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van Ouwerkerk L, Bergstra SA, Maarseveen TD, Huizinga TWJ, Knevel R, Allaart CF. Is glucocorticoid bridging therapy associated with later use of glucocorticoids and biological DMARDs during the disease course of patients with rheumatoid arthritis in daily practice? A real-world data analysis. Semin Arthritis Rheum 2024; 64:152305. [PMID: 37992515 DOI: 10.1016/j.semarthrit.2023.152305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/19/2023] [Accepted: 10/31/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE To evaluate if initially starting glucocorticoid (GC) bridging leads to a higher probability of long-term GC and biological (b)DMARD use in rheumatoid arthritis (RA)-patients. METHODS Electronical health records data from newly diagnosed RA-patients from the Leiden University Medical Center were used. Patients who started GC as part of initial treatment (iGC group) and who did not (niGC group) were compared in terms of GC and bDMARD use later in the disease course. Multivariable adjustment was performed to account for confounding by indication. RESULTS 465/932 newly diagnosed RA-patients (50 %) were treated with GC as initial treatment step. Patients in the iGC group were older, included fewer females, had a higher disease activity at baseline compared to the niGC group plus a more rapid decrease in DAS28 in the first 6 months. During follow-up, 42 % of the iGC group started a second course of GC and 17 % started a bDMARD, compared to 34 % and 13 % In the niGC group. The hazard to start a bDMARD later in the disease course was not significantly different between the two groups in two time periods (0.34 95 %CI(0.09;1.21) resp. 1.48 95 %CI (0.98;2.22)), but the hazard to (re)start GC later on was higher for the iGC group (aHR 1.37 95 %CI(1.09;1.73)). CONCLUSION In this daily practice cohort of newly diagnosed RA patients, patients in the iGC group had a more rapid DAS28 decrease and an increased probability of starting GC later on compared to the niGC group. The probability of bDMARD use was not significantly increased.
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Affiliation(s)
- L van Ouwerkerk
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands.
| | - S A Bergstra
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - T D Maarseveen
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - T W J Huizinga
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - R Knevel
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - C F Allaart
- Department of rheumatology, Leiden University Medical Center, Leiden, the Netherlands
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2
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van Ouwerkerk L, Verschueren P, Boers M, Emery P, de Jong PHP, Landewé RB, Lems W, Smolen JS, Huizinga TW, Allaart CF, Bergstra SA. Initial glucocorticoid bridging in rheumatoid arthritis: does it affect glucocorticoid use over time? Ann Rheum Dis 2024; 83:65-71. [PMID: 37607810 DOI: 10.1136/ard-2023-224270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVES To compare the use of glucocorticoids (GC) over time in patients with rheumatoid arthritis (RA) who were or were not treated initially with GC bridging therapy. METHODS Data from the BeSt, CareRA and COBRA trials were combined in an individual patient data (IPD) meta-analysis. We compared GC use between bridgers and non-bridgers at 12, 18 and 24 months from baseline with mixed-effects regression analysis. Secondary outcomes were mean cumulative GC dose until 24 months after baseline with and without the bridging period, Disease Activity Score based on 28 joints (DAS28) over time and number of disease-modifying antirheumatic drug (DMARD) changes. RESULTS 252/625 patients (40%) were randomised to GC bridging (bridgers). Excluding the period of bridging, later GC use was low in both groups and cumulative doses were similar. Mean DAS28 was similar between the groups, but bridgers improved more rapidly (p<0.001) in the first 6 months and the bridgers required significantly fewer changes in DMARDs (incidence rate ratio 0.59 (95% CI 0.38 to 0.94)). GC use was higher in the bridgers at t=12 months (OR 3.27 (95% CI 1.06 to 10.08)) and the bridging schedules resulted in a difference in cumulative GC dose of 2406 mg (95% CI 1403 to 3408) over 24 months. CONCLUSION In randomised trials comparing GC bridging and no GC bridging, bridgers had a more rapid clinical improvement, fewer DMARD changes and similar late use of GC compared with non-bridgers. GC bridging per protocol resulted, as could be expected, in a higher cumulative GC dose over 2 years.
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Affiliation(s)
| | | | - Maarten Boers
- Rheumatology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Paul Emery
- Rheumatology, University of Leeds Faculty of Medicine and Health, Leeds, UK
| | | | - Robert Bm Landewé
- Rheumatology, Amsterdam UMC, Amsterdam, The Netherlands
- Rheumatology, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Willem Lems
- Rheumatology, Amsterdam UMC, Amsterdam, The Netherlands
- Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Josef S Smolen
- Rheumatology, Medical University of Vienna, Wien, Austria
| | - Tom Wj Huizinga
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Cornelia F Allaart
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
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3
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Boers M. Viewpoint: Glucocorticoids in the treatment of rheumatoid arthritis: points to (re)consider. Rheumatology (Oxford) 2023; 62:3534-3537. [PMID: 37338537 PMCID: PMC10629782 DOI: 10.1093/rheumatology/kead309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/21/2023] Open
Abstract
Glucocorticoids (prednisone) are essential in the treatment of RA and other autoimmune diseases. They are widely used, but treatment guidelines advise against. This viewpoint article explains why and suggests a way forward.
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Affiliation(s)
- Maarten Boers
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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4
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Lukasik Z, Carron P, Webers C. To taper or not to taper biological disease-modifying antirheumatic drugs in axial spondyloarthritis anno 2023: That is the question. Best Pract Res Clin Rheumatol 2023; 37:101869. [PMID: 37658017 DOI: 10.1016/j.berh.2023.101869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/03/2023]
Abstract
The 2022 ASAS-EULAR recommendations for the management of axial spondyloarthritis (axSpA) propose to consider dose reduction of biological disease-modifying antirheumatic drugs (bDMARDs) for patients in sustained remission. However, this recommendation does not offer clear guidance for daily clinical practice. In this review, we analyze randomized clinical trials and real-world data on tapering and discontinuation of bDMARDs in patients with axSpA. We discuss the scientific rationale and benefits of tapering, identify advice to apply tapering in current practice, and delineate aspects to be investigated in future research.
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Affiliation(s)
- Zuzanna Lukasik
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent University Hospital, Ghent, Belgium; VIB Center for Inflammation Research, Ghent, Belgium
| | - Philippe Carron
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent University Hospital, Ghent, Belgium; VIB Center for Inflammation Research, Ghent, Belgium.
| | - Casper Webers
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Centre+, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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5
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Messelink MA, den Broeder AA, Marinelli FE, Michgels E, Verschueren P, Aletaha D, Tekstra J, Welsing PMJ. What is the best target in a treat-to-target strategy in rheumatoid arthritis? Results from a systematic review and meta-regression analysis. RMD Open 2023; 9:rmdopen-2023-003196. [PMID: 37116986 PMCID: PMC10152050 DOI: 10.1136/rmdopen-2023-003196] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 04/09/2023] [Indexed: 04/30/2023] Open
Abstract
OBJECTIVES A treat-to-target (T2T) strategy has been shown to be superior to usual care in rheumatoid arthritis (RA), but the optimal target remains unknown. Targets are based on a disease activity measure (eg, Disease Activity Score-28 (DAS28), Simplified Disease Activity Indices/Clinical Disease Activity Indices (SDAI/CDAI), and a cut-off such as remission or low disease activity (LDA). Our aim was to compare the effect of different targets on clinical and radiographic outcomes. METHODS Cochrane, Embase and (pre)MEDLINE databases were searched (1 June 2022) for randomised controlled trials and cohort studies after 2003 that applied T2T in RA patients for ≥12 months. Data were extracted from individual T2T study arms; risk of bias was assessed with the Cochrane Collaboration tool. Using meta-regression, we evaluated the effect of the target used on clinical and radiographic outcomes, correcting for heterogeneity between and within studies. RESULTS 115 treatment arms were used in the meta-regression analyses. Aiming for SDAI/CDAI-LDA was statistically superior to targeting DAS-LDA regarding DAS-remission and SDAI/CDAI/Boolean-remission outcomes over 1-3 years. Aiming for SDAI/CDAI-LDA was also significantly superior to DAS-remission regarding both SDAI/CDAI/Boolean-remission (over 1-3 years) and mean SDAI/CDAI (over 1 year). Targeting DAS-remission rather than DAS-LDA only improved the percentage of patients in DAS-remission, and only statistically significantly after 2-3 years of T2T. No differences were observed in Health Assessment Questionnaire and radiographic progression. CONCLUSIONS Targeting SDAI/CDAI-LDA, and to a lesser extent DAS-remission, may be superior to targeting DAS-LDA regarding several clinical outcomes. However, due to the risk of residual confounding and the lack of data on (over)treatment and safety, future studies should aim to directly and comprehensively compare targets. PROSPERO REGISTRATION NUMBER CRD42021249015.
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Affiliation(s)
| | | | | | - Edwin Michgels
- Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
| | - P Verschueren
- Rheumatology, KU Leuven University Hospitals, Leuven, Belgium
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Janneke Tekstra
- Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
| | - Paco M J Welsing
- Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, The Netherlands
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6
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Harna B, Kalra P, Arya S, Jeyaraman N, Nallakumarasamy A, Jeyaraman M, Rajendran RL, Oh EJ, Khanna M, Rajendran UM, Chung HY, Ahn BC, Gangadaran P. Mesenchymal stromal cell therapy for patients with rheumatoid arthritis. Exp Cell Res 2023; 423:113468. [PMID: 36621669 DOI: 10.1016/j.yexcr.2023.113468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/22/2022] [Accepted: 01/04/2023] [Indexed: 01/07/2023]
Abstract
Management of relapses and refractory rheumatoid arthritis (RA) patients is complex and difficult. Even after the administration of new biological disease-modifying anti-rheumatic drugs (DMARDs), only a few patients achieve the complete remission phase. DMARDs help only in modifying the disease activity, which sooner or later fails. They do not manage the disease at the patho-etiological level. There are some serious side effects as well as drug interaction with DMARDs. There are few subsets of RA patients who do not respond to DMARDs, reasons unknown. Mesenchymal stem cells (MSCs) provide a promising alternative, especially in such cases. This review elaborates on the studies pertaining to the application of MSCs in rheumatoid arthritis over the last two decades. A total of 14 studies (one review article) including 447 patients were included in the study. Most of the studies administered MSCs in refractory RA patients through the intravenous route with varied dosages and frequency of administration. MSCs help in RA treatment via various mechanisms including paracrine effects. All the studies depicted a better clinical outcome with minimal adverse events. The functional scores including the VAS scores improved significantly in all studies irrespective of dosage and source of MSCs. The majority of the studies depicted no complications. Although the use of MSCs in RA is still in the early stages requiring further refinement in the source of MSCs, dosage, and frequency. The role of MSCs in the management of RA has a promising prospect. MSCs target the RA at the molecular level and has the potential to manage refractory RA cases not responding to conventional treatment. Multicentric, large sample populations, and long-term studies are required to ascertain efficacy and safety.
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Affiliation(s)
- Bushu Harna
- Department of Orthopaedics, Maulana Azad Medical College, New Delhi, 110002, India; Indian Stem Cell Study Group (ISCSG) Association, Lucknow, 226010, Uttar Pradesh, India; Fellow in Orthopaedic Rheumatology, Dr. RML National Law University, Lucknow, 226010, Uttar Pradesh, India
| | - Pulkit Kalra
- Department of Orthopaedics, Maulana Azad Medical College, New Delhi, 110002, India
| | - Shivali Arya
- Department of Radiodiagnosis, Maulana Azad Medical College, New Delhi, 110002, India
| | - Naveen Jeyaraman
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, 226010, Uttar Pradesh, India; Fellow in Orthopaedic Rheumatology, Dr. RML National Law University, Lucknow, 226010, Uttar Pradesh, India; Fellow in Regenerative Interventional Orthobiologics, Dr. RML National Law University, Lucknow, 226010, Uttar Pradesh, India; Department of Orthopaedics, Rathimed Specialty Hospital, Chennai, 600040, Tamil Nadu, India
| | - Arulkumar Nallakumarasamy
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, 226010, Uttar Pradesh, India; Fellow in Orthopaedic Rheumatology, Dr. RML National Law University, Lucknow, 226010, Uttar Pradesh, India; Fellow in Regenerative Interventional Orthobiologics, Dr. RML National Law University, Lucknow, 226010, Uttar Pradesh, India; Department of Orthopaedics, All India Institute of Medical Sciences, Bhubaneswar, 751019, Odisha, India
| | - Madhan Jeyaraman
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, 226010, Uttar Pradesh, India; Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai, 600056, Tamil Nadu, India; Department of Biotechnology, School of Engineering and Technology, Sharda University, Greater Noida, 201310, Uttar Pradesh, India; South Texas Orthopaedic Research Institute (STORI Inc.), Laredo, TX, 78045, USA.
| | - Ramya Lakshmi Rajendran
- Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, 41944, South Korea
| | - Eun Jung Oh
- Department of Plastic and Reconstructive Surgery, CMRI, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, 41944, South Korea
| | - Manish Khanna
- Indian Stem Cell Study Group (ISCSG) Association, Lucknow, 226010, Uttar Pradesh, India
| | | | - Ho Yun Chung
- Department of Plastic and Reconstructive Surgery, CMRI, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, 41944, South Korea
| | - Byeong-Cheol Ahn
- Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, 41944, South Korea; BK21 FOUR KNU Convergence Educational Program of Biomedical Sciences for Creative Future Talents, Department of Biomedical Science, School of Medicine, Kyungpook National University, Daegu, 41944, South Korea.
| | - Prakash Gangadaran
- Department of Nuclear Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, 41944, South Korea; BK21 FOUR KNU Convergence Educational Program of Biomedical Sciences for Creative Future Talents, Department of Biomedical Science, School of Medicine, Kyungpook National University, Daegu, 41944, South Korea.
