EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update

A 10-year knowledge mapping of T cells in rheumatoid arthritis: A bibliometric analysis

Rheumatoid arthritis (RA) is a chronic inflammatory joint disease of autoimmune origin. T cells play crucial roles in the initiation and progression of RA. Although bibliometric methods have been widely used to synthesize knowledge trajectories across different biomedical fields, it has hardly been used to underscore the knowledge trends in relation to T cell and RA. This study used bibliometric methods to delineate the evolution of research on T cells and RA. Data were sourced from the Web of Science™ Core Collection and were scientometrically analyzed using CiteSpace and VOSviewer. From 2014 to 2023, 7037 papers on T cells and RA were retrieved. The number of annual publications is stable between 600 and 800, and the citation frequency continues to rise. The United States, China, the United Kingdom and Japan were the most productive countries. Karolinska Institute, and Harvard Medical School were the institutions that published the most research papers. Wei W, Cho ML, and Park SH were the most prolific authors. Mclnnes IB and Smolen JS were the most frequently cited authors. The journals with the most articles are Frontiers in Immunology, Arthritis Research & Therapy, and Arthritis & Rheumatology. Current research hotspots include pathogenic factors and targeted biological therapy, immune mechanisms, inflammatory mechanisms, and bone destruction mechanisms. The current research frontiers in this field are gut microbiota, identification, fibroblast-like synoviocytes, biologic therapy, mesenchymal stem cells, and risk. This work provides new insights into the scientific research and clinical application of T cells to develop therapeutic targets for RA.

Dual-Energy Computed Tomography Applications in Rheumatology

Dual-energy computed tomography (DECT) has emerged as a transformative tool in the past decade. Initially employed in gout within the field of rheumatology to distinguish and quantify monosodium urate crystals through its dual-material discrimination capability, DECT has since broadened its clinical applications. It now encompasses various rheumatic diseases, employing advanced techniques such as bone marrow edema assessment, iodine mapping, and collagen-specific imaging. This review article aims to examine the unique characteristics of DECT, discuss its strengths and limitations, illustrate its applications for accurately evaluating various rheumatic diseases in clinical practice, and propose future directions for DECT in rheumatology.

The association between difficult-to-treat rheumatoid arthritis and probable sarcopenia

OBJECTIVES

To identify factors associated with probable sarcopenia in patients with rheumatoid arthritis (RA).

METHODS

Probable sarcopenia was diagnosed using the SARC-F questionnaire. Patients with difficult-to-treat RA (D2T-RA) were defined as those with a history of using ≥2 biological/targeted synthetic (b/ts) disease-modifying antirheumatic drugs (b/tsDMARDs) who had moderate or high disease activity. Among 486 patients, 101 were classified into the probable sarcopenia group (SARC-F ≥4), and 385 were classified into the non-probable sarcopenia group (SARC-F <4). Factors associated with probable sarcopenia were examined using multiple logistic regression analysis. Additionally, patients were divided into the D2T-RA (n = 38) and non-D2T-RA (n = 448) groups, and the proportion of probable sarcopenia and RA treatment status were compared.

RESULTS

Factors associated with probable sarcopenia included age [adjusted odds ratio (OR): 1.03], body mass index (OR: 1.16), D2T-RA (OR: 3.39), and Health Assessment Questionnaire-Disability Index (OR: 1.38), and diabetes mellitus (OR: 2.77). The proportion of probable sarcopenia was significantly higher (60.5% vs. 17.4%), and the rate of methotrexate use was significantly lower (34.2% vs. 64.1%), in the D2T-RA group than in the non-D2T-RA group. Moreover, in the D2T-RA group, most patients used two or three b/tsDMARDs (two: 68.4%, three: 21.1%).

CONCLUSIONS

D2T-RA was associated with probable sarcopenia. Tight control by treatment enhancement may help overcome sarcopenia.

Effective Second-Line b/tsDMARDs for Patients with Rheumatoid Arthritis Unresponsive to First-Line b/tsDMARDs from the FIRST Registry

INTRODUCTION

For patients with rheumatoid arthritis (RA) unresponsive to first-line biologic/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), the selection of second-line b/tsDMARDs is crucial to prevent progression to difficult-to-treat rheumatoid arthritis (D2TRA). However, indicators for selection are lacking. This study aimed to identify optimal second-line b/tsDMARDs among the phase III treatment strategies based on European League Against Rheumatism (EULAR) RA management recommendations.

METHODS

A total of 687 RA patients treated with second-line b/tsDMARDs (tumor necrosis factor inhibitor (n = 246), interleukin-6 receptor inhibitor [n = 195], cytotoxic T-lymphocyte-associated protein 4 immunoglobulin [n = 119], and Janus kinase inhibitor [n = 127]) were enrolled between October 2013 and April 2023. Rates of patients achieving Clinical Disease Activity Index (CDAI) remission and CDAI low disease activity (LDA), changes in CDAI, persistence rates, and adverse events within 24 weeks after treatment initiation were compared among the four groups. Propensity score-based inverse probability of treatment weighting (PS-IPTW) was used to minimize selection bias.

RESULTS

After PS-IPTW adjustment, the Janus kinase inhibitor (JAKi) group had the highest persistence rate among the four groups. At 24 weeks, the JAKi group showed the greatest improvement in CDAI and the highest CDAI remission rate. Among patients treated with JAKi as second-line b/tsDMARDs, upadacitinib (UPA) was most likely to achieve CDAI remission at 24 weeks. The comparison between the UPA group (n = 32) and the non-UPA JAKi group (tofacitinib and baricitinib [n = 95]) showed comparable persistence rates but significantly lower CDAI scores and higher CDAI remission rate at 24 weeks in the UPA group. No significant difference was noted in the overall incidence of adverse events among the four groups treated with b/tsDMARDs or between the groups treated with JAKi.

CONCLUSIONS

Selecting JAKi, especially UPA, may effectively improve the disease activity for RA patients unresponsive to first-line b/tsDMARDs. Further large-scale studies are needed to clarify the efficacy and safety of UPA.

TRIAL REGISTRATION

FIRST registry (approval number#04-23): October 2013, retrospectively registered.

Complications of invasive oral procedures in patients with immune-mediated inflammatory disorders treated with biological and conventional disease-modifying antirheumatic drugs or glucocorticoids: a scoping review of the literature

OBJECTIVES

By a scoping review, to evaluate whether patients with immune-mediated inflammatory disorders (IMIDs) treated with biological and conventional disease-modifying antirheumatic drugs (b/cDMARDs) and/or glucocorticoids (GCs) experience complications after invasive oral procedures.

MATERIALS AND METHODS

Primary search was conducted on PubMed/MEDLINE database, Google Scholar, Embase and Web of Science up to December 31, 2023. The PICO question was "Does a patient with IMIDs and treated with b/cDMARDs in mono/bi or combination therapies have delayed oral wound healing or infectious complications after an invasive oral procedure?". To be included, references had to be primary studies written in English or French. Qualitative assessment was performed.

RESULTS

From 1,494 initial articles, 59 full-text articles were selected, including 47 case reports and case series, 7 comparative non-randomized studies, 1 randomized clinical trial, 2 case-case studies, 1 case-control study, and 1 prospective cohort study. Most reports involved patients with rheumatoid arthritis on methotrexate and/or anti-TNF. Complications (medication-related osteonecrosis of the jaw, delayed healing, local infection) occurred predominantly after tooth extractions, particularly affecting women, patients over 50 with bisphosphonate use, unhealthy lifestyle habits, or diabetes. They were generally managed with prolonged antibiotic and antiseptic courses, and surgical interventions.

CONCLUSIONS

Local infectious complication or jaw osteonecrosis could occur post-invasive procedures, especially tooth extractions, in IMIDs patients on b/cDMARDs and/or GCs, often in patients with comorbidities and/or concurrent medications such as bone-modifying drugs.

CLINICAL RELEVANCE

It is essential for dentists to be alert to the existence of local or focal infectious complications after tooth extraction in patients with IMIDs on immunosuppressive therapy.

Urinary total superoxide dismutase activity is low in rheumatoid patients, and its low levels are associated with higher DAS28 scores

AIM

Rheumatoid factor and anti-citrullinated peptide antibodies are generally used to diagnose rheumatoid arthritis (RA). However, these antibodies are negative in 15-20 % of RA cases. This study aimed to investigate new biomarkers that can be used in diagnosing RA and evaluating disease activity.

METHODS

This study included 99 RA patients and 94 healthy volunteers. Modified Disease Activity Score28 (DAS28) erythrocyte sedimentation rate (ESR) was used for disease activity score. Thiol/disulfide molecules were measured using an automatic spectrophotometric method, and ischemia-modified albumin was measured using an albumin-cobalt binding test. A spectrophotometer calculated urinary and serum total superoxide dismutase (SOD) activities at 420 nm wavelength.

RESULTS

In the RA group, serum IMA level was higher (unstandardized beta [B]: 5.552, Odds Ratio [OR]: 250.1, CI 95 %: 1.29-48219.1, p: .040), and urinary total SOD activities were significantly lower (B: 2.640 OR: .071, CI 95 %: .027-.192, p < 0.0001) than in the control group. A cut-off value of 5.06 for urinary total SOD was found to have a sensitivity of 97.9 % and a specificity of 97 % in distinguishing RA patients from healthy controls (AUC [95 %Cl] = .986 [.967-1.000], p < 0.001). Urinary total SOD activity was significantly lower in the RA subgroup with high disease activity compared to the groups with moderate disease activity (B: .954, OR: 2.596, CI 95 %: 1.104-6.103, p: .029) and low disease activity (B: 1.251, OR: 3.494, CI 95 %: 1.143-10.678, p: .028).

