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Hao Y, Oon S, Nikpour M. Efficacy and safety of treat-to-target strategy studies in rheumatic diseases: A systematic review and meta-analysis. Semin Arthritis Rheum 2024; 67:152465. [PMID: 38796922 DOI: 10.1016/j.semarthrit.2024.152465] [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: 03/24/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND The concept of treat-to-target (T2T), a treatment strategy in which treatment is directed to reach and maintain a defined goal such as remission or low disease activity (LDA), has been explored for several diseases including rheumatic diseases such as rheumatoid arthritis (RA). However, a comprehensive review of T2T in all rheumatic diseases has not recently been undertaken. OBJECTIVE To perform a systematic review and meta-analysis of the efficacy and safety of a T2T strategy in the management of adult patients with inflammatory rheumatic diseases. METHODS PUBMED, EMBASE and CINAHL were searched from January 1990 to December 2023 using key words related to a T2T strategy and rheumatic diseases; T2T strategy clinical trials or observational studies were included. Clinical, physical function and radiologic outcomes, cost-effectiveness, and adverse events (AEs) of the T2T strategies were investigated and a random-effect meta-analysis was conducted for the most commonly used outcomes in RA studies. RESULTS The search identified 7896 studies, of which 66 fit inclusion criteria, including 50 in RA, 3 in psoriatic arthritis (PsA), 1 in spondyloarthritis (SpA) and 12 in gout. For the studies comparing a T2T strategy with usual care (UC) in RA, 83.3% (20/24) showed a T2T strategy could achieve significantly better clinical outcomes, and the meta-analysis showed that patients treated with a T2T strategy were more likely to be in remission (pooled RR: 1.68 (1.47-1.92), p<0.001] and achieve DAS-28 response (pooled standardised mean difference (SMD): 0.47 (0.26-0.69), P<0.001] at 1 year than patients treated with UC. Sensitivity analyses showed that a T2T strategy with a predefined treatment protocol had better clinical efficacy than that without protocol. In terms of improving physical function and health-related quality of life (HRQoL), 11/19 (57.9%) studies found a T2T strategy was significantly more likely to achieve these than UC, with the meta-analysis for the mean change of HAQ score supporting this conclusion (pooled SMD: 1.48 (0.46-2.51), p=0.004). Five out of 9 studies (55.6%) demonstrated greater benefit regarding radiographic progression from a T2T strategy. In terms of cost-effectiveness and AEs, 2/2 studies found a T2T strategy was more cost-effective than UC and 8/8 studies showed no tendency for AEs to occur more often with a T2T strategy. For the studies in PsA and SpA, a T2T strategy was also demonstrated to be more effective than UC in clinical and functional benefits, but not in radiologic outcomes. All gout studies showed that sUA level could be controlled more effectively with a T2T strategy, and 2 studies revealed that the T2T strategy could inhibit erosion development or crystal deposition. CONCLUSIONS For patients with active RA, a T2T strategy has been shown in mulitple studies to increase the likelihood of achieving clinical response and improving HRQoL without increasing economic costs and AEs. Limited studies have shown clinical and functional benefits from T2T strategies in active PsA and SpA. A T2T strategy has also been found to improve clinical and radiologic outcomes in gout. T2T trials in other rheumatic diseases are lacking.
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Affiliation(s)
- Yanjie Hao
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia
| | - Shereen Oon
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia.
| | - Mandana Nikpour
- The University of Melbourne at St Vincent's Hospital, 29 Regent Street, Fitzroy, VIC 3065, Australia; Department of Rheumatology, St. Vincent's Hospital Melbourne, 35 Victoria Parade, Fitzroy, VIC 3065, Australia; Sydney MSK Research Flagship Centre, The University of Sydney School of Public Health, Room 132, Edward Ford Building, Fisher Road, University of Sydney, NSW 2006, Australia; Royal Prince Alfred Hospital Institute of Rheumatology and Orthopedics, 59 Missenden Rd, Camperdown NSW 2050, Australia.
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Adinolfi A, Belloli L, Chevallard M, Ughi N, Casu C, Di Cicco M, Filippini D, Gerardi MC, Muscarà M, Verduci E, Musio A, Salvatore S, Parravicini P, Epis OM. Telemonitoring for the management of patients with rheumatoid arthritis or psoriatic arthritis: A qualitative survey. Int J Rheum Dis 2024; 27:e14960. [PMID: 37934917 DOI: 10.1111/1756-185x.14960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/27/2023] [Accepted: 10/20/2023] [Indexed: 11/09/2023]
Affiliation(s)
- Antonella Adinolfi
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laura Belloli
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Michel Chevallard
- Internal Medicine Unit, Multispecialist Medical Department, Ospedale Salvini Garbagnate Milanese, ASST Rhodense, Milan, Italy
| | - Nicola Ughi
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cinzia Casu
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Di Cicco
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Davide Filippini
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Marina Muscarà
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elisa Verduci
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonella Musio
- UOS di Reumatologia, ASST Valtellina e Alto Lario, Sondrio, Italy
- UOC di Medicina Generale, ASST Valtellina e Alto Lario, Sondrio, Italy
| | - Santina Salvatore
- UOS di Reumatologia, ASST Valtellina e Alto Lario, Sondrio, Italy
- UOC di Medicina Generale, ASST Valtellina e Alto Lario, Sondrio, Italy
| | - Pierpaolo Parravicini
- UOS di Reumatologia, ASST Valtellina e Alto Lario, Sondrio, Italy
- UOC di Medicina Generale, ASST Valtellina e Alto Lario, Sondrio, Italy
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Ruyssen-Witrand A, Guernec G, Dupont J, Lapuyade D, Lioté F, Vittecoq O, Degboé Y, Constantin A. Ten-year radiographic and functional outcomes in rheumatoid arthritis patients in remission compared to patients in low disease activity. Arthritis Res Ther 2023; 25:207. [PMID: 37864239 PMCID: PMC10588022 DOI: 10.1186/s13075-023-03176-7] [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: 06/02/2023] [Accepted: 09/19/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND To compare the 10-year structural and functional prognosis between patients in sustained remission versus patients in sustained low disease activity (LDA) in early rheumatoid arthritis (RA). METHODS We included 256 patients from the ESPOIR cohort who fulfilled the 2010 ACR/EULAR criteria for RA and who were in sustained remission using the Simple Disease Activity Index (SDAI) score (n = 48), in sustained LDA (n = 139) or in sustained moderate to high disease activity (MDA or HDA, n = 69) over 10 years. The mTSSs progression over 10 years and the 10-year HAQ-DI scores were compared between the 3 groups. A longitudinal latent process mixed model was used to assess the independent effect of SDAI status over time on 10-year mTSS progression and HAQ-DI at 10 years. RESULTS Patients in sustained remission group were younger, had lower baseline HAQ-DI and mTSS scores and were less exposed to glucocorticoids, methotrexate or biologic disease-modifying anti-rheumatic drugs over 10 years. Patients in sustained remission had lower 10-year structural progression (variation of mTSS in the remission group: 4.06 (± 4.75) versus 14.59 (± 19.76) in the LDA group and 21.04 (± 24.08), p < 0.001 in the MDA or HDA groups) and lower 10-year HAQ-DI scores (10-year HAQ-DI in the remission group: 0.14 (± 0.33) versus 0.53 (± 0.49) in the LDA group and 1.20 (± 0.62) in the MDA or HDA groups, p < 0.001). The incidence of serious adverse events over 10 years was low, about 3.34/100 patient years, without any difference between the three groups. CONCLUSION RA patients in sustained SDAI remission have better long-term structural and functional outcomes in comparison to patients in sustained LDA.
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Affiliation(s)
- Adeline Ruyssen-Witrand
- Rheumatology Centre, Toulouse University Hospital, Centre d'Investigation Clinique de Toulouse CIC1436, Inserm, Team PEPSS "Pharmacologie En Population cohorteS Et biobanqueS, Purpan Teaching Hospital, University of Toulouse 3, 1 Place du Dr Baylac, 31059, Toulouse, Cedex 9, France.
| | - Gregory Guernec
- Inserm, Centre d'Epidémiologie Et de Recherche en Santé Des Populations, UMR1295, Inserm, Toulouse, France
| | - Julia Dupont
- Rheumatology Centre, Toulouse University Hospital, Toulouse, France
| | - Diane Lapuyade
- Rheumatology Centre, Toulouse University Hospital, Toulouse, France
| | - Frédéric Lioté
- Université Paris Cité and Inserm UMR1132 Bioscar Hôpital Lariboisière and Service de Rhumatologie, Hôpital Saint-Joseph, Paris, France
| | - Olivier Vittecoq
- Department of Rheumatology and CIC-CRB1404, Normandie Univ, UNIROUEN, Rouen University Hospital, 76000, Rouen, France
| | - Yannick Degboé
- Rheumatology Center, Toulouse University Hospital, INFINITY, Toulouse Institute for Infectious and Inflammatory Diseases, INSERM U1291, CNRS U5051, University Toulouse 3, Toulouse, France
| | - Arnaud Constantin
- Rheumatology Center, Toulouse University Hospital, INFINITY, Toulouse Institute for Infectious and Inflammatory Diseases, INSERM U1291, CNRS U5051, University Toulouse 3, Toulouse, France
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Bessette L, Haraoui B, Rampakakis E, Dembowy J, Trépanier MO, Pope J. Effectiveness of a treat-to-target strategy in patients with moderate to severely active rheumatoid arthritis treated with abatacept. Arthritis Res Ther 2023; 25:183. [PMID: 37759330 PMCID: PMC10537125 DOI: 10.1186/s13075-023-03151-2] [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: 04/14/2023] [Accepted: 08/27/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND To compare a treat-to-target (T2T) approach and routine care (RC) in adults with active to severely active rheumatoid arthritis (RA) initiating subcutaneous abatacept. METHODS A 12-month cluster-randomized trial in active RA patients treated with abatacept was conducted. Physicians were randomized to RC or T2T with a primary endpoint of achieving sustained Clinical Disease Activity Index (CDAI) low disease activity (LDA) at two consecutive assessments approximately 3 months apart. Additional outcomes included Simple Disease Activity Index (SDAI), Disease Activity Score 28-CRP (DAS28-CRP), Routine Assessment of Patient Index Data 3 (RAPID3), and the Health Assessment Questionnaire-Disability Index (HAQ-DI). Time to achieve therapeutic endpoints was assessed with survival analysis. RESULTS Among the 284 enrolled patients, 130 were in the T2T group and 154 in RC. Primary endpoint was achieved by 36.9% and 40.3% of patients in T2T and RC groups, respectively. No significant between-group differences were observed in the odds of achieving secondary outcomes, except for a higher likelihood of CDAI LDA in the T2T group vs. RC (odds ratio [95% confidence interval]: 1.33 [1.03-1.71], p = 0.0263). Compared with RC, patients in the T2T group achieved SDAI remission significantly faster (Kaplan-Meier-estimated mean [standard error]: 14.0 [0.6] vs. 19.3 [0.8] months, p = 0.0428) with a trend toward faster achievement of CDAI LDA/remission, DAS28-CRP remission, and HAQ-DI minimum clinically important difference. CONCLUSIONS Patients managed per T2T and those under RC experienced significant improvements in RA disease activity at 12 months of abatacept treatment. T2T was associated with higher odds of CDAI LDA and a shorter time to achieving therapeutic endpoints. TRIAL REGISTRATION Name of the registry: ClinicalTrials.gov. TRIAL REGISTRATIONS NCT03274141 . Date of registration: September 6, 2017.
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Affiliation(s)
- Louis Bessette
- Department of Medicine, Laval University, Quebec, QC, Canada
| | - Boulos Haraoui
- Centre Hospitalier de L'Université de Montréal, Montreal, Québec, Canada
| | - Emmanouil Rampakakis
- Department of Pediatrics, McGill University, Montreal, Canada
- JSS Medical Research, Montreal, Canada
| | | | | | - Janet Pope
- Division of Rheumatology, Department of Medicine, Western University, 268 Grosvenor Street, London, ON, N6A 4V2, Canada.
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Ramiro S, Landewé R, van der Heijde D, Sepriano A, FitzGerald O, Østergaard M, Homik J, Elkayam O, Thorne JC, Larché MJ, Ferraccioli G, Backhaus M, Boire G, Combe B, Schaeverbeke T, Saraux A, Dougados M, Rossini M, Govoni M, Sinigaglia L, Cantagrel AG, Allaart CF, Barnabe C, Bingham CO, van Schaardenburg D, Hammer HB, Dadashova R, Hutchings E, Paschke J, Maksymowych WP. Stricter treat-to-target in RA does not result in less radiographic progression: a longitudinal analysis in RA BIODAM. Rheumatology (Oxford) 2023; 62:2989-2997. [PMID: 36645243 DOI: 10.1093/rheumatology/kead021] [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: 10/25/2022] [Revised: 12/02/2022] [Accepted: 01/06/2023] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To investigate whether meticulously following a treat-to-target (T2T)-strategy in daily clinical practice will lead to less radiographic progression in patients with active RA who start (new) DMARD-therapy. METHODS Patients with RA from 10 countries starting/changing conventional synthetic or biologic DMARDs because of active RA, and in whom treatment intensification according to the T2T principle was pursued, were assessed for disease activity every 3 months for 2 years (RA-BIODAM cohort). The primary outcome was the change in Sharp-van der Heijde (SvdH) score, assessed every 6 months. Per 3-month interval DAS44-T2T could be followed zero, one or two times (in a total of two visits). The relation between T2T intensity and change in SvdH-score was modelled by generalized estimating equations. RESULTS In total, 511 patients were included [mean (s.d.) age: 56 (13) years; 76% female]. Mean 2-year SvdH progression was 2.2 (4.1) units (median: 1 unit). A stricter application of T2T in a 3-month interval did not reduce progression in the same 6-month interval [parameter estimates (for yes vs no): +0.15 units (95% CI: -0.04, 0.33) for 2 vs 0 visits; and +0.08 units (-0.06; 0.22) for 1 vs 0 visits] nor did it reduce progression in the subsequent 6-month interval. CONCLUSIONS In this daily practice cohort, following T2T principles more meticulously did not result in less radiographic progression than a somewhat more lenient attitude towards T2T. One possible interpretation of these results is that the intention to apply T2T already suffices and that a more stringent approach does not further improve outcome.
