult patients with RA who received combination therapy with methotrexate plus etanercept, remission (defined as a Simplified Disease Activity Index [SDAI] score of ≤3.3) was sustained in 253 patients through a 24-week open-label period. These 253 patients then entered a 48-week, double-blind period and were randomized to receive either 1) methotrexate monotherapy (n = 101), 2) etanercept monotherapy (n = 101), or 3) methotrexate plus etanercept combination therapy (n = 51). Patients who subsequently experienced disease-worsening received rescue therapy with the combination regimen at the same dosages as used in the initial run-in period. The primary end point was the proportion of patients in whom SDAI-defined remission was maintained without disease-worsening at week 48 in the etanercept monotherapy group as compared to the methotrexate monotherapy group. Secondary end points included time to disease-worsening, and the proportion of patients in whom SDAI-defined remission was recaptured after initiation of rescue therapy. RESULTS Baseline demographic and clinical characteristics of the RA patients were similar across the treatment groups. At week 48, SDAI-defined remission was maintained in significantly more patients in the etanercept monotherapy group than in the methotrexate monotherapy group (49.5% versus 28.7%; P = 0.004). Moreover, as a secondary end point, sustained SDAI-defined remission was achieved in significantly more patients who received combination therapy than in those who received methotrexate monotherapy (52.9% versus 28.7%; P = 0.006). Time to disease-worsening was shorter in those who received methotrexate monotherapy than in those who received etanercept monotherapy or those who received combination therapy (each P < 0.001 versus methotrexate monotherapy). Among the patients who received rescue therapy, SDAI-defined remission was recaptured in 70-80% in each treatment group. No new safety signals were reported. CONCLUSION The efficacy of etanercept monotherapy was superior to that of methotrexate monotherapy and similar to that of combination therapy in maintaining remission in patients with RA. SDAI-defined remission was recaptured in most of the patients who were given rescue therapy. These data could inform decision-making when withdrawal of therapy is being considered to reduce treatment burden in patients with well-controlled RA.
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Affiliation(s)
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Boulos Haraoui
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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Weng C, Xue L, Wang Q, Lu W, Xu J, Liu Z. Comparative efficacy and safety of Janus kinase inhibitors and biological disease-modifying antirheumatic drugs in rheumatoid arthritis: a systematic review and network meta-analysis. Ther Adv Musculoskelet Dis 2021; 13:1759720X21999564. [PMID: 33815570 PMCID: PMC7989112 DOI: 10.1177/1759720x21999564] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/01/2021] [Indexed: 12/21/2022] Open
Abstract
Objective: To evaluate the comparative efficacy and safety of Janus kinase (JAK) inhibitors and biological disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) and an inadequate response to at least one disease-modifying antirheumatic drug (DMARD). Methods: PubMed, Embase, Cochrane library and ClinicalTrials.gov were searched for relevant randomized controlled trials (RCTs) from inception to April 2020. The active drugs included three JAK inhibitors and eight bDMARDs while the control drugs included placebo or conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). Outcomes include American College of Rheumatology 20% response (ACR20), Disease Activity Score in 28 joints (DAS28), Health Assessment Questionnaire–Disability Index (HAQ-DI) and discontinuations for adverse events (AEs). We estimated summary odds ratios (ORs) and weighted mean differences (WMDs) using network meta-analysis with random effects. Results: Eighty-eight RCTs with 31,566 patients were included. All JAK inhibitors and bDMARDs were more effective than placebo in ACR20 (ORs ranging between 3.05 and 5.61), DAS28 (WMDs ranging between −1.91 and −0.80) and HAQ-DI (WMDs ranging between −0.34 and −0.21). Tocilizumab, certolizumab pegol and upadacitinib showed relatively good efficacy in these three outcomes according to their relative ranking. Notably, tocilizumab was more effective than other active drugs in DAS28 (WMDs ranging between −1.11 and −0.49). Compared with the lower recommended doses, increasing the doses of JAK inhibitors (baricitinib 4 mg versus 2 mg, tofacitinib 10 mg versus 5 mg and upadacitinib 30 mg versus 15 mg) cannot provide significant additional benefits. In terms of discontinuations for AEs, all active drugs showed no significant difference compared with placebo except certolizumab pegol [OR 1.65, 95% credible interval (CrI) 1.06–2.61] and rituximab (3.17, 1.11–10.80). Conclusions: Tocilizumab, certolizumab pegol and upadacitinib may have relatively good efficacy in patients with RA after treatment failure with csDMARDs. RA patients taking a JAK inhibitor may have a preference for a lower recommended dose.
