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Ward MM, Madanchi N, Yazdanyar A, Shah NR, Constantinescu F. Prevalence and predictors of sustained remission/low disease activity after discontinuation of induction or maintenance treatment with tumor necrosis factor inhibitors in rheumatoid arthritis: a systematic and scoping review. Arthritis Res Ther 2023; 25:222. [PMID: 37986101 PMCID: PMC10659063 DOI: 10.1186/s13075-023-03199-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/20/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND To determine the prevalence of sustained remission/low disease activity (LDA) in patients with rheumatoid arthritis (RA) after discontinuation of tumor necrosis factor inhibitors (TNFi), separately in induction treatment and maintenance treatment studies, and to identify predictors of successful discontinuation. METHODS We performed a systematic literature review of studies published from 2005 to May 2022 that reported outcomes after TNFi discontinuation among patients in remission/LDA. We computed prevalences of successful discontinuation by induction or maintenance treatment, remission criterion, and follow-up time. We performed a scoping review of predictors of successful discontinuation. RESULTS Twenty-two induction-withdrawal studies were identified. In pooled analyses, 58% (95% confidence interval (CI) 45, 70) had DAS28 < 3.2 (9 studies), 52% (95% CI 35, 69) had DAS28 < 2.6 (9 studies), and 40% (95% CI 18, 64) had SDAI ≤ 3.3 (4 studies) at 37-52 weeks after discontinuation. Among patients who continued TNFi, 62 to 85% maintained remission. Twenty-two studies of maintenance treatment discontinuation were also identified. At 37-52 weeks after TNFi discontinuation, 48% (95% CI 38, 59) had DAS28 < 3.2 (10 studies), and 47% (95% CI 33, 62) had DAS28 < 2.6 (6 studies). Heterogeneity among studies was high. Data on predictors in induction-withdrawal studies were limited. In both treatment scenarios, longer duration of RA was most consistently associated with less successful discontinuation. CONCLUSIONS Approximately one-half of patients with RA remain in remission/LDA for up to 1 year after TNFi discontinuation, with slightly higher proportions in induction-withdrawal settings than with maintenance treatment discontinuation.
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Affiliation(s)
- Michael M Ward
- Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Building 10CRC, Room 4-1339, 10 Center Drive, Bethesda, MD, 20892-1468, USA.
| | - Nima Madanchi
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
- Current address: Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ali Yazdanyar
- Department of Emergency and Hospital Medicine, Lehigh Valley Hospital-Cedar Crest, Allentown, PA, USA
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
- Current address: Division of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nehal R Shah
- Division of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
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Fragoulakis V, Vitsou E, Hernandez AC, Maniadakis N. Economic evaluation of anti-TNF agents for patients with rheumatoid arthritis in Greece. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:85-93. [PMID: 25653545 PMCID: PMC4303331 DOI: 10.2147/ceor.s75323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives We aimed to estimate the total mean annual treatment cost of different therapy options for patients with moderate-to-severe rheumatoid arthritis (RA) in Greece. Methods A cost-minimization approach was adopted. An economic model was developed to estimate the direct costs of the three widely used treatments within a 1-year time horizon, from a health care payer perspective, either for new or for existing patients. Data on resource use, dose escalation, and frequency of therapy were based on a nationwide field survey of rheumatologists. Other analyses were also undertaken based on evidence from the literature. Total cost comprised the cost of drugs, administration, and hospital day care visits. Unit cost data were obtained from the price bulletin and the government gazettes issued by the Ministry of Health. Due to the short time horizon of the study, the cost was not discounted. Results The mean annual total cost per new (or per existing) responder patient on etanercept was estimated at €9,845 (€9,840), and the total cost on etanercept/methotrexate (MTX) was estimated at €9,857 (€9,852). Therapy with etanercept had lower annual cost relative to adalimumab and infliximab. On an annual basis, it was estimated that the difference between etanercept monotherapy and adalimumab monotherapy was €544 (€1,323). Similarly, the difference between etanercept/MTX and infliximab/MTX was €1,871 (€1,490) and €543 (€1,323), respectively, relative to adalimumab/MTX. Results remained constant under other scenario analyses undertaken. Conclusion In the real-life practice setting in Greece, where dose intensity and frequency differences occur, etanercept alone or in combination with MTX, if prescribed as per label, represents the option with lower annual cost per patient when compared with adalimumab or infliximab in patients with RA. These results hold true as long as the assumptions and data used in the analysis remain stable and may alter if any of the underlying parameters, such as drug price, change.
