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Kragsnaes MS, Jensen JRB, Nilsson AC, Malik MI, Munk HL, Pedersen JK, Horn HC, Kruhøffer M, Kristiansen K, Mullish BH, Marchesi JR, Kjeldsen J, Röttger R, Ellingsen T. Dynamics of inflammation-associated plasma proteins following faecal microbiota transplantation in patients with psoriatic arthritis and healthy controls: exploratory findings from the FLORA trial. RMD Open 2024; 10:e003750. [PMID: 38296309 PMCID: PMC10836383 DOI: 10.1136/rmdopen-2023-003750] [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: 09/20/2023] [Accepted: 01/04/2024] [Indexed: 02/05/2024] Open
Abstract
OBJECTIVES The gut microbiota can mediate both pro and anti-inflammatory responses. In patients with psoriatic arthritis (PsA), we investigated the impact of faecal microbiota transplantation (FMT), relative to sham transplantation, on 92 inflammation-associated plasma proteins. METHODS This study relates to the FLORA trial cohort, where 31 patients with moderate-to-high peripheral PsA disease activity, despite at least 3 months of methotrexate treatment, were included in a 26-week, double-blind, randomised, sham-controlled trial. Participants were allocated to receive either one gastroscopic-guided healthy donor FMT (n=15) or sham (n=16). Patient plasma samples were collected at baseline, week 4, 12 and 26 while samples from 31 age-matched and sex-matched healthy controls (HC) were collected at baseline. Samples were analysed using proximity extension assay technology (Olink Target-96 Inflammation panel). RESULTS Levels of 26 proteins differed significantly between PsA and HC pre-FMT (adjusted p<0.05), of which 10 proteins were elevated in PsA: IL-6, CCL20, CCL19, CDCP1, FGF-21, HGF, interferon-γ (IFN-γ), IL-18R1, monocyte chemotactic protein 3, and IL-2. In the FMT group, levels of 12 proteins changed significantly across all timepoints (tumour necrosis factor (TNF), CDCP1, IFN-γ, TWEAK, signalling lymphocytic activation molecule (SLAMF1), CD8A, CD5, Flt3L, CCL25, FGF-23, CD6, caspase-8). Significant differences in protein levels between FMT and sham-treated patients were observed for TNF (p=0.002), IFN-γ (p=0.011), stem cell factor (p=0.024), matrix metalloproteinase-1 (p=0.038), and SLAMF1 (p=0.042). FMT had the largest positive effect on IFN-γ, Axin-1 and CCL25 and the largest negative effect on CCL19 and IL-6. CONCLUSIONS Patients with active PsA have a distinct immunological plasma protein signature compared with HC pre-FMT. FMT affects several of these disease markers, including sustained elevation of IFN-γ. TRIAL REGISTRATION NUMBER NCT03058900.
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Affiliation(s)
- Maja Skov Kragsnaes
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Muhammad Irfan Malik
- Department of Mathematics and Computer Science (IMADA), University of Southern Denmark, Odense, Denmark
| | - Heidi Lausten Munk
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Jens Kristian Pedersen
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Karsten Kristiansen
- Department of Biology, Laboratory of Genomics and Molecular Biomedicine, University of Copenhagen, Copenhagen, Denmark
- Institute of Metagenomics, Qingdao-Europe Advanced Institute for Life Sciences, Qingdao, China
| | - Benjamin H Mullish
- Division of Digestive Diseases, Imperial College London Faculty of Medicine, London, UK
- Department of Gastroenterology and Hepatology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Julian R Marchesi
- Division of Digestive Diseases, Imperial College London Faculty of Medicine, London, UK
| | - Jens Kjeldsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Richard Röttger
- Department of Mathematics and Computer Science (IMADA), University of Southern Denmark, Odense, Denmark
| | - Torkell Ellingsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Kragsnaes MS, Miguens Blanco J, Mullish BH, Serrano‐Contreras JI, Kjeldsen J, Horn HC, Pedersen JK, Munk HL, Nilsson AC, Salam A, Lewis MR, Chekmeneva E, Kristiansen K, Marchesi JR, Ellingsen T. Small Intestinal Permeability and Metabolomic Profiles in Feces and Plasma Associate With Clinical Response in Patients With Active Psoriatic Arthritis Participating in a Fecal Microbiota Transplantation Trial: Exploratory Findings From the FLORA Trial. ACR Open Rheumatol 2023; 5:583-593. [PMID: 37736702 PMCID: PMC10642255 DOI: 10.1002/acr2.11604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVE We investigated intestinal permeability and fecal, plasma, and urine metabolomic profiles in methotrexate-treated active psoriatic arthritis (PsA) and how this related to clinical response following one sham or fecal microbiota transplantation (FMT). METHODS This exploratory study is based on the FLORA trial cohort, in which 31 patients with moderate-to-high peripheral PsA disease activity, despite at least 3 months of methotrexate-treatment, were included in a 26-week, double-blind, 1:1 randomized, sham-controlled trial. Participants were randomly allocated to receive either one healthy donor FMT (n = 15) or sham (n = 16) via gastroscopy. The primary trial end point was the proportion of treatment failures through 26 weeks. We performed a lactulose-to-mannitol ratio (LMR) test at baseline (n = 31) and at week 26 (n = 26) to assess small intestinal permeability. Metabolomic profiles in fecal, plasma, and urine samples collected at baseline, weeks 4, 12, and 26 were measured using 1 H Nuclear Magnetic Resonance. RESULTS Trial failures (n = 7) had significantly higher LMR compared with responders (n = 19) at week 26 (0.027 [0.017-0.33]) vs. 0.012 [0-0.064], P = 0.013), indicating increased intestinal permeability. Multivariate analysis revealed a significant model for responders (n = 19) versus failures (n = 12) at all time points based on their fecal (P < 0.0001) and plasma (P = 0.005) metabolomic profiles, whereas urine metabolomic profiles did not differ between groups (P = 1). Fecal N-acetyl glycoprotein GlycA correlated with Health Assessment Questionnaire Disability Index (coefficient = 0.50; P = 0.03) and fecal propionate correlated with American College of Rheumatology 20 response at week 26 (coefficient = 27, P = 0.02). CONCLUSION Intestinal permeability and fecal and plasma metabolomic profiles of patients with PsA were associated with the primary clinical trial end point, failure versus responder.