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Affiliation(s)
- Chenghua Weng
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Leixi Xue
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qing Wang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wentian Lu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiajun Xu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhichun Liu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Sanxiang Road No.1055, Suzhou, Jiangsu, 215000, P.R. China
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Terslev L, Brahe CH, Hetland ML, Georgiadis S, Ellegaard K, Juul L, Huynh T, Døhn UM, Fana V, Møller T, Krabbe S, Ørnbjerg LM, Glinatsi D, Røgind H, Hansen A, Nørregaard J, Jacobsen S, Jensen DV, Manilo N, Asmussen K, Boesen M, Rastiemadabadi Z, Morsel-Carlsen L, Møller JM, Krogh NS, Østergaard M. Doppler ultrasound predicts successful discontinuation of biological DMARDs in rheumatoid arthritis patients in clinical remission. Rheumatology (Oxford) 2021; 60:5549-5559. [PMID: 33748831 DOI: 10.1093/rheumatology/keab276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the ability of ultrasound to predict successful tapering and successful discontinuation of biological disease-modifying anti-rheumatic drugs (bDMARDs) at 2-year follow-up in rheumatoid arthritis (RA) patients in sustained remission. METHODS Patients in sustained remission (DAS28-CRP≤2.6) and no radiographic progression the previous year tapered bDMARD according to a standardized regime. One-hundred-and-nineteen of these patients were included in this ultrasound sub-study. At baseline, clinical assessment, MRI, x-ray and ultrasound of 24 joints were performed. Ultrasound-detected synovitis was defined and scored 0-3 using the Outcome in Rheumatology (OMERACT) scoring system at joint level for both greyscale and Doppler activity. Sum scores for each ultrasound modality were calculated for 24 joints at patient level. Final state of treatment was assessed after 2 years. The predictive value of ultrasound measures for successful tapering and discontinuation at 2-year follow-up was assessed via logistic regression analyses. RESULTS Negative IgM-RF (OR = 0.29; 95% Confidence Interval (CI)=0.10-0.85; p = 0.024) and lower Doppler sum score of 24 joints (OR(95%CI)=0.44;(0.15-0.87); p = 0.014) were independent predictors for successful discontinuation of bDMARD at 2-year follow-up. The predictive value of Doppler sum score was independent of MRI findings. Previous numbers of bDMARDs were predictive of successful tapering (OR(95% CI)=0.58(0.35-0.91); p = 0.018), whereas ultrasound was not. Clinical parameters were not predictive for successful tapering/discontinuation. CONCLUSIONS Doppler sum score was an independent predictor for successful discontinuation of bDMARDs at 2-year follow-up - the odds for achieving successful discontinuation decreased by 56% per one-unit increase in Doppler sum score. Ultrasound could not predict successful tapering.
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Affiliation(s)
- Lene Terslev
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie Heegaard Brahe
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Merete Lund Hetland
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,DANBIO registry, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Stylianos Georgiadis
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Karen Ellegaard
- The Parker Institute, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | - Lars Juul
- Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Gentofte, Rigshospitalet, Capital Region, Denmark
| | - Tuan Huynh
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Holte Rheumatology Clinic, Capital Region, Denmark
| | - Uffe Møller Døhn
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Viktoria Fana
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Torsten Møller
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Simon Krabbe
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Lykke Midtbøll Ørnbjerg
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Daniel Glinatsi
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Department of Rheumatology, Skaraborg Hospital, Skövde, Sweden
| | - Henrik Røgind
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Anette Hansen
- Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Gentofte, Rigshospitalet, Capital Region, Denmark
| | - Jesper Nørregaard
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark
| | - Søren Jacobsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Lupus and Vasculitis Clinic, Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Dorte Vendelbo Jensen
- DANBIO registry, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Gentofte, Rigshospitalet, Capital Region, Denmark
| | - Natalia Manilo
- Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Frederiksberg, Rigshospitalet, Capital Region, Denmark
| | - Karsten Asmussen
- Center for Rheumatology and Spine Diseases, Center of head and orthopedics, Frederiksberg, Rigshospitalet, Capital Region, Denmark
| | - Mikael Boesen
- Department of Radiology, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Lone Morsel-Carlsen
- Department of Radiology, Bispebjerg-Frederiksberg Hospital, Copenhagen, Denmark
| | | | | | - Mikkel Østergaard
- Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Glostrup, Rigshospitalet, Capital Region, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Zhao J, Zhou W, Wu Y, Ji P, Yang L, Yan X, Zhang Z. The efficacy, safety and cost-effectiveness of hydroxychloroquine, sulfasalazine, methotrexate triple therapy in preventing relapse among patients with rheumatoid arthritis achieving clinical remission or low disease activity: the study protocol of a randomized controlled clinical Trial (ESCoRT study). BMC Med Inform Decis Mak 2021; 21:83. [PMID: 33663487 PMCID: PMC7934358 DOI: 10.1186/s12911-021-01449-2] [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: 07/01/2020] [Accepted: 02/18/2021] [Indexed: 11/25/2022] Open
Abstract
Background Tumor necrosis factor α inhibitors (TNFi) is effective for rheumatoid arthritis (RA) patients who fail to conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Because of high cost, the discontinuation is common but often lead to disease relapse. The study aims to investigate, if the combination therapy of csDMARDs is more effective in reducing disease relapse than methotrexate (MTX) monotherapy, and more cost-effective than continuing TNFi and MTX. Methods It will be a two-stage trial. In the first stage, all RA patients who failed to csDMARDs treatment [disease activity score 28 (DAS28)-CRP > 3.2] will receive MTX plus TNFi for no more than 12 weeks. Patients achieving DAS28-CRP < 3.2 during the first stage will be randomized into three groups at 1:1:1 ratio: (A) add hydroxychloroquine (HCQ) and sulfasalazine (SSZ) for the first 12 weeks and then remove TNFi but continue other treatments for the next 48 weeks; (B) maintain TNFi + MTX for 60 weeks; and (C) maintain TNFi + MTX for the first 12 weeks and then remove TNFi but continue MTX monotherapy for the next 48 weeks. The primary outcome will be disease relapse (DAS28-CRP increases by at least 0.6 and > 3.2). Secondary outcomes will include the incremental cost per reducing 1 case of relapse; patient reported intolerance to the treatment; adverse events; change of mean disease activity measured by DAS28, clinical disease activity index (CDAI) and simplified disease activity index (SDAI); the proportion of modified Sharp score increase < 0.3; ultrasound-detected remission in hands; Health Assessment Questionnaire Disability Index (HAQ-DI) and health related quality of life [the five-level EuroQol-5D (EQ-5D-5L) and short form-6D (SF-6D)]. Discussion The aim of this trail will be to seek effective treatment options of preventing relapse of RA. The results of the current study may provide an instructive recommendation for more economical application of TNFi treatment in RA. Trial registration NCT, NCT02320630. Registered on 16 December 2014. https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=3&cx=-jg9qo2.
