Intervertebral fusion sites in patients with ankylosing spondylitis: A computed tomography study

OBJECTIVES

To examine intervertebral fusion sites along the whole spine of patients with ankylosing spondylitis using computed tomography.

METHODS

This retrospective study examined intervertebral fusion of five sites (anterior/posterior vertebrae, left/right zygapophyseal joints, and spinous process) on 23 vertebrae in the cervical, thoracic, and lumbar regions of the spine in 40 patients diagnosed with ankylosing spondylitis at our institute between January 2004 and December 2022.

RESULTS

Mean age [± standard deviation (SD)] was 40.5 (± 17) years, and mean disease duration (± SD) was 11.4 (± 10.5) years at computed tomography evaluation; 55.9% were human leukocyte antigen B-27-positive. Fifteen (37.5%) patients showed intervertebral fusion in the thoracic and/or cervical regions, but not in the lumbar region. Fusion of posterior vertebrae was observed most frequently in the thoracic region, compared to the cervical and lumbar regions. In particular, more than half of the patients showed fusion of posterior vertebrae Th4-Th5 to Th7-Th8.

CONCLUSIONS

In 37.5% of patients, intervertebral fusion was evident in the thoracic and/or cervical regions but not in the lumbar region. The most common site and region of intervertebral fusion were the posterior vertebrae of the middle thoracic region.

Comparison of effectiveness of methotrexate in patients with late-onset versus younger-onset rheumatoid arthritis: Real-world data from an inception cohort in Japan (NICER-J)

OBJECTIVE

To compare the effectiveness of methotrexate (MTX) as initial therapy in patients with late-onset and younger-onset rheumatoid arthritis (LORA and YORA).

METHODS

Of 114 patients with YORA and 96 patients with LORA, defined as RA occurring at ≥65 years of age, enrolled in a multicentre RA inception cohort study, 71 and 66 patients who had been followed up to 6 months after starting MTX treatment were included in this study.

RESULTS

Proportions of patients on MTX treatment at 6 months were 96% and 92% in the YORA and LORA groups, respectively. Despite lower doses of MTX in the LORA group compared with the YORA group, no significant difference was observed in clinical disease activity index scores between the two groups throughout the follow-up period. The proportion of patients in clinical disease activity index remission at 6 months was 35% in both groups. Logistic regression analysis revealed that knee joint involvement and high Health Assessment Questionnaire-Disability Index were significant negative predictors of achieving clinical disease activity index remission at 6 months in the LORA group.

CONCLUSION

Observations up to 6 months revealed that the effectiveness of MTX administered based on rheumatologist discretion in patients with LORA is comparable to that in patients with YORA in clinical settings.

Well-controlled disease activity with drug treatment will not improve the frailty status of RA patients to robust state: A multicenter observational study (T-FLAG)

OBJECTIVES

To investigate a plateau in treatment enhancement for improving the frailty status of rheumatoid arthritis (RA) patients.

METHODS

A total of 345 RA patients who were not robust in 2021 were assigned to the improved ("robust 2022," n = 51) and non-improved ("pre-frailty/frailty 2022," n = 294) groups. Factors associated with "robust 2022" were examined by logistic regression analysis. Patients were assigned to the stable (Follow-up mean DAS28-ESR in 2020 and 2021 < 3.2, n = 225) and unstable (≥3.2, n = 120) groups, which were further divided into the non-improved (stable: n = 180, unstable: n = 114) and improved (stable: n = 45, unstable: n = 6) groups. Factors influencing Japanese Cardiovascular Health Study (J-CHS) score were examined by multiple regression analysis. Changes over 2 years were compared between the non-improved and improved groups of the stable group.

RESULTS

The associated factor of "robust 2022" was the follow-up meanDAS28-ESR in 2020 and 2021 < 3.2 (i.e., stable state) (OR: 4.01). Follow-up mean DAS28-ESR in 2020 and 2021 was associated with J-CHS score (T = 2.536, p = .013) only in the unstable group. In the stable group, HAQ-DI was lower (2020: 0.32 vs. 0.16; 2021: 0.32 vs. 0.17; 2022: 0.32 vs. 0.21), and the proportion of J-CHS: Q4 (weakness) was lower (2020: 48.4 vs. 17.8%; 2021: 55.0 vs. 29.2%; 2022: 50.4 vs. 0%), in the improved group than in the non-improved group, whereas both groups maintained clinical and functional remission over 2 years.

CONCLUSIONS

Drug treatment to maintain well-controlled disease activity alone is insufficient for improving patients' frailty status after achieving treat-to-target goals, suggesting the need for multifaceted approaches.

Association between laughter, frailty, and depression in rheumatoid arthritis patients

OBJECTIVE

This study aimed to determine whether there are associations between laughter, disease activity, frailty, and depression in rheumatoid arthritis (RA) patients.

METHODS

A total of 240 patients were included in this prospective cohort study on frailty in RA patients between March 2021 and June 2022. Patients were divided into the following four groups according to the frequency of laughter: "almost every day," "1-5 days per week," "1-3 days per month," and "never or almost never." Patient characteristics were compared among the four groups by analysis of variance. Factors associated with laughter were identified by multivariable logistic analysis.

RESULTS

The mean 28-joint Disease Activity Score using CRP was 1.91, with 70.7% of patients in remission and 12.6% in low disease activity. For the "almost every day" (42.5% of patients), "1-5 days per week" (40.0%), "1-3 days per month" (11.3%), and "never or almost never" (6.3%) groups, scores of the Kihon Checklist (KCL) for assessing frailty status were 3.5, 4.6, 7.3, and 8.1 (p < .001), respectively, and scores of the Beck Depression Inventory (BDI-II) were 8.4, 10.7, 15.1, and 16.5 (p < .001), respectively. Multivariable analysis revealed that KCL (OR: 0.81, 95% CI: 0.73-0.90) and BDI-II (OR: 0.91, 95% CI: 0.86-0.95) scores were independently associated with the frequency of laughter.

CONCLUSION

Frailty and depression were associated with laughter in RA patients with controlled disease activity. Interventions aimed at not only disease activity control but also frailty prevention may lead to a life filled with laughter.

Disease activity at baseline is an independent predictor of frailty at one year in pre-frail patients with rheumatoid arthritis; a multicenter retrospective observational study

OBJECTIVES

To investigate factors predicting frailty for one year in pre-frail patients with rheumatoid arthritis (RA).

METHOD

A total of 298 RA patients who were pre-frail in 2020 were evaluated in this structured, retrospective observational study. Of the 298 patients, 42 who were frail and 256 who were not in 2021 were assigned to the frailty and non-frailty groups, respectively. After comparing characteristics of both groups using univariate analysis, predictive factors of frailty were assessed by logistic regression analysis. The proportion of frail patients in 2021 by DAS28-ESR level in 2020 was examined by the Cochran-Armitage trend test and chi-squared test. After dividing pre-frail patients into those with DAS28-ESR ≥3.2 and DAS28-ESR <3.2 in 2020, one-year change in DAS28-ESR in the frailty and non-frailty groups for both subgroups were compared by the paired t-test.

RESULTS

The frailty group was older (mean: 71.0 vs. 65.4 years) and had a higher DAS28-ESR (mean: 3.22 vs. 2.70) than the non-frailty group. DAS28-ESR was identified as a predictive factor for frailty (OR: 1.49). Among patients with DAS28-ESR ≥3.2 in 2020, DAS28-ESR improved in the non-frailty group in 2021 (mean: 3.97 in 2020 vs. 3.13 in 2021) but did not in the frailty group (3.97 in 2020 vs. 3.81 in 2021). Among those with DAS28-ESR <3.2 in 2020, DAS28-ESR was unchanged in the non-frailty group in 2021 (2.15 in 2020 vs. 2.23 in 2021) but increased in the frailty group (2.53 in 2020 vs. 3.23 in 2021).

CONCLUSIONS

Disease activity at baseline is an independent predictor of frailty one year later in pre-frail patients with RA.

Associations of frailty with RA-ILD and poor control of disease activity in patients with rheumatoid arthritis: A multi-center retrospective observational study

BACKGROUND

This study aimed to investigate factors associated with frailty in rheumatoid arthritis (RA) patients.

METHODS

A total of 656 RA patients were evaluated using data from an observational study in 2022. Among these patients, 152 with frailty were assigned to the frailty group, and 504 without frailty were assigned to the non-frailty group. Patient characteristics were compared between the two groups by univariate analysis, and factors associated with frailty were assessed by logistic regression analysis. Patient characteristics were also compared between patients with RA-associated interstitial lung disease (RA-ILD) (n = 102) and those without RA-ILD (n = 554).

RESULTS

The frailty group was older (mean: 73.6 vs. 66.8 years) and had a higher DAS28-ESR (3.67 vs. 2.66), a higher HAQ-DI (1.13 vs. 0.32), and a higher rate of RA-ILD (25.0 vs. 12.7 %) than the non-frailty group. Age (OR: 1.03, 95 % CI: 1.01-1.05), HAQ-DI (3.22, 2.28-4.56), DAS28-ESR (1.44, 1.19-1.75), and RA-ILD (2.21, 1.24-3.94) were associated with frailty. RA patients with RA-ILD were older (73.3 vs. 67.5 years) and had a higher DAS28-ESR (3.30 vs. 2.80), a higher HAQ-DI (1.19 vs. 0.32), a higher proportion of frail patients (37.3 vs. 20.6 %), lower MTX use (26.5 vs. 62.9 %), and higher steroid use (44.1 vs. 26.8 %) than those without RA-ILD.

CONCLUSIONS

Maintaining reasonable control of disease activity is necessary for RA patients, including those with RA-ILD, to recover from frailty.

Increased prevalence of Staphylococcus aureus nasal carriage in rheumatoid arthritis patients with moderate/high disease activity

BACKGROUND

Staphylococcus aureus (S. aureus) nasal carriage is a well-known risk factor for surgical site infection (SSI) after total joint arthroplasty. This study aimed to compare the prevalence of S. aureus nasal carriage between patients with osteoarthritis (OA), a degenerative joint disease, and those with rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease, who underwent total joint arthroplasty, and to investigate the influence of RA disease activity on nasal carriage rate.

METHODS

This retrospective study targeted 508 OA and 107 RA patients who underwent S. aureus nasal screening prior to primary total knee and/or hip arthroplasty. RA patients were divided into two groups based on disease activity: the remission/low disease activity (REM/LDA) group and the moderate/high disease activity (MDA/HDA) group. Factors associated with S. aureus nasal carriage were assessed with multivariate logistic regression models.

RESULTS

Of all 615 patients, 155 (25%) carried S. aureus in their nares. Compared to OA patients, RA patients had a significantly higher rate of S. aureus nasal carriage (24% vs. 33%, p = 0.049). Compared to the REM/LDA group (n = 39), the MDA/HDA group (n = 58) had a significantly higher rate of S. aureus nasal carriage (21% vs. 41%, p = 0.032). Multivariate analysis revealed that the MDA/HDA group, but not the REM/LDA group, had a significantly higher odds of S. aureus nasal carriage compared to the OA group (odds ratio: 2.76, 95% confidence interval: 1.07-7.12).

CONCLUSION

Preoperative nasal screening for S. aureus is beneficial, especially in RA patients with moderate/high disease activity.

Reasons and risk factors for discontinuation of treatment with any biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis: A long-term observational study

OBJECTIVES

Patients with rheumatoid arthritis (RA) usually switch to a second biological disease-modifying antirheumatic drugs (bDMARDs) when the first has proven to be ineffective, although some may discontinue bDMARDs treatment altogether. We investigated the total rate of bDMARDs retention and the risk of bDMARDs discontinuation in patients with RA.