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Affiliation(s)
| | | | - Benjamin H. Mullish
- Imperial College London and St. Mary's Hospital, Imperial College Healthcare National Health Service TrustLondonUK
| | | | - Jens Kjeldsen
- Odense University Hospital and University of Southern DenmarkOdenseDenmark
| | | | | | | | | | - Ash Salam
- Imperial College London, Hammersmith Hospital CampusLondonUK
| | | | | | - Karsten Kristiansen
- University of Copenhagen, Copenhagen, Denmark, and Institute of Metagenomics, Qingdao‐Europe Advanced Institute for Life SciencesQingdaoChina
| | | | - Torkell Ellingsen
- Odense University Hospital and University of Southern DenmarkOdenseDenmark
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Kragsnaes MS, Kjeldsen J, Horn HC, Munk HL, Pedersen JK, Just SA, Ahlquist P, Davidsen JR, Nilsson AC, Röttger R, Kruhøffer M, Marchesi JR, Kristiansen K, Christensen R, Ellingsen T. Response to: 'Correspondence on 'Safety and efficacy of faecal microbiota transplantation for active peripheral psoriatic arthritis: an exploratory randomised placebo-controlled trial'' by McGonagle et al. Ann Rheum Dis 2023; 82:e165. [PMID: 34158373 DOI: 10.1136/annrheumdis-2021-220910] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Maja Skov Kragsnaes
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jens Kjeldsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Hans Christian Horn
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Heidi Lausten Munk
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Søren Andreas Just
- Section of Rheumatology, Department of Medicine, Svendborg Hospital, Svendborg, Denmark
| | | | - Jesper Rømhild Davidsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- South Danish Center for Interstitial Lung Diseases, Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | | | - Richard Röttger
- Department of Mathematics and Computer Science (IMADA), University of Southern Denmark, Odense, Denmark
| | | | - Julian R Marchesi
- Division of Digestive Diseases, Imperial College London Faculty of Medicine, London, UK
| | - Karsten Kristiansen
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen, Denmark
- Institute of Metagenomics, BGI-Shenzhen, Shenzhen, China
| | - Robin Christensen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Torkell Ellingsen
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Sofíudóttir BK, Harders SMW, Lage-Hansen PR, Christensen R, Munk HL, Sorensen GL, Davidsen JR, Ellingsen T. Using thoracic ultrasound to detect interstitial lung disease in patients with rheumatoid arthritis: a protocol for the diagnostic test accuracy AURORA study. BMJ Open 2022; 12:e067434. [PMID: 36564119 PMCID: PMC9791457 DOI: 10.1136/bmjopen-2022-067434] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Pulmonary diseases are significant contributors to morbidity and mortality in patients with rheumatoid arthritis (RA). RA-associated interstitial lung disease (RA-ILD) may be prevalent in up to 30% and clinically evident in 10% of patients with RA. Feasible methods to detect concomitant ILD in RA are warranted. Our objective is to determine the diagnostic accuracy of thoracic ultrasound (TUS) for ILD in patients with RA with respiratory symptoms, by using chest high-resolution CT (HRCT) as the reference standard. Further, we aim to evaluate the diagnostic accuracy for the promising blood biomarkers surfactant protein-D and microfibrillar-associated protein 4 in the detection of ILD in this group of patients. METHODS AND ANALYSIS By use of a standardised 14 zone protocol patients suspected of having RA-ILD will undergo TUS as index test performed by a junior resident in rheumatology (BKS), who is certified by the European Respiratory Society in performing TUS assessments. Participants form a consecutive series of up to 80 individuals in total. The anonymised TUS images will be stored and scored by the junior resident as well as two senior rheumatologists, who have received training in TUS, and a TUS-experienced pulmonologist. HRCT will be used as the gold standard for ILD diagnosis (reference standard). The two basic measures for quantifying the diagnostic test accuracy of the TUS test are the sensitivity and specificity in comparison to the HRCT. ETHICS AND DISSEMINATION Data will be collected and stored in the Research Electronic Data Capture database. The study is approved by the Committees on Health Research Ethics and the Danish Data Protection Agency. The project is registered at clinicaltrials.gov (NCT05396469, pre-results) and data will be published in peer-reviewed journals.
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Affiliation(s)
- Bjørk Khaliqi Sofíudóttir
- Department of Rheumatology, PUlmo-REuma Clinic OUH (PURE), Odense University Hospital, Odense, Syddanmark, Denmark
- Section for Biostatistics and Evidence-Based Research, Parker Instituttet, Frederiksberg, Hovedstaden, Denmark
| | - Stefan M W Harders
- Department of Radiology, Odense University Hospital, Odense, Syddanmark, Denmark
| | | | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, Parker Instituttet, Frederiksberg, Hovedstaden, Denmark
| | - Heidi Lausten Munk
- Department of Rheumatology, Odense University Hospital, Odense, Syddanmark, Denmark
| | - Grith Lykke Sorensen
- Department of Cancer and Inflammation Research, Institute for Molecular Medicine, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Jesper Rømhild Davidsen
- South Danish Center for Interstitial Lung Diseases (SCILS) and PUlmo-REuma Clinic OUH (PURE), Department of Respiratory Medicine, Odense University Hospital, Odense, Syddanmark, Denmark
| | - Torkell Ellingsen
- Department of Rheumatology, PUlmo-REuma Clinic OUH (PURE), Odense University Hospital, Odense, Syddanmark, Denmark
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Nabi H, Hendricks O, Jensen DV, Loft AG, Pedersen JK, Just SA, Danebod K, Munk HL, Kristensen S, Manilo N, Colic A, Linauskas A, Thygesen PH, Christensen LB, Kalisz MH, Lomborg N, Chrysidis S, Raun JL, Andersen M, Mehnert F, Krogh NS, Hetland ML, Glintborg B. Infliximab biosimilar-to-biosimilar switching in patients with inflammatory rheumatic disease: clinical outcomes in real-world patients from the DANBIO registry. RMD Open 2022; 8:rmdopen-2022-002560. [PMID: 36418087 PMCID: PMC9685195 DOI: 10.1136/rmdopen-2022-002560] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Successful uptake of biosimilars in rheumatology is limited by lack of real-world evidence regarding effectiveness of biosimilar-to-biosimilar switching. We investigated infliximab biosimilars CT-P13-to-GP1111 switching among patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (AxSpA). Methods Observational cohort study from the DANBIO registry. Patients were classified as originator-naïve or originator-experienced. Retention rates of 1-year GP1111 treatment were explored (Kaplan-Meier). We identified baseline factors (at the time of switch) associated with withdrawal of GP1111 (multivariable Cox-regression analyses with HRs including originator treatment history). Changes in subjective and objective measures of disease activity 4 months before and after the switch were assessed in individual patients. Results Of 1605 patients (685 RA, 314 PsA and 606 AxSpA, median disease duration was 9 years, 37% in Clinical Disease Activity Index/Ankylosing Spondylitis Disease Activity Score remission), 1171 were originator-naïve. Retention rates at 1-year were 83% (95% CI: 81% to 85%) and 92% (95% CI: 90% to 95%) for the originator-naïve and originator-experienced, respectively. GP1111 retention rates were higher in originator-experienced compared to originator-naïve with RA (HR=0.4 (95% CI: 0.2 to 0.7)) and PsA (HR=0.2 (95% CI: 0.1 to 0.8)), but not significantly for AxSpA: HR=0.6 (95% CI: 0.3 to 1.2). Lower disease activity was associated with higher retention. Changes in disease activity preswitch and postswitch were close to zero. Conclusion This real-world observational study of more than 1600 patients with inflammatory arthritis showed high 1-year retention following a nationwide infliximab biosimilar-to-biosimilar switch. Retention was higher in originator-experienced and in patients with low disease activity, suggesting outcomes to be affected by patient-related rather than drug-related factors.
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Affiliation(s)
- Hafsah Nabi
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Oliver Hendricks
- Danish Hospital for Rheumatic Disease, University Hospital of Southern Denmark, Sønderborg, Syddanmark, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dorte Vendelbo Jensen
- Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Gentofte, Denmark
- Department of Internal Medicine, Rønne Hospital, Rønne, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Kristian Pedersen
- Rheumatology Section, Department of Medicine M, Svendborg Hospital, Svendborg, Syddanmark, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Andreas Just
- Department of Rheumatology, Svendborg Hospital, Svendborg, Syddanmark, Denmark
| | - Kamilla Danebod
- Department of Rheumatology, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Glostrup, Denmark
| | - Heidi Lausten Munk
- Department of Rheumatology, Odense University Hospital, Odense C, Denmark
| | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
| | - Natalia Manilo
- Department of Rheumatology, Frederiksberg Hospital, Copenhagen, Denmark
| | - Ada Colic
- Department of Rheumatology, Zealand University Hospital, Køge, Denmark
| | - Asta Linauskas
- Department of Rheumatology, North Denmark Regional Hospital, Hjørring, Denmark
- Department of Clinical Medicine, Aalborg Universitet, Aalborg, Denmark
| | | | - Louise Brot Christensen
- Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Maren Høgberget Kalisz
- Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Niels Lomborg
- Department of Rheumatology, Vejle Hospital Lillebælt, Vejle, Denmark
| | | | | | - Marlene Andersen
- Department of Rheumatology, North Denmark Regional Hospital, Hjorring, Nordjylland, Denmark
| | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - 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, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Glintborg B, Jensen DV, Terslev L, Hendricks O, Østergaard M, Horskjær Rasmussen S, Jensen MP, Adelsten T, Colic A, Danebod K, Kildemand M, Loft AG, Munk HL, Pedersen JK, Østgård RD, Møller Sørensen C, Krogh NS, Agerbo J, Ziegler C, Hetland ML. Nationwide, large-scale implementation of an online system for remote entry of patient-reported outcomes in rheumatology: characteristics of users and non-users and time to first entry. RMD Open 2022; 8:rmdopen-2022-002549. [PMID: 36418086 PMCID: PMC9685239 DOI: 10.1136/rmdopen-2022-002549] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/25/2022] [Indexed: 11/24/2022] Open
Abstract
Aims In May 2020, a nationwide, web-based system for remote entry of patient-reported outcomes (PROs) in inflammatory rheumatic diseases was launched and implemented in routine care (DANBIO-from-home). After 1.5 years of use, we explored clinical characteristics of patients who did versus did not use the system, and the time to first entry of PROs. Methods All patients followed in DANBIO were informed about DANBIO-from-home by electronic invitations or when attending their clinic. Characteristics of patients who did/did not use DANBIO-from-home in the period after implementation were explored by multivariable logistic regression analyses including demographic and clinical variables (gender, age group, diagnosis, disease duration, use of biological disease-modifying agent (bDMARD), Health Assessment Questionnaire (HAQ), Patient Acceptable Symptom Scale (PASS)). Time from launch to first entry was presented as cumulative incidence curves by age group (<40/40–60/61–80/>80 years). Results Of 33 776 patients, 68% entered PROs using DANBIO-from-home at least once. Median (IQR) time to first entry was 27 (11–152) days. Factors associated with data entry in multivariate analyses (OR (95% CI)) were: female gender (1.19 (1.12 to 1.27)), bDMARD treatment (1.41 (1.33 to 1.50)), age 40–60 years (1.79 (1.63 to 1.97)), 61–80 years (1.87 (1.70 to 2.07), or age >80 years (0.57 (0.50 to 0.65)) (reference: age <40 years), lower HAQ (0.68 (0.65 to 0.71)) and PASS ‘no’ (1.09 (1.02 to 1.17). Diagnosis was not associated. Time to first entry of PROs was longest in patients <40 years of age (119 (24–184) days) and shortest in the 61–80 years age group (25 (8–139) days). Conclusion A nationwide online platform for PRO in rheumatology achieved widespread use. Higher age, male gender, conventional treatment and disability were associated with no use.