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7
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Gao A, Zhao W, Wu R, Su R, Jin R, Luo J, Gao C, Li X, Wang C. Tissue-resident memory T cells: The key frontier in local synovitis memory of rheumatoid arthritis. J Autoimmun 2022; 133:102950. [PMID: 36356551 DOI: 10.1016/j.jaut.2022.102950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/27/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022]
Abstract
Rheumatoid arthritis (RA) is a highly disabling, systemic autoimmune disease. It presents a remarkable tendency to recur, which renders it almost impossible for patients to live without drugs. Under such circumstances, many patients have to suffer the pain of recurrent attacks as well as the side effects of long-term medication. Current therapies for RA are primarily systemic treatments without targeting the problem that RA is more likely to recur locally. Emerging studies suggest the existence of a mechanism mediating local memory during RA, which is closely related to the persistent residence of tissue-resident memory T cells (TRM). TRM, one of the memory T cell subsets, reside in tissues providing immediate immune protection but driving recurrent local inflammation on the other hand. The heterogeneity among synovial TRM is unclear, with the dominated CD8+ TRM observed in inflamed synovium of RA patients coming into focus. Besides local arthritis relapse, TRM may also contribute to extra-articular organ involvement in RA due to their migration potential. Future integration of single-cell RNA sequencing (scRNA-seq) with spatial transcriptomics to explore the gene expression patterns of TRM in both temporal dimension and spatial dimension may help us identify specific therapeutic targets. Targeting synovial TRM to suppress local arthritis flares while using systemic therapies to prevent extra-articular organ involvement may provide a new perspective to address RA recurrence.
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Affiliation(s)
- Anqi Gao
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China; Shanxi Key Laboratory for Immunomicroecology, Shanxi, China
| | - Wenpeng Zhao
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China; Shanxi Key Laboratory for Immunomicroecology, Shanxi, China
| | - Ruihe Wu
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China; Shanxi Key Laboratory for Immunomicroecology, Shanxi, China
| | - Rui Su
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China; Shanxi Key Laboratory for Immunomicroecology, Shanxi, China
| | - Ruqing Jin
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China; Shanxi Key Laboratory for Immunomicroecology, Shanxi, China
| | - Jing Luo
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China; Shanxi Key Laboratory for Immunomicroecology, Shanxi, China
| | - Chong Gao
- Pathology, Joint Program in Transfusion Medicine, Brigham and Women's Hospital/Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Xiaofeng Li
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China; Shanxi Key Laboratory for Immunomicroecology, Shanxi, China
| | - Caihong Wang
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China; Shanxi Key Laboratory for Immunomicroecology, Shanxi, China.
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8
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Chruściak T, Wisłowska M. Assessment of Rheumatoid Hand Function as a Characteristic Feature of Rheumatoid Arthritis in Patients Treated with Methotrexate or Methotrexate with Biological Agents with and without Deformation of Hands. Curr Rheumatol Rev 2022; 18:212-223. [PMID: 35168508 DOI: 10.2174/1573397118666220215092045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/19/2021] [Accepted: 09/20/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The hand is an excellent work tool that provides the functional ability to mechanical work. The hand is affected in rheumatoid arthritis (RA) patients, it is a significant problem in the functional sphere as a result of deformities, the grasping function limitation and muscle strength. OBJECTIVES The aim of the study was the assessment of grip strength, endurance and manipulation abilities of rheumatoid hands with or without deformities treated with methotrexate (MTX) or MTX plus biologics (MTX+BIO). MATERIAL AND METHODS The study involved 80 RA women, (40 received MTX+BIO, 40 MTX), treated at the Rheumatology Department of the Central Clinical Hospital of Interior Affairs in Warsaw. VAS-pain, DAS28, SDAI, HAQ, HAQ hands, estimation of hand grip strength, endurance, manipulation ability were analyzed. RESULTS In group MTX+BIO values of DAS28 (3.7±1.3 vs 4.3±1.2, p=0.019), HAQ (0.72 ± 0.57 vs 1.08± 0.87, p=0.011) and HAQ-hand (0.85±0.65 vs. 1.19±0.68, p=0.024) were statistically lower than in MTX group. Hand deformations recorded in 35 (43.7%) cases, 16 (40%) in MTX group, 19 (47.5%) in MTX+BIO. Comparison of grip strength, endurance, manipulation ability showed better results in MTX+BIO group with deformities (significance level from 0.013 to 0.046) than in MTX group. Relative differences in hand function in MTX + BIO group ranged from 10.8% (maximal power grip strength) to 127.6% (minimal hand endurance), after disease duration adjustment - from 28.2% (maximal power grip strength) to 148.4% (minimal hand endurance). CONCLUSION Measuring grip strength, hand endurance, manipulation abilities are useful in RA patients with hand deformities.
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Affiliation(s)
- Tomasz Chruściak
- Rehabilitation Center, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
| | - Małgorzata Wisłowska
- Internal Disease Department, Central Clinical Hospital of the Ministry of the Interior and Administration, Warsaw, Poland
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9
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Carter LM, McGonagle D, Vital EM, Wittmann M. Applying Early Intervention Strategies to Autoimmune Skin Diseases. Is the Window of Opportunity Preclinical? A Dermato-Rheumatology Perspective. J Invest Dermatol 2022; 142:944-950. [PMID: 35034771 DOI: 10.1016/j.jid.2021.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/22/2021] [Accepted: 11/07/2021] [Indexed: 01/19/2023]
Abstract
Many inflammatory skin diseases exhibit a chronic course with unsatisfactory long-term outcomes. Insights into early intervention approaches in other autoimmune contexts could improve the trajectory of lifelong diseases in terms of sustained remission or minimal disease activity, reduced requirement for therapy and medical resource use, and improved QoL. In both rheumatoid arthritis (RA) and psoriatic arthritis (PsA), we have learned that the timing and intensity of early interventions can influence later outcomes. Investigation into early RA, PsA, and systemic lupus erythematosus has shown that the optimal window of opportunity may even extend into asymptomatic preclinical phases of diseases. Notably, early and preclinical diseases may have pathogenic mechanisms and therapeutic targets that differ from those of the established disease. In this paper, we review the literature on these insights and discuss how similar research and therapeutic strategies may be investigated in cutaneous autoimmunity. We highlight the contribution of skin-resident cells to diseases that were previously thought to be initiated in the primary and secondary lymphoid organs of the immune system. We focus on two dermato‒rheumatology conditions-lupus and psoriasis-which share the commonality that effective early cutaneous disease therapy may have far-reaching implications on abrogating potentially severe systemic disease.
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Affiliation(s)
- Lucy M Carter
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom; Leeds Biomedical Research Centre (BRC), National Institute for Health Research (NIHR), Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom; Leeds Biomedical Research Centre (BRC), National Institute for Health Research (NIHR), Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Miriam Wittmann
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom; Leeds Biomedical Research Centre (BRC), National Institute for Health Research (NIHR), Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
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10
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Nazir AM, Koganti B, Gupta K, Memon MS, Aslam Zahid MB, Shantha Kumar V, Tappiti M, Mostafa JA. Evaluating the Use of Hydroxychloroquine in Treating Patients With Rheumatoid Arthritis. Cureus 2021; 13:e19308. [PMID: 34765383 PMCID: PMC8575345 DOI: 10.7759/cureus.19308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 11/06/2021] [Indexed: 11/05/2022] Open
Abstract
Rheumatoid Arthritis (RA) is one of the most common autoimmune diseases present today. Although treatment options may differ among clinicians, a commonly prescribed treatment is hydroxychloroquine (HCQ), alone or in combination with other medications. HCQ has been studied for its immunomodulatory effects as well as its role in treating adverse conditions associated with RA. This systematic review examined the use of HCQ therapy in RA patients. A systematic search for relevant literature through PubMed, National Institute of Informatics, Japan (CiNii), and Science Direct databases were carried out in August 2021. Literature directly related to HCQ therapy for RA patients, RA-associated chronic kidney disease, and cardiovascular disease (including lipid profile) was considered relevant. HCQ associated retinopathic adverse effects were also selected for this review. Thirty-eight articles were found to be relevant, passed quality assessment, and were included in this review. Nine articles discussed HCQ therapy in comparison with other therapies (mainly methotrexate and sulfasalazine), but were contradictory in their outcomes, as were the seven papers that reviewed kidney function in RA patients with and without HCQ. Five articles credited better cardiovascular outcomes to RA patients taking HCQ. Sixteen articles studied the relationship between HCQ and retinal toxicity, providing insights into the risks associated with HCQ therapy. HCQ therapy was found not only to be beneficial in slowing the disease progression in RA patients but enhanced the effects of methotrexate in treating RA as well. Data strongly associates HCQ therapy with the mitigation of RA-related cardiovascular and kidney conditions. However, if HCQ is prescribed, it is imperative to be aware of the possible (although rare) retinopathic adverse effects associated with this therapy.
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Affiliation(s)
- Armaan M Nazir
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bhavya Koganti
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Kunal Gupta
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Marrium S Memon
- Pathology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Muhammad Bin Aslam Zahid
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Mamatha Tappiti
- Neurosciences, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jihan A Mostafa
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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11
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Almutairi K, Nossent J, Preen DB, Keen H, Inderjeeth C. The temporal association between hospital admissions, biological therapy usage and direct health care costs in rheumatoid arthritis patients. Rheumatol Int 2021; 42:2027-2037. [PMID: 34536090 DOI: 10.1007/s00296-021-04985-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/28/2021] [Indexed: 11/29/2022]
Abstract
The Australian Pharmaceutical Benefits Scheme (PBS) has subsidised biological therapy since 2003. We investigated the association between biological therapy for RA hospitalisation rates and health-care costs.Hospital admissions for RA patients between 1995 and 2014 were identified in the Western Australia (WA) Hospital Morbidity Data Collection (ICD codes 714 and M05.00-M06.99). State-specific dispensing data for conventional and biological therapies for RA was obtained from Statistics Australia and expressed as defined daily doses/1000 population/day (DDD) using WA population census. Principal component analysis (PCA) was applied to determine the relationship between DMARDs use and hospital admission rates.A total of 17,125 patients had 50,353 admissions with a diagnostic code for RA. Between 1995 and 2002, the number of RA admissions fell from 7.9 to 2.6/1000 admissions, while conventional therapy use rose from 1.45 to 1.84 DDD. Between 2003 and 2014, RA admissions decreased further to 1.9/1000 hospital admissions, while conventional therapy use increased to 2.19 DDD and biological therapy from 0.01 to 1.0 DDD. In PCA, conventional and biological therapies use had an inverse relationship with hospital admission rates. Annual costs of biological therapy utilisation was 22.5 million in 2003-2014, while the annual cost saving of RA hospital admissions was 9.2 million.The increased use of conventional therapy use for RA has coincided with a significant decline in hospital admissions for RA patients in WA, while a more modest further decline followed biological therapy introduction. Biological therapy was not as cost-effective as conventional in relation to RA hospital admissions costs.
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Affiliation(s)
- Khalid Almutairi
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia. .,King Fahd Specialist Hospital, Burydah, AlQassim, Saudi Arabia.
| | - Johannes Nossent
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Western Australia, Australia
| | - David B Preen
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen Keen
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Charles Inderjeeth
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,Sir Charles Gairdner and Osborne Park Health Care Group, Perth, Western Australia, Australia
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12
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Scott DL, Ibrahim F, Hill H, Tom B, Prothero L, Baggott RR, Bosworth A, Galloway JB, Georgopoulou S, Martin N, Neatrour I, Nikiphorou E, Sturt J, Wailoo A, Williams FMK, Williams R, Lempp H. Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.
Objectives
To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.
Design
Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.
Setting
Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).
Participants
Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.
Interventions
Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.
Main outcome measures
Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.
Results
Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.
Limitations
The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.
Conclusion
The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.
Future work
Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.