METHODS

The study included 564 patients with RA who started bDMARDs treatment before 2008 (<65 years old, n = 413; ≥65, n = 151). The primary outcome was the incidence of bDMARDs discontinuation due to adverse events (AEs). Risk factors were examined using Fine and Gray regression models.

RESULTS

Among 564 patients, 74 had discontinued bDMARDs treatment due to AEs. Male sex and Steinbrocker class 3-4 were more frequent, while rheumatoid factor and concomitant methotrexate treatment were less frequent, in those aged ≥65 years than in those aged <65 years, respectively. The subdistribution hazard ratio for discontinuation was significantly higher in the ≥65 group than in the <65 years group (hazard ratio = 3.53, 95% confidence interval = 2.07-6.03). Lack of concomitant treatment with MTX was risk factor for discontinuation in patients ≥65 years. Advanced Steinbrocker class was a risk factor in patients <65 years.

CONCLUSIONS

Older patients are at higher risk of discontinuing bDMARDs treatment due to AEs than younger patients.

Relationship between frailty and methotrexate discontinuation due to adverse events in rheumatoid arthritis patients

INTRODUCTION

Methotrexate (MTX) is an anchor drug in the treatment of rheumatoid arthritis (RA). Frailty is the intermediate condition between being healthy and disabled, and can lead to negative health outcomes. Adverse events (AEs) due to RA drugs are expected to be higher in frail patients. The present study aimed to investigate the relationship between frailty and MTX discontinuation due to AEs in RA patients.

METHODS

Of 538 RA patients who visited us between June and August 2020 as part of the retrospective T-FLAG study, 323 used MTX. After 2 years of follow-up, we investigated AEs leading to MTX discontinuation. Frailty was defined as a Kihon Checklist (KCL) score ≥ 8. Cox proportional hazards regression analysis was performed to identify factors associated with MTX discontinuation due to AEs.

RESULTS

Of the 323 RA patients (251 women, 77.7%) who used MTX, 24 (7.4%) discontinued MTX due to AEs during the 2-year follow-up period. Mean ages in the MTX continuation/discontinuation groups were 64.5 ± 13.9/68.5 ± 11.7 years (p = 0.169), Clinical Disease Activity Index was 5.6 ± 7.3/6.2 ± 6.0 (p = 0.695); KCL was 5.9 ± 4.1/9.0 ± 4.9 points (p < 0.001); and the proportion of frailty was 31.8%/58.3% (p = 0.012). MTX discontinuation due to AEs was significantly associated with frailty (hazard ratio 2.34, 95% confidence interval 1.02-5.37) even after adjusting for age and diabetes mellitus. AEs included liver dysfunction (25.0%), pneumonia (20.8%), and renal dysfunction (12.5%).

CONCLUSIONS

Because frailty is a significant factor contributing to MTX discontinuation due to AEs, the latter should be carefully monitored in frail RA patients who use MTX. Key Points • Of the 323 rheumatoid arthritis (RA) patients (251 women, 77.7%) who used methotrexate (MTX), 24 (7.4%) discontinued MTX due to adverse events (AEs) during the 2-year follow-up period. • MTX discontinuation due to AEs was significantly associated with frailty (hazard ratio 2.34, 95% confidence interval 1.02-5.37) even after adjusting for age and diabetes mellitus, and neither the MTX dose, folic acid supplementation, nor GC co-therapy were factors in MTX discontinuation. • Frailty is a predominant factor in MTX discontinuation among established, long-term pretreated RA patients, and the occurrence of AEs due to MTX should be carefully monitored when frail RA patients use MTX.

Choice of and response to treatment in patients with early-diagnosed rheumatoid arthritis: Real-world data from an inception cohort in Japan (NICER-J)

OBJECTIVE

Various guidelines recommend that patients with early rheumatoid arthritis (RA) try to achieve clinical remission within 6 months, and early therapeutic intervention is important to this end. This study aimed to investigate short-term treatment outcomes of patients with early-diagnosed RA in clinical practice and to examine predictive factors for achieving remission.

METHODS

Of the 210 patients enrolled in the multicenter RA inception cohort, 172 patients who were followed up to 6 months after treatment initiation (baseline) were included. Logistic regression analysis was used to examine the impact of baseline characteristics on achievement of Boolean remission at 6 months.

RESULTS

Participants (mean age, 62 years) initiated treatment after a mean of 19 days from RA diagnosis. At baseline and 3 and 6 months after treatment initiation, proportions of patients using methotrexate (MTX) were 87.8%, 89.0%, and 88.3%, respectively, and rates of Boolean remission were 1.8%, 27.8%, and 34.5%, respectively. Multivariate analysis revealed that physician global assessment (PhGA) (Odds ratio (OR): 0.84, 95% confidence interval (CI): 0.71-0.99) and glucocorticoid use (OR: 0.26, 95% CI: 0.10-0.65) at baseline were independent factors that predicted Boolean remission at 6 months.

CONCLUSION

After a diagnosis of RA, satisfactory therapeutic effects were achieved at 6 months after the initiation of treatment centered on MTX according to the treat to target strategy. PhGA and glucocorticoid use at treatment initiation are useful for predicting the achievement of treatment goals.

Effectiveness of tacrolimus concomitant with biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis

OBJECTIVES

The study aimed to investigate the effectiveness and tolerance of biological disease-modifying antirheumatic drugs (bDMARDs) therapy administered concomitantly with tacrolimus (TAC) treatment in patients with rheumatoid arthritis.

METHODS

2792 patients who underwent therapy with five bDMARDs (etanercept: ETN, adalimumab, golimumab, tocilizumab, and abatacept: ABT) were enrolled. Among the study subjects, 1582 were concomitant methotrexate (MTX group), 147 were concomitant TAC (TAC group), and 1063 were non-concomitant MTX and TAC (non-MTX/TAC group). The primary outcome was the incident rate of discontinuation of bDMARDs by adverse events (AEs) or loss of efficacy.

RESULTS

Concerning the analysis for each reasons of discontinuation, including AEs and loss of efficacy, the hazards ratio (HR) was significantly lower in the TAC group than in non-MTX/TAC groups (AEs: HR = 0.39, 95% confidence interval, 0.23-0.68, loss of efficacy: HR = 0.49, 95% confidence interval, 0.30-0.78). The loss of efficacy with the use of ETN and ABT was lower in the TAC group than in non-MTX/TAC groups. Concomitant TAC did not induce elevated risk for discontinuation of AEs in all bDMARD analyses.

CONCLUSIONS

Concomitant TAC with ABT or ETN showed higher retention rates than bDMARDs therapy without TAC or MTX. AEs did not increase over long-term observation.

Factors associated with frailty in rheumatoid arthritis patients with decreased renal function

OBJECTIVES

To investigate factors associated with frailty in rheumatoid arthritis (RA) patients with decreased renal function.

METHODS

RA patients who visited outpatient clinics from June to August 2021 were included (N = 625). Patients with estimated glomerular filtration rate <60 ml/min/1.73 m2 were defined as having decreased renal function (N = 221) and divided into the non-frailty (N = 153) and frailty (N = 58) groups. Patient characteristics were compared between the two groups by univariate analysis. Significant factors in univariate analysis were assessed by logistic regression analysis to determine their association with frailty in patients with decreased renal function.

RESULTS

Patients in the frailty group were older (74.0 vs.79.0 years) and had a longer duration of disease (11.1 vs. 17.8 years), higher Disease Activity Score erythrocyte sedimentation rate (DAS28-ESR; 2.99 vs. 3.80), higher Health Assessment Questionnaire Disability Index (0.42 vs. 1.43), and a lower rate of methotrexate (MTX) use (46.4% vs. 25.9) compared to those in the non-frailty group. Factors associated with frailty in patients with decreased renal function were age (odds ratio: 1.07), duration of disease (1.06), DAS28-ESR (1.85), and MTX use (0.42).

CONCLUSIONS

Among factors associated with frailty in RA patients with decreased renal function, improving DAS28-ESR is likely to be the most feasible approach to promote recovery from frailty (200/200 words).

Periprosthetic humeral fracture revision using a massive allograft in a patient with rheumatoid arthritis: a case report

Total elbow arthroplasty (TEA) is a surgical option for patients with rheumatoid arthritis (RA). Periprosthetic fractures during and after TEA are one of the most common causes of reoperation. Fractures around the stem of a loose prosthesis with associated bone loss are the most technically challenging to treat. Previous reports have demonstrated that the use of massive allografts is a reasonable alternative in salvage situations. Here we report the case of a 78-year-old woman with RA who underwent revision TEA using massive allografts with modifications to the methods described in previous reports. She suffered a right periprosthetic humeral fracture 5 years after primary TEA, with a fracture in the proximal humeral diaphysis and a long spiral fracture in the diaphysis. The fracture around the stem of a loose prosthesis was associated with bone loss. We performed revision TEA using an allograft of the proximal femoral diaphysis. In contrast to previous reports, we preserved part of the humeral diaphysis, which was thin due to osteolysis, without removal. The advantage of this approach was that it preserved attachments, such as the deltoid and brachioradialis muscles. The patient had good elbow function and minimal pain without adverse events at 1 year postoperatively. Our findings suggest that preserving part of a thinned humeral diaphysis is a reasonable option in revision TEA with a massive composite allograft.

Locomotive syndrome in rheumatoid arthritis patients during the COVID-19 pandemic

This study aimed to longitudinally evaluate the development of locomotive syndrome (LS) in rheumatoid arthritis (RA) patients during the COVID-19 pandemic using the 25-question Geriatric Locomotive Function Scale (GLFS-25). Subjects were 286 RA patients (female, 70.6%; mean age, 64.2 years) who had GLFS-25 and Clinical Disease Activity Index (CDAI) data available for a 1-year period during the COVID-19 pandemic and who did not have LS at baseline. Associations between subject characteristics and development of LS were determined using logistic regression analysis. Among the 286 patients, 38 (13.3%, LS group) developed LS at 1 year after baseline. In the LS group, scores of the GLFS-25 categories "GLFS-5" and "Social activities" were significantly increased at 1 year relative to baseline. GLFS-5 is a quick 5-item version of the GLFS-25, including questions regarding the difficulty of going up and down stairs, walking briskly, distance able to walk without rest, difficulty carrying objects weighing 2 kg, and ability to carry out load-bearing tasks and housework. A significant correlation was also observed between changes in "Social activities" and that of "GLFS-5." Multivariable logistic regression analysis revealed that the development of LS was significantly associated with BMI (OR: 1.11 [95% confidence interval (CI): 1.00-1.22]) and CDAI (OR: 1.08 [95%CI: 1.00-1.16]) at baseline. Adequate exercise and tight control of RA disease activity are important for preventing the development of LS in view of restrictions on going out imposed during the COVID-19 pandemic. GLFS-5 is useful for evaluating the physical function of RA patients.

Age and Symptoms at Onset of Ankylosing Spondylitis in Japanese Patients

OBJECTIVE

To examine the age at onset and initial symptoms as clinical features of ankylosing spondylitis (AS) in Japanese patients.

METHODS

This retrospective study included 60 Japanese patients diagnosed with AS at our institute between January 2004 and June 2021. Initial symptoms were considered pain in axial joints and/or extra-axial joints. If a patient had initial symptoms at multiple sites, each site was counted. We assessed trends for the number of patients and sites of initial symptoms according to age at onset.