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Affiliation(s)
- Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Robert Landewé
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
- Department of Rheumatology, Amsterdam Rheumatology Center, Amsterdam, The Netherlands
| | | | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
| | - Oliver FitzGerald
- Conway Institute for Biomolecular Research, School of Medicine, University College Dublin, Ireland
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Joanne Homik
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ori Elkayam
- Tel Aviv Sourasky Medical Center and the "Sackler" Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J Carter Thorne
- The Arthritis Program Research Group, University of Toronto, Toronto, Canada
| | - Maggie J Larché
- Departments of Medicine and Pediatrics, Divisions of Rheumatology, Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | | | - Marina Backhaus
- Park-Klinik Weissensee, Academic Hospital of the Charité, Berlin, Germany
| | - Gilles Boire
- Department of Medicine/Division of Rheumatology, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), University of Sherbrooke, Sherbrooke, Canada
| | - Bernard Combe
- Department of Rheumatology, Montpellier University, Montpellier, France
| | - Thierry Schaeverbeke
- Department of Rheumatology, FHU ACRONIM, University Hospital of Bordeaux, University of Bordeaux, France
| | - Alain Saraux
- LBAI, U1227, Université Brest, Inserm, CHU Brest, Brest, France
| | - Maxime Dougados
- Rheumatology Department, Paris Cité University, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Maurizio Rossini
- Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Marcello Govoni
- Rheumatology Unit, S. Anna Hospital and University of Ferrara, Ferrara, Italy
| | - Luigi Sinigaglia
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - Alain G Cantagrel
- Department of Rheumatology, CHU Toulouse, Paul Sabatier University, Toulouse, France
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cheryl Barnabe
- Departments of Medicine and Community Health Sciences, University of Calgary, Alberta, Canada
| | | | | | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
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Listorti E, Ferrara L, Adinolfi A, Gerardi MC, Ughi N, Tozzi VD, Epis OM. Joining telehealth in rheumatology: a survey on the role played by personalized experience from patients' perspective. BMC Health Serv Res 2023; 23:682. [PMID: 37349713 DOI: 10.1186/s12913-023-09575-5] [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: 10/25/2022] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND The beginning of the Covid-19 pandemic has forced many hospital departments worldwide to implement telehealth strategies for the first time. Telehealth represents the opportunity to increase value for all stakeholders, including patients and healthcare staff, but its success constitutes a challenge for all of them and particularly patients play a crucial role for their needed adherence. This study focuses on the experience of the Rheumatology Unit of Niguarda Hospital in Milan (Italy), where telehealth projects have been implemented for more than a decade with structured design and organized processes. The case study is paradigmatic because patients have experimented personalized mixes of telehealth channels, including e-mails and phone calls, Patient Reported Outcomes questionnaires, and home delivery of drugs. Given all these peculiarities, we decided to deepen patients' perspective through three main aspects related to the adoption of telehealth: (i) the benefits perceived, (ii) the willingness to enrol in future projects, (iii) the preference on the service-mix between remote contacts and in-person visits. Most importantly, we investigated differences in the three areas among all patients based on the mix of telehealth channels experienced. METHODS We conducted a survey from November 2021 to January 2022, enrolling consecutively patients attending the Rheumatology Unit of Niguarda Hospital in Milan (Italy). Our survey comprised an introductory set of questions related to personal, social, clinical and ICT skills information, followed by the central part on telehealth. All the answers were analysed with descriptive statistics and regression models. RESULTS A complete response was given by 400 patients: 283 (71%) were female, 237 (59%) were 40-64 years old, 213 (53%) of them declared to work, and the disease most represented was Rheumatoid Arthritis (144 patients, 36%). Descriptive statistics and regression results revealed that (i) non-users imagined wide-ranging benefits compared to users; (ii) other things being equal, having had a more intense experience of telehealth increased the odds of accepting to participate to future projects by 3.1 times (95% C.I. 1.04-9.25), compared to non-users; (iii) the more telehealth was experienced, the higher the willingness to substitute in-person with online contacts. CONCLUSIONS Our study contributes to enlighten the crucial role played by the telehealth experience in determining patients' preferences.
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Affiliation(s)
| | - Lucia Ferrara
- CERGAS SDA Bocconi, Bocconi University, Milan, Italy
| | - Antonella Adinolfi
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Nicola Ughi
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Oscar M Epis
- Rheumatology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Ramanan AV, Sage AM. Treat to Target (Drug-Free) Inactive Disease in JIA: To What Extent Is This Possible? J Clin Med 2022; 11:jcm11195674. [PMID: 36233546 PMCID: PMC9570877 DOI: 10.3390/jcm11195674] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Treat to target (T2T) is a strategy that has been increasingly employed in the management of several chronic diseases, with demonstrated improved outcomes. The use of T2T in juvenile idiopathic arthritis (JIA), a common rheumatic disease of childhood, is still in its infancy, and the feasibility of its use in attaining drug-free clinical remission is unclear. Aims: We aim to explore the current literature of the use of T2T in JIA, and to review the potential benefits and limitations of this approach in regard to this chronic disease. Sources: A comprehensive PubMed search was conducted using relevant keywords, with full text articles in English included in the review. Content: T2T is an appealing strategy for improving outcomes of pediatric rheumatic diseases given the limited availability of therapeutics and potential cumulative effects of long-term immunosuppression. The application in a cohort of children, however, is limited by heterogeneity of disease, availability of high-quality evidence, and patient and parental preferences. Unlike adult rheumatoid arthritis, the 'window of opportunity' has not been definitively demonstrated in large scale trials, and although early studies of T2T in JIA have been favorable, the timing and means of escalation (especially with regard to biologics) need clarification. Implications: This review outlines several issues of implementing T2T in JIA, including the important extra-articular manifestations of disease and non-pharmacological management, that should be considered in future consensus guidelines.
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Affiliation(s)
- Athimalaipet V. Ramanan
- Bristol Royal Hospital for Children, Bristol BS8 1QU, UK
- Translational Health Sciences, University of Bristol, Bristol BS8 1TS, UK
| | - Anne M. Sage
- Department of Rheumatology, Perth Children’s Hospital, 15 Hospital Avenue, Nedlands, WA 6009, Australia
- Correspondence:
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El Miedany Y, Salah S, Lotfy H, El Gaafary M, Abdulhady H, Salah H, Nasef SI, El-Latif EA, Farag Y, Eissa M, Esam Maher S, Radwan A, El-Shanawany AT, Medhat BM, El Mikkawy D, Mosa DM, El Deriny G, Mortada M, Osman NS, Fouad NA, Elkaraly NE, Mohamed SS, Tabra SA, Hassan WA, Amer Y, Abu-Zaid MH. Updated clinical practice treat-to-target guidelines for JIA management: the Egyptian College of Pediatric Rheumatology initiative. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00125-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Abstract
Background
These updated guidelines aimed to provide appropriate and convenient guidelines for the treatment of various types of juvenile idiopathic arthritis (JIA).
Using the Delphi technique, this study was conducted to reach expert consensus on a treat-to-target management strategy for JIA. According to the PICO (patient/population, intervention, comparison, and outcomes) approach, the preliminary scientific committee identified a total of 17 key clinical questions. To assemble evidence on the advantages and dangers associated with JIA treatments, an evidence-based, systematic literature review was conducted. Researchers and clinicians with experience in JIA management were identified by the core leadership team. To establish a consensus on the management suggestions for JIA patients, a Delphi approach (2 rounds) was used.
Results
An online survey was applied to the expert panel (n = 27), and 26 of them completed both rounds. At the conclusion of round 2, a total of eighteen (18) recommendation items were gathered, which were divided into four sections to address the four key JIA categories. The percentage of those who agreed with the recommendations (ranks 7–9) ranged from 83.2 to 100% (average 86.8%). The phrasing of all 18 clinical standards identified by the scientific committee was agreed upon (i.e. 75% of respondents strongly agreed or agreed). Algorithms have been proposed for the management of JIA polyarthritis, oligoarthritis, and systemic JIA.
Conclusion
A wide and representative panel of experts initiated a consensus about the management of JIA. The created guidelines give a complete approach to the management of JIA for all healthcare professionals involved in its management, as well as a means of monitoring and evaluating these guidelines on a regular basis.
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Spijk-de Jonge MJ, Weijers JM, Teerenstra S, Elwyn G, van de Laar MA, van Riel PL, Huis AM, Hulscher ME. Patient involvement in rheumatoid arthritis care to improve disease activity-based management in daily practice: A randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2022; 105:1244-1253. [PMID: 34465495 DOI: 10.1016/j.pec.2021.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate the effect of an intervention to improve disease activity-based management of RA in daily clinical practice by addressing patient level barriers. METHODS The DAS-pass strategy aims to increase patients' knowledge about DAS28 and to empower patients to be involved in treatment (decisions). It consists of an informational leaflet, a patient held record and guidance by a specialized rheumatology nurse. In a Randomized Controlled Trial, 199 RA patients were randomized 1:1 to intervention or control group. Outcome measures were patient empowerment (EC-17; primary outcome), attitudes towards medication (BMQ), disease activity (DAS28) and knowledge about DAS28. RESULTS Our strategy did not affect EC-17, BMQ, or DAS28 use. However it demonstrated a significant improvement of knowledge about DAS28 in the intervention group, compared to the control group. The intervention had an additional effect on patients with low baseline knowledge compared to patients with high baseline knowledge. CONCLUSION The DAS-pass strategy educates patients about (the importance of) disease activity-based management, especially patients with low baseline knowledge. PRACTICE IMPLICATIONS The strategy supports patient involvement in disease activity-based management of RA and can be helpful to reduce inequalities between patients in the ability to be involved in shared decision making.
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Affiliation(s)
- Marieke J Spijk-de Jonge
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.
| | - Julia M Weijers
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Steven Teerenstra
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department for Health Evidence, Section Biostatistics, Nijmegen, The Netherlands
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Mart Afj van de Laar
- University of Twente, Department of Psychology, Health and Technology, Enschede, The Netherlands
| | - Piet Lcm van Riel
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands; Bernhoven, Department of Rheumatology, Uden, The Netherlands
| | - Anita Mp Huis
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Marlies Ejl Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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10
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Zaninelli TH, Fattori V, Verri WA. Harnessing Inflammation Resolution in Arthritis: Current Understanding of Specialized Pro-resolving Lipid Mediators' Contribution to Arthritis Physiopathology and Future Perspectives. Front Physiol 2021; 12:729134. [PMID: 34539449 PMCID: PMC8440959 DOI: 10.3389/fphys.2021.729134] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/12/2021] [Indexed: 12/26/2022] Open
Abstract
The concept behind the resolution of inflammation has changed in the past decades from a passive to an active process, which reflects in novel avenues to understand and control inflammation-driven diseases. The time-dependent and active process of resolution phase is orchestrated by the endogenous biosynthesis of specialized pro-resolving lipid mediators (SPMs). Inflammation and its resolution are two forces in rheumatic diseases that affect millions of people worldwide with pain as the most common experienced symptom. The pathophysiological role of SPMs in arthritis has been demonstrated in pre-clinical and clinical studies (no clinical trials yet), which highlight their active orchestration of disease control. The endogenous roles of SPMs also give rise to the opportunity of envisaging these molecules as novel candidates to improve the life quality of rhematic diseases patients. Herein, we discuss the current understanding of SPMs endogenous roles in arthritis as pro-resolutive, protective, and immunoresolvent lipids.
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Affiliation(s)
- Tiago H Zaninelli
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Pathology, Londrina State University, Londrina, Brazil
| | - Victor Fattori
- Vascular Biology Program, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, MA, United States
| | - Waldiceu A Verri
- Laboratory of Pain, Inflammation, Neuropathy, and Cancer, Department of Pathology, Londrina State University, Londrina, Brazil
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11
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Pouls BPH, Bekker CL, Gaffo AL, van den Bemt BJF, Flendrie M. Tele-monitoring flares using a smartphone app in patients with gout or suspected gout: a feasibility study. Rheumatol Adv Pract 2021; 5:rkab100. [PMID: 34988359 PMCID: PMC8713010 DOI: 10.1093/rap/rkab100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/29/2021] [Indexed: 02/07/2023] Open
Abstract
Objectives Gout flares are painful and disabling. We developed a smartphone application (app) for patients to tele-monitor gout flares surveyed by clinicians. The aim of this study was to assess patient acceptability and technical and clinical feasibility. Methods Adult patients with either established gout or high suspicion thereof were recruited if they possessed a smartphone and reported a recent arthritis attack. A smartphone application was used to identify gout flares by asking during 90 consecutive days: (1) what is your pain score (0–10); (2) are your joints warm; (3) are your joints swollen; and (4) are you currently experiencing a gout flare? The clinician was alerted via email if a flare occurred. Patient acceptability was assessed using the technology acceptance model. Technical feasibility consisted of reported technical issues and clinical feasibility of actions taken by the clinician regarding gout flare alerts. Results Twenty-nine included patients completed the study. The mean age of participants was 57 years, and all but one were male. The adherence rate was 96% (110 of 2910 queries were missed). Patients had a positive attitude toward app use, found the app very easy to use (mean usability score 81 out of 100) and were neutral to positive on its usefulness. There were four minor technical issues. A total of 100 gout flare alerts were generated that led to 18 proactive contacts with patients. Conclusion A smartphone app to monitor gout flares was developed and tested, showing high adherence, good acceptability and clinical feasibility for established gout patients. Trial registration Netherlands Trial Register, https://www.trialregister.nl, NL6435.
