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Michelsen B, Østergaard M, Nissen MJ, Ciurea A, Möller B, Ørnbjerg LM, Zavada J, Glintborg B, MacDonald A, Laas K, Nordström D, Gudbjornsson B, Iannone F, Hellmand P, Kvien TK, Rodrigues AM, Codreanu C, Rotar Z, Castrejón Fernández I, Wallman JK, Vencovsky J, Loft AG, Heddle M, Vorobjov S, Hokkanen AM, Gröndal G, Sebastiani M, van de Sande M, Kristianslund EK, Santos MJ, Mogosan C, Tomsic M, Díaz-González F, Di Giuseppe D, Hetland ML. Differences and similarities between the EULAR/ASAS-EULAR and national recommendations for treatment of patients with psoriatic arthritis and axial spondyloarthritis across Europe. Lancet Reg Health Eur 2023; 33:100706. [PMID: 37601339 PMCID: PMC10432193 DOI: 10.1016/j.lanepe.2023.100706] [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] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/06/2023] [Accepted: 07/14/2023] [Indexed: 08/22/2023]
Abstract
This is the first report comparing EULAR and national treatment recommendations for PsA patients across Europe, and the first this decade to compare ASAS-EULAR and national treatment recommendations in axSpA patients. An electronic survey was completed from October 2021-April 2022 by rheumatologists in 15 European countries. One and four countries followed all EULAR and ASAS-EULAR recommendations, respectively. Five countries had no national treatment recommendations for PsA and/or axSpA, but followed other regulations. In several countries, national treatment recommendations predated the most recent EULAR/ASAS-EULAR recommendations. Entry criteria for starting biologic/targeted synthetic disease-modifying anti-rheumatic drugs varied considerably. In several countries, for PsA patients with significant skin involvement, interleukin-17 inhibitors were not given preference. The positioning of Janus Kinase inhibitors differed and Phosphodiesterase-4 inhibitors were not in use/reimbursed in most countries. This study may motivate European countries to update their national treatment recommendations, to align them better with the latest international recommendations.
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Affiliation(s)
- Brigitte Michelsen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
- Research Unit, Sørlandet Hospital, Kristiansand, Norway
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Adrian Ciurea
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Burkhard Möller
- Department of Rheumatology and Immunology, Inselspital - University Hospital Bern, Switzerland
| | - Lykke Midtbøll Ørnbjerg
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Jakub Zavada
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Bente Glintborg
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | | | - Karin Laas
- Department of Rheumatology, East-Tallinn Central Hospital, Tallinn, Estonia
| | - Dan Nordström
- Departments of Medicine and Rheumatology, Helsinki University Hospital, Helsinki, Finland
| | - Bjorn Gudbjornsson
- Centre for Rheumatology Research, Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Pasoon Hellmand
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Tore Kristian Kvien
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Ana Maria Rodrigues
- Reuma.pt, Sociedade Portuguesa de Reumatologia, Lisbon, Portugal
- EpiDoC Unit, Nova Medical School, Lisbon, Portugal
- Rheumatology Unit, Hospital dos Lusíadas, Lisbon, Portugal
| | - Catalin Codreanu
- Center for Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Ziga Rotar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, Universitiy of Ljubljana, Ljubljana, Slovenia
| | - Isabel Castrejón Fernández
- Department of Rheumatology, Hospital General, Universitario Gregorio Marañón, Madrid, Spain
- Faculty of Medicine, Complutense University of Madrid, Spain
| | - Johan Karlsson Wallman
- Department of Clinical Sciences Lund, Rheumatology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jiri Vencovsky
- Institute of Rheumatology, Prague, Czech Republic
- Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maureen Heddle
- Aberdeen Centre for Arthritis and Musculoskeletal Health (Epidemiology Group), University of Aberdeen, UK
| | | | - Anna-Mari Hokkanen
- Department of Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Gerdur Gröndal
- Centre for Rheumatology Research, Landspitali University Hospital, Reykjavik, Iceland
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Marleen van de Sande
- Department of Rheumatology & Clinical Immunology and Department of Experimental Immunology, Amsterdam UMC, University of Amsterdam, Amsterdam Institute for Infection & Immunity, Amsterdam, the Netherlands
