1
|
Pappas DA, Brittle C, Concoff A, Holman AJ, Takasugi D, Kremer JM. Perspectives on applying immuno-autonomics to rheumatoid arthritis: results from an online rheumatologist survey. Rheumatol Int 2022; 42:1555-1564. [PMID: 35449236 PMCID: PMC9349152 DOI: 10.1007/s00296-022-05122-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/19/2022] [Indexed: 11/16/2022]
Abstract
The term “immuno-autonomics” has been coined to describe an emerging field evaluating the interaction between stress, autonomic nervous system (ANS), and inflammation. The field remains largely unknown among practicing rheumatologists. Our objective was to evaluate the perspectives of rheumatologists regarding the role of stress in the activity and management of rheumatoid arthritis (RA). A 31-item survey was conducted with 231 rheumatologists. Rheumatologists were asked to assess the role of stress in rheumatoid arthritis (RA) disease activity and were provided with information regarding immuno-autonomics. They were asked to consider how immuno-autonomics resonated with their patient management needs. The majority of rheumatologists are eager to better understand non-response, believe that stress biology and ANS dysfunction interfere with disease activity, and embrace the theory that measurement of ANS via next-generation HRV may be able to evaluate autonomic dysfunction and the biology of stress. Rheumatologists are open to the idea that quantitative measurement of ANS function using next-generation HRV can be a helpful tool to RA practice. The majority agree that ANS state influences RA disease control and that quantitative measures of ANS state are helpful to RA practice. Rheumatologists also agree that patients with poor ANS function may be at risk for not responding adequately to conventional, biologic, or targeted synthetic DMARDs. Almost all would use an in-office test to quantitatively measure ANS using next-generation HRV. This study shows that rheumatologists are open to embracing evaluation of ANS function as a possible tool in the management and treatment of RA.
Collapse
Affiliation(s)
- Dimitrios A Pappas
- CorEvitas LLC, Waltham, MA, USA. .,Corrona Research Foundation, Waltham, MA, USA.
| | | | | | - Andrew J Holman
- Inmedix Inc., Normandy Park, WA, USA.,Pacific Rheumatology Associates, Inc. PS, Seattle, WA, USA
| | | | | |
Collapse
|
2
|
Holman AJ, Keystone E, Choy E, Furst D, Taylor P, Gaylis N. Considering Immuno-autonomics in Stratifying Successful Treatment of Rheumatoid Arthritis with Tumor Necrosis Factor Inhibition: Comment on Cohen et al. Rheumatol Ther 2021 June 19. Rheumatol Ther 2021; 9:305-307. [PMID: 34757532 PMCID: PMC8814136 DOI: 10.1007/s40744-021-00386-w] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/12/2021] [Indexed: 10/28/2022] Open
Affiliation(s)
| | - Edward Keystone
- Department of Medicine, Keystone Consulting Enterprises Inc, University of Toronto, Toronto, Canada
| | - Ernest Choy
- Division of Infection and Immunity, Arthritis Research UK CREATE Centre and Welsh Arthritis Research Network (WARN), Cardiff University School of Medicine, Cardiff, UK
| | - Daniel Furst
- University of California in Los Angeles Academy, Los Angeles, CA, USA
| | - Peter Taylor
- Botnar Research Centre, University of Oxford, Oxford, UK
| | - Norman Gaylis
- Arthritis and Rheumatic Disease Specialties, Aventura, FL, USA
| |
Collapse
|
3
|
Martinez-Lavin M, Holman AJ. Heart rate variability analysis in rheumatology: past, present… and future? Clin Exp Rheumatol 2021; 39:927-930. [DOI: 10.55563/clinexprheumatol/nmvth1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022]
|
4
|
Holman AJ. Immuno-Autonomics as a Complement to Precision Medicine Guiding Treatment of Patients With Rheumatoid Arthritis: Comment on the Article by Tao et al. Arthritis Rheumatol 2021; 73:1945-1946. [PMID: 33982899 DOI: 10.1002/art.41782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/19/2021] [Indexed: 11/06/2022]
|
5
|
Taylor PC, Holman AJ. Rheumatoid arthritis and the emergence of immuno-autonomics. Rheumatology (Oxford) 2019; 58:2079-2080. [PMID: 31177267 DOI: 10.1093/rheumatology/kez216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Peter C Taylor
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Holman
- Division of Rheumatology, University of Washington, Seattle, USA and Inmedix, Inc and Inmedix UK Ltd
| |
Collapse
|
6
|