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Affiliation(s)
- Bart P H Pouls
- Correspondence to: Bart P. H. Pouls, Department of Rheumatology Research, Sint Maartenskliniek, Hengstdal 3, 6500GM Nijmegen, The Netherlands. E-mail:
| | - Charlotte L Bekker
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Angelo L Gaffo
- Division of Rheumatology, University of Alabama Medical Centre
- Division of Rheumatology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Bart J F van den Bemt
- Department of Rheumatology Research, Sint Maartenskliniek
- Department of Pharmacy, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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12
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Bergman M, Zhou L, Patel P, Sawant R, Clewell J, Tundia N. Healthcare Costs of Not Achieving Remission in Patients with Rheumatoid Arthritis in the United States: A Retrospective Cohort Study. Adv Ther 2021; 38:2558-2570. [PMID: 33837497 PMCID: PMC8107161 DOI: 10.1007/s12325-021-01730-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/25/2021] [Indexed: 12/03/2022]
Abstract
Introduction To compare all-cause and rheumatoid arthritis (RA)-related healthcare costs and resource use in patients with RA who do not achieve remission versus those who achieve remission, using clinical practice data. Methods Data were derived from Optum electronic health records linked to claims from commercial and Medicare Advantage health plans. Two cohorts were created: remission and non-remission. Remission was defined as Disease Activity Score 28-joint count with the C-reactive protein level or erythrocyte sedimentation rate (DAS28-CRP/ESR) < 2.6 or Routine Assessment of Patient Index Data 3 (RAPID3 ≤ 3.0). Outcomes were all-cause and RA-related costs and resource use during a 1-year follow-up period. A weighted generalized linear regression and negative binomial regression were used to estimate adjusted annual costs and resource use, respectively, controlling for confounding factors, including patient and socio-demographic characteristics. Results Data from 335 patients (remission: 125; non-remission: 210) were analyzed. Annual all-cause total costs were significantly less in the remission versus non-remission cohort ($30,427 vs. $38,645, respectively; cost ratio [CR] = 0.79; 95% CI 0.63, 0.99). All-cause resource use (mean number of visits) was less in the remission versus non-remission cohort: inpatient (0.23 vs. 0.63; visit ratio [VR] = 0.36; 95% CI 0.19, 0.70), emergency department (0.36 vs. 0.77; VR = 0.47; 95% CI 0.30, 0.74), and outpatient visits (20.7 vs. 28.5; VR = 0.73; 95% CI 0.62, 0.86). Annual RA-related total costs were similar in both cohorts; however, RA-related medical costs were numerically lower in the remission versus non-remission cohort ($8,594 vs. $10,002, respectively; CR = 0.86; 95% CI 0.59, 1.25). RA-related resource use was less in the remission versus non-remission cohort. Conclusions Significant economic burden was associated with patients who did not achieve remission compared with those who did achieve remission. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01730-w.
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13
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Update on the treatment of nonsystemic juvenile idiopathic arthritis including treatment-to-target: is (drug-free) inactive disease already possible? Curr Opin Rheumatol 2021; 32:403-413. [PMID: 32657803 DOI: 10.1097/bor.0000000000000727] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW This review concerns the outcome for nonsystemic juvenile idiopathic arthritis (JIA) with emphasis on treatment-to-target (T2T) and treatment strategies aiming at inactive disease by giving an overview of recent articles. RECENT FINDINGS More efficacious therapies and treatment strategies/T2T with inactive disease as target, have improved the outcome for JIA significantly. Recent studies regarding treatment strategies have shown 47-68% inactive disease after 1 year. Moreover, probability of attaining inactive disease at least once in the first year seems even higher in recent cohort-studies, reaching 80%, although these studies included relatively high numbers of oligoarticular JIA patients. However, 26-76% of patients flare upon therapy withdrawal and prediction of flares is still difficult. SUMMARY Remission can be achieved and sustained in (some) JIA patients, regardless of initial treatment. Cornerstone principles in the management of nonsystemic JIA treatment are early start of DMARD therapy, striving for inactive disease and T2T by close and repeated monitoring of disease activity. T2T and tight control appear to be more important than a specific drug in JIA. Next to inactive disease, it is important that patients/parents are involved in personal targets, like reduction of pain and fatigue. Future studies should focus on predictors (based on imaging-methods or biomarkers) for sustained drug-free remission and flare.
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14
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Spijk-de Jonge MJ, Manders SHM, Huis AMP, Elwyn G, van de Laar MAFJ, van Riel PLCM, Hulscher MEJL. Co-Design of a Disease Activity Based Self-Management Approach for Patients with Rheumatoid Arthritis. Mediterr J Rheumatol 2021; 32:21-30. [PMID: 34386699 PMCID: PMC8314884 DOI: 10.31138/mjr.32.1.21] [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: 12/13/2020] [Revised: 01/10/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The systematic development of an intervention to improve disease activity-based management of rheumatoid arthritis (RA) in daily clinical practice that is based on patient-level barriers. Methods: The self-management strategy was developed through a step-wise approach, in a process of co-design with all stakeholders and by addressing patient level barriers to RA management based on disease activity. Results: The resulting DAS-pass strategy consists of decision supportive information and guidance by a specialised rheumatology nurse. It aims to increase patients’ knowledge on DAS28, to empower patients to be involved in disease management, and to improve patients’ medication beliefs. The decision supportive information includes an informational leaflet and a patient held record. The nurse individualises the information, stimulates patients to communicate about disease activity, and offers the opportunity for questions or additional support. Conclusion: The DAS-pass strategy was found helpful by stakeholders. It can be used to improve RA daily clinical practice. Our systematic approach can be used to improve patient knowledge and self-management on other RA related topics. Also, it can be used to improve the management of other chronic conditions. We therefore provide a detailed description of our methodology to assist those interested in developing an evidence-based strategy for educating and empowering patients.
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Affiliation(s)
- Marieke J Spijk-de Jonge
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | | | - Anita M P Huis
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Glyn Elwyn
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon (NH), United States of America
| | - Mart A F J van de Laar
- University of Twente, Department of Psychology, Health and Technology, Enschede, The Netherlands
| | - Piet L C M van Riel
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.,Bernhoven, Department of Rheumatology, Uden, The Netherlands
| | - Marlies E J L Hulscher
- Radboud University Medical Centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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15
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Ziade N, Arayssi T, Elzorkany B, Daher A, Karam GA, Jbara MA, Aiko A, Alam E, Emadi SA, Mashaleh MA, Badsha H, Kibbi LE, Halabi H, Harifi G, Khan B, Masri AF, Menassa J, Merashli M, Merheb G, Messaykeh J, Mroue' K, Saad S, Salloum N, Uthman I, Masri B. Development of an Educational Video for Self-Assessment of Patients with RA: Steps, Challenges, and Responses. Mediterr J Rheumatol 2021; 32:66-73. [PMID: 34386703 PMCID: PMC8314883 DOI: 10.31138/mjr.32.1.66] [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: 07/05/2020] [Revised: 09/06/2020] [Accepted: 10/15/2020] [Indexed: 01/05/2023] Open
Abstract
Objectives: The primary objective was to develop an educational video to teach patients with rheumatoid arthritis (RA) self-assessment of their disease activity. Secondary objectives were to validate the video, identify the challenges in producing it, and the responses to these challenges. Methods: Rheumatologists from 7 Middle Eastern Arab countries (MEAC) discussed unmet needs in the education of patients with RA. They reviewed pre-existing educational audiovisual material and drafted the script for a new video in Arabic. The video was produced in collaboration with a technical team, then validated by patients using a standardized interview. At each step of production, challenges were identified. Results: Twenty-three rheumatologists from MEAC identified unmet needs in patients’ education. A video was produced, explaining the concepts of treat-to-target and showing a patient performing self-assessment using DAS-28. Sixty-two patients were interviewed for validation and found the video to be useful and easy to understand, albeit not replacing the physician’s visit. Most common challenges encountered included acceptance of patient empowerment, agreement on DAS-28 as composite measure, production of a comprehensible written Arabic text, and addressing the population cultural mix. Conclusion: Despite challenges, the video was well accepted among patients and can be used for clinical and research purposes. It is particularly useful in pandemic periods where social distancing is recommended.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Humeira Badsha
- Dr Humeira Badsha Medical Center, Dubai, United Arab Emirates
| | | | | | - Ghita Harifi
- Dr Humeira Badsha Medical Center, Dubai, United Arab Emirates
| | - Bhavna Khan
- Mediclinic City Hospital, Dubai, United Arab Emirates
| | | | | | | | | | | | | | - Sahar Saad
- Assiut University, Egypt & King Hamad University Hospital, Bahrain
| | | | - Imad Uthman
- American University of Beirut, Beirut, Lebanon
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16
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Nekvindová L, Vencovský J, Pavelka K, Horák P, Křístková Z, Závada J. Switching first-line targeted therapy after not reaching low disease activity within 6 months is superior to conservative approach: a propensity score-matched analysis from the ATTRA registry. Arthritis Res Ther 2021; 23:11. [PMID: 33407803 PMCID: PMC7789592 DOI: 10.1186/s13075-020-02393-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/13/2020] [Indexed: 01/23/2023] Open
Abstract
Background Treat-to-target (T2T) is a widely accepted strategy for patients with rheumatoid arthritis (RA). It recommends attaining a goal of at least low disease activity (LDA) within 6 months; otherwise, the current therapy should be modified. We aimed to investigate whether switching a first-line targeted therapy (TT) in patients not reaching LDA within 6 months leads to a higher probability of meeting LDA at the 12-month visit in daily clinical practice using data from Czech registry ATTRA. Methods We included patients with RA starting the first-line TT from 1 January 2012 to 31 January 2017 with at least 1-year follow-up. We created four mutually exclusive cohorts based on (1) switching to another TT within the first year and (2) reaching a treatment target (DAS28-ESR ≤ 3.2) at the 6-month visit. The primary outcome was the comparison of odds for reaching remission (REM) or LDA at the 12-month visit between patients switching and not switching TT after not reaching treatment target at 6 months. Before using logistic regression to estimate the odds ratio, we employed the propensity score to match patients at the 6-month visit. Results A total of 1275 patients were eligible for the analysis. Sixty-two patients switched within the first 5 months of the treatment before evaluating treatment response at the 6-month visit (C1); 598 patients reached the treatment target within 6 months of therapy (C2); 124 patients did not reach treatment response at 6-month visit and switched to another therapy (C3), and 491 patients continued with the same treatment despite not reaching LDA at the 6-month visit (C4). We matched 75 patients from cohort C3 and 75 patients from C4 using the propensity score. Patients following the T2T principle (C3) showed 2.8 (95% CI 1.4–5.8; p = 0.005) times increased likelihood of achieving REM/LDA at the 12-month visit compared to patients not following the T2T strategy (C4). Conclusions In daily clinical practice, the application of the T2T strategy is underused. Switching TT after not reaching REM/LDA within the first 6 months leads to a higher probability of achieving REM/LDA in RA patients at the 12-month visit.
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Affiliation(s)
- Lucie Nekvindová
- Institute of Biostatistics and Analyses, Ltd., Brno, Czech Republic.,Institute of Rheumatology, Na Slupi 4, 128 00, Prague, Czech Republic
| | - Jiří Vencovský
- Institute of Rheumatology, Na Slupi 4, 128 00, Prague, Czech Republic.,Department of Rheumatology, First Faculty of Medicine, Prague, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, Na Slupi 4, 128 00, Prague, Czech Republic.,Department of Rheumatology, First Faculty of Medicine, Prague, Czech Republic
| | - Pavel Horák
- Department of Internal Medicine III - Nephrology, Rheumatology, Endocrinology, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Czech Republic.,University Hospital, Olomouc, Czech Republic
| | | | - Jakub Závada
- Institute of Rheumatology, Na Slupi 4, 128 00, Prague, Czech Republic. .,Department of Rheumatology, First Faculty of Medicine, Prague, Czech Republic.
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17
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Chan SJ, Yeo HY, Stamp LK, Treharne GJ, Marra CA. What Are the Preferences of Patients With Rheumatoid Arthritis for Treatment Modification? A Scoping Review. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 14:505-532. [PMID: 33336324 DOI: 10.1007/s40271-020-00488-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Optimal care of rheumatoid arthritis (RA) patients entails regular assessment of disease activity and appropriate adjustment of disease-modifying antirheumatic drugs (DMARDs) until a predefined treatment goal is achieved. This raises questions about the approach to treatment decision making among RA patients and their preference for associated treatment changes. We aimed to systematically identify and synthesize the available evidence of RA patients' preferences regarding DMARD modification with an emphasis on escalating, tapering, stopping, or switching of DMARDs. METHODS A scoping review was undertaken to gauge the breadth of evidence from the range of studies relating to RA patients' preferences for DMARD modification. Pertinent databases were searched for relevant studies published between 1988 and 2019. Conventional content analysis was applied to generate themes about how patients perceive changes to their RA treatment. RESULTS Of the 1730 distinct articles identified, 32 were included for review. Eight studies investigated RA patients' perceptions of switching to other DMARDs, 18 studies reported RA patients' preferences for escalating treatment, and six studies explored the possibility of tapering or stopping of biologic DMARDs. Four overarching themes relating to RA patients' preferences for treatment modification were identified: (i) patient satisfaction, (ii) patients' beliefs, (iii) information needs, and (iv) patient-clinician relationships. CONCLUSION Uptake of treatment changes in clinical practice can be improved by understanding how RA patients approach the decision to modify their treatment and how this relates to their satisfaction, beliefs, information needs, and relationships with clinicians. Future work is needed to systematically determine the significance of these factors in RA patients' decision-making processes.
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Affiliation(s)
- Suz Jack Chan
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, 9054, New Zealand
| | - Hui Yee Yeo
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Carlo A Marra
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
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18
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Tirelli F, Xiao R, Brandon TG, Burnham JM, Chang JC, Weiss PF. Determinants of disease activity change over time in Enthesitis related arthritis: effect of structured outcome monitoring and clinical decision support. Pediatr Rheumatol Online J 2020; 18:79. [PMID: 33059694 PMCID: PMC7558695 DOI: 10.1186/s12969-020-00472-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to test if standardized point-of-care outcome monitoring and clinical decision support (CDS), as compared to standard care, improves disease activity and patient-reported pain in children with enthesitis-related arthritis (ERA). METHODS This was a retrospective cohort study of outcomes of children with ERA after phased implementation of I) standardized outcome monitoring with CDS for polyarticular JIA, and II) CDS for ERA, compared to a pre-intervention group of historical controls. We used multivariable mixed-effects models for repeated measures to test whether implementation phase or other disease characteristics were associated with change over time in disease activity, as measured by the clinical juvenile arthritis disease activity score (cJADAS), and pain. RESULTS One hundred fifty-two ERA patients (41% incident cases) were included with a median age of 14.9 years. Implementation of standardized outcome monitoring or ERA-specific CDS did not result in significant differences in cJADAS or pain over time compared to the pre-intervention cohort. Higher cJADAS at the index visit, pain and more tender entheses were significantly associated with higher cJADAS scores over time (all p < 0.01), while biologic use was associated with lower cJADAS (p = 0.02). Regardless of intervention period, incident ERA cases had a greater rate of cJADAS improvement over time compared to prevalent cases (p < 0.01), but pain persisted over time among both incident and prevalent cases. CONCLUSIONS There was no significant effect of point-of-care outcome monitoring or CDS interventions on disease activity or pain over time in children with ERA in this single center study. Future efforts to improve disease outcomes using standardized outcome monitoring and CDS will need to consider the importance of addressing pain as a target in addition to spondyloarthritis-specific disease activity metrics.