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Affiliation(s)
- Juan Zhao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Wei Zhou
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute (PUCRI), Beijing, 100083, China
| | - Ping Ji
- Peking University Clinical Research Institute (PUCRI), Beijing, 100083, China
| | - Li Yang
- Peking University School of Public Health, Beijing, 100083, China
| | - Xiaoyan Yan
- Peking University Clinical Research Institute (PUCRI), Beijing, 100083, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, 100034, China.
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Ochiai M, Tanaka E, Sato E, Inoue E, Abe M, Saka K, Sugano E, Sugitani N, Higuchi Y, Yamaguchi R, Sugimoto N, Ikari K, Nakajima A, Yamanaka H, Harigai M. Successful discontinuation of biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis in real-world settings. Mod Rheumatol 2021; 31:790-795. [PMID: 33538611 DOI: 10.1080/14397595.2021.1883252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To analyze the proportion of successful biological disease-modifying antirheumatic drugs (bDMARDs) discontinuation and related factors in patients with rheumatoid arthritis (RA) in clinical settings. METHODS Among 1775 RA patients who started bDMARDs between 2003 and 2012, 43 patients with DAS28-ESR <3.2 at the time of bDMARD discontinuation were extracted. Patients were divided into two groups (bio-free success: BS and bio-free failure: BF groups) based on bDMARD usage and disease activity 1 year after discontinuation. We evaluated the proportion of bio-free success and assessed factors related to bio-free success. RESULTS Twenty-five patients (58.1%: BS group) maintained discontinuation of bDMARDs and DAS28-ESR <3.2 at 1 year after discontinuation. The median DAS28-ESR at bDMARD initiation was lower in the BS group than in the BF group (3.95 vs 5.04; p = .04). The BS group experienced a larger decrease in average glucocorticoid (GC) dose during bDMARD use than the BF group (-3.0 mg/day vs 0 mg/day; p = .01). CONCLUSION bDMARDs were discontinued without flare up of RA in 58.1% of patients with RA in clinical settings. A lower DAS28-ESR at initiation and reduction of GC dose before discontinuation of bDMARD were important factors associated with bio-free success.
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Affiliation(s)
- Moeko Ochiai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eiichi Tanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eri Sato
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Keyaki Total Clinic, Chiba, Japan
| | - Eisuke Inoue
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Research Administration Center, Showa University, Tokyo, Japan
| | - Mai Abe
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kumiko Saka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Eri Sugano
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naohiro Sugitani
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yoko Higuchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Rei Yamaguchi
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Naoki Sugimoto
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Katsunori Ikari
- Department of Orthopedics, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Ayako Nakajima
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Center for Rheumatic Diseases, Mie University Hospital, Mie, Japan
| | - Hisashi Yamanaka
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan.,Rheumatology, Sanno Medical Center, Tokyo, Japan
| | - Masayoshi Harigai
- Department of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Choi SJ. Biologic therapies for the treatment of rheumatoid arthritis. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.2.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease that primarily affects the synovial joints. If left untreated, persistent synovial inflammation can lead to cartilage and bone destruction, ultimately causing significant longterm disability and mortality. However, since the late 1990s, the combined use of methotrexate, a synthetic diseasemodifying antirheumatic drug (DMARD), and a biological DMARD has revolutionized the treatment of RA. As of 2021, the Korea Food and Drug Administration has approved seven biological DMARDs for RA treatment: four tumor necrosis factor-alpha inhibitors (infliximab, etanercept, adalimumab, and golimumab) and three non-tumor necrosis factor biological products (abatacept, rituximab, and tocilizumab). Although the use of biological products has allowed significant advances in the treatment of RA, there are certain drawbacks, such as high cost, increased infection risk, and the necessity for parenteral route product administration. Therefore, discontinuation of biological DMARD use without a resulting disease flare is the next treatment goal and a desirable result from the standpoint of risk reduction and cost-effectiveness, especially for patients with clinical remission. It is still unclear which biological product is the best. Clinicians must, therefore, personalize the sequence and strategy of treatment by considering patient characteristics, disease activity, comorbidity, and economic condition
