Impact of adalimumab on work participation in rheumatoid arthritis: comparison of an open-label extension study and a registry-based control group

Employment of patients with rheumatoid arthritis - a systematic review and meta-analysis

BACKGROUND

Patients with rheumatoid arthritis (RA) have difficulties maintaining employment due to the impact of the disease on their work ability. This review aims to investigate the employment rates at different stages of disease and to identify predictors of employment among individuals with RA.

METHODS

The study was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines focusing on studies reporting employment rate in adults with diagnosed RA. The literature review included cross-sectional and cohort studies published in the English language between January 1966 and January 2023 in the PubMed, Embase and Cochrane Library databases. Data encompassing employment rates, study demographics (age, gender, educational level), disease-related parameters (disease activity, disease duration, treatment), occupational factors, and comorbidities were extracted. Quality assessment was performed employing Newcastle-Ottawa Scale. Meta-analysis was conducted to ascertain predictors for employment with odds ratios and confidence intervals, and test for heterogeneity, using chi-square and I2-statistics were calculated. This review was registered with PROSPERO (CRD42020189057).

RESULTS

Ninety-one studies, comprising of a total of 101,831 participants, were included in the analyses. The mean age of participants was 51 years and 75.9% were women. Disease duration varied between less than one year to more than 18 years on average. Employment rates were 78.8% (weighted mean, range 45.4-100) at disease onset; 47.0% (range 18.5-100) at study entry, and 40.0% (range 4-88.2) at follow-up. Employment rates showed limited variations across continents and over time. Predictors for sustained employment included younger age, male gender, higher education, low disease activity, shorter disease duration, absence of medical treatment, and the absence of comorbidities. Notably, only some of the studies in this review met the requirements for high quality studies. Both older and newer studies had methodological deficiencies in the study design, analysis, and results reporting.

CONCLUSIONS

The findings in this review highlight the prevalence of low employment rates among patients with RA, which increases with prolonged disease duration and higher disease activity. A comprehensive approach combining clinical and social interventions is imperative, particularly in early stages of the disease, to facilitate sustained employment among this patient cohort.

Bacterial Compositional Shifts of Gut Microbiomes in Patients with Rheumatoid Arthritis in Association with Disease Activity

BACKGROUND

Rheumatoid arthritis (RA) is a chronic inflammatory disabling autoimmune disorder. Little is known regarding the association between the gut microbiome and etiopathogenesis of RA. We aimed to dissect the differences in gut microbiomes associated with RA in comparison to healthy individuals and, in addition, to identify the shifts in the bacterial community in association with disease activity; Methods: In order to identify compositional shifts in gut microbiomes of RA patients, V3-V4 hypervariable regions of 16S rRNA were sequenced using Illumina MiSeq. In total, sixty stool samples were collected from 45 patients with RA besides 15 matched healthy subjects; Results: Notably, RA microbiomes were significantly associated with diverse bacterial communities compared with healthy individuals. Likewise, a direct association between bacterial diversity and disease activity was detected in RA patients (Kruskal Wallis; p = 0.00047). In general, genus-level analysis revealed a positive coexistence between RA and Megasphaera, Adlercreutzia, Ruminococcus, Bacteroides, Collinsella, and Acidaminococcus. Furthermore, Spearman correlation analysis significantly stratified the most dominant genera into distinct clusters that were mainly based on disease activity (r ≥ 0.6; p ≤ 0.05). The predictive metabolic profile of bacterial communities associated with RA could support the potential impact of gut microbiomes in either the development or recovery of RA; Conclusions: The overall shifts in bacterial composition at different disease statuses could confirm the cross-linking of certain genera either to causation or progression of RA.

Functional Disability and Its Determinants in Ecuadorian Patients with Rheumatoid Arthritis

INTRODUCTION

Disability in RA is associated with loss of workdays, greater use of health resources and a higher prevalence of depression. The purpose of this study was to determine the prevalence of functional disability and the factors associated with it.

METHODS

A cross-sectional study was carried out during January-June 2019 at a rheumatology clinic in the city of Guayaquil. Patients with pre-established RA were included. Functional disability was measured using the HAQ-DI. Data were analyzed using the statistical program SPSS v22. We compared characteristics between patients with and without disability using Student's t-test and chi-square. A multiple logistic regression model for functional disability was made.