CONCLUSION

This study showed that urinary total SOD activity has high sensitivity and specificity in distinguishing RA patients from healthy controls and that RA patients with higher DAS28 ESR activity scores have lower urinary total SOD activity.

The Identification of Novel Therapeutic Biomarkers in Rheumatoid Arthritis: A Combined Bioinformatics and Integrated Multi-Omics Approach

Rheumatoid arthritis (RA) is a multifaceted autoimmune disease that is marked by a complex molecular profile influenced by an array of factors, including genetic, epigenetic, and environmental elements. Despite significant advancements in research, the precise etiology of RA remains elusive, presenting challenges in developing innovative therapeutic markers. This study takes an integrated multi-omics approach to uncover novel therapeutic markers for RA. By analyzing both transcriptomics and epigenomics datasets, we identified common gene candidates that span these two omics levels in patients diagnosed with RA. Remarkably, we discovered eighteen multi-evidence genes (MEGs) that are prevalent across transcriptomics and epigenomics, twelve of which have not been previously linked directly to RA. The bioinformatics analyses of the twelve novel MEGs revealed they are part of tightly interconnected protein-protein interaction networks directly related to RA-associated KEGG pathways and gene ontology terms. Furthermore, these novel MEGs exhibited direct interactions with miRNAs linked to RA, underscoring their critical role in the disease's pathogenicity. Overall, this comprehensive bioinformatics approach opens avenues for identifying new candidate markers for RA, empowering researchers to validate these markers efficiently through experimental studies. By advancing our understanding of RA, we can pave the way for more effective therapies and improved patient outcomes.

Disease-Modifying Antirheumatic Drug Therapy of Inflammatory Rheumatic Diseases in End-Stage Kidney Disease

BACKGROUND

Inflammatory rheumatic diseases regularly require the use of disease-modifying antirheumatic drugs (DMARDs). The use of DMARDs in patients with end-stage chronic kidney disease (CKD stage 5D) is particularly challenging due to the lack of systematic studies available for this patient population. This narrative review aimed to address the aspect of DMARD therapy in CKD 5D.

SUMMARY

The current article is a narrative review. References were sourced from the following databases: PubMed, Web of Science, Cochrane Library, and Scopus. The search period spanned from 1975 to 2024. There is a notable lack of systematic data on this topic. The available literature was reviewed to provide insights, despite the limited availability of comprehensive studies. Individuals with terminal kidney disease can presumably be safely treated with leflunomide, mycophenolic acid, sulfasalazine, azathioprine, belimumab, and anti-CD20. For all other substances, there are either significant restrictions, insufficient data, or inadequate experience.

KEY MESSAGES

Some conventional and biologic DMARDs are available for the management of inflammatory rheumatic diseases in CKD stage 5D. It is essential to consider the limitations on kidney function, as they can significantly affect the pharmacokinetics of medications. Consequently, slightly more frequent checkups are recommended when using the defined preparations.

Ultrasound-mediated nanomaterials for the treatment of inflammatory diseases

Sterile and infection-associated inflammatory diseases are becoming increasingly prevalent worldwide. Conventional drug therapies often entail significant drawbacks, such as the risk of drug overdose, the development of drug resistance in pathogens, and systemic adverse reactions, all of which can undermine the effectiveness of treatments for these conditions. Nanomaterials (NMs) have emerged as a promising tool in the treatment of inflammatory diseases due to their precise targeting capabilities, tunable characteristics, and responsiveness to external stimuli. Ultrasound (US), a non-invasive and effective treatment method, has been explored in combination with NMs to achieve enhanced therapeutic outcomes. This review provides a comprehensive overview of the recent advances in the use of US-mediated NMs for treating inflammatory diseases. A comprehensive introduction to the application and classification of US was first presented, emphasizing the advantages of US-mediated NMs and the mechanisms through which US and NMs interact to enhance anti-inflammatory therapy. Subsequently, specific applications of US-mediated NMs in sterile and infection-associated inflammation were summarized. Finally, the challenges and prospects of US-mediated NMs in clinical translation were discussed, along with an outline of future research directions. This review aims to provide insights to guide the development and improvement of US-mediated NMs for more effective therapeutic interventions in inflammatory diseases.

Erosive progression by high-resolution peripheral quantitative computed tomography and conventional radiography in rheumatoid arthritis

OBJECTIVES

To investigate the diagnostic accuracy of high-resolution peripheral quantitative computed tomography (HR-pQCT) to assess erosive progression during 1 year compared with conventional radiography (CR) in rheumatoid arthritis (RA).

METHODS

This prospective study included 359 patients with RA (disease duration ≥5 years) between March 2018 and October 2020. HR-pQCT and CR were obtained at inclusion and after 1 year. Erosive assessment was performed at two metacarpophalangeal joints of the dominant hand using HR-pQCT, and progression was defined as an increase in erosion number ≥1 or an increase in erosive volume > least significant change. CR of hands, wrists and feet was evaluated using Sharp/van der Heijde scores and erosive progression was defined as a 1.1-point increase in erosion score according to the smallest detectable change.

RESULTS

In paired analyses (n = 310), erosive progression was identified in 30 patients using CR and in 40 patients using HR-pQCT. In the 40 patients with erosive progression on HR-pQCT, progression was not identified by CR in 33 patients. Adding HR-pQCT to CR doubled the proportion of patients identified with progression from 30 (10%) to 63 (20%) patients. Using CR as the reference, the sensitivity of HR-pQCT for identifying erosive progression was 23.3% (95% CI: 9.9, 42.3%) and the specificity was 88.2% (95% CI: 83.8, 91.7%).

CONCLUSION

A substantial proportion of patients with erosive progression are overlooked using CR only to monitor erosive progression. Adding high-resolution peripheral CT to CR doubles the proportion of patients who may benefit from individualized therapy targeting erosive progression in RA.

Can the dose of belimumab be reduced in patients with systemic lupus erythematosus?

OBJECTIVES

The aims of this study were to investigate the prevalence of dose reduction in patients with SLE treated with belimumab (BEL) in Spain, analyse treatment modalities, and determine impact on control of disease activity.

METHODS

Retrospective longitudinal and multicentre study of SLE patients treated with BEL. Data on disease activity, treatments and outcomes were recorded before and after reduction (6-12 months), and they were compared.

RESULTS

A total of 324 patients were included. The dose was reduced in 29 patients (8.9%). The dosing interval was increased in nine patients receiving subcutaneous BEL and in six patients receiving intravenous BEL. The dose per administration was reduced in 16 patients. Pre-reduction status was remission (2021 DORIS) in 15/26 patients (57.7%) and LLDAS in 23/26 patients (88.5%). After reduction, 2/24 patients (8.3%) and 3/22 patients (13.6%) lost remission at 6 months and 12 months, respectively [not statistically significant (NS)]. As for LLDAS, 2/23 patients (8.7%) and 2/21 patients (9.5%) lost their status at 6 and 12 months, respectively (NS). Significantly fewer patients were taking glucocorticoids (GCs) at their 12-month visit, although the median dose of GCs was higher at the 12-month visit (5 [0.62-8.75] vs 2.5 [0-5] at baseline).

CONCLUSION

Doses of BEL can be reduced with no relevant changes in disease activity-at least in the short term-in a significant percentage of patients, and most maintain the reduced dose. However, increased clinical or serologic activity may be observed in some patients. Consequently, tighter post-reduction follow-up is advisable.

Efficacy and Safety of Juan Bi Pill with Add-on Methotrexate in Active Rheumatoid Arthritis: A 48-Week, Multicentre, Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To explore the efficacy and safety of Juan Bi Pill (JBP) in treatment of active rheumatoid arthritis (RA).

METHODS

From February 2017 to May 2018, 115 participants from 4 centers were randomly divided into JBP group (57 cases) and placebo group (58 cases) in a 1:1 ratio using a random number table method. Participants received a dose of JBP (4 g, twice a day, orally) combined with methotrexate (MTX, 10 mg per week) or placebo (4 g, twice a day, orally) combined with MTX for 12 weeks. Participants were required with follow-up visits at 24 and 48 weeks, attending 7 assessment visits. Participants were undergo disease activity assessment 7 times (at baseline and 2, 4, 8, 12, 24, 48 weeks) and safety assessments 6 times (at baseline and 4, 8, 12, 24, 48 weeks). The primary endpoint was 28-joint Disease Activity Score (DAS28-ESR and DAS28-CRP). The secondary endpoints included American College of Rheumatology (ACR) criteria for 20% and 50% improvement (ACR20/50), Health Assessment Questionnaire Disability Index (HAQ-DI), clinical disease activity index (CDAI), visual analog scale (VAS), Short Form-36 (SF-36) score, Medial Outcomes Study (MOS) sleep scale score, serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), tender joint count, swollen joint count, and morning stiffness. The adverse reactions were observed during the treatment.

RESULTS

After 12 weeks of treatment, DAS28-ESR and DAS28-CRP scores in both groups were lower than before treatment (both P<0.01), while the remission rate of DAS28-ESR and DAS28-CRP and low disease activity of JBP group were higher than those in the placebo group (both P<0.01). JBP demonstrated better efficacy on ACR20 and ACR50 compliance rate at 12 and 48 weeks comparing to placebo (all P<0.05). The CDAI and HAQ-DI score, pain VAS and global VAS change of RA patients and physicians, the serum ESR and CRP levels, and the number of tenderness and swelling joints were lower than before treatment at 4, 8, 12, 24, 48 weeks in both groups (P<0.05 or P<0.01), while the reduction of above indices in the JBP group was more obvious than those in the placebo group at 12 weeks (ESR and CRP, both P<0.05) or at 12 and 48 weeks (all P<0.01). There was no difference in adverse reactions between the 2 groups during treatment (P=0.75).