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Affiliation(s)
- Francesca Tirelli
- grid.5608.b0000 0004 1757 3470Department of Pediatrics, Rheumatology Unit, Anna Meyer Children’s Hospital and Department of Women’s and Children’s Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Rui Xiao
- grid.25879.310000 0004 1936 8972Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104 USA
| | - Timothy G. Brandon
- grid.239552.a0000 0001 0680 8770Department of Pediatrics, Division of Rheumatology at the Children’s Hospital of Philadelphia, Wood Bldg 1st foor, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Jon M. Burnham
- grid.25879.310000 0004 1936 8972Department of Pediatrics, Division of Rheumatology at the Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Wood Bldg 1st foor, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Joyce C. Chang
- grid.25879.310000 0004 1936 8972Department of Pediatrics, Division of Rheumatology at the Children’s Hospital of Philadelphia and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Wood Bldg 1st foor, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Pamela F. Weiss
- grid.25879.310000 0004 1936 8972Department of Pediatrics, Division of Rheumatology at the Children’s Hospital of Philadelphia and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Wood Bldg 1st foor, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA ,grid.239552.a0000 0001 0680 8770The Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Room 11121, Philadelphia, PA 19104 USA
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19
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Khaled SAA, NasrEldin E, Makarem YS, Mahmoud HFF. Value of Platelet Distribution Width and Mean Platelet Volume in Disease Activity Score of Rheumatoid Arthritis. J Inflamm Res 2020; 13:595-606. [PMID: 33061525 PMCID: PMC7524192 DOI: 10.2147/jir.s265811] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/19/2020] [Indexed: 01/30/2023] Open
Abstract
Background and Objective Disease activity score 28 (DAS28) for rheumatoid arthritis (RA) is the commonly used DAS; it relies on clinical parameters that could be subjective. This work aimed to create a more accurate DAS for RA and assess its validity. Patients and Methods The study included 98 RA patients and 53 matched controls; they were interviewed, clinically examined, their visual analogue scales (VAS) were reported, and then blood samples were withdrawn for erythrocyte sedimentation rate (ESR), complete blood count (CBC), and C-reactive protein (CRP). Platelet indices (PIs) were obtained from the CBC including Plt (platelet count), mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT). DAS28 was calculated for each patient using RheumaHelper mobile software. Minitab Statistical Package® and SPSS v20 software were used for data analysis. Results and Conclusions Results revealed perfect matching between patients and controls as regarding age and gender. ESR, CRP and PDW were significantly higher in patients than controls; also positive correlations were detected among these variables. A new DAS for RA was developed; ESR, CRP, PDW and MPV were the components for this index. Further analyses showed that this new score was significantly higher in patients than controls and correlated with DAS28 of the patients. Furthermore the new score could identify RA patients from healthy subjects (cut off value < -0.79) and stratified RA patients according to their disease activity into low, intermediate, high, or in remission. Conclusively, we developed a more precise, easily obtained new DAS for RA. This new DAS has both diagnostic/prognostic values in patients with RA.
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Affiliation(s)
- Safaa A A Khaled
- Department of Internal Medicine, Clinical Hematology Unit, Assiut University Hospital/Unit of Bone Marrow Transplantation, South Egypt Cancer Institute, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Eman NasrEldin
- Department of Clinical Pathology, Assiut University Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Yasmine S Makarem
- Department of Rheumatology, Rehabilitation and Physical Medicine, Assiut University Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hamdy F F Mahmoud
- Department of Statistics, Virginia Polytechnic Institute and State University, Blacksburg, VA 24061, USA.,Department of Statistics, Mathematics and Insurance, Faculty of Commerce, Assiut University, Assiut, Egypt
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20
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Jurgens MS, Safy-Khan M, de Hair MJH, Bijlsma JWJ, Welsing PMJ, Tekstra J, Lafeber FPJG, Sasso EH, Jacobs JWG. The multi-biomarker disease activity test for assessing response to treatment strategies using methotrexate with or without prednisone in the CAMERA-II trial. Arthritis Res Ther 2020; 22:205. [PMID: 32907614 PMCID: PMC7487793 DOI: 10.1186/s13075-020-02293-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/11/2020] [Indexed: 12/29/2022] Open
Abstract
Objectives The CAMERA-II trial compared two tight-control, treat-to-target strategies, initiating methotrexate with prednisone (MTX+pred) or MTX with placebo (MTX+plac), in early RA-patients. The multi-biomarker disease activity (MBDA) blood test objectively measures RA disease activity with a score of 1–100. In CAMERA-II, response profiles of the MBDA score, its individual biomarkers, and DAS28 were assessed. Methods We evaluated 92 patients from CAMERA-II of whom clinical data and serum for MBDA testing at baseline and ≥ 1 time-point from months 1, 2, 3, 4, 5, 6, 9, or 12 were available. Changes (∆) from baseline for DAS28 and MBDA score and comparisons of ∆DAS28 and ∆MBDA score over time within the MTX+pred versus the MTX+plac strategy were tested for significance with t tests. Changes in biomarker concentration from baseline to months 1–5 were tested with Wilcoxon signed rank test and tested for difference between treatment arms by Mann-Whitney U test. Results MBDA and DAS28 showed similar response profiles, with gradual improvement over the first 6 months in the MTX+plac group, and in the MTX+pred group faster improvement during month 1, followed by gradual improvement. The 12 MBDA biomarkers could be grouped into 4 categories of response profiles, with significant responses for 4 biomarkers during the MTX+plac strategy and 9 biomarkers during the MTX+pred strategy. Conclusions MBDA tracked treatment response in CAMERA-II similarly to DAS28. More individual MBDA biomarkers tracked treatment response to MTX+pred than to MTX+plac. Four response profiles could be observed. Trial registration CAMERA-II International Standard Randomised Controlled Trial Number: ISRCTN 70365169. Registered on 29 March 2006, retrospectively registered.
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Affiliation(s)
- M S Jurgens
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University of Utrecht, G02.228, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - M Safy-Khan
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University of Utrecht, G02.228, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
| | | | - J W J Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University of Utrecht, G02.228, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - P M J Welsing
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University of Utrecht, G02.228, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - J Tekstra
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University of Utrecht, G02.228, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - F P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University of Utrecht, G02.228, PO Box 85500, 3508, GA, Utrecht, The Netherlands
| | - E H Sasso
- Crescendo Bioscience, Inc., South San Francisco, CA, USA
| | - J W G Jacobs
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University of Utrecht, G02.228, PO Box 85500, 3508, GA, Utrecht, The Netherlands
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Ji L, Xie W, Li G, Zhang Z. Maintenance to target was associated with radiological outcomes in patients with rheumatoid arthritis: a real-world observational cohort study. Clin Rheumatol 2020; 40:1307-1315. [PMID: 32897479 DOI: 10.1007/s10067-020-05385-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/22/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the effect of different maintenance to target on radiologic outcomes in patients with rheumatoid arthritis (RA) in real-world setting. METHODS RA patients enrolled were screened from a longitudinal cohort. The radiographies were evaluated at baseline, after 1-2 years and thereafter every 2 years. An increase of mTSS > 3 from baseline was taken as the primary outcome and accelerated annual radiological progression as the secondary outcome of radiological progression. The maintenance rate (MR) to target was calculated as the proportion of the year fulfilling preset criteria of target over the whole follow-up period. COX regression and logistic analysis were used to determine the effect of variables on radiological outcomes. RESULTS Two hundred forty-three patients were enrolled, with median follow-up of 2 years (3.00). Radiological progression was observed in 43 (17.7%) patients, with annual increase of mTSS 0.20 (1.33). In multivariate analysis, MR was the only independent protective factor of both primary and secondary radiological outcomes in two models [HR 0.09, 95% CI (0.04, 0.22), p < 0.001, model 1; OR 0.21, 95% CI (0.09, 0.49), p < 0.001, model 2]. ACPA positivity was another independent risk factor of secondary outcome [OR 2.96, 95% CI (1.27, 6.86), p = 0.012]. Higher MR was also associated with less radiological progression in established RA patients. Partial MR was not inferior to full maintenance within 4 years in terms of halting radiological progression. CONCLUSION Low MR and ACPA positivity were independent risk factors of poor radiological outcomes in RA patients. No significant difference in radiological progression could be detected between partial and full maintenance group within 4 years in daily practice. KEY POINTS • The first study showing that maintenance to target is beneficial to bone protection in established RA patients in real-world setting • No difference in radiological outcomes between partial and full maintenance group within 4 years.
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Affiliation(s)
- Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street West District, Beijing, China
| | - Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street West District, Beijing, China
| | - Guangtao Li
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street West District, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No.8, Xishiku Street West District, Beijing, China.
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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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23
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Brown Z, Metcalf R, Bednarz J, Spargo L, Lee A, Hill C, Wechalekar M, Stavrou C, James M, Cleland L, Proudman S. Modifiable Lifestyle Factors Associated With Response to Treatment in Early Rheumatoid Arthritis. ACR Open Rheumatol 2020; 2:371-377. [PMID: 32453505 PMCID: PMC7301874 DOI: 10.1002/acr2.11132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/13/2020] [Indexed: 01/18/2023] Open
Abstract
Objective We aimed to evaluate the associations between response to algorithm‐directed treat‐to‐target conventional synthetic disease‐modifying antirheumatic drug therapy and potentially modifiable lifestyle factors, including dietary fish oil supplementation, body mass index (BMI), and smoking history in a rheumatoid arthritis (RA) inception cohort. Methods Patients with RA with a duration of less than 12 months were reviewed every 3 to 6 weeks to adjust therapy according to disease response. All patients received advice to take fish oil supplements, and omega‐3 status was measured as plasma levels of eicosapentaenoic acid (EPA). Lifestyle factors and other variables potentially prognostic for 28‐joint Disease Activity Score (DAS28) remission and DAS28 low disease activity (LDA) at the 12‐month visit were included in multivariable logistic regression models. Results Of 300 participants, 57.7% reached DAS28 LDA, and 43.7% were in DAS28 remission at 1 year. Increase in plasma EPA was associated with an increase in the odds of being in LDA (adjusted odds ratio [OR] = 1.27; P < 0.0001) and remission (adjusted OR = 1.21; P < 0.001). There was some evidence that the effect of BMI on LDA might be modified by smoking history. An increase in BMI was associated with a decrease in the odds of being in LDA in current and former smokers but had no impact on LDA in patients who had never smoked. There were no meaningful associations between BMI or smoking history and remission. Conclusion Omega‐3 status, BMI, and smoking history are potential predictors of outcome in early RA. The possibility of an effect modification by smoking on the predictive value of BMI merits further investigation.
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Affiliation(s)
- Zoe Brown
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Robert Metcalf
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jana Bednarz
- University of Adelaide, Adelaide, South Australia, Australia
| | | | - Anita Lee
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Catherine Hill
- Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Mihir Wechalekar
- Flinders Medical Centre and Flinders University, Bedford Park, South Australia, Australia
| | | | - Michael James
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Les Cleland
- Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Susanna Proudman
- Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
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24
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Schoemaker CG, Swart JF, Wulffraat NM. Treating juvenile idiopathic arthritis to target: what is the optimal target definition to reach all goals? Pediatr Rheumatol Online J 2020; 18:34. [PMID: 32299430 PMCID: PMC7164231 DOI: 10.1186/s12969-020-00428-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 04/03/2020] [Indexed: 12/28/2022] Open
Abstract
In 2018, an international Task Force formulated recommendations for treating Juvenile Idiopathic Arthritis (JIA) to target. The Task Force has not yet resolved three issues. The first issue is the lack of a single "best" target. The Task Force decided not to recommend the use of a specific instrument to assess inactive disease or remission. Recent studies underscore the use of a broad target definition. The second issue is the basic assumption that a treatment aggressively aimed at the target will have 'domino effects' on other treatment goals as well. Thus far, this assumption was not confirmed for pain, fatigue and stiffness. The third issue is shared decision-making, and the role of individual patient targets. Nowadays, patients and parents should have a more active role in choosing targets and their personal treatment goals. In our department the electronic medical records have been restructured in such a way that the patient's personal treatment goals with a target date appears on the front page. The visualization of their specific personal goals helps us to have meaningful discussions on the individualized treatment strategy and to share decisions. In conclusion, a joint treat to target (T2T) strategy is a promising approach for JIA. The Task Force formulated valuable overarching principles and a first version of recommendations. However, implementation of T2T needs to capture more than just inactive disease. Patients and parents should have an active role in choosing personal targets as well.
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Affiliation(s)
- Casper G. Schoemaker
- grid.7692.a0000000090126352Department of Pediatric Rheumatology and Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Room KC.03.063.0, P.O. box 85090, 3508 AB Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands ,Netherlands JIA Patient and Parent Organisation, member of ENCA, Rijssen, The Netherlands
| | - Joost F. Swart
- grid.7692.a0000000090126352Department of Pediatric Rheumatology and Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Room KC.03.063.0, P.O. box 85090, 3508 AB Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
| | - Nico M. Wulffraat
- grid.7692.a0000000090126352Department of Pediatric Rheumatology and Immunology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Room KC.03.063.0, P.O. box 85090, 3508 AB Utrecht, The Netherlands ,grid.5477.10000000120346234Faculty of Medicine, Utrecht University, Utrecht, The Netherlands
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25
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Ramiro S, Landewé RB, van der Heijde D, Sepriano A, FitzGerald O, Ostergaard M, Homik J, Elkayam O, Thorne JC, Larche M, Ferraccioli G, Backhaus M, Boire G, Combe B, Schaeverbeke T, Saraux A, Dougados M, Rossini M, Govoni M, Sinigaglia L, Cantagrel AG, Allaart CF, Barnabe C, Bingham CO, Tak PP, van Schaardenburg D, Hammer HB, Dadashova R, Hutchings E, Paschke J, Maksymowych WP. Is treat-to-target really working in rheumatoid arthritis? a longitudinal analysis of a cohort of patients treated in daily practice (RA BIODAM). Ann Rheum Dis 2020; 79:453-459. [PMID: 32094157 DOI: 10.1136/annrheumdis-2019-216819] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate whether following a treat-to-target (T2T)-strategy in daily clinical practice leads to more patients with rheumatoid arthritis (RA) meeting the remission target. METHODS RA patients from 10 countries starting/changing conventional synthetic or biological disease-modifying anti-rheumatic drugs were assessed for disease activity every 3 months for 2 years (RA BIODAM (BIOmarkers of joint DAMage) cohort). Per visit was decided whether a patient was treated according to a T2T-strategy with 44-joint disease activity score (DAS44) remission (DAS44 <1.6) as the target. Sustained T2T was defined as T2T followed in ≥2 consecutive visits. The main outcome was the achievement of DAS44 remission at the subsequent 3-month visit. Other outcomes were remission according to 28-joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR), Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI) and American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) Boolean definitions. The association between T2T and remission was tested in generalised estimating equations models. RESULTS In total 4356 visits of 571 patients (mean (SD) age: 56 (13) years, 78% female) were included. Appropriate application of T2T was found in 59% of the visits. T2T (vs no T2T) did not yield a higher likelihood of DAS44 remission 3 months later (OR (95% CI): 1.03 (0.92 to 1.16)), but sustained T2T resulted in an increased likelihood of achieving DAS44 remission (OR: 1.19 (1.03 to 1.39)). Similar results were seen with DAS28-ESR remission. For more stringent definitions (CDAI, SDAI and ACR/EULAR Boolean remission), T2T was consistently positively associated with remission (OR range: 1.16 to 1.29), and sustained T2T had a more pronounced effect on remission (OR range: 1.49 to 1.52). CONCLUSION In daily clinical practice, the correct application of a T2T-strategy (especially sustained T2T) in patients with RA leads to higher rates of remission.
