POS0506 DIFFERENT BIOACTIVE LIPID PROFILES PREDICT RESPONSE TO TNF OR IL6 INHIBITORS IN RHEUMATOID ARTHRITIS: RESULT OF THE CorEvitas CERTAIN COMPARATIVE EFFECTIVENESS STUDY

Background

Circulating bioactive lipids can provide information about the pathogenesis of specific diseases and potentially help predict therapeutic response. Choosing the right biological therapy earlier in the course of rheumatoid arthritis (RA) could help reach the goal of remission.

Objectives

We hypothesized that circulating bioactive lipids at baseline would identify specific metabolic profiles that predict patient response to therapy and define elements of metabolic pathobiology in arthritis.

Methods

Bioactive lipids were measured in plasma from two cohorts of RA patients from the CorEvitas (formerly known as Corrona) CERTAIN registry (1) at baseline prior to treatment with TNF inhibitors (all biologic naïve, N=102) or anti-IL6 (all previously exposed to biologics, N=114). Response to treatment was categorized by minimal clinically important difference (MCID) in Clinical Disease Activity Index (CDAI) (2) at 6 months after treatment initiation. Patients had to have a 6 month follow up visit and plasma available at both the baseline and the f/u time points. Liquid chromatography (LC) system coupled with high resolution QExactive orbitrap mass spectrometer (LC/MS) was used for bioactive lipids profiling. Around 300 spectral features were identified as potential oxylipins by searching against an in-house MS/MS library. Logistic regression analyses adjusted for gender, age and BMI was perfomed using R software.

Results

102 patients (average age 54, standard deviation [SD] 12.6, 82% female [83], average BMI 29.7, SD 6.7, average CDAI 27.1, SD 13.7) starting anti-TNF therapy and 114 patients (average age 57, SD 13, 90% female [102], average BMI 30.5, SD 7.4, average CDAI 28.7, SD 13.8) starting tocilizumab were analyzed. Twenty-five bioactive metabolites discriminated between RA patients classified as anti-TNF responders (R, n = 74) and non-responders (NR, n = 28). Among these, the anti-inflammatory oxylipin maresin 2 was higher in R while the pro-inflammatory oxylipins 15d PGJ2 and 5,6-diHETE were higher in NR. Twenty different metabolites discriminated anti-IL6 R (n=73) and NR (n=41) as shown in Figure 1. The anti-inflammatory oxylipin 14-15EET was higher in R while the pro-inflammatory oxylipins 16-HETE and 5S-HpETE were higher in NR.

Figure 1.

Volcano plots visualizing baseline metabolites associated with responders vs. non responders in a) anti-TNF and b) anti IL-6 therapy groups. Results are derived from multivariate logistic regression analysis of baseline metabolites and response to treatment categorized by MCID. Data plotted as the metabolite against its statistical significance, respectively reported as odds ratio (OR) and -log10(pvalue).

Conclusion

Circulating bioactive lipid analysis using LC/MS provided a rapid analysis of a wide range of metabolites and can be used to describe metabolic signatures that predict response to therapies. These results lay the groundwork for more deliberate investigations novel metabolic-based interventions to predict response to therapy and reduce arthritis morbidity.

References

[1]Pappas DA, Kremer JM, Reed G, Greenberg JD, Curtis JR. Design characteristics of the CORRONA CERTAIN study: a comparative effectiveness study of biologic agents for rheumatoid arthritis patients. BMC Musculoskeletal Disord 2014; 15: 113

[2]Curtis JR, Yang S, Chen L, Pope JE, Keystone EC, Haraoui B, Boire G, Thorne JC, Tin D, Hitchon CA, Bingham CO 3rd, Bykerk VP. Determining the Minimally Important Difference in the Clinical Disease Activity Index for Improvement and Worsening in Early Rheumatoid Arthritis Patients. Arthritis Care Res (Hoboken). 2015 Oct;67(10):1345-53. doi: 10.1002/acr.22606. PMID: 25988705; PMCID: PMC4580563.

Disclosure of Interests

Mona Alotaibi: None declared, Roxana Coras: None declared, Dimitrios A Pappas Speakers bureau: Sanofi, Novartis, Paid instructor for: Novartis, Consultant of: Roche, Sanofi, Joel M Kremer Speakers bureau: Pfizer, Consultant of: BMS, Geoffrey Thiele: None declared, Ted Mikuls Consultant of: Pfizer, Gilead, BMS, Sanofi, Mohit Jain Employee of: Sapient Bio, Monica Guma Grant/research support from: Pfizer, Novartis.

POS0435 CHARACTERISTICS AND 6-MONTH OUTCOMES AMONG REAL-WORLD PATIENTS WITH RHEUMATOID ARTHRITIS INITIATING UPADACITINIB: ANALYSIS FROM THE CORRONA REGISTRY

Background:

Upadacitinib (UPA) has demonstrated efficacy in randomized controlled trials1-3; however, few data are available from patients with rheumatoid arthritis (RA) who have been treated with UPA in real-world clinical practice.

Objectives:

Describe the characteristics and 6-month outcomes in patients with RA initiating UPA in a real-world setting.

Methods:

We identified adults with RA enrolled in the Corrona RA Registry through October 31, 2020 who initiated UPA during or after August 2019 and had a follow-up visit 6 (±3) months after initiation of UPA. Descriptive statistics were used to summarize characteristics in all patients initiating UPA who had a 6-month follow-up visit. Outcomes (CDAI, modified HAQ-DI, pain, and fatigue) were described at the 6-month visit for all UPA initiators regardless of UPA use at 6 months and for the subset of patients who continued UPA through the 6-month visit. Patients who discontinued UPA before the 6-month visit were considered non-responders for dichotomous variables and were assigned the value at the time of discontinuation for continuous variables. Mean change from baseline in continuous variables was analyzed with one-sample t tests or one-sample Wilcoxon rank sum tests. Minimum clinically important difference (MCID) in HAQ-DI is defined as an improvement of 0.22 units or more. MCID in CDAI is an improvement of at least 2, 7, and 13 units for patients in low, moderate and severe disease at initiation, respectively. MCID for 100-point VAS is an improvement of ≥10 points. Percentages of patients achieving MCID thresholds were calculated.

Results:

We identified 181 patients who initiated UPA and had a 6-month follow-up visit. Mean±SD age was 58.6±12.1 years, 81% were female. Patients had RA for a mean of 11.5±9.8 years. At UPA initiation, 45% of patients were on monotherapy. Prior use of one or more TNFi and JAKi was 79% and 52%, respectively. Seventy-two percent of patients (n=130) initiated UPA as the third or higher line of therapy. Mean CDAI was 18.7±11.6 and mean HAQ-DI was 1.1±0.8 at initiation. Based on CDAI (n=155), 29%, 52%, and 15% of patients had high, moderate, and low disease activity, respectively; 4.5% were in remission at initiation. At 6 months (n=158), 22%, 39%, and 28% had high, moderate, and low disease activity, respectively; 11% were in remission. Among 138 initiators with valid CDAI measures at initiation and 6 months, mean change in CDAI was –4.8±11.8, P<0.01. At 6 months, 46% (63/138) maintained and 39% (54/138) achieved improvement in any CDAI category. Improvements in other outcomes were significantly different from zero. Improvements >=MCID in CDAI, HAQ-DI, pain, and fatigue were achieved in 36–44% of UPA initiators. Improvements were similar, but larger in the subset of patients (n=122) who continued UPA through the 6-month visit (Table 1).

