Predicting disease progression and poor outcomes in patients with moderately active rheumatoid arthritis: a systematic review

Personalised treatment of rheumatoid arthritis based on cytokine profiles and synovial tissue signatures: potentials and challenges

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune, chronic inflammatory disease that mainly affects the joints and periarticular soft tissues. Although there have been significant advances in RA treatment over the past two decades, approximately 40% of patients do not respond to first-line biological disease-modifying antirheumatic drugs (bDMARDs). Physicians often use an empirical, trial-and-error approach to select bDMARDs to treat patients with RA. This is inefficient and can be costly for healthcare systems which have limited resources. Unlike in oncology, where molecular pathology helps guide targeted therapies, reliable, predictive biomarkers for drug response in RA are yet to be identified. This narrative review aims to summarise current knowledge on novel biomarkers of disease activity and drug response in RA, with a particular focus on serum cytokine profiles and macrophage and fibroblast subsets in synovial tissue. We also highlight key areas of further research that could advance the development of targeted therapies for patients with RA.

METHODS

We searched PubMed to identify studies pertaining to biomarkers of disease activity and drug response in the treatment of RA.

RESULTS

We present a detailed overview of the key studies that have identified serum cytokine profiles and synovial macrophage and fibroblast subsets as novel biomarkers of disease activity and drug response in RA.

CONCLUSION

A novel, evidence-based approach to precision medicine in RA, which involves tailoring treatment based on cytokine profiles and synovial tissue signatures, shows promise for improving patient care. However, more research is needed to identify biomarkers that predict drug response.

Efficacy and safety of filgotinib in patients with moderately active rheumatoid arthritis and an inadequate response to methotrexate

OBJECTIVES

Clinical trials restricted to moderately active RA are limited. Filgotinib is approved for treating moderate to severe active RA. This post hoc analysis assessed the efficacy and safety of filgotinib in moderately active RA.

METHODS

In FINCH 1, patients with active moderate to severe RA and inadequate response to methotrexate received filgotinib 200 mg or 100 mg (FIL200/FIL100) once daily, adalimumab 40 mg every 2 weeks or placebo, all with methotrexate (N = 1755). This subgroup analysis was conducted in patients with a moderate baseline Disease Activity Score in 28 joints using C-reactive protein [DAS28-CRP; >3.2 to ≤5.1; n = 425 (24.2%)].

RESULTS

A higher proportion of patients achieved DAS28-CRP <2.6, Clinical Disease Activity Index (CDAI) remission (≤2.8), low disease activity (LDA) (DAS28-CRP ≤3.2 or CDAI ≤10) and American College of Rheumatology (ACR20/50/70) responses with FIL200 and FIL100 vs placebo at weeks 12 and 24. Week 12 ACR20 response rates (primary end point) were 77.9%, 67.8% and 43.8%, respectively. A total of ∼75% of patients achieved DAS28-CRP LDA by week 24 with either filgotinib dose. FIL200 and FIL100 elicited greater improvements in patient-reported outcomes than placebo. The efficacy of filgotinib, maintained through week 52, was comparable to that of adalimumab. Frequency of adverse events (AEs) was similar with filgotinib and adalimumab. Infections were the most common AEs; incidence rates were 40-53% in active treatment groups.

CONCLUSION

In this subpopulation with moderately active RA, the efficacy and safety of filgotinib were similar to those in the overall FINCH 1 population (patients with active moderate to severe RA).

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT02889796.

Distinct clinical outcomes based on multiple serum cytokine and chemokine profiles rather than autoantibody profiles and ultrasound findings in rheumatoid arthritis: a prospective ultrasound cohort study

OBJECTIVES

To evaluate the potential of clinical factors, ultrasound findings, serum autoantibodies, and serum cytokine and chemokine profiles as predictors of clinical outcomes in rheumatoid arthritis (RA).

PATIENTS AND METHODS

We included 200 patients with RA treated with biological and targeted synthetic disease-modifying antirheumatic drugs in a prospective multicentre ultrasound cohort study. Their serum levels of multiple cytokines and chemokines, rheumatoid factors, and serum autoantibodies (anti-cyclic citrullinated peptide-2 (anti-CCP2) and anti-carbamylated protein antibodies) were measured at baseline, 3 months and 12 months.