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Affiliation(s)
- Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands .,Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Robert Bm Landewé
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands.,Department of Rheumatology, Amsterdam Rheumatology Center, Amsterdam, The Netherlands
| | | | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Oliver FitzGerald
- St Vincent's University Hospital and Conway Institute for Biomolecular Research, University College Dublin, Dublin, Ireland
| | - Mikkel Ostergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Joanne Homik
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ori Elkayam
- Tel Aviv Sourasky Medical Center and the "Sackler" Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J Carter Thorne
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Margaret Larche
- Departments of Medicine and Pediatrics, Divisions of Rheumatology, Clinical Immunolgoy and Allergy, McMaster University, Hamilton, Ontario, Canada
| | | | - Marina Backhaus
- Park-Klinik Weissensee, Academic Hospital of the Charité, Berlin, Germany
| | - Gilles Boire
- Department of Medicine/Division of Rheumatology, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Bernard Combe
- CHU Montpellier and Montpellier University, Montpellier, France
| | - Thierry Schaeverbeke
- Department of Rheumatology, FHU ACRONIM, University Hospital of Bordeaux, University of Bordeaux, Bordeaux, France
| | | | - Maxime Dougados
- Rheumatology Department, Paris Descartes University, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Maurizio Rossini
- Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Marcello Govoni
- Rheumatology Unit, S. Anna Hospital and University of Ferrara, Ferrara, Italy
| | - Luigi Sinigaglia
- Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - Alain G Cantagrel
- Department of Rheumatology, Paul Sabatier University, Toulouse, France
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cheryl Barnabe
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Paul P Tak
- Department of Rheumatology, Amsterdam Rheumatology Center, Amsterdam, The Netherlands.,Department of Rheumatology, Ghent University, Ghent, Belgium.,Department of Medicine, Cambridge University, Cambridge, United Kingdom
| | | | | | | | | | - Joel Paschke
- CaRE Arthritis LTD, University of Alberta, Edmonton, Alberta, Canada
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Treatment strategies are more important than drugs in the management of rheumatoid arthritis. Clin Rheumatol 2020; 39:1363-1368. [PMID: 32088801 DOI: 10.1007/s10067-020-05001-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023]
Abstract
The treatment of inflammatory arthritides has been changed dramatically in the past two decades with the introduction of the biological (b) disease-modifying anti-rheumatic drugs (DMARDs) as well as the targeting synthetic (ts) DMARDs that can be used as monotherapy or in combination with conventional synthetic (cs) DMARDs. The concept of treat to target (T2T) and tight control monitoring of disease activity represents a therapeutic paradigm of modern rheumatology. In rheumatoid arthritis (RA), this treatment approach has proven to be effective in many clinical trials and is now a well-established approach. The most common treatment strategies rely on the combination of csDMARDs (mainly methotrexate, sulfasalazine and hydroxychloroquine). This comes from different studies which compare the outcomes of combination therapies versus csDMARD monotherapy or versus methotrexate plus biologics in early RA patients. Here, we review the literature of the most important T2T studies for RA patients. The results showed that a tight control strategy appears to be more important than a specific drug to control RA. T2T approach aiming for remission or low disease activity can be achieved in early RA patients using less expensive drugs in comparison to newer drugs and this may need to be recognised in the future recommendations for the management of RA. KEY POINTS: • Tight-control and treat-to-target (T2T) strategies are the cornerstone in achieving remission or low disease activity in rheumatoid arthritis (RA) • A plethora of clinical trials has confirmed the efficacy of csDMARDs when the tight-control and T2T strategies are applied • T2T and tight-control strategies are a less expensive option in comparison to newer drugs and may be recognised in the future recommendations for the management of RA. • Treatment decisions and strategies are more important than just the drugs.
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Disease activity-based management of rheumatoid arthritis in Dutch daily clinical practice has improved over the past decade. Clin Rheumatol 2020; 39:1131-1139. [PMID: 31997083 DOI: 10.1007/s10067-019-04913-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/18/2019] [Accepted: 12/23/2019] [Indexed: 12/19/2022]
Abstract
To re-evaluate the adherence to clinical practice guidelines recommended disease activity-based management of rheumatoid arthritis (RA) in daily clinical practice, among Dutch rheumatologists in the past decade. In 2007, disease activity was measured in only 16% of outpatient visits. All rheumatologists that participated in the 2007 study were invited to re-enter our study in 2016/2017. If necessary, data were supplemented with data from other rheumatologists. For all 26 rheumatologists who agreed to participate in our study, data were collected from 30 consecutive patients that visited the outpatient clinic. Per patient, data from four consecutive rheumatologist outpatient visits were collected. Since 2007, disease activity was measured more frequently in Dutch daily clinical practice, increasing from 16 to 79% of visits (2440/3081 visits). In addition, intensification of medication based on disease activity scores increased from 33 to 50% of visits (260/525 visits). DAS/DAS28 was the most frequently used disease activity measure (1596/2440 visits). There was a wide variation among rheumatologists in measuring disease activity and intensification of medication, 20-100% and 0-75% respectively. Over the past years, there has been a large improvement in disease activity assessment in daily clinical practice. Disease activity-based medication intensifications, also called tight control or treat to target, increased to a lesser extent. Large variation between different rheumatologists and clinics indicates that there is still room for improvement. Key Points • Following guideline dissemination disease activity is assessed more frequently (79%). • There is large variation between rheumatologists, indicating room for improvement. • Finding factors that explain variation is necessary to improve tight control in daily practice.
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28
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Sepriano A, Ramiro S, FitzGerald O, Østergaard M, Homik J, van der Heijde D, Elkayam O, Thorne JC, Larché MJ, Ferraccioli G, Backhaus M, Burmester GR, Boire G, Combe B, Schaeverbeke T, Saraux A, Dougados M, Rossini M, Govoni M, Sinigaglia L, Cantagrel A, Barnabe C, Bingham CO, Tak PP, van Schaardenburg D, Hammer HB, Paschke J, Dadashova R, Hutchings E, Landewé R, Maksymowych WP. Adherence to Treat-to-target Management in Rheumatoid Arthritis and Associated Factors: Data from the International RA BIODAM Cohort. J Rheumatol 2019; 47:809-819. [DOI: 10.3899/jrheum.190303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2019] [Indexed: 11/22/2022]
Abstract
Objective.Compelling evidence supports a treat-to-target (T2T) strategy for optimal outcomes in rheumatoid arthritis (RA). There is limited knowledge regarding the factors that impede implementation of T2T, particularly in a setting where adherence to T2T is protocol-specified. We aimed to assess clinical factors that associate with failure to adhere to T2T.Methods.Patients with RA from 10 countries who were starting or changing conventional synthetic disease-modifying antirheumatic drugs and/or starting tumor necrosis factor inhibitors were followed for 2 years. Participating physicians were required per protocol to adhere to the T2T strategy. Factors influencing adherence to T2T low disease activity (T2T-LDA; 44-joint count Disease Activity Score ≤ 2.4) were analyzed in 2 types of binomial generalized estimating equations models: (1) including only baseline features (baseline model); and (2) modeling variables that inherently vary over time as such (longitudinal model).Results.A total of 571 patients were recruited and 439 (76.9%) completed 2-year followup. Failure of adherence to T2T-LDA was noted in 1765 visits (40.5%). In the baseline multivariable model, a high number of comorbidities (OR 1.10, 95% CI 1.02–1.19), smoking (OR 1.32, 95% CI 1.08–1.63) and high number of tender joints (OR 1.03, 95% CI 1.02–1.04) were independently associated with failure to implement T2T, while anticitrullinated protein antibody/rheumatoid factor positivity (OR 0.63, 95% CI 0.50–0.80) was a significant facilitator of T2T. Results were similar in the longitudinal model.Conclusion.Lack of adherence to T2T in the RA BIODAM cohort was evident in a substantial proportion despite being a protocol requirement, and this could be predicted by clinical features. [Rheumatoid Arthritis (RA) BIODAM cohort; ClinicalTrials.gov: NCT01476956].
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Batko B, Batko K, Krzanowski M, Żuber Z. Physician Adherence to Treat-to-Target and Practice Guidelines in Rheumatoid Arthritis. J Clin Med 2019; 8:E1416. [PMID: 31500394 PMCID: PMC6780913 DOI: 10.3390/jcm8091416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 08/26/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022] Open
Abstract
Principles of treat-to-target (T2T) have been widely adopted in both multinational and regional guidelines for rheumatoid arthritis (RA). Several questionnaire studies among physicians and real-world data have suggested that an evidence-practice gap exists in RA management. Investigating physician adherence to T2T, which requires a process measure, is difficult. Different practice patterns among physicians are observed, while adherence to protocolized treatment declines over time. Rheumatologist awareness, agreement, and claims of adherence to T2T guidelines are not always consistent with medical records. Comorbidities, a difficult disease course, communication barriers, and individual preferences may hinder an intensive, proactive treatment stance. Interpreting deviations from protocolized treatment/T2T guidelines requires sufficient clinical context, though higher adherence seems to improve clinical outcomes. Nonmedical constraints in routine care may consist of barriers in healthcare structure and socioeconomic factors. Therefore, strategies to improve the institution of T2T should be tailored to local healthcare. Educational interventions to improve T2T adherence among physicians may show a moderate, although beneficial effect. Meanwhile, a proportion of patients with inadequately controlled RA exists, while management decisions may not be in accordance with T2T. Physicians tend to be aware of current guidelines, but their institution in routine practice seems challenging, which warrants attention and further study.
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Affiliation(s)
- Bogdan Batko
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, Gustawa Herlinga-Grudźińskiego 1 St, 30-705 Cracow, Poland.
- Department of Rheumatology, J. Dietl Specialist Hospital, Skarbowa 1 St, 31-121 Cracow, Poland.
| | - Krzysztof Batko
- Chair and Head of Nephrology, Jagiellonian University Medical College, Kopernika St 15c, 31-501 Cracow, Poland.
| | - Marcin Krzanowski
- Chair and Head of Nephrology, Jagiellonian University Medical College, Kopernika St 15c, 31-501 Cracow, Poland.
| | - Zbigniew Żuber
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski University, Gustawa Herlinga-Grudźińskiego 1 St, 30-705 Cracow, Poland.
- Ward for Older Children with Neurology and Rheumatology Subdivision, St. Louis Regional Specialised Children's Hospital, 31-503 Cracow, Poland.
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Falzer PR. Treat‐to‐target and shared decision making in rheumatoid arthritis treatment: Is it feasible? Int J Rheum Dis 2019; 22:1706-1713. [PMID: 31359630 DOI: 10.1111/1756-185x.13664] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 05/15/2019] [Accepted: 06/19/2019] [Indexed: 02/01/2023]
Affiliation(s)
- Paul R. Falzer
- Department of Veterans Affairs, Clinical Epidemiology Research Center VA Connecticut West Haven Campus West Haven CT USA
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Gazitt T, Oren S, Reitblat T, Lidar M, Gurman AB, Rosner I, Halabe N, Feld J, Kassem S, Lavi I, Elkayam O, Zisman D. Treat-to-target concept implementation for evaluating rheumatoid arthritis patients in daily practice. Eur J Rheumatol 2019; 6:136-141. [PMID: 31329541 DOI: 10.5152/eurjrheum.2019.18195] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/14/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE We aimed to assess the implementation of the treat-to-target (T2T) concept in rheumatoid arthritis (RA) patients in daily practice. METHODS All RA patients visiting one of the 7 academic medical centers in Israel in June 2015 with at least 3 previous clinic visits were included in this study. A common questionnaire was used to collect data from patients' medical records, and two independent rheumatologists evaluated the collected data for the implementation of the T2T concept. The associations between T2T implementation and the categorical and continuous variables were assessed. RESULTS The study included 724 patients with a mean (standard deviation) age of 62.6 (13.97) years and 575 (80.4%) of them were women. Four centers used more than one scoring method, with Disease Activity Score-28 and Clinical Disease Activity Index) being most commonly used. Only 276 (38.1%) patients had disease score results in ≥3 visits, and the T2T recommendations were implemented for 245 (33.8%) of the 724 patients. The rate of implementation was higher in younger (p=0.028) rheumatoid factor-positive patients (p=0.011) and varied between centers (11.1%-87% p<0.0001). T2T implementation did not correlate to gender, place of residence, education, tobacco use, treatment regimens, and presence of erosions or comorbidities. CONCLUSION The T2T concept was implemented on only 33.8% of patients and was not affected by RA disease severity. Further studies are needed to determine the reasons for this deviation from the T2T standard of care for RA as well as its consequences.