Trial registration
Current Controlled Trials ISRCTN70160382.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David L Scott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Fowzia Ibrahim
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Harry Hill
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Brian Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Louise Prothero
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Rhiannon R Baggott
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | | | - James B Galloway
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Naomi Martin
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Isabel Neatrour
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Jackie Sturt
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK
| | - Allan Wailoo
- ScHARR Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Frances MK Williams
- Twin Research and Genetic Epidemiology, School of Life Course Sciences, King’s College London, St Thomas’ Hospital, London, UK
| | - Ruth Williams
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, King’s College London, London, UK
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Versteeg GA, Steunebrink L, Vonkeman HE, Ten Klooster PM, Van Der Bijl AE, Van De Laar M. Early radiological progression remains associated with long-term joint damage in real-world rheumatoid arthritis patients treated to the target of remission. Scand J Rheumatol 2021; 51:87-96. [PMID: 34151716 DOI: 10.1080/03009742.2021.1917161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: To evaluate radiological damage and to explore characteristics associated with radiological progression in rheumatoid arthritis (RA) treated to the target of remission in a real-world setting.Method: Baseline to 6 year follow-up data were used from an observational early RA cohort. Radiographs of hands and feet at baseline, 6 months, and 1, 3, and 6 years were scored using the modified Sharp/van der Heijde score (SHS). The threshold for rapid radiological progression (RRP) after 6 months was based on the calculated smallest detectable change of 3.95. Negative binomial generalized linear mixed model and logistic regression analyses were performed to examine which variables were associated with RRP and 6 year radiological progression.Results: Most radiological damage occurred in the first year of treatment [median 2.0 interquartile range (IQR) 1.0-4.0 SHS points] compared to the subsequent 5 years of follow-up (median 3.0 IQR 1.0-5.0 SHS points). While low disease activity was achieved within 6 months on average, 18.8% of the patients developed RRP. Anti-cyclic citrullinated peptide (anti-CCP) positivity [incidence rate ratio (IRR) 1.42, p = 0.03], baseline erosive disease (IRR 1.60, p = 0.02), and RRP (IRR 3.28, p < 0.001) were associated with 6 year radiological progression. Erosive disease was the strongest predictor of RRP (odds ratio 8.8, p < 0.001).Conclusion: Long-term radiological outcome is limited in most real-world RA patients treated to the target of remission, but RRP still occurs. Anti-CCP positivity, baseline erosive disease, and RRP remain associated with long-term radiological outcome.
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Affiliation(s)
- G A Versteeg
- Department of Psychology, Health & Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands.,Department of Rheumatology, Deventer Hospital, Deventer, The Netherlands
| | - Lmm Steunebrink
- Department of Psychology, Health & Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - H E Vonkeman
- Department of Psychology, Health & Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands.,Department of Rheumatology, Arthritis Centre Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - P M Ten Klooster
- Department of Psychology, Health & Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - A E Van Der Bijl
- Department of Rheumatology, Isala Hospital, Zwolle, The Netherlands
| | - Mafj Van De Laar
- Department of Psychology, Health & Technology, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands.,Department of Rheumatology, Arthritis Centre Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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14
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Verstappen M, van Mulligen E, de Jong PHP, van der Helm-Van Mil AHM. DMARD-free remission as novel treatment target in rheumatoid arthritis: A systematic literature review of achievability and sustainability. RMD Open 2021; 6:rmdopen-2020-001220. [PMID: 32393523 PMCID: PMC7299506 DOI: 10.1136/rmdopen-2020-001220] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 01/08/2023] Open
Abstract
Objectives Although current treatment guidelines for rheumatoid arthritis (RA) suggest tapering disease-modifying anti-rheumatic drugs (DMARDs), it is unclear whether DMARD-free remission (DFR) is an achievable and sustainable outcome. Therefore, we systematically reviewed the literature to determine the prevalence and sustainability of DFR and evaluated potential predictors for DFR. Methods A systematic literature search was performed in March 2019 in multiple databases. All clinical trials and observational studies reporting on discontinuation of DMARDs in RA patients in remission were included. Our quality assessment included a general assessment and assessment of the description of DFR. Prevalence of DFR and its sustainability and flares during tapering and after DMARD stop were summarised. Also, potential predictors for achieving DFR were reviewed. Results From 631 articles, 51 were included, comprising 14 clinical trials and 5 observational studies. DFR definition differed, especially for the duration of DMARD-free state. Considering only high- and moderate-quality studies, DFR was achieved in 5.0%–24.3% and sustained DFR (duration>12 months) in 11.6%–19.4% (both relative to the number of patients eligible for tapering). Flares occurred frequently during DMARD tapering (41.8%–75.0%) and in the first year after achieving DFR (10.4%–11.8%), while late flares, >1 year after DMARD-stop, were infrequent (0.3%–3.5%). Many patient characteristics lacked association with DFR. Absence of autoantibodies and shared epitope alleles increased the chance of achieving DFR. Conclusions DFR is achievable in RA and is sustainable in ~10%–20% of patients. DFR can become an important outcome measure for clinical trials and requires consistency in the definition. Considering the high rate of flares in the first year after DMARD stop, a DMARD-free follow-up of >12 months is advisable to evaluate sustainability.
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Affiliation(s)
- M Verstappen
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - E van Mulligen
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - P H P de Jong
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - A H M van der Helm-Van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
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15
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So H, Cheng I, Tam LS. The Role of Imaging in Predicting the Development of Rheumatoid Arthritis. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2021; 2:27-33. [PMID: 36467903 PMCID: PMC9524776 DOI: 10.2478/rir-2021-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/19/2021] [Indexed: 06/17/2023]
Abstract
Rheumatoid arthritis (RA) remains a chronic debilitating disease with a significant negative societal impact, despite the expanding landscape of treatment options. This condition is often preceded by a phase of systemic autoimmunity with circulating autoantibodies, elevated pro-inflammatory cytokines, or subtle structural changes. The capability of identifying individuals in the preclinical phase of RA disease makes a "preventive window of opportunity" possible. Much recent work has focused on the role of imaging modalities including ultrasound (US), magnetic resonance imaging (MRI), and high-resolution peripheral quantitative computer tomography (HR-pQCT) in identifying at-risk individuals with or without early joint symptoms for the development of inflammatory arthritis. This article will review the evidence and discuss the challenges as well as opportunities of proactive risk assessment by imaging in RA.
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Affiliation(s)
- Ho So
- Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Isaac Cheng
- Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Lai-Shan Tam
- Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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16
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Factors predicting addition of disease-modifying antirheumatic drugs after initial methotrexate monotherapy in patients with rheumatoid arthritis. Clin Rheumatol 2021; 40:2657-2663. [PMID: 33483918 DOI: 10.1007/s10067-021-05599-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/13/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION We investigated factors predicting the addition of disease-modifying antirheumatic drugs (DMARDs) after an initial methotrexate (MTX) monotherapy in rheumatoid arthritis (RA) patients to support an early decision on the DMARDs addition. METHODS This retrospective cohort study included 311 patients who were diagnosed with RA and started on MTX monotherapy at Showa University Hospital, Japan. The outcome was addition of DMARDs after an initial MTX monotherapy at 6 months. Baseline patient characteristics were compared between the DMARDs addition and MTX monotherapy continuation groups, and significant independent predictive factors for the addition of DMARDs were selected using multivariate analysis. RESULTS The median age of patients was 62 years (range 24-90), 170 patients (73%) were women, the median swollen 28-joint count (SJC28) was 3 (0-28), and the median tender 28-joint count (TJC28) was 5 (0-28). DMARDs were added in 65 (27.9%) patients. In the univariate analysis, higher TJC28 and SJC28, concomitant use of nonsteroidal anti-inflammatory drugs, and intra-articular glucocorticoid (GC) injection history were significantly associated with the DMARDs addition. In the multivariate analysis, by adding covariates to the variables identified in the univariate analysis, SJC28 (odds ratio [OR] 1.390 per 5 joints increase; 95% confidence interval [CI], 1.036-1.866) and intra-articular GC injection history (OR 3.678; 95% CI, 1.170-11.557) were independent predictors of DMARDs addition. CONCLUSION A higher SJC28 and intra-articular GC injection history may be useful predictors of DMARDs addition after the initial MTX monotherapy. We expect that using these predictors will enable an earlier shift to a more aggressive treatment. Key Points ・We performed a retrospective cohort study with the addition of DMARDs as the outcome in patients with RA who were started on MTX monotherapy. ・A higher SJC28 (OR 1.390; 95% CI, 1.036-1.866) and an intra-articular GC injection history (OR 3.678; 95% CI, 1.170-11.557) may be useful predictors for the addition of DMARDs of initiating MTX monotherapy at 6 months. ・The use of such indicators may support an early decision on the addition of DMARDs after the initial MTX monotherapy.
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17
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Zhang C. Flare-up of cytokines in rheumatoid arthritis and their role in triggering depression: Shared common function and their possible applications in treatment (Review). Biomed Rep 2020; 14:16. [PMID: 33269077 PMCID: PMC7694594 DOI: 10.3892/br.2020.1392] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/31/2020] [Indexed: 01/01/2023] Open
Abstract
Chronic illnesses are associated with an increased risk of depression and anxiety. Rheumatoid arthritis (RA) is a chronic autoimmune disease that typically causes damage to the joints. RA extensively impacts patients, both physically and psychologically. Depression is a common comorbid disorder with RA, which leads to worsened health outcomes. There are several cytokines that are active in the joints of patients with RA. Inflammatory cytokines serve important roles in the key processes in the joints, which usually cause inflammation, articular damage and other comorbidities associated with RA. The key role of inflammatory cytokines could be attributed to their interactions within signaling pathways. In RA, IL-1, and the cytokines of TNF-α, IL-6 and IL-18 are primarily involved. Furthermore, depression is hypothesized to be strongly associated with systemic inflammation, particularly with dysregulation of the cytokine network. The present review summarizes the current state of knowledge on these two diseases from the perspective of inflammation and cytokines, and emphasizes the possible bridge between them by exploring the involvement of systemic cytokines in both conditions.
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Affiliation(s)
- Chunhai Zhang
- Thyroid Surgery Department, China-Japan Union Hospital of Jilin University, Changchun, Jilin 1300332, P.R. China
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18
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He X, Yang Y, Yao M, Yang L, Ao L, Hu X, Li Z, Wu X, Tan Y, Xing W, Guo W, Bellanti JA, Zheng SG, Xu X. Combination of human umbilical cord mesenchymal stem (stromal) cell transplantation with IFN-γ treatment synergistically improves the clinical outcomes of patients with rheumatoid arthritis. Ann Rheum Dis 2020; 79:1298-1304. [PMID: 32561603 DOI: 10.1136/annrheumdis-2020-217798] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To clarify the key role of circulating interferon-γ (IFN-γ) and to improve the clinical efficacy of mesenchymal stem cell (MSC) transplantation (MSCT) in patients with rheumatoid arthritis (RA). METHODS Study of wild-type or IFN-γR-/- MSCT was first evaluated in a murine model of collagen-induced arthritis (CIA) following which a phase 1/2 randomised controlled study was conducted in 63 patients with RA who responded poorly to regular clinical treatments. Subjects were randomly assigned to an MSCT monotherapy group (n=32) or an MSCT plus recombinant human IFN-γ treatment group (n=31), with 1 year of follow-up. The primary end points consisted of efficacy as assessed as good or moderate EULAR response rates and the proportion of patients at 3 months attaining American College of Rheumatology 20 (ACR20) response rates. RESULTS In the murine studies, wild-type MSCT significantly improved the clinical severity of CIA, while IFN-γR-/- MSCT aggravated synovitis, and joint and cartilage damage. Transitioning from the murine to the clinical study, the 3-month follow-up results showed that the efficacy and ACR20 response rates were attained in 53.3% patients with MSCT monotherapy and in 93.3% patients with MSCT combined with IFN-γ treatment (p<0.05). No new or unexpected safety issues were encountered in 1-year follow-up for either treatment group. CONCLUSIONS The results of this study show that IFN-γ is a key factor in determining the efficacy of MSCT in the treatment of RA, and that an MSC plus IFN-γ combination therapeutic strategy can greatly improve the clinical efficacy of MSC-based therapy in RA patients.
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Affiliation(s)
- Xiao He
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China.,PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Yi Yang
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Department of Rheumatology and Clinical Immunology, Daping Hospital, Army Military Medical University, Chongqing, China
| | - Mengwei Yao
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Army Medical University, Chongqing, China
| | - Lei Yang
- Force Health Team of 61365 Troops of the Chinese People's Liberation Army, Tianjin, China
| | - Luoquan Ao
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China
| | - Xueting Hu
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China
| | - Zhan Li
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China
| | - Xiaofeng Wu
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China
| | - Yan Tan
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China
| | - Wei Xing
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China
| | - Wei Guo
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China.,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China
| | - Joseph A Bellanti
- Departments of Pediatrics and Microbiology-Immunology, Georgetown University Medical Center, Washington, DC, USA
| | - Song Guo Zheng
- Division of Rheumatology, Department of Internal Medicine, Ohio State University College of Medicine and Wexner Medical Center, Columbus, Ohio, USA
| | - Xiang Xu
- Department of Stem Cell & Regenerative Medicine, Daping Hospital, Army Military Medical University,Chongqing, Chongqing, China .,Central Laboratory, State Key Laboratory of Trauma, Burn and Combined Injury, Chongqing, China.,Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Army Medical University, Chongqing, China
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19
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Nijhawan P, Behl T. The Role of Endostatin in Rheumatoid Arthritis. Curr Rheumatol Rev 2020; 17:68-75. [PMID: 32348230 DOI: 10.2174/1573397115666191127141801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/19/2020] [Accepted: 04/25/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Endostatin by its therapeutic value against rheumatoid arthritis has recently gained significant interest in biomedical science. A recent study revealed that various approaches have been made to prevent rheumatoid arthritis by either controlling or inhibiting the progression of angiogenesis. OBJECTIVE The main objective of the current manuscript is to enumerate the intrinsic role of endostatin in rheumatoid arthritis. METHODS A thorough and detailed review of literature from the papers published from the year 1997-2019 was studied for the preparation of the current article. RESULTS Endostatin is one such agent of the subfamily of ECM called as multiplexins obtained from proteolytic cleavage of XVIII and its carboxylic terminal fragments and is known for its antiangiogenic and antiproliferative property. The exact mechanism of endostatin is still unclear, but it acts by downregulating or inhibiting the responses of various factors, including Id1, Id3, matrix metalloproteinase, and Nuclear factor Kappa B that are liable for angiogenesis. The mutual effects on adipogenesis and angiogenesis, endostatin inhibits dietary-induced obesity and its related metabolic disorders, such as insulin resistance, glucose intolerance, and hepatic steatosis. CONCLUSION The present review demonstrates the intrinsic usage of endostatin as a novel molecule in rheumatoid arthritis. It focuses on the status of the therapeutic potential of endostatin in inhibiting the activity of angiogenesis is also very well explored.