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Affiliation(s)
- Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dorte Vendelbo Jensen
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Rheumatology, Center for Rheumatology and Spine Diseases, Gentofte University Hospital, Gentofte, Denmark
| | - Lene Terslev
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Oliver Hendricks
- Danish Hospital for Rheumatic Diseases, University of Southern Denmark, Sønderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Mikkel Østergaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Simon Horskjær Rasmussen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Mogens Pfeiffer Jensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Thomas Adelsten
- Department of Rheumatology, Zealand University Hospital Koge, Koge, Denmark
| | - Ada Colic
- Department of Rheumatology, Zealand University Hospital Koge, Koge, Denmark
| | - Kamilla Danebod
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Malene Kildemand
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Heidi Lausten Munk
- Rheumatology Research Unit, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Jens Kristian Pedersen
- Department of Rheumatology, Odense University Hospital, Svendborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | | | - Jette Agerbo
- Danish Rheumatism Association/Gigtforeningen, Copenhagen, Denmark
| | - Connie Ziegler
- Danish Rheumatism Association/Gigtforeningen, Copenhagen, Denmark
| | - Merete Lund Hetland
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen, Rigshospitalet Glostrup, Glostrup, Denmark
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7
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Glintborg B, Jensen DV, Terslev L, Hendricks O, Østergaard M, Rasmussen SH, Jensen MP, Adelsten T, Colic A, Danebod K, Kildemand M, Loft AG, Munk HL, Pedersen JK, Østgård RD, Sørensen CM, Krogh NS, Agerbo JN, Ziegler C, Hetland ML. Long-term Behavioral Changes During the COVID-19 Pandemic and Impact of Vaccination in Patients With Inflammatory Rheumatic Diseases. J Rheumatol 2022; 49:1163-1172. [PMID: 35705237 DOI: 10.3899/jrheum.211280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To explore anxiety and self-isolation in patients with inflammatory rheumatic disease (IRD)15 months into the coronavirus disease 2019 (COVID-19) pandemic, including attitudes toward and effects of SARS-CoV-2 vaccination. METHODS A nationwide online survey was conducted at 3 timepoints: May 2020, November 2020, and May 2021. Patients with IRD followed in the Danish Rheumatology Quality Registry (DANBIO) were asked about the effects of the pandemic, including SARS-CoV-2 infection and their behavior, anxiety, and concerns. The May 2021 survey included attitudes toward SARS-CoV-2 and influenza vaccination. Characteristics associated with self-isolation in May 2021 were explored with adjusted logistic regression analyses that included patient characteristics and SARS-CoV-2 vaccination status. RESULTS Respondents to surveys 1, 2, and 3 included 12,789; 14,755; and 13,921 patients, respectively; 64% had rheumatoid arthritis and 63% were female. Anxiety and concerns were highest in May 2020 and decreased to stable levels in November 2020 and May 2021; 86%, 50%, and 52% of respondents reported self-isolation, respectively. In May 2021, 4% of respondents self-reported previous SARS-CoV-2 infection. The SARS-CoV-2 vaccine acceptance rate was 86%, and the proportion of patients vaccinated against influenza had increased from 50% in winter 2019-2020 to 64% in winter 2020-2021. The proportion of patients with anxiety appeared similar among those vaccinated and unvaccinated against SARS-CoV-2. In multivariable analyses, being unvaccinated, female gender, receiving biologic drugs, and poor quality of life were independently associated with self-isolation. CONCLUSION Levels of anxiety and self-isolation decreased after the initial lockdown period in patients with IRD. Half of the patients reported self-isolation in May 2021, a phase that included widespread reopening of society and large-scale vaccination. The lack of prepandemic data prevented a full understanding of the long-term effects of the pandemic on anxiety and self-isolation in patients with IRD.
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Affiliation(s)
- Bente Glintborg
- B. Glintborg, MD, PhD, DMSc, M. Østergaard, MD, PhD, DMSc, Professor, M.L. Hetland, MD, PhD, DMSc, Professor, DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen Rigshospitalet, Glostrup, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen;
| | - Dorte Vendelbo Jensen
- D.V. Jensen, MD, DANBIO, Rigshospitalet, Glostrup, Copenhagen, and Department of Rheumatology, Center for Rheumatology and Spine Diseases Gentofte and Herlev Hospital, Gentofte
| | - Lene Terslev
- L. Terslev, MD, PhD, Professor, M. Pfeiffer Jensen, MD, PhD, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Oliver Hendricks
- O. Hendricks, MD, Professor, Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, and Department of Regional Health Research, University of Southern Denmark, Odense
| | - Mikkel Østergaard
- B. Glintborg, MD, PhD, DMSc, M. Østergaard, MD, PhD, DMSc, Professor, M.L. Hetland, MD, PhD, DMSc, Professor, DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen Rigshospitalet, Glostrup, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Simon Horskjær Rasmussen
- S.H. Rasmussen, PhD, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen
| | - Mogens Pfeiffer Jensen
- L. Terslev, MD, PhD, Professor, M. Pfeiffer Jensen, MD, PhD, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Glostrup, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Thomas Adelsten
- T. Adelsten, MD, A. Colic, MD, Department of Rheumatology, Zealand University Hospital, Køge
| | - Ada Colic
- T. Adelsten, MD, A. Colic, MD, Department of Rheumatology, Zealand University Hospital, Køge
| | - Kamilla Danebod
- K. Danebod, MD, Department of Rheumatology, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Glostrup
| | - Malene Kildemand
- M. Kildemand, RN, Department of Rheumatology, Odense University Hospital, Odense
| | - Anne Gitte Loft
- A. Gitte Loft, MD, DMSc, Department of Rheumatology, Aarhus University Hospital, and Department of Clinical Medicine, Health, Aarhus University, Aarhus
| | - Heidi Lausten Munk
- H.L. Munk, MD, PhD, Rheumatology Research Unit, Odense University Hospital and University of Southern Denmark, Odense
| | - Jens Kristian Pedersen
- J.K. Pedersen, MD, PhD, Rheumatology Section, Department of Medicine, Odense University Hospital and Svendborg Hospital, Svendborg, and Department of Clinical Research, University of Southern Denmark, Odense
| | - René Drage Østgård
- R.D. Østgård, MD, PhD, Diagnostic Center, Silkeborg Regional Hospital, Silkeborg
| | | | | | - Jette Nørgaard Agerbo
- J.N. Agerbo, Patient Representative, C. Ziegler, Patient Representative, Gigtforeningen/Danish Rheumatism Association, Denmark
| | - Connie Ziegler
- J.N. Agerbo, Patient Representative, C. Ziegler, Patient Representative, Gigtforeningen/Danish Rheumatism Association, Denmark
| | - Merete Lund Hetland
- B. Glintborg, MD, PhD, DMSc, M. Østergaard, MD, PhD, DMSc, Professor, M.L. Hetland, MD, PhD, DMSc, Professor, DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, University Hospital of Copenhagen Rigshospitalet, Glostrup, and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
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8
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Glintborg B, Jensen DV, Terslev L, Pfeiffer Jensen M, Hendricks O, Østergaard M, Engel S, Horskjær Rasmussen S, Adelsten T, Colic A, Danebod K, Kildemand M, Loft AG, Munk HL, Pedersen JK, Østgård RD, Møller Sørensen C, Krogh NS, Nørgaard Agerbo J, Ziegler C, Hetland ML. Impact of the COVID-19 pandemic on treat-to-target strategies and physical consultations in >7000 patients with inflammatory arthritis. Rheumatology (Oxford) 2021; 60:SI3-SI12. [PMID: 34146099 PMCID: PMC8344418 DOI: 10.1093/rheumatology/keab500] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 04/14/2021] [Accepted: 06/09/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To explore the impact of the COVID-19 pandemic on treat-to-target strategies (disease activity, remission rates) and access to physical consultations in patients with inflammatory rheumatic disease, as well as to explore characteristics of patients with/without physical consultations in the clinic and the impact of early vs established disease. METHODS Patients with RA, PsA or axial SpA (axSpA) prospectively followed in the nationwide DANBIO registry answered online questionnaires and reported patient-reported outcomes (PROs) in June and November 2020. Patient characteristics, disease activity and physical consultations in the clinic before and during the pandemic were identified in DANBIO [all patients and subgroups with early disease (disease duration ≤2 years)]. In individual patients, changes in PROs before and during the pandemic were calculated. Characteristics of patients with/without physical consultations were described (age, gender, education level, comorbidities, disease duration, treatment). RESULTS We included 7836 patients (22% of eligible patients), 12% of which had early disease. PROs were stable before and during the pandemic, with median changes approximating zero, as well as in patients with early disease. Remission rates were stable. The relative decrease in the number of patients with physical consultations was 21-72%, which was highest in axSpA. Characteristics of patients with/without physical consultations were similar. Self-reported satisfaction with treatment options and access was >70%; the preferred contact form was physical consultation (66%). CONCLUSION In this nationwide study performed during the first 8 months of the pandemic, patient satisfaction was high and the PROs and remission rates remained stable despite the remarkable reduction in physical consultations, as well as in patients with early disease. Characteristics of patients with/without physical consultations appeared similar.