Conclusion:

Among patients in the Corrona RA Registry, UPA is frequently started in those who failed multiple previous therapies. UPA initiators responded to therapy in the first 6 months with improvements in several disease activity measures including CDAI and HAQ-DI, as well as patient-reported pain and fatigue.

References:

[1]Fleischmann R. Arthritis Rheumatol. 2019;71:1788–800.

[2]Smolen JS. Lancet. 2019;393:2303–11.

[3]Burmester GR. Lancet. 2018;382:2505–12.

Outcomes at 6-month follow-upAll initiators(n=181)Subset remainingon UPA (n=122)nValueanValueaRemission (CDAI <2.8)15818 (11)10512 (11)Low (CDAI >=2.8 and <10)15844 (28)10538 (36)Moderate (CDAI >=10 and <22)15862 (39)10536 (34)High (CDAI >=22)15834 (22)10519 (18)Improvement in any CDAI category13854 (39)8940 (45)Maintenance of CDAI category13863 (46)10539 (44)Mean change in CDAI138–4.8±11.8*89–7.1±12.0* HAQ-DI154–0.1±0.5*101–0.2±0.5* Pain154–9.3±25.1*101–13.5±25.8* Fatigue153–7.6±27.3*100–12.5±27.5*MCID achievement in CDAI13857 (41)8943 (48) HAQ-DI15455 (36)10139 (39) Pain15468 (44)10153 (52) Fatigue15365 (42)10049 (49)

aMean±SD or n (%).

*P<0.01 for improvement significantly different from zero.

Acknowledgements:

This study was sponsored by Corrona, LLC. Corrona has been supported through contracted subscriptions in the last 2 years by AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Crescendo, Eli Lilly and Company, Genentech, Gilead, GSK, Janssen, Merck, Momenta Pharmaceuticals, Novartis, Pfizer, Regeneron, Roche, Sun, UCB, and Valeant. The design, study conduct, and financial support for the study were provided by AbbVie. AbbVie participated in the interpretation of data, review, and approval of the abstract. No honoraria or payments were made for authorship.

Medical writing services were provided by Joann Hettasch of Fishawack Facilitate Ltd., part of Fishawack Health, and funded by AbbVie.

Disclosure of Interests:

Joel M Kremer Shareholder of: Corrona, Consultant of: AbbVie, Grant/research support from: AbbVie, Employee of: Corrona, Namita Tundia Shareholder of: AbbVie, Employee of: AbbVie, Robert McLean Employee of: Corrona, Taylor Blachley Employee of: Corrona, anna maniccia Shareholder of: AbbVie, Employee of: AbbVie, Dimitrios A Pappas Shareholder of: Corrona, Consultant of: AbbVie, Genentech, Novartis, Regeneron, and Roche Hellas, Employee of: Corrona

FRI0100 COMPARISON OF PATIENTS (PTS) WITH RHEUMATOID ARTHRITIS (RA) AMONG DISEASE ACTIVITY CATEGORIES AFTER 6 MONTHS OF TREATMENT WITH A TUMOUR NECROSIS FACTOR INHIBITOR (TNFI): RESULTS FROM THE CORRONA® RA REGISTRY

Background:

Targeting remission (REM) or low disease activity (LDA) is a widely accepted treatment strategy for RA. However, there are limited data on the proportion of pts who achieve these targets, or remain in moderate (MDA) or high disease activity (HDA) following advanced therapy.

Objectives:

To estimate the proportion of RA pts in disease activity states (REM, LDA, MDA, and HDA) who were biologic-naïve at initiation and had continuous treatment with a TNFi for 6–12 months in the Corrona RA registry.

Methods:

Eligible pts were aged ≥18 years, biologic-naïve, initiated TNFi treatment between January 1, 2010 and July 31, 2019, and had continuous use of a TNFi for 6–12 months. Disease activity was defined based on Clinical Disease Activity Index (CDAI) at the visit closest to 6-month follow-up: REM, ≤2.8; LDA, >2.8–10; MDA, >10–22; and HDA, >22. Disease characteristics, disease activity measures, and pt-reported outcomes (PROs) were reported at TNFi initiation and at the 6-month follow-up visit.

Results:

2586 biologic-naïve pts who initiated a TNFi and had continuous use for 6–12 months were included. At TNFi initiation, 167 (6%) were in REM, 479 (19%) had LDA, 907 (35%) had MDA, and 1033 (40%) had HDA. After 6–12 months of treatment, 563 (21.8%) were in REM, 923 (35.7%) had LDA, 674 (26.1%) had MDA, and 426 (16.5%) had HDA. Pts with HDA/MDA at 6–12 months were more likely to have a history of hypertension (32.7% HDA; 34.0% MDA; vs 23.6% REM) and had higher mean body mass index (BMI) (30.9 HDA; 31.1 MDA; vs 29.0 REM) at baseline compared with pts in REM. Disease activity measures and PROs were worse in pts with MDA and HDA vs LDA and REM after 6–12 months (Table). Pt Global Assessment was higher than Physician Global Assessment across all groups.

Conclusion:

While 57.4% of pts who initiated a TNFi experienced a favorable outcome, >40% required additional or alternative intervention to achieve REM/LDA. Pts who remained in MDA/HDA continued to have an inadequate response to TNFi (as measured by disease activity measures and PROs) after 6–12 months of treatment compared with those who achieved REM/LDA.

Table

Summary of disease activity measures and PROs in previously biologic-naïve pts at the 6–12-month follow-up visit, stratified by disease activity category at the 6–12-month follow-up visit

Characteristics at 6–12 months, mean (standard deviation)Disease activity category at 6–12 monthsREM (n=563)LDA (n=923)MDA (n=674)HDA (n=426)CDAI1.2 (0.8)6.2 (2.1)15.4 (3.4)32.7 (9.2)Tender joint count (28)0.1 (0.3)1.0 (1.3)4.3 (3.3)13.4 (7.0)Swollen joint count (28)0.1 (0.3)1.1 (1.6)4.0 (3.6)9.1 (5.9)C-reactive protein6.4 (22.7)7.0 (10.6)11.1 (19.9)12.6 (22.1)Modified health assessment questionnaire0.1 (0.2)0.3 (0.4)0.5 (0.5)0.8 (0.5)Pt global assessment6.6 (6.8)28.6 (20.9)43.7 (25.7)58.0 (22.7)Physician global assessment3.6 (4.3)12.1 (10.4)27.4 (15.9)44.9 (19.8)Pt pain assessment8.7 (11.0)30.3 (23.5)46.1 (27.0)59.9 (24.4)Pt fatigue assessment15.7 (19.2)34.5 (26.6)48.3 (28.0)59.4 (27.5)Morning stiffness (min)16.5 (36.5)55.4 (146.3)96.9 (197.5)143.6 (260.0)