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Affiliation(s)
- Priya Nijhawan
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India
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20
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Abstract
Insights into rheumatoid arthritis (RA) have slowly evolved over the last century, but with breathtaking speed over the last 2 decades. While only aspirin and parenteral gold were available in early 20th century, the efficacy of sulfasalazine, glucocorticoids and methotrexate was established around its middle. Identification of pathogenetic pathways was slow, and until today the role of T-cells is enigmatic, while it is clear that genetics via the shared epitope and other genes as well as environmental factors including the metagenome play major roles. More clarity evolved on importance of proinflammatory cytokines, especially TNF and IL-6. The activation of osteoclasts, the culprits of bony joint damage, is amplified by the proinflammatory cytokines. The realization of TNF's central role led to the successful introduction of TNF-inhibitors and subsequently also inhibitors of other cytokines and cells as well as signal transduction. In parallel, the evolution of outcomes research has contributed importantly to RA management. At the turn to the 21st century, improvement criteria and continuous indices were created, allowing reliable therapeutic response determination, including definition of endpoints like remission. Also our understanding of the role of disease activity relative to disease pathology has increased, ultimately fostering the treat-to-target concept and recommendations and, thus, optimal outcomes for RA patients as never been seen before. Similar developments are now ultimately being introduced in the field of psoriatic arthritis. Here many of these aspects are reviewed from a very personal perspective of the author in the hopes of further helping parients with chronic forms of arthritis.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Austria.
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Hamidi Z, Aryaeian N, Abolghasemi J, Shirani F, Hadidi M, Fallah S, Moradi N. The effect of saffron supplement on clinical outcomes and metabolic profiles in patients with active rheumatoid arthritis: A randomized, double-blind, placebo-controlled clinical trial. Phytother Res 2020; 34:1650-1658. [PMID: 32048365 DOI: 10.1002/ptr.6633] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 12/30/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022]
Abstract
Rheumatoid arthritis (RA) is a systemic autoimmune and inflammatory disease. Our study aimed to determine the effect of saffron supplement on clinical outcomes and metabolic profiles in patients with active RA. In this randomized, double-blind, placebo-controlled trial, 66 women older than 18 years old received 100 mg/day either saffron supplement in the intervention group (n = 33) or matched placebo in the placebo group (n = 33) for a period of 12 weeks. Sixty-one patients (30 in the control and 31 in the saffron group) remained for the final analysis. No adverse effects were reported by the patients. Saffron supplementation significantly decreased the number of tender (-1.38 ± 1.66 vs. 0.10 ± 0.40, p < .001) and swollen (-2.12 ± 2.34 vs. 0.63 ± 2.79, p < .001) joints, pain intensity based on visual analogue scale (-18.36 ± 15.07 vs. -2.33 ± 5.04), p < .001), and disease activity score (DAS28) (-0.75 ± 0.67 vs. 0.26 ± 0.77, p < .001) at the end of intervention between the two groups and in saffron group compared with baseline values. Physician Global Assessment (p = .002) and erythrocyte sedimentation rate were significantly improved after intervention (24.06 ± 12.66 vs. 32.00 ± 14.75, p = 0.028). High-sensitivity C-reactive protein reduced at the end of the intervention in the saffron group compared with baseline values (12.00 ± 7.40 vs. 8.82 ± 7.930, p = .004). Tumor necrosis factor alpha, interferon gamma, and malondialdehyde were decreased, and total antioxidant capacity were increased, but their differences between the two groups were not significant (p > .05). According to the results, saffron supplements could positively and significantly improve clinical outcomes in RA patients.
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Affiliation(s)
- Zahra Hamidi
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Naheed Aryaeian
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Jamileh Abolghasemi
- Department of Biostatistics, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Shirani
- Department of Internal Medicine, Faculty of Medicine, Rasoul-e-Akram Hospital, Tehran, Iran
| | - Mahsa Hadidi
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Soudabeh Fallah
- Department of Clinical Biochemistry, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nariman Moradi
- Department of Clinical Biochemistry, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
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22
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Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, Dougados M, Kerschbaumer A, McInnes IB, Sepriano A, van Vollenhoven RF, de Wit M, Aletaha D, Aringer M, Askling J, Balsa A, Boers M, den Broeder AA, Buch MH, Buttgereit F, Caporali R, Cardiel MH, De Cock D, Codreanu C, Cutolo M, Edwards CJ, van Eijk-Hustings Y, Emery P, Finckh A, Gossec L, Gottenberg JE, Hetland ML, Huizinga TWJ, Koloumas M, Li Z, Mariette X, Müller-Ladner U, Mysler EF, da Silva JAP, Poór G, Pope JE, Rubbert-Roth A, Ruyssen-Witrand A, Saag KG, Strangfeld A, Takeuchi T, Voshaar M, Westhovens R, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020; 79:685-699. [PMID: 31969328 DOI: 10.1136/annrheumdis-2019-216655] [Citation(s) in RCA: 1564] [Impact Index Per Article: 391.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 12/16/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To provide an update of the European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) management recommendations to account for the most recent developments in the field. METHODS An international task force considered new evidence supporting or contradicting previous recommendations and novel therapies and strategic insights based on two systematic literature searches on efficacy and safety of disease-modifying antirheumatic drugs (DMARDs) since the last update (2016) until 2019. A predefined voting process was applied, current levels of evidence and strengths of recommendation were assigned and participants ultimately voted independently on their level of agreement with each of the items. RESULTS The task force agreed on 5 overarching principles and 12 recommendations concerning use of conventional synthetic (cs) DMARDs (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b) DMARDs (tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, sarilumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (the Janus kinase (JAK) inhibitors tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target) and tapering on sustained clinical remission is provided. Cost and sequencing of b/tsDMARDs are addressed. Initially, MTX plus GCs and upon insufficient response to this therapy within 3 to 6 months, stratification according to risk factors is recommended. With poor prognostic factors (presence of autoantibodies, high disease activity, early erosions or failure of two csDMARDs), any bDMARD or JAK inhibitor should be added to the csDMARD. If this fails, any other bDMARD (from another or the same class) or tsDMARD is recommended. On sustained remission, DMARDs may be tapered, but not be stopped. Levels of evidence and levels of agreement were mostly high. CONCLUSIONS These updated EULAR recommendations provide consensus on the management of RA with respect to benefit, safety, preferences and cost.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Robert B M Landewé
- Amsterdam University Medical Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Maxime Dougados
- Rhumatologie B, Hopital Cochin, 27 rue du Fbg Saint-Jacques, Paris, France
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alexandre Sepriano
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal, and Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Maarten de Wit
- EULAR Patient Research Partner; Department Medical Humanities, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center and Faculty of Medicine Carl Gustav Carus, Dresden, Germany
| | - John Askling
- Department of Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Alejandro Balsa
- Servicio de Reumatologia Hospital Universitario La Paz, Instituto de Investigacion IdiPAZ, Madrid, Spain
| | - Maarten Boers
- Department of Epidemiology and Biostatistics and Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Maya H Buch
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, and IRCCS S Matteo Foundation, Pavia, Italy
| | | | - Diederik De Cock
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven; Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Catalin Codreanu
- Center of Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Maurizio Cutolo
- Research Laboratory and Division of Clinical Rheumatology, Department of Internal Medicine - University of Genoa, Genoa, Italy
| | - Christopher John Edwards
- Musculoskeletal Research Unit, NIHR Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Yvonne van Eijk-Hustings
- Department of Patient & Care and Department of Rheumatology, University of Maastricht, Maastricht, The Netherlands
| | - Paul Emery
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Axel Finckh
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Laure Gossec
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris and Pitié Salpêtrière hospital, AP-HP, Rheumatology Department, Paris, France
| | - Jacques-Eric Gottenberg
- Strasbourg University Hospital and University of Strasbourg, CNRS, Institut de Biologie Moléculaire et Cellulaire, Immunopathologie, et Chimie Thérapeutique, Strasbourg, France
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marios Koloumas
- European League Against Rheumatism, Zurich, Switzerland.,Cyprus League against Rheumatism, Nikosia, Cyprus
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China
| | - Xavier Mariette
- Université Paris-Sud, AP-HP, Université Paris-Saclay, Le Kremlin Bicêtre, France
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Campus Kerckhoff, Justus-Liebig University Giessen, Bad Nauheim, Germany
| | | | - Jose A P da Silva
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra Praceta Mota Pinto, and Coimbra Institute for Clinical and Biomedical Research (i-CRB), Faculty of Medicine of Coimbra, Coimbra, Portugal
| | - Gyula Poór
- National Institute of Rheumatology & Physiology, Semmelweis University, Budapest, Hungary
| | - Janet E Pope
- University of Western Ontario, Schulich School of Medicine & Dentistry, Department of Medicine, London, Ontario, Canada
| | | | | | - Kenneth G Saag
- Department of Medicine, Division of Rheumatology, University of Alabama at Birmingham, Brmingham, Alabama, USA
| | - Anja Strangfeld
- Programme Area Epidemiology, Deutsches Rheumaforschungszentrum Berlin, Berlin, Germany
| | - Tsutomu Takeuchi
- Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - Marieke Voshaar
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven; Rheumatology, University Hospitals Leuven, Leuven, Belgium
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Liu LF, Chen JS, Gu J, Xu JH, Jin HZ, Pang XW, Wang G, Yu C, Song ZQ, Guo ZP, Li W, Lai W, Cui PG, Chen M, Fang H, Lyu CZ, Li YZ, Sun Q, Xie HF, Liu XM, Gao XH, Shi YL, Zhao NQ, Zhang W, Zheng M. Etanercept biosimilar (recombinant human tumor necrosis factor-α receptor II: IgG Fc fusion protein) and methotrexate combination therapy in Chinese patients with moderate-to-severe plaque psoriasis: a multicentre, randomized, double-blind, placebo-controlled trial. Arch Dermatol Res 2019; 312:437-445. [DOI: 10.1007/s00403-019-02024-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/12/2019] [Accepted: 12/07/2019] [Indexed: 02/08/2023]
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Yamaguchi A, Hirata S, Kubo S, Fukuyo S, Hanami K, Nakano K, Nakayamada S, Saito K, Tanaka Y. 5-year remission rate after the discontinuation of adalimumab in patients with rheumatoid arthritis: Long-term follow-up results of the HONOR study. Mod Rheumatol 2019; 30:799-806. [PMID: 31814496 DOI: 10.1080/14397595.2019.1702141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objectives: To determine the rate and factors associated with remission (disease activity score (DAS) 28-erythrocyte sedimentation rate (ESR) of <2.6) during a 5-year follow-up after the discontinuation of adalimumab (ADA) in patients with rheumatoid arthritis (RA).Methods: 75 patients who had been treated with ADA + methotrexate (MTX) and maintained DAS28-ESR <2.6 for at least 6 months were enrolled. Among them, 52 patients discontinued ADA, and 46 patients completed a 5-year follow-up.Results: During the 5 years, 11 patients had DAS28-ESR <2.6. In 15 patients with DAS28-ESR <3.2, no significant changes were found in the health assessment questionnaire disability index (HAQ-DI) and modified total Sharp score (mTSS). When comparing patients with DAS28-ESR ≤1.61 versus 1.61 <DAS28-ESR <2.6, 50% and 15% of the two groups demonstrated sustained remission, respectively. Remission was more common in patients with shorter disease duration (≤2 years) than those with longer duration (>2 years). Among 31 patients who experienced flare, ADA was restarted in 24 patients, and 17 patients of these achieved DAS28-ESR <3.2 within 1-year.Conclusion: During the 5-year ADA-free period, remission rate was persistent in 21% of the patients. ADA-free remission was possible especially in patients with deeper remission (DAS28-ESR ≤1.61) and shorter disease duration (≤2 years).