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Affiliation(s)
- Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Dorte Vendelbo Jensen
- DANBIO and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet
- Department of Rheumatology, Center for Rheumatology and Spine Diseases, Gentofte and Herlev Hospital
| | - Lene Terslev
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen
| | - Mogens Pfeiffer Jensen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen
| | - Oliver Hendricks
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg
- Department of Regional Health Research, University of Southern Denmark, Odense
| | - Mikkel Østergaard
- DANBIO and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Sara Engel
- DANBIO and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet
| | - Simon Horskjær Rasmussen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen
| | - Thomas Adelsten
- Department of Rheumatology, Zealand University Hospital, Køge
| | - Ada Colic
- Department of Rheumatology, Zealand University Hospital, Køge
| | - Kamilla Danebod
- Department of Rheumatology, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Glostrup
| | | | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital
- Department of Clinical Medicine, Health, Aarhus University, Aarhus
| | - Heidi Lausten Munk
- Department of Rheumatology, Odense University Hospital, Odense
- Department of Clinical Research, University of Southern Denmark, Odense
| | - Jens Kristian Pedersen
- Department of Clinical Research, University of Southern Denmark, Odense
- Rheumatology Section, Department of Medicine M, Odense University Hospital and Svendborg Hospital, Svendborg
| | - René Drage Østgård
- Rheumatology Section, Department of Medicine M, Odense University Hospital and Svendborg Hospital, Svendborg
- Diagnostic Center, Silkeborg Regional Hospital, Silkeborg
| | | | | | | | | | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
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9
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Glintborg B, Jensen DV, Engel S, Terslev L, Pfeiffer Jensen M, Hendricks O, Østergaard M, Horskjær Rasmussen S, Adelsten T, Colic A, Danebod K, Kildemand M, Loft AG, Munk HL, Pedersen JK, Østgård RD, Møller Sørensen C, Krogh NS, Nørgaard Agerbo J, Ziegler C, Lund Hetland M. Anxiety and concerns related to the work situation during the second wave of the COVID-19 pandemic in >5000 patients with inflammatory rheumatic disease followed in the DANBIO registry. RMD Open 2021; 7:rmdopen-2021-001649. [PMID: 33941664 PMCID: PMC8098969 DOI: 10.1136/rmdopen-2021-001649] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/12/2021] [Accepted: 04/18/2021] [Indexed: 12/18/2022] Open
Affiliation(s)
- Bente Glintborg
- DANBIO, Rigshospitalet Glostrup, Glostrup, Denmark .,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Kobenhavn, Denmark.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Dorte Vendelbo Jensen
- DANBIO, Rigshospitalet Glostrup, Glostrup, Denmark.,Department of Rheumatology, Center for Rheumatology and Spine Diseases, Gentofte University Hospital, Hellerup, Hovedstaden, Denmark
| | - Sara Engel
- DANBIO, Rigshospitalet Glostrup, Glostrup, Denmark.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Lene Terslev
- DANBIO, Rigshospitalet Glostrup, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Kobenhavn, Denmark.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Mogens Pfeiffer Jensen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Kobenhavn, Denmark.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Oliver Hendricks
- Danish Hospital for Rheumatology, University of Southern Denmark, Sønderborg, Syddanmark, Denmark.,Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Mikkel Østergaard
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Kobenhavn, Denmark.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Simon Horskjær Rasmussen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Thomas Adelsten
- Department of Rheumatology, Sjællands Universitetshospital Køge, Koge, Sjælland, Denmark
| | - Ada Colic
- Department of Rheumatology, Sjællands Universitetshospital Køge, Koge, Sjælland, Denmark
| | - Kamilla Danebod
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Malene Kildemand
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Health, Aarhus Universitet, Aarhus, Midtjylland, Denmark
| | - Heidi Lausten Munk
- Department of Rheumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Jens Kristian Pedersen
- Department of Clinical Research, University of Southern Denmark, Odense, Syddanmark, Denmark.,Department of Medicine M, Svendborg, Odense University Hospital, Svendborg, Denmark
| | - René Drage Østgård
- Diagnostic center, Silkeborg Regional Hospital, Silkeborg, Midtjylland, Denmark
| | | | | | | | - Connie Ziegler
- Danish Rheumatism Association/Gigtforeningen, Copenhagen, Denmark
| | - Merete Lund Hetland
- DANBIO, Rigshospitalet Glostrup, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Kobenhavn, Denmark.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
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10
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Kragsnaes MS, Kjeldsen J, Horn HC, Munk HL, Pedersen JK, Just SA, Ahlquist P, Pedersen FM, de Wit M, Möller S, Andersen V, Kristiansen K, Kinggaard Holm D, Holt HM, Christensen R, Ellingsen T. Safety and efficacy of faecal microbiota transplantation for active peripheral psoriatic arthritis: an exploratory randomised placebo-controlled trial. Ann Rheum Dis 2021; 80:1158-1167. [PMID: 33926922 DOI: 10.1136/annrheumdis-2020-219511] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Although causality remains to be established, targeting dysbiosis of the intestinal microbiota by faecal microbiota transplantation (FMT) has been proposed as a novel treatment for inflammatory diseases. In this exploratory, proof-of-concept study, we evaluated the safety and efficacy of FMT in psoriatic arthritis (PsA). METHODS In this double-blind, parallel-group, placebo-controlled, superiority trial, we randomly allocated (1:1) adults with active peripheral PsA (≥3 swollen joints) despite ongoing treatment with methotrexate to one gastroscopic-guided FMT or sham transplantation into the duodenum. Safety was monitored throughout the trial. The primary efficacy endpoint was the proportion of participants experiencing treatment failure (ie, needing treatment intensification) through 26 weeks. Key secondary endpoints were change in Health Assessment Questionnaire Disability Index (HAQ-DI) and American College of Rheumatology (ACR20) response at week 26. RESULTS Of 97 screened, 31 (32%) underwent randomisation (15 allocated to FMT) and 30 (97%) completed the 26-week clinical evaluation. No serious adverse events were observed. Treatment failure occurred more frequently in the FMT group than in the sham group (9 (60%) vs 3 (19%); risk ratio, 3.20; 95% CI 1.06 to 9.62; p=0.018). Improvement in HAQ-DI differed between groups (0.07 vs 0.30) by 0.23 points (95% CI 0.02 to 0.44; p=0.031) in favour of sham. There was no difference in the proportion of ACR20 responders between groups (7 of 15 (47%) vs 8 of 16 (50%)). CONCLUSIONS In this first preliminary, interventional randomised controlled trial of FMT in immune-mediated arthritis, we did not observe any serious adverse events. Overall, FMT appeared to be inferior to sham in treating active peripheral PsA. TRIAL REGISTRATION NUMBER NCT03058900.
