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Fanouriakis A, Kostopoulou M, Andersen J, Aringer M, Arnaud L, Bae SC, Boletis J, Bruce IN, Cervera R, Doria A, Dörner T, Furie RA, Gladman DD, Houssiau FA, Inês LS, Jayne D, Kouloumas M, Kovács L, Mok CC, Morand EF, Moroni G, Mosca M, Mucke J, Mukhtyar CB, Nagy G, Navarra S, Parodis I, Pego-Reigosa JM, Petri M, Pons-Estel BA, Schneider M, Smolen JS, Svenungsson E, Tanaka Y, Tektonidou MG, Teng YO, Tincani A, Vital EM, van Vollenhoven RF, Wincup C, Bertsias G, Boumpas DT. EULAR recommendations for the management of systemic lupus erythematosus: 2023 update. Ann Rheum Dis 2024; 83:15-29. [PMID: 37827694 DOI: 10.1136/ard-2023-224762] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To update the EULAR recommendations for the management of systemic lupus erythematosus (SLE) based on emerging new evidence. METHODS An international Task Force formed the questions for the systematic literature reviews (January 2018-December 2022), followed by formulation and finalisation of the statements after a series of meetings. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned, and participants finally provided their level of agreement with each item. RESULTS The Task Force agreed on 5 overarching principles and 13 recommendations, concerning the use of hydroxychloroquine (HCQ), glucocorticoids (GC), immunosuppressive drugs (ISDs) (including methotrexate, mycophenolate, azathioprine, cyclophosphamide (CYC)), calcineurin inhibitors (CNIs, cyclosporine, tacrolimus, voclosporin) and biologics (belimumab, anifrolumab, rituximab). Advice is also provided on treatment strategies and targets of therapy, assessment of response, combination and sequential therapies, and tapering of therapy. HCQ is recommended for all patients with lupus at a target dose 5 mg/kg real body weight/day, considering the individual's risk for flares and retinal toxicity. GC are used as 'bridging therapy' during periods of disease activity; for maintenance treatment, they should be minimised to equal or less than 5 mg/day (prednisone equivalent) and, when possible, withdrawn. Prompt initiation of ISDs (methotrexate, azathioprine, mycophenolate) and/or biological agents (anifrolumab, belimumab) should be considered to control the disease and facilitate GC tapering/discontinuation. CYC and rituximab should be considered in organ-threatening and refractory disease, respectively. For active lupus nephritis, GC, mycophenolate or low-dose intravenous CYC are recommended as anchor drugs, and add-on therapy with belimumab or CNIs (voclosporin or tacrolimus) should be considered. Updated specific recommendations are also provided for cutaneous, neuropsychiatric and haematological disease, SLE-associated antiphospholipid syndrome, kidney protection, as well as preventative measures for infections, osteoporosis, cardiovascular disease. CONCLUSION The updated recommendations provide consensus guidance on the management of SLE, combining evidence and expert opinion.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, INSERM UMR-S 1109, Centre National de Référence des Maladies Auto-immunes Systémiques Rares (RESO), Strasbourg, France
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology Research and Hanyang Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK; National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charite Universitätsmedizin Berlin; Deutsches Rheumaforschungszentrum, Berlin, Germany
| | - Richard A Furie
- Division of Rheumatology, Northwell Health, Great Neck, New York City, New York, USA
| | - Dafna D Gladman
- Lupus Program, Centre for Prognosis Studies in the Rheumatic Disease, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Frederic A Houssiau
- Service de Rhumatologie, Cliniques Universitaires Saint-Luc and Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Luís Sousa Inês
- Department of Rheumatology, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal; School of Health Sciences, Universidade da Beira Interior, Covilha, Portugal
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - László Kovács
- Department of Rheumatology and Immunology, Faculty of Medicine, University of Szeged, Hungary
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
| | - Eric F Morand
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Gabriella Moroni
- Department of Biomedical Sciences Humanitas University, Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Johanna Mucke
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - György Nagy
- Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Sandra Navarra
- Section of Rheumatology, Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - José M Pego-Reigosa
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) - VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - Michelle Petri
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bernardo A Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Joint Academic Rheumatology Program, Athens, Greece
