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Emery P, Tanaka Y, Bykerk VP, Huizinga TWJ, Citera G, Bingham CO, Banerjee S, Soule BP, Nys M, Connolly SE, Lozenski KL, Zhuo J, Wong R, Huang KHG, Fleischmann R. Sustained Remission and Outcomes with Abatacept plus Methotrexate Following Stepwise Dose De-escalation in Patients with Early Rheumatoid Arthritis. Rheumatol Ther 2023; 10:707-727. [PMID: 36869251 PMCID: PMC10140217 DOI: 10.1007/s40744-022-00519-9] [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: 03/08/2022] [Accepted: 12/02/2022] [Indexed: 03/05/2023] Open
Abstract
INTRODUCTION One target of rheumatoid arthritis (RA) treatment is to achieve early sustained remission; over the long term, patients in sustained remission have less structural joint damage and physical disability. We evaluated Simplified Disease Activity Index (SDAI) remission with abatacept + methotrexate versus abatacept placebo + methotrexate and impact of de-escalation (DE) in anti-citrullinated protein antibody (ACPA)-positive patients with early RA. METHODS The phase IIIb, randomized, AVERT-2 two-stage study (NCT02504268) evaluated weekly abatacept + methotrexate versus abatacept placebo + methotrexate. PRIMARY ENDPOINT SDAI remission (≤ 3.3) at week 24. Pre-planned exploratory endpoint: maintenance of remission in patients with sustained remission (weeks 40 and 52) who, from week 56 for 48 weeks (DE period), (1) continued combination abatacept + methotrexate, (2) tapered abatacept to every other week (EOW) + methotrexate for 24 weeks with subsequent abatacept withdrawal (abatacept placebo + methotrexate), or (3) withdrew methotrexate (abatacept monotherapy). RESULTS Primary study endpoint was not met: 21.3% (48/225) of patients in the combination and 16.0% (24/150) in the abatacept placebo + methotrexate arm achieved SDAI remission at week 24 (p = 0.2359). There were numerical differences favoring combination therapy in clinical assessments, patient-reported outcomes (PROs) and week 52 radiographic non-progression. After week 56, 147 patients in sustained remission with abatacept + methotrexate were randomized (combination, n = 50; DE/withdrawal, n = 50; abatacept monotherapy, n = 47) and entered DE. At DE week 48, SDAI remission (74%) and PRO improvements were mostly maintained with continued combination therapy; lower remission rates were observed with abatacept placebo + methotrexate (48.0%) and with abatacept monotherapy (57.4%). Before withdrawal, de-escalating to abatacept EOW + methotrexate preserved remission. CONCLUSIONS The stringent primary endpoint was not met. However, in patients achieving sustained SDAI remission, numerically more maintained remission with continued abatacept + methotrexate versus abatacept monotherapy or withdrawal. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02504268. Video abstract (MP4 62241 KB).
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Affiliation(s)
- Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and Leeds NIHR Biomedical Research Centre, Leeds, UK.
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Vivian P Bykerk
- Department of Rheumatology, Hospital for Special Surgery, New York City, NY, USA
| | - Thomas W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gustavo Citera
- Department of Rheumatology, Instituto de Rehabilitación Psicofísca, Buenos Aires, Argentina
| | - Clifton O Bingham
- Divisions of Rheumatology and Allergy, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Subhashis Banerjee
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Benjamin P Soule
- Fibrosis Business Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Marleen Nys
- Global Biometrics and Data Science, Bristol Myers Squibb, Braine-l'Alleud, Belgium
| | - Sean E Connolly
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Karissa L Lozenski
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Joe Zhuo
- Worldwide Health Economics and Outcomes Research, Bristol Myers Squibb, Princeton, NJ, USA
| | - Robert Wong
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Kuan-Hsiang Gary Huang
- Immunology and Fibrosis/Global Drug Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Roy Fleischmann
- Division of Rheumatology, University of Texas Southwestern Medical Center and Metroplex Clinical Research Center, Dallas, TX, USA
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Koo BS, Eun S, Shin K, Hong S, Kim YG, Lee CK, Yoo B, Oh JS. Differences in trajectory of disease activity according to biologic and targeted synthetic disease-modifying anti-rheumatic drug treatment in patients with rheumatoid arthritis. Arthritis Res Ther 2022; 24:233. [PMID: 36242075 PMCID: PMC9563490 DOI: 10.1186/s13075-022-02918-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 10/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background
The purpose of this study was to stratify patients with rheumatoid arthritis (RA) according to the trend of disease activity by trajectory-based clustering and to identify contributing factors for treatment response to biologic and targeted synthetic disease-modifying anti-rheumatic drugs (DMARDs) according to trajectory groups. Methods We analyzed the data from a nationwide RA cohort from the Korean College of Rheumatology Biologics and Targeted Therapy registry. Patients treated with second-line biologic and targeted synthetic DMARDs were included. Trajectory modeling for clustering was used to group the disease activity trend. The contributing factors using the machine learning model of SHAP (SHapley Additive exPlanations) values for each trajectory were investigated. Results The trends in the disease activity of 688 RA patients were clustered into 4 groups: rapid decrease and stable disease activity (group 1, n = 319), rapid decrease followed by an increase (group 2, n = 36), slow and continued decrease (group 3, n = 290), and no decrease in disease activity (group 4, n = 43). SHAP plots indicated that the most important features of group 2 compared to group 1 were the baseline erythrocyte sedimentation rate (ESR), prednisolone dose, and disease activity score with 28-joint assessment (DAS28) (SHAP value 0.308, 0.157, and 0.103, respectively). The most important features of group 3 compared to group 1 were the baseline ESR, DAS28, and estimated glomerular filtration rate (eGFR) (SHAP value 0.175, 0.164, 0.042, respectively). The most important features of group 4 compared to group 1 were the baseline DAS28, ESR, and blood urea nitrogen (BUN) (SHAP value 0.387, 0.153, 0.144, respectively). Conclusions The trajectory-based approach was useful for clustering the treatment response of biologic and targeted synthetic DMARDs in patients with RA. In addition, baseline DAS28, ESR, prednisolone dose, eGFR, and BUN were important contributing factors for 4-year trajectories.
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Affiliation(s)
- Bon San Koo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Seongho Eun
- Department of Management Engineering, College of Business, KAIST, Seoul, South Korea
| | - Kichul Shin
- Division of Rheumatology, Seoul Metropolitan Government-Seoul National University Hospital Boramae Medical Center, Seoul, South Korea
| | - Seokchan Hong
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yong-Gil Kim
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chang-Keun Lee
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Bin Yoo
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Seon Oh
- Department of Information Medicine, Big Data Research Center, Asan Medical Center, Seoul, South Korea.
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Disease activity trajectories for early and established rheumatoid arthritis: Real-world data from a rheumatoid arthritis cohort. PLoS One 2022; 17:e0274264. [PMID: 36070307 PMCID: PMC9451079 DOI: 10.1371/journal.pone.0274264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 08/24/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Disease activity status described at fixed time points does not accurately reflect disease course in chronic and relapsing diseases such as rheumatoid arthritis (RA). We described longitudinal disease activity trajectories in early and established RA. Methods Patients with available 28-Joint Disease Activity Score-erythrocyte sedimentation rate (DAS28-ESR) and Clinical Disease Activity Index (CDAI) over two years were included. Using latent growth curve modelling (LCGM), subgroups of patients following distinct patterns were identified. Results 1920 patients were included with 34.4% in early RA (< 2 years’ disease duration). Three subgroups were identified using DAS28-ESR in early RA: 1) low disease activity to remission (LDA-REM: 19.1%); 2) moderate disease to remission (MD-REM: 54%); 3) high to moderate disease (HD-MD: 26.9%). The HD-MD group had a significantly higher number of comorbidities, biologic and steroid use and lower post-secondary education. Using CDAI, we identified seven subgroups with only 1.9% remission in early RA. In established RA, seven subgroups were identified using either DAS28-ESR or CDAI. Using DAS28-ESR 27.8% with HD showed improvement in disease status (14.2% HD-REM, 10.3% HD-LDA and 3.3% HD-MD) while using CDAI 17.9% showed improvement. Conclusion Disease course was different in early and established RA. Only 14.2% of established RA reached DAS28-ESR remission compared to 73.1% of early RA. Using CDAI only 1.9% of early RA and none of the established RA achieved remission, likely reflecting the impact of the patient global assessment on this score. Findings also illustrate the impact of sociodemographic characteristics and early treatment on disease course.