CONCLUSION

JBP combined with MTX could effectively reduce disease activity in patients with RA in active stage, reduce the symptoms of arthritis, and improve the quality of life, while ensuring safety, reliability, and fewer adverse effects. (Trial Registration: ClinicalTrials.gov, No. NCT02885597).

Helicobacter pylori and rheumatoid arthritis: Investigation of relation from traditional Chinese medicine

Rheumatoid arthritis (RA) is an autoimmune condition that predominantly affects synovial joints, manifesting with joint swelling, pain, and stiffness. In advanced stages, unchecked inflammation can inflict damage on bone and cartilage, resulting in disabilities and deformities of the joints. Additionally, systemic and extra-articular complications may arise due to the consequences of uncontrolled inflammation. Helicobacter pylori (H. pylori) is one of the most prevalent chronic bacterial infections in humans. This microorganism is a spiral-shaped, flagellated, microaerophilic gram-negative bacterium. Prolonged exposure leads to the activation of the immune system, with infected gastric mucosa epithelial cells continuously producing cytokines. This production, in turn, triggers the generation of antibodies as well as T Helper 1 and T Helper 2 effector T cells. The persistent antigenic stimulation resulting from H. pylori infection could lead to the progression of autoimmune diseases. Numerous clinical and pharmacological trials have illustrated the efficacy of traditional Chinese medicine against H. pylori. This review aims to delve into the connection between H. pylori and rheumatoid arthritis so as understand the pathogenesis. The concluding section of this review explores the interplay of Chinese medicine and Helicobacter pylori concerning rheumatoid arthritis.

Disease activity-guided dose optimization including discontinuation of TNF inhibitors in rheumatoid arthritis is effective for up to 10 years: an observational follow-up of the DRESS study

OBJECTIVE

The objective of this study was to investigate the safety and effectiveness of disease activity-guided dose optimization of TNF inhibitors in RA over 10 years.

METHODS

The study involved an observational long-term extension of a randomized study of participants who completed the 3-year extension of the DRESS-study. After the randomized phase (months 0-18), disease activity-guided dose optimization was allowed for all. The main outcomes were mean time-weighted DAS28-CRP; biologic and targeted synthetic DMARD (b/tsDMARD) use per year, as proportion of daily defined dose; proportion of patients reaching discontinuation; durability and effectiveness of subsequent dose reduction attempts; and radiographic progression between years 3 and 10 using the Sharp-van der Heijde score.

RESULTS

A total of 170 patients were included, of whom 127 completed the 10-year follow-up. The mean disease activity remained low (DAS28-CRP 2.13, 95% CI 2.10-2.16), while the b/tsDMARD dose reduced from 97% at baseline (95% CI 96-99%, n = 170) to 56% at year 10 (95% CI 49-63%, n = 127). Of 161 participants with an optimization attempt, 119 (74%) reached discontinuation with a median duration of 7 months (interquartile range 3-33 months), and 25 participants never had to restart their b/tsDMARD (21%, 95% CI 14-29%). The mean dose reduction after dose optimization was 48% (n = 159) for the first optimization attempt, and 33% for a subsequent attempt (n = 86). Of the 86 participants, 41 (48%) had radiographic progression exceeding the smallest detectable change (5.7 units), and progression was associated with disease activity, not b/tsDMARD use.

CONCLUSION

Long-term disease activity-guided dose optimization of TNF inhibitors in RA, including discontinuation and multiple tapering attempts, remains safe and effective.

Deciphering Immunometabolic Landscape in Rheumatoid Arthritis: Integrative Multiomics, Explainable Machine Learning and Experimental Validation

Purpose

Immunometabolism is pivotal in rheumatoid arthritis (RA) pathogenesis, yet the intricacies of its pathological regulatory mechanisms remain poorly understood. This study explores the complex immunometabolic landscape of RA to identify potential therapeutic targets.

Patients and Methods

We integrated genome-wide association study (GWAS) data involving 1,400 plasma metabolites, 731 immune cell traits, and RA outcomes from over 58,000 participants. Mendelian randomization (MR) and mediation analyses were applied to evaluate causal relationships among plasma metabolites, immune cells, and RA. We further analyzed single-cell and bulk transcriptomes to investigate differential gene expression, immune cell interactions, and relevant biological processes. Machine learning models identified hub genes, which were validated via quantitative real-time PCR (qRT-PCR). Then, potential small-molecule drugs were screened using the Connectivity Map (CMAP) and molecular docking. Finally, a phenome-wide association study (PheWAS) was conducted to evaluate potential side effects of drugs targeting the hub genes.

Results

Causalities were found between six plasma metabolites, five immune cells and RA in genetically determined levels. Notably, DC mediated 18% of the protective effect of PE on RA. Autophagy-related scores were elevated in both RA and DC subsets in PE-associated biological processes. Through observation in the functional differences in cellular interactions between the identified clusters, DCs with high autophagy scores may process such as necroptosis and the activation of the Jak-STAT signaling pathway in contributing the pathogenesis of RA. Explainable machine learning, PPI network analysis, and qPCR jointly identified four hub genes (PFN1, SRP14, S100A11, and SAP18). CMAP, molecular docking, and PheWAS analysis further highlighted vismodegib as a promising therapeutic candidate.

Conclusion

This study clarifies the key immunometabolic mechanisms in RA, pinpointing promising paths for better prevention, diagnosis, and treatment.

RNA therapies for musculoskeletal conditions

Musculoskeletal conditions impact 1.71 billion individuals, posing significant challenges due to their complexity, varying clinical courses, and unclear molecular mechanisms. Conventional spectrum treatments often prove inadequate, underscoring the importance of targeted therapies. Recently, RNA-based technologies have emerged as a groundbreaking approach in therapeutics, showing applications in joint related ailments. This perspective aims to examine endeavors exploring the use of RNA-based treatments in both experimental and clinical contexts for addressing joint issues like osteoarthritis, rheumatoid arthritis, and cartilage injuries. The cited studies demonstrate how mRNA can stimulate the production of proteins that aid in controlling inflammation, fostering tissue regeneration and repairing cartilage damage. In summary, this perspective offers an overview of the progress made in mRNA-based technologies for treating related conditions by highlighting favorable findings from preclinical research and encouraging results from clinical trials. With advancements in the field, mRNA therapeutics have the potential to revolutionize treatment approaches for musculoskeletal disorders, bringing renewed hope to the future of musculoskeletal conditions.

Useful treatment selection strategy for endoscopic hemostasis in colonic diverticular bleeding according to endoscopic findings (with video)

Background and study aims

Direct or indirect clipping and endoscopic band ligation (EBL) are widely used for hemostasis in patients with colonic diverticular bleeding (CDB). However, no treatment selection strategy has been established. This report describes our approach and its outcomes.

Patients and methods

We select direct clipping if the bleeding point is visible and clips could be inserted into the diverticulum. When direct clipping is not feasible, we select EBL as the second choice and indirect clipping as the third. We reviewed data from 192 patients treated with clipping or EBL for definitive CDB with stigmata of recent hemorrhage (SRH) at our hospital between March 2016 and February 2023.

Results

The hemostatic method was clipping in 84 patients (direct, n=78; indirect, n=6) and EBL in 108. The rate of SRH with active bleeding was significantly higher in the EBL group (33.3% vs. 60.2%, p <0.001). Median hemostasis time was significantly shorter in the clipping group (9 min vs. 22 min, P <0.001). There was no significant difference in the 30-day rebleeding rate between clipping and EBL (15.5% vs. 13.0%; P =0.619). There was one case of delayed perforation post-EBL. There were no complications after clipping.

Conclusions

Direct clipping when placement of clips at the bleeding point is feasible and EBL when direct clipping is not feasible is a reasonable strategy in terms of effectiveness, efficiency, and safety. Selection of hemostatic method according to the visual field of SRH and maneuverability of the endoscope allows the advantages of both methods to be realized.

Structural basis of signaling complex inhibition by IL-6 domain-swapped dimers

Interleukin-6 (IL-6) is a multifaceted cytokine essential in many immune system processes and their regulation. It also plays a key role in hematopoiesis, and in triggering the acute phase reaction. IL-6 overproduction is critical in chronic inflammation associated with autoimmune diseases like rheumatoid arthritis and contributes to cytokine storms in COVID-19 patients. Over 20 years ago, researchers proposed that IL-6, which is typically monomeric, can also form dimers via a domain-swap mechanism, with indirect evidence supporting their existence. The physiological significance of IL-6 dimers was shown in B-cell chronic lymphocytic leukemia. However, no structures have been reported so far. Here, we present the crystal structure of an IL-6 domain-swapped dimer that computational approaches could not predict. The structure explains why the IL-6 dimer is antagonistic to the IL-6 monomer in signaling complex formation and provides insights for IL-6 targeted therapies.

Detecting new erosions in rheumatoid arthritis over one year - Radiography and high-resolution computed tomography of finger joints

OBJECTIVE

To compare the number of new erosions in two metacarpophalangeal (MCP) joints over one year assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT) and conventional radiography (CR). Furthermore, to estimate the diagnostic accuracy of erosive progression by CR with HR-pQCT as the reference standard.