| | - Yk Onno Teng
- Centre of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Chris Wincup
- Department of Rheumatology, King's College Hospital, London, UK
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Greece, University Hospital of Heraklion, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece, Medical School, University of Cyprus, Nicosia, Cyprus
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Studenic P, Stamm TA, Mosor E, Bini I, Caeyers N, Gossec L, Kouloumas M, Nikiphorou E, Olsder W, Padjen I, Ramiro S, Stones S, Wilhelmer TC, Alunno A. EULAR points to consider for including the perspective of young patients with inflammatory arthritis into patient-reported outcomes measures. RMD Open 2022; 8:rmdopen-2022-002576. [PMID: 35906026 PMCID: PMC9345076 DOI: 10.1136/rmdopen-2022-002576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Paul Studenic
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Wien, Austria .,Department of Medicine (Solna), Division of Rheumatology, Karolinska Institute, Stockholm, Sweden
| | - Tanja A Stamm
- Ludwig Boltzmann Institut für Arthritis und Rehabilitation, Wien, Austria.,Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Erika Mosor
- Ludwig Boltzmann Institut für Arthritis und Rehabilitation, Wien, Austria.,Section for Outcomes Research, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Ilaria Bini
- Anmar Young, Rome, Italy.,EULAR Young PARE, Zürich, Switzerland
| | | | - Laure Gossec
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France.,AP-HP.Sorbonne Université, Rheumatology department, Hopital Universitaire Pitie Salpetriere, Paris, France
| | | | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK.,Rheumatology Department, King's College Hospital, London, UK
| | - Wendy Olsder
- EULAR Young PARE, Zürich, Switzerland.,Youth-R-Well, Nieuwegein, The Netherlands
| | - Ivan Padjen
- Department of Internal Medicine, Division of Clinical Immunology and Rheumatology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Simon Stones
- EULAR PARE, Zürich, Switzerland.,Envision Pharma Group Limited, Wilmslow, UK
| | | | - Alessia Alunno
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aguila, Italy.,Internal Medicine and Nephrology Unit, Department of Medicine, ASL Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, L'Aquila, Italy
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Sekhon M, De Thurah A, Fragoulis GE, Stamm T, Vliet Vlieland TPM, Esbensen BA, Lempp H, Bearne L, Kouloumas M, Pchelnikova P, Swinnen TW, Blunt C, Ferreira RJO, Carmona L, Nikiphorou E. POS1552-HPR A SYNTHESIS OF GUIDANCE AVAILABLE FOR ASSESSING METHODOLOGICAL QUALITY AND GRADING OF EVIDENCE FROM QUALITATIVE RESEARCH TO INFORM CLINICAL RECOMMENDATIONS: A SYSTEMATIC REVIEW. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.4614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundQualitative research is crucial to understand key stakeholders experiences and perspectives of care and health services. However, there is a lack of explicit frameworks and guidelines about how best to use qualitative evidence to formulate clinical recommendations. Part of the problem includes uncertainties about the contributions of qualitative research to the evidence, and the empirical and theoretical basis for appraising and synthesizing qualitative evidence in a standardized manner. In addition, most existing grading systems of qualitative research originates from quantitative research, and there is no clear guidance about how to incorporate qualitative research into the evidence hierarchy.ObjectivesTo conduct a systematic literature review (SLR) to answer two research questions (RQ):RQ1) What guidance (e.g., tools, checklists, frameworks) exists to assess the methodological quality of qualitative research employed to inform clinical recommendations?;RQ2) What methods exist specifically to grade levels of evidence for qualitative research?MethodsThe protocol for this review was registered on www.researchregistry.com (reviewregistry1240). Electronic databases (PubMed/Medline, EMBASE, Web of Science, COCHRANE, Emcare, PsycINFO, ERIC, Academic Search Premier, Sociological Abstracts, ProQuest Dissertations and Thesis Global) were searched for published and unpublished studies. Searches were completed from inception to 23rd October 2020. No restrictions were applied to clinical population. Eligible studies for both questions included primary articles and guideline documents available in English, describing the: i) development; ii) application of validated tools (e.g., checklists); iii) guidance on how to assess methodological quality of qualitive research and iv) guidance on how to grade levels of qualitative evidence. Opinion pieces and conference abstracts were excluded. Manual searches of the reference lists of full text articles were conducted. Two reviewers independently screened the