Disclosure of Interests:

Joel M Kremer Shareholder of: May own stocks and opinions, Grant/research support from: Research and consulting fees from AbbVie Inc., Consultant of: AbbVie, Amgen, BMS, Genentech, Inc., Gilead, GSK, Lilly, Pfizer, Regeneron and Sanofi, Employee of: Corrona, LLC employee, Anne Winkler Consultant of: AbbVie, Pfizer, and Novratis, Speakers bureau: AbbVie, Janssen, Sanofi, Genentech, Celgene, Eli Lilly, and Novartis., Laura Anatale-Tardiff Employee of: Corrona, LLC employee, Robert McLean Employee of: Corrona, LLC, Ying Shan Employee of: Corrona, LLC employee, Page Moore Employee of: Corrona, LLC employee, Namita Tundia Shareholder of: May own stocks and options, Employee of: AbbVie employee, Jessica Suboticki Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., John Tesser Consultant of: Sanofi/Regeneron, Speakers bureau: Sanofi/Regeneron

FRI0104 PERSISTENCE OF TOCILIZUMAB THERAPY AMONG PATIENTS WITH RHEUMATOID ARTHRITIS: DATA FROM THE US-BASED CORRONA RHEUMATOID ARTHRITIS REGISTRY

Background:

Understanding the persistence of biologic therapies and factors associated with discontinuation can help inform treatment decisions for patients with rheumatoid arthritis (RA).

Objectives:

To evaluate the persistence of tocilizumab (TCZ) therapy and identify factors associated with its discontinuation among US patients with RA in routine clinical practice.

Methods:

Eligible participants were TCZ-naïve patients enrolled in the Corrona RA registry who initiated TCZ after January 1, 2010 and had ≥ 1 follow-up visit. Persistence of therapy was defined as maintaining continuous TCZ treatment with no interruptions; patients were considered no longer persistent upon the first discontinuation of TCZ. Persistence was calculated using Kaplan-Meier survival analysis for the overall population; secondary analyses evaluated persistence excluding patients who stopped TCZ with no reported reason for discontinuation (patients with non-medical reasons for discontinuation [eg, insurance] were censored) and in only those patients who initiated intravenous (IV) TCZ. Cox proportional hazards modeling was used to identify factors associated with persistence.

Results:

A total of 1789 TCZ initiators were included; 81.0% were female, 85.0% were white and 75.4% were overweight or obese. The mean (SD) age was 58.5 (12.6) years and mean (SD) disease duration was 12.0 (9.6) years. Most patients (93.4%) had prior biologic use and 67.4% had received ≥ 2 prior biologics. Overall, 28.8% initiated TCZ as monotherapy. Among all TCZ initiators, the median (95% CI) duration of persistence was 20 (18 to 22) months (Fig 1). Factors associated with an increased hazard of TCZ discontinuation included smoking and higher baseline CDAI, whereas prior tumor necrosis factor inhibitor (TNFi) use was associated with a reduced hazard (Fig 2A). After excluding patients with no reported reason for discontinuation (remaining n = 1303), the median (95% CI) duration of persistence was 46 (38 to 55) months (Fig 1); smoking, use of 1 prior non-TNFi and higher baseline patient pain score were associated with an increased hazard of discontinuation (Fig 2B). Among the 1284 patients who initiated TCZ IV, median (95% CI) duration of persistence was 22 (19 to 25) months (Fig 1); smoking, lack of insurance and higher baseline patient fatigue score were associated with an increased hazard of discontinuation, whereas use of 1 prior TNFi was associated with a decreased hazard (Fig 2C).

Conclusion:

In this real-world population of US patients with RA, TCZ was most frequently initiated after an inadequate response to ≥ 2 biologics. Overall median duration of persistence was approximately 20 months and was higher (46 months) when patients with no reported reason for TCZ discontinuation were excluded. As expected, factors indicative of higher baseline disease activity were associated with shorter persistence.

Acknowledgments:

This study was sponsored by Corrona, LLC. Corrona is supported through contracted subscriptions with multiple pharmaceutical companies. The abstract was a collaborative effort between Corrona and Genentech, Inc., with financial support provided by Genentech, Inc.

Disclosure of Interests:

Dimitrios A Pappas: None declared, Taylor Blachley Employee of: Corrona, LLC, Jennie H. Best Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Steve Zlotnick Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Kelechi Emeanuru Employee of: Corrona, LLC – employment, Joel M Kremer Shareholder of: May own stocks and opinions, Grant/research support from: Research and consulting fees from AbbVie Inc., Consultant of: AbbVie, Amgen, BMS, Genentech, Inc., Gilead, GSK, Lilly, Pfizer, Regeneron and Sanofi, Employee of: Corrona, LLC employee

SAT0118 COMPARATIVE EFFECTIVENESS OF TOCILIZUMAB IN COMBINATION WITH METHOTREXATE VERSUS TUMOR NECROSIS FACTOR INHIBITORS (TNFIS) IN COMBINATION WITH METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH PRIOR EXPOSURE TO TNFIS

Background:

Clinical studies have demonstrated the efficacy of tocilizumab (TCZ) administered with methotrexate (MTX) in improving rheumatoid arthritis (RA) disease activity in patients who have had an inadequate response to tumor necrosis factor inhibitors (TNFis).

Objectives:

To compare the effectiveness of TCZ + MTX with that of TNFis + MTX in patients with RA who had prior exposure to TNFis in routine clinical practice.

Methods:

Eligible participants were TCZ-naïve patients from the Corrona RA registry who initiated TCZ + MTX or a TNFi + MTX after January 1, 2010 and had a 6-month follow-up visit. Patients in both groups must have used ≥ 1 TNFi, had a Clinical Disease Activity Index (CDAI) score available at initiation (baseline) and 6 months and had a CDAI score > 10 at baseline. The primary outcome was mean change in CDAI from baseline to 6 months. Secondary outcomes included achievement of low disease activity (LDA; CDAI ≤ 10) and mean change in modified Health Assessment Questionnaire (mHAQ) at 6 months. Patients were grouped by baseline MTX dose (≤ 10 mg; > 10 to ≤ 15 mg; > 15 to ≤ 20 mg; > 20 mg); outcomes were compared between patients initiating TCZ and those initiating a TNFi overall and within each MTX dose group using propensity score (PS)-trimmed populations. As a sensitivity analysis, TCZ and TNFi initiators in each group were PS-matched 1:1 and outcomes were assessed in the matched populations. Linear and logistic regression models were estimated in the trimmed and matched populations, adjusting for covariates not balanced after PS trimming or matching, respectively.

