1
|
Komiya T, Takase-Minegishi K, Sakurai N, Nagai H, Hamada N, Soejima Y, Sugiyama Y, Tsuchida N, Kunishita Y, Kishimoto D, Kobayashi K, Kamiyama R, Yoshimi R, Kirino Y, Ohno S, Nakajima H. Dose down-titration of biological disease-modifying antirheumatic drugs in daily clinical practice: Shared decision-making and patient treatment preferences in Japanese patients with rheumatoid arthritis. Int J Rheum Dis 2019; 22:2009-2016. [PMID: 31515933 DOI: 10.1111/1756-185x.13692] [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: 06/26/2019] [Revised: 08/05/2019] [Accepted: 08/13/2019] [Indexed: 11/28/2022]
Abstract
AIM To determine characteristics of rheumatoid arthritis (RA) patients in Japan who received the same biological disease-modifying antirheumatic drugs (bDMARDs) for at least 6 months and to identify factors associated with successful down-titration of bDMARDs dependent on shared decision-making. METHODS We included consecutive RA patients who received the same bDMARD with low disease activity or remission for at least 6 months in our two university hospitals. Patients treated with the bDMARD standard dose were defined as SD, while those treated with bDMARD down-titration were defined as DT. We retrospectively reviewed clinical charts and compared data between the two groups. RESULTS Of 288 patients with RA, 204 (70.8%) and 84 (29.2%) continued standard dose treatment and underwent down-titration treatment, respectively. Sixty-six of 84 (78.6%) down-titration-treated patients continued to show low disease activity or remission, whereas 18 (21.4%) relapsed 18.9 ± 24.4 months after bDMARD down-titration was started. Univariate predictor analysis showed that the probable factors of down-titration were no history of bDMARD treatment (P = .001) and low initial Disease Activity Assessment of 28 joint score (P = .048). Other clinical characteristics had no significant relationship with successful down-titration. CONCLUSIONS Thus, bDMARD-naïve patients and those with low initial disease activity are more likely to agree to attempt down-titration. However, the timing and method of down-titration should be made in shared decision-making between patients and rheumatologists.
Collapse
Affiliation(s)
- Takaaki Komiya
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kaoru Takase-Minegishi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Natsuki Sakurai
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideto Nagai
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Naoki Hamada
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yutaro Soejima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yumiko Sugiyama
- Center for Rheumatic Diseases, Yokohama City University Medical Center, Yokohama, Japan
| | - Naomi Tsuchida
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yosuke Kunishita
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Daiga Kishimoto
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kouji Kobayashi
- Center for Rheumatic Diseases, Yokohama City University Medical Center, Yokohama, Japan
| | - Reikou Kamiyama
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shigeru Ohno
- Center for Rheumatic Diseases, Yokohama City University Medical Center, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| |
Collapse
|
2
|
Simpson E, Hock E, Stevenson M, Wong R, Dracup N, Wailoo A, Conaghan P, Estrach C, Edwards C, Wakefield R. What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-258. [PMID: 29712616 PMCID: PMC5949573 DOI: 10.3310/hta22200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US). OBJECTIVE To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness. DATA SOURCES Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015. REVIEW METHODS A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken. MATHEMATICAL MODEL A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated. RESULTS Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used. LIMITATIONS Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed. CONCLUSION Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017216. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Philip Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
| | - Cristina Estrach
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christopher Edwards
- National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| | - Richard Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
| |
Collapse
|
3
|
Yoshimi R, Takeno M, Toyota Y, Tsuchida N, Sugiyama Y, Kunishita Y, Kishimoto D, Kamiyama R, Minegishi K, Hama M, Kirino Y, Ishigatsubo Y, Ohno S, Ueda A, Nakajima H. On-demand ultrasonography assessment in the most symptomatic joint supports the 8-joint score system for management of rheumatoid arthritis patients. Mod Rheumatol 2016; 27:257-265. [PMID: 27409294 DOI: 10.1080/14397595.2016.1206173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To investigate whether on-demand ultrasonography (US) assessment alongside a routine examination is useful in the management of rheumatoid arthritis (RA). METHODS US was performed in eight (bilateral MCP 2, 3, wrist and knee) joints as the routine in a cumulative total of 406 RA patients. The most symptomatic joint other than the routine joints was additionally scanned. Power Doppler (PD) and gray-scale images were scored semiquantitatively. Eight-joint scores were calculated as the sum of individual scores for the routine joints. RESULTS The most symptomatic joint was found among the routine joints in 209 patients (Group A) and in other joints in 148 (Group B). The PD scores of the most symptomatic joint correlated well with the 8-joint scores in Group A (rs = 0.66), but not in Group B (rs = 0.33). The sensitivity and specificity of assessment of the most symptomatic joint for routine assessment positivity were high (84.0% and 100%, respectively) in Group A, but low (50.0% and 61.8%, respectively) in Group B. Additional examination detected synovitis in 38% of Group B with negative results in the routine. CONCLUSIONS On-demand US assessment in the most symptomatic joint, combined with the routine assessment, is useful for detecting RA synovitis.