RESULTS

Dimensionality reduction using 38 cytokines and chemokines demonstrated four distinct clusters that differed significantly regarding the frequencies of remission defined by clinical composite measures and ultrasound evaluations. Prominent differences in IL-1β, IL-5, IL-7, IL-10, IFNγ, GRO, IP-10, MCP-1 and MIP-1β characterised the between-cluster differences. Two distinct groups made of four clusters showed a significant difference in IgM-anti-CCP2 positivity. The least absolute shrinkage and selection operator regression of 38 cytokines and chemokines for Clinical Disease Activity Index (CDAI) remission at 12 months resulted in the selection of MIP-1β. Logistic regression using baseline levels of anti-citrullinated protein antibody, IgM-anti-CCP2 positivity, the CDAI, the total power Doppler score, the cluster by cytokines and chemokines, MIP-1β, methotrexate dose and mechanisms of action revealed that cluster by cytokines and chemokines was the sole significant factor for CDAI remission at 12 months.

CONCLUSIONS

Specific patterns of cytokines and chemokines-no other clinical factors and autoantibody profiles-were important to distinguish patients with RA achieving remission at 12 months.

TRIAL REGISTRATION NUMBER

UMIN000012524.

Biomechanical determinants of rheumatoid arthritis severity and excess cardiovascular disease: common origins of two complex diseases

OBJECTIVES

The determinants of rheumatoid arthritis (RA) severity and excess cardiovascular disease (CVD) are incompletely understood. Biomechanical factors are known to influence RA severity. Articular stiffness correlates with arterial and skin stiffness. This study explored the hypothesis that constitutional stiffness is a common determinant of RA severity and excess CVD.

METHODS

Fifty-eight patients with anti-CCP antibody (ACPA) positive RA and 57 controls were enrolled noting age, sex, body mass index, alcohol and tobacco exposure, Shared Epitope status and in RA disease duration, disease activity, ACPA titre and radiographic damage. Severe RA was defined as radiographic progression >1.3 mSharp points/year or requiring biological disease-modifying antirheumatic drugs (bDMARDs). Articular stiffness (Beighton Score and right 5th metacarpophalangeal (MCP) joint stress-strain responses), carotid-femoral pulse wave velocity and skin extensibility (percent increase distance two dots with manual traction dorsum right hand) were assessed.

RESULTS

Right 5th MCP stiffness correlated with Beighton Score and with arterial and skin stiffness. High radiographic rate was associated with greater MCP articular (t test p 0.014), arterial (p 0.044) and, in RA <5 years duration, greater skin stiffness (p 0.002) with similar trends in subjects requiring bDMARDs. In RA, arterial stiffness correlated with age (ß p<0.005), articular (ß p<0.001) and skin stiffness (ß p 0.037) and inversely with alcohol consumption (p 0.035).

CONCLUSIONS

Articular, arterial and skin stiffness correlated with each other and with RA severity. As skin is not affected by RA, this association suggests that constitutional stiffness might be a common determinant of RA and CVD. Prospective studies of at-risk preclinical and early RA are required to determine if this relationship is causal.

TRIALS REGISTRATION NUMBER

ACTRN12617000170325.

Multicohort study testing the generalisability of the SASKit-ML stroke and PDAC prognostic model pipeline to other chronic diseases

OBJECTIVES

To validate and test the generalisability of the SASKit-ML pipeline, a prepublished feature selection and machine learning pipeline for the prediction of health deterioration after a stroke or pancreatic adenocarcinoma event, by using it to identify biomarkers of health deterioration in chronic disease.

DESIGN

This is a validation study using a predefined protocol applied to multiple publicly available datasets, including longitudinal data from cohorts with type 2 diabetes (T2D), inflammatory bowel disease (IBD), rheumatoid arthritis (RA) and various cancers. The datasets were chosen to mimic as closely as possible the SASKit cohort, a prospective, longitudinal cohort study.

DATA SOURCES

Public data were used from the T2D (77 patients with potential pre-diabetes and 18 controls) and IBD (49 patients with IBD and 12 controls) branches of the Human Microbiome Project (HMP), RA Map (RA-MAP, 92 patients with RA, 22 controls) and The Cancer Genome Atlas (TCGA, 16 cancers).

METHODS

Data integration steps were performed in accordance with the prepublished study protocol, generating features to predict disease outcomes using 10-fold cross-validated random survival forests.

OUTCOME MEASURES

Health deterioration was assessed using disease-specific clinical markers and endpoints across different cohorts. In the HMP-T2D cohort, the worsening of glycated haemoglobin (HbA1c) levels (5.7% or more HbA1c in the blood), fasting plasma glucose (at least 100 mg/dL) and oral glucose tolerance test (at least 140) results were considered. For the HMP-IBD cohort, a worsening by at least 3 points of a disease-specific severity measure, the "Simple Clinical Colitis Activity Index" or "Harvey-Bradshaw Index" indicated an event. For the RA-MAP cohort, the outcome was defined as the worsening of the "Disease Activity Score 28" or "Simple Disease Activity Index" by at least five points, or the worsening of the "Health Assessment Questionnaire" score or an increase in the number of swollen/tender joints were evaluated. Finally, the outcome for all TCGA datasets was the progression-free interval.