METHODS

Paired sets of image data were available from patients with RA (n=310), who underwent HR-pQCT and CR, including the 2nd and 3rd MCP joints only of the dominant hand at baseline and at the one-year follow-up. Erosion number was determined using HR-pQCT and CR. Erosive volume was estimated from segmented HR-pQCT images, and erosion scores were obtained by the Sharp/van der Heijde method from CR. Erosive progression was defined as an increase in total erosion number or a study-specified increase in total erosive volume or total erosion score.

RESULTS

At baseline, 250 erosions were identified by CR compared to 1864 erosions by HR-pQCT. After one year, 3 new erosions were detected by CR compared to 66 new erosions by HR-pQCT. Erosive progression was identified in 40 patients using HR-pQCT and in 3 patients using CR. With HR-pQCT as reference, CR had a sensitivity of 2.5% (95% CI: 0.1-13.2%) and a specificity of 99.3% (95% CI: 97.3-99.9%) for detecting erosive progression.

CONCLUSION

HR-pQCT identified more than 20 times the number of new erosions, and more than 10 times as many patients with erosive progression than CR. HR-pQCT is a sensitive tool for monitoring new erosions and erosive progression over one year in RA.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Anti-Rheumatic potential of biological DMARDS and protagonistic role of bio-markers in early detection and management of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily affects the synovial joint linings, resulting in progressive disability, increased mortality, and considerable economic costs. Early treatment with disease-modifying antirheumatic medications (DMARDs) can significantly improve the overall outlook for people with RA. Contemporary pharmaceutical interventions, encompassing standard, biological, and emerging small molecule disease- modifying anti-rheumatic medications continue to be the cornerstone of RA management, with substantial advancements made in the pursuit of achieving remission from the disease and preventing joint deformities. Nevertheless, a substantial segment of individuals with RA do not experience a satisfactory response to existing treatments, underscoring the pressing need for novel therapeutic options. Biologic DMARDs are among the therapy choices. Non-tumor necrosis factor inhibitors (Non-TNFi) such as abatacept, rituximab, tocilizumab, and sarilumab are examples, as are anti-tumor necrosis factor (TNF) medications such as infliximab, adalimumab, etanercept, golimumab, and certolizumab pegol. More recent biomarkers have emerged and showed usefulness in the early detection of RA. These biomarkers, often referred to simply as "biomarkers", are quantifiable indicators of normal or pathologic processes, and they can also gauge treatment response. The assessment of RA treatment response typically combines patient-reported outcomes, physical evaluations, and laboratory findings, as there isn't a single biomarker that has proven sufficient for measuring disease activity. This review explores the usage of biologic DMARDs as a therapeutic approach for RA, as well as the biomarkers typically used for RA early diagnosis, prognosis prediction, and disease activity evaluation.

Anti-Inflammatory effect of INSL-3 on experimental arthritis model and LPS-induced macrophage cell line

Rheumatoid arthritis (RA) is a multifactorial autoimmune disease that affects the joints of approximately 1 % of the population worldwide and is seen 2-4 times less in males. INSL3 is a gender-specific peptide hormone produced much higher in males than in females and may have an anti-inflammatory role in RA. So, in this study, it was aimed to determine the possible anti-inflammatory effect and dose of insulin-like factor-3(INSL3) in an experimental Complete Freund's adjuvant(CFA)-induced RA male rat model and lipopolysaccharide(LPS)-induced macrophage cell line and compare it with prednisolone therapy. For in vivo experiments, 48 male mice were randomly divided into 6 groups with 8 subjects in each group: Control group, Arthritis group, Arthritis + Prednisolone(10 mg/kg) group, Arthritis + INSL3(0.08-0.8-8 μg/day) groups. Joint tissue samples obtained from sacrificed subjects were examined by histochemical and immunohistochemically methods after biometric analyses, arthritis severity scoring, and thermal latency experiments. LPS-induced macrophage cells were also treated with prednisolone(1 µg/ml) and INSL3(50-100-200 nM). Cell viability, cell morphology, and TNF-α and IL-6 immune reactivity were evaluated. According to the data obtained from in vivo analyses, it was seen that INSL3 reduced the paw diameter and arthritis severity scoring, degenerative changes, and inflammation and increased the thermal latency, compared to the arthritis group, although not as much as the prednisolone treatment group. In vitro analyses showed that high doses of INSL3 had positive effects on cell viability, morphology, TNF-α, and IL-6 immune reactivity. In conclusion, it was determined that the anti-inflammatory effect of INSL3 was not as pronounced as prednisolone, but it had a more favorable impact on macrophage cell viability and morphology. It was concluded that INSL3 may be a protective therapeutic agent in combination with existing treatment protocols in treating many autoimmune diseases.

Revolutionizing rheumatoid arthritis treatment with emerging cutaneous drug delivery systems: overcoming the challenges and paving the way forward

Rheumatoid arthritis (RA) is a chronic inflammatory disorder of the articulating joints. Though considerable progress has been made in understanding the disease in the past 50 years, its pathogenesis remains unclear. The therapies for RA, such as nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs, and glucocorticoids through conventional therapeutic delivery systems by percutaneous, intra-articular, intraperitoneal, oral, and intravenous administration, have shown their own disadvantages, which eventually reduce patient compliance for long-term therapy. Recently, drug delivery via a topical or transdermal route has gained attention as an alternative to the conventional approach. Though skin acts as a barrier for the delivery of drugs due to its structure, various permeation pathways are manipulated to enhance the drug delivery across or into the skin. However, poor skin retention is the reason for the failure of many conventional topical dosage forms, such as gels, sprays, and creams. Hence, there is an urgent need for conquering the skin boundary to improve skin partitioning. Nanotechnology is a developing and dynamic field gaining popularity in the nanoscale design. This review extensively describes the potential of various nanoformulations, such as vesicular systems, lipid nanoparticles, and polymeric nanoparticles, with a targeted approach to deliver the drugs to the inflamed joint region. Limelight has also been provided to next-generation approaches like surface modification, stimuli-responsive formulations, multifunctional carrier systems, microneedles, and microsponge systems. Physical methods for enhancing the transdermal delivery, such as electroporation and sonophoresis, and emerging treatment therapies, such as gene therapy, photothermal therapy, and photodynamic therapy, have been evaluated to enhance the treatment efficacy. The clinical status, patents and current challenges associated with nanotechnology and the future prospects of targeted drug delivery have also been discussed.

The pattern of anti-IL-6 versus non-anti-IL-6 biologic disease modifying anti-rheumatic drugs use in patients with rheumatoid arthritis in Wales, UK: a real-world study using electronic health records

Objective

Investigating factors associated with drug initiation and discontinuation in patients treated with anti-IL-6 biologic DMARDs (bDMARDs) (tocilizumab or sarilumab) vs non-anti-IL-6 (anti-TNF, B or T cell therapies) bDMARDs for RA.

Methods

A retrospective cohort study of patients with the diagnosis of RA in the Secure Anonymised Information Linkage Databank, comprising primary and secondary care and specialist rheumatology clinic records for >90% of the population in Wales, UK. Patients initiated on first bDMARD treatment, discontinuation and clinical outcomes including infection and hospitalisation were analysed using Cox regression analysis.

Results

Of patients identified with RA in their primary care records, 95.7% (4691/4922) received conventional synthetic DMARDs (csDMARDs). More than one-third (36.2%) were treated with bDMARDs (1784/4922). Of these biologic-naïve patients, 6.5% (116) were treated with anti-IL-6 bDMARDs; this treatment was associated with a previous history of infection [difference 8.8% (95% CI 1.1, 17.8)] and kidney disease [14.3% (95% CI 8.0, 22.5)]. Treatment discontinuation was significantly higher in the non-anti-IL-6 bDMARD-treated patients (23.1%) compared with the anti-IL-6 bDMARD-treated individuals (18.1%) [difference 9.4% (95% CI 1.1, 15.7)]. For those discontinuing a first line of treatment, 385 patients (23%) and 21 patients (18%) switched to an alternative bDMARD from the non-anti-IL-6 and anti-IL-6 groups, respectively.

Conclusion

Comorbidities, history of infection and kidney disease were associated with choosing anti-IL-6 bDMARDs in biologic-naïve RA patients in Wales. Anti-IL-6 bDMARD-treated biologic-naïve patients were more likely to continue treatment than non-IL-6 bDMARD-treated patients.

Plasma exchange alone versus combination with intravenous immunoglobulin/methylprednisolone pulse therapy in severe systemic rheumatic diseases: a retrospective study

Background

For severe systemic rheumatic diseases (SRDs), therapeutic plasma exchange (TPE) may be applied as a rescue therapy; it usually combined with intravenous immunoglobulin (IVIG) or intravenous methylprednisolone pulse (IVMP) in severe SRDs. However, the necessity of this combination treatment strategy in SRDs remains uncertain.

Objective

This retrospective study aimed to evaluate the effectiveness of TPE alone versus TPE combined with IVIG/IVMP in treating severe SRDs.

Methods

Patients with severe SRDs treated with TPE who were admitted to the department of intensive care unit (ICU) from January 2011 to December 2019 were included. These patients were divided into two groups: the TPE-alone group (TPE group) and the TPE plus IVIG/IVMP group (TPE + IVIG/IVMP group). The patients' clinical characteristics, the Sequential Organ Failure Assessment score, the 28-day mortality rate, and the length of ICU stay were evaluated in the two groups.