titles, abstracts, and full text. A narrative synthesis was conducted to identify key aspects between the included studies.Results9071 records were retrieved (Figure 1). After de-duplication and title/abstract screening, 51 full-articles articles were assessed for eligibility yielding 15 included articles. For RQ1, six articles were included that described six tools (1) The society for Critical Care Medicine Family – Cantered Care Guidelines; 2) Nursing Management of the Second Stage of Labour evidence based clinical practice guidelines; 3) Jonna Briggs Institute Critical Appraisal of Qualitative Studies; 4) Critical Skill’s Appraisal Programme (CASP) and 6) the Modified CASP checklist). All tools ranged from 10 to 30 items, and evaluated research design, recruitment, ethical rigour, data collection and data analysis. Seven articles described one approach (GRADE CER-Qual) to assess methodological quality of qualitative research. This approach advised on the importance for assessing methodological limitations. For RQ2, two articles were included, one described a qualitative hierarchy of evidence, and another described a research pyramid that included a section on qualitative research.Figure 1.PRISMA diagram of included papersConclusionThis review highlights lack of consensus and limited availability of tools, checklists, and approaches to 1) appraise the methodological quality of qualitative research used to inform clinical recommendations and 2) grade levels of evidence for qualitative research. Current research agendas will need to determine the most relevant and appropriate method for the quality appraisal of qualitative research. This way, qualitative research could be more consistently and appropriately applied to the development of clinical recommendations.ReferencesN/ADisclosure of InterestsMandeep Sekhon: None declared, Annette de Thurah: None declared, George E. Fragoulis: None declared, Tanja Stamm: None declared, T.P.M. Vliet Vlieland: None declared, Bente Appel Esbensen: None declared, Heidi Lempp: None declared, Lindsay Bearne: None declared, Marios Kouloumas: None declared, Polina Pchelnikova: None declared, Thijs W. Swinnen: None declared, Chris Blunt: None declared, Ricardo J. O. Ferreira: None declared, Loreto Carmona: None declared, Elena Nikiphorou Speakers bureau: Celltrion, Pfizer, Sanofi, Gilead, Galapgos, AbbVie, Eli Lilly, Grant/research support from: Pfizer, Eli Lilly
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Siddle HJ, Chapman LS, Mankia K, Zăbălan C, Kouloumas M, Raza K, Falahee M, Kerry J, Kerschbaumer A, Aletaha D, Emery P, Richards SH. Perceptions and experiences of individuals at-risk of rheumatoid arthritis (RA) knowing about their risk of developing RA and being offered preventive treatment: systematic review and thematic synthesis of qualitative studies. Ann Rheum Dis 2021; 81:159-168. [PMID: 34750103 PMCID: PMC8762008 DOI: 10.1136/annrheumdis-2021-221160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/07/2021] [Indexed: 11/04/2022]
Abstract
Objectives There is increasing interest in identifying individuals at-risk of rheumatoid arthritis (RA) and initiating early treatment to prevent or delay the onset of arthritis. We aimed to describe the perceptions and experiences of at-risk individuals and to inform the conduct of clinical trials and studies, and clinical practice. Methods A systematic review and thematic synthesis of qualitative studies was conducted. Two review authors independently screened studies for inclusion, appraised their methodological quality using the Critical Appraisal Skills Programme checklist and assessed confidence in the findings using the Grading of Recommendations Assessment, Development and Evaluation–Confidence in Evidence from Reviews of Qualitative Research approach. Results Seven studies involving 115 individuals at-risk of developing RA were included. Three major themes (seven subthemes) were identified: understanding the risk of developing RA (knowledge of RA and identification of potential risk factors); preventive interventions to reduce the risk of developing RA (understanding the value and role of preventive interventions, and engagement with preventive interventions); and perceptions of predictive testing for RA (benefits of predictive testing, decision to undertake predictive testing and concerns about predictive testing). Moderate confidence in most review findings was evident. Conclusion While there are clear benefits in informing individuals at-risk of RA about their risk following predictive testing and offering preventive treatment, there are potential barriers to engagement, intensified by the burden of uncertainty. Identification of the optimum approaches for presenting risk information, including the risks and benefits of engaging with preventive interventions, is urgently needed to support individuals at-risk of RA in their decision making. PROSPERO registration number CRD42021236034.