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Affiliation(s)
- Maja Skov Kragsnaes
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jens Kjeldsen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Hans Christian Horn
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Heidi Lausten Munk
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Søren Andreas Just
- Section of Rheumatology, Department of Medicine, Svendborg Hospital, Svendborg, Denmark
| | | | | | | | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,OPEN - Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Vibeke Andersen
- IRS-Center Sønderjylland, University Hospital of Southern Denmark, Aabenraa, Denmark.,Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Karsten Kristiansen
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen, Denmark.,Institute of Metagenomics, BGI-Shenzhen, Shenzhen, China
| | | | - Hanne Marie Holt
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Robin Christensen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Torkell Ellingsen
- Rheumatology Research Unit, Department of Rheumatology, Odense University Hospital, Odense, Denmark .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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11
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Nabi H, Georgiadis S, Loft AG, Hendricks O, Jensen DV, Andersen M, Chrysidis S, Colic A, Danebod K, Hussein MR, Kalisz MH, Kristensen S, Lomborg N, Manilo N, Munk HL, Pedersen JK, Raun JL, Mehnert F, Krogh NS, Hetland ML, Glintborg B. Comparative effectiveness of two adalimumab biosimilars in 1318 real-world patients with inflammatory rheumatic disease mandated to switch from originator adalimumab: nationwide observational study emulating a randomised clinical trial. Ann Rheum Dis 2021; 80:1400-1409. [PMID: 33926921 DOI: 10.1136/annrheumdis-2021-219951] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES In 2018, a nationwide mandatory switch from originator to biosimilar adalimumab was conducted in Denmark. The available biosimilar was GP2017 (Hyrimoz) in Eastern regions and SB5 (Imraldi) in Western regions. We aimed to assess the comparative effectiveness of GP2017 versus SB5 in patients with rheumatoid arthritis (RA)/psoriatic arthritis (PsA)/axial spondyloarthritis (AxSpA). METHODS Observational cohort study based on the DANBIO registry with geographical cluster pseudo-randomisation, analysed by emulating a randomised clinical trial. Main outcome was adjusted 1-year treatment retention (Cox regression). Furthermore, 6 months' remission rates (logistic regression), reasons for withdrawal and back-switching to originator were investigated (overall and stratified by indication). RESULTS Overall, of 1570 eligible patients, 1318 switched and were included (467 RA/321 PsA/530 AxSpA); 623 (47%) switched to GP2017, 695 (53%) to SB5. Baseline characteristics of the two clusters were largely similar, but some differences in registration practice were observed. The combined 1-year retention rate for the two biosimilars was 89.5%. Compared with SB5, estimated risk of withdrawal for GP2017 was lower (HR 0.60; 95% CI 0.42 to 0.86) and 6 months' remission rate was higher (OR 1.72; 95% CI 1.25 to 2.37). Stratified analyses gave similar results (statistically significant for RA). During 1 year, 8.5% and 12.9% withdrew GP2017 and SB5, respectively (primarily lack of effect and adverse events), of whom 48 patients (3.6%) back-switched. CONCLUSION This head-to-head comparison of GP2017 versus SB5 following a mandatory switch from the originator indicated differences in effectiveness in routine care. This may reflect a true difference, but other explanations, for example, differences in excipients, differences between clusters and residual confounding cannot be ruled out.
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Affiliation(s)
- Hafsah Nabi
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark .,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Stylianos Georgiadis
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Oliver Hendricks
- Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Dorte Vendelbo Jensen
- Department of Internal Medicine, Rønne Hospital, Rønne, Denmark.,Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Marlene Andersen
- Department of Rheumatology, North Denmark Regional Hospital, Hjørring, Denmark
| | | | - Ada Colic
- Department of Rheumatology, Zealand University Hospital, Køge, Denmark
| | - Kamilla Danebod
- Department of Rheumatology, Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen University Hospital, Glostrup, Denmark
| | | | - Maren Høgberget Kalisz
- Department of Rheumatology, Gentofte and Herlev Hospital, Copenhagen University Hospital, Gentofte, Denmark
| | - Salome Kristensen
- Department of Rheumatology, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Lomborg
- Department of Rheumatology, Vejle Hospital Lillebælt, Vejle, Denmark
| | - Natalia Manilo
- Department of Rheumatology, Frederiksberg Hospital, Copenhagen, Denmark
| | - Heidi Lausten Munk
- Department of Rheumatology, Odense University Hospital, Odense C, Denmark
| | | | | | - Frank Mehnert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Merete Lund Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
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12
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Kragsnaes MS, Sødergren ST, Kjeldsen J, Horn HC, Munk HL, Pedersen JK, Klinkby CS, de Wit M, Ahlmark NG, Tjørnhøj-Thomsen T, Ellingsen T. Experiences and perceptions of patients with psoriatic arthritis participating in a trial of faecal microbiota transplantation: a nested qualitative study. BMJ Open 2021; 11:e039471. [PMID: 34006020 PMCID: PMC7942243 DOI: 10.1136/bmjopen-2020-039471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Patients' first-hand experiences of faecal microbiota transplantation (FMT) performed in a rheumatological care setting have yet to be elucidated. The objectives were to explore participants' perceptions of being part of an FMT trial thereby identifying potential trial participation effects and enlightening the patient perspective on the outlook for future FMT trials in rheumatic diseases. DESIGN In a qualitative study nested within a double-blind, randomised, placebo-controlled trial (RCT) testing FMT as a potential new antirheumatic treatment, semistructured telephone interviews were conducted following the trial participants' final 26-week visit. Qualitative researchers, who did not take part in the main trial, performed the interviews and the primary analysis. The experiences explored related to the conduct of the RCT and changes in the participants' everyday life. The analysis was carried out using a thematic approach. SETTING A Danish rheumatology university outpatient clinic with nationwide inclusion. PARTICIPANTS The study included 10 patients with psoriatic arthritis (PsA) who were unaware of their treatment allocation (FMT/sham transplantation) and completed the final 26-week trial visit. RESULTS Participation in the RCT influenced the patients' understanding of PsA and induced positive changes in their everyday life. Renewed hopes for the future in addition to a feeling of enhanced care contributed to significant trial participation effects. FMT was deemed a tolerable and safe treatment. CONCLUSIONS Discrepancies between the clinical and the research setting should be considered when discussing the clinical relevance of the results of the RCT. Overall, patients with PsA who have participated in an RCT testing FMT find the treatment acceptable and safe encouraging more research into the field of microbiota-targeted interventions in rheumatic diseases. TRIAL REGISTRATION NUMBER NCT03058900; Pre-results.
