Diagnostic issues in difficult-to-treat rheumatoid arthritis: a systematic literature review informing the EULAR recommendations for the management of difficult-to-treat rheumatoid arthritis

Decreased serum TIMP4 levels in patients with rheumatoid arthritis

The current study was designed to explore the clinical significance of serum tissue inhibitor of metalloproteinase 4 (TIMP4) levels in rheumatoid arthritis (RA). The GSE1919 chip was analyzed, differentially expressed genes (DEGs) were identified, and gene ontology as well as Kyoto Encyclopedia of Genes and Genomes analyses of the identified DEGs were conducted. Patients with RA (n = 96) and healthy individuals (n = 96) were enrolled in this study. Serum from the participants was collected, and RT-qPCR as well as WB have been conducted to examine TIMP4 levels; additionally, interleukin (IL)-6 and IL-1β levels were determined using the ELISA method. Pearson's correlation analysis was conducted for evaluating relationships between the expression levels of TIMP4 and those of IL-6 or IL-1β. A receiver operating characteristic (ROC) curve was drawn to determine the potential diagnostic value of serum TIMP4 for RA. TIMP4 was identified as a markedly downregulated gene involved in RA development. TIMP4 levels were significantly decreased in patients with RA, and the results of the ROC analysis showed that TIMP4 may be a potential diagnostic marker. Furthermore, the concentrations of IL-6 and IL-1β were markedly elevated in patients with RA. Finally, TIMP4 levels showed negative correlation with the levels of either IL-6 or IL-1β. TIMP4 is downregulated in RA and is a reliable serum marker for RA diagnosis.

Prevalence and characteristics of adults with difficult-to-treat rheumatoid arthritis in a large patient registry

OBJECTIVES

An estimated 5-20% of patients with rheumatoid arthritis (RA) fail multiple treatments and are considered 'difficult-to-treat' (D2T), posing a substantial clinical challenge for rheumatologists. A European League Against Rheumatism (EULAR) task force proposed a definition of D2T-RA in 2021. We applied EULAR's D2T definition in a cohort of patients with established RA to assess prevalence, and we compared clinical characteristics of participants with D2T-RA with matched comparisons.

METHODS

Data from the longitudinal Brigham and Women's Hospital Rheumatoid Arthritis Sequential Study (BRASS) registry were used. Participants were classified as D2T if they met EULAR's definition. A comparison group of non-D2T-RA patients were matched 2:1 to every D2T patient, and differences in characteristics were evaluated in descriptive analyses. Prevalence rates of D2T were estimated using Poisson regression.

RESULTS

We estimated the prevalence of D2T-RA to be 14.4 (95% CI: 12.8, 16.3) per 100 persons among 1581 participants with RA, and 22.3 (95% CI: 19.9, 25.0) per 100 persons among 1021 who were biologic/targeted synthetic DMARD experienced. We observed several differences in demographics, comorbidities and RA disease activity between D2T-RA and non-D2T-RA comparisons. Varying EULAR sub-criteria among all participants in BRASS resulted in a range of D2T-RA prevalence rates, from 0.6 to 17.5 per 100 persons.

CONCLUSION

EULAR's proposed definition of D2T-RA identifies patients with RA who have not achieved treatment targets. Future research should explore heterogeneity in these patients and evaluate outcomes to inform the design of future studies aimed at developing more effective RA management protocols.

Self-management behaviors do not affect remission but mediate between mental health and disease outcomes in a longitudinal study of rheumatoid arthritis

Mental health has been shown to impact rheumatoid arthritis (RA) outcomes and is associated with self-management behaviors. The extent to which mental health impacts outcomes via different self-management behaviours has not been thoroughly investigated. Adult RA patients who were starting a new medication or dosage were recruited to a prospective cohort with follow-ups at 3 and 12-months covering clinical and patient-reported outcomes. The longitudinal relationships between mental health, self-management behaviors (diet, physical activity, sleep, smoking, alcohol, and medication nonadherence), disease outcome, and function were assessed. Self-management behaviors were considered mediators of mental health at baseline on outcomes at 3 and 12 months. Depression did not worsen the odds of EULAR response for the total PHQ at 3 months (OR = 0.96, p = 0.36) or 12 months (OR = 0.99, p = 0.99) nor for the categorical PHQ at 3 months (OR = 0.64, p = 0.34) or 12 months (OR = 0.67, p = 0.44). Anxiety also did not worsen the odds of EULAR response for the total GAD at 3 months (OR = 0.98, p = 0.76) or 12 months (OR1.04, 0.53) nor for the categorical GAD at 3 months (OR = 0.99, p = 0.99) or 12 months (OR = 0.94, p = 0.75). However, depression was associated with the DAS-28 at 3 months (b = 0.22, p = 0.04). Among the self-management behaviors, insomnia was found to be a significant mediator between depression and the WSAS (b = 0.08, p = 0.03) as well as anxiety and the WSAS (b = 0.07, p = 0.03). Alcohol was also a significant mediator between depression and the DAS-28 (b = 0.21, p = 0.04). Mental health was associated with worse quality of life and disease outcomes, but not EULAR response. Self-management behaviors were associated with disease outcomes and mental health.

