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Suzuki T, Ohshima M, Suzuki A. Magnetic resonance imaging including bone erosion may be useful for predicting disease flares in patients with rheumatoid arthritis: A hypothesis. Int J Rheum Dis 2023; 26:2559-2562. [PMID: 37847067 DOI: 10.1111/1756-185x.14941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 09/06/2023] [Accepted: 10/01/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Takeshi Suzuki
- Department of Rheumatology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Miho Ohshima
- Department of Rheumatology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Akitake Suzuki
- Department of Rheumatology, Mitsui Memorial Hospital, Tokyo, Japan
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Affiliation(s)
- Ellen M Gravallese
- From the Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston (E.M.G.); and the Division of Rheumatology, Allergy, and Immunology, University of California at San Diego School of Medicine, La Jolla (G.S.F.)
| | - Gary S Firestein
- From the Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston (E.M.G.); and the Division of Rheumatology, Allergy, and Immunology, University of California at San Diego School of Medicine, La Jolla (G.S.F.)
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D'Onofrio B, van der Helm-van Mil A, W J Huizinga T, van Mulligen E. Inducibility or predestination? Queries and concepts around drug-free remission in rheumatoid arthritis. Expert Rev Clin Immunol 2023; 19:217-225. [PMID: 36511619 DOI: 10.1080/1744666x.2023.2157814] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Drug-free remission (DFR) and its maintenance have been defined as the most desirable outcome for rheumatoid arthritis (RA) patients. DFR is linked to resolution of arthritis-related symptoms and restoration of normal functioning. However, there is currently no consensus if an optimal strategy, upon the initiation of treatment to the proper drugs withdrawal, is enough to induce it, or whether it is a predetermined condition related to patients' intrinsic characteristics. AREAS COVERED This review focuses on two key concepts around DFR. First, we analyze patients' intrinsic factors that may increase the chance of DFR, regardless of therapeutic choices. Second, we discuss on the evidence that it can be induced thanks to adequate, extrinsic disease management. Finally, we provide a glimpse into consequences of drugs discontinuation. EXPERT OPINION The early initiation of DMARD and the subsequent strict monitoring and drug adjustments are of primary importance to allow patients to achieve DFR, irrespective of initial treatment strategy. Once remission is obtained and maintained, it is possible to gradually taper and discontinue drugs with no dramatic consequences on the disease course. Among those who stop medication, ACPA-negative patients more often maintain the remission. Thus, DFR might depend on a combination of intrinsic and extrinsic factors.
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Affiliation(s)
- Bernardo D'Onofrio
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Elise van Mulligen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Labinsky H, Ukalovic D, Hartmann F, Runft V, Wichmann A, Jakubcik J, Gambel K, Otani K, Morf H, Taubmann J, Fagni F, Kleyer A, Simon D, Schett G, Reichert M, Knitza J. An AI-Powered Clinical Decision Support System to Predict Flares in Rheumatoid Arthritis: A Pilot Study. Diagnostics (Basel) 2023; 13:diagnostics13010148. [PMID: 36611439 PMCID: PMC9818406 DOI: 10.3390/diagnostics13010148] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/11/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Treat-to-target (T2T) is a main therapeutic strategy in rheumatology; however, patients and rheumatologists currently have little support in making the best treatment decision. Clinical decision support systems (CDSSs) could offer this support. The aim of this study was to investigate the accuracy, effectiveness, usability, and acceptance of such a CDSS-Rheuma Care Manager (RCM)-including an artificial intelligence (AI)-powered flare risk prediction tool to support the management of rheumatoid arthritis (RA). Longitudinal clinical routine data of RA patients were used to develop and test the RCM. Based on ten real-world patient vignettes, five physicians were asked to assess patients' flare risk, provide a treatment decision, and assess their decision confidence without and with access to the RCM for predicting flare risk. RCM usability and acceptance were assessed using the system usability scale (SUS) and net promoter score (NPS). The flare prediction tool reached a sensitivity of 72%, a specificity of 76%, and an AUROC of 0.80. Perceived flare risk and treatment decisions varied largely between physicians. Having access to the flare risk prediction feature numerically increased decision confidence (3.5/5 to 3.7/5), reduced deviations between physicians and the prediction tool (20% to 12% for half dosage flare prediction), and resulted in more treatment reductions (42% to 50% vs. 20%). RCM usability (SUS) was rated as good (82/100) and was well accepted (mean NPS score 7/10). CDSS usage could support physicians by decreasing assessment deviations and increasing treatment decision confidence.