Results:

A total of 415 TCZ + MTX initiators and 725 TNFi + MTX initiators met the inclusion criteria prior to PS trimming or matching. The overall trimmed population included 402 TCZ + MTX initiators and 703 TNFi + MTX initiators. In the trimmed population, patient demographics were generally comparable between TCZ + MTX and TNFi + MTX initiators; the mean age was 57.1 years in the TCZ + MTX group and 57.7 years in the TNFi + MTX group, the majority of patients in both groups were female (≥ 80%) and white (≥ 82%) and the mean duration of RA was 11.8 and 10.5 years in the TCZ + MTX and TNFi + MTX groups, respectively. Higher proportions of patients initiating TCZ had received ≥ 2 prior biologics (66.0% to 76.3%) compared with those initiating a TNFi (33.2% to 42.2%) across all MTX dose groups. Patients initiating TCZ had higher mean baseline CDAI scores (26.5 to 29.3) than those initiating a TNFi (24.7 to 27.5). Patients in both cohorts had improvements in CDAI and mHAQ scores and achieved LDA in similar proportions at 6 months regardless of baseline MTX dose (Fig 1). Results were comparable between TCZ and TNFi initiators across all MTX groups in the trimmed population after adjustment for potential confounding variables. Similar results were observed in the PS-matched cohorts.

Conclusion:

In this real-world population of US patients with RA who had prior TNFi exposure, there was no statistically significant or clinically meaningful difference in the effectiveness of therapy in patients who initiated TCZ + MTX compared with TNFi + MTX.

Acknowledgments :

This study was sponsored by Corrona, LLC. Corrona is supported through contracted subscriptions with multiple pharmaceutical companies. The abstract was a collaborative effort between Corrona and Genentech, Inc., with financial support provided by Genentech, Inc.

Disclosure of Interests: :

Dimitrios A Pappas: None declared, Taylor Blachley Employee of: Corrona, LLC, Steve Zlotnick Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Jennie H. Best Shareholder of: Genentech, Inc., Employee of: Genentech, Inc., Kelechi Emeanuru Employee of: Corrona, LLC – employment, Joel M Kremer Shareholder of: May own stocks and opinions, Grant/research support from: Research and consulting fees from AbbVie Inc., Consultant of: AbbVie, Amgen, BMS, Genentech, Inc., Gilead, GSK, Lilly, Pfizer, Regeneron and Sanofi, Employee of: Corrona, LLC employee

Disease activity in rheumatoid arthritis and the risk of cardiovascular events

OBJECTIVE

Use of several immunomodulatory agents has been associated with reduced numbers of cardiovascular (CV) events in epidemiologic studies of rheumatoid arthritis (RA). However, it is unknown whether time-averaged disease activity in RA correlates with CV events.

METHODS

We studied patients with RA whose cases were followed in a longitudinal US-based registry. Time-averaged disease activity was assessed during followup using the area under the curve of the Clinical Disease Activity Index (CDAI), a validated measure of RA disease activity. Age, sex, presence of diabetes mellitus, hypertension, or hyperlipidemia, body mass index, family history of myocardial infarction (MI), use of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), presence of CV disease, and baseline use of an immunomodulator were assessed at baseline. Cox proportional hazards regression models were examined to determine the risk of a composite CV end point that included MI, stroke, and death from CV causes.

RESULTS

A total of 24,989 patients who had been followed up for a median of 2.7 years were included in these analyses. During followup, we observed 534 confirmed CV end points, for an incidence rate of 7.8 per 1,000 person-years (95% confidence interval [95% CI] 6.7-8.9). In models adjusted for variables noted above, a 10-point reduction in the time-averaged CDAI was associated with a 21% reduction in CV risk (95% CI 13-29). These results were robust in subgroup analyses stratified by the presence of CV disease, use of corticosteroids, use of NSAIDs or selective cyclooxygenase 2 inhibitors, and change in RA treatment, as well as when restricted to events adjudicated as definite or probable.

CONCLUSION

Our findings showed that reduced time-averaged disease activity in RA is associated with fewer CV events.

Greater remission rates in patients with early versus long-standing disease in biologic-naive rheumatoid arthritis patients treated with abatacept: a post hoc analysis of randomized clinical trial data

OBJECTIVES

Current aim of rheumatoid arthritis (RA) treatment is to achieve remission in as many patients as possible. Rates of remission and clinical outcomes after treatment with abatacept in biologic-naive rheumatoid arthritis (RA) patients with early disease and an inadequate response to methotrexate (MTX) versus patients with ≥ 10 years of disease were assessed.

METHODS

Data from two trials assessing the efficacy of abatacept in MTX inadequate responders were pooled for this exploratory post hoc analysis. Patients with disease duration of ≤ 2 years at baseline (early disease), originally assigned to an abatacept approximately 10 mg/kg treatment arm and entered into a long-term extension (LTE), were compared with patients with ≥ 10 years of disease (long-standing RA). Remission, DAS28-CRP, ACR 70 responses and the Routine Assessment of Patient Index Data 3 (RAPID3), improvement in physical function as measured by the Health Assessment Questionnaire Disability Index (HAQ-DI).

RESULTS

Twenty-three percent of these patients (n=108) had early disease. A higher percentage of patients with early disease achieved DAS28-CRP remission versus patients with long-standing disease (35.2% vs. 19.4% at year 1, p<0.01; 46.0% vs. 30.9% at year 3, p<0.05). In addition, a higher percentage of the subgroup with early RA achieved ACR70 responses. More patients with early RA had a meaningful improvement in their HAQ-DI (75.2% vs. 60.4%; p<0.05) and RAPID3 scores at one year (mean changes from baseline of -9.6 vs. -8.1; p=0.009).

CONCLUSIONS

These data provide additional support for the possible use of abatacept in biologic-naive patients who have had inadequate response to MTX, earlier in their disease course.

Elevated liver enzyme tests among patients with rheumatoid arthritis or psoriatic arthritis treated with methotrexate and/or leflunomide

INTRODUCTION

Potential hepatotoxicity associated with disease-modifying antirheumatic drugs (DMARDs) requires laboratory monitoring. In patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA), the incidence of elevated alanine aminotransferase/aspartate aminotransferase (ALT/AST) enzymes associated with methotrexate (MTX), leflunomide (LEF) and MTX+LEF versus other DMARDs was examined.

METHODS

Patients with RA and PsA enrolled in the Consortium of Rheumatology Researchers of North America (CORRONA) initiating DMARDs were identified. Abnormalities were identified when either was 1- or 2-fold times above the upper limits of normal (ULN). Odds ratios (OR) between MTX/LEF dose and elevated ALT/AST enzymes were estimated using generalised estimating equations. Interaction terms for use of MTX+LEF quantified the incremental risk of the combination compared with each individually.