Collapse
Affiliation(s)
- Ryusuke Yoshimi
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Mitsuhiro Takeno
- b Department of Allergy and Rheumatology , Nippon Medical School Graduate School of Medicine , Tokyo , Japan , and
| | - Yukihiro Toyota
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Naomi Tsuchida
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Yumiko Sugiyama
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Yosuke Kunishita
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Daiga Kishimoto
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Reikou Kamiyama
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Kaoru Minegishi
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Maasa Hama
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Yohei Kirino
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Yoshiaki Ishigatsubo
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Shigeru Ohno
- c Center for Rheumatic Disease, Yokohama City University Medical Center , Yokohama , Japan
| | - Atsuhisa Ueda
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| | - Hideaki Nakajima
- a Department of Hematology and Clinical Immunology , Yokohama City University School of Medicine , Yokohama , Japan
| |
Collapse
|
4
|
Ikeda K, Narita A, Ogasawara M, Ohno S, Kawahito Y, Kawakami A, Ito H, Matsushita I, Suzuki T, Misaki K, Ogura T, Kamishima T, Seto Y, Nakahara R, Kaneko A, Nakamura T, Henmi M, Fukae J, Nishida K, Sumida T, Koike T. Consensus-based identification of factors related to false-positives in ultrasound scanning of synovitis and tenosynovitis. Mod Rheumatol 2015; 26:9-14. [PMID: 26382930 DOI: 10.3109/14397595.2015.1091123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION We aimed to identify causes of false-positives in ultrasound scanning of synovial/tenosynovial/bursal inflammation and provide corresponding imaging examples. METHODS We first performed systematic literature review to identify previously reported causes of false-positives. We next determined causes of false-positives and corresponding example images for educational material through Delphi exercises and discussion by 15 experts who were an instructor and/or a lecturer in the 2013 advanced course for musculoskeletal ultrasound organized by Japan College of Rheumatology Committee for the Standardization of Musculoskeletal Ultrasonography. RESULTS Systematic literature review identified 11 articles relevant to sonographic false-positives of synovial/tenosynovial inflammation. Based on these studies, 21 candidate causes of false-positives were identified in the consensus meeting. Of these items, 11 achieved a predefined consensus (≥ 80%) in Delphi exercise and were classified as follows: (I) Gray-scale assessment [(A) non-specific synovial findings and (B) normal anatomical structures which can mimic synovial lesions due to either their low echogenicity or anisotropy]; (II) Doppler assessment [(A) Intra-articular normal vessels and (B) reverberation)]. Twenty-four corresponding examples with 49 still and 23 video images also achieved consensus. CONCLUSIONS Our study provides a set of representative images that can help sonographers to understand false-positives in ultrasound scanning of synovitis and tenosynovitis.
Collapse
Affiliation(s)
- Kei Ikeda
- a Department of Allergy and Clinical Immunology , Chiba University Hospital , Chiba , Japan
| | - Akihiro Narita
- b Hokkaido Medical Center for Rheumatic Diseases , Sapporo , Japan
| | - Michihiro Ogasawara
- c Department of Internal Medicine and Rheumatology , Juntendo University Faculty of Medicine , Tokyo , Japan
| | - Shigeru Ohno
- d Center for Rheumatic Diseases, Yokohama City University Medical Center , Yokohama , Japan
| | - Yutaka Kawahito
- e Department of Inflammation and Immunology , Kyoto Prefectural University of Medicine , Kyoto , Japan
| | - Atsushi Kawakami
- f Unit of Translational Medicine, Department of Immunology and Rheumatology , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Hiromu Ito
- g Department of Orthopaedic Surgery , Kyoto University Graduate School of Medicine , Kyoto , Japan
| | - Isao Matsushita
- h Department of Orthopaedic Surgery , University of Toyama , Toyama , Japan
| | - Takeshi Suzuki
- i Division of Allergy and Rheumatology , Japanese Red Cross Medical Center , Tokyo , Japan
| | - Kenta Misaki
- j Department of Endocrinology and Rheumatology , Kurashiki Central Hospital , Kurashiki , Okayama , Japan
| | - Takehisa Ogura
- k Division of Rheumatology , Toho University Ohashi Medical Center , Tokyo , Japan
| | | | - Yohei Seto
- m Department of Rheumatology , Tokyo Women's Medical University Yachiyo Medical Center , Yachiyo , Chiba , Japan