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Affiliation(s)
- Ayako Yamaguchi
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shintaro Hirata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.,Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Satoshi Kubo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shunsuke Fukuyo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kentaro Hanami
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuyoshi Saito
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Health outcomes and unmet needs in patients with long-standing rheumatoid arthritis attending tertiary care in Greece: a cohort study. Health Qual Life Outcomes 2019; 17:73. [PMID: 31036012 PMCID: PMC6489275 DOI: 10.1186/s12955-019-1127-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/27/2019] [Indexed: 12/03/2022] Open
Abstract
Background No previous studies have characterized a patient’s experience of rheumatoid arthritis (RA) management in Greece and unmet needs may exist despite a broad range of available treatments. Therefore, we assessed quality of life (QoL), functional ability, and healthcare resource utilization in patients with established RA and receiving treatment in a tertiary care setting in Greece. Methods This was a prospective, observational cohort of patients aged ≥18 years, receiving any type of treatment for RA, and followed for 12 months at 7 rheumatology referral centers across mainland Greece (NCT01001182). Patient data were collected at the initial visit and 3, 6, and 9 months. QoL was evaluated using the Euro Quality of Life-5 dimensions questionnaire (EQ-5D) and functional ability was evaluated using the Health Assessment Questionnaire (HAQ). Results A total of 210 patients with RA were enrolled (76.7% women, mean ± standard deviation [SD] age: 59.1 ± 12.6 years, median [interquartile range] disease duration: 11.9 [5.0–16.0] years). Baseline mean ± SD EQ-5D and HAQ scores were 0.57 ± 0.32 and 0.75 ± 0.63, respectively, and remained largely unchanged throughout the study. Post-hoc comparison showed that patients receiving non-biologic disease-modifying antirheumatic drugs (non-bDMARDs) had significantly higher EQ-5D and lower HAQ-DI scores compared with those receiving biologic DMARDs. A majority of patients reported having difficulty doing housework or other duties (61.4 and 61.9%, respectively), and 55.2% reported needing external support for these tasks. Positive correlation was observed between QoL and functional ability. Hospitalization at least once during the study occurred in 9.5% of the patients, and 12.5% of these cases were due to exacerbation of RA. At baseline, 52.4% of the patients were retired, with 38.5% of retirees having retired early due to RA. Among the patients who were retired at baseline, the mean ± SD period from actual retirement to expected retirement age was 12.1 ± 8.1 years. Conclusion QoL and functional ability were positively correlated in patients with long-standing RA, with a large proportion showing impairments in both. Timely, target-oriented treatment initiated as soon as possible after diagnosis may help to improve patient-reported outcomes and limit the burden of RA. Trial registration ClinicalTrials.gov NCT01001182. Registered 23 October 2009. Electronic supplementary material The online version of this article (10.1186/s12955-019-1127-8) contains supplementary material, which is available to authorized users.
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Ten Klooster PM, Versteeg LGA, Oude Voshaar MAH, de la Torre I, De Leonardis F, Fakhouri W, Zaremba-Pechmann L, van de Laar M. Radiographic progression can still occur in individual patients with low or moderate disease activity in the current treat-to-target paradigm: real-world data from the Dutch Rheumatoid Arthritis Monitoring (DREAM) registry. Arthritis Res Ther 2019; 21:237. [PMID: 31718678 PMCID: PMC6852758 DOI: 10.1186/s13075-019-2030-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 10/09/2019] [Indexed: 11/26/2022] Open
Abstract
Background The aim of this retrospective study was to examine the longitudinal association between disease activity and radiographic damage in a cohort of patients with early RA (symptom onset < 1 year) treated according to treat-to-target (T2T) therapy. Methods Baseline to 3-year follow-up data were used from patients included in the DREAM remission induction cohort. Patients received protocolized T2T treatment, aimed at 28-joint disease activity score-erythrocyte sedimentation rate (DAS28-ESR) remission. Disease activity (DAS28-ESR and C-reactive protein, CRP) were assessed at least every 3 months; X-rays of the hand and feet at inclusion, 6 months, and 1, 2, and 3 years were scored using modified Sharp/van der Heijde scoring (SHS). Between and within-person associations between time-integrated disease activity and radiographic progression over time were examined. Results A subset of 229 out of 534 included patients were available for analysis. At the between-patient level, time-integrated DAS28-ESR scores were not significantly correlated with progression at the 6 month and 2-year follow-up and only weakly at the 1-year (Pearson’s correlation coefficient r = 0.17, P < 0.05) and 3-year follow-up (r = 0.21, P < 0.05). Individual slopes of the relationship between DAS28-ESR and progression scores in each time interval were significantly correlated over time and the slope of the first 6 months was moderately associated with this slope at later time points (r between 0.39 and 0.59; P values < 0.001). Between 15.9 to 22.7% and 16.7 to 38.5% of patients with low and moderate time-integrated disease activity, respectively, experienced relevant (ΔSHS ≥ 3) radiographic progression at the different time intervals. Analyses using CRP showed similar results. Conclusions In early RA patients treated according to T2T, radiographic progression appears to be an individually determined disease process, driven by factors other than consistent high disease activity. For individual patients, the intra-patient relation between disease activity and cumulative radiographic damage during the first 6 months is a good indicator for this relation in later years. Trial registration Netherlands Trial Register NTR578, 12 January 2006.
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Affiliation(s)
- Peter M Ten Klooster
- Transparency in Healthcare, Hengelo, the Netherlands. .,Arthritis Centre Twente, University of Twente, Enschede, the Netherlands. .,Department of Psychology, Health & Technology, University of Twente, PO BOX 217, 7500 AE, Enschede, the Netherlands.
| | - Letty G A Versteeg
- Arthritis Centre Twente, University of Twente, Enschede, the Netherlands.,Arthritis Centre Twente, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Martijn A H Oude Voshaar
- Transparency in Healthcare, Hengelo, the Netherlands.,Arthritis Centre Twente, University of Twente, Enschede, the Netherlands
| | | | | | | | | | - Mart van de Laar
- Transparency in Healthcare, Hengelo, the Netherlands.,Arthritis Centre Twente, University of Twente, Enschede, the Netherlands.,Arthritis Centre Twente, Medisch Spectrum Twente, Enschede, the Netherlands
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28
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Schapink L, van den Ende CHM, Gevers LAHA, van Ede AE, den Broeder AA. The effects of methotrexate and hydroxychloroquine combination therapy vs methotrexate monotherapy in early rheumatoid arthritis patients. Rheumatology (Oxford) 2019; 58:131-134. [PMID: 30189019 DOI: 10.1093/rheumatology/key275] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Indexed: 01/02/2023] Open
Abstract
Objectives To investigate the added value of MTX-HCQ combination therapy (CTG) in early RA in a controlled cohort study. MTX monotherapy (MTG) is recommended as (part of) first choice treatment but no head-to-head comparisons are available comparing MTX-HCQ CTG with MTG. Methods RA patients from the Sint Maartenskliniek and Radboudumc Nijmegen who started MTX with or without concomitant HCQ from April 2010 to October 2015 were included. The primary outcome was the between-group ΔDAS28-CRP at 6 months, and secondary outcomes were ΔDAS28-CRP at 12 months, EULAR response at 6 and 12 months, and treatment intensification. Regression modelling was used to correct for confounding. Results We included 325 patients, with only small between-group differences at baseline. The DAS28-CRP improvement at 6 months was larger in the CTG (Δ = 0.38 (CI: 0.01, 0.76)), and the difference between groups in DAS28-CRP improvement was smaller at 12 months (Δ = 0.22 points (CI:-0.19, -0.62)). At 6 months, a higher percentage of patients had a good EULAR response in the CTG (Δ = 15% (CI: 2.7%, 27%)). This difference was reduced at 12 months (Δ = 6% (CI -6.4%, 19%)). Treatment intensification with conventional synthetic DMARDs was more likely in the MTG (Δ = 31% (CI: -43%, 19%)). The proportion of patients starting biologic DMARD treatment during the observation period was comparable (Δ = 2% (CI: -8%, 12%)). Discussion In contrast to indirect comparison review data, MTX-HCQ seems somewhat more effective after 6 months than MTX monotherapy in early RA patients. After 12 months, we observed no significant differences between the two strategies, probably due to treat-to-target efforts.
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Affiliation(s)
- Lisa Schapink
- Department of Rheumatology, Sint Maartenskliniek, the Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, the Netherlands
| | - Cornelia H M van den Ende
- Department of Rheumatology, Sint Maartenskliniek, the Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, the Netherlands
| | | | | | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, the Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, the Netherlands
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Abstract
BACKGROUND Medication-based strategies to treat rheumatoid arthritis are crucial in terms of outcome. They aim at preventing joint destruction, loss of function and disability by early and consistent inhibition of inflammatory processes. OBJECTIVE Achieving consensus about evidence-based recommendations for the treatment of rheumatoid arthritis with disease-modifying anti-rheumatic drugs in Germany. METHODS Following a systematic literature research, a structured process among expert rheumatologists was used to reach consensus. RESULTS The results of the consensus process can be summed up in 6 overarching principles and 10 recommendations. There are several new issues compared to the version of 2012, such as differentiated adjustments to the therapeutic regime according to time point and extent of treatment response, the therapeutic goal of achieving remission as assessed by means of the simplified disease activity index (SDAI) as well as the potential use of targeted synthetic DMARDs (JAK inhibitors) and suggestions for a deescalating in case of achieving a sustained remission. Methotrexate still plays the central role at the beginning of the treatment and as a combination partner in the further treatment course. When treatment response to methotrexate is inadequate, either switching to or combining with another conventional synthetic DMARD is an option in the absence of unfavourable prognostic factors. Otherwise biologic or targeted synthetic DMARDs are recommended according to the algorithm. Rules for deescalating treatment with glucocorticoids and-where applicable-DMARDs give support for the management of patients who have reached a sustained remission. DISCUSSION The new guidelines set up recommendations for RA treatment in accordance with the treat-to-target principle. Modern disease-modifying drugs, now including also JAK inhibitors, are available in an algorithm.
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Zrubka Z, Gulácsi L, Brodszky V, Rencz F, Alten R, Szekanecz Z, Péntek M. Long-term efficacy and cost-effectiveness of infliximab as first-line treatment in rheumatoid arthritis: systematic review and meta-analysis. Expert Rev Pharmacoecon Outcomes Res 2019; 19:537-549. [PMID: 31340686 DOI: 10.1080/14737167.2019.1647104] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Early biological treatment of rheumatoid arthritis (RA) may reverse the autoimmune response in some patients resulting in favorable long-term outcomes. Although the cost-effectiveness of this strategy has been questioned, biosimilar entries warrant the revision of clinical and pharmaco-economic evidence. Areas covered: We conducted a systematic review of randomized controlled trials (RCTs) published up to 24 May 2018 in Pubmed, EMBASE and Cochrane CENTRAL, comparing infliximab with non-biological therapy in patients with RA naïve to methotrexate. We performed meta-analyses for efficacy outcomes at month 6 and years 1 and 2. Six RCTs were identified, involving 1832 patients. At month 6 ACR70 response and remission, and at year 1 ACR20/ACR70 responses and remission were improved significantly with first-line infliximab versus control. The differences were not significant at year 2. We reviewed cost-utility studies, up to 31 October 2018 in PubMed, Cochrane CENTRAL and the CRD HTA databases. Four studies indicated that first-line use of originator infliximab calculated at 2005-2008 prices was not cost-effective. Expert opinion: We demonstrated the efficacy benefits of first-line infliximab therapy up to 1 year in methotrexate-naïve RA. We highlighted the need for standardized reporting of outcomes and conducting cost-effectiveness analyses of first-line biosimilar therapy in RA.
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Affiliation(s)
- Zsombor Zrubka
- Department of Health Economics, Corvinus University of Budapest , Budapest , Hungary.,Doctoral School of Business and Management, Corvinus University of Budapest , Budapest , Hungary
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest , Budapest , Hungary
| | - Valentin Brodszky
- Department of Health Economics, Corvinus University of Budapest , Budapest , Hungary
| | - Fanni Rencz
- Department of Health Economics, Corvinus University of Budapest , Budapest , Hungary
| | - Rieke Alten
- Rheumatology Research Center, Schlosspark-Klinik Charite, University Medicine Berlin , Berlin , Germany
| | - Zoltán Szekanecz
- Division of Rheumatology, Department of Medicine, University of Debrecen Faculty of Medicine , Debrecen , Hungary
| | - Márta Péntek
- Department of Health Economics, Corvinus University of Budapest , Budapest , Hungary.,Department of Rheumatology, Flór Ferenc County Hospital , Kistarcsa , Hungary
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Burgers LE, van der Pol JA, Huizinga TWJ, Allaart CF, van der Helm-van Mil AHM. Does treatment strategy influence the ability to achieve and sustain DMARD-free remission in patients with RA? Results of an observational study comparing an intensified DAS-steered treatment strategy with treat to target in routine care. Arthritis Res Ther 2019; 21:115. [PMID: 31064384 PMCID: PMC6505077 DOI: 10.1186/s13075-019-1893-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/04/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To study the impact of treatment strategy on achieving and sustaining disease-modifying antirheumatic drug (DMARD)-free remission in patients with rheumatoid arthritis (RA). METHODS Two hundred seventy-nine RA patients (median follow-up 7.8 years) were studied. Of these, 155 patients participated in a disease activity score (DAS) < 1.6 steered trial aimed at DMARD-free remission. Initial treatment comprised methotrexate with high-dose prednisone (60 mg/day) and a possibility to start biologicals after 4 months. In the same period and hospital, 124 patients were treated according to routine care, comprising DAS < 2.4 steered treatment. Percentages of DMARD-free remission (absence of synovitis for ≥ 1 year after DMARD cessation), late flares (recurrence of clinical synovitis ≥ 1 year after DMARD cessation), and DMARD-free sustained remission (DMARD-free remission sustained during complete follow-up) were compared between both treatment strategies. RESULTS Patients receiving intensive treatment were younger and more often ACPA-positive. On a group level, there was no significant association between intensive treatment and DMARD-free remission (35% vs 29%, corrected hazard ratio (HR) 1.4, 95%CI 0.9-2.2), nor in ACPA-negative RA (49% versus 44%). In ACPA-positive RA intensive treatment resulted in more DMARD-free remission (25% vs 6%, corrected HR 4.9, 95%CI 1.4-17). Intensive treatment was associated with more late flares (20% versus 8%, HR 2.3, 95%CI 0.6-8.3). Subsequently, there was no difference in DMARD-free sustained remission on a group level (28% versus 27%), nor in the ACPA-negative (43% versus 42%) or ACPA-positive stratum (17% versus 6%, corrected HR 3.1, 95%CI 0.9-11). CONCLUSIONS Intensive treatment did not result in more DMARD-free sustained remission, compared to routine up-to-date care. The data showed a tendency towards an effect of intensive treatment in ACPA-positive RA; this needs further investigation.