RESULTS

Elevated ALT/AST levels (>1x ULN) occurred in 22%, 17%, 31% and 14% of patients with RA receiving MTX, LEF, MTX+LEF or neither, respectively; elevations were 2.76-fold (95% CI 1.84 to 4.15) more likely in patients with PsA. Elevations >2x ULN occurred in 1-2% of patients on MTX or LEF monotherapy compared with 5% with the combination. After multivariable adjustment and compared with either monotherapy, the combination of MTX and LEF was associated with a greater risk according to MTX dose used as part of the combination: MTX 10-17.5 mg/week, OR 2.91 (95% CI 1.23 to 6.90); MTX > or =20 mg/week, OR 3.98 (95% CI 1.72 to 9.24).

CONCLUSIONS

Abnormal ALT/AST levels developed in 14-35% of patients with RA or PsA initiating DMARD therapy. The risks were incrementally greater in those with PsA and in those receiving MTX (> or =10 mg/day) + LEF. These findings should help inform monitoring for potential hepatotoxicity in these patient populations.

Improved pain, physical functioning and health status in patients with rheumatoid arthritis treated with CP-690,550, an orally active Janus kinase (JAK) inhibitor: results from a randomised, double-blind, placebo-controlled trial

OBJECTIVES

To determine the efficacy of CP-690,550 in improving pain, function and health status in patients with moderate to severe active rheumatoid arthritis (RA) and an inadequate response to methotrexate or a tumour necrosis factor alpha inhibitor.

METHODS

Patients were randomised equally to placebo, CP-690,550 5, 15 or 30 mg twice daily for 6 weeks, with 6 weeks' follow-up. The patient's assessment of arthritis pain (pain), patient's assessment of disease activity, Health Assessment Questionnaire-Disability Index (HAQ-DI) and Short Form-36 (SF-36) were recorded.

RESULTS

At week 6, significantly more patients in the CP-690,550 5, 15 and 30 mg twice-daily groups experienced a 50% improvement in pain compared with placebo (44%, 66%, 78% and 14%, respectively), clinically meaningful reductions in HAQ-DI (> or =0.3 units) (57%, 75%, 76% and 36%, respectively) and clinically meaningful improvements in SF-36 domains and physical and mental components.

CONCLUSIONS

CP-690,550 was efficacious in improving the pain, function and health status of patients with RA, from week 1 to week 6.

Prevalence of low hemoglobin levels and associations with other disease parameters in rheumatoid arthritis patients: evidence from the CORRONA registry

OBJECTIVE

To estimate the prevalence of low hemoglobin (Hb) levels in a large US cohort of patients with rheumatoid arthritis (RA) and examine the relationship between Hb levels and RA severity, associated comorbidities, and quality-of-life parameters by cross-sectional analysis of data from the Consortium of Rheumatology Researchers of North America (CORRONA) registry.

METHODS

The study population comprised patients with RA >18 years of age and clinical information recorded in the CORRONA registry between October 1, 2001 and February 1, 2007. Patients were separated into low (Hb <13 g/dl for men; <12 g/dl for women) and normal Hb groups (Hb >13 g/dl for men; >12 g/dl for women). Hb levels were calculated from recorded hematocrit values.

RESULTS

Of the 10,397 study patients, 1734 (16.7%) had low Hb levels and 8663 (83.3%) had normal Hb levels. More patients in the low Hb group had a history of comorbid cardiovascular disease, diabetes, and gastrointestinal disease. The low Hb group exhibited greater disease severity and activity (p<0.05) as reported by patients and rheumatologists. In multivariate analyses, RA severity ([odds ratio] OR 1.24; 95% confidence interval [CI]: 1.07-1.44) and ESR (OR 1.04; 95% CI: 1.03-1.05), and comorbid bleeding ulcers (OR 2.04; 95% CI: 1.01-4.12) were predictive of low Hb levels.

CONCLUSION

Despite changes in treatment paradigms, low Hb levels remain prevalent in RA patients. This analysis suggests that low Hb levels may be associated with RA disease severity and the presence of certain comorbidities.

Association of methotrexate and tumour necrosis factor antagonists with risk of infectious outcomes including opportunistic infections in the CORRONA registry

OBJECTIVE

To examine the association of methotrexate (MTX) and tumour necrosis factor (TNF) antagonists with the risk of infectious outcomes including opportunistic infections in patients with rheumatoid arthritis (RA).

METHODS

Patients with RA enrolled in the Consortium of Rheumatology Researchers of North America (CORRONA) registry prescribed MTX, TNF antagonists or other disease-modifying antirheumatic drugs (DMARDs) were included. The primary outcomes were incident overall and opportunistic infections. Incident rate ratios were calculated using generalised estimating equation Poisson regression models adjusted for demographics, comorbidities and RA disease activity measures.

RESULTS

A total of 7971 patients with RA were followed. The adjusted rate of infections per 100 person-years was increased among users of MTX (30.9, 95% CI 29.2 to 32.7), TNF antagonists (40.1, 95% CI 37.0 to 43.4) and a combination of MTX and TNF antagonists (37.1, 95% CI 34.9 to 39.3) compared with users of other non-biological DMARDs (24.5, 95% CI 21.8 to 27.5). The adjusted incidence rate ratio (IRR) was increased in patients treated with MTX (IRR 1.30, 95% CI 1.12 to 1.50) and TNF antagonists (IRR 1.52, 95% CI 1.30 to 1.78) compared with those treated with other DMARDs. TNF antagonist use was associated with an increased risk of opportunistic infections (IRR 1.67, 95% CI 0.95 to 2.94). Prednisone use was associated with an increased risk of opportunistic infections (IRR 1.63, 95% CI 1.20 to 2.21) and an increased risk of overall infection at doses >10 mg daily (IRR 1.30, 95% CI 1.11 to 1.53).

CONCLUSIONS

MTX, TNF antagonists and prednisone at doses >10 mg daily were associated with increased risks of overall infections. Low-dose prednisone and TNF antagonists (but not MTX) increased the risk of opportunistic infections.

Abatacept inhibits progression of structural damage in rheumatoid arthritis: results from the long-term extension of the AIM trial

OBJECTIVE

Assess the effect of abatacept on progression of structural damage over 2 years in patients with rheumatoid arthritis who had an inadequate response to methotrexate.

METHODS

539 patients entered an open-label extension of the AIM (Abatacept in Inadequate responders to Methotrexate) trial and received abatacept. Radiographic assessment of the hands and feet was performed at baseline, year 1 and year 2. At year 2, each patient's radiographs were scored for progression blinded to sequence and treatment allocation.

RESULTS

In patients treated with abatacept for 2 years, greater reduction in progression of structural damage was observed in year 2 than in year 1. The mean change in total Genant-modified Sharp scores was reduced from 1.07 units in year 1 to 0.46 units in year 2. Similar reductions were observed in erosion and joint space narrowing scores. Following 2 years of treatment with abatacept, 50% of patients had no progression of structural damage as defined by a change in the total score of < or =0 compared with baseline. 56% of patients treated with abatacept had no progression during the first year compared with 45% of patients treated with placebo. In their second year of treatment with abatacept, more patients had no progression than in the first year (66% vs 56%).