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Affiliation(s)
| | - Shaun Theodor Sødergren
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jens Kjeldsen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | | | | | - Jens Kristian Pedersen
- Department of Medicine, Svendborg Hospital, Odense University Hospital, Svendborg, Denmark
| | | | | | - Nanna Gram Ahlmark
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Tine Tjørnhøj-Thomsen
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Torkell Ellingsen
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
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13
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Glintborg B, Jensen DV, Engel S, Terslev L, Pfeiffer Jensen M, Hendricks O, Ostergaard M, Horskjær Rasmussen S, Adelsten T, Colic A, Danebod K, Kildemand M, Loft AG, Munk HL, Pedersen JK, Østgård RD, Møller Sørensen C, Krogh NS, Agerbo J, Ziegler C, Hetland M. Self-protection strategies and health behaviour in patients with inflammatory rheumatic diseases during the COVID-19 pandemic: results and predictors in more than 12 000 patients with inflammatory rheumatic diseases followed in the Danish DANBIO registry. RMD Open 2021; 7:e001505. [PMID: 33402443 PMCID: PMC7786545 DOI: 10.1136/rmdopen-2020-001505] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [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: 11/02/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 12/14/2022] Open
Abstract
AIMS In Danish patients with inflammatory rheumatic diseases to explore self-protection strategies and health behaviour including adherence to disease-modifying antirheumatic treatment (DMARD) during the initial phase of the COVID-19 pandemic and again after the reopening of the society started. Furthermore, to identify characteristics of patients with high levels of anxiety and self-isolation. METHODS Patients in routine care followed prospectively in the nationwide DANBIO registry were invited to answer an online questionnaire regarding disease activity and COVID-19 infection, behaviour in March and June 2020. Responses were linked to patient data in DANBIO. Characteristics potentially associated with anxiety, self-isolation and medication adherence (gender/age/diagnosis/education/work status/comorbidity/DMARD/smoking/EQ-5D/disease activity) were explored with multivariable logistic regression analyses. RESULTS We included 12 789 patients (8168 rheumatoid arthritis/2068 psoriatic arthritis/1758 axial spondyloarthritis/795 other) of whom 65% were women and 36% treated with biological DMARD. Self-reported COVID-19 prevalence was 0.3%. Patients reported that they were worried to get COVID-19 infection (March/June: 70%/45%) and self-isolated more than others of the same age (48%/38%). The fraction of patients who changed medication due to fear of COVID-19 were 4.1%/0.6%. Female gender, comorbidities, not working, lower education, biological treatment and poor European Quality of life, 5 dimensions were associated with both anxiety and self-isolation. CONCLUSION In >12 000 patients with inflammatory arthritis, we found widespread anxiety and self-isolation, but high medication adherence, in the initial phase of the COVID-19 pandemic. This persisted during the gradual opening of society during the following months. Attention to patients' anxiety and self-isolation is important during this and potential future epidemics.
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Affiliation(s)
- Bente Glintborg
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Dorte Vendelbo Jensen
- DANBIO, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Rheumatology, Center for Rheumatology and Spine Diseases, Gentofte University Hospital, Hellerup, Hovedstaden, Denmark
| | - Sara Engel
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Lene Terslev
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Mogens Pfeiffer Jensen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Oliver Hendricks
- Danish Hospital for Rheumatic Diseases, University of Southern Denmark, Sønderborg, Syddanmark, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Syddanmark, Denmark
| | - Mikkel Ostergaard
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Simon Horskjær Rasmussen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Thomas Adelsten
- Department of Rheumatology, Sjællands Universitetshospital Køge, Koge, Sjælland, Denmark
| | - Ada Colic
- Department of Rheumatology, Sjællands Universitetshospital Køge, Koge, Sjælland, Denmark
| | - Kamilla Danebod
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Malene Kildemand
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Midtjylland, Denmark
| | - Heidi Lausten Munk
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Syddanmark, Denmark
| | | | - René Drage Østgård
- Diagnostic Center, Silkeborg Regional Hospital, Silkeborg, Midtjylland, Denmark
| | | | | | - Jette Agerbo
- Danish Rheumatism Association/Gigtforeningen, Copenhagen, Denmark
| | - Connie Ziegler
- Danish Rheumatism Association/Gigtforeningen, Copenhagen, Denmark
| | - Merete Hetland
- DANBIO and Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopedics, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
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14
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Kragsnaes MS, Kjeldsen J, Horn HC, Munk HL, Pedersen FM, Holt HM, Pedersen JK, Holm DK, Glerup H, Andersen V, Fredberg U, Kristiansen K, Christensen R, Ellingsen T. Efficacy and safety of faecal microbiota transplantation in patients with psoriatic arthritis: protocol for a 6-month, double-blind, randomised, placebo-controlled trial. BMJ Open 2018; 8:e019231. [PMID: 29703851 PMCID: PMC5922473 DOI: 10.1136/bmjopen-2017-019231] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION An unbalanced intestinal microbiota may mediate activation of the inflammatory pathways seen in psoriatic arthritis (PsA). A randomised, placebo-controlled trial of faecal microbiota transplantation (FMT) infused into the small intestine of patients with PsA with active peripheral disease who are non-responsive to methotrexate (MTX) treatment will be conducted. The objective is to explore clinical aspects associated with FMT performed in patients with PsA. METHODS AND ANALYSIS This trial is a randomised, two-centre stratified, double-blind (patient, care provider and outcome assessor), placebo-controlled, parallel-group study. Eighty patients will be included and randomised (1:1) to either placebo (saline) or FMT provided from an anonymous healthy donor. Throughout the study, both groups will continue the weekly self-administered subcutaneous MTX treatment, remaining on the preinclusion dosage (15-25 mg/week). The clinical measures of psoriasis and PsA disease activity used include the Short (2-page) Health Assessment Questionnaire, the Dermatology Quality of Life Index, the Spondyloarthritis Research Consortium of Canada Enthesitis Index, the Psoriasis Area Severity Index, a dactylitis digit count, a swollen/tender joint count (66/68), plasma C reactive protein as well as visual analogue scales for pain, fatigue and patient and physician global assessments. The primary end point is the proportion of patients who experience treatment failure during the 6-month trial period. The number of adverse events will be registered throughout the study. ETHICS AND DISSEMINATION This is a proof-of-concept clinical trial and will be performed in agreement with Good Clinical Practice standards. Approvals have been obtained from the local Ethics Committee (DK-S-20150080) and the Danish Data Protection Agency (15/41684). The study has commenced in May 2017. Dissemination will be through presentations at national and international conferences and through publications in international peer-reviewed journal(s). TRIAL REGISTRATION NUMBER NCT03058900; Pre-results.
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Affiliation(s)
- Maja Skov Kragsnaes
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Odense Patient data Explorative Network (OPEN), Department of Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Jens Kjeldsen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | | | | | | | - Hanne Marie Holt
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | | | | | - Henning Glerup
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Vibeke Andersen
- IRS-Centre Sonderjylland, Hospital of Southern Jutland, Aabenraa, Denmark
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Karsten Kristiansen
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen, Denmark
- Institute of Metagenomics, BGI-Shenzhen, Shenzhen, China
| | - Robin Christensen
- Musculoskeletal Statistics Unit, Parker Institute, Frederiksberg and Bispebjerg Hospital, Copenhagen, Denmark
| | - Torkell Ellingsen
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
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15
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Christensen R, Heitmann BL, Andersen KW, Nielsen OH, Sørensen SB, Jawhara M, Bygum A, Hvid L, Grauslund J, Wied J, Glerup H, Fredberg U, Villadsen JA, Kjær SG, Fallingborg J, Moghadd SAGR, Knudsen T, Brodersen J, Frøjk J, Dahlerup JF, Bojesen AB, Sorensen GL, Thiel S, Færgeman NJ, Brandslund I, Bennike TB, Stensballe A, Schmidt EB, Franke A, Ellinghaus D, Rosenstiel P, Raes J, Boye M, Werner L, Nielsen CL, Munk HL, Nexøe AB, Ellingsen T, Holmskov U, Kjeldsen J, Andersen V. Impact of red and processed meat and fibre intake on treatment outcomes among patients with chronic inflammatory diseases: protocol for a prospective cohort study of prognostic factors and personalised medicine. BMJ Open 2018; 8:e018166. [PMID: 29439003 PMCID: PMC5829767 DOI: 10.1136/bmjopen-2017-018166] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Chronic inflammatory diseases (CIDs) are frequently treated with biological medications, specifically tumour necrosis factor inhibitors (TNFi)). These medications inhibit the pro-inflammatory molecule TNF alpha, which has been strongly implicated in the aetiology of these diseases. Up to one-third of patients do not, however, respond to biologics, and lifestyle factors are assumed to affect treatment outcomes. Little is known about the effects of dietary lifestyle as a prognostic factor that may enable personalised medicine. The primary outcome of this multidisciplinary collaborative study will be to identify dietary lifestyle factors that support optimal treatment outcomes. METHODS AND ANALYSIS This prospective cohort study will enrol 320 patients with CID who are prescribed a TNFi between June 2017 and March 2019. Included among the patients with CID will be patients with inflammatory bowel disease (Crohn's disease and ulcerative colitis), rheumatic disorders (rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis), inflammatory skin diseases (psoriasis, hidradenitis suppurativa) and non-infectious uveitis. At baseline (pretreatment), patient characteristics will be assessed using patient-reported outcome measures, clinical assessments of disease activity, quality of life and lifestyle, in addition to registry data on comorbidity and concomitant medication(s). In accordance with current Danish standards, follow-up will be conducted 14-16 weeks after treatment initiation. For each disease, evaluation of successful treatment response will be based on established primary and secondary endpoints, including disease-specific core outcome sets. The major outcome of the analyses will be to detect variability in treatment effectiveness between patients with different lifestyle characteristics. ETHICS AND DISSEMINATION The principle goal of this project is to improve the quality of life of patients suffering from CID by providing evidence to support dietary and other lifestyle recommendations that may improve clinical outcomes. The study is approved by the Ethics Committee (S-20160124) and the Danish Data Protecting Agency (2008-58-035). Study findings will be disseminated through peer-reviewed journals, patient associations and presentations at international conferences. TRIAL REGISTRATION NUMBER NCT03173144; Pre-results.