RESULTS

Mean age (± standard deviation) at onset was 28.9 (± 14.3) years. Approximately one-third of patients experienced onset before age 20. The back was the most common site of initial symptoms (36.7%), followed by the hip (26.7%), knee (15%), buttocks (15%), neck (10%), finger (6.7%), shoulder (3.3%), and others (including overlapping sites). Thirty-two (53.3%) and 25 (41.7%) patients had initial symptom only in axial joints and only in extra-axial joints, respectively. The proportion of patients with initial symptoms only in extra-axial joints significantly decreased with increasing age (p=0.024).

CONCLUSION

Sites of initial symptoms were frequently the back, hip, knee, and buttocks, and 41.7% had initial symptom only in extra-axial joints. Younger onset patients frequently had extra-axial involvement.

Changes in perioperative C-reactive protein levels in patients with rheumatoid arthritis undergoing total knee arthroplasty in the biologic era

This study aimed to investigate changes in and factors associated with perioperative serum C-reactive protein (CRP) levels in rheumatoid arthritis (RA) patients undergoing total knee arthroplasty (TKA) in the biologic era. A total of 173 patients (228 knees) with RA underwent elective primary TKA at our institute between January 1, 2006 and December 31, 2018. Of these, 214 cases among 161 patients were examined in this retrospective study after excluding 3cases among 3 patients who developed postoperative complications and 11 cases among 9 patients who were treated with tocilizumab. Factors associated with changes in CRP levels between baseline (preoperative) and day 7 after TKA [ΔCRP (0-7days)] were assessed by multiple regression analysis. Median (interquartile range) CRP levels were 0.69 (0.21, 1.82) mg/dl preoperatively, 5.66 (4.21, 7.61) mg/dl on postoperative day 1, 12.75 (9.79, 16.74) mg/dl on postoperative days 3-4, 3.26 (2.21, 4.85) mg/dl on postoperative day 7, and 0.87 (0.45, 1.81) mg/dl on postoperative day 14. Multivariate regression analysis revealed that body mass index ≥25 [partial regression coefficient (B)=1.03, P=0.012] and use of glucocorticoids (B=-0.86, P=0.017) were independently associated with ΔCRP (0-7days), whereas use of methotrexate and targeted drug modifying antirheumatic drugs and preoperative CRP levels (an objective biomarker of RA activity) were not. In conclusion, serum CRP levels increased rapidly after TKA and peaked on postoperative days 3-4, followed by a return to preoperative levels by postoperative day 14 in patients with RA. Obesity and the use of glucocorticoids were independently associated with changes in CRP levels.

Influence of frailty on patient global assessment in rheumatoid arthritis

AIM

Patient Global Assessment (PtGA; range 0-10 cm) is an important indicator of clinical outcomes, including physical function, in self-assessment of patients with rheumatoid arthritis (RA). Frailty is a concept that encompasses not only physical, but also mental, psychological and social vulnerability. This study aimed to investigate the influence of frailty on PtGA in patients with RA.

METHODS

Among 581 patients with RA who completed a questionnaire survey on frailty between June and August 2020, 559 who completed the Kihon Checklist (KCL; a 25-item questionnaire with seven domains) were included. The proportion of patients with PtGA ≤1 was compared between the frailty (KCL score ≥8), pre-frailty (KCL score 4-7) and robust (KCL score 0-3) groups. Factors associated with PtGA ≤1 were examined using multivariate logistic regression models.

RESULTS

Of the 559 patients, 221 (39.5%) had frailty. The proportion of patients with PtGA ≤1 was significantly lower in the frailty group (33.9%) than in the robust (65.4%, P < 0.001) and pre-frailty (55.7%, P < 0.001) groups. Multivariate analysis revealed that frailty (vs robust, OR 0.37, 95% CI 0.22-0.69), as well as disease duration and tender joint count, were factors independently associated with PtGA ≤1. When each domain of the KCL was examined, activities of daily living, physical strength, isolation and depressive mood were factors associated with PtGA ≤1.

CONCLUSION

Frailty affects PtGA in patients with RA. As frailty impacts the physical, mental and social vulnerability aspects of PtGA, a multifaceted approach, including inflammation suppression, is required to improve PtGA in patients with RA. Geriatr Gerontol Int 2022; 22: 399-404.

The Efficacy and Safety of a Novel Extramedullary Guide Coordinated with 3D Surgical Assistive Software for Total Knee Arthroplasty: an Open-Label Single-Arm Trial

To improve component-placement accuracy in total knee arthroplasty, we developed two devices: an original extramedullary patient-specific guide for the femur and an original extramedullary universal guide for the tibia (EM-TIBIA). We also developed a new function in ZedView, a three-dimensional surgical assistive software, that provides the parameters necessary to install the EM-TIBIA. Compared with conventional manual methods based on X-ray two-dimensional images or ZedView, these newly developed devices function as an extramedullary intraoperative support guide in conjunction with ZedView, simplifying surgical procedures. We conducted a study to evaluate the efficacy and safety of the surgery using the new guides and software function. Nineteen patients underwent surgery. On the femoral side, the mean absolute difference of the installation alignment was within 3° for all parameters. On the other hand, on the tibial side, the mean absolute difference from the preoperative plan for the rotation was 5.26±5.30°. The proportion of patients whose difference fell within ±3° was 52.6% (95% confi dence interval: 28.9 to 75.6%), and did not meet the pre-specified criteria for efficacy (P=0.261). No serious adverse events were reported, and no excessive bleeding, thrombosis, infections, or intraoperative or postoperative fractures were noted. The two new guides can easily reproduce the preoperative plan as 3D intraoperative support jigs, but errors can occur on the tibia side due to soft tissue that is not recognized by CT, creating problems in installation accuracy.

Relationship between locomotive syndrome and frailty in rheumatoid arthritis patients by locomotive syndrome stage

OBJECTIVES

This study aimed to evaluate the association between locomotive syndrome (LS) and frailty in rheumatoid arthritis (RA) patients.

METHODS

Subjects were 538 RA patients (female, 72.9%; mean age ± standard deviation, 66.8 ± 13.4 years). LS and frailty were defined as ≥16 points on the 25-question Geriatric Locomotive Function Scale (Stage ≥2) and ≥8 points on the Kihon Checklist (KCL), respectively.

RESULTS

There were 214 subjects with Stage ≥2 LS (39.8%) and 213 subjects with frailty (39.6%). Among subjects with Stage 0, 1, 2, and 3 LS, 11.0%, 21.9%, 48.3%, and 84.6% had frailty, respectively. The KCL points for cognitive and psychosocial factors had no significant differences across LS stages. Multivariable logistic regression analysis revealed that the Health Assessment Questionnaire was independently associated with frailty and LS stage, and the Clinical Disease Activity Index was associated with LS stage but not frailty.

CONCLUSIONS

As LS worsens in RA patients, the likelihood of developing physical frailty increases. RA patients with a low LS stage can still develop frailty, and suppressing disease activity may not be sufficient to prevent frailty. These findings highlight the need to screen for frailty in RA patients and consider appropriate interventions based on each patient's condition, focusing on nonphysical factors.

Activation of transient receptor potential vanilloid 4 protects articular cartilage against inflammatory responses via CaMKK/AMPK/NF-κB signaling pathway

Transient receptor potential vanilloid 4 (TRPV4) plays an important role in chondrocytes via Ca²⁺ signaling. However, its role in the progression of osteoarthritis is unclear. This study aimed to evaluate the effects of TRPV4 activation on articular cartilage and chondrocytes stimulated with interleukin (IL)-1β. Bovine and human articular chondrocytes were stimulated with various agents, including IL-1β, GSK1016790A (GSK101; a TRPV4 agonist), Compound C (an AMP-activated protein kinase (AMPK) inhibitor), and STO-609 (a calmodulin-dependent protein kinase kinase (CaMKK) inhibitor), and were processed for Western blot analysis and real-time PCR. The dimethylmethylene blue (DMMB) assay and Safranin O staining were also performed. GSK101 reversed the IL-1β-induced increase in expression of matrix metalloproteinase (MMP)-13 and decrease in expression of aggrecan. GSK101 also decreased proteoglycan release in the DMMB assay and retained Safranin O staining of articular cartilage tissue. Furthermore, GSK101 increased AMPK phosphorylation and decreased IL-1β-induced nuclear factor kappa B (NF-κB) phosphorylation. Compound C and STO-609 reversed the suppressive effects of GSK101 on NF-κB activation and MMP-13 expression. In conclusion, TRPV4 activation had chondroprotective effects on articular cartilage stimulated with IL-1β by activating CaMKK/AMPK and suppressing the NF-κB pathway. TRPV4 activators may offer a promising therapeutic option for preventing the progression of osteoarthritis.

Metabolic changes in synovial cells in early inflammation: Involvement of CREB phosphorylation in the anti-inflammatory effect of 2-deoxyglucose

The involvement of metabolic reprogramming has been suggested to contribute to the pathophysiology of rheumatoid arthritis (RA). Glycolysis is enhanced in synovial cell metabolism in RA patients. Inhibitors of glycolysis are known to have anti-inflammatory effects. But, changes in the metabolism of normal synovial membranes or synovial cells during the early stages of inflammation remains unknown. Moreover, there are still many aspects of inflammatory signaling pathways altered by glycolysis inhibitors, that remain unclear. In this study we found that, in normal, non-pathological bovine synovial cells, most of ATP synthesis was generated by mitochondrial respiration. However, during the early of stages inflammation, initiated by lipopolysaccharide (LPS) exposure, synovial cells shifted to glycolysis for ATP production. The glycolysis inhibitor 2-deoxyglucose (2DG) reversed LPS induced increases in glycolysis for ATP production and suppressed the expression of inflammatory cytokines and proteolytic enzymes. 2DG suppressed the phosphorylation of the transcription factor cAMP response element binding protein (CREB) enhanced by LPS. Treatment with a CREB inhibitor reversed the expression of LPS-stimulated inflammatory cytokines and proteolytic enzymes. This study showed that changes in metabolism occur during the early stages of inflammation of synovial cells and can be reversed by 2DG and signaling pathways associated with CREB phosphorylation.

AB0233 REASONS AND RISK FACTOR FOR DISCONTINUATION OF BIOLOGIC AGENTS FOR RHEUMATOID ARTHRITIS PATIENTS IN LONG-TERM OBSERVATION

Background:

Rheumatoid arthritis (RA) patients who failed a first biologic agent due to any reasons have the option of switching to a second one along with the strategy of biologic agent treatment. Patients go over switching to the next one at failing their biologic agent. On the other hand, there are some patients who discontinue any biologic agent treatment due to various reasons such as tolerability concern, complications, economic issue, remission and so on1 2. The impact of this concern has been less studied.

Objectives:

The objective of this study was to investigate the reasons and the risk factors for discontinuation any biologic agent in RA patients.

Methods:

To Include patients who are observed long-term, patients who underwent biologic agent treatment between 2003 and 2007 at Nagoya University Hospital and 12 other institutes (Tsurumai Biologics Communication Study Group) were enrolled. 570 patients who were confirmed continuation or discontinuation of biologic agent treatment were enrolled. The last observation was September 2017. We analyzed the retention rate of biologic agent treatment and the reasons for discontinuation. To identify the risks for discontinuation, baseline demographics were compared between the continuing group and the disc continuing group using cox hazard regression analysis.