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Danila MI, Chen L, Ruderman EM, Owensby JK, O'Beirne R, Melnick JA, Harrold LR, Curtis D, Nowell WB, Curtis JR. Evaluation of an Intervention to Support Patient-Rheumatologist Conversations About Escalating Treatment in Patients with Rheumatoid Arthritis: A Proof-of-Principle Study. ACR Open Rheumatol 2021; 4:279-287. [PMID: 34962093 PMCID: PMC8992469 DOI: 10.1002/acr2.11393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/01/2021] [Accepted: 11/09/2021] [Indexed: 12/03/2022] Open
Abstract
Objective This study’s objective was to test whether an online video intervention discussing appropriate treatment escalation improves willingness to change treatment in people living with rheumatoid arthritis (RA). Methods We conducted a controlled, randomized trial among patients with RA enrolled in ArthritisPower, a United States patient registry. We recruited participants by email and surveyed their assessment of disease activity (patient global), satisfaction with disease control (patient acceptable symptom state), attitudes about RA medications, decisional conflict (decisional conflict scale), and willingness to modify RA treatment (choice predisposition scale, higher scores are better) if or when recommended by their rheumatologist. Intervention groups watched educational videos relevant to a treat‐to‐target (T2T) strategy, whereas control groups viewed vaccination‐related videos as an “attention control.” We compared the between‐group difference in patients’ willingness to modify RA treatment (primary outcome) and difference in decisional conflict about changing RA treatment (secondary outcome) after watching the videos using t tests. Results Participants with self‐reported RA (n = 208) were 90% White and 90% women, with a mean (standard deviation) age of 50 (11) years, and 52% reported familiarity with the RA T2T strategy. We found a significant improvement in between‐group difference in willingness to change RA treatment among intervention versus control participants (0.49 [95% confidence interval 0.09‐0.88], P = 0.02). The effect size (Glass’s delta) for the intervention was 0.48. Decisional conflict about treatment change decreased, but the between‐group difference was not significant. Conclusion This novel educational patient‐directed intervention discussing appropriate treatment escalation was associated with improved willingness to change RA treatment if or when recommended by a rheumatologist. Further studies should evaluate whether this change in patients’ predisposition translates into actual treatment escalation.
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Affiliation(s)
- Maria I Danila
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Lang Chen
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Ronan O'Beirne
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Leslie R Harrold
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - David Curtis
- Global Healthy Living Foundation, Upper Nyack, New York
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Andersen KM, Schieir O, Valois MF, Bartlett SJ, Bessette L, Boire G, Haraoui B, Hazlewood G, Hitchon C, Keystone EC, Pope J, Tin D, Throne JC, Bykerk VP. A Bridge Too Far? Real-World Practice Patterns of Early Glucocorticoid Use in the Canadian Early Arthritis Cohort. ACR Open Rheumatol 2021; 4:57-64. [PMID: 34708574 PMCID: PMC8754017 DOI: 10.1002/acr2.11334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/05/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To describe patterns of glucocorticoid use in a large real-world cohort with early rheumatoid arthritis (RA) and assess the impact on disease activity and treatment. METHODS Data are from adults with new RA (≤1 year) recruited to the Canadian Early Arthritis Cohort (CATCH) and are stratified on the basis of whether a person was prescribed oral glucocorticoids within 3 months of study entry. Disease activity was compared over 24 months. Mixed-effects logistic regression was used for adjusted odds ratios (aORs) of escalation to biologics separately for 12 and 24 months, with random effects terms to account for prescribing patterns clustering by study site. RESULTS Among 1891 persons, 30% received oral steroids. Users were older, were less often employed, and had shorter disease duration and higher disease activity. Disease activity improved over time, with early glucocorticoid users starting at higher levels of disease activity. Participants with early oral glucocorticoids were more likely to be on a biologic at 12 months (aOR = 2.4; 95% confidence interval [CI], 1.5-3.7) and 24 months (aOR = 1.9; 95% CI, 1.3-3.0). Despite Canadian clinical practice guidelines to limit corticosteroid use to short-term or 'bridge' therapy, 30% of patients who used oral glucocorticoids still used them 2 years later. CONCLUSION Early steroids were prescribed sparingly in CATCH and were often indicative of more active baseline disease as well as the need for progression to biologics.
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Affiliation(s)
| | | | | | - Susan J Bartlett
- McGill University, Montreal, Quebec, Canada, and Johns Hopkins University, Baltimore, Maryland
| | - Louis Bessette
- Centre Hôspitalier Universitairé de Québec-Université Laval, Québec, Québec, Canada
| | - Gilles Boire
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Boulos Haraoui
- Institut de Rhumatologie de Montreal, Montreal, Quebec, Canada
| | | | | | | | - Janet Pope
- St. Joseph's Health Care London and University of Western Ontario, London, Ontario, Canada
| | - Diane Tin
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - J Carter Throne
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Vivian P Bykerk
- Hospital for Special Surgery and Weill Cornell Medicine, New York City, New York
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Marques ML, Alunno A, Boonen A, Ter Wee MM, Falzon L, Ramiro S, Putrik P. Methodological aspects of design, analysis and reporting of studies with work participation as an outcome domain in patients with inflammatory arthritis: results of two systematic literature reviews informing EULAR points to consider. RMD Open 2021; 7:rmdopen-2020-001522. [PMID: 33542048 PMCID: PMC7868290 DOI: 10.1136/rmdopen-2020-001522] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/06/2021] [Accepted: 01/14/2021] [Indexed: 12/12/2022] Open
Abstract
Objective To summarise the methodological aspects in studies with work participation (WP) as outcome domain in inflammatory arthritis (IA) and other chronic diseases. Methods Two systematic literature reviews (SLRs) were conducted in key electronic databases (2014–2019): search 1 focused on longitudinal prospective studies in IA and search 2 on SLRs in other chronic diseases. Two reviewers independently identified eligible studies and extracted data covering pre-defined methodological areas. Results In total, 58 studies in IA (22 randomised controlled trials, 36 longitudinal observational studies) and 24 SLRs in other chronic diseases were included. WP was the primary outcome in 26/58 (45%) studies. The methodological aspects least accounted for in IA studies were as follows (proportions of studies positively adhering to the topic are shown): aligning the studied population (16/58 (28%)) and sample size calculation (8/58 (14%)) with the work-related study objective; attribution of WP to overall health (28/58 (48%)); accounting for skewness of presenteeism/sick leave (10/52 (19%)); accounting for work-related contextual factors (25/58 (43%)); reporting attrition and its reasons (1/58 (2%)); reporting both aggregated results and proportions of individuals reaching predefined meaningful change or state (11/58 (16%)). SLRs in other chronic diseases confirmed heterogeneity and methodological flaws identified in IA studies without identifying new issues. Conclusion High methodological heterogeneity was observed in studies with WP as outcome domain. Consensus around various methodological aspects specific to WP studies is needed to improve quality of future studies. This review informs the EULAR Points to Consider for conducting and reporting studies with WP as an outcome in IA.
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Affiliation(s)
- Mary Lucy Marques
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands .,Rheumatology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Alessia Alunno
- Rheumatology Unit, University of Perugia Department of Medicine, Perugia, Umbria, Italy
| | - Annelies Boonen
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands.,Department of Health Services Research, Universiteit Maastricht Care and Public Health Research Institute, Maastricht, Limburg, The Netherlands
| | - Marieke M Ter Wee
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Rheumatology and immunology, AI&I, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Louise Falzon
- Center for Personalized Health, Feinstein Institutes for Medical Research, Northwell Health, New York, New York, USA
| | - Sofia Ramiro
- Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, Limburg, The Netherlands
| | - Polina Putrik
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands.,Department of Health Services Research, Universiteit Maastricht Care and Public Health Research Institute, Maastricht, Limburg, The Netherlands
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Bykerk VP, Lee EB, van Vollenhoven R, Gruben DC, Fallon L, Woolcott JC, Keystone E. Identification of Distinct Disease Activity Trajectories in Methotrexate-Naive Patients With Rheumatoid Arthritis Receiving Tofacitinib Over Twenty-Four Months. Arthritis Care Res (Hoboken) 2021; 74:131-141. [PMID: 34057820 PMCID: PMC9303215 DOI: 10.1002/acr.24709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/18/2021] [Indexed: 12/18/2022]
Abstract
Objective Tofacitinib is an oral JAK inhibitor for the treatment of rheumatoid arthritis (RA). To better understand tofacitinib treatment responses, we used group‐based trajectory modeling to investigate distinct disease activity trajectories and associated baseline variables in patients with active RA. Methods This post hoc analysis used data from a phase III study of methotrexate‐naive patients receiving tofacitinib 5 mg twice daily. Changes in the 4‐variable Disease Activity Score in 28 joints, using the erythrocyte sedimentation rate (DAS28‐ESR) from baseline to month 24 were used in group‐based trajectory modeling to identify distinct disease activity trajectories. Patient and disease characteristics, changes in radiographic progression and patient‐reported outcomes, and safety up to month 24 were compared among trajectory groups. Results From 346 methotrexate‐naive patients, 5 disease trajectory groups, defined by DAS28‐ESR scores, were identified, which progressed from high disease activity (HDA) to remission (group 1, n = 28), to low disease activity (LDA) rapidly (group 2, n = 107), to moderate disease activity (group 3, n = 98), to LDA gradually (group 4, n = 46), or remained in HDA (group 5, n = 67), at month 24. At baseline, groups 1 and 2 generally had lower disease activity and more favorable patient‐reported outcomes, compared with other groups. Improvements in radiographic progression and patient‐reported outcomes over 24 months were generally consistent with DAS28‐ESR–predicted disease activity trajectories. Adverse event rates were generally comparable across groups. Conclusion Distinct phenotypic subgroups identified heterogeneity in patients with RA normally analyzed as a single population. Trajectory modeling may enable separation of clinically meaningful subsets of patients with RA, and may help optimize treatment outcomes.