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Affiliation(s)
- Tal Gazitt
- Department of Rheumatology, Carmel Medical Center, Haifa, Israel
| | - Shirley Oren
- Department of Rheumatology, Rabin Medical Center, Petah Tikva, Israel
| | - Tatiana Reitblat
- Department of Rheumatology, Barzilai Medical Center, Ashkelon, Israel
| | - Merav Lidar
- Rheumatology Unit, Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel Aviv, Israel
| | | | - Itzhak Rosner
- Department of Rheumatology, Bnai Zion Medical Center, Haifa, Israel
| | - Nimer Halabe
- Department of Internal Medicine, Carmel Medical Center, Haifa, Israel
| | - Joy Feld
- Department of Rheumatology, Carmel Medical Center, Haifa, Israel
| | - Sameer Kassem
- Department of Internal Medicine, Carmel Medical Center, Haifa, Israel
| | - Idit Lavi
- Department of Community Medicine and Epidemiology, Carmel Medical Center, Haifa, Israel
| | - Ori Elkayam
- Department of Rheumatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Devy Zisman
- Department of Rheumatology, Carmel Medical Center, Haifa, Israel
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Wei W, Sullivan E, Blackburn S, Chen CI, Piercy J, Curtis JR. The prevalence and types of discordance between physician perception and objective data from standardized measures of rheumatoid arthritis disease activity in real-world clinical practice in the US. BMC Rheumatol 2019; 3:25. [PMID: 31312786 PMCID: PMC6610934 DOI: 10.1186/s41927-019-0073-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 05/31/2019] [Indexed: 02/06/2023] Open
Abstract
Background Heterogeneity in assessments of rheumatoid arthritis (RA) disease remission, based on physician judgment and patient self-reports versus standardized measures, have previously been reported. This study explored the prevalence and types of discordance between physician perception versus objective data of RA disease activity in real-world clinical practice in the US. Methods Data were from the Adelphi RA Disease Specific Programme (DSP; January to March 2014), a cross-sectional survey of US rheumatologists and their patients. RA remission based on physician judgment versus Disease Activity Score in 28 joints (3)-erythrocyte sedimentation rate (DAS28(3)-ESR) and Clinical Disease Activity Index (CDAI) scores were compared using descriptive analyses; patient and physician factors associated with discordance were identified using bivariate and multivariate analyses. Results Of 101 rheumatologists participating (completing patient-record forms for 843 patients), 56.4% based assessment of remission on clinical judgment alone. Of 531 patients eligible for the discordance analysis, 49.7% were in remission based on rheumatologists' evaluation, and 30.7% were eligible based on DAS28(3)-ESR. Compared with DAS28(3)-ESR criteria, 25.8% of patients' disease remission was negatively discordant (overestimated remission) based on clinical perception. These patients were mostly administered biologic disease-modifying antirheumatic drugs and were without a treat-to-target strategy followed by their rheumatologist (P < 0.05). These patients were also more likely to have experienced a higher level of pain as well as increased joint inflammation and damage (e.g. destruction of cartilage, thinning of bone, and/or synovium inflammation) compared with concordant patients (P < 0.005). Conversely, 6.8% of rheumatologists were positively discordant (under estimated remission) versus the DAS28(3)-ESR. Sensitivity analysis indicated different levels of discordance using CDAI, with 35.6% negative discordance and 1.3% positive discordance of rheumatologist-assessed disease remission compared with objective data. Conclusion There is discordance between RA remission as assessed by rheumatologist perception versus standardized measures among those in the US DSP sample. Our study identified the factors associated with the discordance which may inform strategies to enhance assessments of RA disease remission.
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Affiliation(s)
- Wenhui Wei
- 1Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY USA
| | | | | | - Chieh-I Chen
- 1Regeneron Pharmaceuticals, Inc., 777 Old Saw Mill River Road, Tarrytown, NY USA
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Buckley L, Ware E, Kreher G, Wiater L, Mehta J, Burnham JM. Outcome Monitoring and Clinical Decision Support in Polyarticular Juvenile Idiopathic Arthritis. J Rheumatol 2019; 47:273-281. [PMID: 31308202 DOI: 10.3899/jrheum.190268] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Inconsistent assessment and treatment may impair juvenile idiopathic arthritis (JIA) outcomes. We aimed to improve polyarticular JIA (rheumatoid factor-positive and -negative) outcomes by standardizing point-of-care disease activity monitoring and implementing clinical decision support (CDS) to reduce treatment variation. METHODS We performed a quality improvement initiative in an outpatient pediatric rheumatology practice. The interventions, implemented from April to November 2016, included standardized disease activity measurement, disease activity target review, and phased introduction of polyarticular JIA CDS to guide medication selection, dosing, treatment duration, and tapering. Process measures included visit-level target attestation (goal: 50%) and CDS use (goal: 15%). Our goal was to reduce the polyarticular JIA clinical Juvenile Arthritis Disease Activity Score (cJADAS-10) by at least 10%. Included patients had at least 2 visits from April 2016 through July 2017, and were classified as having early (≤ 6 mos) or established disease (> 6 mos). RESULTS Patients with polyarticular JIA (n = 97; 81% established disease) were observed for 10.3 months (interquartile range: 6.4-12.3). Target attestation and CDS use occurred in a mean of 77% and 45% of polyarticular JIA visits, respectively. The median cJADAS-10 decreased significantly in both early (16.5 to 2.7, p < 0.001) and established polyarticular JIA (2.1 to 1.0, p = 0.01). A high proportion of patients with early disease received biologic therapy (73.7%). In established disease, although prescription of nonbiologic and biologic disease-modifying antirheumatic drugs remained similar overall, adalimumab prescribing increased (12.8% to 23.1%, p = 0.008). CONCLUSION Implementation of structured disease activity monitoring and CDS in polyarticular JIA was associated with significant reductions in disease activity scores in both early and established disease.
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Affiliation(s)
- Lisa Buckley
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Eileen Ware
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Genna Kreher
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Lisa Wiater
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Jay Mehta
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia
| | - Jon M Burnham
- From the Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA. .,L. Buckley, MD, Fellow, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; E. Ware, RN, BSN, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; G. Kreher, MPH, Office of Clinical Quality Improvement, Children's Hospital of Philadelphia; L. Wiater, RN, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J. Mehta, MD, Associate Professor, Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia; J.M. Burnham, MD, MSCE, Associate Professor, Department of Pediatrics, Division of Rheumatology, and the Office of Clinical Quality Improvement, Children's Hospital of Philadelphia.
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Verhoef LM, van den Bemt BJF, van der Maas A, Vriezekolk JE, Hulscher ME, van den Hoogen FHJ, Jacobs WCH, van Herwaarden N, den Broeder AA. Down-titration and discontinuation strategies of tumour necrosis factor-blocking agents for rheumatoid arthritis in patients with low disease activity. Cochrane Database Syst Rev 2019; 5:CD010455. [PMID: 31125448 PMCID: PMC6534285 DOI: 10.1002/14651858.cd010455.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anti-tumour necrosis factor (TNF) agents are effective in treating people with rheumatoid arthritis (RA), but are associated with (dose-dependent) adverse effects and high costs. To prevent overtreatment, several trials have assessed the effectiveness of down-titration compared with continuation of the standard dose. This is an update of a Cochrane Review published in 2014. OBJECTIVES To evaluate the benefits and harms of down-titration (dose reduction, discontinuation, or disease activity-guided dose tapering) of anti-TNF agents on disease activity, functioning, costs, safety, and radiographic damage compared with usual care in people with RA and low disease activity. SEARCH METHODS We searched MEDLINE, Embase, Web of Science and CENTRAL (29 March 2018) and four trial registries (11 April 2018) together with reference checking, citation searching, and contact with study authors to identify additional studies. We screened conference proceedings (American College of Rheumatology and European League Against Rheumatism 2005-2017). SELECTION CRITERIA Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing down-titration (dose reduction, discontinuation, disease activity-guided dose tapering) of anti-TNF agents (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab) to usual care/no down-titration in people with RA and low disease activity. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. MAIN RESULTS One previously included trial was excluded retrospectively in this update because it was not an RCT/CCT. We included eight additional trials, for a total of 14 studies (13 RCTs and one CCT, 3315 participants in total) reporting anti-TNF down-titration. Six studies (1148 participants) reported anti-TNF dose reduction compared with anti-TNF continuation. Eight studies (2111 participants) reported anti-TNF discontinuation compared with anti-TNF continuation (three studies assessed both anti-TNF discontinuation and dose reduction), and three studies assessed disease activity-guided anti-TNF dose tapering (365 participants). These studies included data on all anti-TNF agents, but primarily adalimumab and etanercept. Thirteen studies were available in full text, one was available as abstract. We assessed the included studies generally at low to moderate risk of bias; our main concerns were bias due to open-label treatment and unblinded outcome assessment. Clinical heterogeneity between the trials was high. The included studies were performed at clinical centres around the world and included people with early as well as established RA, the majority of whom were female with mean ages between 47 and 60. Study durations ranged from 6 months to 3.5 years.We found that anti-TNF dose reduction leads to little or no difference in mean disease activity score (DAS28) after 26 to 52 weeks (high-certainty evidence, mean difference (MD) 0.06, 95% confidence interval (CI) -0.11 to 0.24, absolute risk difference (ARD) 1%) compared with continuation. Also, anti-TNF dose reduction does not result in an important deterioration in function after 26 to 52 weeks (Health Assessment Questionnaire Disability Index (HAQ-DI)) (high-certainty evidence, MD 0.09, 95% CI 0.00 to 0.19, ARD 3%). Next to this, anti-TNF dose reduction may slightly reduce the proportion of participants switched to another biologic (low-certainty evidence), but probably slightly increases the proportion of participants with minimal radiographic progression after 52 weeks (moderate-certainty evidence, risk ratio (RR) 1.22, 95% CI 0.76 to 1.95, ARD 2% higher). Anti-TNF dose reduction may cause little or no difference in serious adverse events, withdrawals due to adverse events and proportion of participants with persistent remission (low-certainty evidence).Results show that anti-TNF discontinuation probably slightly increases the mean disease activity score (DAS28) after 28 to 52 weeks (moderate-certainty evidence, MD 0.96, 95% CI 0.67 to 1.25, ARD 14%), and that the RR of persistent remission lies between 0.16 and 0.77 (low-certainty evidence). Anti-TNF discontinuation increases the proportion participants with minimal radiographic progression after 52 weeks (high-certainty evidence, RR 1.69, 95% CI 1.10 to 2.59, ARD 7%) and may lead to a slight deterioration in function (HAQ-DI) (low-certainty evidence). It is uncertain whether anti-TNF discontinuation influences the number of serious adverse events (due to very low-certainty evidence) and the number of withdrawals due to adverse events after 28 to 52 weeks probably increases slightly (moderate-certainty evidence, RR 1.46, 95% CI 0.75 to 2.84, ARD 1% higher).Anti-TNF disease activity-guided dose tapering may result in little or no difference in mean disease activity score (DAS28) after 72 to 78 weeks (low-certainty evidence). Furthermore, anti-TNF disease activity-guided dose tapering results in little or no difference in the proportion of participants with persistent remission after 18 months (high-certainty evidence, RR 0.89, 95% CI 0.75 to 1.06, ARD -9%) and may result in little or no difference in switching to another biologic (low-certainty evidence). Anti-TNF disease activity-guided dose tapering may slightly increase proportion of participants with minimal radiographic progression (low-certainty evidence) and probably leads to a slight deterioration of function after 18 months (moderate-certainty evidence, MD 0.2 higher, 0.02 lower to 0.42 higher, ARD 7% higher), It is uncertain whether anti-TNF disease activity-guided dose tapering influences the number of serious adverse events due to very low-certainty evidence. AUTHORS' CONCLUSIONS We found that fixed-dose reduction of anti-TNF, after at least three to 12 months of low disease activity, is comparable to continuation of the standard dose regarding disease activity and function, and may be comparable with regards to the proportion of participants with persistent remission. Discontinuation (also without disease activity-guided adaptation) of anti-TNF is probably inferior to continuation of treatment with respect to disease activity, the proportion of participants with persistent remission, function, and minimal radiographic damage. Disease activity-guided dose tapering of anti-TNF is comparable to continuation of treatment with respect to the proportion of participants with persistent remission and may be comparable regarding disease activity.Caveats of this review are that available data are mainly limited to etanercept and adalimumab, the heterogeneity between studies, and the use of superiority instead of non-inferiority designs.Future research should focus on the anti-TNF agents infliximab and golimumab; assessment of disease activity, function, and radiographic outcomes after longer follow-up; and assessment of long-term safety, cost-effectiveness, and predictors for successful down-titration. Also, use of a validated flare criterion, non-inferiority designs, and disease activity-guided tapering instead of fixed-dose reduction or discontinuation would allow researchers to better interpret study findings and generalise to clinical practice.
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Affiliation(s)
- Lise M Verhoef
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
| | - Bart JF van den Bemt
- Sint MaartenskliniekDepartment of PharmacyHengstdal 3NijmegenGelderlandNetherlands6522JV
- Radboud University Medical CenterDepartment of PharmacyNijmegenNetherlands
| | - Aatke van der Maas
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
| | - Johanna E Vriezekolk
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
| | - Marlies E Hulscher
- Radboud Institute for Health Sciences, Radboud University Medical CenterIQ healthcarePO Box 9101117 KWAZONijmegenNetherlands6500 HB
| | - Frank HJ van den Hoogen
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
- Radboud University Medical CenterDepartment of RheumatologyNijmegenNetherlands
| | - Wilco CH Jacobs
- The Health ScientistFraeylemastraat 13The HagueNetherlands2532 TX
| | - Noortje van Herwaarden
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
| | - Alfons A den Broeder
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
- Radboud University Medical CenterDepartment of RheumatologyNijmegenNetherlands
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Zak A, Corrigan C, Yu Z, Bitton A, Fraenkel L, Harrold L, Smolen JS, Solomon DH. Barriers to treatment adjustment within a treat to target strategy in rheumatoid arthritis: a secondary analysis of the TRACTION trial. Rheumatology (Oxford) 2019; 57:1933-1937. [PMID: 29982720 DOI: 10.1093/rheumatology/key179] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Indexed: 11/15/2022] Open
Abstract
Objectives Adherence to a treat to target (TTT) strategy is a recommended paradigm for RA; however, research shows there are many barriers to implementation. We conducted a trial to improve TTT implementation, and herein examine barriers to treatment adjustment within TTT among patient visits not in agreement with the TTT paradigm. Methods Chart review assessed TTT implementation based on documentation of four items: designation of a treatment target, recording a disease activity measure, shared-decision making when applicable and adjusting treatment when disease activity was not at target. A treatment decision not in agreement with the TTT paradigm was defined as lack of treatment adjustment when disease activity was not at the pre-determined treatment target. Providers were encouraged to report the barriers to treatment change; these were categorized and analysed by study staff. Multiple barriers were possible for one visit. Results Eighty-three visits not in agreement with the TTT strategy were observed in 74 patients, during which 90 reported barriers to treatment adjustment were noted. Common barriers to adjusting treatment included patient preference in 37.1% of visits and elevated disease activity measure despite no objective evidence of active RA in 38.6% of visits. Conclusion An elevated disease activity measure not reflective of RA disease activity and patient preference are the two leading barriers to treatment adjustment to TTT in RA. Understanding barriers to adherence should guide interventions aimed at using better markers of disease activity and improving alignment with patient preference, with the overarching goal of enhancing TTT adherence.