Results:

In total 570 patients, the average duration of treatment with biologics was 6.6±3.3 (years) and total patient-year was 3739 in this study. 458 patients were administered biologics continuously, 112 patients were withdrawn. Table 1 showed the demographic data in total patients. The retention rate was 96.0% (discontinuation n=23) at least 1 year from starting biologics treatment, 92.6% (n=42) at 3 years, 88.2% (n=67) at 5 years, 84.4% (n=89) at 7 years, 81.1% (n=108) at 10 years. In 112 patients who discontinued, the reasons were adverse events in 74 patients, lack of effectiveness in 11 patients, others in 27 patients. Comparison of incidence for discontinuation using cumulative hazard function, the reason of adverse events was significantly higher than others reasons (Figure 1). To identify the risks of discontinuation, we analyzed by multivariable Cox proportional hazard modeling in patients who discontinued treatment due to adverse events, the risk factors (hazard ratio: HR, confidence interval: CI) were over 3 of Steinblocker class (HR 1.85 [1.02-2.04]), age (HR:1.07 [1.04-1.10]) and Non-concomitant with methotrexate (HR 1.90 [1.08-3.33]) (Figure 2).

Table 1.Age (years)56.1 ± 13.4Gender n (% male)110 (19%) n (% female)460 (81%)Disease duration (years)11.1 ± 9.8stage 1,2104 (19%) 3,4455 (81%)class 1,2336 (60%) 3,4225 (40%)Methotrexate use, no (%)400 (70%)Glucocorticoid use, no (%)262 (47%)Rheumatoid Factor, no (%)287 (65%)anti CCP antibody, no (%)137 (87%)

Conclusion:

The most common reason for discontinuation was adverse events in long term observation. The risk factors for discontinuation were class, age, and non-concomitant MTX. These results suggested that comorbidity has a significant impact on continuation rates because there are some reasons of non-concomitant MTX in addition to relate with age and the activities of daily living.

References:

[1]Marussa B, et al. j.clin thera. 2011; 33(7): 901-913

[2]Alejandro S, et al. Rheumatol. 2016; 55(3): 523-34

Disclosure of Interests:

KENYA TERABE: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Yasuhide Kanayama: None declared, Toshihisa Kojima Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Consultant of: AbbVie, Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis

Higher doses of methotrexate associated with discontinuation of oral glucocorticoids after initiation of biological DMARDs: A retrospective observational study based on data from a Japanese multicenter registry study

OBJECTIVE

Glucocorticoids are important drugs used to treat rheumatoid arthritis. We recommend glucocorticoid discontinuation as soon as possible given the associated side-effects, but many patients continue to take oral glucocorticoids long-term. The present study aimed to explore factors associated with glucocorticoid discontinuation at 52 weeks after initiating biological disease-modifying antirheumatic drugs (bDMARDs).

METHODS

Subjects were 564 patients from a Japanese multicenter registry who were administered glucocorticoids and methotrexate (MTX) followed by initiation of the first bDMARD. We examined the status of oral glucocorticoid use at 52 weeks after initiating the first bDMARD.

RESULTS

By 52 weeks after bDMARD initiation, 164 patients (29.1%) discontinued glucocorticoids. Multivariable analysis identified age, MTX dose, and glucocorticoid dose as factors independently associated with glucocorticoid discontinuation. After adjusting for baseline characteristics using propensity score matching, among patient groups administered MTX ≤ 8 mg/week and MTX > 8 mg/week, 105 pairs remained. A significantly higher rate of glucocorticoid discontinuation (41.0%) was noted for patients administered MTX > 8 mg/week.

CONCLUSION

Our findings suggest that glucocorticoids may be discontinued after initiating bDMARDs. Moreover, higher MTX doses (>8 mg/week) at the time of bDMARD initiation were associated with glucocorticoid discontinuation among patients treated with bDMARDs.

Predictors for clinical effectiveness of baricitinib in rheumatoid arthritis patients in routine clinical practice: data from a Japanese multicenter registry

This study aimed to evaluate the short-term effectiveness and safety profiles of baricitinib and explore factors associated with improved short-term effectiveness in patients with rheumatoid arthritis (RA) in clinical settings. A total of 113 consecutive RA patients who had been treated with baricitinib were registered in a Japanese multicenter registry and followed for at least 24 weeks. Mean age was 66.1 years, mean RA disease duration was 14.0 years, 71.1% had a history of use of biologics or JAK inhibitors (targeted DMARDs), and 48.3% and 40.0% were receiving concomitant methotrexate and oral prednisone, respectively. Mean DAS28-CRP significantly decreased from 3.55 at baseline to 2.32 at 24 weeks. At 24 weeks, 68.2% and 64.1% of patients achieved low disease activity (LDA) and moderate or good response, respectively. Multivariate logistic regression analysis revealed that no previous targeted DMARD use and lower DAS28-CRP score at baseline were independently associated with achievement of LDA at 24 weeks. While the effectiveness of baricitinib was similar regardless of whether patients had a history of only one or multiple targeted DMARDs use, patients with previous use of non-TNF inhibitors or JAK inhibitors showed lower rates of improvement in DAS28-CRP. The overall retention rate for baricitinib was 86.5% at 24 weeks, as estimated by Kaplan-Meier analysis. The discontinuation rate due to adverse events was 6.5% at 24 weeks. Baricitinib significantly improved RA disease activity in clinical practice. Baricitinib was significantly more effective when used as a first-line targeted DMARDs.

A retrospective analysis of the relationship between anti-cyclic citrullinated peptide antibody and the effectiveness of abatacept in rheumatoid arthritis patients

This study aimed to evaluate the effectiveness of abatacept (ABA) by anti-cyclic citrullinated peptide (ACPA) status on disease activity as well as radiographic progression in patients with rheumatoid arthritis (RA) in clinical settings. A retrospective cohort study was conducted using data from a multicenter registry. Data from a total of 553 consecutive RA patients treated with intravenous ABA were included. We primarily compared the status of disease activity (SDAI) and radiographic progression (van der Heijde modified total Sharp score: mTSS) between the ACPA-negative (N = 107) and ACPA-positive (N = 446) groups. 'ACPA positive' was defined as ≥ 13.5 U/mL of anti-CCP antibody. Baseline characteristics between groups were similar. The proportion of patients who achieved low disease activity (LDA; SDAI ≤ 11) at 52 weeks was significantly higher in the ACPA-positive group. Multivariate logistic regression analysis identified ACPA positivity as an independent predictor for achievement of LDA at 52 weeks. Drug retention rate at 52 weeks estimated by the Kaplan-Meier curve was significantly higher in the ACPA-positive group. Achievement rate of structural remission (ΔmTSS ≤ 0.5) at 52 weeks was similar between groups. ABA treatment demonstrated a significantly higher clinical response and higher drug retention rate in ACPA-positive patients. Progression of joint destruction was similar between the ACPA-negative and ACPA-positive groups. Close attention should be paid to joint destruction even in patients showing a favorable response to ABA, especially when the ACPA status is positive.

Improvement in matrix metalloproteinase-3 independently predicts low disease activity at 52 weeks in bio-switch rheumatoid arthritis patients treated with abatacept

OBJECTIVES

To explore predictive factors including MMP-3 for achievement of low disease activity (LDA) at 52 weeks in bio-switch rheumatoid arthritis (RA) patients treated with abatacept, for whom obtaining a good clinical response can be difficult.

METHODS

Participants were 423 consecutive patients with RA treated with abatacept who were observed for longer than 52 weeks and registered in the TBCR, a Japanese multicentre registry system. Multivariate logistic regression analysis was used to study factors that predict the achievement of LDA at 52 weeks in bio-naïve (n=234) and bio-switch (n=189) groups.

RESULTS

ROC analysis revealed that MMP-3 improvement rates at 12 weeks in bio-switch patients had the highest AUC with a cut-off value of 20.0% for predicting LDA achievement at 52 weeks. Multivariate logistic regression analysis revealed that, in addition to DAS28-CRP at baseline, achieving 20% improvement in MMP-3 levels at 12 weeks was an independent predictive factor (adjusted OR: 4.277, p=0.003) in the bio-switch group, whereas DAS28 was the only predictor in the bio-naïve group. Patients who achieved 20% improvement in MMP-3 levels at 12 weeks had significantly higher achievement rates of LDA at 52 weeks compared to those who did not achieve 20% improvement in the bio-switch group (60.0 vs. 33.3%, p=0.001).

CONCLUSIONS

Our findings suggest that improvement in MMP-3 levels is key to predicting the clinical efficacy of abatacept. Closer attention paid not only to major clinical indices, but also changes in MMP-3 levels, could improve our ability to optimise clinical results when treating bio-switch patients.

AB0353 COMPARATIVE STUDY OF PATIENT BACKGROUND AND TREATMENT OUTCOME BY BARICITINIB DOSE UNDER REAL CLINICAL CONDITIONS

Background:

Balicitinib (BAR) is one of the Janus kinase (JAK) inhibitors, which mainly inhibits JAK1 and JAK2 and has an anti-inflammatory effect on rheumatoid arthritis(RA). In Japan, it is necessary to use different doses of BAR depending on the RA patient’s estimated glomerular filtration rate (eGFR). The RA-BEACOM and RA-BUILD trials reported the treatment effects by BAR dose at 24 weeks and concluded that there was no difference in DAS(disease activity score)28CRP between BAR 2mg and 4mg. The patient background treated in these double-blind RCTs is uniform even at different BAR doses.There is uncertainty about the difference in the therapeutic effects of BAR dose under the real clinical setting where the patient background differs from that of the trial patients.

Objectives:

To compare patient backgrounds and treatment outcome by Baricitinib dose under real clinical setting.

Methods:

113 RA patients taking BAR who were registered in the Nagoya University Orthopedic Surgery Multicenter Study (TBCR) were included in this study. Patient characteristics (such as age, illness duration, combined anti-rheumatic drugs, eGFR) and DAS28CRP, clinical and simplified disease activity index(CDAI, SDAI respectively) up to 24 weeks were compared between BAR 2mg and 4mg groups. The continuation rates, including the discontinuation due to ineffectiveness and adverse events (AEs), were also compared between the two groups. For these comparisons, Student’s t-test and Pearson’s chi-square test, Kaplan-Meier survival curve were used. Missing data due to discontinuation of BAR was complemented by LOCF method and analyzed statistically. The significance level was set to less than 0.05.

Results:

There were 39 subjects (8 males and 31 females) in BAR2mg group and 74 patients (17 males and 57 females) in BAR4mg group. There was a significant difference in mean age (73.5 vs. 62.3 years old,p<0.001), average eGFR (65.1vs 84.8ml / min / 1.73m2,p<0.001), methotrexete(MTX) use rate (28 vs 58%,p<0.01), average MTX dose (3.0 vs 5.5mg,p<0.01),glucocorticoid(GC) use rate(51.3 vs 33.8%,p<0.01) between the two groups(Table). DAS28CRP improved from week 0 (3.2 vs 3.5) to week 24 (2.5 vs 2.4), and no significant difference was observed between the two groups at each time point (Fig.1-A). The same was true for CDAI and SDAI(Fig.1-B,-C). The rate of DAS28CRP remission and low disease activity was not significantly different at 24 weeks (0.64 vs. 0.69, Fig.1-D). The same was true for CDAI and SDAI(Fig.1-E,-F). Kaplan-Meier analysis showed that there was no difference in discontinuation rate due to ineffectiveness in the two groups. The same was true for the discontinuation rate due to AEs (Figure 2-B,-C). The total continuation rate including discontinuation due to ineffectiveness and AEs was significantly lower in BAR2mg group (0.691 vs 0.843,p<0.05, Fig.2-A).