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Affiliation(s)
| | - Eun Bong Lee
- Seoul National University College of Medicine, Seoul, Republic of Korea
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Widdifield J, Bernatsky S, Pope JE, Kuriya B, Barber CEH, Eder L, Ahluwalia V, Ling V, Gozdyra P, Hofstetter C, Lyddiatt A, Paterson JM, Thorne C. Evaluation of Rheumatology Workforce Supply Changes in Ontario, Canada, from 2000 to 2030. ACTA ACUST UNITED AC 2021; 16:119-134. [PMID: 33720829 PMCID: PMC7957360 DOI: 10.12927/hcpol.2021.26428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Rheumatology workforces are increasingly challenged by too few physicians in face of the growing burden of rheumatic and musculoskeletal diseases (RMDs). Rheumatology is one of the most frequent non-surgical specialty referrals and has the longest wait times for subspecialists. We used a population-based approach to describe changes in the rheumatology workforce, patient volumes and geographic variation in the supply of and access to rheumatologists, in Ontario, Canada, between 2000 and 2019, and projected changes in supply by 2030. Over time, we observed greater feminization of the workforce and increasing age of workforce members. We identified a large regional variation in rheumatology supply. Fewer new patients are seen annually, which likely contributes to increasing wait times and reduced access to care. Strategies and policies to raise the critical mass and improve regional distribution of supply to effectively provide rheumatology care and support the healthcare delivery of patients with RMDs are needed.
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Affiliation(s)
- Jessica Widdifield
- Scientist, Sunnybrook Research Institute Holland Bone & Joint Program; Assistant Professor, University of Toronto, Institute of Health Policy, Management & Evaluation Toronto, ON; Scientist, ICES Toronto, ON
| | - Sasha Bernatsky
- Rheumatologist and Scientist, Research Institute of the McGill University Health Centre; Associate Professor, Department of Epidemiology, McGill University, Montreal, QC
| | - Janet E Pope
- Rheumatologist, St Joseph's Health Care London; Professor of Medicine Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University London, ON
| | - Bindee Kuriya
- Rheumatologist, Sinai Health System; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON
| | - Claire E H Barber
- Rheumatologist, Assistant Professor, University of Calgary, Calgary, AB; Research Scientist, Arthritis Research Canada, Richmond, BC
| | - Lihi Eder
- Rheumatologist, Clinician Scientist, Women's College Research Institute, Toronto, ON
| | | | | | | | | | | | - J Michael Paterson
- Scientist, ICES, Toronto, ON; Assistant Professor, Department of Family Medicine, McMaster University, Hamilton, ON; Assistant Professor, University of Toronto, Institute of Health Policy, Management & Evaluation, Toronto, ON
| | - Carter Thorne
- Rheumatologist, Southlake Regional Health Centre, Newmarket, ON; Assistant Professor of Medicine, University of Toronto, Toronto, ON
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Characterization of disease course and remission in early seropositive rheumatoid arthritis: results from the TACERA longitudinal cohort study. Ther Adv Musculoskelet Dis 2021; 13:1759720X211043977. [PMID: 34707695 PMCID: PMC8544781 DOI: 10.1177/1759720x211043977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 08/17/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND To characterise disease course and remission in a longitudinal observational study of newly diagnosed, initially treatment-naïve patients with seropositive rheumatoid arthritis (RA). METHODS Patients with early untreated seropositive RA were recruited from 28 UK centres. Multiple clinical and laboratory measures were collected every 3 months for up to 18 months. Disease activity was measured using the 28-joint Disease Activity Score with C-reactive protein (DAS28-CRP) and Simplified Disease Activity Index (SDAI). Logistic regression models examined clinical predictors of 6-month remission and latent class mixed models characterised disease course. RESULTS We enrolled 275 patients of whom 267 met full eligibility and provided baseline data. According to SDAI definition, 24.3% attained 6-month remission. Lower baseline Health Assessment Questionnaire (HAQ) and SDAI predicted 6-month remission (p = 0.013 and 0.011). Alcohol intake and baseline prescribing of methotrexate with a second disease-modifying antirheumatic drug (DMARD; vs monotherapy without glucocorticoids) were also predictive. Three distinct SDAI trajectory subpopulations emerged; corresponding to an inadequate responder group (6.5%), and higher and lower baseline activity responder groups (22.4% and 71.1%). Baseline HAQ and Short Form-36 Health Survey - Mental Component Score (SF-36 MCS) distinguished these groups. In addition, a number of baseline clinical predictors correlated with disease activity severity within subpopulations. Beneficial effects of alcohol intake were found across subpopulations. CONCLUSION Three distinct disease trajectory subpopulations were identified. Differential effects of functional and mental well-being, alcohol consumption, and baseline RA medication prescribing on disease activity severity were found across subpopulations. Heterogeneity across trajectories cannot be fully explained by baseline clinical predictors. We hypothesise that biological markers collected early in disease course (within 6 months) may help patient management and better targeting of existing and novel therapies.
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Scott IC, Mount J, Barry J, Kirkham B. Factors associated with disability in patients with rheumatoid arthritis with persistent moderate disease activity: a retrospective cohort study. BMC Rheumatol 2020; 4:63. [PMID: 33094270 PMCID: PMC7576705 DOI: 10.1186/s41927-020-00161-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/19/2020] [Indexed: 11/17/2022] Open
Abstract
Background Many patients with rheumatoid arthritis (RA) do not attain remission/low disease activity, remaining in a moderate disease activity state (MDAS) with ongoing disability and impaired quality of life (QoL). If patients in persistent MDAS with poor future outcomes could be prospectively identified, they could arguably be treated more intensively. We evaluated baseline factors predicting function (Health Assessment Questionnaire-Disability Index [HAQ-DI] scores) and QoL (3-level EuroQol-5 dimensions questionnaire [EQ-5D-3L] index scores) at 12 months in patients with RA in persistent MDAS in a real-world setting. Methods Patients with persistent MDAS (Disease Activity Score for 28-joint count based on erythrocyte sedimentation rate [DAS28-ESR] 3.2–5.1 on at least two consecutive outpatient appointments over 12 months) were identified retrospectively from Guy’s Hospital RA Centre and analysed in two groups: (1) biologic naïve at baseline or (2) receiving/ever received biologics. The baseline timepoint was the second-visit MDAS DAS28-ESR score; the endpoint was the closest visit to 12 months. Linear regression analyses evaluated relationships between baseline variables and (1) 12-month HAQ-DI scores, (2) 12-month rank-transformed EQ-5D-3L index scores, (3) 12-month changes in HAQ-DI scores, and (4) 12-month changes in EQ-5D-3L index scores. Results The analysis included 207 biologic-naïve and 188 biologic-experienced patients. All patients had moderate disability (mean HAQ-DI 1.21 and 1.46) and impaired QoL (mean EQ-5D-3L index scores 0.52 and 0.50). Many reported moderate/severe pain (93 and 96%) and showed little change in HAQ-DI and EQ-5D-3L index scores over 12 months. In both biologic-naïve and biologic-experienced groups, multivariate analysis revealed a significant association between baseline HAQ-DI scores and endpoint HAQ-DI scores (β = 0.67, P < 0.001 and β = 0.76, P < 0.001, respectively), 12-month changes in HAQ-DI scores (both β = − 0.21, P < 0.001), and 12-month EQ-5D-3L index scores (β = − 0.57, P < 0.001 and β = − 0.29, P = 0.004, respectively). Baseline EQ-5D-3L index scores were significantly associated with 12-month changes in EQ-5D-3L index scores in both groups (β = − 0.73, P < 0.001 and β = − 0.40, P = 0.003, respectively). Conclusions Patients with RA in persistent MDAS experience substantial ongoing physical disability, poor QoL, and pain. HAQ-DI is an important predictor of future disability and reduced QoL, supporting current national recommendations to measure HAQ-DI in routine care.