RESULTS

Models for the prediction of health deterioration in T2D, IBD, RA and 16 cancers were produced. The T2D (C-index of 0.633 and Integrated Brier Score (IBS) of 0.107) and the RA (C-index of 0.654 and IBS of 0.150) models were modestly predictive. The IBD model was uninformative. TCGA models tended towards modest predictive power.

CONCLUSIONS

The SASKit-ML pipeline produces informative and useful features with the power to predict health deterioration in a variety of diseases and cancers; however, this performance is disease-dependent.

Diagnostic accuracy of the neutrophil-to-lymphocyte ratio and the platelet-to-lymphocyte ratio in rheumatoid arthritis: a systematic review and meta-analysis

Existing challenges with the early diagnosis of rheumatoid arthritis (RA) and active disease, mainly by non-rheumatologists, have prompted the search for novel biomarkers. Elevations in indices derived from blood cell counts, e.g., the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR), have been reported in RA patients. However, their diagnostic accuracy has not been comprehensively assessed. Therefore, we conducted a systematic review and meta-analysis of studies reporting the sensitivity and specificity of the NLR and PLR, obtained by receiver operating characteristic (ROC) curve analysis, for the presence of RA and active disease. We searched electronic databases from inception to 15 March 2024 and assessed the risk of bias using the JBI Critical Appraisal Checklist (PROSPERO registration number: CRD42024533546). In 15 studies, the NLR exhibited acceptable accuracy for the presence of RA (area under the curve, AUC = 0.76, 95% CI 0.72 to 0.80) and active disease (AUC = 0.70, 95% CI 0.66 to 0.74). The PLR exhibited good accuracy for the presence of RA (AUC = 0.80, 95% CI 0.76 to 0.83). There were insufficient studies to assess the accuracy of the PLR for the presence of active disease. Our systematic review and meta-analysis suggests that the NLR and the PLR are promising biomarkers of RA (NLR and PLR) and active disease (NLR). Further research is required to investigate whether the NLR and PLR can significantly enhance the capacity to diagnose RA and active disease in clinical practice.

Neutrophil-to-monocyte ratio is the better new inflammatory marker associated with rheumatoid arthritis activity

Background

Rheumatoid arthritis (RA) is a systemic autoimmune disease that chronically affects patients with episodes of inflammation. New inflammatory hematological markers were investigated for follow-up, such as the neutrophil-monocyte ratio (NMR), lymphocyte monocyte ratio (LMR), and neutrophil-lymphocyte ratio (NLR). This study was conducted to determine the most useful marker based on studies of association with RA disease activity and correlation with the classical markers C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF).

Methods

This case-control study included 62 chronic RA patients who had previously been diagnosed and experienced episodes of symptoms while attending a variety of public and private rheumatology clinics in Ibb City, Republic of Yemen, for the period of September 1 to November 30, 2021. Twenty healthy volunteers were included in this study. Complete blood count, CRP, ESR, and RF levels were measured in all participants.

Results

The total leukocyte count, neutrophil count, platelet count, NMR, LMR, and NLR were positively correlated with CRP and ESR, but the monocyte count was reversed. The area under the curve (AUC = 0.861, 95% confidence interval [CI] = 0.769-0.948) for the NMR cutoff value of 4.7 was equal to that of CRP and close to that of ESR. This NMR cutoff value had 87% sensitivity and 80% specificity. LMR and NLR cutoff values of 4.35 and 1.35, respectively, resulted in AUCs of (AUC = 0.807, 95% CI, 0.708-0.905) and (AUC = 0.699, 95% CI, 0.571-0.819); their sensitivity and specificity were 62.3%, 90%, 57.4%, and 80%, respectively.

Conclusions

As a convenient and low-cost inflammatory marker of RA activity, NMR outperformed LMR and NLR.

Association of serum hepatoma-derived growth factor levels with disease activity in rheumatoid arthritis: A pilot study

Background

Hepatoma‐derived growth factor (HDGF) is reported to play an important role in tumorigenesis and cancer progression. However, growing evidence indicates its participation in immune system activation. This study analyzed the relationship among serum HDGF levels, disease activity, and laboratory markers in patients with rheumatoid arthritis (RA).