Results

Ninety-one patients were enrolled in this study: 51 patients in the TPE group and 40 patients in the TPE + IVIG/IVMP group. In the TPE group, the median age was 51.39 ± 15.34 years, and 64.71% were women. In the TPE + IVIG/IVMP group, the median age of the patients was 42.93 ± 16.56 years, and 75% were women. The infection rate in the TPE + IVIG/IVMP group was significantly higher than that in the TPE group (P < 0.05). Both the 28-day mortality and the length of ICU stay did not differ statistically between the two groups (P > 0.05).

Conclusion

This study showed no benefit of combing IVIG/IVMP with TPE in improving the outcome of patients with severe SRDs, suggesting that IVIG/IVMP may not be necessary when used conjunction with TPE for the treatment of severe SRDs.

Radiographic Progression in Patients with Rheumatoid Arthritis in Clinical Remission or Low Disease Activity: Results from a Swiss National Registry (SCQM)

Background/Objectives: The therapeutic aim for rheumatoid arthritis (RA) is to control disease activity and prevent radiographic progression. Various clinical scores are used to assess disease activity in RA patients. The DAS 28 score can define states of low disease activity (LDA) and remission. Despite achieving LDA or remission, radiographic progression may, nevertheless, occur. However, the rates and frequency of this occurrence have not been analyzed in detail. (1) To characterize radiographic progression in patients with persistent DAS 28-defined LDA or remission. (2) Analyze the potential benefits of modifying therapeutic strategies in response to observed radiographic progression in patients with persistent LDA or remission. Methods: An analysis was conducted on RA patients enrolled in the SCQM (Swiss Clinical Quality Management) cohort. Persistent LDA or remission was defined as DAS 28 ≤ 3.2 or <2.6, respectively, recorded at two consecutive follow-up time points. Inclusion criteria involved patients with a minimum of two sets of radiographs taken during these LDA and/or remission periods. Radiographic progression was measured using the Ratingen score, a numerical scale ranging from 0 to 190, which quantifies joint erosions. Repair was defined as a decrease in the Ratingen score > 5 points/year, while progression was characterized by an increase of >1, >2, or >5 points change in the Ratingen score within a one-year timeframe. Results: Among 10'141 RA patients, there were 1'447 episodes of remission and 2'614 episodes of LDA, with two sets of X-rays available for assessment during these episodes. The rates of radiographic progression (>5 points change in the Ratingen score per year) were 11.2% for LDA and 8.8% for remission. Therapeutic adaptations were made in 7.0% of patients in remission and 12.9% of patients in LDA following radiographic progression. After radiographic progression despite LDA, loss of LDA was observed in 19% of patients with treatment intensification versus in 8.5% under continued treatment during follow-up within 36 months. Conclusions: We report a considerable rate of radiographic progression occurring in RA patients with LDA or clinical remission. Notwithstanding minor radiographic progression, maintaining therapeutic continuity seemed more favorable than altering the therapeutic regimen.

2024 update of the recommendations of the French Society of Rheumatology for the diagnosis and management of patients with rheumatoid arthritis

The French Society of Rheumatology recommendations for managing rheumatoid arthritis (RA) has been updated by a working group of 21 rheumatology experts, 4 young rheumatologists and 2 patient association representatives on the basis of the 2023 version of the European Alliance of Associations for Rheumatology (EULAR) recommendations and systematic literature reviews. Two additional topics were addressed: people at risk of RA development and RA-related interstitial lung disease (RA-ILD). Four general principles and 19 recommendations were issued. The general principles emphasize the importance of a shared decision between the rheumatologist and patient and the need for comprehensive management, both drug and non-drug, for people with RA or at risk of RA development. In terms of diagnosis, the recommendations stress the importance of clinical arthritis and in its absence, the risk factors for progression to RA. In terms of treatment, the recommendations incorporate recent data on the cardiovascular and neoplastic risk profile of Janus kinase inhibitors. With regard to RA-ILD, the recommendations highlight the importance of clinical screening and the need for high-resolution CT scan in the presence of pulmonary symptoms. RA-ILD management requires collaboration between rheumatologists and pulmonologists. The treatment strategy is based on controlling disease activity with methotrexate or targeted therapies (mainly abatacept or rituximab). The prescription for anti-fibrotic treatment should be discussed with a pulmonologist with expertise in RA-ILD.

Molecular Determinants of Neutrophil Extracellular Vesicles That Drive Cartilage Regeneration in Inflammatory Arthritis

OBJECTIVE

This study was undertaken to establish the potential therapeutic profile of neutrophil-derived extracellular vesicles (EVs) in experimental inflammatory arthritis and associate pharmacological activity with specific EV components, focusing on microRNAs.

METHODS

Neutrophil EVs were administered intra-articularly through a prophylactic or therapeutic protocol to male C57BL/6 mice undergoing serum-transfer-induced inflammatory arthritis. Transcriptomic analysis of knees was performed on joints following EV administration, naive and arthritic mice (untreated; n = 4/group) and EV-treated diseased mice (intra-articular administration) with contralateral (vehicle-treated; n = 8/group). Comparison of healthy donor and patients with rheumatoid arthritis (RA) neutrophil EVs was performed.

RESULTS

EVs afforded cartilage protection with an increase in collagen-II and reduced collagen-X expression within the joint. To gain mechanistic insights, RNA sequencing of the arthritic joints was conducted. A total of 5,231 genes were differentially expressed (P < 0.05), with 257 unique to EV treatment. EVs affected key regenerative pathways involved in joint development, including Wnt and Notch signaling. This wealth of genomic alteration prompted to identify microRNAs in EVs, 10 of which are associated with RA. As a proof of concept, we focused on miR-455-3p, which was detected in both healthy donor and RA EVs. EV addition to chondrocyte cultures elevated miR-455-3p and exerted anticatabolic effects upon interleukin-1β stimulation; these effects were blocked by actinomycin or miR-455-3p antagomir.

CONCLUSION

Neutrophils from patients with RA yielded EVs with composition, efficacy, and miR-455-3p content similar to those of healthy volunteers, suggesting that neutrophil EVs could be developed as an autologous treatment to protect and repair joint tissue of patients affected by inflammatory arthritides.

How to Distinguish Non-Inflammatory from Inflammatory Pain in RA?

PURPOSE OF THE REVIEW

Managing non-inflammatory pain in rheumatoid arthritis (RA) can be a huge burden for the rheumatologist. Pain that persists despite optimal RA treatment is extremely challenging for patient and physician alike. Here, we outline the latest research relevant to distinguishing non-inflammatory from inflammatory RA pain and review the current understanding of its neurobiology and management.

RECENT FINDINGS

Nociplastic pain is a recently introduced term by the international pain community. Its definition encompasses the non-inflammatory pain of RA and describes pain that is not driven by inflamed joints or compromised nerves, but that is instead driven by a functional reorganisation of the central nervous system (CNS). Insights from all areas of nociplastic pain research, including fibromyalgia, support a personalised pain management approach for non-inflammatory pain of RA, with evidence-based guidelines favouring use of non-pharmacological interventions. Future developments include novel CNS targeting pharmacotherapeutic approaches to treat nociplastic pain.

An international multicentre analysis of current prescribing practices and shared decision-making in psoriatic arthritis

OBJECTIVES

Shared decision-making (SDM) is advocated to improve patient outcomes in PsA. We analysed current prescribing practices and the extent of SDM in PsA across Europe.

METHODS

The ASSIST study was a cross-sectional observational study of PsA patients ≥18 years of age attending face-to-face appointments between July 2021 and March 2022. Patient demographics, current treatment and treatment decisions were recorded. SDM was measured by the clinician's effort to collaborate (CollaboRATE questionnaire) and patient communication confidence (PEPPI-5 tool).

RESULTS

A total of 503 patients were included from 24 centres across the UK, France, Germany, Italy and Spain. Physician- and patient-reported measures of disease activity were highest in the UK. Conventional synthetic DMARDs constituted a higher percentage of current PsA treatment in the UK than continental Europe (66.4% vs 44.9%), which differed from biologic DMARDs (36.4% vs 64.4%). Implementing treatment escalation was most common in the UK. CollaboRATE and PEPPI-5 scores were high across centres. Of 31 patients with low CollaboRATE scores (<4.5), no patients with low PsAID-12 scores (<5) had treatment escalation. However, of 465 patients with CollaboRATE scores ≥4.5, 59 patients with low PsAID-12 scores received treatment escalation.

CONCLUSIONS

Higher rates of treatment escalation seen in the UK may be explained by higher disease activity and a younger cohort. High levels of collaboration in face-to-face PsA consultations suggests effective implementation of the SDM approach. Our data indicate that in patients with mild disease activity, only those with higher perceived collaboration underwent treatment escalation. Prospective studies should examine the impact of SDM on PsA patient outcomes.

TRIAL REGISTRATION

clinicaltrials.gov, NCT05171270.

Comparative Analysis of Coagulation Activation in Rheumatoid Arthritis Patients Treated With TNF Inhibitors Versus JAK Inhibitors: A Longitudinal Study

OBJECTIVES

This study aims to investigate the activation of the coagulation system of RA patients and assess changes during anti-inflammatory treatment with tumor necrosis factor blockers (anti-TNF) and Janus kinase inhibitors (JAKi).

METHODS

Biomarkers for the coagulation system, including D-dimer, fibrinogen, prothrombin time, activated partial thrombin time, prothrombin fragment 1 + 2, thrombin-antithrombin complex (TAT), activated factor IX, antithrombin complex, and von Willebrand factor (vWF), were longitudinally measured in 83 RA patients treated with anti-TNF and 38 RA patients with JAKi. Data were collected at baseline, after 1, 3, and 6 months.