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Affiliation(s)
- Ian C Scott
- Primary Care Centre Versus Arthritis, School of Primary, Community and Social Care, Keele University, Keele, Staffordshire ST5 5BG UK.,Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, High Lane, Burslem, Staffordshire ST6 7AG UK
| | - Julie Mount
- Eli Lilly and Company, Priestly Road, Basingstoke, Hampshire, RG24 9NL UK
| | - Jane Barry
- Eli Lilly and Company, Priestly Road, Basingstoke, Hampshire, RG24 9NL UK
| | - Bruce Kirkham
- Department of Rheumatology, Guy's and St. Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT UK
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11
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Fatima S, Schieir O, Valois MF, Bartlett SJ, Bessette L, Boire G, Hazlewood G, Hitchon C, Keystone EC, Tin D, Thorne C, Bykerk VP, Pope JE. Health Assessment Questionnaire at One Year Predicts All-Cause Mortality in Patients With Early Rheumatoid Arthritis. Arthritis Rheumatol 2020; 73:197-202. [PMID: 32892510 DOI: 10.1002/art.41513] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 08/06/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Higher self-reported disability (high Health Assessment Questionnaire [HAQ] score) has been associated with hospitalizations and mortality in established rheumatoid arthritis (RA), but associations in early RA are unknown. METHODS Patients with early RA (symptom duration <1 year) enrolled in the Canadian Early Arthritis Cohort who initiated disease-modifying antirheumatic drugs and had completed HAQ data at baseline and 1 year were included in the study. Discrete-time proportional hazards models were used to estimate crude and multi-adjusted associations of baseline HAQ and HAQ at 1 year with all-cause mortality in each year of follow-up. RESULTS A total of 1,724 patients with early RA were included. The mean age was 55 years, and 72% were women. Over 10 years, 62 deaths (3.6%) were recorded. Deceased patients had higher HAQ scores at baseline (mean ± SD 1.2 ± 0.7) and at 1 year (0.9 ± 0.7) than living patients (1.0 ± 0.7 and 0.5 ± 0.6, respectively; P < 0.001). Disease Activity Score in 28 joints (DAS28) was higher in deceased versus living patients at baseline (mean ± SD 5.4 ± 1.3 versus 4.9 ± 1.4) and at 1 year (mean ± SD 3.6 ± 1.4 versus 2.8 ± 1.4) (P < 0.001). Older age, male sex, lower education level, smoking, more comorbidities, higher baseline DAS28, and glucocorticoid use were associated with mortality. Contrary to HAQ score at baseline, the association between all-cause mortality and HAQ score at 1 year remained significant even after adjustment for confounders. For baseline HAQ score, the unadjusted hazard ratio (HR) was 1.46 (95% confidence interval [95% CI] 1.02-2.09), and the adjusted HR was 1.25 (95% CI 0.81-1.94). For HAQ score at 1 year, the unadjusted HR was 2.58 (95% CI 1.78-3.72), and the adjusted HR was 1.75 (95% CI 1.10-2.77). CONCLUSION Our findings indicate that higher HAQ score and DAS28 at 1 year are significantly associated with all-cause mortality in a large early RA cohort.
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Affiliation(s)
- Safoora Fatima
- University of Western Ontario Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - O Schieir
- University of Toronto, Toronto, Ontario, Canada
| | - M F Valois
- McGill University, Montreal, Quebec, Canada
| | | | - L Bessette
- CHU de Québec-Université Laval, Laval, Québec, Canada
| | - G Boire
- Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie, CHU de Sherbrooke, and Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - G Hazlewood
- University of Calgary, Calgary, Alberta, Canada
| | - C Hitchon
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - D Tin
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - C Thorne
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - V P Bykerk
- University of Toronto, Toronto, Ontario, Canada, and Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - J E Pope
- University of Western Ontario Schulich School of Medicine and Dentistry and St. Joseph's Health Care London, London, Ontario, Canada
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12
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Dagliati A, Plant D, Nair N, Jani M, Amico B, Peek N, Morgan AW, Isaacs J, Wilson AG, Hyrich KL, Geifman N, Barton A. Latent Class Trajectory Modeling of 2-Component Disease Activity Score in 28 Joints Identifies Multiple Rheumatoid Arthritis Phenotypes of Response to Biologic Disease-Modifying Antirheumatic Drugs. Arthritis Rheumatol 2020; 72:1632-1642. [PMID: 32475078 DOI: 10.1002/art.41379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/21/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine whether using a reweighted disease activity score that better reflects joint synovitis, i.e., the 2-component Disease Activity Score in 28 joints (DAS28) (based on swollen joint count and C-reactive protein level), produces more clinically relevant treatment outcome trajectories compared to the standard 4-component DAS28. METHODS Latent class mixed modeling of response to biologic treatment was applied to 2,991 rheumatoid arthritis (RA) patients in whom treatment with a biologic disease-modifying antirheumatic drug was being initiated within the Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate cohort, using both 4-component and 2-component DAS28 scores as outcome measures. Patient groups with similar trajectories were compared in terms of pretreatment baseline characteristics (including disability and comorbidities) and follow-up characteristics (including antidrug antibody events, adherence to treatments, and blood drug levels). We compared the trajectories obtained using the 4- and 2-component scores to determine which characteristics were better captured by each. RESULTS Using the 4-component DAS28, we identified 3 trajectory groups, which is consistent with previous findings. We showed that the 4-component DAS28 captures information relating to depression. Using the 2-component DAS28, 7 trajectory groups were identified; among them, distinct groups of nonresponders had a higher incidence of respiratory comorbidities and a higher proportion of antidrug antibody events. We also identified a group of patients for whom the 2-component DAS28 scores remained relatively low; this group included a high percentage of patients who were nonadherent to treatment. This highlights the utility of both the 4- and 2-component DAS28 for monitoring different components of disease activity. CONCLUSION Here we show that the 2-component modified DAS28 defines important biologic and clinical phenotypes associated with treatment outcome in RA and characterizes important underlying response mechanisms to biologic drugs.
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Affiliation(s)
- Arianna Dagliati
- Centre for Health Informatics and Manchester Molecular Pathology Innovation Centre, University of Manchester, Manchester, UK
| | - Darren Plant
- Versus Arthritis Centre for Genetics and Genomics, University of Manchester, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, and Manchester Academic Health Science Centre, Manchester, UK
| | - Nisha Nair
- Versus Arthritis Centre for Genetics and Genomics, University of Manchester, Manchester, UK
| | - Meghna Jani
- Versus Arthritis Centre for Epidemiology, University of Manchester, Manchester, UK
| | | | - Niels Peek
- Centre for Health Informatics, University of Manchester, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, and Manchester Academic Health Science Centre, Manchester, UK
| | - Ann W Morgan
- University of Leeds School of Medicine, NIHR Leeds Biomedical Research Centre, and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John Isaacs
- Translational and Clinical Research Institute, Newcastle University, and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Anthony G Wilson
- Centre for Arthritis Research, Conway Institute, University College Dublin, Dublin, Ireland
| | - Kimme L Hyrich
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, and Versus Arthritis Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Nophar Geifman
- Centre for Health Informatics and Manchester Molecular Pathology Innovation Centre, University of Manchester, Manchester, UK
| | - Anne Barton
- Versus Arthritis Centre for Genetics and Genomics, University of Manchester, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, and Manchester Academic Health Science Centre, Manchester, UK
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13
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Brunet SC, Finzel S, Engelke K, Boyd SK, Barnabe C, Manske SL. Bone changes in early inflammatory arthritis assessed with High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT): A 12-month cohort study. Joint Bone Spine 2020; 88:105065. [PMID: 32896669 DOI: 10.1016/j.jbspin.2020.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/21/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Erosion development is of crucial significance as it impacts prognosis and therapy decisions in patients with inflammatory joint diseases. Our study aimed to determine the sensitivity of high-resolution peripheral quantitative computed tomography (HR-pQCT) to detect change of bone surface over time and to identify erosion development in early inflammatory arthritis (EIA) patients. Moreover, the contribution of prognostic factors on periarticular bone damage in the first year of diagnosis assessed by HR-pQCT was explored. METHODS 46 patients with arthritic symptoms for less than one year, and a clinical diagnosis of inflammatory arthritis were prospectively imaged at baseline and 12-months. HR-pQCT scans of the 2nd and 3rd MCP joints and CR of the hands and feet were performed. Joint space width (JSW), total bone mineral density (Tt.BMD), erosion presence and volume were assessed with HR-pQCT. Scan-rescan precision was assessed to define an individual-level least significant change (LSC) criterion. Regression analyses explored prognostic factors for bone damage progression. RESULTS We observed no significant group-level changes in JSW, Tt.BMD or erosion volume. 20% or fewer joints demonstrated individual-level changes greater than the LSC criterion for mean JSW, Tt.BMD and erosion volume. HR-pQCT detected more erosions than CR in the 2nd and 3rd MCP. Increased symptom duration at diagnosis was weakly associated (P<0.10) with lower JSW minimum and higher JSW standard deviation. CONCLUSIONS Gradual degradation of JSW, proportional to symptom duration, was detected by HR-pQCT. EIA patients need to be closely monitored for exacerbation of arthritis and progression of periarticular bone damage.