- Amsterdam Rheumatology and Immunology Center (ARC), Amsterdam, the Netherlands
| | - Eirik Klami Kristianslund
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Maria José Santos
- Department of Rheumatology, Hospital Garcia de Orta, Almada, Portugal
- Instituto Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Corina Mogosan
- Center for Rheumatic Diseases, University of Medicine and Pharmacy, Bucharest, Romania
| | - Matija Tomsic
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, Universitiy of Ljubljana, Ljubljana, Slovenia
| | - Federico Díaz-González
- Department of Internal Medicine, Dermatology and Psychiatry, Universidad de la Laguna, La Laguna, Spain
- Rheumatology Service, Hospital Universitario de Canarias, La Laguna, Spain
| | - Daniela Di Giuseppe
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Hokkanen AM, Aaltonen K, Relas H, Rutanen J, Kononoff A, Taimen K, Kauppi M, Puolakka K, Trokovic N, Nordström D. Impact of TNF inhibitor medication on working ability in axial spondyloarthritis: an observational national registry-based cohort study. Rheumatol Adv Pract 2023; 7:rkad050. [PMID: 37332300 PMCID: PMC10272299 DOI: 10.1093/rap/rkad050] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/03/2023] [Indexed: 06/20/2023] Open
Abstract
Objective The aim was to investigate the effect of TNF inhibitor (TNFi) initiation on working ability and health-care resource utilization among axial SpA patients in a real-life setting. Methods Patients with a clinical diagnosis of non-radiographic (nr-axSpA) or radiographic axial SpA initiating their first TNFi were identified from the National Register for Antirheumatic and Biologic Treatment in Finland. Sickness absences, including sick leave and disability pension, in- and outpatient days and rehabilitation rates, 1 year before and after initiating the medication were retrieved from national registries. Factors affecting result variables were studied using multivariate regression analysis. Results Overall, 787 patients were identified. Rates of work disability days per year were 55.6 the year before treatment onset and 55.2 the year after, with significant differences between patient subgroups. The rate of sick leave decreased after starting TNFi treatment. However, the rate of disability pension continued to rise. Patients with a diagnosis of nr-axSpA experienced a decrease in overall work disability and, especially, fewer sick leaves. No sex differences were detected. Conclusion TNFi interrupts the increase in work disabled days evident during the year before its initiation. However, the overall work disability remains high. Treating patients earlier in the nr-axSpA phase, regardless of sex, appears important in maintaining the ability to work.
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Affiliation(s)
- Anna-Mari Hokkanen
- Correspondence to: Anna-Mari Hokkanen, ROB-FIN Register, Division of Rheumatology, Helsinki University Hospital, Keskussairaalankatu 7, 15850 Lahti, Finland. E-mail:
| | - Kalle Aaltonen
- Pharmaceuticals Pricing Board, Ministry of Social Affairs and Health, Helsinki, Finland
| | - Heikki Relas
- Division of Rheumatology, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - Jarno Rutanen
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
- Centre for Rheumatic Diseases, Tampere University Hospital, Tampere, Finland
| | | | - Kirsi Taimen
- Division of Medicine, Turku University Hospital, Turku, Finland
| | - Markku Kauppi
- Division of Rheumatology, Päijät-Häme Central Hospital, Lahti, Finland
- Division of Rheumatology, Helsinki University, Helsinki, Finland
| | - Kari Puolakka
- Helsinki Rheumatic Diseases and Inflammation Research Group, University of Helsinki, Helsinki, Finland
| | - Nina Trokovic
- ROB-FIN Register, Division of Rheumatology, Helsinki University Hospital, Helsinki, Finland
| | - Dan Nordström
- ROB-FIN Register, Division of Rheumatology, Helsinki University Hospital, Helsinki, Finland