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Tikhonova IA, Yang H, Bello S, Salmon A, Robinson S, Hemami MR, Dodman S, Kharechko A, Haigh RC, Jani M, McDonald TJ, Hoyle M. Enzyme-linked immunosorbent assays for monitoring TNF-alpha inhibitors and antibody levels in people with rheumatoid arthritis: a systematic review and economic evaluation. Health Technol Assess 2021; 25:1-248. [PMID: 33555998 DOI: 10.3310/hta25080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis is a chronic autoimmune disease that primarily causes inflammation, pain and stiffness in the joints. People with severe disease may be treated with biological disease-modifying anti-rheumatic drugs, including tumour necrosis factor-α inhibitors, but the efficacy of these drugs is hampered by the presence of anti-drug antibodies. Monitoring the response to these treatments typically involves clinical assessment using response criteria, such as Disease Activity Score in 28 joints or European League Against Rheumatism. Enzyme-linked immunosorbent assays can also be used to measure drug and antibody levels in the blood. These tests may inform whether or not adjustments to treatment are required or help clinicians to understand the reasons for treatment non-response or a loss of response. METHODS Systematic reviews were conducted to identify studies reporting on the clinical effectiveness and cost-effectiveness of using enzyme-linked immunosorbent assays to measure drug and anti-drug antibody levels to monitor the response to tumour necrosis factor-α inhibitors [adalimumab (Humira®; AbbVie, Inc., North Chicago, IL, USA), etanercept (Enbrel®; Pfizer, Inc., New York, NY, USA), infliximab (Remicade®, Merck Sharp & Dohme Limited, Hoddesdon, UK), certolizumab pegol (Cimzia®; UCB Pharma Limited, Slough, UK) and golimumab (Simponi®; Merck Sharp & Dohme Limited)] in people with rheumatoid arthritis who had either achieved treatment target (remission or low disease activity) or shown primary or secondary non-response to treatment. A range of bibliographic databases, including MEDLINE, EMBASE and CENTRAL (Cochrane Central Register of Controlled Trials), were searched from inception to November 2018. The risk of bias was assessed using the Cochrane ROBINS-1 (Risk Of Bias In Non-randomised Studies - of Interventions) tool for non-randomised studies, with adaptations as appropriate. Threshold and cost-utility analyses that were based on a decision tree model were conducted to estimate the economic outcomes of adding therapeutic drug monitoring to standard care. The costs and resource use were considered from the perspective of the NHS and Personal Social Services. No discounting was applied to the costs and effects owing to the short-term time horizon of 18 months that was adopted in the economic analysis. The impact on the results of variations in testing and treatment strategies was explored in numerous clinically plausible sensitivity analyses. RESULTS Two studies were identified: (1) a non-randomised controlled trial, INGEBIO, that compared standard care with therapeutic drug monitoring using Promonitor® assays [Progenika Biopharma SA (a Grifols-Progenika company), Derio, Spain] in Spanish patients receiving adalimumab who had achieved remission or low disease activity; and (2) a historical control study. The economic analyses were informed by INGEBIO. Different outcomes from INGEBIO produced inconsistent results in both threshold and cost-utility analyses. The cost-effectiveness of therapeutic drug monitoring varied, from the intervention being dominant to the incremental cost-effectiveness ratio of £164,009 per quality-adjusted life-year gained. However, when the frequency of testing was assumed to be once per year and the cost of phlebotomy appointments was excluded, therapeutic drug monitoring dominated standard care. LIMITATIONS There is limited relevant research evidence and much uncertainty about the clinical effectiveness and cost-effectiveness of using enzyme-linked immunosorbent assay-based testing for therapeutic drug monitoring in rheumatoid arthritis patients. INGEBIO had serious limitations in relation to the National Institute for Health and Care Excellence scope: only one-third of participants had rheumatoid arthritis, the analyses were mostly not by intention to treat and the follow-up was 18 months only. Moreover, the outcomes might not be generalisable to the NHS. CONCLUSIONS Based on the available evidence, no firm conclusions could be made about the cost-effectiveness of therapeutic drug monitoring in England and Wales. FUTURE WORK Further controlled trials are required to assess the impact of using enzyme-linked immunosorbent assays for monitoring the anti-tumour necrosis factors in people with rheumatoid arthritis. STUDY REGISTRATION This study is registered as PROSPERO CRD42018105195. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Irina A Tikhonova
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK.,Southampton Health Technology Assessments Centre, University of Southampton, Southampton, UK
| | - Huiqin Yang
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Segun Bello
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Andrew Salmon
- Peninsula Collaboration for Health Operational Research and Development, University of Exeter Medical School, Exeter, UK
| | - Sophie Robinson
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Mohsen Rezaei Hemami
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Sophie Dodman
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | - Andriy Kharechko
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
| | | | - Meghna Jani
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Manchester, UK
| | - Timothy J McDonald
- Royal Devon & Exeter NHS Foundation Trust, Exeter, UK.,University of Exeter Medical School, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter Medical School, Exeter, UK