Conclusion:

BAR2mg group under real clinical setting was older and had lower eGFR than BAR4mg group. Although the treatment effect for 24 weeks was similar, safety management was considered more important because the discontinuation rate due to AEs tended to be higher in BAR2mg group.

References:

[1]Taylor PC, (2017) The New England journal of medicine. 376(7), 652.

[2]Takeuchi T, Ann Rheum Dis 2019;78:171–178.

[3]Keystone EC, Ann Rheum Dis 2015;74:333–340

Table 1.

ITT outcomes at week 13

BAR2mg (n=39)BAR4mg (n=74)pvalueAge, years old73.5±9.762.3±12.6<0.001Female31(79)57(77)0.767Disease duration, year13.7±11.314.2±15.40.857Stage(1/2/3/4)6/17/8/815/24/14/210.473ACPA >4.5U/ml29(74.4)59(79.7)0.629eGFR, ml/min/1.73m265.1±27.784.8±23.2<0.001MTX dose, mg/week3.03±4.835.54±5.480.018MTX use11(28.2)41(55.4)0.003GC dose, mg/day1.91±2.361.32±2.200.191GC use20(51.3)25(33.8)0.007DAS28CRP3.42±1.043.52±13.00.689CDAI12.6±7.615.1±10.90.222SDAI14.7±9.716.2±11.40.279

Values are the mean±SD or the number (%).

Disclosure of Interests:

Tsuyoshi Nishiume: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

FRI0107 EFFECTIVENESS OF ABATACEPT ON CLINICAL DISEASE ACTIVITY AND RADIOGRAPHIC PROGRESSION IN RHEUMATOID ARTHRITIS PATIENTS IN DAILY CLINICAL PRACTICE IN JAPAN: COMPARISONS ACCORDING TO ACPA STATUS

Background:

The clinical effectiveness of abatacept (ABA) in rheumatoid arthritis (RA) patients has been reported to be higher when the patients’ anti-cyclic citrullinated peptide antibody (ACPA) status is positive. The report from the ORA registry demonstrated that the ACPA positivity was associated with a better response to ABA [1]. In a sub-analysis of the AMPLE trial, patients with very high ACPA titers who were treated with ABA had a statistically significant response compared to patients with lower titers [2]. However, these studies did not demonstrate the data regarding the structural progression.

Objectives:

This study aimed to evaluate the effectiveness of ABA on the clinical disease activity as well as the radiographic progression in patients with RA in the clinical settings.

Methods:

All eligible patients were registered in the TBCR, a Japanese multicenter registry system for RA patients treated with biologics [3]. The present study included 553 consecutive patients whose ACPA data were obtained, treated with ABA and observed for longer than 52 weeks. We primarily compared the status of disease activity (SDAI) and radiographic progression (van der Heijde modified total Sharp score: mTSS) between ACPA-positive [ACPA (+)] and ACPA-negative [ACPA (-)] RA patients. The ACPA positive was defined as ≥13.5 U/ml of anti-CCP antibody.

Results:

Number of cases was 446/ 107 [ACPA (+)/ ACPA (-)], respectively. Baseline characteristics between groups were quite similar; mean age was 68.0/ 67.3 years, rate of methotrexate (MTX) use rate was 41.2/ 50.0%, rate of bio-naive was 28.0/ 31.8%, and mean SDAI score was 22.2/ 20.8. Significant difference was observed in mean change in SDAI score from baseline to 52 weeks between the ACPA (+) and ACPA (-) group (-13.4 vs -9.9, p = 0.027) (Figure 1A). Proportion of patents that achieved low disease activity (LDA; SDAI ≤11) at 52 weeks was significantly higher in the ACPA (+) group compared to the ACPA (-) group (72.1 vs 56.0%, p < 0.01) (Figure 1B). In univariate and multivariate logistic regression analysis, ACPA positivity was an independent predictor for achievement of LDA at 52 weeks (Table). There observed no significant difference between ACPA (+) and ACPA (-) group in the proportion of patients that achieved structural remission (ΔmTSS ≤0.5) at 52 weeks (66.2 vs 62.1%) (Figure 2A) as well as mean change in mTSS (1.66 vs 1.17), erosion score (0.60 vs 0.53), and joint narrowing (JSN) score (1.06 vs 0.64) (Figure 2B).

Table.UnivariateMultivariateVariablesOR (95%CI)p-valueadjusted OR (95%CI)p-valueAge0.99 (0.98-1.01)0.4391.00 (0.97-1.02)0.749male (vs female)1.12 (0.70-1.80)0.6340.79 (0.40-1.58)0.511disease duration0.99 (0.97-1.00)0.0530.99 (0.97-1.01)0.468Biologics-naïve1.23 (0.81-1.85)0.3351.18 (0.67-2.08)0.575Concomitant MTX use1.12 (0.75-1.69)0.5851.14 (0.66-1.95)0.649Concomitant PSL use0.82 (0.55-1.23)0.3290.97 (0.58-1.64)0.923SDAI @baseline0.96 (0.94-0.97)<0.0010.96 (0.94-0.98)<0.001mHAQ @baseline0.50 (0.36-0.69)<0.0010.57 (0.38-0.86)0.008ACPA positive2.03 (1.29-3.17)0.0022.61 (1.36-5.00)0.004Bold italic, p<0.05

Conclusion:

Consistent with previous reports, the ACPA-positive group demonstrated significantly higher LDA achievement rate at 52 weeks and indeed the ACPA positivity was significantly associated with LDA achievement in multivariate analysis. However, the ACPA-negative group demonstrated quite similar transition of SDAI score and LDA achievement rate except at 52 weeks compared with the ACPA-positive group. Additionally, there was no significant difference in the structural progression at 52 weeks between the groups. ABA treatment may be considered not only in the ACPA-positive RA patients but also in the ACPA-negative patients in the clinical practice.

References:

[1]Gottenberg JE, et al. Ann Rheum Dis. 2012;71:1815.

[2]Sokolove J, et al. Ann Rheum Dis. 2016;75:709.

[3]Takahashi N, et al. Rheumatology (Oxford). 2015;54:854.

Disclosure of Interests:

Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

AB0178 PERIARTICULAR OSTEOPHYTE FORMATION PROTECTS AGAINST TOTAL KNEE ARTHROPLASTY IN RHEUMATOID ARTHRITIS PATIENTS WITH ADVANCED JOINT DAMAGE

Background:

New medications including biologics and aggressive treatment strategies can halt the inflammatory and destructive disease processes in patients with rheumatoid arthritis (RA), and in some cases repair damaged joints. In the process of damaged joint repair, periarticular osteophyte formation might be detected radiographically (1). However, little is known about the clinical and functional role of osteophyte formation in RA joints. Total joint arthroplasty, a common procedure for treating damaged large joints, can serve as a surrogate for the long-term outcome of large joint destruction in patients with RA.

Objectives:

To determine the influence of periarticular osteophyte formation on the incidence of total knee arthroplasty (TKA) in patients with RA.

Methods:

This retrospective longitudinal study used data from a registry of patients with RA starting biologics. A flow chart summarizing the study design is shown in Figure 1. A total of 130 symptomatic (tender and/or swollen) knee joints in 80 patients were studied with a median follow-up of 12 years. All data were analyzed using the knee joint as the statistical unit of analysis. The cumulative incidences of TKA were estimated using Kaplan-Meier curves, and compared according to the presence or absence of osteophyte on plain anteroposterior radiograph [osteophyte (+/-)] and the extent of advanced joint damage as defined by Larsen’s grading system (0-II vs. III-V).

Results:

Baseline characteristics of all subjects included in this study are shown in Table 1. A total of 42 knees underwent TKA during the follow-up period. There was no significant difference in the cumulative incidence of TKA between the osteophyte (+) and osteophyte (-) groups (31% vs. 34% at 10 years, P=0.718) (Fig. 2A). The cumulative incidence of TKA was significantly higher for the Larsen grade III-V group compared to the Larsen grade 0-II group (56% vs. 10% at 10 years, P<0.001) (Fig. 2B). While no significant difference was observed in the cumulative incidence of TKA between the osteophyte (+) and osteophyte (-) groups in the Larsen grade 0-II group (9% vs. 10% at 10 years, P=0.774) (Fig. 2C), the cumulative incidence of TKA was significantly lower for the osteophyte (+) group compared to the osteophyte (-) group in the Larsen grade III-V group (38% vs. 74% at 10 years, P=0.010) (Fig. 2D). Multivariate analysis using Cox proportional hazards models revealed that older age [hazard ratio (HR): 1.04 per 1 year, 95% confidence interval (CI): 1.01-1.08] and osteophyte formation (HR: 0.39, 95% CI: 0.19-0.79) independently predicted TKA in the Larsen grade III-V group, whereas none of the assessed variables predicted TKA in the Larsen grade 0-II group.

Table 1.

Baseline characteristics by presence or absence of osteophyte formation

TotalOsteophyte (+)Osteophyte (-)Characteristicsn = 130n = 44n = 86PvalueAge, years57(41-63)59(52-65)56(39-63)0.051Sex, female, n (%)108(83)40(91)68(80)0.137Body mass index21.3(19.0-23.8)21.3(18.9-24.4)21.2(19.0-23.7)0.744Disease duration, years8(3-12)9(5-18)7(3-11)0.007Larsen grade, n (%)<0.001Grade 0-II66(51)11(25)55(64)Grade III-V64(59)33(75)31(36)Osteophyte formation, n (%)44(34)---RF or ACPA positive, n (%)85(83)35(90)50(78)0.183CRP, mg/dl3.2(1.5-4.9)2.9(1.0-4.1)3.4(1.8-5.2)0.172First biologic agent, n (%)1.000Infliximab57(44)19(43)38(44)Etanercept73(56)25(57)48(56)Use of methotrexate, n (%)98(75)33(75)65(76)1.000Methotrexate dose, mg/week*8(6-10)8(6-9)8(6-10)0.104Use of glucocorticoids, n (%)79(61)22(50)57(66)0.088Glucocorticoid dose, mg/day*†5.0(5.0-7.5)5.0(5.0-5.0)5.0(5.0-7.8)0.204

Data are presented as median (interquartile range) or number of subjects (percentages). *Median among subjects receiving the drug. †Prednisolone equivalent (mg/day).

Conclusion:

Osteophyte formation reduces the incidence of TKA in patients with RA who have advanced joint damage.

References:

[1]Rau R. Clin Exp Rheumatol 2006;24:S-41-4.

Disclosure of Interests:

Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, KENYA TERABE: None declared, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

THU0182 THE EFFECTIVENESS OF BIOLOGICAL AGENTS CONCOMITANT WITH TACROLIMUS IN RHEUMATOID ARTHRITIS

Background:

In Japan, oral tacrolimus (TAC) was approved for the treatment of RA in 2005 and the improvement of symptoms thorough the use concomitant with disease modifying antirheumatic drugs (DMARDs), including MTX has been reported1 2. On the other hand, the efficacy and tolerance of biological agents therapy concomitant with TAC are unknown.

Objectives:

The objective of this study was to investigate the efficacy and tolerance of biological agents concomitant with TAC in Japanese patients with RA using retention rate analysis.