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Glintborg B, Di Giuseppe D, Wallman JK, Provan SA, Nordström D, Hokkanen AM, Österlund J, Kristianslund E, Kvien TK, Gudbjornsson B, Hetland ML, Michelsen B, Jacobsson L, Askling J, Lindström U. Is the risk of infection higher during treatment with secukinumab than with TNF inhibitors? An observational study from the Nordic countries. Rheumatology (Oxford) 2023; 62:647-658. [PMID: 35723604 PMCID: PMC9891432 DOI: 10.1093/rheumatology/keac358] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES The positioning of secukinumab in the treatment of axial SpA (axSpA) and PsA is debated, partly due to a limited understanding of the comparative safety of the available treatments. We aimed to assess the risk of the key safety outcome infections during treatment with secukinumab and TNF inhibitors (TNFi). METHODS Patients with SpA and PsA starting secukinumab or TNFi year 2015 through 2018 were identified in four Nordic rheumatology registers. The first hospitalized infection during the first year of treatment was identified through linkage to national registers. Incidence rates (IRs) with 95% CIs per 100 patient-years were calculated. Adjusted hazard ratios were estimated through Cox regression, with secukinumab as the reference. Several sensitivity analyses were performed to investigate confounding by indication. RESULTS Among 7708 patients with SpA and 5760 patients with PsA, we identified 16 229 treatment courses of TNFi (53% bionaïve) and 1948 with secukinumab (11% bionaïve). For secukinumab, the first-year risk of hospitalized infection was 3.5% (IR 5.0; 3.9-6.3), compared with 1.7% (IR 2.3; 1.7-3.0) during 3201 courses with adalimumab, with the IRs for other TNFi lying in between these values. The adjusted HR for adalimumab, compared with secukinumab, was 0.58 (0.39-0.85). In sensitivity analyses, the difference from secukinumab was somewhat attenuated and in some analyses no longer statistically significant. CONCLUSION When used according to clinical practice in the Nordic countries, the observed first-year absolute risk of hospitalized infection was doubled for secukinumab compared with adalimumab. This excess risk seemed largely explained by confounding by indication.
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Affiliation(s)
| | | | - Johan K Wallman
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Skane University Hospital, Lund, Sweden
| | - Sella A Provan
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Dan Nordström
- Department of Medicine and Rheumatology, Helsinki University and Helsinki University Hospital, Helsinki
| | | | - Jenny Österlund
- Division of Medicine, Helsinki University, Helsinki, Finland
| | | | - Tore K Kvien
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Bjorn Gudbjornsson
- Centre for Rheumatology Research, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Glostrup
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Brigitte Michelsen
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
- Division of Rheumatology, Department of Medicine, Hospital of Southern Norway Trust, Kristiansand, Norway
| | - Lennart Jacobsson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm
| | - Ulf Lindström
- Correspondence to: Ulf Lindström, Department of Rheumatology and Inflammation Research, University of Gothenburg, Box 115, Gothenburg, Sweden. E-mail:
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Michelsen B, Lindström U, Codreanu C, Ciurea A, Zavada J, Loft AG, Pombo-Suarez M, Onen F, Kvien TK, Rotar Z, Santos MJ, Iannone F, Hokkanen AM, Gudbjornsson B, Askling J, Ionescu R, Nissen MJ, Pavelka K, Sanchez-Piedra C, Akar S, Sexton J, Tomsic M, Santos H, Sebastiani M, Österlund J, Geirsson AJ, Macfarlane G, van der Horst-Bruinsma I, Georgiadis S, Brahe CH, Ørnbjerg LM, Hetland ML, Østergaard M. Drug retention, inactive disease and response rates in 1860 patients with axial spondyloarthritis initiating secukinumab treatment: routine care data from 13 registries in the EuroSpA collaboration. RMD Open 2021; 6:rmdopen-2020-001280. [PMID: 32950963 PMCID: PMC7539854 DOI: 10.1136/rmdopen-2020-001280] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [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: 04/20/2020] [Revised: 07/02/2020] [Accepted: 08/21/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To explore 6-month and 12-month secukinumab effectiveness in patients with axial spondyloarthritis (axSpA) overall, as well as across (1) number of previous biologic/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), (2) time since diagnosis and (3) different European registries. METHODS Real-life data from 13 European registries participating in the European Spondyloarthritis Research Collaboration Network were pooled. Kaplan-Meier with log-rank test, Cox regression, χ² and logistic regression analyses were performed to assess 6-month and 12-month secukinumab retention, inactive disease/low-disease-activity states (Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) <2/<4, Ankylosing Spondylitis Disease Activity Score (ASDAS) <1.3/<2.1) and response rates (BASDAI50, Assessment of Spondyloarthritis International Society (ASAS) 20/40, ASDAS clinically important improvement (ASDAS-CII) and ASDAS major improvement (ASDAS-MI)). RESULTS We included 1860 patients initiating secukinumab as part of routine care. Overall 6-month/12-month secukinumab retention rates were 82%/72%, with significant (p<0.001) differences between the registries (6-month: 70-93%, 12-month: 53-86%) and across number of previous b/tsDMARDs (b/tsDMARD-naïve: 90%/73%, 1 prior b/tsDMARD: 83%/73%, ≥2 prior b/tsDMARDs: 78%/66%). Overall 6-month/12-month BASDAI<4 were observed in 51%/51%, ASDAS<1.3 in 9%/11%, BASDAI50 in 53%/47%, ASAS40 in 28%/22%, ASDAS-CII in 49%/46% and ASDAS-MI in 25%/26% of the patients. All rates differed significantly across number of previous b/tsDMARDs, were numerically higher for b/tsDMARD-naïve patients and varied significantly across registries. Overall, time since diagnosis was not associated with secukinumab effectiveness. CONCLUSIONS In this study of 1860 patients from 13 European countries, we present the first comprehensive real-life data on effectiveness of secukinumab in patients with axSpA. Overall, secukinumab retention rates after 6 and 12 months of treatment were high. Secukinumab effectiveness was consistently better for bionaïve patients, independent of time since diagnosis and differed across the European countries.
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Affiliation(s)
- Brigitte Michelsen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet Glostrup, Copenhagen, Denmark .,Division of Rheumatology, Department of Medicine, Hospital of Southern Norway Trust, Kristiansand, Norway.,Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Ulf Lindström
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catalin Codreanu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Bucharest, Romania
| | - Adrian Ciurea
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Jakub Zavada
- Institute of Rheumatology, Prague, Czech Republic
| | - Anne Gitte Loft
- DANBIO Registry, Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet Glostrup, Copenhagen, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Manuel Pombo-Suarez
- Rheumatology Service, Hospital Clinico Universitario, Santiago De Compostela, Spain
| | - Fatos Onen
- TURKBIO Registry, Division of Rheumatology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Ziga Rotar
- biorx.si and the Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Maria Jose Santos
- Reuma.pt Registry and Instituto De Medicina Molecular, Faculdade De Medicina, Universidade De Lisboa, Lisboa, Lisboa, Portugal
| | - Florenzo Iannone
- GISEA Registry, Rheumatology Unit - DETO, University of Bari, Bari, Italy
| | - Anna-Mari Hokkanen
- ROB-FIN Registry, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Bjorn Gudbjornsson
- Centre for Rheumatology Research (ICEBIO), University Hospital and Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ruxandra Ionescu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Bucharest, Romania
| | - Michael J Nissen
- Department of Rheumatology, Geneva University Hospital, Geneve, Switzerland
| | - Karel Pavelka
- Institute of Rheumatology and Department of Rheumatology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Servet Akar
- Department of Rheumatology, Izmir Kâtip Çelebi University, Izmir, Turkey
| | - Joseph Sexton
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Matija Tomsic
- biorx.si and the Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Helena Santos
- Reuma.pt registry and Instituto Português de Reumatologia, Lisbon, Portugal
| | - Marco Sebastiani
- Rheumatology Unit, CHIMOMO, Azienda Policlinico of Modena, University of Modena, Modena, Italy
| | - Jenny Österlund
- ROB-FIN Registry, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Arni Jon Geirsson
- Department of Rheumatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Gary Macfarlane
- Epidemiology Group, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Irene van der Horst-Bruinsma
- Amsterdam University Medical Centres, VU University Medical Centre, Department Rheumatology & Immunology Center (ARC), Amsterdam, Netherlands
| | - Stylianos Georgiadis
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet Glostrup, Copenhagen, Denmark
| | - Cecilie Heegaard Brahe
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet Glostrup, Copenhagen, Denmark
| | - Lykke Midtbøll Ørnbjerg
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet Glostrup, Copenhagen, Denmark
| | - Merete Lund Hetland
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet Glostrup, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopedics, Rigshospitalet Glostrup, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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