Zimmermann M, Vodicka E, Holman AJ, Garrison LP. Heart rate variability testing: could it change spending for rheumatoid arthritis patients in the United States? An exploratory economic analysis. J Med Econ 2018; 21:712-720. [PMID: 29701508 DOI: 10.1080/13696998.2018.1470519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Autonomic nervous system (ANS) testing with heart rate variability (HRV) has been shown in early research to predict 52-week outcomes in rheumatoid arthritis (RA). HRV testing could be combined with putative ANS biologic pathways to improve treatment response for RA patients. This study explored potential costs and health outcomes of introducing HRV testing into RA treatment, without and with ANS optimization. METHODS A decision tree exploratory economic model compared HRV testing to standard care in moderate-to-severe biologic-eligible patients over a 10-year time horizon. HRV data was derived from an observational study of RA patients (n = 33). Patients were stratified into treatment groups based on HRV test scores indicating "low probability of response" and "moderate to high probability of response". This study explored adding ANS optimization based on HRV score followed by clinically-appropriate treatment. Costs and quality-adjusted life-years (QALYs) for the US population were estimated. RESULTS HRV testing in biologic-eligible patients decreased non-effective biologic use, reducing US healthcare costs by $34.6 billion over 10 years with QALYs unchanged. When combined with ANS optimization in biologic-eligible patients, HRV testing could increase costs by $3.6 billion over 10 years but save over 350,000 QALYs. Among all RA patients, HRV testing with ANS optimization could save over $8 billion and over 100,000 QALYs over 10 years, depending on the positive predictive value (PPV) of the HRV test. CONCLUSIONS The potential economic impact of introducing HRV testing and ANS optimization into RA treatment appears substantial and cost-effective based on the exploratory analysis. Additional rigorous studies are warranted in larger patient samples to better inform decision-making.
Collapse
|
7
|
Holman AJ, Ng E. 224 Quantified impact of autonomic nervous system state onimmunotherapy treatment outcome in rheumatoid arthritis. Rheumatology (Oxford) 2018. [DOI: 10.1093/rheumatology/key075.448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Edmund Ng
- Biostatistics, Edmund Ng Statistical Consulting LLC, Seattle, WA, USA
| |
Collapse
|
8
|
Abstract
Fibromyalgia remains one of the most common and enigmatic musculoskeletal disorders among patients with pain and, until recently, few effective treatments have been discovered. This review will briefly consider the rationale supporting traditional treatment options and their efficacy, including the role of exercise and pharmacotherapy. Juxtaposed with these common approaches to relieve fibromyalgia pain and fatigue are the promising new medications that are being developed, such as pregabalin, milnacipran, duloxetine, sodium oxybate, ropinirole and pramipexole. Outcomes from recent randomized trials will be reviewed and compared.
Collapse
Affiliation(s)
- Andrew J Holman
- Pacific Rheumatology Associates Inc., PS 4300, Talbot Road South, Suite 101, Renton, Washington, USA.
| |
Collapse
|
9
|
Holman AJ, Neradilek MB, Dryland DD, Neiman RA, Brown PB, Ettlinger RE. Patient-derived determinants for participation in placebo-controlled clinical trials for fibromyalgia. Curr Pain Headache Rep 2011; 14:470-6. [PMID: 20953741 DOI: 10.1007/s11916-010-0152-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Perspectives of patients with fibromyalgia influence their likelihood of participating in randomized placebo-controlled trials and potentially clash with current, well-established methodology of randomized controlled trial design. Mandates to use only acetaminophen for breakthrough pain and that require discontinuation of concomitant medications, especially in studies lacking an active comparator arm, could bias a trial cohort to thereby reduce the generalizability of study findings and conclusions. This study evaluates factors affecting willingness to participate in such clinical trials, including the impact of altruism, payment, study duration, forced discontinuation of specific medications, and subject demographics for patients seen by rheumatologists proficient and avidly interested in treating fibromyalgia.