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Affiliation(s)
- L E Burgers
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands.
| | - J A van der Pol
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - T W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - C F Allaart
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - A H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, C-01-046, PO Box 9600, 2300 RC, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, the Netherlands
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Brinkmann GH, Norvang V, Norli ES, Grøvle L, Haugen AJ, Lexberg ÅS, Rødevand E, Bakland G, Nygaard H, Krøll F, Widding-Hansen IJ, Bjørneboe O, Thunem C, Kvien T, Mjaavatten MD, Lie E. Treat to target strategy in early rheumatoid arthritis versus routine care – A comparative clinical practice study. Semin Arthritis Rheum 2019; 48:808-814. [DOI: 10.1016/j.semarthrit.2018.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/28/2018] [Accepted: 07/10/2018] [Indexed: 11/16/2022]
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Benabdoun HA, Kulbay M, Rondon EP, Vallières F, Shi Q, Fernandes J, Fahmi H, Benderdour M. In vitro and in vivo assessment of the proresolutive and antiresorptive actions of resolvin D1: relevance to arthritis. Arthritis Res Ther 2019; 21:72. [PMID: 30867044 PMCID: PMC6416871 DOI: 10.1186/s13075-019-1852-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/20/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Resolvin D1 (RvD1), an important member of resolvins, exerts a wide spectrum of biological effects, including resolution of inflammation, tissue repair, and preservation of cell viability. The aim of the present study is to investigate the anti-arthritic potential and clarify the bone protective actions of RvD1 in vitro and in vivo. METHODS RAW264.7 cells were treated with 50 ng/ml LPS for 72 h in the presence or absence of RvD1 (0-500 nM). Primary human monocytes were treated with M-CSF + RANKL for 14 days ± RvD1 (0-500 nM) with or without siRNA against RvD1 receptor FPR2. Expressions of inflammatory mediators, degrading enzymes, osteoclasts (OC) formation, and bone resorption were analyzed. The therapeutic effect of RvD1 (0-1000 ng) was carried out in murine collagen antibody-induced arthritis. Arthritis scoring, joint histology, and inflammatory and bone turnover markers were measured. RESULTS RvD1 is not toxic and inhibits OC differentiation and activation. It decreases bone resorption, as assessed by the inhibition of TRAP and cathepsin K expression, hydroxyapatite matrix resorption, and bone loss. In addition, RvD1 reduces TNF-α, IL-1β, IFN-γ, PGE2, and RANK and concurrently enhances IL-10 in OC. Moreover, in arthritic mice, RvD1 alleviates clinical score, paw inflammation, and bone and joint destructions. Besides, RvD1 reduces inflammatory mediators and markedly decreases serum markers of bone and cartilage turnover. CONCLUSION Our results provide additional evidence that RvD1 plays a key role in preventing bone resorption and other pathophysiological changes associated with arthritis. The study highlights the clinical relevance of RvD1 as a potential compound for the treatment of inflammatory arthritis and related bone disorders.
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Affiliation(s)
- Houda Abir Benabdoun
- Department of Pharmacology, Université de Montréal, Montreal,, QC, Canada.,Orthopedic Research Laboratory, Hôpital du Sacré-Cœur de Montréal, Room K-3045, 5400 Gouin Blvd. West, Montreal, QC, H4J 1C5, Canada
| | - Merve Kulbay
- Orthopedic Research Laboratory, Hôpital du Sacré-Cœur de Montréal, Room K-3045, 5400 Gouin Blvd. West, Montreal, QC, H4J 1C5, Canada
| | - Elsa-Patricia Rondon
- Orthopedic Research Laboratory, Hôpital du Sacré-Cœur de Montréal, Room K-3045, 5400 Gouin Blvd. West, Montreal, QC, H4J 1C5, Canada
| | - Francis Vallières
- Orthopedic Research Laboratory, Hôpital du Sacré-Cœur de Montréal, Room K-3045, 5400 Gouin Blvd. West, Montreal, QC, H4J 1C5, Canada
| | - Qin Shi
- Orthopedic Research Laboratory, Hôpital du Sacré-Cœur de Montréal, Room K-3045, 5400 Gouin Blvd. West, Montreal, QC, H4J 1C5, Canada
| | - Julio Fernandes
- Orthopedic Research Laboratory, Hôpital du Sacré-Cœur de Montréal, Room K-3045, 5400 Gouin Blvd. West, Montreal, QC, H4J 1C5, Canada.,Department of Surgery, Université de Montréal, Montreal, QC, Canada
| | - Hassan Fahmi
- Osteoarthritis Research Unit, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Department of Medicine, University of Montreal, Montreal, QC, Canada
| | - Mohamed Benderdour
- Orthopedic Research Laboratory, Hôpital du Sacré-Cœur de Montréal, Room K-3045, 5400 Gouin Blvd. West, Montreal, QC, H4J 1C5, Canada. .,Department of Surgery, Université de Montréal, Montreal, QC, Canada.
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Daien C, Hua C, Gaujoux-Viala C, Cantagrel A, Dubremetz M, Dougados M, Fautrel B, Mariette X, Nayral N, Richez C, Saraux A, Thibaud G, Wendling D, Gossec L, Combe B. Update of French society for rheumatology recommendations for managing rheumatoid arthritis. Joint Bone Spine 2019; 86:135-150. [DOI: 10.1016/j.jbspin.2018.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
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Long-Term Efficacy of Tumor Necrosis Factor Inhibitors for the Treatment of Methotrexate-Naïve Rheumatoid Arthritis: Systematic Literature Review and Meta-Analysis. Adv Ther 2019; 36:721-745. [PMID: 30637590 DOI: 10.1007/s12325-018-0869-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Synthesis of evidence on the long-term use of first-line biologic therapy in patients with early rheumatoid arthritis (RA) is required. We compared the efficacy of up to 5 years' treatment with first-line tumor necrosis factor inhibitors (TNFis) versus other treatment strategies in this population. METHODS Previous systematic reviews, PubMed and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) involving treatment of methotrexate-naïve RA patients with first-line TNFis. Literature was synthesized qualitatively, and a meta-analysis conducted to evaluate American College of Rheumatology (ACR) responses, clinical remission defined by any standard measure, and Health Assessment Questionnaire Disability Index (HAQ) at Years 2 and/or 5. RESULTS Ten RCTs involving 4306 patients [first-line TNFi, n = 2234; other treatment strategies (control), n = 2072] were included in the meta-analysis. Three studies were double-blind for the first 2 years, while seven were partly/completely open label during this period. Five studies reported data at Year 5; all were open label at this time point. At Year 2, ACR50 response, ACR70 response and remission rates were significantly improved with first-line TNFi versus control in double-blind RCTs [log-odds ratio (OR) 0.32 [95% confidence interval (CI) 0.02, 0.62; p = 0.035], log-OR 0.48 (95% CI 0.20, 0.77; p = 0.001), and log-OR 0.44 (95% CI 0.13, 0.74; p = 0.005), respectively], but not in open-label studies. No significant between-group differences were observed in mean HAQ at Year 2 in double-blind or open-label RCTs or in ACR response or remission outcomes at Year 5. CONCLUSION In double-blind studies, 2-year efficacy outcomes were significantly improved with first-line TNFi versus other treatment strategies in patients with MTX-naïve RA. No significant differences in these outcomes were observed when data from open-label RCTs were considered on their own. Further data on the efficacy of TNFi therapy over ≥ 2 years in patients with methotrexate-naïve RA are required. Plain language summary available for this article.
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36
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Strategies toward rheumatoid arthritis therapy; the old and the new. J Cell Physiol 2018; 234:10018-10031. [DOI: 10.1002/jcp.27860] [Citation(s) in RCA: 150] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 11/14/2018] [Indexed: 12/12/2022]
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Zhao J, Zhan T, Zhu J, Fan M, Huang Q, Ren H, Wu J, Yu Q, Lin J, Ouyang Q, An S, Yang M. Long-term prognosis and quality of life in patients with early rheumatoid arthritis treated according to the 2015 ACR guideline (LELAND): protocol for a multicentre prospective observational study in Southern China. BMJ Open 2018; 8:e023798. [PMID: 30446575 PMCID: PMC6252632 DOI: 10.1136/bmjopen-2018-023798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is a chronic systemic disease and one of the most disabling diseases for patients. The American College of Rheumatology (ACR) issued a new guideline in 2015 for the treatment of RA based on the treat-to-target strategy to achieve better outcomes. This study will focus on the real-world rates of remission and low disease activity of patients with early RA in China, who will be treated according to the 2015 ACR guideline. Additionally, factors influencing treat-to-target outcomes will be analysed, and long-term prognosis and quality of life will be assessed. METHOD AND ANALYSIS Two-hundred patients with early RA will be enrolled, treated and followed up once every 3 months for 48 months. These patients should fulfil the 2010 RA classification criteria of the ACR/European League Against Rheumatism with a disease course of no more than 6 months and should also fulfil other eligibility criteria. The patients will be treated following the 2015 ACR guideline. Their disease activity will be assessed, and they will be instructed to complete several questionnaires once every 3 months. The primary outcomes are the Disease Activity Score on 28 joints and Health Assessment Questionnaire Disability Index. The secondary outcome variables are the Simplified Disease Activity Index, Clinical Disease Activity Index and Routine Assessment of Patient Index Data 3 results, imaging data and personal medical costs. The data will be analysed using appropriate statistical analyses. ETHICS AND DISSEMINATION This research was approved by the Nanfang Hospital Ethics Committee (NFEC-2017-192). The results of the study will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03508713; Pre-results.
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Affiliation(s)
- Jinjun Zhao
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Taihe Zhan
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Junqing Zhu
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Meida Fan
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qin Huang
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hao Ren
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Wu
- Department of Rheumatology and Clinical Immunology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Qinghong Yu
- Department of Rheumatology and Clinical Immunology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jingli Lin
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingqing Ouyang
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengli An
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Min Yang
- Department of Rheumatology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Calvo Alén J, Pérez T, Romero Yuste S, Ferraz-Amaro I, Alegre Sancho JJ, Pinto Tasende JA, Maceiras Pan F, Quevedo JC, Hernández-Hernández MV, Hidalgo Calleja C, San Martín Álvarez A, Sánchez MIT, Sanmartí R. Efficacy and Safety of Combined Therapy With Synthetic Disease-modifying Antirheumatic Drugs in Rheumatoid Arthritis: Systematic Literature Review. ACTA ACUST UNITED AC 2018; 16:324-332. [PMID: 30241955 DOI: 10.1016/j.reuma.2018.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/14/2018] [Accepted: 07/19/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE 1) To systematically and critically review the evidence of combined therapy with synthetic disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis (RA); 2) To design practical recommendations on their use. METHODS A systematic literature review (SLR) was performed with a sensitive bibliographic search strategy in Medline, EMBASE and Cochrane Library. We selected randomized clinical trials that analyzed the efficacy and/or safety of 1) combined therapy of synthetic compared with sequential therapy of synthetic DMARD in early RA; and 2) combination of methotrexate+leflunomide or triple therapy with synthetic DMARD in established RA refractory to synthetic DMARD. Two reviewers made the first selection by title and abstract and 11 performed the selection after detailed review of the articles and data collection. The quality of the studies was evaluated with the Jadad scale. Based on the results, related recommendations were agreed upon in a nominal group meeting. RESULTS Ultimately, no articles were included in the SLR. The analysis of the reviewed articles demonstrated the effectiveness of the treatment with synthetic DMARD following a "treat to target" strategy in early RA patients, and of combination therapy of synthetic DMARD in established RA refractory to synthetic DMARD. This resulted in 6 recommendations concerning combination therapy with synthetic DMARD. CONCLUSIONS These recommendations aim to facilitate decision-making with the use of combined therapy with DMARD in RA.