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Affiliation(s)
- Scott Cameron Brunet
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary AB, Canada; Biomedical Engineering Graduate Program and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Stephanie Finzel
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Engelke
- Department of Medicine, FAU University Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Steven Kyle Boyd
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary AB, Canada; Biomedical Engineering Graduate Program and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Cheryl Barnabe
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary AB, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary AB, Canada
| | - Sarah Lynn Manske
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary AB, Canada; Biomedical Engineering Graduate Program and Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary AB, Canada.
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14
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Leu Agelii M, Andersson M, Jones BL, Sjöwall C, Kastbom A, Hafström I, Forslind K, Gjertsson I. Disease activity trajectories in rheumatoid arthritis: a tool for prediction of outcome. Scand J Rheumatol 2020; 50:1-10. [PMID: 32856510 DOI: 10.1080/03009742.2020.1774646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objective: Predicting treatment response and disease progression in rheumatoid arthritis (RA) remains an elusive endeavour. Identifying subgroups of patients with similar progression is essential for understanding what hinders improvement. However, this cannot be achieved with response criteria based on current versus previous Disease Activity Scores, as they lack the time component. We propose a longitudinal approach that identifies subgroups of patients while capturing their evolution across several clinical outcomes simultaneously (multi-trajectories). Method: For exploration, the RA cohort BARFOT (n = 2829) was used to identify 24 month post-diagnosis simultaneous trajectories of 28-joint Disease Activity Score and its components. Measurements were available at inclusion (0), 3, 6, 12, 24, and 60 months. Multi-trajectories were found with latent class growth modelling. For validation, the TIRA-2 cohort (n = 504) was used. Radiographic changes, assessed by the modified Sharp van der Heijde score, were correlated with trajectory membership. Results: Three multi-trajectories were identified, with 39.6% of the patients in the lowest and 18.9% in the highest (worst) trajectory. Patients in the worst trajectory had on average eight tender and six swollen joints after 24 months. Radiographic changes at 24 and 60 months were significantly increased from the lowest to the highest trajectory. Conclusion: Multi-trajectories constitute a powerful tool for identifying subgroups of RA patients and could be used in future studies searching for predictive biomarkers for disease progression. The evolution and shape of the trajectories in TIRA-2 were very similar to those in BARFOT, even though TIRA-2 is a newer cohort.
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Affiliation(s)
- M Leu Agelii
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, Gothenburg University , Gothenburg, Sweden
| | - Mle Andersson
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University , Lund, Sweden.,Spenshult Research and Development Center , Halmstad, Sweden
| | - B L Jones
- Department of Psychiatry, University of Pittsburgh Medical Center , Pittsburgh, PA, USA
| | - C Sjöwall
- Department of Rheumatology in Östergötland, and Department of Biomedical and Clinical Sciences, Linköping University , Linköping, Sweden
| | - A Kastbom
- Department of Rheumatology in Östergötland, and Department of Biomedical and Clinical Sciences, Linköping University , Linköping, Sweden
| | - I Hafström
- Division of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, and Karolinska University Hospital , Stockholm, Sweden
| | - K Forslind
- Section of Rheumatology, Department of Clinical Sciences Lund, Lund University , Lund, Sweden.,Department of Research and Education, Skånevård Sund, Region Skåne, Helsingborg´s Hospital , Helsingborg, Sweden
| | - I Gjertsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, Gothenburg University , Gothenburg, Sweden
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15
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Blair JPM, Bay-Jensen AC, Tang MH, Frederiksen P, Bager C, Karsdal M, Brunak S. Identification of heterogenous treatment response trajectories to anti-IL6 receptor treatment in rheumatoid arthritis. Sci Rep 2020; 10:13975. [PMID: 32811969 PMCID: PMC7434906 DOI: 10.1038/s41598-020-70942-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disease with fluctuating course of progression. Despite substantial improvement in treatments in recent years, treatment response is still not guaranteed. The aim of this study was to identify variation in Disease Activity Score 28 (DAS28) of RA patients in response to Tocilizumab, and to investigate both molecular and clinical factors influencing response. Clinical and biochemical data for 485 RA patients receiving Tocilizumab in combination with methotrexate were extracted from the LITHE phase III clinical study (NCT00106535), and post-hoc analysis conducted. Latent class mixed models were used to identify statistically distinct trajectories of DAS28 after the initiation of treatment. Biomarker measurements were then analysed cross-sectionally and temporally, to characterise patients by serological biomarkers and clinical factors. We identified three distinct trajectories of drug response: class 1 (n = 85, 17.5%), class 2 (n = 338, 69.7%) and class 3 (n = 62, 12.8%). All groups started with high DAS28 on average (DAS28 > 5.1). Class 1 showed the least reduction in DAS28, with significantly more patients seeking escape therapy (p < 0.001). Class 3 showed significantly higher rates of improvement in DAS28, with 58.1% achieving ACR response levels compared to 2.4% in class 1 (p < 0.0001). Biomarkers of inflammation, MMP-3, CRP, C1M, showed greater reduction in class 3 compared to the other classes. Identification of more homogenous patient sub-populations of drug response may allow for more targeted therapeutic treatment regimens and a better understanding of disease aetiology.
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Affiliation(s)
- J P M Blair
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. .,ProScion, Herlev Hovedgade 205-207, 2730, Herlev, Denmark.
| | - A-C Bay-Jensen
- ImmunoScience, Nordic Bioscience, Biomarkers and Research, Herlev, Denmark
| | - M H Tang
- ProScion, Herlev Hovedgade 205-207, 2730, Herlev, Denmark
| | - P Frederiksen
- ImmunoScience, Nordic Bioscience, Biomarkers and Research, Herlev, Denmark
| | - C Bager
- ProScion, Herlev Hovedgade 205-207, 2730, Herlev, Denmark
| | - M Karsdal
- ImmunoScience, Nordic Bioscience, Biomarkers and Research, Herlev, Denmark
| | - S Brunak
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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16
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Michaud K, Pope J, van de Laar M, Curtis JR, Kannowski C, Mitchell S, Bell J, Workman J, Paik J, Cardoso A, Taylor PC. Systematic Literature Review of Residual Symptoms and an Unmet Need in Patients With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2020; 73:1606-1616. [PMID: 32619340 PMCID: PMC8596735 DOI: 10.1002/acr.24369] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 06/25/2020] [Indexed: 12/11/2022]
Abstract
Objective To evaluate the nature and burden of residual disease in rheumatoid arthritis (RA) in patients who meet treatment targets. Second, for those who did not meet targets, to evaluate how much is due to patient symptoms. Methods Prospective and retrospective studies were searched in Medline, Embase, and Cochrane Library in the English language from January 1, 2008 to April 18, 2018; conference abstracts (from January 2016 to April 2018) and reference lists of relevant studies were also screened. Results Of 8,339 records identified, 55 were included in the review; 53 were unique studies, including 10 randomized controlled trials. Of these, 48 reported on patients who achieved low disease activity (LDA) or remission. Studies varied in population, treatment goals, and outcome reporting. The proportions of patients with residual symptoms in these studies varied by the definitions used for LDA or remission and were more often reported in patients with LDA than those in remission. The most commonly reported outcome measures were functional disability (n = 34 studies), tender or swollen joints (n = 18), pain (n = 17), patient global assessment (n = 15), and fatigue (n = 14). However, few studies reported the percentage of patients achieving a specific threshold, which could then be used to easily define the presence of residual symptoms. Conclusion Residual symptoms are present in some patients despite their achieving LDA or remission, highlighting an unmet need, especially with respect to improving pain, fatigue, and function. Standardized reporting in future observational studies would facilitate better understanding of this issue in defined RA populations.
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Affiliation(s)
- Kaleb Michaud
- University of Nebraska Medical Center, Omaha, and FORWARD, The National Databank for Rheumatic Diseases, Wichita, Kansas
| | - Janet Pope
- University of Western Ontario, London, Ontario, Canada
| | | | | | | | | | | | | | - Jim Paik
- Eli Lilly and Company, Indianapolis, Indiana
| | | | - Peter C Taylor
- Botnar Research Centre, University of Oxford, Oxford, UK
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17
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Hamann PDH, Pauling JD, McHugh N, Hyrich K, Shaddick G. Early response to anti-TNF predicts long-term outcomes including sustained remission: an analysis of the BSRBR-RA. Rheumatology (Oxford) 2020; 59:1709-1714. [PMID: 31714580 PMCID: PMC7310091 DOI: 10.1093/rheumatology/kez518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/18/2019] [Indexed: 01/06/2023] Open
Abstract
Objective To identify different trajectories of disease activity in patients with RA following initiation of a first anti-TNF. Methods Patients with RA starting their first anti-TNF between 2001 and 2013 were selected from the British Society for Rheumatology Biologics Register for RA. Six-monthly DAS28-ESR scores were used to identify trajectories of disease activity using latent class modelling. Data were included for six follow-ups after registration (approximately 3 years). Subgroup analysis examined changes in disease activity profiles over time. Results A total of 14 436 patients with RA starting their first anti-TNF were enrolled between 2001 and 2013 (13 115 between 2001 and 2008, 1321 between 2010 and 2013). The mean number of DAS28-ESR scores was 3.5/patient (s.d. 2.1), with a mean of 184.9 days (s.d. 69.9) between scores. The DAS28-ESR nadir was achieved within 250 days of commencing anti-TNF, although apparent trajectory divergence emerged by first 6-monthly follow-up at 180 days. Four distinct response trajectories comprised the most stable model. Most patients fitted into ‘modest’ (7986 patients; 55.3%) or ‘substantial’ (4676 patients; 32.4%) response trajectories. Of the remainder, 1254 (8.7%) and 520 (3.6%) fitted ‘maximal’ and ‘minimal’ response trajectories, respectively. There was a significant (P < 0.01) increase in proportion achieving ‘maximal’ response between 2001–2008 and 2010–2013. Conclusion This is the largest study to identify long-term response trajectories with anti-TNF. By 6 months, longer-term trajectory profiles of DAS28 could already be identified, with many patients identified earlier. The majority of patients had persistent moderate response, equivalent to maintained DAS28-ESR moderate disease activity. The maximal response trajectory (equivalent to sustained DAS2-ESR remission) was only achieved by approximately one-third of patients.