Obesity and fibromyalgia are associated with Difficult-to-Treat Rheumatoid Arthritis (D2T-RA) independent of age and gender

BACKGROUND

There is still a significant proportion of patients with rheumatoid arthritis (RA) in whom multiple therapeutic lines are ineffective. These cases are defined by the EULAR criteria as Difficult-to-Treat RA (D2T-RA) for which there is limited knowledge of predisposing factors.

OBJECTIVE

To identify the clinical features associated with D2T-RA in real-life practice.

METHODS

We retrospectively collected demographic, clinical, and serological data on 458 patients consecutively seen for RA between January 2019 and January 2023. We compared patients fulfilling the D2T-RA criteria with the remaining RA cohort using univariate comparisons and logistic regression to determine the impact of clinical features, comorbidities on outcome variable, adjusted for confounders.

RESULTS

Seventy-one/458 (16%) patients fulfilled the 2021 EULAR criteria for D2T-RA with no significant differences for age (median 62 years interquartile range -IQR- 58- 65 vs. 62 IQR 60 - 63 in non-D2T), gender prevalence (23% in both groups) and positivity rates for rheumatoid factors (62% vs. 62% in non-D2T) and Anti-Citrullinated Protein Antibodies (ACPA) (69% vs. 61% in non-D2T). Conversely, D2T-RA cases had significant longer disease duration (median 15 years IQR 13-17 vs. 10 years IQR 9-11 in non-D2T; p < 0.0001). D2T-RA also had more erosions at baseline (24% vs. 11% in non-D2T; p < 0.0001) and higher disease activity index (CDAI) at the last follow up visit (15.7 ± 10.5 vs. 7.5 ± 8.8 in non-D2T; p < 0.0001). D2T-RA cases suffered with higher frequency of obesity (33% vs. 19% in non-D2T, p = 0.021) and fibromyalgia (25% vs. 10% in non-D2T, p < 0.0001). The multivariate analysis confirmed the correlations of D2T-RA with disease duration (Odds ratio -OR- 1.06, 95% confidence interval -CI-1.03-1.09; p < 0.0001), baseline erosions (OR 2.73, 95% CI 1.28-5.82; p = 0.009), obesity (OR 2.22, 95% CI 1.10-4.50; p = 0.026) and fibromyalgia (OR 3.91, 95% CI 1.76-8.70; p = 0.001), independent of age and gender.

CONCLUSIONS

High disease activity, baseline erosions and disease duration are significantly associated with the D2T phenotype of RA while we confirm the importance of obesity and fibromyalgia.

Difficult-to-treat rheumatoid arthritis: what have we learned and what do we still need to learn?

Difficult-to-treat RA (D2T RA) is an area of high unmet need. The prevalence reported in the first D2T RA cohort studies ranged from 5.5% to 27.5%. Key to the definition is a conviction by the patient and/or rheumatologist that disease management has become problematic and failure of at least two biological or targeted synthetic DMARDs. D2T RA is a multifactorial disease state which was reflected in data from D2T RA cohort studies: these pointed towards high prevalence of comorbidities and/or lower socioeconomic status in D2T RA subgroups, while others had persistent symptoms without these factors being present. A holistic approach is necessary to identify the root problems underlying D2T RA in individual patients. In this review, biological and non-biological drivers that should be considered to be optimized will be discussed in view of what we have learned from patient data emerging from the first D2T RA cohort studies.