RESULTS

The mean age was 57 (±14) years; 76% was female. The mean DAS28-CRP was 3.6 (±1.3) for anti-TNF users and 4.1 (±1.4) for JAKi users at baseline and declined in both groups. Baseline coagulation markers levels were comparable between groups. In anti-TNF users, D-dimer and fibrinogen levels significantly declined (-0.31 mg/L, p = 0.01 and -0.71 g/L, p < 0.001, respectively), whereas TAT significantly increased after 6 months follow-up (1.46 μg/L, p = 0.03) and no effect on vWF ( p = 0.98). In JAKi users, vWF declined significantly during the 6 months follow-up (-37.41%, p < 0.001); additionally, there were reductions of D-dimer, fibrinogen, and TAT that did not reach significance (-0.17 mg/L, p = 0.59; -0.49 g/L, p = 0.12; and 0.68 μg/L, p = 0.27, respectively).

CONCLUSIONS

The prothrombotic tendency in active RA declined during effective treatment with both anti-TNF and JAKi. Altogether, the biomarkers used in this study suggest that an increased VTE risk in the first 6 months due to either treatment with anti-TNF or JAKi is unlikely.

Optimized co-delivery of curcumin and methylprednisolone using polyvinyl alcohol-coated CuO nanoparticles for synergistic rheumatoid arthritis treatment

The combination of methylprednisolone (MPDL) and curcumin (CUR) for treating rheumatoid arthritis (RA) offers several therapeutic advantages. This synergy allows for a reduction in the dosage of methylprednisolone, minimizing potential side effects associated with long-term steroid use while maintaining or enhancing the treatment's effectiveness. The objective of this study is to prepare drug carriers for MPDL and CUR aimed at treating RA, utilizing Freund's Complete Adjuvant-induced arthritic rat model (AIA). CuO nanoparticles (NPs) were synthesized using ultrasound by reducing copper (II) sulfte pentahydrate with sodium borohydride in a basic solution. Subsequently, these nanoparticles were incrementally added to a polyvinyl alcohol (PVA) solution to ensure controlled integration of PVA-coated CuO NPs. Field Emission Scanning Electron Microscopy (FE-SEM) analysis revealed that the CuO nanoparticles and PVA-coated CuO NPs averaged sizes of 50.7 nm and 104.8 nm, respectively. Furthermore, the PVA-coated CuO NPs demonstrated remarkable biocompatibility, with cell viability ranging from 88.1 % to 92.1 % at concentrations of 0.1 μg/mL and 50 μg/mL after 72 h, as validated through the MTT assay. The PVA-coated CuO NPs exhibited a more controlled and gradual drug release profile for both CUR and MPDL when compared to the PVA matrix. CUR@MPDL@PVA-coated CuO NPs demonstrated the most substantial reduction in hind paw swelling and the minimal clinical scores among all treatment groups, signaling enhanced anti-inflammatory effects. CUR@MPDL@PVA-coated CuO NPs also notably reduced the concentrations of pro-inflammatory cytokines TNF-α and IL-1β when measured against the AIA rats and the groups treated with free agents. Therefore, CUR@MPDL@PVA-coated CuO nanoparticles can be used in biomedical applications due to their size, biocompatibility, and anti-inflammatory properties.

NF-κB Signaling Pathway in Rheumatoid Arthritis: Mechanisms and Therapeutic Potential

Rheumatoid arthritis (RA) is an autoimmune chronic inflammatory disease that imposes a heavy economic burden on patients and society. Bone and cartilage destruction is considered an important factor leading to RA, and inflammation, oxidative stress, and mitochondrial dysfunction are closely related to bone erosion and cartilage destruction in RA. Currently, there are limitations in the clinical treatment methods for RA, which urgently necessitates finding new effective treatments for patients. Nuclear transcription factor-κB (NF-κB) is a signaling transcription factor that is widely present in various cells. It plays an important role as a stress source in the cellular environment and regulates gene expression in processes such as immunity, inflammation, cell proliferation, and apoptosis. NF-κB has long been recognized as a pathogenic factor of RA, and its activation can exacerbate RA by promoting inflammation, oxidative stress, mitochondrial dysfunction, and bone destruction. Conversely, inhibiting the activity of the NF-κB pathway effectively inhibits these pathological processes, thereby alleviating RA. Therefore, NF-κB may be a potential therapeutic target for RA. This article describes the physiological structure of NF-κB and its important role in RA through the regulation of oxidative stress, inflammatory response, mitochondrial function, and bone destruction. Meanwhile, we also summarized the impact of NF-κB crosstalk with other signaling pathways on RA and the effect of related drugs or inhibitors targeting NF-κB on RA. The purpose of this article is to provide evidence for the role of NF-κB in RA and to emphasize its significant role in RA by elucidating the mechanisms, so as to provide a theoretical basis for targeting the NF-κB pathway as a treatment for RA.

Effectiveness and Persistence of Anti-TNFα Treatment in Patients with Rheumatoid Arthritis - A 7 Years Real-World Cohort Study

Purpose

To describe the effectiveness and persistence of treatment with three anti-TNFα drugs, Infliximab, Etanercept, and Adalimumab, in patients with Rheumatoid Arthritis (RA) in a rheumatology center.

Patients and Methods

A longitudinal, retrospective cohort study was conducted. Data were obtained from the health records of patients with RA who were followed up in a rheumatology center between 2011 and 2019 under a multidisciplinary healthcare model (MCM). The drugs used in this study were indicated according to the treatment guidelines for prescription. In order to follow-up of disease activity, at least three DAS28 reports for every analyzed year were used. The chi-square test and Fisher's exact test were used for statistical analyses of categorical variables. For the analysis of treatment persistence, the Kaplan-Meier method was used based on the recorded follow-up time of disease activity.

Results

One hundred and eighty-three RA patients included (80% women, median age 60 years), who received adalimumab (n = 56) (30.6%), etanercept (n = 64) (34.9%), or infliximab (n = 63) (34.4%) during the 7-year study period. A higher proportion of patients had moderate or high disease activity for all three anti-TNFα. In first-year treatment, 67% to 87% of the cohort achieved disease activity control and disease response to treatment. For the first three years, 95% to 98% of patients continued with the medications. In years 5th and 7th, the proportion of patients on medication was 80% to 90% and 42% to 54%, respectively.

Conclusion

The efficacy and persistence of anti-TNF-α were similar among the three molecules. These findings regarding long-term persistence in treatment may be useful for therapeutic decision-making based on real-life cohort results.

CONTExT-RA: a cross-sectional study evaluating disease activity, quality of life and the socio-demographic profile of Irish patients with rheumatoid arthritis

Objectives

CONTExT-RA is a cross-sectional, non-interventional multicentre study which enrolled patients diagnosed with RA and receiving DMARD treatment in a secondary care setting. The study evaluated disease control and associated disease burden amongst this Irish population.

Methods

Patients with RA attending six Irish rheumatology centres were invited to participate. Each consented patient attended a single routine study visit. Disease activity was assessed using Clinical Disease Activity Index (CDAI). The primary endpoint was EuroQol-5 dimensions (EQ-5D-5L) stratified by CDAI, compared using a non-parametric Wilcoxon Rank-Sum test.

Results

130 patients were included. Using CDAI, 34 (26.2%) patients were in clinical remission (CR), 42 (32.3%) had low disease activity (LDA), 41 (31.5%) had moderate disease activity (MDA) and 13 (10.0%) had high disease activity (HDA). QoL (EQ-5D-5L index (median)) scores were significantly (P < 0.001) greater for patients in CR or CR/LDA than for those with MDA/HDA, 0.866 (0.920), 0.777 (0.822) vs 0.578 (0.691), respectively. Patients in CR reported higher levels of work productivity, mean (s.d.) rating of 1.7 (2.52) vs those in MDA/HDA of 4.2 (3.28) (higher rating indicates greater impairment). Similar findings were observed for non-work-related activities.

Conclusion

Disease control for many patients with RA, treated in secondary care in Ireland, is sub-optimal with only 1 in 4 in CDAI remission. The impact of poor disease control on QoL is significant, and the superior outcomes for patients in CR provide compelling evidence that by achieving greater disease control, the burden of disease on patients can be greatly reduced.

Network-Based Drug Repurposing and Genomic Analysis to Unveil Potential Therapeutics for Monkeypox Virus

The emergence of the human monkeypox virus (MPXV) and the lack of effective medications have necessitated the exploration of various strategies to combat its infection. This study employs a network-based approach to drug discovery, utilizing the BLASTn and phylogenetic analysis to compare the MPXV genome with those of 18 related orthopoxviruses, revealing over 75 % genomic similarity. Through a literature review, 160 human-host proteins linked to MPXV and its relatives were identified, leading to the construction of a human-host protein interactome. Analysis of this interactome highlighted 39 central hub proteins, which were then examined for potential drug targets. The process successfully revealed 15 targets already approved for use with medications. Additionally, the functional enrichment analysis provided insights into potential pathways and disorders connected with these targets. Four medications, namely Baricitinib, Infliximab, Adalimumab, and Etanercept, have been identified as potential candidates for repurposing to combat MPXV. In addition, the pharmacophore-based screening identified a molecule that is comparable to Baricitinib and has the potential to be effective against MPXV. The findings of the study suggest that ZINC22060520 is a promising medication for treating MPXV infection and proposes these medications as potential options for additional experimental and clinical assessment in the battle against MPXV.