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P-glycoprotein and drug resistance in systemic autoimmune diseases. Int J Mol Sci 2014; 15:4965-76. [PMID: 24658440 PMCID: PMC3975434 DOI: 10.3390/ijms15034965] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 03/06/2014] [Accepted: 03/13/2014] [Indexed: 02/07/2023] Open
Abstract
Autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are chronic inflammatory disorders of unknown etiology characterized by a wide range of abnormalities of the immune system that may compromise the function of several organs, such as kidney, heart, joints, brain and skin. Corticosteroids (CCS), synthetic and biologic immunosuppressive agents have demonstrated the capacity to improve the course of autoimmune diseases. However, a significant number of patients do not respond or develop resistance to these therapies over time. P-glycoprotein (P-gp) is a transmembrane protein that pumps several drugs out of the cell, including CCS and immunosuppressants; thus, its over-expression or hyper-function has been proposed as a possible mechanism of drug resistance in patients with autoimmune disorders. Recently, different authors have demonstrated that P-gp inhibitors, such as cyclosporine A (CsA) and its analogue Tacrolimus, are able to reduce P-gp expression and or function in SLE, RA and PsA patients. These observations suggest that P-gp antagonists could be adopted to revert drug resistance and improve disease outcome. The complex inter-relationship among drug resistance, P-gp expression and autoimmunity still remains elusive.
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Salini V, Saggini A, Maccauro G, Caraffa A, Shaik-Dasthagirisaheb Y, Conti P. Inflammatory Markers: Serum Amyloid A, Fibrinogen and C-Reactive Protein — A Revisited Study. EUR J INFLAMM 2011. [DOI: 10.1177/1721727x1100900202] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The acute phase response is the part of the innate defence system of an animal against trauma, inflammation or infection. During this response, there is increased production and release of certain plasma proteins known as acute phase proteins, which include C-reactive protein (CRP), serum amyloid A (SAA) and fibrinogen (Fg). CRP consists of five identical subunits of 206 amino acids with a molecular weight of approximately 23 kDa. There is strong evidence from numerous studies that CRP is a predictor of inflammation. The acute-phase protein serum amyloid A (SAA) is a clinically useful marker of inflammation. SAA plays not only an important role in the development of AA amyloidosis (an important complication of rheumatoid arthritis) but also interacts with events closely involved in the metabolic syndrome as a high- and low-grade inflammatory modulator. Fibrinogen (Fg) is a high molecular weight plasma adhesion protein and is a biomarker of inflammation. It is synthesized and assembled in hepatocytes and fibroblasts and when secreted into the circulation, its plasma half-life ranges from 3 to 4 days. Several cytokines, are involved in the induction of acute phase protein synthesis, but the mutual importance of these cytokines seems to be cell-type specific and to vary in various experimental settings. Here we revisited the classic acute phase proteins SAA, C-Reactive protein and fibrinogen in their role in inflammation and their interrelationship with some cytokines.
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Affiliation(s)
- V. Salini
- Orthopaedic Division University of Chieti-Pescara, Medical School, Chieti, Italy
| | - A. Saggini
- Department of Dermatology, University of Rome Tor Vergata, Rome, Italy
| | - G. Maccauro
- Department of Orthopaedics, Catholic University of Rome, Rome, Italy
| | - A. Caraffa
- Orthopaedics Division, University of Perugia, Perugia, Italy
| | | | - P. Conti
- Immunology Division, University of Chieti-Pescara, Medical School, Chieti, Italy
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Saggini A, Tripodi D, Maccauro G, Castellani M, Anogeianaki A, Teté S, Felaco P, De Luths M, Galzio R, Fulcheri M, Theoharides T, Caraffa A, Antinolfi P, Felaco M, Conti F, Neri G, Pandolfi F, Tomato E, Shaik-Dasthagirisaheb Y. Tumor Necrosis Factor-Alpha and Mast Cells: Revisited Study. EUR J INFLAMM 2011. [DOI: 10.1177/1721727x1100900103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Mast cells reside in connective tissues and are widely recognized as effector cells important in innate and acquired immunity. These cells are the only ones capable of storing preformed TNFα in their cytoplasmatic granules and release upon activation. TNF-alpha is a potent multifunctional cytokine involved in autoimmune diseases, cancer, allergy, and acute and chronic inflammation. In this study, we revisit the interrelationship between TNFα and mast cells.