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Affiliation(s)
- Jaime Calvo Alén
- Servicio de Reumatología, Hospital Universitario Araba, Vitoria-Gasteiz, España.
| | - Trinidad Pérez
- Servicio de Reumatología, Hospital de León, León, España
| | - Susana Romero Yuste
- Servicio de Reumatología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, España
| | - Iván Ferraz-Amaro
- Servicio de Reumatología, Hospital Universitario de Canarias, Tenerife, España
| | | | | | | | - Juan Carlos Quevedo
- Servicio de Reumatología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, España
| | | | | | - Alejandro San Martín Álvarez
- Sección Reumatología, Clínica HLA Vistahermosa, Alicante, España; Sección Reumatología, Hospital HLA, Denia, España
| | | | - Raimon Sanmartí
- Servicio de Reumatología, Hospital Universitari Clínic, Barcelona, España
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Wailoo A, Hock ES, Stevenson M, Martyn-St James M, Rawdin A, Simpson E, Wong R, Dracup N, Scott DL, Young A. The clinical effectiveness and cost-effectiveness of treat-to-target strategies in rheumatoid arthritis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 21:1-258. [PMID: 29206093 DOI: 10.3310/hta21710] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Treat to target (TTT) is a broad concept for treating patients with rheumatoid arthritis (RA). It involves setting a treatment target, usually remission or low disease activity (LDA). This is often combined with frequent patient assessment and intensive and rapidly adjusted drug treatment, sometimes based on a formal protocol. OBJECTIVE To investigate the clinical effectiveness and cost-effectiveness of TTT compared with routine care. DATA SOURCES Databases including EMBASE and MEDLINE were searched from 2008 to August 2016. REVIEW METHODS A systematic review of clinical effectiveness was conducted. Studies were grouped according to comparisons made: (1) TTT compared with usual care, (2) different targets and (3) different treatment protocols. Trials were subgrouped by early or established disease populations. Study heterogeneity precluded meta-analyses. Narrative synthesis was undertaken for the first two comparisons, but was not feasible for the third. A systematic review of cost-effectiveness was also undertaken. No model was constructed as a result of the heterogeneity among studies identified in the clinical effectiveness review. Instead, conclusions were drawn on the cost-effectiveness of TTT from papers relating to these studies. RESULTS Sixteen clinical effectiveness studies were included. They differed in terms of treatment target, treatment protocol (where one existed) and patient visit frequency. For several outcomes, mixed results or evidence of no difference between TTT and conventional care was found. In early disease, two studies found that TTT resulted in favourable remission rates, although the findings of one study were not statistically significant. In established disease, two studies showed that TTT may be beneficial in terms of LDA at 6 months, although, again, in one case the finding was not statistically significant. The TICORA (TIght COntrol for RA) trial found evidence of lower remission rates for TTT in a mixed population. Two studies reported cost-effectiveness: in one, TTT dominated usual care; in the other, step-up combination treatments were shown to be cost-effective. In 5 of the 16 studies included the clinical effectiveness review, no cost-effectiveness conclusion could be reached, and in one study no conclusion could be drawn in the case of patients denoted low risk. In the remaining 10 studies, and among patients denoted high risk in one study, cost-effectiveness was inferred. In most cases TTT is likely to be cost-effective, except where biological treatment in early disease is used initially. No conclusions could be drawn for established disease. LIMITATIONS TTT refers not to a single concept, but to a range of broad approaches. Evidence reflects this. Studies exhibit substantial heterogeneity, which hinders evidence synthesis. Many included studies are at risk of bias. FUTURE WORK Future studies comparing TTT with usual care must link to existing evidence. A consistent definition of remission in studies is required. There may be value in studies to establish the importance of different elements of TTT (the setting of a target, the intensive use of drug treatments and protocols pertaining to those drugs and the frequent assessment of patients). CONCLUSION In early RA and studies of mixed early and established RA populations, evidence suggests that TTT improves remission rates. In established disease, TTT may lead to improved rates of LDA. It remains unclear which element(s) of TTT (the target, treatment protocols or increased frequency of patient visits) drive these outcomes. Future trials comparing TTT with usual care and/or different TTT targets should use outcomes comparable with existing literature. Remission, defined in a consistent manner, should be the target of choice of future studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017336. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma S Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Andrew Rawdin
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David L Scott
- King's College Hospital NHS Foundation Trust, London, UK
| | - Adam Young
- West Hertfordshire Hospitals NHS Trust, Watford, UK
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Yang Y, He X, Zhao R, Guo W, Zhu M, Xing W, Jiang D, Liu C, Xu X. Serum IFN-γ levels predict the therapeutic effect of mesenchymal stem cell transplantation in active rheumatoid arthritis. J Transl Med 2018; 16:165. [PMID: 29903026 PMCID: PMC6003078 DOI: 10.1186/s12967-018-1541-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/06/2018] [Indexed: 01/14/2023] Open
Abstract
Background To explore the mechanism of the different clinical efficacies of mesenchymal stem cell transplantation (MSCT) and identify a possible serum biomarker for predicting the therapeutic effect of MSCT in rheumatoid arthritis (RA) patients. Methods A total of 105 patients with persistently active RA and poor responses to traditional medication were randomly divided into MSCT and control groups. Outcomes were evaluated according to the 28-joint Disease Activity Score and Health Assessment Questionnaire, serological indicators, regulatory T cell (Treg) to T helper 17 (Th17) cell ratio, and inflammatory cytokine levels. Twelve weeks after MSCT, the outcomes of the MSCT group were evaluated according to the European League against Rheumatism response criteria. Patients with a good or moderate response were added to the response group, and those with no response were added to the no-response group. Results No serious adverse events were reported for either MSCT subgroup (28 in the response group and 24 in the no-response group). The therapeutic effects lasted for 48 weeks without continuous administration. Notably, a transient increase in serum IFN-γ (>2 pg/ml) levels was observed in the response group, but not in the no-response group. Furthermore, an increase in IL-10 levels and the Treg/Th17 ratio and a reduction in IL-6 levels appeared 2–3 weeks after the transient IFN-γ increase. Conclusions Allogeneic MSCT is safe and feasible, and we propose high serum IFN-γ levels as a potent biomarker for predicting MSCT response. Trial registration chictr.org, ChiCTR-ONC-16008770. Registered 3 July 2016, http://www.chictr.org.cn/showproj.aspx?proj=14820 Electronic supplementary material The online version of this article (10.1186/s12967-018-1541-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yi Yang
- First Department, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China.,Department of Rheumatology and Clinical Immunology, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Xiao He
- First Department, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Rongseng Zhao
- First Department, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Wei Guo
- First Department, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Ming Zhu
- First Department, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Wei Xing
- First Department, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Dongpo Jiang
- Department of Critical Care Medicine, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China
| | - Chongyang Liu
- Department of Rheumatology and Clinical Immunology, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China.
| | - Xiang Xu
- First Department, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital and Research Institute of Surgery, Third Military Medical University, Chongqing, 400042, People's Republic of China.
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Mota LMHD, Kakehasi AM, Gomides APM, Duarte ALBP, Cruz BA, Brenol CV, de Albuquerque CP, Castelar Pinheiro GDR, Laurindo IMM, Pereira IA, Bertolo MB, Ubirajara Silva de Souza MPG, de Freitas MVC, Louzada-Júnior P, Xavier RM, Giorgi RDN. 2017 recommendations of the Brazilian Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis. Adv Rheumatol 2018; 58:2. [PMID: 30657071 DOI: 10.1186/s42358-018-0005-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/18/2018] [Indexed: 12/29/2022] Open
Abstract
The objective of this document is to provide a comprehensive update of the recommendations of Brazilian Society of Rheumatology on drug treatment of rheumatoid arthritis (RA), based on a systematic literature review and on the opinion of a panel of rheumatologists. Four general principles and eleven recommendations were approved. General principles: RA treatment should (1) preferably consist of a multidisciplinary approach coordinated by a rheumatologist, (2) include counseling on lifestyle habits, strict control of comorbidities, and updates of the vaccination record, (3) be based on decisions shared by the patient and the physician after clarification about the disease and the available therapeutic options; (4) the goal is sustained clinical remission or, when this is not feasible, low disease activity. Recommendations: (1) the first line of treatment should be a csDMARD, started as soon as the diagnosis of RA is established; (2) methotrexate (MTX) is the first-choice csDMARD; (3) the combination of two or more csDMARDs, including MTX, may be used as the first line of treatment; (4) after failure of first-line therapy with MTX, the therapeutic strategies include combining MTX with another csDMARD (leflunomide), with two csDMARDs (hydroxychloroquine and sulfasalazine), or switching MTX for another csDMARD (leflunomide or sulfasalazine) alone; (5) after failure of two schemes with csDMARDs, a bDMARD may be preferably used or, alternatively a tsDMARD, preferably combined, in both cases, with a csDMARD; (6) the different bDMARDs in combination with MTX have similar efficacy, and therefore, the therapeutic choice should take into account the peculiarities of each drug in terms of safety and cost; (7) the combination of a bDMARD and MTX is preferred over the use of a bDMARD alone; (8) in case of failure of an initial treatment scheme with a bDMARD, a scheme with another bDMARD can be used; in cases of failure with a TNFi, a second bDMARD of the same class or with another mechanism of action is effective and safe; (9) tofacitinib can be used to treat RA after failure of bDMARD; (10) corticosteroids, preferably at low doses for the shortest possible time, should be considered during periods of disease activity, and the risk-benefit ratio should also be considered; (11) reducing or spacing out bDMARD doses is possible in patients in sustained remission.
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Affiliation(s)
- Licia Maria Henrique da Mota
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina- Universidade de Brasília; Serviço de Reumatologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil. .,Rheos, Centro Médico Lúcio Costa, SGAS 610, bloco 1, salas T50- T51, L2 Sul, Asa Sul, Brasília, DF, 70200700, Brazil.
| | - Adriana Maria Kakehasi
- Disciplina de Reumatologia, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ana Paula Monteiro Gomides
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina- Universidade de Brasília; Serviço de Reumatologia, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil.,Centro Universitário de Brasília- UniCEUB, Brasília, Brazil
| | | | | | - Claiton Viegas Brenol
- Serviço de Reumatologia, Departamento de Medicina Interna, Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | | | - Manoel Barros Bertolo
- Disciplina de Reumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brazil
| | | | | | - Paulo Louzada-Júnior
- Disciplina de Reumatologia, Faculdade de Medicina de Universidade de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - Ricardo Machado Xavier
- Serviço de Reumatologia, Departamento de Medicina Interna, Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rina Dalva Neubarth Giorgi
- Serviço de Reumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual, São Paulo, Brazil
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Akdemir G, Markusse IM, Bergstra SA, Goekoop RJ, Molenaar ET, van Groenendael JHLM, Kerstens PJSM, Lems WF, Huizinga TWJ, Allaart CF. Comparison between low disease activity or DAS remission as treatment target in patients with early active rheumatoid arthritis. RMD Open 2018; 4:e000649. [PMID: 29862045 PMCID: PMC5976116 DOI: 10.1136/rmdopen-2018-000649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/06/2018] [Accepted: 04/15/2018] [Indexed: 11/17/2022] Open
Abstract
Objectives To compare outcomes of targeted treatment aimed at either low disease activity or remission in patients with early active rheumatoid arthritis (RA). Methods Five-year outcomes were compared in 133 patients with early active RA (1987), starting with methotrexate, sulfasalazine and tapered high dose of prednisone (arm 3 of the BehandelStrategieën (Treatment Strategies for Rheumatoid Arthritis) (BeSt) study), targeted at Disease Activity Score (DAS) ≤2.4 (low disease activity), and 175 patients with early RA, starting methotrexate and tapered high dose of prednisone, targeted at DAS <1.6 (selected from IMPROVED study who would have fulfilled inclusion criteria of the BeSt study). Association of treatment target with outcomes DAS <1.6, Boolean remission at year 1 and drug-free DAS remission (DFR) at year 5 were analysed by logistic regression analysis. Results At baseline, DAS <1.6 steered patients had a milder disease than DAS ≤2.4 steered patients (mean DAS 4.1±SD 0.7vs4.4±0.9, p=0.012) and less radiological damage. DAS decrease, functional ability and radiological damage progression over time were similar in both patient groups. DAS ≤2.4 was achieved in similar percentages in both patient groups, but more DAS <1.6 steered patients achieved DAS <1.6 and DFR. DAS <1.6 steered treatment was associated with achieving DAS <1.6 (OR 3.04 (95% CI 1.64 to 5.62)) and Boolean remission (3.03 (1.45 to 6.33)) at year 1 and DFR at year 5 (3.77 (1.51 to 9.43)). Conclusions In patients with early active RA who start with comparable disease-modifying antirheumatic drug+prednisone combination therapy, subsequent DAS <1.6 steered treatment is associated with similar clinical and radiological outcomes over time as DAS ≤2.4 steered treatment; however, in the DAS <1.6 steered group, more patients achieved remission and drug-free remission.