Collapse
Affiliation(s)
- Andrew J Holman
- Pacific Rheumatology Research, 4300 Talbot Road South, Renton, WA 98055, USA.
| | | | | | | | | | | |
Collapse
|
10
|
Holman AJ. Pregabalin as treatment for fibromyalgia: the rest of the story? Curr Pain Headache Rep 2009; 13:420-2. [PMID: 19889281 DOI: 10.1007/s11916-009-0079-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Andrew J Holman
- Department of Internal Medicine/Rheumatology, University of Washington School of Medicine, WA, USA.
| |
Collapse
|
11
|
Holman AJ. Assessing patients with fibromyalgia from a rheumatologist’s perspective: a three-step methodology for differential diagnosis. ACTA ACUST UNITED AC 2009. [DOI: 10.2217/ijr.09.31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
12
|
Abstract
A flurry of recent randomized, placebo-controlled trials assessing dissimilar pharmacotherapeutic treatment options for fibromyalgia (FM) have been presented in the past few years. This review evaluates these trials in light of recent pathophysiological concepts germane to FM, including mood disorders, autonomic dysregulation, altered sleep stage architecture, and the diagnostic tender point controversy. Studies with gabapentin, pregabalin, duloxetine, milnacipran, sodium oxybate, and pramipexole for treatment of FM are discussed.
Collapse
|
13
|
Holman AJ. An alternative, autonomic rationale for decreased risk of myocardial infarction in patients with rheumatoid arthritis responsive to anti-tumor necrosis factor therapy: comment on the article by Dixon et al. Arthritis Rheum 2008; 58:1886; author reply 1886. [PMID: 18512805 DOI: 10.1002/art.23511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
|
14
|
Abstract
Fibromyalgia is a common disorder that is characterized by chronic widespread pain, tenderness to light palpation, fatigue and sleep disturbances. The present lack of a well-accepted model of the disorder has hampered progress towards adequate treatment. A review of potential models to explain the pathophysiology underlying its primary symptom (i.e., chronic widespread pain) lends insight on the therapeutic potential of novel therapies. Following this, a mechanistic evaluation of those medications that are under consideration for the treatment of the disorder is offered. Adequate treatment will be likely to involve the identification of biologic subgroups within the greater fibromyalgia construct. Key insights from basic research are the basis for increased optimism for effective relief among patients and clinicians.
Collapse
Affiliation(s)
- Patrick B Wood
- Louisiana State University Health Sciences Center--Shreveport, Department of Family Medicine, Shreveport, LA 71130, USA.
| | | | | |
Collapse
|
15
|
Holman AJ. Considering cardiovascular mortality in patients with rheumatoid arthritis from a different perspective: a role for autonomic dysregulation and obstructive sleep apnea. J Rheumatol 2007; 34:671-3. [PMID: 17407228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
|
16
|
Holman AJ, Myers RR. A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. ACTA ACUST UNITED AC 2005; 52:2495-505. [PMID: 16052595 DOI: 10.1002/art.21191] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of pramipexole, a dopamine 3 receptor agonist, in patients with fibromyalgia. METHODS In this 14-week, single-center, double-blind, placebo-controlled, parallel-group, escalating-dose trial, 60 patients with fibromyalgia were randomized 2:1 (pramipexole:placebo) to receive 4.5 mg of pramipexole or placebo orally every evening. The primary outcome was improvement in the pain score (10-cm visual analog scale [VAS]) at 14 weeks. Secondary outcome measures were the Fibromyalgia Impact Questionnaire (FIQ), the Multidimensional Health Assessment Questionnaire (MDHAQ), the pain improvement scale, the tender point score, the 17-question Hamilton Depression Inventory (HAM-d), and the Beck Anxiety Index (BAI). Patients with comorbidities and disability were not excluded. Stable dosages of concomitant medications, including analgesics, were allowed. RESULTS Compared with the placebo group, patients receiving pramipexole experienced gradual and more significant improvement in measures of pain, fatigue, function, and global status. At 14 weeks, the VAS pain score decreased 36% in the pramipexole arm and 9% in the placebo arm (treatment difference -1.77 cm). Forty-two percent of patients receiving pramipexole and 14% of those receiving placebo achieved > or =50% decrease in pain. Secondary outcomes favoring pramipexole over placebo included the total FIQ score (treatment difference -9.57) and the percentages of improvement in function (22% versus 0%), fatigue (29% versus 7%), and global (38% versus 3%) scores on the MDHAQ. Compared with baseline, some outcomes showed a better trend for pramipexole treatment than for placebo, but failed to reach statistical significance, including improvement in the tender point score (51% versus 36%) and decreases in the MDHAQ psychiatric score (37% versus 28%), the BAI score (39% versus 27%), and the HAM-d score (29% versus 9%). No end points showed a better trend for the placebo arm. The most common adverse events associated with pramipexole were transient anxiety and weight loss. No patient withdrew from the study because of inefficacy or an adverse event related to pramipexole. CONCLUSION In a subset of patients with fibromyalgia, approximately 50% of whom required narcotic analgesia and/or were disabled, treatment with pramipexole improved scores on assessments of pain, fatigue, function, and global status, and was safe and well-tolerated.