CONCLUSIONS

Abatacept has a sustained effect that inhibits progression of structural damage. Furthermore, the mean change in radiographic progression in patients treated with abatacept for 2 years was significantly lower in year 2 versus year 1, suggesting that abatacept may have an increasing disease-modifying effect on structural damage over time.

The CORRONA database

BACKGROUND

Large, long-term databases are needed in order to provide information on the safety and efficacy of new agents used in the treatment of rheumatoid arthritis (RA) and psoriatic arthritis (PsA). These databases can provide data which is well beyond what is available from industry-sponsored investigations.

METHODS

The structure, governance, content, context and developmental plan of the CORRONA database is described.

RESULTS

The CORRONA database has grown from start up in 2002 to the largest independent database in North America which collects data from both rheumatologists and patients at the time of a clinical encounter. Data are collected as often as every 3 months in RA and every 6 months in PsA. As of the time of this writing, the CORRONA database consists of approximately 9,000 patients with RA and 1,000 with PsA. Data can be used to elucidate toxicities found in frequencies which would be considerably less common than can be uncovered in industry-sponsored investigations. In addition, actual prescribing patterns and responses in clinical practice can be investigated and described.

CONCLUSION

After 3 years of data collection, the CORRONA database is now appropriately able to make significant contributions to our understanding of the safety, efficacy of drugs, as well as demographic, and socioeconomic profiles of patients with RA and PsA. It has evolved from a nascent database to a mature one poised to make significant contributions.

Methotrexate dosage reduction in patients with rheumatoid arthritis beginning therapy with infliximab: the Infliximab Rheumatoid Arthritis Methotrexate Tapering (iRAMT) trial

OBJECTIVE

Infliximab plus methotrexate (MTX) is approved for the treatment of rheumatoid arthritis (RA). Based on the benefit/risk profile of this combination therapy, lower doses of MTX would be preferable when infliximab efficacy can be maintained. We evaluated the ability of patients receiving infliximab plus MTX to achieve and maintain a clinical response while the dose of MTX was tapered.

METHODS

Infliximab infusions were administered at a minimum dosage of 3 mg/kg at 8-week intervals (following three loading doses at weeks 0, 2, and 6) to patients who had an inadequate response to MTX. MTX tapering was initiated at week 22 or later when at least a 40% improvement in the combined tender and swollen joint count was achieved; dosages were reduced by 5 mg every 8 weeks to a protocol-specified minimum dosage of 5 mg per week. If the required dosage of MTX after a flare was greater than the baseline dosage, the patient was considered a treatment failure.

RESULTS

Of the 210 patients enrolled, 159 (76%) achieved a 40% or better improvement in the combined tender and swollen joint count and had their MTX doses tapered. In these 159 responders, the median (mean) dose of MTX was reduced from 15 (16.5) mg per week at baseline to 5 (7.1) mg per week at week 54. From the time of initial response, 79% of these patients had a zero- or a one-vial increase in infliximab, corresponding to an approximate dose increase of 1 mg/kg, through week 54.

CONCLUSION

Approximately 75% of the patients participating in this trial achieved at least a 40% reduction in the combined swollen and tender joint count (correlating with an American College of Rheumatology 20% [ACR20] response in 83% of patients) while reducing the mean MTX dose by 57%.

Benefit/risk of leflunomide in rheumatoid arthritis

Leflunomide was first shown to have disease-modifying properties in a rat model of adjuvant-induced arthritis. Leflunomide has been subsequently used with success in several animal models of tissue and organ allograft and of autoimmune disease including collagen- and adjuvant-induced arthritis, interstitial nephritis, myasthenia gravis, and systemic lupus erythematosus. Based on its success as an immunosuppressive agent in these models, leflunomide was tested for the treatment of rheumatoid arthritis (RA).

A randomized, double-blind, crossover clinical trial of diclofenac plus misoprostol versus acetaminophen in patients with osteoarthritis of the hip or knee

OBJECTIVE

To perform a randomized, double-blind, crossover clinical trial of diclofenac + misoprostol versus acetaminophen in ambulatory patients with osteoarthritis of the hip or knee.

METHODS

Patients in 12 ambulatory care settings were eligible if they were age >40 years and if they had Kellgren/Lawrence radiographic grade 2-4 osteoarthritis of the knee or hip and a score of > or =30 mm on a 100-mm visual analog pain scale. Patients were randomized to one of two groups, 75 mg diclofenac + 200 microg misoprostol twice daily or 1,000 mg acetaminophen 4 times daily (each for 6 weeks), and were then crossed over to the other treatment for 6 weeks. A placebo was included in each treatment regimen to enable double blinding. The primary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index and the visual analog pain scale of the Multidimensional Health Assessment Questionnaire. Safety was assessed using a standard form to review adverse events.

RESULTS

We enrolled 227 patients, of whom 218 provided data for the first treatment period and 181 provided data for both treatment periods. Significantly higher levels of improvement in the primary outcomes were seen for diclofenac + misoprostol than for acetaminophen (P < 0.001). Adverse events were more common when patients took diclofenac + misoprostol (P = 0.046). Diclofenac + misoprostol was rated as "better" or "much better" by 57% of the 174 patients who provided such ratings for both treatment periods, while acetaminophen was rated as "better" or "much better" by 20% of these patients, and 22% reported no difference (P < 0.001). Differences favoring diclofenac + misoprostol over acetaminophen were greater in patients with more severe osteoarthritis according to baseline pain scores, radiographs, or number of involved joints.

CONCLUSION

Patients with osteoarthritis of the hip or knee had significantly greater improvements in pain scores over 6 weeks with diclofenac + misoprostol than with acetaminophen, although patients with mild osteoarthritis had similar improvements with both drugs. Acetaminophen was associated with fewer adverse events.

Rational use of new and existing disease-modifying agents in rheumatoid arthritis

Because of radiographic evidence of progressive bone loss and the inability to eliminate synovial proliferation with methotrexate, it became apparent that therapy for rheumatoid arthritis needed further advancement. Methotrexate is not a remission-inducing drug and may have dose-limiting toxicity. In the past 2 years, three new disease-modifying antirheumatic drugs (DMARDs) have been approved: leflunomide, etanercept, and infliximab. Each of these agents has demonstrated efficacy compared with placebo in randomized, controlled studies. Because methotrexate had a dominant therapeutic role, the new drugs were also studied in combination with it. Other established DMARDs, such as sulfasalazine and hydroxychloroquine, have also demonstrated efficacy when used together with methotrexate. The results of these combination studies clearly demonstrate that clinical responses can be meaningfully improved when new and existing DMARDs are added to methotrexate. Although toxicity remains a serious concern when powerful immune modulators and antimetabolites are used in combination, relatively few serious adverse events have been reported during 2-year treatment periods. It has also become apparent that combinations of new DMARDs and methotrexate virtually halt radiographic progression over 2 years. The new agents are expensive, but annual costs must be weighed against the personal and societal expense of joint arthroplasty, hospitalizations, disability, and diminished quality of life that accompanies poorly controlled rheumatoid arthritis. The ultimate value of combination DMARD therapy with methotrexate will be determined by long-term data on safety, efficacy, and effects on radiographic deterioration of bone. Additional long-term observational data on the incidence of joint arthroplasty and disability will help to place the issue of societal costs in a better perspective. This will allow the value of aggressive treatment to be established with certainty.