Methods:

Total patients (n=2860) who underwent 5 biological agents (etanercept: ETN, adalimumab: ADA, golimumab:GLM, tocilizumab: TCZ, abatacept: ABT) treatment between 2003 and 2017 at Nagoya University Hospital and 12 other institutes (Tsurumai Biologics Communication Study Group) were enrolled3. In each biologics analysis, patients were divided into three groups: (1) concomitant only MTX (MTX group) (2) concomitant only TAC (TAC group) (3) others (others group). In TAC or MTX group, these drugs were only ones which concomitant with biologics. Kaplan-Meier analysis was used to estimate retention rate in each biologics group. To estimate the tolerance of concomitant biologics with TAC, cumulative hazard function in adverse events rate was performed in each biologics group. In both analyses, hazard ratios (HR) were assessed by Cox proportional hazards modeling adjusted for age, sex, disease duration and previously used biologics.

Results:

In total 2860 patients, 142 patients (5.0%) administered each biologics concomitant with TAC (ETN: n=47, ADA: n=10 GLM: n=14, TCZ: n=27, ABT: n=49). Baseline characteristics of 142 patients were shown in table 1. Average dosages of TAC at starting were ETN: 2.2±0.7mg ADA: 2.4±1.0mg GLM: 1.9±1.0mg TCZ: 1.7±0.9mg ABT: 1.9±0.9mg. With comparison of retention rate between 3 groups in each biologics under analysis of cox proportional hazard modeling, in ETN and ABT analysis, the retention rate of TAC group was higher than others group (table 2, figure 1). Comparison of incidence of adverse event between 3 group using cumulative hazard function and cox proportional hazard modeling in ETN and ABT analysis. In ETN analysis, incident rate of other group was higher than TAC group. In ABT analysis, there was no significant difference between 3 gruops (figure 2).

Table 1.Baseline characteristic (n=142)age (years)63 ± 3gendermale33 (23%)female109 (77%)disease duration (years)12.0 ± 7.8stage1,234 (24%)3,4108 (76%)class1,299 (70%)3,443 (30%)naïve vs switchnaïve71 (50%)switch71 (50%)corticosteroid use, no (%)+98 (75%)-32 (25%)corticosteroid dose (mg)5.6 ± 3.2DAS28-ESR4.71 ± 1.55Table 2.HR (95%CI)/p-valuen (MTX/TAC/others)ETNADAGLMTCZABT(774/ 47/ 486)(339/ 10/ 135)(156/ 14/ 61)(272/ 27/ 207)(213/ 49/ 178)TAC vs others0.27 (0.16-0.45)<0.0010.9 (0.37-2.20)ns0.46 (0.13-1.63)ns0.55 (0.24-1.31)ns0.51 (0.26-0.97)<0.05TAC vs MTX0.65 (0.38-1.08)ns1.42 (0.61-3.31)ns0.83 (0.24-2.87)ns0.5 (0.21-1.17)ns0.74 (0.39-1.42)nsMTX vs others0.42 (0.35-0.50)<0.0010.9 (0.50-0.88)<0.0010.56 (0.33-0.96)<0.051.01 (0.78-1.57)ns0.68 (0.46-0.99)<0.05

Bold italic: p<0.05CI: confidence interval ns: not significant

Conclusion:

We suspected that, in ETN and ABT treatment, combination therapy with TAC are subsequent options for treatment to RA patients, especially in whom MTX cannot be administration.

References:

[1]Kino T, et al. Antibiot. 1987 Sep 40(9): 1256-65

[2]Kondo H, et al. J Rheumatol. 2004 Feb;31(2):243-51

[3]Kojima T, et al. Mod Rheumatol. 2011 Sep 3.

Disclosure of Interests:

KENYA TERABE: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Atsushi Kaneko Speakers bureau: Abbvie, Asahi-Kasei, Astellas, Bristol-Myers Squibb, Chugai, Eisai, Eli Lily, Mitsubishi-Tanabe, Pfizer, and UCB Japan, Yuji Hirano Speakers bureau: Tanabe-Mitsubishi, Pfizer, Eisai, Abbie, Chugai, Bristol-Meyers, Jansen, Astellas, UCB, Eli-Lilly, Asahikasei, Daiichi-Sankyo, Amgen, Yasuhide Kanayama: None declared, Yuichiro Yabe Speakers bureau: Asahi Kasei, Janssen, and Mitsubishi Tanabe, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

FRI0135 PREDICTORS FOR SHORT-TERM CLINICAL EFFECTIVENESS OF BARICITINIB IN RHEUMATOID ARTHRITIS PATIENTS IN ROUTINE CLINICAL PRACTICE: DATA FROM A JAPANESE MULTICENTER REGISTRY

Background:

Baricitinib is considered as a specific JAK1/2 inhibitor. While a number of randomized controlled trials have reported on the clinical efficacy and safety profile of baricitinib in rheumatoid arthritis (RA) patients, clinical data for RA patients in routine clinical practice are scarce.

Objectives:

This study aimed to evaluate the short-term effectiveness and safety profiles of baricitinib and explore factors associated with improved short-term effectiveness in patients with RA in clinical settings.

Methods:

A total of 113 consecutive RA patients who had been treated with baricitinib were registered in the TBCR, a Japanese multicenter registry for RA patients treated with biologics or JAK inhibitors (targeted DMARDs) [3], and followed for at least 24 weeks. Univariate and multivariate logistic regression analysis was used to study predictive factors for achievement of low disease activity (LDA) at 24 weeks.

Results:

Mean age was 66.1 years, mean RA disease duration was 14.0 years, 71.1% had a history of use targeted DMARDs, and 48.3% and 40.0% were receiving concomitant methotrexate (MTX) and oral prednisone, respectively. Mean DAS28-CRP significantly decreased from 3.55 at baseline to 2.32 at 24 weeks (Figure 1A). At 24 weeks, 68.2% and 64.1% of patients achieved LDA and moderate or good response, respectively (Figure 1B). Multivariate logistic regression analysis revealed that no previous targeted DMARD use and lower DAS28-CRP score at baseline were independently associated with achievement of LDA at 24 weeks (Table). While the percent change in DAS28-CRP was similar regardless of whether patients used concomitant MTX (Figure 2A), patietns with previous use of targeted DMARDs (Switch group) showed lower percent improvement in DAS28-CRP compared to targeted DMARDs-naïve patients (Naïve group) (Figure 2B). The overall retention rate for baricitinib was 86.5% at 24 weeks, as estimated by Kaplan-Meier analysis. The discontinuation rate due to adverse events was 6.5% at 24 weeks. In the present study cohort, seven patients developed herpes zoster, with an incidence rate of 8.4 per 100 patient-years. All seven patients were treated with antiviral agents for herpes zoster and restarted baricitinib treatment.

TableUnivariateMultivariatevariablesOR (95%CI)p-valueadjusted OR (95%CI)p-valueMale1.17 (0.43-3.16)0.755Age, <65 years1.46 (0.62-3.44)0.388Disease duration, <10 years1.41 (0.61-3.23)0.419ACPA positive1.56 (0.51-4.80)0.433no previous biological DMARDs4.67 (1.49-14.66)0.00833.4 (2.53-442.62)0.008concomitant MTX0.860 (0.40-2.02)0.789concomitant PSL0.24 (0.10-0.56)0.001DAS28-CRP@baseline0.55 (0.38-0.80)0.0020.28 (0.13-0.62)0.002mHAQ@baseline0.27 (0.09-0.77)0.015Bold italic, p<0.05

Conclusion:

In this study, we demonstrated the short-term clinical effectiveness and safety profile of baricitinib in Japanese RA patients in the ‘real-world’ setting. To the best of our knowledge, this study is the first to report the clinical outcomes of baricitinib in routine clinical practice in Japan. Baricitinib significantly improved disease activity, with an expected safety profile. We observed some interesting features regarding the effectiveness of baricitinib. Baricitinib was significantly more effective when used as a first-line targeted DMARD and may play a key role in the modern treatment strategy for RA, although careful observation is necessary for possible complications and AEs including herpes zoster.

References:

[1]Taylor PC, et al. (2017) The New England journal of medicine. 376(7), 652.

[2]Tanaka Y, et al. (2018) Modern rheumatology. 28(1), 20-9.

[3]Takahashi N, et al. (2014) Rheumatology (Oxford) 2014.

Disclosure of Interests:

Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

SAT0122 HIGHER DOSES OF METHOTREXATE ASSOCIATED WITH DISCONTINUATION OF ORAL GLUCOCORTICOIDS AFTER INITIATION OF BIOLOGICAL DMARDS: A RETROSPECTIVE OBSERVATIONAL STUDY BASED ON DATA FROM A JAPANESE MULTICENTER REGISTRY STUDY

Background:

Glucocorticoids exert anti-inflammatory effects and are important drugs used to treat rheumatoid arthritis(1). We recommend glucocorticoid discontinuation as soon as possible because glucocorticoid caused several side effects, but many patients continue to take oral glucocorticoids long-term in daily clinical practice. The frequency of use of glucocorticoid has gradually declined, and there are several reports on discontinuation of glucocorticoid due to the initiation of biological disease-modifying antirheumatic drugs (bDMARDs)(2). However, there is no report showing the relation between discontinuation of glucocorticoid and MTX dose.

Objectives:

The present study aimed to explore factors associated with glucocorticoid discontinuation at 52 weeks after initiating bDMARDs.

Methods:

We established the large observational cohort, the Nagoya University orthopedic facility multicenter study (TBCR), and a total of 3119 patients used bDMARD and examined the status of oral glucocorticoid use at 52 weeks after initiating the 1stbDMARD. In predictive analyses, the outcome variable was glucocorticoid discontinuation at 52 weeks after bDMARD initiation. Factors associated with baseline characteristics at bDMARD initiation were assessed with univariate and stepwise forward multivariate logistic regression analyses. This cohort study was not randomized. Propensity score (PS) matching was used to align patient backgrounds to avoid selection bias.

Results:

Subjects were 564 patients administered glucocorticoids and methotrexate (MTX) following initiation of the 1stbDMARD (Figure 1). Mean DAS28-CRP at bDMARD initiation was 4.70 ± 1.16. Percentages of patients with low, moderate, and high disease activity as evaluated by DAS28-CRP at bDMARD initiation were 4.7%, 23.5%, and 71.8%, respectively. By 52 weeks after bDMARD initiation, 164 patients (29.1%) discontinued glucocorticoids. Multivariate analysis identified age (odds ratio (OR), 0.98), MTX dose (OR, 1.11), and glucocorticoid dose (OR, 0.87) as factors independently associated with glucocorticoid discontinuation at the time of bDMARD initiation (Table 1). After adjusting for baseline characteristics using propensity score matching among patient groups administered MTX ≤ 8 mg/week and MTX > 8 mg/week, 105 pairs remained. Among patients administered MTX > 8 mg/week, 41.0% discontinued glucocorticoids. Among those administered MTX ≤ 8 mg/week, 22.9% discontinued glucocorticoids, with a significant difference between the two groups (Figure 2, P=0.007).

Table 1.

Factors associated with baseline characteristics at bDMARD initiation

Continuation(n=400)Discontinuation(n=164)UnivariateOdds ratio (95% CI)MultivariateOdds ratio (95% CI)Age, years58.4 ± 12.954.3 ± 14.30.98 (0.97-0.99)*0.98 (0.97-0.99)*Disease duration, years9.4 ± 9.47.5 ± 8.50.98 (0.95-0.99)*–Female, %80.381.11.06 (0.67-1.68)–DAS28-CRP4.78 ± 1.154.50 ± 1.160.81 (0.69-0.96)*–Seropositivity, %90.086.10.69 (0.38-1.25)–MTX dose, mg/week7.7 ± 2.58.8 ± 3.01.16 (1.09-1.24)*1.11 (1.03-1.21)*Glucocorticoid dose, mg/day4.9 ± 2.14.3 ± 2.10.86 (0.78-0.95)*0.87 (0.78-0.97)*TNF inhibitor use, %88.885.40.74 (0.43-1.26)-

Data are presented as mean ± standard deviation.