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Mikuls TR, Johnson SR, Fraenkel L, Arasaratnam RJ, Baden LR, Bermas BL, Chatham W, Cohen S, Costenbader K, Gravallese EM, Kalil AC, Weinblatt ME, Winthrop K, Mudano AS, Turner A, Saag KG. American College of Rheumatology Guidance for the Management of Rheumatic Disease in Adult Patients During the COVID-19 Pandemic: Version 3. Arthritis Rheumatol 2020; 73:e1-e12. [PMID: 33277981 DOI: 10.1002/art.41596] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To provide guidance to rheumatology providers on the management of adult rheumatic disease in the context of the coronavirus disease 2019 (COVID-19) pandemic. METHODS A task force, including 10 rheumatologists and 4 infectious disease specialists from North America, was convened. Clinical questions were collated, and an evidence report was rapidly generated and disseminated. Questions and drafted statements were reviewed and assessed using a modified Delphi process. This included asynchronous anonymous voting by email and webinars with the entire panel. Task force members voted on agreement with draft statements using a 1-9-point numerical scoring system, and consensus was determined to be low, moderate, or high based on the dispersion of votes. For approval, median votes were required to meet predefined levels of agreement (median values of 7-9, 4-6, and 1-3 defined as agreement, uncertainty, or disagreement, respectively) with either moderate or high levels of consensus. RESULTS Draft guidance statements approved by the task force have been combined to form final guidance. CONCLUSION These guidance statements are provided to promote optimal care during the current pandemic. However, given the low level of available evidence and the rapidly evolving literature, this guidance is presented as a "living document," and future updates are anticipated.
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Affiliation(s)
- Ted R Mikuls
- University of Nebraska Medical Center, Omaha, Nebraska and VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Liana Fraenkel
- Berkshire Health Systems, Pittsfield, Massachusetts, and Yale University, New Haven, Connecticut
| | | | | | | | | | | | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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Reduction of biologics in rheumatoid arthritis: a systematic review and meta-analysis. Rheumatol Int 2020; 40:1949-1959. [PMID: 32710197 DOI: 10.1007/s00296-020-04651-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
The effects of dose reduction or spacing of all types of biologics in rheumatoid arthritis has not been consistently assessed in systematic reviews. We aimed to assess the effects of biologics reduction compared with dose maintenance in patients with rheumatoid arthritis in low disease activity or remission. We performed a systematic review with meta-analysis according to a previously registered protocol (PROSPERO registration: CRD42017069080); and searched MEDLINE, Embase, Scopus, Cochrane Library and trial registers up to July, 2020. Two researchers selected, extracted and assessed the risk of bias of controlled trials that randomized patients to reduction/spacing or dose maintenance of biologics. Low disease activity, disability and other clinically important outcomes were summarized in random effect meta-analyses. We rated the certainty of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation approach. We included ten studies (n = 1331 patients), which assessed reduction or spacing of abatacept, adalimumab, certolizumab pegol, etanercept, or tocilizumab. Risk of bias was high in over half of trials, mainly due to lack of blinding. No statistically significant difference was found in low disease activity (RR = 0.90; 95% CI 0.78-1.04; I2 = 60%, very low certainty), and other outcomes. Subgroup analysis of blinded studies led to homogeneous results, which remained heterogeneous in open-label studies. Reduction or spacing biologics did not affect disease activity and other important outcome. Changes in the doses regimen should consider patient preferences, considering the low certainty of evidence.
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Thomas K, Lazarini A, Kaltsonoudis E, Drosos A, Papalopoulos I, Sidiropoulos P, Tsatsani P, Gazi S, Pantazi L, Boki KA, Katsimbri P, Boumpas D, Fragkiadaki K, Tektonidou M, Sfikakis PP, Karagianni K, Sakkas LI, Grika EP, Vlachoyiannopoulos PG, Evangelatos G, Iliopoulos A, Dimitroulas T, Garyfallos A, Melissaropoulos K, Georgiou P, Areti M, Georganas C, Vounotrypidis P, Kitas GD, Vassilopoulos D. Treatment patterns and achievement of the treat-to-target goals in a real-life rheumatoid arthritis patient cohort: data from 1317 patients. Ther Adv Musculoskelet Dis 2020; 12:1759720X20937132. [PMID: 33062066 PMCID: PMC7534096 DOI: 10.1177/1759720x20937132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
Background Data regarding the real-life predictors of low disease activity (LDA) in rheumatoid arthritis (RA) patients are limited. Our aim was to evaluate the rate and predictors of LDA and treatment patterns in RA. Methods This was a multicenter, prospective, RA cohort study where patients were evaluated in two different time points approximately 12 months apart. Statistical analysis was performed in order to identify predictors of LDA while patterns of disease-modifying anti-rheumatic drug [DMARDs; conventional synthetic (csDMARD) or biologic (bDMARD)] and glucocorticoid (GC) use were also recorded. Results The total number of patients included was 1317 (79% females, mean age: 62.9 years, mean disease duration: 10.3 years). After 1 year, 57% had achieved LDA (DAS28ESR<3.2) while 43% did not (34%: moderate disease activity: DAS28ESR ⩾3.2 to <5.1, 9%: high disease activity, DAS28ESR ⩾5.1). By multivariate analysis, male sex was positively associated with LDA [odds ratio (OR) = 2.29 p < 0.001] whereas advanced age (OR = 0.98, p = 0.005), high Health Assessment Questionnaire (HAQ) score (OR = 0.57, p < 0.001), use of GCs (OR = 0.75, p = 0.037) or ⩾2 bDMARDs (OR = 0.61, p = 0.002), high co-morbidity index (OR = 0.86, p = 0.011) and obesity (OR = 0.62, p = 0.002) were negative predictors of LDA. During follow-up, among active patients (DAS28ESR >3.2), 21% initiated (among csDMARDs users) and 22% switched (among bDMARDs users) their bDMARDs. Conclusion In a real-life RA cohort, during 1 year of follow-up, 43% of patients do not reach treatment targets while only ~20% of those with active RA started or switched their bDMARDs. Male sex, younger age, lower HAQ, body mass index and co-morbidity index were independent factors associated with LDA while use of GCs or ⩾2 bDMARDs were negative predictors.