Leflunomide for the treatment of rheumatoid arthritis

Leflunomide treatment appears to offer an alternative to methotrexate and sulfasalazine and is a welcome addition to the therapeutic armamentarium for treating active RA. Leflunomide treatment for more than 12 months results in clinically meaningful improvements in disease-specific measures of physical function. The phase 3 trials have shown leflunomide to be as effective as methotrexate and sulfasalazine and an option for initial DMARD therapy. As with all new agents, the long-term safety and value of leflunomide will be determined by use in the clinic.

n-3 fatty acid supplements in rheumatoid arthritis

Ingestion of dietary supplements of n-3 fatty acids has been consistently shown to reduce both the number of tender joints on physical examination and the amount of morning stiffness in patients with rheumatoid arthritis. In these cases, supplements were consumed daily in addition to background medications and the clinical benefits of the n-3 fatty acids were not apparent until they were consumed for > or =12 wk. It appears that a minimum daily dose of 3 g eicosapentaenoic and docosahexaenoic acids is necessary to derive the expected benefits. These doses of n-3 fatty acids are associated with significant reductions in the release of leukotriene B(4) from stimulated neutrophils and of interleukin 1 from monocytes. Both of these mediators of inflammation are thought to contribute to the inflammatory events that occur in the rheumatoid arthritis disease process. Several investigators have reported that rheumatoid arthritis patients consuming n-3 dietary supplements were able to lower or discontinue their background doses of nonsteroidal antiinflammatory drugs or disease-modifying antirheumatic drugs. Because the methods used to determine whether patients taking n-3 supplements can discontinue taking these agents are variable, confirmatory and definitive studies are needed to settle this issue. n-3 Fatty acids have virtually no reported serious toxicity in the dose range used in rheumatoid arthritis and are generally very well tolerated.

Combination therapy with multiple disease-modifying antirheumatic drugs in rheumatoid arthritis: a preventive strategy

The traditional "pyramid" or sequential approach to treatment of patients with rheumatoid arthritis involved use of a nonsteroidal anti-inflammatory drug for months to years while seeking to avoid use of second-line antirheumatic drugs until evidence of joint damage was seen. This approach led to short-term reduction of inflammation and a few remissions. However, long-term remissions were rare, and most patients experienced poor long-term outcomes, including joint destruction, severe functional declines, considerable economic losses, work disability, and premature mortality. At this time, a "preventive" strategy is evolving in which early aggressive treatment with disease-modifying antirheumatic drugs is used, seeking to minimize long-term joint damage. When residual inflammation remains after maximum doses of single agents, as is usually the case, combinations of disease-modifying antirheumatic drugs appear to be a reasonable consideration for many patients. Methotrexate is the most commonly used "anchor drug" in combination therapy. Evidence from randomized, controlled clinical trials and observational studies have indicated increased efficacy and acceptable (and often lower) toxicity for combinations of methotrexate plus cyclosporine, hydroxychloroquine, sulfasalazine, leflunomide, etanercept, and infliximab. Further studies lasting 5 years or more are needed to determine the long-term effectiveness, toxicities, and optimal clinical use of disease-modifying antirheumatic drug combinations. At this time, such combinations are taken by at least some patients under care of almost all rheumatologists, and it appears likely that they will be used increasingly in the coming decades.

Methotrexate and leflunomide combination therapy for patients with active rheumatoid arthritis

An open-label, one-year study was conducted to evaluate the safety and clinical response to leflunomide and methotrexate combination therapy for rheumatoid arthritis. Study results revealed tolerable safety, no significant pharmacokinetic interactions between methotrexate and leflunomide, and suggested improved clinical response with combination therapy.

Methotrexate and emerging therapies

More publications in the medical literature have described the clinical efficacy and toxicity of methotrexate (MTX) than of any other drug ever used for rheumatic diseases. A knowledgeable clinical can thus rely on evidence-based medicine to guide the use of this agent. Because MTX is not remission-inducing, many new therapies are being combined with it in order to achieve a greater therapeutic response. This trend will likely continue and expand as more novel agents are introduced.

Methotrexate and leflunomide: biochemical basis for combination therapy in the treatment of rheumatoid arthritis

OBJECTIVES

Methotrexate is currently one of the most widely prescribed disease-modifying antirheumatic drugs (DMARDs) for the treatment of rheumatoid arthritis (RA). Combination therapy of methotrexate with other DMARDs increases the clinical success of low-dose methotrexate treatment. Leflunomide is a new DMARD that may have a high potential for success in combination therapy with methotrexate. This review compares the mode of action of methotrexate and leflunomide and speculates on how this contributes to therapeutic efficacy in RA when these agents are used singly or in combination.

METHODS

A literature review of the biochemical mechanisms considered to be the basis for the therapeutic efficacy of methotrexate and leflunomide in treating RA is presented.

RESULTS

Low-dose methotrexate inhibits cytokine production, purine biosynthesis, and, in an animal model, causes the release of adenosine, a potent antiinflammatory agent. Leflunomide, through inhibition of de novo pyrimidine biosynthesis, can regulate lymphocyte proliferation.

CONCLUSIONS

The biochemical mechanisms underlying the therapeutic efficacy of low-dose methotrexate and leflunomide in the treatment of RA are quite different. The potentially complementary mechanisms of action of these two effective DMARDs should provide a rationale for their use in combination therapy for patients whose condition no longer responds to methotrexate alone.

Pharmacokinetics, safety, and efficacy of combination treatment with methotrexate and leflunomide in patients with active rheumatoid arthritis

OBJECTIVE

To examine the safety and pharmacokinetics of and clinical response to leflunomide, a de novo pyrimidine synthesis inhibitor, when administered to patients with active rheumatoid arthritis (RA) who have been receiving long-term methotrexate therapy.

METHODS

This was an open-label, 52-week study in which 30 patients with RA that remained active despite therapy with methotrexate at 17+/-4 mg/week (mean +/- SD) for > or =6 months were given leflunomide, 10-20 mg/day. Patients were assessed for adverse effects, pharmacokinetic measurements of leflunomide and methotrexate, and clinical response by American College of Rheumatology (ACR) 20% response criteria.

RESULTS

Twenty-three patients completed 1 year of treatment. No significant pharmacokinetic interactions between leflunomide and methotrexate were noted. This combination therapy was generally well tolerated clinically, with the exception of elevations of liver enzyme levels. Seven patients withdrew from the treatment regimen: 2 withdrawals were voluntary, 3 were due to persistent elevation of plasma transaminase levels, and 2 were due to lack of efficacy. Of the patients, 16 (53%) met ACR 20% response criteria. Two met ACR criteria for remission after 1 year.