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Affiliation(s)
- Gülşah Akdemir
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris M Markusse
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Robbert J Goekoop
- Department of Rheumatology, Haga Hospital, The Hague, The Netherlands
| | | | | | | | - Willem F Lems
- Department of Rheumatology, Reade, Amsterdam, The Netherlands.,Department of Rheumatology, VUMC, Amsterdam, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Bugatti S, Sakellariou G, Luvaro T, Greco MI, Manzo A. Clinical, Imaging, and Pathological Suppression of Synovitis in Rheumatoid Arthritis: Is the Disease Curable? Front Med (Lausanne) 2018; 5:140. [PMID: 29868592 PMCID: PMC5962817 DOI: 10.3389/fmed.2018.00140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/24/2018] [Indexed: 12/18/2022] Open
Abstract
The management of patients with rheumatoid arthritis (RA) has witnessed a dramatic revolution in recent years, and disease remission has become an increasingly achievable outcome. Rheumatologists are now facing the urgent question of whether, once remission has been achieved and stably maintained, drugs can be tapered, and even discontinued. The concept of disease remission however encompasses progressive layers of complexity, all of which need to be disentangled before considering RA as a “curable” condition. As the synovial membrane represents the ultimate target of the pathological process of RA, a critical issue remains whether disease remission coincides with true suppression of inflammation and definitive tissue “healing.” In this short review, we will provide a critical summary of recent studies investigating the possibility of controlling RA synovitis at the clinical, imaging or pathological level. Potential advantages and limitations of these perspectives in the definition of remission are also discussed.
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Affiliation(s)
- Serena Bugatti
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Garifallia Sakellariou
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Terenzj Luvaro
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Maria Immacolata Greco
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - Antonio Manzo
- Division of Rheumatology, Rheumatology and Translational Immunology Research Laboratories (LaRIT), IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
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Versteeg GA, Steunebrink LMM, Vonkeman HE, Ten Klooster PM, van der Bijl AE, van de Laar MAFJ. Long-term disease and patient-reported outcomes of a continuous treat-to-target approach in patients with early rheumatoid arthritis in daily clinical practice. Clin Rheumatol 2018; 37:1189-1197. [PMID: 29388086 PMCID: PMC5913385 DOI: 10.1007/s10067-017-3962-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/14/2017] [Accepted: 12/18/2017] [Indexed: 12/02/2022]
Abstract
Patients in real life may differ from those in clinical trials. The aim of this study is to report 5-year outcomes of a continuous treat-to-target (T2T) approach in patients with rheumatoid arthritis (RA) in daily clinical practice. In the Dutch RhEumatoid Arthritis Monitoring cohort, all patients with a clinical diagnosis of RA were treated according to a protocolled T2T strategy, aimed at 28-joint Disease Activity Score (DAS28) < 2.6. Outcomes were percentages of patients in distinct levels of disease activity, mean course of DAS28 and prevalence of sustained (drug-free) remission. Also, data on functional disability (Health Assessment Questionnaire) and health-related quality of life (Short-Form 36) were examined. Mean DAS28 improved from 4.93 (95% CI 4.81-5.05) at baseline to 2.49 (95% CI 2.35-2.63) after 12 months and remained stable thereafter. Percentages of patients at 12 months with DAS28 < 2.6 (remission), DAS28 ≥ 2.6 and ≤ 3.2 (low disease activity), DAS28 > 3.2 and ≤ 5.1 (moderate disease activity) and DAS28 > 5.1 (high disease activity) were 63, 16, 18 and 3%, respectively. Sustained remission (DAS28 < 2.6 during ≥ 6 months) was observed at least once in 84% of the patients and drug-free remission (DAS28 < 2.6 during ≥ 6 months after withdrawal of all disease-modifying anti-rheumatic drugs) in 36% of the patients. Functional disability and health-related quality of life significantly improved during the first 24 weeks. Continuous application of T2T in real-life RA patients leads to favourable disease- and patient-related outcomes.
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Affiliation(s)
- G A Versteeg
- Arthritis Centre Twente, Department of Rheumatology, Medisch Spectrum Twente, P.O. Box 50 000, 7500, KA, Enschede, The Netherlands.
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - L M M Steunebrink
- Arthritis Centre Twente, Department of Rheumatology, Medisch Spectrum Twente, P.O. Box 50 000, 7500, KA, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - H E Vonkeman
- Arthritis Centre Twente, Department of Rheumatology, Medisch Spectrum Twente, P.O. Box 50 000, 7500, KA, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - P M Ten Klooster
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - A E van der Bijl
- Department of Rheumatology, Isala Hospital, Zwolle, The Netherlands
| | - M A F J van de Laar
- Arthritis Centre Twente, Department of Rheumatology, Medisch Spectrum Twente, P.O. Box 50 000, 7500, KA, Enschede, The Netherlands
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
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Smolen JS, Aletaha D, Barton A, Burmester GR, Emery P, Firestein GS, Kavanaugh A, McInnes IB, Solomon DH, Strand V, Yamamoto K. Rheumatoid arthritis. Nat Rev Dis Primers 2018; 4:18001. [PMID: 29417936 DOI: 10.1038/nrdp.2018.1] [Citation(s) in RCA: 1248] [Impact Index Per Article: 208.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic, inflammatory, autoimmune disease that primarily affects the joints and is associated with autoantibodies that target various molecules including modified self-epitopes. The identification of novel autoantibodies has improved diagnostic accuracy, and newly developed classification criteria facilitate the recognition and study of the disease early in its course. New clinical assessment tools are able to better characterize disease activity states, which are correlated with progression of damage and disability, and permit improved follow-up. In addition, better understanding of the pathogenesis of RA through recognition of key cells and cytokines has led to the development of targeted disease-modifying antirheumatic drugs. Altogether, the improved understanding of the pathogenetic processes involved, rational use of established drugs and development of new drugs and reliable assessment tools have drastically altered the lives of individuals with RA over the past 2 decades. Current strategies strive for early referral, early diagnosis and early start of effective therapy aimed at remission or, at the least, low disease activity, with rapid adaptation of treatment if this target is not reached. This treat-to-target approach prevents progression of joint damage and optimizes physical functioning, work and social participation. In this Primer, we discuss the epidemiology, pathophysiology, diagnosis and management of RA.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Anne Barton
- Arthritis Research UK Centre for Genetics and Genomics and NIHR Manchester Biomedical Research Centre, Manchester Academic Health Sciences Centre, The University of Manchester and Central Manchester Foundation Trust, Manchester, UK
| | - Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gary S Firestein
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego School of Medicine, La Jolla, CA, USA
| | - Arthur Kavanaugh
- Division of Rheumatology, Allergy and Immunology, University of California-San Diego School of Medicine, La Jolla, CA, USA
| | - Iain B McInnes
- Institute of Infection Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Daniel H Solomon
- Division of Rheumatology, Brigham and Women's Hospital, Boston, MA, USA
| | - Vibeke Strand
- Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, USA
| | - Kazuhiko Yamamoto
- Laboratory for Autoimmune Diseases, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
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Ishiguro N, Dougados M, Cai Z, Zhu B, Ishida M, Sato M, Gaich C, Quebe A, Stoykov I, Tanaka Y. Relationship between disease activity and patient-reported outcomes in rheumatoid arthritis: Post hoc analyses of overall and Japanese results from two phase 3 clinical trials. Mod Rheumatol 2018; 28:950-959. [PMID: 29278006 DOI: 10.1080/14397595.2017.1422232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine patient-reported outcomes (PROs) in patients with different rheumatoid arthritis (RA) disease activity levels and identify residual symptoms. METHODS Post hoc analyses of overall and Japanese data from two randomized controlled trials including RA patients with previous inadequate responses to methotrexate (NCT01710358) or no/minimal previous disease-modifying antirheumatic drug treatment (NCT01711359) (sponsor: Eli Lilly and Company). Week 24 assessments were disease activity (Simplified Disease Activity Index, Disease Activity Score/Disease Activity Score 28 joints-erythrocyte sedimentation rate) and PROs (pain visual analog scale [VAS], morning joint stiffness [MJS], Health Assessment Questionnaire-Disability Index, Functional Assessment of Chronic Illness Therapy-Fatigue, and Medical Outcomes Study Short Form 36 Health Survey Physical and Mental Component Scores). RESULTS Patients achieving remission/low disease activity (LDA) at Week 24 had larger/significant improvements from baseline in pain, MJS, disability, fatigue, and physical and emotional quality of life versus patients with high/moderate disease activity. Some patients achieving remission and LDA, reported residual pain (pain VAS >10 mm): 20.8-39.3% and 48.7-70.0% (overall study populations), 16.0-34.5% and 47.1-62.0% (Japanese patients). Residual MJS and fatigue were also reported. CONCLUSION Remission/LDA were associated with improvements in PROs in overall and Japanese patient populations; however, some patients achieving remission had residual symptoms, including pain.
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Affiliation(s)
- Naoki Ishiguro
- a Department of Orthopedic Surgery , Nagoya University Graduate School and School of Medicine , Nagoya , Japan
| | | | | | | | | | | | | | | | | | - Yoshiya Tanaka
- e The First Department of Internal Medicine, School of Medicine , University of Occupational and Environmental Health , Kitakyushu , Japan
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Steunebrink LMM, Versteeg LGA, Vonkeman HE, Ten Klooster PM, Hoekstra M, van de Laar MAFJ. Radiographic progression in early rheumatoid arthritis patients following initial combination versus step-up treat-to-target therapy in daily clinical practice: results from the DREAM registry. BMC Rheumatol 2018; 2:1. [PMID: 30886952 PMCID: PMC6390778 DOI: 10.1186/s41927-018-0009-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 01/07/2018] [Indexed: 02/08/2023] Open
Abstract
Background Early and intensive targeted treatment with disease modifying anti-rheumatic drugs (DMARDs) has been shown to lead to substantial reductions in disease activity and radiograph damage in patients with early rheumatoid arthritis (RA). The aim of this quasi-experimental study was to compare the first-year radiographic progression rates between a treat-to-target (T2 T) strategy with initial combination therapy (strategy II, started in 2012) versus an initial step-up monotherapy (strategy I, started in 2006). Methods A total of 128 patients from strategy II was individually matched with 128 patients from strategy I on sex, age (± 5 yrs.) and baseline disease activity (± 0.5 on the DAS28). Differences in radiographic progression (Sharp/van der Heijde) scores (SHS) and the number of patients experiencing a minimal clinically important difference (MCID; ≥ 5 SHS points) between both strategies were tested with Mann Whitney U and chi-square tests. Next, linear and logistic regression analyses were performed to examine which baseline variables were associated with radiographic progression scores and the probability of experiencing an MCID within 1 year. Results Patients with initial combination therapy had slightly higher baseline disease activity scores and pain scores, but better mental health scores. Patients with initial monotherapy had significantly more, and more frequently clinically relevant, radiographic progression after 1 year. Experiencing a MCID was independently associated with fewer tender joints (p = 0.050) and higher erythrocyte sedimentation rate (p = 0.015) at baseline. Conclusion Treating early RA patients with initial combination therapy results in better radiographic outcomes than initial monotherapy in daily clinical practice. Trial registration Netherlands Trial Register NTR578, 12 January 2006.
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Affiliation(s)
- Laura M M Steunebrink
- 1Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO BOX 50 000, 7500 KA Enschede, The Netherlands.,2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Letty G A Versteeg
- 1Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO BOX 50 000, 7500 KA Enschede, The Netherlands.,2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Harald E Vonkeman
- 1Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO BOX 50 000, 7500 KA Enschede, The Netherlands.,2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | - Peter M Ten Klooster
- 2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
| | | | - Mart A F J van de Laar
- 1Arthritis Center Twente, Department of Rheumatology, Medisch Spectrum Twente, PO BOX 50 000, 7500 KA Enschede, The Netherlands.,2Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands
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Perretti M, Norling LV. Actions of SPM in regulating host responses in arthritis. Mol Aspects Med 2017; 58:57-64. [DOI: 10.1016/j.mam.2017.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 04/21/2017] [Accepted: 04/25/2017] [Indexed: 12/20/2022]
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Danve A, Deodhar A. Treat to Target in Axial Spondyloarthritis: What Are the Issues? Curr Rheumatol Rep 2017; 19:22. [PMID: 28386759 DOI: 10.1007/s11926-017-0648-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF THE REVIEW Treat to Target (T2T) strategy has been widely used in the management of chronic medical conditions, such as hypertension, diabetes, and hypothyroidism, as well as rheumatic diseases, such as rheumatoid arthritis and gout. The purpose of this review is to discuss the importance, feasibility, and challenges in adopting the T2T strategy for the management of axial spondyloarthritis (axSpA). RECENT FINDINGS In 2014, a panel of international experts published recommendations for T2T in axSpA. Recent Tight Control of Inflammation in Early Psoriatic Arthritis (TICOPA) trial demonstrated efficacy of T2T in the management of the psoriatic arthritis. However, there are several issues in the adoption of T2T in axSpA. They include lack of evidence of the impact of aggressive management on clinical and radiographic outcomes in axSpA and unavailability of a definite target for the treatment, as well as limited therapeutic options. In this review, we discuss the intricacies of the T2T strategy in axSpA. We need more clinical evidence in the form of randomized clinical studies to assess the impact of T2T on outcomes in axSpA. We also need a definite target which is useful in the routine clinical practice, as well as for clinical trials.
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Affiliation(s)
- Abhijeet Danve
- Division of Rheumatology, Yale University School of Medicine, New Haven, CT, 06519, USA
| | - Atul Deodhar
- Division of Arthritis & Rheumatic diseases, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
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