Towards understanding the role of nanomedicine in targeting TNFR2 in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation of the synovium and progressive joint destruction which significantly affects both quality of life and socioeconomic status. Admittedly, various treatments are available, but they are usually accompanied by various side effects, from mild to severe, and potentially with adverse events. Tumour necrosis factor-alpha (TNF-α) plays a crucial role in the pathophysiology of RA. It promotes inflammatory, apoptosis and necroptosis via TNF receptor-1 (TNFR1) but elicit anti-inflammatory effects via TNFR2. Herein, targeting TNFR2 has gained attention in RA studies. Understanding the role of nanomedicine in modulating TNFR2 signalling may be the instrument in development of RA therapies. Nanotechnology has made a significant progress in treating various conditions of diseases since its inception. Due to this, nanomedicine has emerged as a promising therapeutics approach for RA. Recent studies have demonstrated the potential of nanomedicine in RA theranostics, combining therapy and diagnostics for improved treatment outcomes. Owing to the challenges and advancements in the field of nanotechnology, nanoparticles are seen as an applicable candidate in the treatment of RA. In this review, we provide an overview of the role of nanomedicine in targeting TNFR2 for the treatment of RA and highlight the limitations of current therapies as well as the potential of nanocarriers with controlled drug release and active targeting abilities.

Chinese guidelines for the diagnosis and treatment of rheumatoid arthritis: 2024 update

Rheumatoid arthritis (RA) is an autoimmune disease with destructive arthritis as its main clinical manifestation, which is a major cause of disability. It is very important to formulate and update a guideline for the diagnosis and treatment of RA that adhere to international guideline development standards and can be applied to clinical practice in China. This guideline is endorsed and developed by the National Clinical Research Center for Dermatologic and Immunologic Diseases, collaborated with Rheumatologists Branch of Chinese Medical Doctor Association, Rheumatology Rehabilitation Branch of Chinese Association of Rehabilitation Medicine, Rheumatology Branch of Chinese Research Hospital Association, and Rheumatology Branch of Beijing Association of Holistic Integrative Medicine, based on grading of recommendations assessment, development and evaluation (GRADE) and reporting items for practice guidelines in healthcare (RIGHT). Evidence-based recommendation were developed for 10 clinical scenario that are most relevant to Chinese rheumatologists, aiming to improve and standardize the diagnosis and treatment of RA in China, which may finally improve the quality of life and prognosis of patients.

Subsequent biologic and targeted synthetic disease modifying anti rheumatic drugs after fulfilling difficult-to-treat rheumatoid arthritis criteria: a survival analysis

OBJECTIVES

To evaluate the survival of different biologic or targeted-synthetic disease-modifying antirheumatic drugs (b/tsDMARD) administered after fulfilling difficult-to-treat rheumatoid arthritis (D2TRA) criteria, and to assess factors related to treatment discontinuation.

METHODS

Retrospective study including D2TRA patients. Drug retention of the b/tsDMARD administered after fulfilling D2TRA was assessed by Kaplan-Meier plots and the log-rank test. Cox hazard models were used to identify factors affecting treatment discontinuation.

RESULTS

Of the 122 patients included, 75 maintained active treatment (61.5%) with a subsequent line after D2T compared to 47 (38.5%) who discontinued and required more successive lines of b/tsDMARDs. The median survival of the treatments was 78.3(7.6) months and the treatment after D2T with the better rate of survival was rituximab, followed by JAKi and IL6Ri, while worse survival rates were associated with abatacept and TNFi. Significant differences were noted among b/tsDMARDs (log-rank p < 0.01) and to evaluate these differences, a Cox regression was performed, taking each b/tsDMARD as a reference and comparing it with the others. DAS28 values 6-months after initiation of treatment were higher in those patients who discontinued treatment [4.4(1.2) vs 3.5(1.3), p = 0.01]. The multivariate cox regression model revealed that treatment choice after D2T [HR = 1.26(95%CI 1.06-1.05)] and lower DAS28 values at 6 months [HR = 1.49(95%CI 1.16-1.52)] were independent risk factors associated with treatment discontinuation.

CONCLUSIONS

Once patients met the D2TRA criteria, the subsequent line of b/tsDMARDs with the best survival rates were rituximab, JAKi and IL6Ri. Moreover, DAS28 at 6-months of treatment after D2T was an independent risk factor for drug discontinuation. Key Points • Rituximab, IL6Ri and JAKi have better retention rates in patients after fulfilling D2TRA criteria • Clinical disease activity in the first six months after fulfillment of D2TRA criteria is an independent risk factor of subsequent treatment survival.

A Review of Difficult-to-Treat Rheumatoid Arthritis: Definition, Clinical Presentation, and Management

PURPOSE OF REVIEW

A subset of patients with rheumatoid arthritis (RA) who fail multiple biologic therapies are deemed to have "difficult-to-treat" (D2T) RA. In 2021, a European Alliance of Associations for Rheumatology (EULAR) task force proposed a clinical definition of D2T RA. Here we review RA phenotypes and clinical assessment of RA, propose a different definition of D2T RA, discuss possible D2T RA risk factors, and summarize existing literature on the management of D2T RA.