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Affiliation(s)
- Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark
| | - Berit L Heitmann
- Research Unit for Dietary Studies, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark
- Section for General Medicine, Department of Public Health, University of Copenhagen, Denmark
- National Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Karina Winther Andersen
- Focused Research Unit for Molecular Diagnostic and Clinical Research, IRS-Center Sonderjylland, Hospital of Southern Jutland, Aabenraa, Denmark
- Organ Centre, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Ole Haagen Nielsen
- Department of Gastroenterology D112, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Signe Bek Sørensen
- Focused Research Unit for Molecular Diagnostic and Clinical Research, IRS-Center Sonderjylland, Hospital of Southern Jutland, Aabenraa, Denmark
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Mohamad Jawhara
- Focused Research Unit for Molecular Diagnostic and Clinical Research, IRS-Center Sonderjylland, Hospital of Southern Jutland, Aabenraa, Denmark
- Organ Centre, Hospital of Southern Jutland, Aabenraa, Denmark
- institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Lone Hvid
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark
| | - Jakob Grauslund
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
| | - Jimmi Wied
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark
| | - Henning Glerup
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Søren Geill Kjær
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Jan Fallingborg
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Seyed A G R Moghadd
- Department of Internal Medicine, Herning Regional Hospital, Herning, Denmark
| | - Torben Knudsen
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Jacob Brodersen
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Jesper Frøjk
- Department of Gastroenterology, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Bo Bojesen
- Focused Research Unit for Molecular Diagnostic and Clinical Research, IRS-Center Sonderjylland, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Grith Lykke Sorensen
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Steffen Thiel
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Nils J Færgeman
- Department of Biochemistry and Molecular Biology, Villum Center for Bioanalytical Sciences, University of Southern Denmark, Odense, Denmark
| | - Ivan Brandslund
- institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Biochemistry, Lillebaelt Hospital, Vejle, Denmark
| | - Tue Bjerg Bennike
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Allan Stensballe
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Erik Berg Schmidt
- Department of Cardiology, Aalborg University Hospital, Ålborg, Denmark
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - David Ellinghaus
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Philip Rosenstiel
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Jeroen Raes
- Departmentof Microbiology and Immunology, Rega Institute, KU Leuven—University of Leuven, Leuven, Belgium
- VIB, Center for the Biology of Disease, Leuven, Belgium
| | - Mette Boye
- Focused Research Unit for Molecular Diagnostic and Clinical Research, IRS-Center Sonderjylland, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Lars Werner
- The Danish Psoriasis Association, The Danish Psoriasis Association, Tåstrup, Denmark
| | | | - Heidi Lausten Munk
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Torkell Ellingsen
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | - Uffe Holmskov
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Jens Kjeldsen
- Department of Gastroenterology, Odense University Hospital, Odense, Denmark
| | - Vibeke Andersen
- Focused Research Unit for Molecular Diagnostic and Clinical Research, IRS-Center Sonderjylland, Hospital of Southern Jutland, Aabenraa, Denmark
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
- institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- OPEN, University of Southern Denmark, Odense, Denmark
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16
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Gudmann NS, Siebuhr AS, Christensen AF, Ejstrup L, Sørensen GL, Loft AG, Karsdal MA, Bay-Jensen AC, Munk HL, Junker P. Type I and III collagen turnover is increased in axial spondyloarthritis and psoriatic arthritis. Associations with disease activity and diagnostic capacity. Clin Exp Rheumatol 2017; 35:653-659. [PMID: 28240584] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/20/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To investigate the turnover of type I and III collagen by neo-epitope markers in patients with axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA). METHODS Patients with PsA (n=101) or axSpA (n=110) and healthy subjects (n=120) were included. Demographic and clinical data were recorded. Markers of type I and III collagen were quantified by RIA (ICTP) or ELISA (C1M and C3M). Non-parametric statistics were applied for intergroup comparisons and correlation studies. The diagnostic potential of these marker molecules was assessed by ROC analysis. RESULTS C1M and C3M, which originate from soft connective tissues, were significantly higher in axSpA and PsA as compared with healthy control subjects. CIM and C3M correlated with ASDAS and DAS28. Overall, ICTP, which arises from bone degradation, did not differ between disease versus healthy. However, ICTP was lower in HLA-B27 positive than in HLA-B27 negative patients with axSpA. There was no association between bone and soft connective tissue collagen I markers (ICTP and C1M), while C1M and C3M were highly correlated (p<0.0001). C1M discriminated between healthy and diseased with AUCs of 0.83 for PsA and 0.79 for axSpA. C3M AUCs were 0.77 for PsA and 0.78 for axSpA. CONCLUSIONS Type I and III collagen remodelling in soft connective tissue is increased in axSpA and PsA and associates with disease activity. Bone collagen degradation is lower in HLA-B27 positive compared with HLA-B27 negative axSpA, which may represent an aspect of enhanced enthesopathic bone proliferation in HLA-B27 carriers. C1M and C3M distinguish well between healthy and diseased individuals.
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Affiliation(s)
| | | | | | - Leif Ejstrup
- Department of Rheumatology, Esbjerg Hospital, Denmark
| | | | - Anne Gitte Loft
- Department of Rheumatology, Vejle Hospital; and Department of Rheumatology, Aarhus University Hospital, Denmark
| | | | | | | | - Peter Junker
- Department of Rheumatology, Odense University Hospital, Denmark
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17
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Hermansen LT, Loft AG, Christiansen AA, Munk HL, Gilbert L, Jurik AG, Arnbak B, Manniche C, Weber U, Østergaard M, Pedersen SJ, Barington T, Junker P, Hørslev-Petersen K, Hendricks O. No diagnostic utility of antibody patterns against Klebsiella pneumoniae capsular serotypes in patients with axial spondyloarthritis vs. patients with non-specific low back pain: a cross-sectional study. Scand J Rheumatol 2016; 46:296-302. [DOI: 10.1080/03009742.2016.1205659] [Citation(s) in RCA: 5] [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] [Indexed: 10/21/2022]
Affiliation(s)
- LT Hermansen
- King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - AG Loft
- Department of Medicine, Hospital Lillebælt, Vejle, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - AA Christiansen
- King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - HL Munk
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - L Gilbert
- Department of Biology and Environmental Science and NanoScience Centre, University of Jyväskylä, Jyväskylä, Finland
| | - AG Jurik
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebælt, Middelfart, Denmark
| | - B Arnbak
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebælt, Middelfart, Denmark
| | - C Manniche
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebælt, Middelfart, Denmark
| | - U Weber
- King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - M Østergaard
- Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - SJ Pedersen
- Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Copenhagen, Denmark
| | - T Barington
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - P Junker
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - K Hørslev-Petersen
- King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - O Hendricks
- King Christian 10th Hospital for Rheumatic Diseases, Gråsten, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
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18
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Gudmann NS, Munk HL, Christensen AF, Ejstrup L, Sørensen GL, Loft AG, Karsdal MA, Bay-Jensen AC, He Y, Siebuhr AS, Junker P. Chondrocyte activity is increased in psoriatic arthritis and axial spondyloarthritis. Arthritis Res Ther 2016; 18:141. [PMID: 27306080 PMCID: PMC4910260 DOI: 10.1186/s13075-016-1040-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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: 04/05/2016] [Accepted: 05/31/2016] [Indexed: 01/22/2023] Open
Abstract
Background Psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) are chronic inflammatory rheumatic diseases with complex origins. Both are characterized by altered extracellular matrix remodeling in joints and entheses that results in destructive and osteochondral proliferative lesions. There is a need for biomarkers reflecting core disease pathways for diagnosis and disease mapping. Pro-C2 reflects mature cartilage collagen type IIB formation, while C-Col10 represents turnover of type X collagen, which is exclusively expressed by hypertrophic chondrocytes. The objectives of this study were to study cartilage metabolism in axSpA and PsA by assessing Pro-C2 and C-Col10 and to evaluate their diagnostic utility against a healthy reference population. Methods Patients with PsA (n = 101) or axSpA (n = 110) were recruited consecutively from three rheumatology outpatient clinics. Demographic and clinical disease measures were recorded. Pro-C2 and C-Col10 were quantified in serum by using newly developed and specific competitive enzyme-linked immunosorbent assays based on monoclonal antibodies. One-way analysis of variance and Tukey’s multiple comparison tests were performed on log-transformed data. ROC curve analysis was carried out to evaluate their discriminative power. Results Pro-C2 levels in serum were significantly increased in both axSpA (median concentration 1.11 ng/ml, 0.67–1.64) and PsA (median concentration 1.03 ng/ml, 0.53–1.47) compared with healthy controls (median concentration 0.30 ng/ml, 0.16–0.41) (p < 0.0001). Pro-C2 did not differ according to treatment. C-Col10 was slightly but equally elevated in the PsA and axSpA groups vs. the control group, but it was significantly lower in patients with axSpA undergoing tumor necrosis factor-α inhibitor (TNFi) treatment. ROC curve analysis revealed AUCs of 0.85 (95 % CI 0.79–0.89) for axSpA and 0.81 (95 % CI 0.75–0.86) for PsA. Conclusions These findings indicate that cartilage collagen metabolism was enhanced in the axSpA and PsA groups compared with the healthy control group. The lower C-Col10 level in patients with axSpA undergoing TNFi treatment may reflect that hypertrophic chondrocytes in axSpA are targeted by TNFi. ROC curve analysis showed a diagnostic potential for Pro-C2 in axSpA and PsA.