Conclusion:

Data from the TBCR revealed that, from a clinical perspective, glucocorticoid use decreased among RA patients treated with bDMARDs. Higher doses of MTX (> 8 mg/week) at the time of bDMARD initiation were found to be associated with glucocorticoid discontinuation in patients treated with bDMARDs. In addition, we found that aggressive use of MTX was sufficient to fulfill the Treat-to-Target approach, demonstrating that glucocorticoid discontinuation is a viable option.

References:

[1]Smolen JS. Ann Rheum Dis. 2014;73(3):492-509.

[2]Shimizu Y. Mod Rheumatol. 2018;28(3):461-7.

Disclosure of Interests:

Mochihito Suzuki Speakers bureau: Bristol-Myers Squibb, Eisai, and Asahi Kasei, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Shuji Asai Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Janssen, Takeda, and UCB Japan, Kenya Terabe: None declared, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

OP0207 MECHANISM OF CHONDROPROTECTIVE EFFECTS OF 2-DEOXYGLUCOSE

Background:

We recently reported that the inhibitor of hyaluronan (HA) biosynthesis, 4-methylumbelliferone (4-MU) blocked IL-1β activation of MMP13 mRNA and protein expression in human osteoarthritic (OA), bovine as well as bovine or OA cartilage explants [1]. This was a somewhat counterintuitive observation because we have also demonstrated that the overexpression of HAS2 (HAS2-OE) exerted the same chondroprotective effects on human and bovine chondrocytes. Others [2] have reported that HAS2-OE in tumor cells generates a flux in intracellular UDP-sugar pools that resulted in changes in cell metabolism; switching from a dependence on glycolysis to aerobic respiration. HAS2-OE and 4-MU likely also cause dramatic fluxes in intracellular UDP-GlcUA pools. From these results, we hypothesized that the effect of HAS2-OE and 4-MU relate to changing metabolism and the possibility of inhibition of glycolysis induce chondroprotective effect. To determine that, we used the glycolysis inhibitor, 2-Deoxyglucose (2DG) as an alternative agent to change metabolism in chondrocytes.

Objectives:

The objective of this study was to investigate the mechanism of chondroprotective effects of 2DG

Methods:

Bovine and human chondrocyte were stimulated with IL-1β (2ng/ml) in the presence or absence of 4MU (1.0 mM), 2DG (0.2-20 mM). Bovine chondrocytes were tested using Seahorse Flux Analyzer (Agilent Tech) to determine rate changes in medium accumulation of +H protons (indicative of lactic acid accumulation: ECAR) and for O2 consumption (indicative of mitochondrial respiration: OCR). Accumulation of MMP13 and phosphor AMPK (pAMPK) protein was quantified with Western blotting. Human and Bovine cartilage explants were cultured with L-1β in the presence or absence of 2DG (20 mM) and d 5-Aminoimidazole-4-carboxamide 1-β-D-ribofuranoside (AICAR) to pharmacologically induce AMPK for 7 days and stained with Safranin O.

Results:

Reduced mitochondrial potential and enhanced dependence on glycolysis was observed in IL-1β stimulated chondrocytes. Co-treatment with 4-MU and 2DG returned the cell metabolism to levels at or below baseline (Fig 1A, B). The Seahorse ATP Rate Assay means the contributions of glycolysis and mitochondrial respiration to chondrocyte ATP production (Fig 1C). In control chondrocytes, the use of glycolysis contributes to the majority of ATP produced (grey bars) approximately 1/5th from the TCA cycle (red bars). IL1β-activated chondrocytes display increase in glycolysis and decrease in mitochondrial contributions. These changes are reversed by co-treatment with 4MU and 2DG. As shown in Figs 2A, 2DG reversed the IL1β-induced increases accumulation of MMP13 protein in human OA chondrocytes by Western blotting analysis. Although IL-1β lost safranin O staining in human and bovine samples, co-incubation with 2DG blocked in the loss of proteoglycan (Fig 2B). pAMPK is associate with energy homeostasis in chondrocytes. IL-1β treatment decreased accumulation of phosphor AMPK. Co-treatment with 4-MU and 2DG resulted in a rescue of the pAMPK status (Figure 3A). Co treatment with AICAR, which is inducer of AMPK, also blocked in the loss of proteoglycan (Fig 3B).

Conclusion:

4-MU and 2DG have chondroprotective effect by changing metabolism and upregulate AMPK. We propose that 4MU and 2DG become useful when these endogenous responses are not enough to rescue cells from a pro-catabolic phenotype.

References:

[1]J. Biol. Chem. 291:12087, 2016; [2] J. Biol. Chem. 291:24105, 2016

Disclosure of Interests:

KENYA TERABE: None declared, Nobunori Takahashi Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Ono, Pfizer, Takeda, and UCB Japan, Ohashi Yoshifumi: None declared, Maeda Masataka: None declared, Warren Knudson: None declared, Cheryl Knudson: None declared, Toshihisa Kojima Grant/research support from: Chugai, Eli Lilly, Astellas, Abbvie, and Novartis, Consultant of: AbbVie, Speakers bureau: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi-Sankyo, Eli Lilly, Janssen, Mitsubishi Tanabe, Pfizer, and Takeda, Naoki Ishiguro Grant/research support from: AbbVie, Asahi Kasei, Astellas, Chugai, Daiichi-Sankyo, Eisai, Kaken, Mitsubishi Tanabe, Otsuka, Pfizer, Takeda, and Zimmer Biomet, Consultant of: Ono, Speakers bureau: Astellas, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Pfizer, and Taisho Toyama

Relationship between disease activity of rheumatoid arthritis and development of locomotive syndrome: A five-year longitudinal cohort study

OBJECTIVE

This study aimed to longitudinally evaluate the association between rheumatoid arthritis (RA) and locomotive syndrome (LS) in RA patients using the 25-question Geriatric Locomotive Function Scale (GLFS-25).

METHODS

Subjects were 58 RA patients (female, 48 (82.8%); mean age, 60.9 ± 10.9 years) who had GLFS-25 scores available for five consecutive years and who did not have LS at baseline (i.e. GLFS-25 < 16 points). Associations between DAS28-CRP and the development of LS were determined using linear regression analysis and receiver operating characteristic (ROC) curve analysis.

RESULTS

Subjects were divided into the LS group (n = 15, GLFS-25 ≥ 16 points) and non-LS group (n = 43, GLFS-25 < 16 points) based on GLFS-25 scores at the 5th year of the study period. In the LS group, DAS28-CRP worsened every year. The linear regression model adjusted for age and sex revealed that ΔGLFS-25 increased by 3.80 (95% confidence interval: 1.81-5.79) each time ΔDAS28-CRP increased by 1 (p<.001). Among patients in remission (DAS28-CRP < 2.3), 13.5% had LS. ROC curve analysis yielded a five-year mean DAS28-CRP of 1.99 (sensitivity, 86.7%; specificity, 62.8%) as the cut-off point for the development of LS.

CONCLUSION

Tight control of RA disease activity for deeper remission may be needed to prevent the development of LS.

Chondroprotective effects of 4-methylumbelliferone and hyaluronan synthase-2 overexpression involve changes in chondrocyte energy metabolism

Hyaluronan is a critical component of articular cartilage and partially helps retain aggrecan within the extracellular matrix of this tissue. During osteoarthritis, hyaluronan and aggrecan loss are an early sign of tissue damage. However, our recent attempts to mimic hyaluronan loss with the hyaluronan inhibitor 4-methylumbelliferone (4MU) did not exacerbate arthritis-like features of in vitro models of arthritis, but surprisingly, caused the reverse (i.e. provided potent chondroprotection). Moreover, the protective effects of 4MU did not depend on its role as a hyaluronan inhibitor. To understand the molecular mechanism in 4MU-mediated chondroprotection, we considered recent studies suggesting that shifts in intracellular UDP-hexose pools promote changes in metabolism. To determine whether such metabolic shifts are associated with the mechanism of 4MU-mediated pro-catabolic inhibition, using molecular and metabolomics approaches, we examined whether bovine and human chondrocytes exhibit changes in the contribution of glycolysis and mitochondrial respiration to ATP production rates as well as in other factors that respond to or might drive these changes. Overexpression of either HA synthase-2 or 4MU effectively reduced dependence on glycolysis in chondrocytes, especially enhancing glycolysis use by interleukin-1β (IL1β)-activated chondrocytes. The reduction in glycolysis secondarily enhanced mitochondrial respiration in chondrocytes, which, in turn, rescued phospho-AMP-activated protein kinase (AMPK) levels in the activated chondrocytes. Other glycolysis inhibitors, unrelated to hyaluronan biosynthesis, namely 2-deoxyglucose and dichloroacetate, caused metabolic changes in chondrocytes equivalent to those elicited by 4MU and similarly protected both chondrocytes and cartilage explants. These results suggest that fluxes in UDP-hexoses alter metabolic energy pathways in cartilage.

Investigation of Ag and Cu Filament Formation Inside the Metal Sulfide Layer of an Atomic Switch Based on Point-Contact Spectroscopy

The atomic switches have attracted wide attention owing to their applications in nonvolatile electric devices. The atomic switch is operated by the formation and dissipation of a metallic filament inside a metal sulfide film, which is controlled by a solid electrochemical reaction. Although the metallic filament is considered to consist of metal atoms, the chemical species of the metallic filament are difficult to be identified due to challenges in observing the metallic filament inside the solid. In this study, we report the investigation on the metallic filament in the atomic switch with metal sulfide based on point-contact spectroscopy (PCS). By cooling the atomic switch, the switch voltage increased to 1 V, which allowed for the PCS measurement. The PCS revealed that the metallic filament was composed of Ag atoms in the case of the Pt/Ag₂S/Ag atomic switch. We applied this technique to the Pt/Cu₂S/Ag and Pt/Ag₂S/Cu atomic switches to uncover the formation process of the metallic filament. In both atomic switches, the chemical species of the metallic filament were Ag. The metal atoms were supplied from both the metal electrode and the sulfide layer.

Hyaluronan synthase 2 (HAS2) overexpression diminishes the procatabolic activity of chondrocytes by a mechanism independent of extracellular hyaluronan

Osteoarthritis (OA) is a progressive degenerative disease of the joints caused in part by a change in the phenotype of resident chondrocytes within affected joints. This altered phenotype, often termed proinflammatory or procatabolic, features enhanced production of endoproteinases and matrix metallo-proteinases (MMPs) as well as secretion of endogenous inflammatory mediators. Degradation and reduced retention of the proteoglycan aggrecan is an early event in OA. Enhanced turnover of hyaluronan (HA) is closely associated with changes in aggrecan. Here, to determine whether experimentally increased HA production promotes aggrecan retention and generates a positive feedback response, we overexpressed HA synthase-2 (HAS2) in chondrocytes via an inducible adenovirus construct (HA synthase-2 viral overexpression; HAS2-OE). HAS2-OE incrementally increased high-molecular-mass HA >100-fold within the cell-associated and growth medium pools. More importantly, our results indicated that the HAS2-OE expression system inhibits MMP3, MMP13, and other markers of the procatabolic phenotype (such as TNF-stimulated gene 6 protein (TSG6)) and also enhances aggrecan retention. These markers were inhibited in OA-associated chondrocytes and in chondrocytes activated by interleukin-1β (IL1β), but also chondrocytes activated by lipopolysaccharide (LPS), tumor necrosis factor α (TNFα), or HA oligosaccharides. However, the enhanced extracellular HA resulting from HAS2-OE did not reduce the procatabolic phenotype of neighboring nontransduced chondrocytes as we had expected. Rather, HA-mediated inhibition of the phenotype occurred only in transduced cells. In addition, high HA biosynthesis rates, especially in transduced procatabolic chondrocytes, resulted in marked changes in chondrocyte dependence on glycolysis versus oxidative phosphorylation for their metabolic energy needs.