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Affiliation(s)
| | - John D Pauling
- Department of Pharmacy and Pharmacology, University of Bath, Bath
| | - Neil McHugh
- Department of Pharmacy and Pharmacology, University of Bath, Bath
| | - Kimme Hyrich
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester.,National Institute of Health Research Musculoskeletal Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science, Manchester, UK
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18
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Cairns E, Saunders S, Bell DA, Blackler G, Lac P, Barra L. The effect of sex on immune responses to a homocitrullinated peptide in the DR4-transgenic mouse model of Rheumatoid Arthritis. J Transl Autoimmun 2020; 3:100053. [PMID: 32743533 PMCID: PMC7388343 DOI: 10.1016/j.jtauto.2020.100053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 04/02/2020] [Indexed: 12/12/2022] Open
Abstract
Rheumatoid Arthritis (RA) is more common and severe in women compared to men. Both women and men with RA express autoantibodies to post-translationally modified antigens, including citrullinated and homocitrullinated proteins or peptides. These autoantibodies are strongly linked with the HLA-DR4 gene. The objective of this study was to determine sex differences in immune responses to homocitrullinated antigens. We used a humanized animal model of RA, DR4-transgenic mice and immunized them with a homocitrullinated peptide called HomoCitJED. Immune responses in these mice were measured for splenocyte proliferation by tritiated thymidine incorporation, serum autoantibody production by ELISA and cytokine levels by multiplex. We found that T cell and antibody responses to homocitrullinated antigens were similar in male and female mice. However, we found sex differences in serum cytokine profiles with female mice having higher ratio of IL-1α to IL-5, suggesting imbalances in immune regulation. This is the first study to report that immune responses to homocitrullinated antigens can be differentiated by sex. Splenocyte proliferation and antibody responses in DR4tg mice immunized with a homocitrullinated peptide were similar for females and males. The cytokine profile of homocitrullinated peptide-immunized DR4tg mice was differentiated by sex: females had a higher ratio of IL-1α to IL-5. Anti-homocitrullinated peptide splenocyte and antibody responses were more frequent in DR4tg than wild-type B6 mice.
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Affiliation(s)
- Ewa Cairns
- Department of Microbiology and Immunology, The University of Western Ontario, London, ON, Canada.,Department of Medicine/Rheumatology, The University of Western Ontario, London, ON, Canada
| | - Sheri Saunders
- Department of Microbiology and Immunology, The University of Western Ontario, London, ON, Canada
| | - David A Bell
- Department of Microbiology and Immunology, The University of Western Ontario, London, ON, Canada
| | - Garth Blackler
- Department of Microbiology and Immunology, The University of Western Ontario, London, ON, Canada
| | - Patrick Lac
- Department of Microbiology and Immunology, The University of Western Ontario, London, ON, Canada.,Current Address: Michael Smith Genome Sciences Centre, BC Cancer Research Centre, Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lillian Barra
- Department of Microbiology and Immunology, The University of Western Ontario, London, ON, Canada.,Department of Medicine/Rheumatology, The University of Western Ontario, London, ON, Canada
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Zou Y, Cheung PP, Teoh LK, Chen C, Lahiri M. Sociodemographic factors as determinants of disease, disability and quality of life trajectories in early rheumatoid arthritis: A multi-ethnic inception cohort study. Int J Rheum Dis 2019; 23:55-64. [PMID: 31746145 DOI: 10.1111/1756-185x.13747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aims to describe the association between sociodemographic factors and trajectories of disease, disability and health-related quality of life (HRQoL) in early rheumatoid arthritis (ERA). METHODS Data were collected prospectively over 3 years in the Singapore Early Arthritis Cohort study. Trajectories were modeled using multi-trajectory group-based trajectory modeling (GBTM) and determinants of trajectory membership were identified using multinomial logistic regression. RESULTS Two hundred and thirteen patients were included: 58.2% Chinese, 16.4% Malay, 21.6% Indian, mean (SD) age 51.3 (12.6) years and symptom duration 21.8 (15.3) weeks. In the multi-trajectory analysis, three groups of disease trajectories and corresponding disability and HRQoL trajectories were identified: group 1 (moderate disease rapid response, 49.9%), group 2 (high disease rapid response, 31.1%) and group 3 (high disease slow response, 19.1%). Malay patients had higher relative risk ratio (RRR) of being in trajectory groups 2 and 3 compared to group 1 (RRR = 2.30, 95% CI 1.05-3.98 and RRR = 4.02, 95% CI 1.45-6.43, respectively) while patients with tertiary education had lower relative risk (RRR = 0.56, 95% CI 0.45-0.89 and RRR = 0.33, (95% CI 0.14-0.83, respectively). In the analysis of individual outcomes, ethnicity, education level and body mass index were determinants of the heterogeneous disease activity trajectories. Gender and education level were determinants of the disability trajectories. Only gender was a determinant of the HRQoL trajectories. Further, 96.2% of the patients were treated with conventional synthetic disease-modifying antirheumatic drugs. CONCLUSION Disparities in sociodemographic factors should be taken into consideration in formulating treatment strategies in ERA.
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Affiliation(s)
- Yuhan Zou
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Peter P Cheung
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore.,Division of Rheumatology, University Medicine Cluster, National University Hospital, Singapore City, Singapore
| | - Lay Kheng Teoh
- Division of Rheumatology, University Medicine Cluster, National University Hospital, Singapore City, Singapore
| | - Cynthia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore City, Singapore
| | - Manjari Lahiri
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore.,Division of Rheumatology, University Medicine Cluster, National University Hospital, Singapore City, Singapore
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20
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Carpenter L, Barnett R, Mahendran P, Nikiphorou E, Gwinnutt J, Verstappen S, Scott DL, Norton S. Secular changes in functional disability, pain, fatigue and mental well-being in early rheumatoid arthritis. A longitudinal meta-analysis. Semin Arthritis Rheum 2019; 50:209-219. [PMID: 31521376 DOI: 10.1016/j.semarthrit.2019.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/09/2019] [Accepted: 08/21/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To conduct a systematic review and longitudinal meta-analysis of early rheumatoid arthritis (RA) cohorts with long-term data on pain, fatigue or mental well-being. METHODS Searches using PUBMED, EMBASE and PyscInfo were performed to identify all early RA cohorts with longitudinal measures of pain, fatigue or mental well-being, along with clinical measures. Using longitudinal meta-analyses, the progression of each outcome over the first 60-months was estimated. Cohorts were stratified based on the median recruitment year to investigate secular trends in disease progression. RESULTS Of 7,319 papers identified, 75 met the inclusion criteria and 46 cohorts from 41 publications provided sufficient data on 18,046 patients for meta-analysis. The Disease Activity Scores (DAS28) and the Short-Form 36 (SF-36) Physical Component Score (PCS) indicated that post-2002 cohorts had statistically significant improvements over the first 60-months compared to pre-2002 cohorts, with standardised mean differences (SMD) of 0.86 (95% Confidence Intervals 0.34 to 1.37) and 0.76 (95% CI 0.25 to 1.27) respectively at month-60. However, post-2002 cohorts indicated statistically non-significant improvements in pain, fatigue, functional disability and SF-36 Mental Component Score (MCS) compared to pre-2002 cohorts, with SMD of 0.24 (95% CI -0.25 to 0.74), 0.38 (95% CI -0.11 to 0.88), 0.34 (95% CI -0.15-0.84) and -0.08 (95% CI -0.41 to 0.58) at month-60 respectively. CONCLUSIONS Recent cohorts indicate improved levels of disease activity and physical quality of life, however this has not translated into similar improvements in levels of pain, fatigue and functional disability by 60-months.