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Affiliation(s)
- Konstantinos Thomas
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Argiro Lazarini
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Ioannis Papalopoulos
- Clinical Immunology and Allergy Department, University of Crete, Heraklion, Greece
| | | | | | | | - Lina Pantazi
- Rheumatology Unit, Sismanoglio Hospital, Athens, Greece
| | | | - Pelagia Katsimbri
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Boumpas
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kalliopi Fragkiadaki
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Tektonidou
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros P Sfikakis
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Lazaros I Sakkas
- Department of Rheumatology, University of Thessaly, Larissa, Greece
| | - Eleftheria P Grika
- Joint Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | | | | | | | | | | | | | - Dimitrios Vassilopoulos
- Joint Rheumatology Program, Clinical Immunology-Rheumatology Unit, 2nd Department of Medicine and Laboratory, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, 114 Vass. Sophias Avenue, Athens, 115 27, Greece
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Tornero-Molina J, Alperi-López M, Castellví I, de Agustín-de Oro JJ, Escudero A, García-Vicuña R, González-Gay MÁ, Hidalgo C, Rubio E, Sanmartí R, Casamira N, Calvo-Alén J. Experts document on methotrexate use in combined therapy with biological or targeted synthetic disease modifying drugs in patients with rheumatoid arthritis. REUMATOLOGIA CLINICA 2020; 18:S1699-258X(20)30200-X. [PMID: 33041228 DOI: 10.1016/j.reuma.2020.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/16/2020] [Accepted: 08/20/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We aimed to develop recommendations for the management of methotrexate (MTX) when considering the combination with biological (b) or targeted synthetic (ts) disease modifying drugs (DMARDs) in rheumatoid arthritis (RA). METHODS Eleven experts on RA were selected. Two coordinators formulated 13 questions about the combination therapy of MTX with bDMARDs or tsDMARDs. A systematic review was conducted to answer the questions. Inclusion and exclusion criteria were established as well as the search strategies (Medline, Embase and the Cochrane Library were searched up to January 2019). Two reviewers selected the articles and collected data. Simultaneously, EULAR and ACR meeting abstracts were evaluated. Based on this evidence, the coordinators proposed preliminary recommendations that the experts discussed and voted in a nominal group meeting. The level of evidence and grade of recommendation was established using the Oxford Center for Evidence Based Medicine and the level of agreement with a Delphi. Agreement was established if at least 80% of the experts voted 'yes' (yes/no). RESULTS The systematic review retrieved 513 citations of which 61 were finally included. A total of 10 recommendations were generated, voted and accepted. The level of agreement was very high in all of them and it was achieved in the first Delphi round. Final recommendations cover aspects such as the optimal MTX dosage, tapering strategy or patients' risk management. CONCLUSIONS This document is intended to help clinicians solve usual clinical questions and facilitate decision making when treating RA patients with MTX in combination with bDMARDs or tsDMARDs.