An Open-label Single-arm Trial of a Novel Extramedullary Guide Coordinated with 3D Surgical Assistive Software for Total Knee Arthroplasty

There is no assistive device for extramedullary surgery coordinated with 3D surgical assistive software for the total knee arthroplasty (TKA). We developed a novel extramedullary universal guide coordinated with 3D surgical assistive software and a novel extramedullary patient-specific assistive guide for the placement of femoral components by referring to an area not affected by cartilage or bone spurs, and filed a patent application. In this study, we visualize and reconstruct the total alignment of the lower extremity in TKA using these surgical devices, and validate their precision. A report releasing study results will be submitted in an appropriate journal.

Mechanical stress loading induces CD44 cleavage in human chondrocytic HCS-2/8 cells

Although excessive mechanical stress loading is known to induce articular cartilage degradation, the mechanism underlying this process is unclear. The interaction between hyaluronan (HA) and its primary receptor CD44 maintains the homeostasis of articular chondrocytes. CD44 cleavage and the generation of CD44-intracellular domain (ICD) can lead to the loss of extracellular matrices in chondrocytes. Here we studied the effects of cyclic tensile strain (CTS) loading, a representative mechanical stress, on CD44 cleavage. CTS loading (1 Hz and 20% elongation for 48 h) increased ADAM10 expression and CD44 cleavage in HCS-2/8 cells, a human chondrocytic cell line. Co-treatment with a chemical ADAM10 inhibitor significantly suppressed CTS loading-induced CD44 cleavage. Chemical inhibition of transient receptor potential vanilloid 4 (TRPV4) significantly suppressed CTS loading-induced ADAM10 expression and CD44 cleavage. Conversely, chemical activation of TRPV4 increased ADAM10 expression and enhanced CD44 cleavage. Our findings suggest that CTS loading significantly increases the expression of ADAM10, which in turn enhances CD44 cleavage in HCS-2/8 cells. The primary mechanoreceptor mediating this process is TRPV4. This signature event could provide an avenue for intervention in the prevention of cartilage degradation leading to OA.

Longterm Retention Rate and Risk Factors for Adalimumab Discontinuation Due To Efficacy and Safety in Japanese Patients with Rheumatoid Arthritis: An Observational Cohort Study

Objective.

To evaluate the rates of retention and discontinuation of adalimumab (ADA) due to efficacy and safety in Japanese patients with rheumatoid arthritis (RA).

Methods.

All patients with RA (n = 476) who were treated with ADA in the Tsurumai Biologics Communication Registry were enrolled.

Results.

The retention rate of ADA was 46% at 5 years. When focusing on insufficient efficacy, previous biologics use and high baseline disease activity were significant risk factors for up to 1 year. Methotrexate (MTX) use was a significantly low risk factor after 1 year of treatment.

Conclusion.

Concomitant MTX contributes to the longterm efficacy of ADA therapy.

Simvastatin inhibits CD44 fragmentation in chondrocytes

In human osteoarthritic chondrocytes, the hyaluronan receptor CD44 undergoes proteolytic cleavage at the cell surface. CD44 cleavage is thought to require transit of CD44 into cholesterol-rich lipid rafts. The purpose of this study was to investigate whether statins exert a protective effect on articular chondrocytes due to diminution of cholesterol. Three model systems of chondrocytes were examined including human HCS-2/8 chondrosarcoma cells, human osteoarthritic chondrocytes and normal bovine articular chondrocytes. Treatment with IL-1β + Oncostatin M resulted in a substantial increase in CD44 fragmentation in each of the three chondrocyte models. Pre-incubation with simvastatin prior to treatment with IL-1β + Oncostatin M decreased the level of CD44 fragmentation, decreased the proportion of CD44 that transits into the lipid raft fractions, decreased ADAM10 activity and diminished the interaction between CD44 and ADAM10. In HCS-2/8 cells and bovine articular chondrocytes, fragmentation of CD44 was blocked by the knockdown of ADAM10. Inhibition of CD44 fragmentation by simvastatin also resulted in improved retention of pericellular matrix. Addition of cholesterol and farnesyl-pyrophosphate reversed the protective effects of simvastatin. Thus, the addition of simvastatin exerts positive effects on chondrocytes including reduced CD44 fragmentation and enhanced the retention of pericellular matrix.

Effects of Concomitant Methotrexate on Large Joint Replacement in Patients With Rheumatoid Arthritis Treated With Tumor Necrosis Factor Inhibitors: A Multicenter Retrospective Cohort Study in Japan

OBJECTIVE

To determine the effects of concomitant methotrexate (MTX) on the incidence of large joint replacement resulting from the progression of large joint destruction in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor (TNF) inhibitors.

METHODS

A retrospective cohort study was performed using a multicenter registry. In total, 803 patients with RA who received etanercept or adalimumab were included. The first large joint replacement during treatment with etanercept or adalimumab was used as the outcome variable in predictive analyses. The cumulative incidence of large joint replacement was estimated using Kaplan-Meier curves, and the impact of concomitant MTX on the incidence of large joint replacement was assessed with Cox proportional hazards models. Propensity score matching was used to reduce selection bias.

RESULTS

Of all patients, 601 (75%) received concomitant MTX at a median dosage of 8 mg/week (interquartile range 6-8). A total of 49 patients (62 joints) underwent large joint replacement during treatment with etanercept or adalimumab. The incidence of large joint replacement for patients with concomitant MTX was significantly lower than that for patients without MTX (P < 0.001). Multivariate analysis revealed that concomitant MTX independently predicted large joint replacement (hazard ratio 0.36, 95% confidence interval 0.20-0.65). Additionally, propensity score-matched analysis demonstrated that patients with concomitant MTX had a significantly lower incidence of large joint replacement than those without concomitant MTX (P = 0.032).

CONCLUSION

Concomitant MTX reduces the incidence of large joint replacement in patients with RA treated with TNF inhibitors.

Predictive factors for achieving low disease activity at 52 weeks after switching from tumor necrosis factor inhibitors to abatacept: results from a multicenter observational cohort study of Japanese patients

This study aimed to identify predictive factors for achieving low disease activity (LDA) in rheumatoid arthritis (RA) patients switching from tumor necrosis factor inhibitors (TNFis) to abatacept (ABT). Patients who were registered in the multicenter observational Tsurumai Biologics Communication Registry (TBCR) were enrolled in this study. Predictive factors for LDA achievement at each time point were determined by univariate and multivariate logistic regression analyses. The cutoffs of 28-point count Disease Activity Score (DAS28)-C-reactive protein (CRP) and ΔDAS28-CRP from baseline up to 24 weeks for LDA achievement at 52 weeks were explored using receiver operating characteristic (ROC) curves. Of 2771 RA patients registered until 2013, 76 with moderate or high disease activity were selected. Twenty-six percent of the patients achieved LDA. Multivariate analysis confirmed that DAS28-CRP at 12 weeks and ΔDAS28-CRP from baseline to 12 weeks were independent factors for LDA achievement at 52 weeks [odds ratio (OR) 0.26, 95% confident interval (CI) (0.12-0.56), OR 0.25, 95% CI (0.11-0.57), respectively]. The best cutoff values of DAS28-CRP at 12 weeks and ΔDAS28-CRP from baseline to 12 weeks for LDA at 52 weeks were 3.9 (sensitivity 0.85, specificity 0.78) and -0.97 (sensitivity 0.70, specificity 0.70), respectively. Seventy-one percent of patients who achieved both of these cutoff values at 12 weeks achieved LDA at 52 weeks. Our findings suggest that the clinical course up to 12 weeks is important for predicting long-term outcomes when switching from TNFis to ABT.

Concomitant Methotrexate Protects Against Total Knee Arthroplasty in Patients with Rheumatoid Arthritis Treated with Tumor Necrosis Factor Inhibitors

OBJECTIVE

To determine the effects of concomitant methotrexate (MTX) on the incidence of total knee arthroplasty (TKA) resulting from the progression of joint destruction in patients with rheumatoid arthritis (RA) during longterm treatment with tumor necrosis factor (TNF) inhibitors.

METHODS

A total of 155 patients with RA (310 knee joints) received TNF inhibitors at our institute between May 1, 2001, and May 31, 2008. A total of 111 symptomatic (tender and/or swollen) knee joints in 68 patients were retrospectively studied over the course of a minimum of 5 years of followup. The median (interquartile range) followup period was 8.1 (7.0-9.3) years. All data were analyzed using the knee joint as the statistical unit of analysis. TKA during treatment with TNF inhibitors was used as the outcome variable in predictive analyses. The cumulative incidence of TKA was compared by concomitant or no MTX use (MTX±).

RESULTS

There were 79 subjects (71%) who received concomitant MTX. According to Kaplan-Meier estimates, the cumulative incidence of TKA for the MTX+ group was significantly lower than that for the MTX- group (24% vs 45% at 5 yrs, respectively, p = 0.035). Multivariate analysis using the Cox proportional hazards model revealed that concomitant MTX (HR 0.44, 95% CI 0.22-0.89), Larsen grade (HR 2.93, 95% CI 1.94-4.41), and older age at baseline (HR 1.04, 95% CI 1.01-1.08) were independent predictors of TKA.

CONCLUSION

Concomitant MTX reduces the incidence of TKA by 56% in patients with RA during longterm treatment with TNF inhibitors.

Disease activity early in treatment as a predictor of future low disease activity in RA patients treated with iguratimod

OBJECTIVES

This retrospective observational study aimed to examine the efficacy of iguratimod with and without concomitant methotrexate (MTX) and to estimate the adequate observational period for predicting low disease activity (LDA) achievement at 24 weeks in patients with rheumatoid arthritis (RA).

METHODS

All patients treated with iguratimod were registered in a Japanese multicenter registry. Multivariate analyses were performed to identify predictive factors for LDA achievement at 24 weeks. Receiver operating characteristic (ROC) curve analyses were performed to estimate the association of 28-joint disease activity score based on erythrocyte sedimentation rate (DAS28-ESR) at each time point with achievement of LDA at 24 weeks and determine a cut-off for DAS28-ESR.

RESULTS

A total of 123 patients were treated with iguratimod with (n = 65) or without (n = 58) MTX. Iguratimod therapy resulted in significant clinical improvement in both groups. Multivariate analysis revealed that DAS28-ESR at each time point was an independent significant predictor of LDA achievement at 24 weeks. Cut-off values of DAS28-ESR at 12 weeks based on ROC curves were 3.2 and 3.6 in patients with and without MTX, respectively.

CONCLUSIONS

Iguratimod was effective in RA patients in clinical practice. Our results suggest that 12 weeks may be a sufficient period to judge the medium-term efficacy of iguratimod in patients treated with and without MTX.