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Affiliation(s)
- L Carpenter
- Health Psychology Section, King's College London, London, United Kingdom.
| | - R Barnett
- Health Psychology Section, King's College London, London, United Kingdom
| | - P Mahendran
- Health Psychology Section, King's College London, London, United Kingdom
| | - E Nikiphorou
- Department of Inflammation Biology, King's College London, London, United Kingdom
| | - J Gwinnutt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - S Verstappen
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom; NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - D L Scott
- Department of Inflammation Biology, King's College London, London, United Kingdom
| | - S Norton
- Health Psychology Section, King's College London, London, United Kingdom; Department of Inflammation Biology, King's College London, London, United Kingdom
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21
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Bykerk VP. Low-dose Glucocorticoid Use Does Not Reduce Biologic Use in Early RA, Nor Do Biologics Reduce the Need for Glucocorticoids. J Rheumatol 2019; 46:331-332. [PMID: 30936221 DOI: 10.3899/jrheum.181262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Vivian P Bykerk
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA.
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22
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McWilliams DF, Dawson O, Young A, Kiely PDW, Ferguson E, Walsh DA. Discrete Trajectories of Resolving and Persistent Pain in People With Rheumatoid Arthritis Despite Undergoing Treatment for Inflammation: Results From Three UK Cohorts. THE JOURNAL OF PAIN 2019; 20:716-727. [PMID: 30658176 DOI: 10.1016/j.jpain.2019.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/06/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022]
Abstract
Rheumatoid arthritis (RA) is an example of human chronic inflammatory pain. Modern treatments suppress inflammation, yet pain remains a major problem for many people with RA. We hypothesized that discrete RA subgroups might display favorable or unfavorable pain trajectories when receiving treatment, and that baseline characteristics will predict trajectory allocation. Growth mixture modelling was used to identify discrete trajectories of Short Form-36 bodily pain scores during 3 years in 3 RA cohorts (Early RA Network (n = 683), British Society for Rheumatology Biologics Register Biologics (n = 7,090) and nonbiologics (n = 1,720) cohorts. Logistic regression compared baseline predictor variables between trajectories. The role of inflammation was examined in a subgroup analysis of people with normal levels of inflammatory markers after 3 years. The mean Short Form-36 bodily pain scores in each cohort improved but remained throughout 3 years of follow-up of >1 standard deviation worse than the UK general population average. Discrete persistent pain (59-79% of cohort participants) and resolving pain (19-27%) trajectories were identified in each cohort. In Early RA Network, a third trajectory displaying persistently low pain (23%) was also identified. In people with normal levels of inflammatory markers after 3 years, 65% were found to follow a persistent pain trajectory. When trajectories were compared, greater disability (adjusted odds ratio = 2.3-2.5 per unit baseline Health Assessment Questionnaire score) and smoking history (adjusted odds ratio = 1.6-1.8) were risk factors for persistent pain trajectories in each cohort. In conclusion, distinct trajectories indicate patient subgroups with very different pain prognosis during treatment for RA. Inflammation does not fully explain the pain trajectories, and noninflammatory factors as well as acute phase response predict which trajectory an individual will follow. Targeted treatments additional to those which suppress inflammation might reduce the long-term burden of arthritis pain. PERSPECTIVE: Immunosuppression decreases inflammation in RA, but pain outcomes are less favorable. Discrete persistent and resolving pain trajectories were identified after treatment, both in early and established RA. Smoking and greater disability at baseline predicted persistent pain. Identifying patient subgroups with a poor pain prognosis could enable adjunctive treatment to improve outcomes.
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Affiliation(s)
- Daniel F McWilliams
- Arthritis Research UK Pain Centre and NIHR Nottingham Biomedical Research Centre, and; Division of ROD, University of Nottingham, Nottingham, UK.
| | - Olivia Dawson
- Arthritis Research UK Pain Centre and NIHR Nottingham Biomedical Research Centre, and; Division of ROD, University of Nottingham, Nottingham, UK
| | - Adam Young
- Centre for Health Services & Clinical Research (CHSCR) & Postgraduate Medicine, University of Herts, Hatfield, UK
| | - Patrick D W Kiely
- Department of Rheumatology, St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Eamonn Ferguson
- Arthritis Research UK Pain Centre and NIHR Nottingham Biomedical Research Centre, and; School of Psychology, University of Nottingham, Nottingham, UK
| | - David A Walsh
- Arthritis Research UK Pain Centre and NIHR Nottingham Biomedical Research Centre, and; Division of ROD, University of Nottingham, Nottingham, UK; Department of Rheumatology, Sherwood Forest Hospitals NHS Foundation Trust, Sutton in Ashfield, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK
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23
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Schulman E, Bartlett SJ, Schieir O, Andersen KM, Boire G, Pope JE, Hitchon C, Jamal S, Thorne JC, Tin D, Keystone EC, Haraoui B, Goodman SM, Bykerk VP. Overweight, Obesity, and the Likelihood of Achieving Sustained Remission in Early Rheumatoid Arthritis: Results From a Multicenter Prospective Cohort Study. Arthritis Care Res (Hoboken) 2018; 70:1185-1191. [PMID: 29193840 DOI: 10.1002/acr.23457] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 10/17/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Obesity is implicated in rheumatoid arthritis (RA) development, severity, outcomes, and treatment response. We estimated the independent effects of overweight and obesity on ability to achieve sustained remission (sREM) in the 3 years following RA diagnosis. METHODS Data were from the Canadian Early Arthritis Cohort, a multicenter observational trial of early RA patients treated by rheumatologists using guideline-based care. sREM was defined as Disease Activity Score in 28 joints (DAS28) <2.6 for 2 consecutive visits. Patients were stratified by body mass index (BMI) as healthy (18.5-24.9 kg/m2 ), overweight (25-29.9 kg/m2 ), and obese (≥30 kg/m2 ). Cox regression was used to estimate the effect of the BMI category on the probability of achieving sREM over the first 3 years, controlling for age, sex, race, education, RA duration, smoking status, comorbidities, baseline DAS28, Health Assessment Questionnaire disability index, C-reactive protein level, and initial treatment. RESULTS Of 982 patients, 315 (32%) had a healthy BMI, 343 (35%) were overweight, and 324 (33%) were obese; 355 (36%) achieved sREM within 3 years. Initial treatment did not differ by BMI category. Compared to healthy BMI, overweight patients (hazard ratio [HR] 0.75 [95% confidence interval (95% CI) 0.58-0.98]) and obese patients (HR 0.53 [95% CI 0.39-0.71]) were significantly less likely to achieve sREM. CONCLUSION Rates of overweight and obesity were high (69%) in this early RA cohort. Overweight patients were 25% less likely, and obese patients were 47% less likely, to achieve sREM in the first 3 years, despite similar initial disease-modifying antirheumatic drug treatment and subsequent biologic use. This is the largest study demonstrating the negative impact of excess weight on RA disease activity and supports a call to action to better identify and address this risk in RA patients.
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Affiliation(s)
- Elizabeth Schulman
- Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | | | | | - Kathleen M Andersen
- Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Gilles Boire
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Janet E Pope
- St. Joseph's Health Care London, University of Western Ontario, London, Ontario, Canada
| | | | - Shahin Jamal
- University of British Columbia, Vancouver, British Columbia, Canada
| | - J Carter Thorne
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Diane Tin
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Edward C Keystone
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Susan M Goodman
- Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Vivian P Bykerk
- Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, and Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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24
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James RJE, Walsh DA, Ferguson E. General and disease-specific pain trajectories as predictors of social and political outcomes in arthritis and cancer. BMC Med 2018; 16:51. [PMID: 29628016 PMCID: PMC5890349 DOI: 10.1186/s12916-018-1031-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/28/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND While the heterogeniety of pain progression has been studied in chronic diseases, the extent to which patterns of pain progression among people in general as well as across different diseases affect social, civic and political engagement is unclear. We explore these issues for the first time. METHODS Using data from the English Longitudinal Study of Ageing, latent class growth models were used to estimate trajectories of self-reported pain in the entire cohort, and within subsamples reporting diagnoses of arthritis and cancer. These were compared at baseline on physical health (e.g. body mass index, smoking) and over time on social, civic and political engagement. RESULTS Very similar four-trajectory models fit the whole sample and arthritis subsamples, whereas a three-trajectory model fit the cancer subsample. All samples had a modal group experiencing minimal chronic pain and a group with high chronic pain that showed slight regression (more pronounced in cancer). Biometric indices were more predictive of the most painful trajectory in arthritis than cancer. In both samples the group experiencing the most pain at baseline reported impairments in social, civic and political engagement. CONCLUSIONS The impact of pain differs between individuals and between diseases. Indicators of physical and psychological health differently predicted membership of the trajectories most affected by pain. These trajectories were associated with differences in engagement with social and civic life, which in turn were associated with poorer health and well-being.