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Affiliation(s)
- Hannah Labinsky
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | | | - Fabian Hartmann
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | | | | | | | - Kira Gambel
- Siemens Healthineers, 91502 Erlangen, Germany
| | | | - Harriet Morf
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Jule Taubmann
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Filippo Fagni
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Arnd Kleyer
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - David Simon
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | | | - Johannes Knitza
- Department of Internal Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie, Friedrich-Alexander University Erlangen-Nürnberg and Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Correspondence:
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Abstract
With the arrival of biologics and the shift toward treat-to-target therapy, the possibility of a sustained clinical response has become an achievable goal for many patients with rheumatoid arthritis (RA). Although biologics have revolutionized the treatment of RA, they are costly, potentially inconvenient, and carry risks of side effects. Whether they can or should be tapered in patients with tight disease control is a matter of clinical uncertainty. The major international rheumatology professional societies have all issued guidelines on this question, but across recommendations, consensus is lacking on how and when to consider therapy de-escalation. Recent evidence suggests that sustained remission or low disease activity is more attainable with dose reduction as opposed to outright discontinuation of biologic therapy, and certain predictors of successful taper have begun to be described. This article will (1) summarize the current evidence base for biologic tapering in RA, (2) outline real-world outcomes findings, (3) review important contextual factors relevant to therapy de-escalation, such as cost-effectiveness considerations and patient perspectives, and (4) conclude by summarizing current guidelines.
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Affiliation(s)
- Genna Braverman
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA; Department of Medicine, Division of Rheumatology, Weill Cornell Medicine, New York, NY, USA.
| | - S Louis Bridges
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA; Department of Medicine, Division of Rheumatology, Weill Cornell Medicine, New York, NY, USA
| | - Larry W Moreland
- Department of Medicine, Division of Rheumatology, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO, USA
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Verstappen M, van der Helm-van Mil AHM. Sustained DMARD-free remission in rheumatoid arthritis - about concepts and moving towards practice. Joint Bone Spine 2022; 89:105418. [PMID: 35636705 PMCID: PMC7615888 DOI: 10.1016/j.jbspin.2022.105418] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
Abstract
Sustained DMARD-free remission (SDFR) is the best possible outcome in RA. It is characterized by sustained absence of clinical arthritis, which is accompanied by resolution of symptoms and restoration of normal physical functioning. Therefore it's the best proxy for cure in RA. The mechanisms underlying SDFR-development are yet unidentified. Hypothetically, there are two possible scenarios. The first hypothesis is based on the concept of regaining immune-tolerance, which implies that RA-patients are similar at diagnosis and that disease-processes during the disease-course shift into a favorable direction, resulting in regaining a state in which arthritis is persistently absent. This could imply that SDFR is theoretically achievable for all RA-patients. The alternative hypothesis is that RA-patients who achieve SDFR are intrinsically different from those who cannot. This would imply that DMARD-cessation could be restricted to a subgroup of RA-patients. Since the 1990s, DMARD-discontinuation and SDFR have been increasingly studied as long-term-outcome in RA. In this review, we describe hitherto results of clinical, genetic, serological, histological and imaging studies and looked for arguments for the first or second hypothesis in both auto-antibody-positive and auto-antibody-negative RA. In auto-antibody-negative RA, SDFR is presumably restricted to a subgroup of patients with high serological-markers of inflammation at diagnosis and a rapid and sustained decrease in inflammation after treatment-start. Identifying these RA-patients could be helpful in realizing personalized-medicine. In auto-antibody-positive RA, only few patients achieve SDFR and no definite conclusions can be drawn, but data could suggest that SDFR-patients might be a subgroup with relatively low inflammation from disease-presentation onwards.
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Affiliation(s)
- Marloes Verstappen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands; Department of Rheumatology, Erasmus Medical Centre, Rotterdam, The Netherlands
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