RECENT FINDINGS

High disease activity at the time of diagnosis or prior to treatment with a biologic is associated with the development of D2T RA. Prolonged time from diagnosis to beginning treatment has been consistently associated with the development of D2T RA. Other clinical factors such as burden of disease, extraarticular disease, obesity, smoking, pain, fatigue, and psychological conditions have inconsistent associations with D2T RA according to current literature. D2T RA is a relatively new concept that represents an area of great need for research regarding the characterization of those with the disease as well as how best to treat the disease. With this gained knowledge, rheumatologists will be able to better identify patients at the time of diagnosis that are likely to develop D2T RA to help guide management.

Difficult-to-treat rheumatoid arthritis: Current concept and unsolved problems

Over the past several decades, the treatment of rheumatoid arthritis (RA) has advanced significantly, and clinical, structural, and functional remission are achievable therapeutic goals. However, a substantial number of patients show resistance to multiple drugs. In particular, patients whose disease activity cannot be controlled despite the use of two or more biological disease-modifying antirheumatic drugs (DMARDs) or targeted synthetic DMARDs (tsDMARDs) with different mechanisms of action (MOA) have recently been referred to as having difficult-to-treat RA (D2T RA). D2T RA is a heterogeneous and multifactorial disease state, and the major problems are uncontrolled disease activity and decreased quality of life, as well as the economic burden due to frequent healthcare utilization and multiple admissions. Since the concept of D2T RA is relatively new and publication regarding D2T RA is limited, the mechanism underlying DMARD inefficacy and which factors form a "difficult-to-treat" state in such patients are not yet fully understood. It is also possible that factors contributing to D2T RA may differ by patient, sex, country, and race. The present Mini Review introduces the current concept and unsolved problems of D2T RA, including the definition, prevalence, and factors contributing to D2T RA. We then discuss the management and therapeutic strategies for D2T RA. Finally, we explore a clinical approach to prevent patients from developing D2T RA.

Difficult-to-treat rheumatoid arthritis in real clinical practice. Preliminary results

Aim. To compare the features of the course of the disease and the therapy in rheumatoid arthritis (RA) patients who meet the criteria of difficult-to-treat RA (D2T). Materials and methods. The study included 505 RA patients (ACR/EULAR 2010). Rheumatologist experts discussed all patients, since the treatment of RA ware perceived as problematic and/or insufficient. All patients had at least one of the following signs: the activity of the disease is no lower than moderate; the inability to reduce the dose of glucocorticoids to low; rapid radiological progression; RA symptoms causing a decrease in quality of life. The D2T group included 35 patients with true inefficiency or intolerance of two or more of bDMARDs/tsDMARDs of different mechanism of action. The control group (K) included patients with RA who already had experience of taking at least one class of bDMARDs/tsDMARDs (n=291). Results. On average, every 15 patients (7%) with RA met the EULAR criteria for D2T. The median age of patients in the D2T group was 45 years, which is less than in K (Me 54 [43; 62] years; p=0.046). The duration of RA in both groups was comparable. The severity of articular destruction in D2T was higher than in K (stage IV in 40% and 23%, respectively). Positivity for the RF and ACPA in D2T was less common than in K (60% and 85.9%; 60% and 76.6%, respectively). The presence of systemic manifestations of RA was more typical for K than for D2T (28.6% and 63%, p=0.0001). In the group of D2T patients, the number of previously taken DMARDs was higher than in K (p=0.002). Methotrexate was more often prescribed as the first DMARDs in both groups (in 62.9 and 65.7%, respectively). Initiation of bDMARDs/tsDMARDs therapy in D2T was more often performed by TNF-a inhibitors (OR 2.8; p=0.003) and co-stimulation blocker abatacept (OR 4.6; p=0.004), and in control by B-cell inhibitor rituximab (OR 6.9; p0.0001). Conclusion. The results of this study suggest that in Russia, as well as abroad, the principle of RA treatment treat to target has not yet become widespread, and the development of adequate therapy takes too much time.

OUP accepted manuscript

OBJECTIVES

Control of disease activity in RA is a crucial part of its management to prevent long-term joint damage and disability. This study aimed to identify early predictors of poor disease activity at 5 and 10 years, focusing on comorbidities and clinical/sociodemographic factors at first presentation.

METHODS

Patients from two UK-based RA cohorts were classified into two groups; low (&lt;3.2) and moderate/high (≥3.2) DAS using 28 joint counts (DAS28) at 5/10 years. Clinical variables (e.g. rheumatoid nodules, erosions), sociodemographic factors (e.g. ethnicity, deprivation) and comorbidities were recorded at baseline and yearly thereafter. The Rheumatic Diseases Comorbidity Index quantified patient comorbidity burden. Binary logistic regression models (outcome low vs moderate/high DAS28) were fitted using multiple imputation.