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Affiliation(s)
| | | | - Ivan Castellví
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Alejandro Escudero
- Servicio de Reumatología, Hospital Universitario Reina Sofía, IMIBIC, Córdoba, Spain
| | | | | | - Cristina Hidalgo
- Servicio de Reumatología, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Esteban Rubio
- Servicio de Reumatología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Raimon Sanmartí
- Servicio de Reumatología, Hospital Universitari Clínic, Barcelona, Spain
| | - Núria Casamira
- Departamento Médico, Laboratorios Gebro Pharma, Barcelona, Spain
| | - Jaime Calvo-Alén
- Servicio de Reumatología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
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Persistence on biologic DMARD monotherapy after achieving rheumatoid arthritis disease control on combination therapy: retrospective analysis of corrona registry data. Rheumatol Int 2020; 41:381-390. [PMID: 32876744 PMCID: PMC7835165 DOI: 10.1007/s00296-020-04667-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
Biological disease-modifying antirheumatic drugs (bDMARDs) monotherapy may enhance adherence and decrease adverse events compared to combination therapy with conventional synthetic DMARDs (csDMARDs); however, persistence with bDMARD monotherapy has not been extensively studied. We explore persistence of etanercept monotherapy and monotherapy with other tumor necrosis factor inhibitors (TNFis) among patients first achieving remission/low disease activity (LDA) while on combination therapy with csDMARDs and a TNFi. Using Corrona registry data, the percentage of patients persistent with the index TNFi (etanercept versus other TNFis) over 6 and 12 months was determined. Factors influencing persistence and treatment patterns at 6 and 12 months were examined. Among 617 eligible patients, 56% of 182 patients on etanercept and 45% of 435 patients on other TNFis persisted with monotherapy at 6 months, 46% and 33%, respectively, at 12 months. Across first-line and subsequent biologic DMARDs, etanercept persistence was greater than other TNFi persistence by 10.8% (95% CI 2.1%, 19.6%) at 6 months and 11.4% (95% CI 0.9%, 21.9%) at 12 months. Patients on other TNFis were more likely to require reintroduction of csDMARD after 6 months (45% versus 35% for etanercept). Remission was the key predictor of persistence for both etanercept and other TNFi monotherapies. This retrospective, cohort study of registry data reflecting real-world practice indicates patients who achieve remission/LDA with combination csDMARD and TNFi therapy may successfully transition to TNFi monotherapy. Patients on etanercept monotherapy experienced greater persistence and less frequent reintroduction of a csDMARD than was observed for patients on other TNFi monotherapies.
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van Mulligen E, Weel AE, Hazes JM, van der Helm-van Mil A, de Jong PHP. Tapering towards DMARD-free remission in established rheumatoid arthritis: 2-year results of the TARA trial. Ann Rheum Dis 2020; 79:1174-1181. [PMID: 32482645 PMCID: PMC7456559 DOI: 10.1136/annrheumdis-2020-217485] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To evaluate the 2-year clinical effectiveness of two gradual tapering strategies. The first strategy consisted of tapering the conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) first (i.e., methotrexate in ~90%), followed by the tumour necrosis factor inhibitor (TNF-inhibitor), the second strategy consisted of tapering the TNF-inhibitor first, followed by the csDMARD. METHODS This multicentre single-blinded randomised controlled trial included patients with rheumatoid arthritis (RA) with well-controlled disease for ≥3 consecutive months, defined as a Disease Activity Score (DAS) measured in 44 joints ≤2.4 and a swollen joint count ≤1, which was achieved with a csDMARD and a TNF-inhibitor. Eligible patients were randomised into gradual tapering the csDMARD followed by the TNF-inhibitor, or vice versa. The primary outcome was the number of disease flares. Secondary outcomes were DMARD-free remission (DFR), DAS, functional ability (Health Assessment Questionnaire Disability Index (HAQ-DI)) and radiographic progression. RESULTS 189 patients were randomly assigned to tapering their csDMARD (n=94) or TNF-inhibitor (n=95) first. The cumulative flare rate after 24 months was, respectively, 61% (95% CI 50% to 71%) and 62% (95% CI 52% to 72%). The patients who tapered their csDMARD first were more often able to go through the entire tapering protocol and reached DFR more often than the group that tapered the TNF-inhibitor first (32% vs 20% (p=0.12) and 21% vs 10% (p=0.07), respectively). Mean DAS and HAQ-DI over time, and radiographic progression did not differ between groups (p=0.45, p=0.17, p=0.8, respectively). CONCLUSION The order of tapering did not affect flare rates, DAS or HAQ-DI. DFR was achievable in 15% of patients with established RA, slightly more frequent in patients that first tapered csDMARDs. Because of similar effects from a clinical viewpoint, financial arguments may influence the decision to taper TNF-inhibitors first.
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Affiliation(s)
| | - Angelique E Weel
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Rheumatology, Maasstad Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus Universiteit Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - J M Hazes
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Annette van der Helm-van Mil
- Rheumatology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
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Biological Dose Tapering in Daily Clinical Practice: A 10 Year Follow-up Study. ACTA ACUST UNITED AC 2020; 16:319-323. [DOI: 10.1016/j.reuma.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/21/2018] [Accepted: 08/25/2018] [Indexed: 01/07/2023]
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Rezk MF, Pieper B. Unlocking the Value of Anti-TNF Biosimilars: Reducing Disease Burden and Improving Outcomes in Chronic Immune-Mediated Inflammatory Diseases: A Narrative Review. Adv Ther 2020; 37:3732-3745. [PMID: 32740789 PMCID: PMC7444394 DOI: 10.1007/s12325-020-01437-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Indexed: 02/07/2023]
Abstract
Immune-mediated inflammatory diseases (IMIDs) are chronic conditions that create a significant disease burden on millions of patients while adding a major financial burden to societies and healthcare systems. The introduction of biologic medicines has contributed majorly to improving the clinical outcomes of IMIDs and as such these modalities have gained first- or second-line positions in a wide range of treatment guidelines from different international clinical societies. However, the high cost of these biologics traditionally limited their accessibility and delayed their initiation, leaving millions of patients with unmet medical needs for a more affordable and sustainable solution. The introduction of cost-efficient biosimilar anti-TNFs within Europe since 2013 has allowed more patients with IMIDs to access biologic therapies earlier and for longer, potentially altering the course of the disease into a milder phenotype and reducing the long-term disease burden. This review provides the latest evidence for the impact of biosimilars on patient outcomes and demonstrates their clinical value beyond a reduction in price.