RESULTS

We included 395 patients, 87.8% female and 12.2% male with a mean age of 51.4±12 years and mean duration of disease 13.8±7 years. Most patients had extra-articular manifestations (80.8%) and comorbidities (81.3%). The mean HAQ-DI was 0.8±0.9, with a prevalence of disability of 26.6%. We found a statistically significant relationship between disability and female sex (p=0.018), age (p=0.020), presence of extra-articular manifestations (p=0.008), myalgia (p<0.001) and fatigue (p<0.001). In addition, patients with disabilities had a lower employment rate (26.7%) compared to those without disability (45.5%, p=0.001). In the multivariate logistic analysis, only depression (p=0.029), diabetes (p=0.003), SJC (p=0.001) and VAS of pain (p=0.004) were significantly related to functional disability.

CONCLUSION

Disability affects a quarter of patients with RA. Among the determinants of disability, we found female sex, older age, grade of pain, inflammatory markers and the level of disease activity.

Elevated levels of inflammatory markers in women with rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune and progressive disease. Evidence indicates that inflammatory mediators may contribute to the genesis and/or evolution of this clinical condition. Thus, the objective was to evaluate and compare the plasma levels of Interleukin-17 (IL-17), Tumor Necrosis Factor-Alpha (TNF-α) and Complement 3 (C3) in women with RA and healthy controls (HC), as well as to evaluate the association them with the disease activity. 25 women with RA and 15 HC were recruited. Plasma levels of biomarkers were measured by ELISA. All statistical analyzes were performed with a significance level set at α = 0.05. In the women with RA, the median age was 55 and, in the HC, was 50 years. The median value of DAS-28 was 3.79. The plasma levels of IL-17 (p = .03), TNF-α (p ≤ 0.01) and C3 (p ≤ 0.01) were higher in women with RA. The ROC curve showed that TNF- α has a higher discriminating ability than IL-17 and C3. DAS-28 score correlated significantly with C3 levels in women with RA (r = 0.91; p < .01). These findings reaffirm the participation of the immune system in pathophysiology of RA, suggest that TNF-α levels may be a good biomarker and that elevated C3 levels contribute to the worsening of the disease.

The role of microbiome in rheumatoid arthritis treatment

Rheumatoid arthritis (RA) is an autoimmune disorder with multifactorial etiology; both genetic and environmental factors are known to be involved in pathogenesis. Treatment with disease-modifying antirheumatic drugs (DMARDs) plays an essential role in controlling disease progression and symptoms. DMARDs have immunomodulatory properties and suppress immune response by interfering in various pro-inflammatory pathways. Recent evidence has shown that the gut microbiota directly and indirectly modulates the host immune system. RA has been associated with dysbiosis of the gut microbiota. Patients with RA treated with DMARDs show partial restoration of eubiotic gut microbiome. Hence, it is essential to understand the impact of DMARDs on the microbial composition and its consequent influences on the host immune system to identify novel therapies for RA. In this review, we discuss the importance of antirheumatic-drug-induced host microbiota modulations and possible probiotics that can generate eubiosis.

Impact of Adalimumab on Work Productivity and Activity Impairment in Japanese Patients with Rheumatoid Arthritis: Large-Scale, Prospective, Single-Cohort ANOUVEAU Study

INTRODUCTION

The Adalimumab Non-interventional Trial for Up-verified Effects and Utility (ANOUVEAU) was a large-scale, multicenter, prospective, observational, single-cohort study that evaluated the effects of adalimumab (ADA) on rheumatoid arthritis (RA)-related work productivity and activity impairment (RA-related WPAI) and disease activity in routine rheumatology care in Japan.

METHODS

Patients with RA were categorized as paid workers (PWs, ≥35 h/week), part-time workers (PTWs, <35 h/week), or homemakers (HMs, unemployed) and were administered the WPAI for RA (WPAI/RA) questionnaire. All patients who received ADA were followed for 48 weeks to evaluate safety and effectiveness.

RESULTS

Of the 1808 patients analyzed, 825, 243, and 740 patients were PWs, PTWs, and HMs, respectively. WPAI/RA domain scores significantly improved at weeks 12, 24, and 48 in all groups, with maximum improvement observed for PWs (p < 0.05). Additionally, remission rates (according to Disease Activity Score 28, erythrocyte sedimentation rate, Simplified Disease Activity Index, or Health Assessment Questionnaire-Disability Index scores) and EuroQol 5-Dimension 3-Level scores significantly increased from baseline to 48 weeks in all groups (p < 0.0001). Analysis of patient subgroups revealed better WPAI/RA outcomes for patients who were biologic-naïve, treated with concomitant methotrexate, or with RA duration of ≤2 years (p < 0.05). The rate of serious adverse events over 48 weeks of ADA treatment was 5.23%.