Prescription of non-steroidal anti-inflammatory drugs for patients with inflammatory arthritis decreases with the initiation of tumour necrosis factor inhibitor therapy: results from the ICEBIO registry

OBJECTIVE

To study the impact of tumour necrosis factor-α inhibitor (TNFi) therapy on the use of non-steroidal anti inflammatory drugs (NSAIDs) in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (axSpA) in Iceland.

METHOD

This registry cohort study used data from the nationwide database on biologics in Iceland (ICEBIO) and the Icelandic Prescription Medicines Register on disease activity, and filled prescriptions for NSAIDs, to study the period from 2 years before to 2 years after initiation of a first TNFi. Five randomly selected individuals from the general population matched on age, sex, and calendar time for each patient served as comparators.

RESULTS

Data from 940 patients and 4700 comparators were included. Patients with arthritis were prescribed 6.7 times more defined daily doses of NSAIDs than comparators (149 vs 22 per year). After TNFi initiation, NSAID use decreased to a mean of 85 DDD per year, or by 42% in RA, 43% in PsA, and 48% in axSpA. At TNFi initiation, the quintile of axSpA patients who used most NSAIDs reported significantly worse pain (mean ± sd 66 ± 21 vs 60 ± 23 mm), global health (70 ± 20 vs 64 ± 23 mm), and Health Assessment Questionnaire score (1.21 ± 0.66 vs 1.02 ± 0.66) than the other patients, whereas no significant differences were observed in the groups with peripheral arthritis.

CONCLUSION

Patients with inflammatory arthritides requiring TNFi therapy use more NSAIDs than matched comparators, and consumption decreased following TNF initiation. Patient-reported measures are not associated with high NSAID use in patients with peripheral arthritis.

A Canadian Retrospective Chart Review Evaluating Concomitant Methotrexate De-escalation Patterns in Patients with Rheumatoid Arthritis Treated with Biologic or Targeted Synthetic DMARDs

INTRODUCTION

Rheumatoid arthritis (RA) guidelines recommend methotrexate (MTX)-anchored therapy with biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs); however, tolerability issues often lead to non-adherence. Canadian data on MTX tapering and/or withdrawal following b/tsDMARD initiation are minimal. This chart review assessed frequency of MTX tapering or withdrawal following b/tsDMARD initiation and the impact on disease status in Canadian adults with RA.

METHODS

Eligible patients had received MTX for ≥ 3 months before b/tsDMARD initiation. The b/tsDMARD was prescribed continuously for ≥ 18 months. Patients taking > 10 mg/day oral prednisone or equivalent were excluded.

RESULTS

Eight hundred eighty-nine patients (mean baseline MTX dose 19.0 mg/week) prescribed b/tsDMARDs (tumor necrosis factor inhibitor 52.1%, Janus kinase inhibitor 18.3%, interleukin-6 inhibitor [IL-6i] 11.9%, other 17.7%) were evaluated at 22 Canadian centers. Within 2 years of b/tsDMARD initiation, MTX was tapered in 123 (13.8%) patients and discontinued in 147 (16.5%), most commonly due to planned tapering (36.6%) and patient decision (27.2%), respectively, and most commonly with IL-6i use (34.9%). The MTX dose was unchanged for 582 (65.5%) patients and increased for 37 (4.2%). Missing data limit interpretations of MTX dose effects on some secondary endpoints and challenge the assertion that a disease activity measure-based treat-to-target approach is routinely used in Canadian rheumatology practice.

CONCLUSIONS

Methotrexate tapering or withdrawal occurred in 30.4% of Canadians with RA within 2 years following b/tsDMARD initiation. Baseline disease activity measures were missing from many medical records. However, for patients with baseline assessments, MTX tapering or discontinuation did not worsen disease activity.

Krebs von den Lungen-6 as biomarker of the new progressive fibrotic phenotype of interstitial lung disease

BACKGROUND

Novel progressive fibrotic phenotype has recently been proposed characterized by progressive and inexorable worsening of the disease. Krebs von den Lungen-6 (KL-6) has been proposed as fibrotic-ILD biomarker. We aimed to assess the role of KL-6 in fibrotic-ILD and the progressive phenotype in accordance with serial serum KL-6.

METHODS

107 patients were enrolled in the study (median age,IQR, 65(54-71)y/o) followed at respiratory diseases and rheumatology units of University of Siena. Thirty-five had diagnoses of IPF, 18 sarcoidosis, 10 PLCH, 5 LAM, 24 fibrotic HP(fHP), 13 RA (4/13 RA-ILD) and 22 SSc (18/22 SSc-ILD). Serial serum samples were collected before therapy (t0) and 24 months later (t1) from IPF, SSc- and RA-ILD patients. Twenty-two healthy controls (HC) were enrolled. Serum samples were assayed for KL-6 concentrations (Fujirebio Europe, Gent, Belgium).

RESULTS

Higher KL-6 concentrations were reported in IPF, fHP and SSc-ILD patients than HC (p<0.0001). KL-6 cut-off value of 885 U/mL identified fibrotic-ILD patients. Logistic regression analysis indicated KL-6 (p=0.004) and smoking-habit (p=0.005) affected the ILD diagnosis. The decision tree model showed KL-6>1145 U/mL, DLco≤60.15 %, FVC≤86 % to classify 86 % IPF patients. Inverse correlation between T0-KL-6 and T1-FVC%(r=-0.314, p=0.046) and T1-DLco%(r=-0.327, p=0.038) in the progressive group.

CONCLUSION

KL-6 proved to be a reliable marker for diagnosis and prognosis of fibrotic ILD patients with predictive value in progressive fibrotic patients and a useful marker to identify the new and similar progressive phenotype of IPF and SSc-ILD patients assessing the functional progression in accordance with serial serum KL-6 measurements.

The potential role of fatigue in difficult-to-treat rheumatoid arthritis

OBJECTIVES

A subset of patients with rheumatoid arthritis (RA) who remains symptomatic after failing to multiple drugs are deemed to have "difficult-to-treat RA" (D2T RA). Fatigue is a burdensome symptom for RA patients, hindering their improvement. Our purpose was to evaluate the role of fatigue in D2T RA.

METHODS

This cross-sectional study included rheumatoid arthritis (RA) patients between 2018 and 2022, treated with biological agents or targeted synthetic disease-modifying antirheumatic drugs. D2T RA was defined attending EULAR criteria. Independent variable was fatigue (dimensions and impact) assessed by the Bristol Rheumatoid Arthritis Fatigue Multidimensional Questionnaire and Numerical Rating Scales. Covariables: sociodemographic, clinical and treatment. To identify factors independently associated to D2T RA, multivariable logistic regression was run.

RESULTS

The study included 145 patients and 38 (26.21%) developed D2T RA. D2T RA group were older, with more comorbidity and disability. D2T RA patients scored higher for global fatigue (p = 0.003), and almost for all their dimensions except for cognitive fatigue (p = 0.06) and fatigue coping (p = 0.07). Females with D2T RA showed more fatigue than those with non-D2T RA. In the adjusted models, all fatigue dimensions were associated with D2T RA: global fatigue RA (OR: 1.03; p = 0.007), physical (OR: 1.09; p = 0.008), living (OR: 1.09; p = 0.016), cognitive (OR: 1.1; p = 0.046) and emotional (OR: 1.18; p = 0.012).

CONCLUSIONS

Despite the absence of an explicit mention of fatigue in the definition of D2T RA, it appears to be associated to this outcome. Fatigue should be evaluated in a multidimensional perspective, and gender-specific differences should be considered.

Long-Term Survival of Subcutaneous Biosimilar Tumor Necrosis Factor Inhibitors Compared to Originators: Results From a Multicenter Prospective Registry

OBJECTIVE

To analyze the long-term survival of subcutaneous biosimilar tumor necrosis factor inhibitors compared to the originator molecules in patients with rheumatic diseases, as well as the factors associated with drug discontinuation.

METHODS

Retrospective analysis of BIOBADASER, the Spanish multicenter prospective registry of patients with rheumatic disease receiving biologic and targeted disease-modifying antirheumatic drugs. Patients who started etanercept (ETN) or adalimumab (ADA) from January 2016 to October 2023 were included. The survival probabilities of biosimilars and originators were compared using Kaplan-Meier estimating curves. To identify factors associated with differences in the retention rates, hazard ratios (HR) were estimated using Cox regression models for all and specific causes (inefficacy or adverse events [AEs]) of discontinuation.

RESULTS

A total of 4162 patients received 4723 treatment courses (2991 courses of ADA and 1732 courses of ETN), of which 722 (15.29%) were with originator molecules and 4001 (84.71%) were with biosimilars. The originators were more frequently discontinued than biosimilars (53.32% vs 33.37%, respectively). The main reason for discontinuation was inefficacy (60.35% of the treatments). The risk of overall discontinuation was lower for biosimilars (adjusted HR 0.84, 95% CI 0.75-0.95). Female sex, obesity, and second or later treatment lines increased the risk of discontinuation, whereas disease duration and the use of concomitant methotrexate were associated with a greater survival. When assessing cause-specific reasons of discontinuation, excluding nonmedical switching, the results from the crude and adjusted analyses showed no significant differences in the retention rate between biosimilars and originators.

CONCLUSION

No significant differences were found between treatments in long-term survival due to inefficacy or AEs.