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Affiliation(s)
- Mourad F Rezk
- Biogen International GmbH, Neuhofstrasse 30, 6340, Baar, Switzerland.
| | - Burkhard Pieper
- Biogen International GmbH, Neuhofstrasse 30, 6340, Baar, Switzerland
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Wu Q, Zhao Y, Xu D, Zhang Z, Li Z. Efficacy of methotrexate and etanercept biosimilar rhTNFR:Fc in Chinese patients with active rheumatoid arthritis: A controlled, randomized and multicenter study. Sci Rep 2020; 10:14270. [PMID: 32868798 PMCID: PMC7458921 DOI: 10.1038/s41598-020-64991-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/07/2020] [Indexed: 12/31/2022] Open
Abstract
Rheumatoid arthritis is a chronic inflammatory disease which could lead to severe joint damage and disability. This study was performed to determine the efficacy and safety of methotrexate (MTX) therapy combined with maintenance or discontinuation of etanercept biosimilar rhTNFR:Fc in active rheumatoid arthritis patients in Chinese patients. In this controlled, randomized and open-label study, 89 patients with active rheumatoid arthritis were enrolled at 7 institutions in China between September 2010 and May 2011. In a period of 52 weeks, patients were randomly assigned to one of three treatment groups: MTX plus rhTNFR:Fc for 52 weeks, MTX plus rhTNFR:Fc for 24 weeks, or MTX monotherapy. The primary endpoint was the joint damage evaluated by change from baseline (CFB) of van de Heijde modified Total Sharp Score (mTSS). Intention-to-treat population were used for analysis. A total of 89 enrolled patients were eligible for this study, of whom 32 were assigned to MTX plus rhTNFR:Fc52 group, 31 to MTX plus rhTNFR:Fc24, and 26 to MTX monotherapy. Only one patient was lost to follow up in the MTX plus rhTNFR:Fc24 group. The mTSS CFB was lower in the rhTNFR:Fc pooled group (combination of data in the MTX plus rhTNFR:Fc52 group and MTX plus rhTNFR:Fc24 group) comparing with MTX monotherapy at week 24 and 52 (P = 0.03 and P < 0.01). Additionally, ACR50 and ACR70 response rates were both higher in the rhTNFR:Fc pooled group than MTX monotherapy (P < 0.05). Combination of MTX and rhTNFR:Fc in patients with active rheumatoid arthritis could effectively inhibit joint structure damage.
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Affiliation(s)
- Qingjun Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Beijing, China.
| | - Zhuoli Zhang
- Department of Rheumatology, Peking University First Hospital, Beijing, China.
| | - Zhenbin Li
- Department of Rheumatology, Bethune International Peace Hospital, Shijiazhuang, Hebei Province, China.
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Dose tapering of biologic agents in patients with rheumatoid arthritis-results from a cohort study in Germany. Clin Rheumatol 2020; 40:887-893. [PMID: 32822057 DOI: 10.1007/s10067-020-05316-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/19/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the association of demographic and clinical factors with the clinical decision of tapering biologic disease modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA) in daily practice. METHODS All RA patients receiving bDMARDs were documented by 14 rheumatologists when presenting in 9 specialized private practices. Statistical analyses employed multivariable logistic models for dose reduction with the covariates age, gender, disease duration until bDMARD start, smoking status, disease activity, comorbidity, functional capacity, radiographic damage, concomitant methotrexate (MTX) treatment, rheumatoid factor positivity, and glucocorticoid use. In the multivariable model (MVM), missing values were imputed. RESULTS Data of 586 RA patients on bDMARD treatment were available, 171 of which (29%) received a reduced dose. The highest rates of patients with dose reduction were seen for rituximab (67%) and infliximab (50%). The degree of dose reduction was most prominent for rituximab (57%). In the MVM, 6/11 covariates were significantly associated with dose reduction: age (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.05; P = 0.002), time between disease onset and bDMARD start (OR 1.03, 95% CI 1.01-1.06; P = 0.015), DAS 28 < 2.6 (OR 1.55, 95% CI 1.01-2.37; P = 0.045), MTX therapy (OR 1.52, 95% CI 1.03-2.25; P = 0.036), comorbidity (OR 1.20, 95% CI 1.01-1.42; P = 0.036), and glucocorticoid dose (OR 0.82, 95% CI 0.76-0.89; P < 0.001). CONCLUSION DAS 28 remission, concomitant MTX, and lower glucocorticoid doses were positively associated with dose tapering of bDMARDs in RA patients. While this could be expected, the reason for the association with age, comorbidity, and the time between disease onset and bDMARD start is less clear. Key points • In rheumatology practice, tapering of biologic disease modifying antirheumatic drugs is feasible in nearly 30% of patients with rheumatoid arthritis. • The degree of dose reduction may exceed 50% of the recommended dose. • In a multivariable model, concomitant methotrexate is positively associated with dose tapering of biologic disease modifying antirheumatic drugs.
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