CONCLUSIONS

Treatment with ADA provided sustained improvement in WPAI and had an acceptable safety profile in patients with RA.

FUNDING

AbbVie GK and Eisai Co., Ltd.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT01346488.

Effect of Adalimumab on Work Ability Assessed in Rheumatoid Arthritis Disease Patients in Saudi Arabia (AWARDS)

Objectives :

Rheumatoid arthritis (RA) is a chronic disabling disease that can jeopardize the ability of affected individuals to participate in paid work. Our objective was to evaluate the effectiveness of a 6-month course of tumor necrosis factor (TNF) antagonist (adalimumab) on work ability, overall health, and fatigue in RA patients.

Methods :

Between October 2012 and February 2014, this prospective, observational study enrolled 63 consecutive patients with established adult RA at outpatient clinics in Makkah, Jeddah, Riyadh and Abha (Saudi Arabia). Patients received subcutaneous injections of adalimumab (40 mg every 2 weeks). Outcomes were measured at baseline and 6 months using the following tools: Work Productivity and Activity Impairment (WPAI), Health Assessment Questionnaire Disability Index (HAQ-DI), Fatigue Severity Scale (FSS), Visual Analog Scale for Fatigue (VAS-F), and work disability self-assessment.

Results :

All outcomes showed improvements after 6 months of adalimumab therapy. Significant improvements from baseline were observed in absenteeism (64% ± 11.62 to 11.60% ± 11.17 [p<0.0001]), presenteeism (62.15% ± 20.11 to 34.92% ± 20.61 [p<0.0001]), overall work impairment (69.08% ± 18.86 to 40.73% ± 22.29 [p<0.0001]), overall activity impairment (68.46% ± 18.58 to 36.46% ± 20.79 [p<0.0001]), HAQ score (1.69 ± 0.57 to 0.81 ± 0.61 [p<0.0001]), and FSS score (47.08 ± 9.55 to 27.86 ± 13.43 [p<0.0001]).

Conclusion :

A 6-month course of adalimumab improved work ability, fatigue, and overall health assessments in patients with established RA. Our findings encourage randomized controlled trials investigating the cost-effectiveness and long-term effects of TNF inhibitors on work disability.

Assessment of income growth in patients with rheumatoid arthritis treated with anti-tumor necrosis factor therapy

OBJECTIVES

To compare income growth over time between employees with RA treated with anti-TNFs and those treated with methotrexate (MTX).

METHODS

Privately insured employees (aged ≥18) with ≥1 RA diagnosis (ICD-9: 714.0) were identified from a large-scale US employer claims database (1998-2011). Patients were stratified into treatment groups (anti-TNF-treated patients and MTX-monotherapy patients) based on their treatment history. The anti-TNF-treated patients comprised patients who filled ≥1 prescription for anti-TNFs, with or without MTX (index date defined as the date of the first anti-TNF prescription). The MTX-treated patients comprised patients who filled ≥1 prescription for MTX-monotherapy (index date randomly selected). The primary study outcome was the annual income growth rate (US dollars). Patients were followed from their index date to health plan disenrollment or the end of data availability (maximum follow-up of 5 years). The effect of treatment type on income growth was assessed using a multivariable generalized estimating equation model, adjusting for key baseline characteristics. Income growth was compared to that of the general employed population using Social Security data (1998-2011).

RESULTS

The regression-adjusted annual growth rate in income for anti-TNF-treated patients (n = 1848) was 2.8% (CI = 1.9-3.6%), significantly greater (p < 0.05) than the 0.6% (CI = -0.2-1.4%) for MTX-monotherapy patients (n = 1866). Compared to the general employed population, income growth was lower (p < 0.05) for MTX-monotherapy patients and comparable for anti-TNF-treated patients.

CONCLUSIONS

Compared to MTX-monotherapy, anti-TNF treatment is associated with a higher income growth rate among employees with RA. Anti-TNF-treated patients experienced comparable income growth to the general employed population norm.

Work productivity loss in early arthritis during the first 3 years of disease: a study from a French National Multicenter Cohort

OBJECTIVE

To assess work productivity (WP) loss during the first 3 years of disease in a cohort of patients with early arthritis (EA) diagnosed between 2002 and 2005.

METHODS

The ESPOIR (Etude et Suivi des Polyarthrites Indifférenciées Récentes) cohort included 813 EA patients; we included those of working age at baseline in the present study. WP loss was assessed by 3 components: sick leave, permanent disability, and early retirement. The proportion of affected patients and the mean number of days off work were assessed for each component. WP costs were estimated and determinants of positive and extreme costs were assessed by logistic regression models.