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Affiliation(s)
- Agnes Zak
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Zhi Yu
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Asaf Bitton
- Division of General Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Liana Fraenkel
- Division of Rheumatology, Yale School of Medicine, West Haven Veterans Affairs Health System, New Haven, CT, USA
| | - Leslie Harrold
- Department of Orthopaedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, MA, USA
| | - Josef S Smolen
- Division of Rheumatology, University of Vienna, Vienna, Austria
| | - Daniel H Solomon
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
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Daien C, Hua C, Gaujoux-Viala C, Cantagrel A, Dubremetz M, Dougados M, Fautrel B, Mariette X, Nayral N, Richez C, Saraux A, Thibaud G, Wendling D, Gossec L, Combe B. Update of French society for rheumatology recommendations for managing rheumatoid arthritis. Joint Bone Spine 2019; 86:135-150. [DOI: 10.1016/j.jbspin.2018.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
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Hughes CD, Scott DL, Ibrahim F. Intensive therapy and remissions in rheumatoid arthritis: a systematic review. BMC Musculoskelet Disord 2018; 19:389. [PMID: 30376836 PMCID: PMC6208111 DOI: 10.1186/s12891-018-2302-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 10/11/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND We systematically reviewed the effectiveness of intensive treatment strategies in achieving remission in patients with both early and established Rheumatoid Arthritis (RA). METHODS A systematic literature review and meta-analysis evaluated trials and comparative studies reporting remission in RA patients treated intensively with disease modifying anti-rheumatic drugs (DMARDs), biologics and Janus Kinase (JAK) inhibitors. Analysis used RevMan 5.3 to report relative risks (RR) in random effects models with 95% confidence intervals (CI). RESULTS We identified 928 publications: 53 studies were included (48 superiority studies; 6 head-to-head trials). In the superiority studies 3013/11259 patients achieved remission with intensive treatment compared with 1211/8493 of controls. Analysis of the 53 comparisons showed a significant benefit for intensive treatment (RR 2.23; 95% CI 1.90, 2.61). Intensive treatment increased remissions in both early RA (23 comparisons; RR 1.56; 1.38, 1.76) and established RA (29 comparisons RR 4.21, 2.92, 6.07). All intensive strategies (combination DMARDs, biologics, JAK inhibitors) increased remissions. In the 6 head-to-head trials 317/787 patients achieved remission with biologics compared with 229/671 of patients receiving combination DMARD therapies and there was no difference between treatment strategies (RR 1.06; 0.93. 1.21). There were differences in the frequency of remissions between early and established RA. In early RA the frequency of remissions with active treatment was 49% compared with 34% in controls. In established RA the frequency of remissions with active treatment was 19% compared with 6% in controls. CONCLUSIONS Intensive treatment with combination DMARDs, biologics or JAK inhibitors increases the frequency of remission compared to control non-intensive strategies. The benefits are seen in both early and established RA.
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Affiliation(s)
- Catherine D Hughes
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, Cutcombe Road, London, SE5 9RJ, UK.
| | - David L Scott
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, Cutcombe Road, London, SE5 9RJ, UK
| | - Fowzia Ibrahim
- Department of Rheumatology, King's College London School of Medicine, Weston Education Centre, King's College London, Cutcombe Road, London, SE5 9RJ, UK
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Abstract
Crohn's disease (CD) is a chronic, progressive, and destructive disease of the gastrointestinal tract. Although its incidence appears to be stable or decreasing in most countries in the North America and Europe, the incidence is rising rapidly in Asian countries. Immunomodulators and biologics are increasingly used to avoid long-term bowel damage and subsequent disability. Therapeutic drug monitoring facilitates optimizing thiopurines and anti-TNFs use. New biologic agents targeting various pathological pathways of CD are blooming in recent years, and the high cost of biologics and expiration of patents for several biologic agents have driven the utility of biosimilars for CD treatment. Here, the literature regarding the efficacy, safety, and withdrawal of the drugs, as well as the evolution of therapeutic targets will be reviewed.
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Affiliation(s)
- Hai Yun Shi
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing, China
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Siew Chien Ng
- Department of Medicine and Therapeutics, Institute of Digestive Disease, State Key Laboratory of Digestive Disease, LKS Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China.
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Wailoo A, Hock ES, Stevenson M, Martyn-St James M, Rawdin A, Simpson E, Wong R, Dracup N, Scott DL, Young A. The clinical effectiveness and cost-effectiveness of treat-to-target strategies in rheumatoid arthritis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 21:1-258. [PMID: 29206093 DOI: 10.3310/hta21710] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Treat to target (TTT) is a broad concept for treating patients with rheumatoid arthritis (RA). It involves setting a treatment target, usually remission or low disease activity (LDA). This is often combined with frequent patient assessment and intensive and rapidly adjusted drug treatment, sometimes based on a formal protocol. OBJECTIVE To investigate the clinical effectiveness and cost-effectiveness of TTT compared with routine care. DATA SOURCES Databases including EMBASE and MEDLINE were searched from 2008 to August 2016. REVIEW METHODS A systematic review of clinical effectiveness was conducted. Studies were grouped according to comparisons made: (1) TTT compared with usual care, (2) different targets and (3) different treatment protocols. Trials were subgrouped by early or established disease populations. Study heterogeneity precluded meta-analyses. Narrative synthesis was undertaken for the first two comparisons, but was not feasible for the third. A systematic review of cost-effectiveness was also undertaken. No model was constructed as a result of the heterogeneity among studies identified in the clinical effectiveness review. Instead, conclusions were drawn on the cost-effectiveness of TTT from papers relating to these studies. RESULTS Sixteen clinical effectiveness studies were included. They differed in terms of treatment target, treatment protocol (where one existed) and patient visit frequency. For several outcomes, mixed results or evidence of no difference between TTT and conventional care was found. In early disease, two studies found that TTT resulted in favourable remission rates, although the findings of one study were not statistically significant. In established disease, two studies showed that TTT may be beneficial in terms of LDA at 6 months, although, again, in one case the finding was not statistically significant. The TICORA (TIght COntrol for RA) trial found evidence of lower remission rates for TTT in a mixed population. Two studies reported cost-effectiveness: in one, TTT dominated usual care; in the other, step-up combination treatments were shown to be cost-effective. In 5 of the 16 studies included the clinical effectiveness review, no cost-effectiveness conclusion could be reached, and in one study no conclusion could be drawn in the case of patients denoted low risk. In the remaining 10 studies, and among patients denoted high risk in one study, cost-effectiveness was inferred. In most cases TTT is likely to be cost-effective, except where biological treatment in early disease is used initially. No conclusions could be drawn for established disease. LIMITATIONS TTT refers not to a single concept, but to a range of broad approaches. Evidence reflects this. Studies exhibit substantial heterogeneity, which hinders evidence synthesis. Many included studies are at risk of bias. FUTURE WORK Future studies comparing TTT with usual care must link to existing evidence. A consistent definition of remission in studies is required. There may be value in studies to establish the importance of different elements of TTT (the setting of a target, the intensive use of drug treatments and protocols pertaining to those drugs and the frequent assessment of patients). CONCLUSION In early RA and studies of mixed early and established RA populations, evidence suggests that TTT improves remission rates. In established disease, TTT may lead to improved rates of LDA. It remains unclear which element(s) of TTT (the target, treatment protocols or increased frequency of patient visits) drive these outcomes. Future trials comparing TTT with usual care and/or different TTT targets should use outcomes comparable with existing literature. Remission, defined in a consistent manner, should be the target of choice of future studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017336. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma S Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Andrew Rawdin
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David L Scott
- King's College Hospital NHS Foundation Trust, London, UK
| | - Adam Young
- West Hertfordshire Hospitals NHS Trust, Watford, UK
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Tam LHP, Shang Q, Li EKM, Wong PCH, Kwok KY, Kun EWL, Yim ICW, Lee VKL, Yip RML, Pang SHT, Lao VWN, Mak QWY, Cheng ITH, Lau XSL, Li TKY, Zhu TY, Lee APW, Tam LS. Effect of Treat-to-target Strategies Aiming at Remission of Arterial Stiffness in Early Rheumatoid Arthritis: A Randomized Controlled Study. J Rheumatol 2018; 45:1229-1239. [DOI: 10.3899/jrheum.171128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2018] [Indexed: 11/22/2022]
Abstract
Objective.To determine the efficacy of 2 tight control treatment strategies aiming at Simplified Disease Activity Score (SDAI) remission (SDAI ≤ 3.3) compared to 28-joint count Disease Activity Score (DAS28) remission (DAS28 < 2.6) in the prevention of arterial stiffness in patients with early rheumatoid arthritis (RA).Methods.This was an open-label study in which 120 patients with early RA were randomized to receive 1 year of tight control treatment. Group 1 (n = 60) aimed to achieve SDAI ≤ 3.3 and Group 2 (n = 60), DAS28 < 2.6. Pulse wave velocity (PWV) and augmentation index (AIx) were measured at baseline and 12 months. A posthoc analysis was also performed to ascertain whether achieving sustained remission could prevent progression in arterial stiffness.Results.The proportions of patients receiving methotrexate monotherapy were significantly lower in Group 1 throughout the study period. At 12 months, the proportions of patients achieving DAS28 and SDAI remission, and the change in PWV and AIx, were comparable between the 2 groups. In view of the lack of differences between the 2 groups, a posthoc analysis was performed at Month 12, including all 110 patients with PWV, to elucidate the independent predictors associated with the change in PWV. Multivariate analysis revealed that achieving sustained DAS28 remission at months 6, 9, and 12 and a shorter disease duration were independent explanatory variables associated with less progression of PWV.Conclusion.With limited access to biologic disease-modifying antirheumatic drugs, treatment efforts toward DAS28 and SDAI remission had similar effects in preventing the progression of arterial stiffness at 1 year. However, achieving sustained DAS28 remission was associated with a significantly greater improvement in PWV. [Clinical Trial registration: Clinicaltrial.govNCT01768923.]
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Effect of treat-to-target strategies on bone erosion progression in early rheumatoid arthritis: An HR-pQCT study. Semin Arthritis Rheum 2018; 48:374-383. [PMID: 29858113 DOI: 10.1016/j.semarthrit.2018.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 03/12/2018] [Accepted: 05/01/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To investigate the efficacy of two tight-control treatment strategies aimed at simplified disease activity score [SDAI] remission (SDAI ≤ 3.3) compared to DAS28 remission (DAS28 < 2.6) on progression of bone erosions in early rheumatoid arthritis (ERA) patients using high-resolution peripheral quantitative computed tomography (HR-pQCT). METHODS This was an open-label study in which 80 early RA patients were randomized to receive 1-year of tight-control treatment. Group 1 (n = 37) aimed at SDAI ≤ 3.3 and group 2 (n = 43) aimed at DAS28-CRP < 2.6. The number and size of bone erosions, as well as the bone mineral density (BMD) surrounding bone erosion at the second metacarpophalangeal joint (MCP2), were measured at baseline and 12 months. RESULTS After 12 months, images were analyzed in 63 patients. Changes in clinical parameters, number and size of bone erosions as well as the BMD surrounding bone erosion between the two treatment groups were similar. Therefore, a post-hoc analysis including all 63 patients was performed to elucidate the independent predictors of erosion progression and repair. Multivariate analysis revealed that not achieving sustained SDAI remission at month 6, 9 and 12 (p = 0.034) and rheumatoid factor >16U (p = 0.021) were independent predictors associated with an increase in erosion volume. Logistic regression analysis showed that achieving sustained SDAI remission (p = 0.043) was associated with partial erosion repair. CONCLUSIONS Although more stringent treatment target did not notably affect clinical treatment outcome and erosion progression at 1 year, achieving sustained SDAI remission was found to be associated with partial erosion repair.
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Versteeg GA, Steunebrink LMM, Vonkeman HE, Ten Klooster PM, van der Bijl AE, van de Laar MAFJ. Long-term disease and patient-reported outcomes of a continuous treat-to-target approach in patients with early rheumatoid arthritis in daily clinical practice. Clin Rheumatol 2018; 37:1189-1197. [PMID: 29388086 PMCID: PMC5913385 DOI: 10.1007/s10067-017-3962-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/14/2017] [Accepted: 12/18/2017] [Indexed: 12/02/2022]
Abstract
Patients in real life may differ from those in clinical trials. The aim of this study is to report 5-year outcomes of a continuous treat-to-target (T2T) approach in patients with rheumatoid arthritis (RA) in daily clinical practice. In the Dutch RhEumatoid Arthritis Monitoring cohort, all patients with a clinical diagnosis of RA were treated according to a protocolled T2T strategy, aimed at 28-joint Disease Activity Score (DAS28) < 2.6. Outcomes were percentages of patients in distinct levels of disease activity, mean course of DAS28 and prevalence of sustained (drug-free) remission. Also, data on functional disability (Health Assessment Questionnaire) and health-related quality of life (Short-Form 36) were examined. Mean DAS28 improved from 4.93 (95% CI 4.81-5.05) at baseline to 2.49 (95% CI 2.35-2.63) after 12 months and remained stable thereafter. Percentages of patients at 12 months with DAS28 < 2.6 (remission), DAS28 ≥ 2.6 and ≤ 3.2 (low disease activity), DAS28 > 3.2 and ≤ 5.1 (moderate disease activity) and DAS28 > 5.1 (high disease activity) were 63, 16, 18 and 3%, respectively. Sustained remission (DAS28 < 2.6 during ≥ 6 months) was observed at least once in 84% of the patients and drug-free remission (DAS28 < 2.6 during ≥ 6 months after withdrawal of all disease-modifying anti-rheumatic drugs) in 36% of the patients. Functional disability and health-related quality of life significantly improved during the first 24 weeks. Continuous application of T2T in real-life RA patients leads to favourable disease- and patient-related outcomes.
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Affiliation(s)
- G A Versteeg
- Arthritis Centre Twente, Department of Rheumatology, Medisch Spectrum Twente, P.O. Box 50 000, 7500, KA, Enschede, The Netherlands.