Collapse
Affiliation(s)
- Andrew J Holman
- Pacific Rheumatology Associates, Renton, Washington 98055, USA.
| | | |
Collapse
|
17
|
Holman AJ. Fibromyalgia and pramipexole: promise and precaution. J Rheumatol 2003; 30:2733. [PMID: 14719231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
|
18
|
|
19
|
Holman AJ. The value of rheumatologists to patients with fibromyalgia: comment on the presidential address by Weinblatt. Arthritis Rheum 2002; 46:3390; author reply 3390. [PMID: 12483749 DOI: 10.1002/art.10569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
20
|
Holman AJ. Is hypermobility a factor in fibromyalgia? J Rheumatol 2002; 29:396-8. [PMID: 11838864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
|
21
|
Holman AJ, Gardner GC, Richardson ML, Simkin PA. Quantitative magnetic resonance imaging predicts clinical outcome of core decompression for osteonecrosis of the femoral head. J Rheumatol 1995; 22:1929-33. [PMID: 8991993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether the course of femoral head osteonecrosis after core decompression can be predicted from the extent of necrotic bone in the preoperative magnetic resonance imaging (MRI). METHODS In 31 femoral head lesions (Ficat stage I or II), the percentage volume of necrotic bone was calculated by dividing the sum of the necrotic areas from all MRI slices by the sum of the femoral head areas. Osteonecrosis risk factors, pain scores, and the need for further surgery were assessed at a minimum of 12 mo post-core decompression. Clinical outcomes were considered good when post-core decompression pain scores improved and further surgery was not required. RESULTS Fourteen of the 15 hips with good outcomes after a mean followup of 32 mo had less than 21% femoral head involvement. All 16 hips with poor outcomes after a mean followup of 17 mo had more than 21% of the femoral head affected. CONCLUSION Quantitative MRI of femoral head necrosis was a useful predictor of clinical outcome following core decompression.
Collapse
Affiliation(s)
- A J Holman
- Department of Medicine, University of Washington, Seattle 98195, USA
| | | | | | | |
Collapse
|
22
|
Affiliation(s)
- V Mukerji
- Department of Medicine, University of Missouri Health Sciences Center, Columbia 65212
| | | | | |
Collapse
|
23
|
Abstract
To determine the importance of traditional risk factors for coronary artery disease (CAD) in the elderly, the authors studied 64 consecutive patients with angiographically normal or near-normal coronary arteries and 64 patients with CAD. All patients were greater than or equal to sixty years old. The risk factors studied were male sex, hypertension, diabetes mellitus, hypercholesterolemia, cigarette smoking, sedentary life-style, and family history. The prevalence of these risk factors in the two groups of patients was compared. The results suggest that in persons greater than or equal to 60 years old, male sex and cigarette smoking continue to remain risk factors for CAD. Since most of the patients with diabetes and hypertension were on medical management for their condition, the authors' findings also suggest that diabetes mellitus, even under treatment, remains an important risk factor for CAD in the elderly but controlled hypertension does not. Other traditional risk factors (hypercholesterolemia, sedentary life-style, and family history) do not discriminate individuals with moderate to severe CAD from those with normal or near-normal coronary arteries in persons greater than or equal to sixty years old.
Collapse
Affiliation(s)
- V Mukerji
- Department of Medicine, University of Missouri Health Sciences Center, Columbia
| | | | | | | | | |
Collapse
|
24
|
Depaolis AM, Britt TE, Holman AJ, McGonigle EJ, Kaplan G, Davies WC. Determination of meclocycline, a tetracycline analogue, in cream formulations by liquid chromatography. J Pharm Sci 1984; 73:1650-1. [PMID: 6520775 DOI: 10.1002/jps.2600731143] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A rapid and sensitive high-performance liquid chromatographic quantitation of meclocycline (I) in a cream formulation is described. The acidified methanolic extract of the sample was diluted with mobile phase and analyzed on a reverse-phase column by using a mobile phase consisting of EDTA buffer (pH 6.6)-tetrahydrofuran (85:15 v/v). The method gave linear, quantitative, and reproducible results with a detection limit of 0.4 ppm for meclocycline.
Collapse
|