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Affiliation(s)
- Natasja Stæhr Gudmann
- Nordic Bioscience Biomarkers and Research, Herlev Hovedgade 207, Herlev, 2730, Denmark.
| | | | | | - Leif Ejstrup
- Department of Rheumatology, Esbjerg Hospital, Esbjerg, Denmark
| | - Grith Lykke Sørensen
- Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Vejle Hospital, Vejle, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Asser Karsdal
- Nordic Bioscience Biomarkers and Research, Herlev Hovedgade 207, Herlev, 2730, Denmark
| | | | - Yi He
- Nordic Bioscience Biomarkers and Research, Herlev Hovedgade 207, Herlev, 2730, Denmark
| | - Anne Sofie Siebuhr
- Nordic Bioscience Biomarkers and Research, Herlev Hovedgade 207, Herlev, 2730, Denmark
| | - Peter Junker
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
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Munk HL, Gudmann NS, Christensen AF, Ejstrup L, Sorensen GL, Loft AG, Bay-Jensen AC, Siebuhr AS, Junker P. Cartilage collagen type II seromarker patterns in axial spondyloarthritis and psoriatic arthritis: associations with disease activity, smoking and HLA-B27. Rheumatol Int 2015; 36:541-9. [PMID: 26620690 DOI: 10.1007/s00296-015-3397-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 11/12/2015] [Indexed: 02/01/2023]
Abstract
The aim of the study was to assess the possible association between type II collagen turnover seromarkers and disease profile in patients with axial spondyloarthritis (SpA) and psoriatic arthritis (PsA). Outpatients with axial SpA (n = 110) or PsA (n = 101) underwent clinical examination including disease activity measures and HLA-B27 typing. The procollagen IIA N-terminal peptide (PIIANP) and a matrix metalloproteinase-generated type II collagen fragment (C2M) were quantified in serum by ELISA. C2M was higher in SpA than in controls, 0.41 versus 0.36 ng/ml (p = 0.004), while PIIANP did not differ between patients and healthy subjects, 2252 versus 2142 ng/ml (p = 0.13). However, DMARD-naïve SpA patients had higher PIIANP, 2461 ng/ml (p = 0.01) and C2M, 0.44 ng/ml (p = 0.0007) levels than controls, and PIIANP correlated with CRP (ρ = 0.34). C2M was lower in SpA smokers, 0.36 ng/ml versus non-smokers, 0.43 ng/ml (p = 0.02), while PIIANP was higher in HLA-B27 positive, 2312 ng/ml versus negative patients, 2021 ng/ml (p = 0.03). In PsA, PIIANP and C2M did not differ between patients and controls, but PIIANP was elevated in patients not receiving DMARDs, 2726 ng/ml. In PsA, PIIANP and C2M did not differ according to smoking and HLA-B27. Cartilage degradation assessed by C2M is increased in SpA irrespective of treatment but not in PsA. Cartilage synthesis reflected by PIIANP is increased in untreated SpA and PsA. PIIANP correlates with CRP in SpA while not in PsA. In DMARD-naïve SpA but not in PsA, HLA-B27 positivity and smoking are associated with a chondro-proliferative metabolic pattern.
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Affiliation(s)
- Heidi Lausten Munk
- Department of Rheumatology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| | | | | | - Leif Ejstrup
- Department of Rheumatology, Esbjerg Hospital, Esbjerg, Denmark
| | - Grith Lykke Sorensen
- Institute of Molecular Medicine, University of Southern Denmark, Odense C, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Vejle Hospital, Vejle, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne C Bay-Jensen
- Rheumatology Biomarkers and Research, Nordic Bioscience, Herlev, Denmark
| | - Anne Sofie Siebuhr
- Rheumatology Biomarkers and Research, Nordic Bioscience, Herlev, Denmark
| | - Peter Junker
- Department of Rheumatology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
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Munk HL, Svendsen AJ, Hjelmborg JVB, Sorensen GL, Kyvik KO, Junker P. Heritability assessment of cartilage metabolism. A twin study on circulating procollagen IIA N-terminal propeptide (PIIANP). Osteoarthritis Cartilage 2014; 22:1142-7. [PMID: 25008205 DOI: 10.1016/j.joca.2014.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 06/05/2014] [Accepted: 06/28/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this investigation was to estimate the heritability of circulating collagen IIA N-terminal propeptide (PIIANP) by studying mono- and dizygotic healthy twin pairs at different age and both genders. DESIGN 598 monozygotic (MZ) and dizygotic (DZ) twin individuals aged 18-59 years were recruited from the Danish Twin Registry. PIIANP was measured by competitive ELISA. The similarity of circulating PIIANP among MZ and DZ twins was assessed by intraclass correlations according to traits. The heritability was estimated by variance component analysis accounting for additive and dominant genetic factors as well as shared and non-shared environment but ignoring epistasis (genetic inter-locus interaction) and gene-environment interaction. RESULTS The intraclass correlation of PIIANP in MZ and DZ twins was 0.69 (0.60-0.76) and 0.46 (0.34-0.58) respectively indicating a significant genetic impact on PIIANP in serum. Additive genetic effects explained 45% (21-70%), shared environment 24% (7-53%) and non-shared environment 31% (24-39%) of the total variance. The heritability estimate did not differ across ages and between genders. CONCLUSIONS The study shows that approximately 45% of the collagen IIA synthesis as assessed by the collagen IIA N-terminal propeptide in serum is attributable to genetic effectors while individual and shared environment account for 24% and 31% respectively. The heritability does not differ between genders or according to age.
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Affiliation(s)
- H L Munk
- Department of Rheumatology C, Odense University Hospital, Denmark; University of Southern Denmark, Denmark.
| | - A J Svendsen
- The Danish Twin Registry, Epidemiology, Institute of Public Health, Denmark; University of Southern Denmark, Denmark.
| | - J v B Hjelmborg
- Epidemiology and Statistics, Institute of Public Health, Denmark; University of Southern Denmark, Denmark.
| | - G L Sorensen
- Institute for molecular Medicine, Denmark; University of Southern Denmark, Denmark.
| | - K O Kyvik
- Institute of Regional Health Services Research, Denmark; University of Southern Denmark, Denmark.
| | - P Junker
- Department of Rheumatology C, Odense University Hospital, Denmark; University of Southern Denmark, Denmark.
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