CONCLUSION

The combination of methotrexate and leflunomide has therapeutic potential in RA.

The psychosocial effects of rheumatoid arthritis on the patient and the well partner

Rheumatoid arthritis (RA) is a chronic disorder that can have a severe impact on patient's lives. This present study investigated four questions regarding the psychosocial effects on patients and their well partners. First we found that depression for both patients and partners were slightly elevated and 35.7% of patients and 23.3% of well partners had scores above the cut-off for possible clinical depression on the Center for Epidemiological Studies Depression Scale. Second, there was no significant difference between the patients' level of distress and that of the partners. Third, there were moderate positive correlations between patients' and partners' scores on measure of psychological functioning. Fourth, there were no differences in either the patients' or partners' well-being based on the gender of the patient. Finally, an exploratory analysis was conducted to examine the factors which influence the patients' and partners' depression and their view of the relationship.

A trial of etanercept, a recombinant tumor necrosis factor receptor:Fc fusion protein, in patients with rheumatoid arthritis receiving methotrexate

BACKGROUND

Patients treated with methotrexate for rheumatoid arthritis often improve but continue to have active disease. This study was undertaken to determine whether the addition of etanercept, a soluble tumor necrosis factor receptor (p75):Fc fusion protein (TNFR:Fc), to methotrexate therapy would provide additional benefit to patients who had persistent rheumatoid arthritis despite receiving methotrexate.

METHODS

In a 24-week, double-blind trial, we randomly assigned 89 patients with persistently active rheumatoid arthritis despite at least 6 months of methotrexate therapy at a stable dose of 15 to 25 mg per week (or as low as 10 mg per week for patients unable to tolerate higher doses) to receive either etanercept (25 mg) or placebo subcutaneously twice weekly while continuing to receive methotrexate. The primary measure of clinical response was the American College of Rheumatology criteria for a 20 percent improvement in measures of disease activity (ACR 20) at 24 weeks.

RESULTS

The addition of etanercept to methotrexate therapy resulted in rapid and sustained improvement. At 24 weeks, 71 percent of the patients receiving etanercept plus methotrexate and 27 percent of those receiving placebo plus methotrexate met the ACR 20 criteria (P<0.001); 39 percent of the patients receiving etanercept plus methotrexate and 3 percent of those receiving placebo plus methotrexate met the ACR 50 criteria (for a 50 percent improvement) (P<0.001). Patients receiving etanercept plus methotrexate had significantly better outcomes according to all measures of disease activity. The only adverse events associated with etanercept were mild injection-site reactions, and no patient withdrew from the study because of adverse events associated with etanercept.

CONCLUSIONS

In patients with persistently active rheumatoid arthritis, the combination of etanercept and methotrexate was safe and well tolerated and provided significantly greater clinical benefit than methotrexate alone.

Methotrexate and emerging therapies

It is likely that all new therapeutic interventions will be used with methotrexate in combination therapy. These combinations may yield real therapeutic advances. The potential for end organ toxicity, opportunistic infection, and malignancy will need to be carefully monitored with long-term, meticulously conducted observational studies. Expense, ease of use, and perceived benefit-to-risk ratio will determine which new agents become most commonly prescribed with methotrexate.

Treatment of rheumatoid arthritis with oral type II collagen. Results of a multicenter, double-blind, placebo-controlled trial

OBJECTIVE

Oral administration of cartilage-derived type II collagen (CII) has been shown to ameliorate arthritis in animal models of joint inflammation, and preliminary studies have suggested that this novel therapy is clinically beneficial and safe in patients with rheumatoid arthritis (RA). The present study was undertaken to test the safety and efficacy of 4 different dosages of orally administered CII in patients with RA.

METHODS

Two hundred seventy-four patients with active RA were enrolled at 6 different sites and randomized to receive placebo or 1 of 4 dosages (20, 100, 500, or 2,500 microg/day) of oral CII for 24 weeks. Efficacy parameters were assessed monthly. Cumulative response rates (percentage of patients meeting the criteria for response at any time during the study) were analyzed utilizing 3 sets of composite criteria: the Paulus criteria, the American College of Rheumatology criteria for improvement in RA, and a requirement for > or = 30% reduction in both swollen and tender joint counts.

RESULTS

Eighty-three percent of patients completed 24 weeks of treatment. Numeric trends in favor of the 20 microg/day treatment group were seen with all 3 cumulative composite measures. However, a statistically significant increase (P = 0.035) in response rate for the 20 microg/day group versus placebo was detected using only the Paulus criteria. The presence of serum antibodies to CII at baseline was significantly associated with an increased likelihood of responding to treatment. No treatment-related adverse events were detected. The efficacy seen with the lowest dosage is consistent with the findings of animal studies and with known mechanisms of oral tolerance in which lower doses of orally administered autoantigens preferentially induce disease-suppressing regulatory cells.

CONCLUSION

Positive effects were observed with CII at the lowest dosage tested, and the presence of serum antibodies to CII at baseline may predict response to therapy. No side effects were associated with this novel therapeutic agent. Further controlled studies are required to assess the efficacy of this treatment approach.

Long-term exposure to methotrexate induces immunophenotypic changes, decreased methotrexate uptake and increased dihydrofolate gene copy number in Jurkat T cells

Methotrexate (MTX) treatment of rheumatoid arthritis may require increasing doses to maintain clinical efficacy. An overall plateau of clinical response is reached after only six months of treatment. To study the immunologic, biochemical and genetic effects of MTX on T cells, the Jurkat T cell line was made MTX-resistant by serial addition of methotrexate sodium into culture medium. Cells proliferated and divided successfully in MTX concentrations ranging to 15 microM. MTX resistance of Jurkat T cells in vitro was accompanied by significantly (P < 0.05) decreased expression of CD2, CD3, CD4, CD28, and CD69, IL-2 production, and MTX uptake assessed by cell association or disassociation of 3[H]-MTX or fluoresceinated MTX (FMTX), respectively. In addition, there was DHFR gene amplification and increased levels of DHFR in all resistant cell lines. Both permanent and transient phenotypic changes developed in resultant cell lines exposed to increasing concentrations of MTX in vitro. Expression of CD4 and CD25 and sensitivity to MTX returned to near-parental levels after removal of MTX from culture medium, whereas expression of CD26 and MTX uptake were significantly increased. Expression of CD2, CD3, CD69 and IL-2 production as well as the DHFR levels did not return to the parental phenotype after removal from MTX. We conclude that MTX-cultured cells express depressed levels of cell-surface markers vital for T cell function and activation. The return of enhancement of these cell-surface markers critical to T cell activation suggests a possible mechanism for the severe flares experienced by rheumatoid arthritis patients when drug treatment is discontinued.