RESULTS

A total of 2701 patients living with RA were recruited (mean age 56.1 years, 66.9% female); 5-year data were available for 1718 (63.4%) patients and 10-year data for 820 (30.4%). Baseline Rheumatic Diseases Comorbidity Index was not associated with DAS28 at 5 [odds ratio (OR) 1.05, 95% CI 0.91, 1.22] or 10 years (OR 0.99, 95% CI 0.75, 1.31) in multivariable analyses. Sociodemographic factors (female gender, worse deprivation) and poorer baseline HAQ-Disability Index were associated with DAS28 ≥3.2 at both timepoints. Being seropositive was associated with 5-year DAS28 ≥3.2.

CONCLUSION

This study demonstrates an association between sociodemographic and clinical factors and long-term RA disease activity, in models adjusting for comorbidity burden. The findings call for more holistic and targeted patient management in patients with RA and provide insights for more individualized management plans even on first presentation to rheumatology.

Identification and prediction of difficult-to-treat rheumatoid arthritis patients in structured and unstructured routine care data: results from a hackathon

Background

The new concept of difficult-to-treat rheumatoid arthritis (D2T RA) refers to RA patients who remain symptomatic after several lines of treatment, resulting in a high patient and economic burden. During a hackathon, we aimed to identify and predict D2T RA patients in structured and unstructured routine care data.

Methods

Routine care data of 1873 RA patients were extracted from the Utrecht Patient Oriented Database. Data from a previous cross-sectional study, in which 152 RA patients were clinically classified as either D2T or non-D2T, served as a validation set. Machine learning techniques, text mining, and feature importance analyses were performed to identify and predict D2T RA patients based on structured and unstructured routine care data.

Results

We identified 123 potentially new D2T RA patients by applying the D2T RA definition in structured and unstructured routine care data. Additionally, we developed a D2T RA identification model derived from a feature importance analysis of all available structured data (AUC-ROC 0.88 (95% CI 0.82–0.94)), and we demonstrated the potential of longitudinal hematological data to differentiate D2T from non-D2T RA patients using supervised dimension reduction. Lastly, using data up to the time of starting the first biological treatment, we predicted future development of D2TRA (AUC-ROC 0.73 (95% CI 0.71–0.75)).

Conclusions

During this hackathon, we have demonstrated the potential of different techniques for the identification and prediction of D2T RA patients in structured as well as unstructured routine care data. The results are promising and should be optimized and validated in future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02560-5.

Pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis: a systematic literature review informing the EULAR recommendations for the management of difficult-to-treat rheumatoid arthritis

OBJECTIVES

To summarise, by a systematic literature review (SLR), the evidence regarding pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis (D2T RA), informing the EULAR recommendations for the management of D2T RA.

METHODS

PubMed, Embase and Cochrane databases were searched up to December 2019. Relevant papers were selected and appraised.

RESULTS

Two hundred seven (207) papers studied therapeutic strategies. Limited evidence was found on effective and safe disease-modifying antirheumatic drugs (DMARDs) in patients with comorbidities and other contraindications that limit DMARD options (patients with obesity, hepatitis B and C, risk of venous thromboembolisms, pregnancy and lactation). In patients who previously failed biological (b-)DMARDs, all currently used b/targeted synthetic (ts-)DMARDs were found to be more effective than placebo. In patients who previously failed a tumour necrosis factor inhibitor (TNFi), there was a tendency of non-TNFi bDMARDs to be more effective than TNFis. Generally, effectiveness decreased in patients who previously failed a higher number of bDMARDs. Additionally, exercise, psychological, educational and self-management interventions were found to improve non-inflammatory complaints (mainly functional disability, pain, fatigue), education to improve goal setting, and self-management programmes, educational and psychological interventions to improve self-management.The identified evidence had several limitations: (1) no studies were found in patients with D2T RA specifically, (2) heterogeneous outcome criteria were used and (3) most studies had a moderate or high risk of bias.

CONCLUSIONS

This SLR underscores the scarcity of high-quality evidence on the pharmacological and non-pharmacological treatment of patients with D2T RA. Effectiveness of b/tsDMARDs decreased in RA patients who had failed a higher number of bDMARDs and a subsequent b/tsDMARD of a previously not targeted mechanism of action was somewhat more effective. Additionally, a beneficial effect of non-pharmacological interventions was found for improvement of non-inflammatory complaints, goal setting and self-management.