RESULTS

Among the 664 patients included, 81.6% were in the workforce at baseline. During the first 3 years of disease, 45% reported at least 1 sick leave day and 11% reported permanent disability. Only a few patients (1%) reported early retirement. The mean number of days on sick leave due to EA decreased regularly from 44 to 13, whereas the mean number of days on permanent disability tripled from 10 to 33. The mean annual cost was 1,333 (95% confidence interval 1,075-1,620). Sick leave longer than 30 days due to EA before inclusion and a decrease in mental and physical scores of the Medical Outcomes Study Short Form 36 at inclusion were independent determinants of positive and extreme costs in multivariate models.

CONCLUSION

WP loss is substantial in EA patients and is due to permanent disability before the third year of disease. Work absence and poor mental and physical health status at baseline are major determinants of WP costs.

anti-TNF agents as therapeutic choice in immune-mediated inflammatory diseases: focus on adalimumab

The complex pathogenesis of immune-mediated inflammatory diseases (IMIDs) has been extensively investigated and dysregulation of cytokines, such as tumour necrosis factor (TNF) has been shown to play a dominant role in the pathogenesis of various IMIDs, such as rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, psoriasis and psoriatic arthritis. The subsequent development of biological agents capable of blocking TNF has led to important advances in the pharmacotherapy of such diseases and confirmed the concept of a common pathophysiology among IMIDs with TNF having a predominant role. Five TNF inhibitors have currently been approved for treatment of one or more IMIDs; these include infliximab, etanercept, adalimumab, golimumab and certolizumab pegol. Given the similarities in the pathogenic background of IMIDs, one could expect that anti-TNF agents be similarly effective and with comparable tolerability profiles; however, this may not be the case. Structural and pharmacological differences among the anti-TNF drugs are likely to result in differences in efficacy and tolerability among the agents in the different IMIDs, together with differences in potency, therapeutic dose ranges, dosing regimens, administration routes, and propensity for immunogenicity. Among the five TNF inhibitors approved for treatment of IMIDs, adalimumab has the widest range of indications. Data from controlled clinical trials of adalimumab, showing its excellent efficacy and tolerability in a wide range of indications, are supported by real-world long-term data from observational studies, which confirm the value of adalimumab as a suitable choice in the management of IMIDs.

Adalimumab in the treatment of rheumatoid arthritis

Introduction: Rheumatoid arthritis (RA) is a systemic inflammatory disease that causes increased morbidity and mortality. The treatment of the disease has considerably advanced with the addition of biological agents targeting pro-inflammatory cytokines such as tumor necrosis factor (TNF). Adalimumab (ADA) is one of the currently available five TNF inhibitors for clinical use in RA. It is a fully humanized monoclonal antibody which may be prescribed as monotherapy or in combination with methotrexate or other disease-modifying antirheumatic drugs. Areas covered: This review summarizes the recent available data on efficacy and safety of ADA in patients with early and established RA as well as improvement of quality of life and finally we provide data on biologic drug comparison. Expert opinion: ADA has been evaluated in various randomized placebo-controlled trials in RA, prospective observational studies as well as open-label extensions of the original double-blind trials providing experience and data about the long-term efficacy and safety of the drug. Effectiveness of the drug is sustained, while in most cases RA patients treated with ADA experienced a slower radiographic progression and consequently less disability and improved health-related quality of life outcomes. Clinical trials demonstrated no new safety signals and a safety profile consistent with that of the anti-TNF class.

Analysis of direct medical and nonmedical costs for care of rheumatoid arthritis patients using the large cohort database, IORRA

OBJECTIVES

Our goal was to determine the annual direct medical and nonmedical costs for the care of patients with rheumatoid arthritis (RA) using data from a large cohort database in Japan.

METHODS

Direct medical costs [out of pocket to hospitals and pharmacies and for complementary and alternative medicine (CAM)] and nonmedical costs (caregiving, transportation, self-help devices, house modifications) were determined for RA patients who were participants in the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) studies conducted in October 2007 and April 2008. Correlations between these costs and RA disease activity, disability level, and quality of life (QOL) were assessed.

RESULTS

Data were analyzed from 5,204 and 5,265 RA patients in October 2007 and April 2008, respectively. The annual direct medical costs were JPY132,000 [out of pocket to hospital (US$1 = JPY90 in 2007)], JPY84,000 (out of pocket to pharmacy), and JPY146,000 (CAM). Annual direct nonmedical costs were JPY105,000 (caregiving), JPY22,000 (transportation), JPY30,000 (self-help devices), and JPY188,000 (house modifications). Based on the utilization rate for each cost component, the annual medical and nonmedical costs for each RA patient were JPY262,136 and JPY61,441, respectively. Costs increased with increasing RA disease activity and disability level or worsening quality of life (QOL).