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - L M M Steunebrink
- Arthritis Centre Twente, Department of Rheumatology, Medisch Spectrum Twente, P.O. Box 50 000, 7500, KA, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - H E Vonkeman
- Arthritis Centre Twente, Department of Rheumatology, Medisch Spectrum Twente, P.O. Box 50 000, 7500, KA, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - P M Ten Klooster
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - A E van der Bijl
- Department of Rheumatology, Isala Hospital, Zwolle, The Netherlands
| | - M A F J van de Laar
- Arthritis Centre Twente, Department of Rheumatology, Medisch Spectrum Twente, P.O. Box 50 000, 7500, KA, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
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Westby MD, Marshall DA, Jones CA. Development of quality indicators for hip and knee arthroplasty rehabilitation. Osteoarthritis Cartilage 2018; 26:370-382. [PMID: 29292095 DOI: 10.1016/j.joca.2017.10.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop quality indicators (QIs) reflecting the minimum acceptable standard of rehabilitation care before and after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA). METHODS Informed by high quality evidence and using a modified RAND-UCLA Delphi approach, an 18-member Canadian panel of clinicians, researchers and patients considered 81 proposed QIs (40 for THA, 42 for TKA) addressing rehabilitation before and after elective THA and TKA. Panelists rated QIs for their importance and validity on a 9-point Likert scale through two rounds of online rating interspersed with a moderated and anonymous online discussion forum. Those QIs with median ratings of ≥7 for importance and validity with no disagreement based on the inter-percentile range adjusted for symmetry were included in the final sets. RESULTS Fifteen panelists from seven provinces and varied practice settings completed the Delphi process. Of the 81 plus one additional QIs (total of 82), 67 (82%) were rated as both important and valid (31 for THA, 36 for TKA). For THA, 14 pre-op, six acute and eight post-acute QIs were accepted. For TKA, 16 pre-op, 10 acute and eight post-acute indicators were accepted. Two of three 'across-continuum' QIs were rated appropriate for both procedures. CONCLUSION This work represents the first QIs with which to measure, report and benchmark quality of care in patients receiving rehabilitation before and after THA/TKA surgery. The QIs will be further tested for reliability and feasibility before being widely disseminated in clinical settings and used to assess care gaps.
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Affiliation(s)
- M D Westby
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, 2635 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada.
| | - D A Marshall
- Department of Community Health Sciences, Arthur JE Child Chair in Rheumatology Research, University of Calgary, Calgary, Alberta, Canada
| | - C A Jones
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
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Treat to Target in Juvenile Idiopathic Arthritis: Challenges and Opportunities. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2018. [DOI: 10.1007/s40674-018-0090-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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de Jonge MJ, Oude Voshaar MAH, Huis AMP, van de Laar MAFJ, Hulscher MEJL, van Riel PLCM. Development of an item bank to measure factual disease and treatment related knowledge of rheumatoid arthritis patients in the treat to target era. PATIENT EDUCATION AND COUNSELING 2018; 101:67-73. [PMID: 28811047 DOI: 10.1016/j.pec.2017.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 04/21/2017] [Accepted: 07/17/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To develop a Disease and treatment associated Knowledge in RA item bank (DataK-RA) based on item response theory. METHODS Initial items were developed from a systematic review. Rheumatology professionals identified relevant content trough a RAND modified Delphi scoring procedure and consensus meeting. RA patients provided additional content trough a focus group. Patients and professionals rated readability, feasibility and comprehensiveness of resulting items. Cross-sectional data were collected to evaluate psychometric properties of the items. RESULTS Data of 473 patients were used for item reduction and calibration. Twenty items were discarded based on corrected item-total point biserial correlation <0.30. Confirmatory factor analysis with weighted least squares estimation on the polychoric correlation matrix suggested good fit for a unidimensional model for the remaining 42 items (CFI 0.97 TLI=0.97, RMSEA=0.02, WRMR=0.97), supporting the proposed scoring procedure. Scores were highly reliable and normally distributed with minimal ceiling (1.8%) and no floor effects. 75% of tested hypotheses about the association of DataK-RA scores with related constructs were supported, indicating good construct validity. CONCLUSION DataK-RA is a psychometrically sound item bank. PRACTICE IMPLICATIONS DataK-RA provides health professionals and researchers with a tool to identify and target patients' information needs or to assess effects of educational efforts.
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Affiliation(s)
- Marieke J de Jonge
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands.
| | - Martijn A H Oude Voshaar
- University of Twente, Department of Psychology, Health and Technology, Enschede, The Netherlands.
| | - Anita M P Huis
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands.
| | - Mart A F J van de Laar
- University of Twente, Department of Psychology, Health and Technology, Enschede, The Netherlands.
| | - Marlies E J L Hulscher
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands.
| | - Piet L C M van Riel
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands; Bernhoven, Department of Rheumatology, Uden, The Netherlands.
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bDMARD Dose Reduction in Rheumatoid Arthritis: A Narrative Review with Systematic Literature Search. Rheumatol Ther 2017; 4:1-24. [PMID: 28255897 PMCID: PMC5443724 DOI: 10.1007/s40744-017-0055-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Indexed: 12/20/2022] Open
Abstract
Introduction Although bDMARDs are effective in the treatment of RA, they are associated with dose-dependent side effects, patient burden, and high costs. Recently, many studies have investigated the possibility of discontinuing or tapering bDMARDs when patients have reached their treatment goal. The aim of this review is to provide a narrative overview of the existing evidence on bDMARD dose reduction and to provide answers to specific dose-reduction-related questions that are of interest to clinicians. Methods We systematically searched for relevant studies in four scientific databases. Furthermore, we screened the references of reviews and relevant studies. Results Our searches resulted in 45 original studies of bDMARD dose reduction in RA patients (15 RCTs and 30 observational studies). Current evidence shows that bDMARD dose reduction can be considered in all RA patients who achieve stable (e.g., ≥6 months) low disease activity or remission. The best strategies seem to be disease-activity-guided dose optimization and fixed dose reduction, since direct bDMARD discontinuation (without restarting) results in a high flare rate, worse physical functioning, and more joint damage. When tapering the bDMARD treatment of a patient, disease activity should be monitored closely, and if a flare occurs, the dose should be increased to the lowest effective dose. Current evidence shows that restarting bDMARD treatment is effective and safe. Unfortunately, no clear predictors of successful dose reduction have been identified so far. Conclusion The current evidence and rising healthcare costs urge that dose reduction should be considered for eligible patients. However, the decision to start dose reduction should be made in shared decision-making. Future research should focus not only on a better understanding of the effects of dose reduction on clinical outcomes but also on the perspectives of patients and physicians as well as the implementation of this new treatment principle. Electronic supplementary material The online version of this article (doi:10.1007/s40744-017-0055-5) contains supplementary material, which is available to authorized users.
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Berenbaum F, Pham T, Claudepierre P, de Chalus T, Joubert JM, Saadoun C, Riou França L, Fautrel B. Early non-response to certolizumab pegol in rheumatoid arthritis predicts treatment failure at one year. Data from a randomised phase III clinical trial. Joint Bone Spine 2017; 85:59-64. [PMID: 28214596 DOI: 10.1016/j.jbspin.2017.01.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 01/05/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To compare different early clinical criteria of non-response determined at three months as predictors of clinical failure at one year in patients with rheumatoid arthritis starting therapy with certolizumab pegol. METHODS Data were derived from a randomised Phase III clinical trial in patients with rheumatoid arthritis who failed to respond to methotrexate monotherapy. Patients included in this post-hoc analysis were treated with certolizumab pegol (400mg qd reduced to 200mg qd after one month) and with methotrexate. The study duration was twelve months. Response at three months was determined with the American College of Rheumatology-50, Disease Assessment Score-28 ESR, Health Assessment Questionnaire and the Clinical Disease Activity Index. The performance of these measures at predicting treatment failure at twelve months defined by the American College of Rheumatology-50 criteria was determined, using the positive predictive values as the principal evaluation criterion. RESULTS Three hundred and eighty two patients were available for analysis and 225 completed the twelve-month follow-up. At Week 52, 149 (38.1%) patients met the American College of Rheumatology-50 response criterion. Positive predictive values ranged from 81% for a decrease in Health Assessment Questionnaire- Disability index score since baseline >0.22 to 95% for a decrease in Disease Assessment Score-28 score since baseline≥1.2. Sensitivity was≤70% in all cases. Performance of these measures was similar irrespective of the definition of treatment failure at 12months. CONCLUSIONS Simple clinical measures of disease activity can predict future treatment failure reliably and are appropriate for implementing treat-to-target treatment strategies in everyday practice.
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Affiliation(s)
- Francis Berenbaum
- Inserm UMRS 938, Department of Rheumatology, Saint-Antoine Hospital, AP-HP, UPMC, Paris 6 University, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
| | - Thao Pham
- Rheumatology Department, Aix-Marseille University, 13284 Marseille, France; Rheumatology Department, Sainte-Marguerite Hospital, AP-HM, 13009 Marseille, France
| | - Pascal Claudepierre
- Laboratoire d'Investigation Clinique (LIC) EA4393, Rheumatology Department, AP-HP, Henri-Mondor hospital, Paris Est Créteil University, 94010 Créteil, France
| | | | | | - Carine Saadoun
- Market Access Department, UCB Pharma, 92700 Colombes, France
| | | | - Bruno Fautrel
- Rheumatology Department, Paris 6 University-GRC UPMC-08, AP-HP, 75005 Paris, France; Rheumatology Department, Groupe Hospitalier Pitié-Salpêtrière, 75013 Paris, France
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Colombel JF, Narula N, Peyrin-Biroulet L. Management Strategies to Improve Outcomes of Patients With Inflammatory Bowel Diseases. Gastroenterology 2017; 152:351-361.e5. [PMID: 27720840 DOI: 10.1053/j.gastro.2016.09.046] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 09/07/2016] [Accepted: 09/16/2016] [Indexed: 12/12/2022]
Abstract
Strategies for management of inflammatory bowel diseases are shifting from simple control of symptoms toward full control of these diseases (clinical and endoscopic remission), with the final aim of blocking their progression and preventing bowel damage and disability. New goals have been proposed for treatment, such as treat to target and tight control based on therapeutic monitoring and early intervention. For patients who achieve clinical remission, there is often interest in discontinuation of therapy due to safety or economic concerns. We review the evidence supporting these emerging paradigms, the reasons that early effective treatment can alter progression of inflammatory bowel diseases, the importance of examining objective signs of inflammation, and the safety of reducing treatment dosage. We also discuss recent findings regarding personalization of care, including factors that predict patient outcomes and response to therapies, as well as preventative strategies.
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Affiliation(s)
| | - Neeraj Narula
- Division of Gastroenterology, Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Laurent Peyrin-Biroulet
- Institut National de la Santé et de la Recherche Médicale U954 and Department of Gastroenterology, Nancy University Hospital, Lorraine University, France
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Cárdenas M, de la Fuente S, Castro-Villegas MC, Romero-Gómez M, Ruiz-Vílchez D, Calvo-Gutiérrez J, Escudero-Contreras A, Del Prado JR, Collantes-Estévez E, Font P. Cost-effectiveness of clinical remission by treat to target strategy in established rheumatoid arthritis: results of the CREATE registry. Rheumatol Int 2016; 36:1627-1632. [PMID: 27778067 DOI: 10.1007/s00296-016-3583-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/19/2016] [Indexed: 12/16/2022]
Abstract
To analyse the cost-effectiveness, in daily clinical practice, of the strategy of treating to the target of clinical remission (CR) in patients with established rheumatoid arthritis (RA), after 2 years of treatment with biological therapy. Adult patients with established RA were treated with biological therapy and followed up for 2 years by a multidisciplinary team responsible for their clinical management. Treatment effectiveness was evaluated by the DAS28 score. The direct costs incurred during this period were quantified from the perspective of the healthcare system. We calculated the cost-effectiveness of obtaining a DAS28 < 2.6, considered as CR. The study included 144 RA patients treated with biological therapies. After 2 years of treatment, 32.6% of patients achieved CR. The mean cost of achieving CR at 2 years was 79,681 ± 38,880 euros. The strategy of treatment to the target of CR is considered the most effective, but in actual clinical practice in patients with established RA, it has a high cost.
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Affiliation(s)
- M Cárdenas
- Pharmacy Department, Reina Sofía Universitary Hospital, University of Córdoba, Córdoba, Spain.
| | - S de la Fuente
- Pharmacy Department, Reina Sofía Universitary Hospital, University of Córdoba, Córdoba, Spain
| | - M C Castro-Villegas
- Rheumatology Department, Reina Sofía Universitary Hospital, IMIBIC/University of Córdoba, Córdoba, Spain
| | - M Romero-Gómez
- Rheumatology Department, Reina Sofía Universitary Hospital, IMIBIC/University of Córdoba, Córdoba, Spain
| | - D Ruiz-Vílchez
- Rheumatology Department, Reina Sofía Universitary Hospital, IMIBIC/University of Córdoba, Córdoba, Spain
| | - J Calvo-Gutiérrez
- Rheumatology Department, Reina Sofía Universitary Hospital, IMIBIC/University of Córdoba, Córdoba, Spain
| | - A Escudero-Contreras
- Rheumatology Department, Reina Sofía Universitary Hospital, IMIBIC/University of Córdoba, Córdoba, Spain
| | - J R Del Prado
- Pharmacy Department, Reina Sofía Universitary Hospital, University of Córdoba, Córdoba, Spain
| | - E Collantes-Estévez
- Rheumatology Department, Reina Sofía Universitary Hospital, IMIBIC/University of Córdoba, Córdoba, Spain
| | - P Font
- Rheumatology Department, Reina Sofía Universitary Hospital, IMIBIC/University of Córdoba, Córdoba, Spain
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Lesuis N, Verhoef LM, Nieboer LM, Bruyn GA, Baudoin P, van Vollenhoven RF, Hulscher MEJL, van den Hoogen FHJ, den Broeder AA. Implementation of protocolized tight control and biological dose optimization in daily clinical practice: results of a pilot study. Scand J Rheumatol 2016; 46:152-155. [DOI: 10.1080/03009742.2016.1194457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- N Lesuis
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - LM Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - LM Nieboer
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - GA Bruyn
- Department of Rheumatology, MC Zuiderzee, Lelystad, The Netherlands
| | - P Baudoin
- Department of Rheumatology, MC Zuiderzee, Lelystad, The Netherlands
| | - RF van Vollenhoven
- Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institute, Stockholm, Sweden
| | - MEJL Hulscher
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - FHJ van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rheumatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - AA den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
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