Methods

Blood samples from 165 patients with RA, 42 with osteoarthritis (OA), and 28 healthy controls, were used to evaluate the serum HDGF levels. Correlations of serum HDGF levels with age, 28‐joint count disease activity score (DAS28), and laboratory findings were assessed by Pearson correlation and receiver operator characteristic (ROC) curve analyses to obtain HDGF optimal cutoffs according to the disease status. Immunohistochemical staining was performed on the knee synovial tissue samples from patients with RA and OA (n = 10 each) to investigate HDGF joint expression.

Results

Serum HDGF levels were significantly correlated with DAS28 erythrocyte sedimentation rate (r = 0.412, p < 0.001) and C‐reactive protein values (r = 0.376, p < 0.001). The optimal cutoffs of serum HDGF levels from the ROC analysis were 5.79 and 5.14 for the differentiation of active/inactive disease and remission/non‐remission, respectively. The ideal cutoff of serum HDGF levels to differentiate RA and OA was determined as 5.47. Serial serum HDGF level analyses in 21 patients with RA revealed that serum HDGF levels significantly decreased after improvement in disease activity (p = 0.046). HDGF expression was not observed in the synovial tissues of the patients with RA and OA.

Conclusion

Serum HDGF level could be a potential laboratory biomarker for the severity of RA.

Rheumatoid arthritis management in the APLAR region: Perspectives from an expert panel of rheumatologists, patients and community oriented program for control of rheumatic diseases

Rheumatoid arthritis (RA) is a major health burden in Asia Pacific affecting the quality of life of patients and consuming healthcare resources. According to recent estimates from the World Health Organization-International League Against Rheumatism-Community Oriented Program for Control of Rheumatic Diseases, prevalence is around 0.3%-0.5%. Management guidelines have helped to improve treatment across this diverse region. To gain better insight into current real-world management applications in view of these guidelines, virtual meetings were conducted in mid-2020 to explore perspectives of rheumatologists and patients, as well as discuss the impact of coronavirus disease 2019 on RA management. Patients and rheumatologists from Hong Kong, Malaysia, Singapore, the Philippines, Thailand, India, Pakistan, and Taiwan were included, representing a diverse mix of healthcare systems, wealth, ethnicity and culture. Despite many countries having prospered in recent years, similar challenges in RA diagnosis and treatment were identified. The daily impact and patient experience of RA were also similar across countries, marked by "silent" pain and disability, and universal misunderstanding of the disease. Late diagnosis and treatment, and barriers to access to appropriate treatment, remain problematic. The experience shared by Taiwan offers a glimmer of hope, however, wherein patient advocacy groups have succeeded in being included in policy-making decisions and securing access to advanced treatment. Real-world solutions that pay heed to the unique local needs and diversity of Asia Pacific are required to improve RA management, which will take time. In the interim, help can be sought from the trained, non-rheumatologist community to reduce some of the disease burden.

Time to initiation of biologic disease-modifying antirheumatic drugs in the French cohort ESPOIR

OBJECTIVE

To assess the time to initiation of biologic disease-modifying anti-rheumatic drugs (bDMARDs) in ESPOIR, the French cohort of patients with rheumatoid arthritis (RA), and factors associated with the timing of bDMARD initiation.

METHODS

In total, 658 patients with early RA satisfying the 2010 ACR/EULAR criteria were included between 2003 and 2005 and followed annually for 10 years (end of follow up: 2013-2015). The timing of bDMARD introduction and predictors of use were analysed by the Kaplan-Meier method based on Cox proportional-hazard models.

RESULTS

Overall, 178 patients (31.0%, 95% confidence interval [27.0-34.7]) initiated a bDMARD during the 10-year follow-up, with a mean delay of 43.6 months. The penetration rate was higher during the first 2 years of follow-up (6% between the first and second year, approximately 3.3% each year between the second and seventh year, and<2.0% after the eighth year). The first-used bDMARD was etanercept for 72 patients and adalimumab for 71. On multivariate analysis, Disease Activity Score in 28 joints, radiologic progression and positivity for anti-citrullinated protein antibodies were significantly associated with rapid initiation of a bDMARD (P<0.0001), whereas older age at first joint pain was inversely associated (P<0.0001).

CONCLUSIONS

Although access to bDMARDs is widespread in France, less than one third of patients with early RA in the ESPOIR cohort initiated a bDMARD over the 10-year follow-up. Poor prognostic factors for RA were associated with more rapid initiation, as expected.