CONCLUSIONS

Based on the IORRA database, patients with RA bear heavy economic burdens that increase as the disease is exacerbated. The results also suggest that the increase in medical and nonmedical costs may be ameliorated by the proactive control of disease activity.

Experiences and needs for work participation in employees with rheumatoid arthritis treated with anti-tumour necrosis factor therapy

PURPOSE

To investigate the experiences and needs with respect to work participation of employees with rheumatoid arthritis (RA) treated with anti-tumour necrosis factor (TNF) therapy.

METHOD

Face-to-face interviews in 14 employees with RA on anti-TNF therapy focused on experiences, offered support and needs with respect to work participation.

RESULTS

Experiences regarding work participation varied and ranged from fatigue at work, having no job control, not being understood by the work environment or difficulty dealing with emotions as a result of interaction within the work environment. Support by health care professionals for work participation was considered important, especially concerning social or psychological issues. Advice in becoming aware of one's changes in abilities was highly appreciated, as was the availability of professional advice in times of an urgent work issue due to RA. Employees mentioned an increase in social support at work and job control as important facilitating factors for work participation.

CONCLUSION

Although patients with RA report improvement in their work functioning after starting anti-TNF therapy, employees continue facing challenges in working life due to RA. For support concerning work participation, it is recommended that health care professionals are more aware of work-related problems in patients with RA treated with anti-TNF therapy.

Improvements in participation in usual daily activities in patients with rheumatoid arthritis treated with abatacept

OBJECTIVE

To examine changes in activity participation following abatacept treatment for rheumatoid arthritis (RA), and which factors contributed to such changes.

METHODS

Data were analyzed from the Abatacept in Inadequate responders to Methotrexate (AIM) and Abatacept Trial in Treatment of Anti-TNF INadequate responders (ATTAIN) clinical trials of abatacept in patients with RA. Activity participation was evaluated by the validated Activity Participation Questionnaire (APaQ), along with measures of clinical response and health-related quality of life. Changes in the APaQ during the two study periods were compared between treatment groups. Multiple regression analyses were performed to investigate the determinants of change in activity participation. The relationship between clinical efficacy measures (including low disease activity state [LDAS], Disease Activity Score 28-defined remission, and European League Against Rheumatism [EULAR] responses) and changes in activity participation were investigated.

RESULTS

Statistically significant, substantive improvements in activity participation were observed over the entire study period in patients treated with abatacept. Abatacept-treated patients showed improvements from baseline of 8.4 and 7.3 days in activity participation, compared with 4.5 and 1.4 days in the placebo group (P < 0.005 vs. placebo in both trials), at the end of AIM and ATTAIN, respectively. The Short Form-36 physical and mental component scores, patient global assessment, and the Health Assessment Questionnaire-Disability Index score were found to be the strongest determinants of changes in activity participation. Patients who achieved LDAS, disease remission and good EULAR responses experienced greater improvements in activity participation measures.

CONCLUSIONS

Abatacept treatment substantively and significantly improved patients' ability to participate in their usual activities. The gain in activity was closely related to improvements in clinical status, physical function and quality of life.

Long-term use of adalimumab in the treatment of rheumatic diseases

Adalimumab, a fully humanized monoclonal antibody against tumor necrosis factor-alpha (TNFα), has been evaluated in various randomized placebo-controlled trials in rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and juvenile idiopathic arthritis. In the short time frame of these trials adalimumab has been shown to be effective in reducing disease activity, slowing radiographic disease progression and improving patients' quality of life, while at the same time demonstrating an acceptable safety profile. Furthermore, release of adalimumab on the market, prospective observational studies, as well as open-label extensions of the original double-blind trials have provided experience and data about the long-term efficacy and safety of the drug. Initial effectiveness, in terms of reducing disease activity, is sustained, while in most cases patients treated with adalimumab experienced a slower radiographic progression and consequently less disability and improved health-related quality-of-life outcomes. Moreover, long-standing treatment of thousands of patients with adalimumab outside the controlled context of clinical trials was not related to new safety signals, with the most common adverse events being respiratory infections. The most common serious adverse events seem to be tuberculosis reactivation, while a putative association with malignant lymphoma development is not yet proven. Besides, both of these adverse reactions pertain to the whole TNFα blocker group. In conclusion, adalimumab is a safe and effective option for the treatment of patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and juvenile idiopathic arthritis.