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Affiliation(s)
- Richard J E James
- School of Psychology, University of Nottingham, University Park, Nottingham, NG7 2RD, UK. .,Arthritis UK Pain Centre and NIHR Nottingham Biomedical Research Centre, Academic Rheumatology, City Hospital, Nottingham, NG5 1PB, UK.
| | - David A Walsh
- Arthritis UK Pain Centre and NIHR Nottingham Biomedical Research Centre, Academic Rheumatology, City Hospital, Nottingham, NG5 1PB, UK
| | - Eamonn Ferguson
- School of Psychology, University of Nottingham, University Park, Nottingham, NG7 2RD, UK.,Arthritis UK Pain Centre and NIHR Nottingham Biomedical Research Centre, Academic Rheumatology, City Hospital, Nottingham, NG5 1PB, UK
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25
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Lim LSH, Pullenayegum E, Feldman BM, Lim L, Gladman DD, Silverman ED. From Childhood to Adulthood: Disease Activity Trajectories in Childhood-Onset Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2018; 70:750-757. [DOI: 10.1002/acr.23319] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 07/11/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Lily Siok Hoon Lim
- University of Manitoba, Winnipeg, Manitoba, Canada; and Institute of Health Policy Management & Evaluation; Toronto Ontario Canada
| | | | - Brian M. Feldman
- The Hospital for Sick Children (SickKids); Toronto Ontario Canada
| | - Lillian Lim
- The Hospital for Sick Children (SickKids); Toronto Ontario Canada
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26
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Wabe N, Wojciechowski J, Wechalekar MD, Cleland LG, McWilliams L, Lee A, Proudman S, Wiese MD. Disease activity trajectories in early rheumatoid arthritis following intensive DMARD therapy over 3 years: association with persistence to therapy. Int J Rheum Dis 2017; 20:1447-1456. [PMID: 28952204 DOI: 10.1111/1756-185x.13184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To identify the disease activity trajectories during intensive triple disease modifying anti-rheumatic drug (DMARD) therapy over 3 years in rheumatoid arthritis (RA) patients and to evaluate the association with treatment persistence. METHODS Disease Activity Score in 28 joints, baseline risk factors and medication usage were obtained from a longitudinal observational cohort of early RA patients, most of whom were treated with combination DMARD therapy consisting of methotrexate, sulfasalazine and hydroxychloroquine. Persistence of each DMARD was defined as the duration of time from initiation to cessation. A group-based trajectory modelling technique was used to identify disease activity trajectories. RESULT Three disease activity trajectories (good [43.8%], moderate [39.7%] and poor [16.5%]) were identified in a cohort of 297 patients. Most baseline risk factors, medication usage, the rate of treatment persistence and the effect of persistence on disease activity differed among patients in each of the three trajectories. Although the rate of persistence was higher in the trajectory with a good outcome, the association with persistence was more pronounced among patients who were in the poor outcome trajectory. Persistence with at least two or all three baseline DMARDs was associated with a decrease in disease activity to a broadly similar degree in all trajectories. CONCLUSION After correction for other baseline prognostic factors, persistence with initial DMARDs contributes to heterogeneity in disease activity trajectory and there was an association between persistence with initial DMARD therapy and lower long-term disease activity.
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Affiliation(s)
- Nasir Wabe
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia
| | - Jessica Wojciechowski
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia.,Australian Centre for Pharmacometrics, University of South Australia, Adelaide, South Australia, Australia
| | - Mihir D Wechalekar
- Rheumatology Unit, Repatriation General Hospital, Adelaide, South Australia, Australia
| | - Leslie G Cleland
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Leah McWilliams
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Anita Lee
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael D Wiese
- School of Pharmacy and Medical Sciences and Sansom Institute for Health Research, Adelaide, South Australia, Australia
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28
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Adherence to combination DMARD therapy and treatment outcomes in rheumatoid arthritis: a longitudinal study of new and existing DMARD users. Rheumatol Int 2017; 37:897-904. [PMID: 28160071 DOI: 10.1007/s00296-017-3655-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
Medication adherence is believed to be a major contributor to treatment outcomes yet studies quantifying this relationship as rare in rheumatoid arthritis (RA). To determine the association of adherence to DMARD therapy with treatment outcomes among new and existing DMARD users over 2 years. Relevant clinical parameters were obtained from a longitudinal cohort of RA patients, most of who were treated with combination therapy. Patients were classified as adherent if the proportion of days covered for each DMARD was ≥80%. Outcome measures were the change in the disease activity score in 28 joints (DAS28), simplified disease activity index (SDAI), modified health assessment questionnaires (mHAQ) and proportion of patients who achieved response criteria. An inverse propensity-score weighting method was used to estimate the association of adherence with each outcome. Of 194 patients invited, a total of 111 patients (new = 45 and existing = 66 DMARD users) met study eligibility. DMARD-naive patients demonstrated relatively higher rates of adherence compared to existing users. After controlling for confounding variables, adherence was significantly associated with reduction in DAS28 (β = -1.5, 95% CI of β = - 2.17 to -0.83, p < 0.0001), SDAI (β = -9.44, 95% CI of β = -15.53 to -3.35, p = 0.002) and mHAQ (β = -0.269, 95% CI of β, -0.462 to -0.077, p = 0.017) over 2 years among new patients and adherent patients were more likely to achieve most response criteria compared to non-adherent patients. Such associations were not replicated among existing DMARD users. Adherence to combination DMARD therapy was associated with improvements in disease activity and functional outcomes in the first 2 years of therapy.
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Courvoisier DS, Alpizar-Rodriguez D, Gottenberg JE, Hernandez MV, Iannone F, Lie E, Santos MJ, Pavelka K, Turesson C, Mariette X, Choquette D, Hetland ML, Finckh A. Rheumatoid Arthritis Patients after Initiation of a New Biologic Agent: Trajectories of Disease Activity in a Large Multinational Cohort Study. EBioMedicine 2016; 11:302-306. [PMID: 27558858 PMCID: PMC5049989 DOI: 10.1016/j.ebiom.2016.08.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/15/2016] [Accepted: 08/16/2016] [Indexed: 12/25/2022] Open
Abstract
Background Response to disease modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA) is often heterogeneous. We aimed to identify types of disease activity trajectories following the initiation of a new biologic DMARD (bDMARD). Methods Pooled analysis of nine national registries of patients with diagnosis of RA, who initiated Abatacept and had at least two measures of disease activity (DAS28). We used growth mixture models to identify groups of patients with similar courses of treatment response, and examined these patients' characteristics and effectiveness outcomes. Findings We identified three types of treatment response trajectories: ‘gradual responders’ (GR; 3576 patients, 91·7%) had a baseline mean DAS28 of 4·1 and progressive improvement over time; ‘rapid responders’ (RR; 219 patients, 5·6%) had higher baseline DAS28 and rapid improvement in disease activity; ‘inadequate responders’ (IR; 103 patients, 2·6%) had high DAS28 at baseline (5·1) and progressive worsening in disease activity. They were similar in baseline characteristics. Drug discontinuation for ineffectiveness was shorter among inadequate responders (p = 0.03), and EULAR good or moderate responses at 1 year was much higher among ‘rapid responders’ (p < 0.001). Interpretation Clinical information and baseline clinical characteristics do not allow a reliable prediction of which trajectory the patients will follow after bDMARD initiation. This study examined disease activity trajectories in a multinational cohort of 3898 rheumatoid arthritis patients. Growth mixture models identified three groups: gradual, rapid, and inadequate responders (GR: 91·7%, RR: 5·6%, IR: 2·6%). At baseline, groups were similar in demographic and clinical characteristics, and moderately different in function and disease activity. The groups had large difference in drug retention and in good or moderate response rate. Using nine national registries, this study of 3898 established RA patients initiating a new bDMARD identified distinct types of responders: gradual, rapid and inadequate responders. Neither socio-demographic nor clinical characteristics at baseline allowed the prediction of the type of response trajectory after treatment initiation, but effectiveness outcomes strongly differed, suggesting that these empirically derived subgroups have clinical relevance. As a major aim of precision medicine is to make anti-rheumatic therapy more personalized, the detection of responder types following initiation of a specific bDMARD underscores the need to find reliable predictors of trajectories to identify patients needing a distinct treatment strategy.
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Affiliation(s)
| | | | | | | | - F Iannone
- Rheumatology Unit, University Hospital, Bari, Italy
| | - E Lie
- Diakonhjemmet Hospital, Oslo, Norway
| | - M J Santos
- Rheumatology Research Unit, Instituto de Medicina Molecular, Lisbon, Portugal
| | - K Pavelka
- Institute of Rheumatology, Prague, Czech Republic
| | - C Turesson
- Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden; Department of Rheumatology, Skåne University Hospital, Malmö, Sweden
| | - X Mariette
- Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, France
| | - D Choquette
- Institut de Rhumatologie de Montréal, CHUM, Canada
| | - M L Hetland
- The DANBIO registry Rigshospitalet, Glostrup, University of Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - A Finckh
- University Hospitals Geneva, Switzerland
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