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Affiliation(s)
| | - D. Tripodi
- School of Dentistry, University of Chieti, Italy
| | - G. Maccauro
- Department of Orthopaedics, Catholic University of Rome, Italy
| | | | - A. Anogeianaki
- Physiology Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - S. Teté
- School of Dentistry, University of Chieti, Italy
| | - P. Felaco
- Department of Human Dynamics, University of Chieti, Italy
| | - M.A. De Luths
- Department of Human Dynamics, University of Chieti, Italy
| | - R. Galzio
- Department of Health Sciences, University of L'Aquila, Italy
| | - M. Fulcheri
- Department of Clinical Psychology, University of Chieti, Italy
| | - T.C. Theoharides
- Department of Pharmacology and Experimental Therapeutics, Biochemistry and Internal Medicine Tufts University School of Medicine, Tufts-New England Medical Center, Boston, MA, USA
| | - A. Caraffa
- Orthopaedics Division, University of Perugia, Perugia, Italy
| | - P. Antinolfi
- Orthopaedics Division, University of Perugia, Perugia, Italy
| | - M. Felaco
- Department of Human Dynamics, University of Chieti, Italy
| | - F. Conti
- Orthopaedics Division, University of Perugia, Perugia, Italy
| | - G. Neri
- Institute of Internal Medicine, University of Chieti, Italy
| | - F. Pandolfi
- Institute of Internal Medicine, Catholic University, Rome, Italy
| | - E. Tomato
- Department of Oncology and Experimental Medicine, University of Chieti, Chieti, Italy
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Migliore A, Bizzi E, Massafra U, Vacca F, Martin LM, Ferlito C, Podestà E, Granata M, Laganà B. A New Chance to Maintain Remission Induced by Anti-TNF Agents in Rheumatoid Arthritis Patients: CynAR Study II of a 12-Month Follow-up. Int J Immunopathol Pharmacol 2011; 24:167-74. [DOI: 10.1177/039463201102400119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The advent of biological therapies represented the beginning of a new era in the therapy of Rheumatoid Arthritis (RA), as demonstrated in several studies, but still many questions about their safety, especially in long term use, and correct administration time remain unanswered. Once remission is achieved, the orientation of clinicians regarding the maintenance of biological therapy or the switch to another immunosuppressive therapy is still uncertain. In our previous study 21 patients affected by RA who reached remission by the use of a combined therapy of anti-TNF drugs and methotrexate (MTX) underwent CyA-MTX combination therapy for maintaining remission state and were evaluated during a 6-month follow-up. The present study aims to investigate these data by a longer follow-up (12 months) and on a larger population. Fifty-three RA patients, with a disease duration of less than 3 years and DAS28<3.2 that reached a level of low disease activity within 6–8 months from the beginning of anti-TNF and methotrexate therapy, were enrolled in the study. By the suspension of anti-TNF therapy, patients underwent A-Cyclosporine (2–3 mg/kg/day) and methotrexate (15mg/week) therapy. DAS28, Pain VAS, Erythrosedimentation rate (ESR), C Reactive Protein (CRP) were all tested at time 0 and every 2 months after the interruption of the anti-TNF therapy and the beginning of A-Cyclosporine and methotrexate therapy, as well as liver and kidney profiles. Side effects were also recorded. Of 53 patients, 50 completed the study with a 12-month follow-up. Twenty-one (42%) patients maintained clinical parameters within low disease activity values at 12 months, while 29 (58%) patients showed an increase in DAS28 and other parameters: 16 (32%) patients at the 6-month control, 13 (26%) patients at the 12-month control. Our data show that 42% of the patients undergoing A-Cyclosporin and Methotrexate therapy maintained low disease activity parameters of rheumatoid arthritis, obtained after 6–8 months of anti-TNF therapy. Further studies on larger populations are necessary in order to confirm such results and identify predictor factors for different responses.
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Affiliation(s)
- A. Migliore
- Operative Unito f Rheumatology, S. Pietro FBF Hospital, Rome, Italy
| | - E. Bizzi
- Operative Unito f Rheumatology, S. Pietro FBF Hospital, Rome, Italy
| | - U. Massafra
- Operative Unito f Rheumatology, S. Pietro FBF Hospital, Rome, Italy
| | - F. Vacca
- Operative Unito f Rheumatology, S. Pietro FBF Hospital, Rome, Italy
| | - L.S. Martin Martin
- Department of Internal Medicine, Regina Apostolorum Hospital, Albano Laziale, Rome, Italy
| | - C. Ferlito
- UOS for Autoimmune diseases, “Sapienza” University, Second Medical School of Rome, Italy
| | - E. Podestà
- UOS for Autoimmune diseases, “Sapienza” University, Second Medical School of Rome, Italy
| | - M. Granata
- UOC of Rheumatology, San Filippo Neri Hospital, Rome, Italy
| | - B. Laganà
- UOS for Autoimmune diseases, “Sapienza” University, Second Medical School of Rome, Italy
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