Reexamining remission definitions in rheumatoid arthritis: considering the twenty-eight-joint Disease Activity Score, C-reactive protein level and patient global assessment

Transsulfuration and folate pathways in rheumatoid arthritis: A systematic review and meta-analysis

BACKGROUND

Metabolomic assessment of the transsulfuration and folic acid biochemical pathways could lead to the identification of promising biomarkers of nitric oxide dysregulation and oxidative stress in rheumatoid arthritis (RA).

METHODS

We conducted a systematic review and meta-analysis of transsulfuration (methionine, homocysteine, and cysteine) and folic acid (folic acid, vitamin B6 , and vitamin B12 ) metabolites in RA patients in remission and healthy controls. Electronic databases were searched from inception to 15 July 2023 for relevant articles. We assessed the risk of bias using the JBI checklist and the certainty of evidence using GRADE.

RESULTS

In 28 eligible studies, compared to controls, RA patients had significantly higher concentrations of homocysteine (standardized mean difference, SMD = 0.74, 95% CI 0.54-0.93, p < 0.001; low certainty of evidence) and methionine (SMD = 1.00, 95% CI 0.57-1.44, p < 0.001; low certainty) and lower concentrations of vitamin B6 (SMD = -6.62, 95% CI -9.65 to -3.60, p < 0.001; low certainty). By contrast, there were non-significant between-group differences in vitamin B12 and folic acid. In meta-regression and subgroup analysis, there were no associations between the effect size and several study and patient characteristics except for homocysteine (year of publication, C-reactive protein, triglycerides, and analytical method) and folic acid (biological matrix).

CONCLUSIONS

The results of our study suggest that homocysteine, methionine, and vitamin B6 are promising biomarkers to assess nitric oxide dysregulation and oxidative stress in RA. (PROSPERO registration number: CRD42023461081).

Remission, response, retention and persistence to treatment with disease-modifying agents in patients with rheumatoid arthritis: a study of harmonised Swedish, Danish and Norwegian cohorts

OBJECTIVE

Precision medicine in rheumatoid arthritis (RA) requires a good understanding of treatment outcomes and often collaborative efforts that call for data harmonisation. We aimed to describe how harmonisation across study cohorts can be achieved and investigate how the observed proportions reaching remission vary across remission criteria, study types, disease-modifying antirheumatic drugs (DMARDs) and countries, and how they relate to other treatment outcomes.

METHODS

We used data from eight existing large-scale, clinical RA registers and a pragmatic trial from Sweden, Denmark and Norway. In these, we defined three types of treatment cohorts; methotrexate monotherapy (as first DMARD), tumour necrosis factor inhibitors (TNFi) (as first biological DMARD) and rituximab. We developed a harmonised study protocol defining time points during 36 months of follow-up, collected clinical visit data on treatment response, retention, persistence and six alternative definitions of remission, and investigated how these outcomes differed within and between cohorts, by treatment.

RESULTS

Cohort sizes ranged from ~50 to 22 000 patients with RA. The proportions reaching each outcome varied across outcome metric, but with small to modest variations within and between cohorts, countries and treatment. Retention and persistence rates were high (>50% at 1 year), yet <33% of patients starting methotrexate or TNFi, and only 10% starting rituximab, remained on drug without other DMARDs added and achieved American Congress of Rheumatology/European Alliance of Associations for Rheumatology or Simplified Disease Activity Index remission at 1 year.

CONCLUSION

Harmonisation of data from different RA data sources can be achieved without compromising internal validity or generalisability. The low proportions reaching remission, point to an unmet need for treatment optimisation in RA.

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratio and disease activity in rheumatoid arthritis: A systematic review and meta-analysis

BACKGROUND

Inflammatory indexes derived from routine haematological parameters, particularly the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR), have been shown to discriminate between patients with and without rheumatoid arthritis (RA). However, their capacity to discriminate between RA patients with and without active disease has not been systematically appraised.

METHODS

We searched PubMed, Web of Science, Scopus and Google Scholar, from inception to June 2022, for studies comparing NLR and/or PLR values between RA patients with and without active disease. Risk of bias and certainty of evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist and GRADE, respectively.

RESULTS

In 18 studies (2122 RA patients with active disease, mean age 50 years, 20% males; 1071 RA patients with nonactive disease, mean age 50 years, 25% males), active disease was associated with significantly higher NLR (standard mean difference, SMD = 0.37, 95% CI 0.19 to 0.55, p < .001; low certainty of evidence) and PLR values (SMD = 0.48, 95% CI 0.32 to 0.64, p < .001; low certainty of evidence). In sensitivity analysis, the SMD values were not substantially influenced by sequentially removing individual studies. There was no publication bias. In meta-regression, the effect size was not associated with other study and patient characteristics, including sex, Disease Activity Score-28, C-reactive protein and erythrocyte sedimentation rate.

CONCLUSIONS

NLR and PLR can significantly discriminate between RA patients with and without active disease. Further studies are required to determine their diagnostic performance, singly or in combination with other parameters, in routine practice.

Controversies in rheumatology: Ultrasound for monitoring of RA - do we need it?

Clinical joint examination is the cornerstone for evaluation of patients with rheumatoid arthritis (RA). However, since large discrepancies have been shown even between experienced rheumatologists in evaluation of joint inflammation, and tender joints may have limited value in reflecting inflammation, ultrasound has in the last decennials been introduced in the clinical assessments of RA patients. Ultrasound has high accordance with other imaging modalities and enables detection of clinically difficult pathologies and contributes to assessments of joints difficult to evaluate clinically. However, there is no general agreement on the optimal use of ultrasound in rheumatology and the prevalence of machines as well as the level of experience is highly different across the countries. In addition, standardized use of ultrasound in treat-to-target follow-up of RA patients was found not to have any added value. Thus, how to use ultrasound in monitoring of RA patients is open for debate. The present article will discuss the pros and cons for using ultrasound in the clinical setting.