Improving Reliability of Immunological Assays by Defining Minimal Criteria for Cell Fitness

Human PBMC-based assays are often used as biomarkers for the diagnosis and prognosis of disease, as well as for the prediction and tracking of response to biological therapeutics. However, the development and use of PBMC-based biomarker assays is often limited by poor reproducibility. Complex immunological assays can be further complicated by variation in cell handling before analysis, especially when using cryopreserved cells. Variation in postthaw viability is further increased if PBMC isolation and cryopreservation are done more than a few hours after collection. There is currently a lack of evidence-based standards for the minimal PBMC viability or "fitness" required to ensure the integrity and reproducibility of immune cell-based assays. In this study, we use an "induced fail" approach to examine the effect of thawed human PBMC fitness on four flow cytometry-based assays. We found that cell permeability-based viability stains at the time of thawing did not accurately quantify cell fitness, whereas a combined measurement of metabolic activity and early apoptosis markers did. Investigation of the impact of different types and levels of damage on PBMC-based assays revealed that only when cells were >60-70% live and apoptosis negative did biomarker values cease to be determined by cell fitness rather than the inherent biology of the cells. These data show that, to reproducibly measure immunological biomarkers using cryopreserved PBMCs, minimal acceptable standards for cell fitness should be incorporated into the assay protocol.

Dual-Energy Computed Tomography Applications in Rheumatology

Dual-energy computed tomography (DECT) has emerged as a transformative tool in the past decade. Initially employed in gout within the field of rheumatology to distinguish and quantify monosodium urate crystals through its dual-material discrimination capability, DECT has since broadened its clinical applications. It now encompasses various rheumatic diseases, employing advanced techniques such as bone marrow edema assessment, iodine mapping, and collagen-specific imaging. This review article aims to examine the unique characteristics of DECT, discuss its strengths and limitations, illustrate its applications for accurately evaluating various rheumatic diseases in clinical practice, and propose future directions for DECT in rheumatology.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of denosumab with serum cytokines, chemokines, and bone-related factors in patients with rheumatoid arthritis: A post hoc analysis of a multicentre, open-label, randomised, parallel-group study

OBJECTIVES

To clarify changes in serum cytokines, chemokines, and bone-related factors during denosumab treatment in rheumatoid arthritis (RA) patients.

METHODS

This was a post hoc analysis of a multicentre, open-label, randomised, parallel-group study. Patients were randomly assigned to continue treatment with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) plus receive treatment with denosumab (csDMARDs plus denosumab group) or to continue treatment with csDMARD therapy alone for 12 months. Serum biomarker levels were measured at baseline and at 6 and 12 months.

RESULTS

Baseline and 6-month data from the csDMARDs plus denosumab (n = 22) and csDMARD therapy alone (n = 22) groups were analysed. Statistically significant changes from baseline were seen: Dickkopf-related protein 1 decreased at 6 and 12 months (both groups); osteopontin decreased at 6 months in the csDMARDs plus denosumab group; osteopontin and soluble CD40 ligand increased at 6 and 12 months in the csDMARD therapy alone group; osteocalcin decreased at 6 and 12 months, epidermal growth factor decreased at 12 months, and macrophage-derived chemokine decreased at 6 months in the csDMARDs plus denosumab group; and interferon gamma-induced protein-10 increased at 12 months in the csDMARD therapy alone group.

CONCLUSIONS

Denosumab may inhibit bone destruction by suppressing bone-related factors/chemokines.

Disease-modifying antirheumatic drug selection in Japanese patients with rheumatoid arthritis treated with biologics or JAK inhibitors without methotrexate: A retrospective hospital-based administrative claims database study

OBJECTIVES

We evaluated the medication selection and clinical characteristics of rheumatoid arthritis patients who started treatment with/without methotrexate (MTX) (using biologic disease-modifying antirheumatic drugs or Janus kinase inhibitors instead) in Japan.

METHODS

Using a Japanese hospital-based administrative claims database, rheumatoid arthritis patients who received treatment [abatacept (ABA), interleukin-6 receptor inhibitor, tumor necrosis factor inhibitor, or Janus kinase inhibitor] between 1 January 2015 and 31 December 2019 were enrolled.

RESULTS

Overall, 19,301 patients were included (10,530 receiving MTX; 8771 not receiving MTX within 60 days of the first treatment). Mean ages at diagnosis were 60.7 and 65.9 years in the MTX and non-MTX groups, respectively (P < .0001). The non-MTX group had higher proportions of patients with Charlson Comorbidity Index ≥1 (P < .0001) and higher comorbidity rates. ABA was the most frequently used drug among patients with infectious/parasitic, circulatory, and respiratory diseases at baseline. Interleukin-6 receptor inhibitor had the highest use rate among patients with neoplasms; blood, gastrointestinal, and genitourinary diseases; and abnormal clinical/laboratory findings. ABA had the highest persistence probability from 6 months onward.

CONCLUSIONS

MTX is used less frequently among older Japanese rheumatoid arthritis patients or those with comorbidities. In such patients, ABA is the most frequently used drug, followed by interleukin-6 receptor inhibitor, when MTX is not used at treatment start.

Incidence and predisposing factors of extra-articular manifestations in contemporary rheumatoid arthritis

OBJECTIVE

Rheumatoid arthritis [RA) is a chronic inflammatory disease, with potential for extra-articular manifestations (ExRA). The incidence and predisposing factors for ExRA and the mortality were evaluated in an early RA inception cohort.

METHODS

Patients (n = 1468; 69 % females, mean age (SD) 57.3(16.3) years) were consecutively included at the date of diagnosis, between 1 January 1996 and 31 December 2016, and assessed prospectively. In December 2016 development of ExRA was evaluated by a patient questionnaire and a review of medical records. Cumulative incidence and incidence rates were compared between 5-year periods and between patients included before and after 1 January 2001. Cox proportional hazard regression models were used to identify predictors for ExRA, and models with ExRA as time-dependent variables to estimate the mortality.

RESULTS

After a mean (SD) follow-up of 9.3(4.9) years, 238 cases (23.3 %) had ExRA and 151 (14.7 %) had ExRA without rheumatoid nodules. Most ExRA developed within 5 years from diagnosis. Rheumatoid nodules (10.5 %) and keratoconjunctivitis sicca (7.1 %) were the most frequent manifestations, followed by pulmonary fibrosis (6.1 %). The ExRA incidence among more recently diagnosed patients was similar as to the incidence among patients diagnosed before 2001. Seropositivity, smoking and early biological treatment were associated with development of ExRA. After 15 years 20 % had experienced ExRA. ExRA was associated with increased mortality, HR 3.029 (95 % CI 2.177-4.213).

CONCLUSIONS

Early development of ExRA is frequent, particularly rheumatoid nodules. Predisposing factors were age, RF positivity, smoking and early biological treatment. The patients with ExRA had a 3-fold increase in mortality.

Adipose-derived mesenchymal stem cell therapy for connective tissue diseases and complications

Mesenchymal stem cells (MSCs) may be effective in treating connective tissue disease and associated organ damage, leveraging their anti-inflammatory and immunoregulatory effects. Moreover, MSCs may possess the ability to produce antiapoptotic, proliferative, growth, angiogenic, and antifibrotic factors. Among MSCs, adipose-derived MSCs (ASCs) stand out for their relative ease of harvesting and abundance. Additionally, studies have indicated that compared with bone marrow-derived MSCs, ASCs have superior immunomodulatory, proangiogenic, antiapoptotic, and antioxidative properties. However, relatively few reviews have focused on the efficacy of ASC therapy in treating connective tissue disease (CTD) and interstitial lung disease (ILD). Therefore, this review aims to evaluate evidence from preclinical studies that investigate the effectiveness of MSC therapy, specifically ASC therapy, in managing CTD and ILD. Moreover, we explore the outcomes of documented clinical trials. We also introduce an innovative approach involving the utilization of pharmacologically primed ASCs in the CTD model to address the current challenges associated with ASC therapy.

Real-world comparative study of drug retention of Janus kinase inhibitors in patients with rheumatoid arthritis

BACKGROUND

Janus kinase (JAK) inhibitors (JAKis) are effective therapeutic agents against rheumatoid arthritis (RA). However, patients having RA with particular risk factors may have a higher incidence of adverse effects (AEs), including major cardiovascular events (MACE) and infections. In this multicenter cohort study, we aimed to clarify the risk factors affecting the drug retention of JAKis in patients with RA.

METHODS

We retrospectively evaluated patients with RA who received their first JAKi (tofacitinib, baricitinib, upadacitinib, or filgotinib) at our institute. The clinical outcomes, including AEs, were recorded, particularly MACE and serious infections. The drug retention rates were analyzed using the Kaplan-Meier method, and risk factors affecting drug retention rates were determined using a multivariable Cox regression hazards model.

RESULTS

Overall 184 patients with RA receiving their first use of baricitinib (57.6%), tofacitinib (23.9%), upadacitinib (12.0%), or filgotinib (6.5%) were included in this study. Fifty-six (30.4%) patients discontinued JAKi treatment owing to ineffectiveness (9.2%) or AEs, including infections (21.2%). The overall drug retention rates were significantly lower in patients treated with pan-JAKi than in those treated with JAK1 inhibitors (p = 0.03). In the Cox regression model, the presence of baseline high RA disease activity, use of glucocorticoid and treatments with pan-JAKis were associated with reduced drug retention rates of JAKis (p < 0.001, p = 0.01 and 0.04, respectively). Pan-JAKi treated patients with high disease activity had significantly lower drug retention rates (p < 0.001).

CONCLUSIONS

In a real-world setting, the drug retention rates of JAKis were reduced mainly by treatment discontinuation owing to AEs. Treatment with pan-JAKis and high baseline RA disease activity were identified as predictive factors for the discontinuation of JAKis. Lower drug retention rates were found in patients receiving pan-JAKis with high disease activity than in those without high disease activity.