| | - Ryuichi Nakahara
- n Department of Human Morphology , Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine , Okayama , Japan
| | - Atsushi Kaneko
- o Department of Orthopaedic Surgery and Rheumatology , Nagoya Medical Center, National Hospital Organization , Nagoya , Japan
| | - Takayuki Nakamura
- a Department of Allergy and Clinical Immunology , Chiba University Hospital , Chiba , Japan
| | - Mihoko Henmi
- b Hokkaido Medical Center for Rheumatic Diseases , Sapporo , Japan
| | - Jun Fukae
- b Hokkaido Medical Center for Rheumatic Diseases , Sapporo , Japan
| | - Keiichiro Nishida
- n Department of Human Morphology , Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine , Okayama , Japan
| | - Takayuki Sumida
- p Department of Internal Medicine , Faculty of Medicine, University of Tsukuba , Tsukuba , Japan , and
| | - Takao Koike
- q NTT Sapporo Medical Center , Sapporo , Japan
| |
Collapse
|
5
|
Kirino Y, Hama M, Takase-Minegishi K, Kunishita Y, Kishimoto D, Yoshimi R, Asami Y, Ihata A, Oba MS, Tsunoda S, Ohno S, Ueda A, Takeno M, Ishigatsubo Y. Predicting joint destruction in rheumatoid arthritis with power Doppler, anti-citrullinated peptide antibody, and joint swelling. Mod Rheumatol 2015; 25:842-8. [PMID: 25736364 DOI: 10.3109/14397595.2015.1026025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine combined evaluation of musculoskeletal ultrasonography (MSUS) and power Doppler (PD) signals, anti-citrullinated peptide antibody (ACPA), and other clinical findings improve the prediction of joint destruction in rheumatoid arthritis (RA). METHODS We performed a retrospective study of 331 RA patients (female n = 280 and male n = 51, mean age: 57.9 ± 13.2 years) who underwent MSUS from 2002 to 2012. Correlations with progression of joint destructions in 1,308 2nd and 3rd metacarpophalangeal (MCP) joints and various factors including PD signals of the same joints, clinical findings, age, disease duration at the study entry, gender, observation period, radiographic bone scores according to modified Sharp-van der Heijde methods, ACPA, and rheumatoid factor (RF) were analyzed in patient- and joint-based fashions, using univariate and multivariate logistic regression analyses and generalized linear mixed model. RESULTS Patients' characteristics were as follows: mean disease duration: 5.7 ± 7.5 years, observation period: 4.6 ± 2.6 years, RF positivity: 79.9%, and ACPA positivity: 77.5%. PD-positive 2nd and 3rd joints showed higher rate of joint destruction, especially in ACPA-positive patients. Moreover, PD-positive joints in ACPA-positive patients showed joint destruction even in joints without swelling. Multivariate analysis determined PD, swollen joint (SJ), observation period, basal radiographic bone scores, and ACPA as independent risks for joint destruction. CONCLUSION PD, SJ, basal radiographic bone scores, and ACPA are independent predictors for the joint destruction of 2nd and 3rd MCPs in RA; thus, considering these factors would be useful in daily practice.
Collapse
Affiliation(s)
- Yohei Kirino
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Maasa Hama
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Kaoru Takase-Minegishi
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Yosuke Kunishita
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Daiga Kishimoto
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Ryusuke Yoshimi
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Yukiko Asami
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Atsushi Ihata
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan.,b Department of Rheumatology and Infectious disease , Minami Kyosai Hospital, Yokohama Minami Kyosai Hospital , Yokohama, Kanagawa , Japan
| | - Mari S Oba
- c Department of Biostatistics and Epidemiology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Shinichiro Tsunoda
- d Division of Rheumatology, Department of Internal Medicine , Hyogo College of Medicine , Nishinomiya, Hyogo , Japan
| | - Shigeru Ohno
- e Center for Rheumatic diseases, Yokohama City University Medical Center , Yokohama, Kanagawa , Japan
| | - Atsuhisa Ueda
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Mitsuhiro Takeno
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| | - Yoshiaki Ishigatsubo
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Kanagawa , Japan
| |
Collapse
|
6
|
Yoshimi R, Ihata A, Kunishita Y, Kishimoto D, Kamiyama R, Minegishi K, Hama M, Kirino Y, Asami Y, Ohno S, Ueda A, Takeno M, Ishigatsubo Y. A novel 8-joint ultrasound score is useful in daily practice for rheumatoid arthritis. Mod Rheumatol 2014; 25:379-85. [DOI: 10.3109/14397595.2014.974305] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|