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Affiliation(s)
- Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Lara S Chapman
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | | | | | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Marie Falahee
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Joel Kerry
- Library and Information Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
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Mosor E, Studenic P, Alunno A, Padjen I, Olsder W, Ramiro S, Bini I, Caeyers N, Gossec L, Kouloumas M, Nikiphorou E, Stones S, Wilhelmer TC, Stamm TA. Young people's perspectives on patient-reported outcome measures in inflammatory arthritis: results of a multicentre European qualitative study from a EULAR task force. RMD Open 2021; 7:rmdopen-2020-001517. [PMID: 33514672 PMCID: PMC7849893 DOI: 10.1136/rmdopen-2020-001517] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/24/2020] [Accepted: 01/14/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Although patient-reported outcome measures (PROMs) are increasingly used in clinical practice and research, it is unclear whether these instruments cover the perspective of young people with inflammatory arthritis (IA). The aims of this study were to explore whether PROMs commonly used in IA adequately cover the perspective of young people from different European countries. METHODS A multinational qualitative study was conducted in Austria, Croatia, Italy and the Netherlands. Young people with either rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), Still's disease, psoriatic arthritis (PsA) or spondyloarthritis (SpA), aged 18-35 years, participated in semistructured focus group interviews. Thematic analysis was used and data saturation was defined as no new emergent concepts in at least three subsequent focus groups. RESULTS Fifty-three patients (21 with RA/JIA/Still's, 17 with PsA, 15 with SpA; 72% women) participated in 12 focus groups. Participants expressed a general positive attitude towards PROMs and emphasised their importance in clinical practice. In addition, 48 lower level concepts were extracted and summarised into 6 higher level concepts describing potential issues for improvement. These included: need for lay-term information regarding the purpose of using PROMs; updates of certain outdated items and using digital technology for data acquisition. Some participants admitted their tendency to rate pain, fatigue or disease activity differently from what they actually felt for various reasons. CONCLUSIONS Despite their general positive attitude, young people with IA suggested areas for PROM development to ensure that important concepts are included, making PROMs relevant over the entire course of a chronic disease.
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Affiliation(s)
- Erika Mosor
- Section for Outcomes Research, Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Wien, Austria
| | - Paul Studenic
- Internal Medicine 3, Division of Rheumatology, Medical University Vienna, Wien, Austria.,Department of Medicine (Solna), Division of Rheumatology, Karolinska Institute, Stockholm, Sweden
| | - Alessia Alunno
- Department of Medicine, Rheumatology Unit, University of Perugia, Perugia, Umbria, Italy
| | - Ivan Padjen
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.,University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Wendy Olsder
- EULAR Young PARE, Zürich, Switzerland.,Youth-R-Well, Nieuwegein, The Netherlands
| | - Sofia Ramiro
- Rheumatology, Leiden University Medical Center, Leiden, South Holland, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, Limburg, The Netherlands
| | - Ilaria Bini
- EULAR Young PARE, Zürich, Switzerland.,Anmar Young, Rome, Italy
| | - Nele Caeyers
- EULAR PARE, Zurich, Switzerland.,ReumaNET, Leuven, Belgium
| | - Laure Gossec
- Pierre Louis Institute of Epidemiology and Public Health, Sorbonne University, Paris, France.,APHP, Rheumatology Department, Pitie Salpetriere University Hospital, Paris, France
| | | | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK.,Rheumatology Department, King's College Hospital NHS Trust, London, UK
| | - Simon Stones
- EULAR Patient Research Partner, Manchester, UK.,University of Leeds, Leeds, West Yorkshire, UK
| | | | - Tanja A Stamm
- Section for Outcomes Research, Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University Vienna, Wien, Austria
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Alunno A, Nikiphorou E, Philippou E, Daien C, Wiek D, Kouloumas M, Cutolo M. Nutrition in RMDs: is it really food for thought? Focus on rheumatoid arthritis. BMC Rheumatol 2020; 4:10. [PMID: 32175525 PMCID: PMC7063796 DOI: 10.1186/s41927-020-0113-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 01/08/2020] [Indexed: 01/04/2023] Open
Abstract
Background The relationship between food and health is known since the antiquity and in the field of rheumatic and musculoskeletal diseases (RMDs), mainly rheumatoid arthritis (RA), a large number of studies has been published over the last 50 years encompassing different aspects of nutrition. This led to postulate a role of nutrients for both primary prevention of RMDs in the general population and secondary prevention of disease flares and complications in patients with an established RMD. Main body of abstract We aimed to summarise and critically discuss current evidence on the role of different nutrients and dietary regimens in RMDs with a focus on RA. Over the last years, some seminal papers proved that some compounds, such as salt, can directly modulate the immune system and large epidemiological studies have been linking dietary patters with the risk to develop RMDs. However, physicians' knowledge about the role of diet in disease prevention and treatment is often poor and ultimately diet is rarely perceived as a companion of pharmacological treatment. Conclusions Based on the currently available evidence, we are not (yet?) in the phase of putting diet on the same level as pharmacological treatment in RMDs and in particular, RA, but future studies will likely shed additional light on this controversial topic and at least might suggest a value as dietary prevention of risk factors.
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Affiliation(s)
- Alessia Alunno
- 1Rheumatology Unit, Department of Medicine, University of Perugia, Piazzale Menghini 1, 06129 Perugia, Italy
| | - Elena Nikiphorou
- 2Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, King's College London, London, UK.,3Rheumatology Department, King's College Hospital, London, UK
| | - Elena Philippou
- 4Department of Life and Health Sciences, School of Sciences and Engineering, University of Nicosia, Nicosia, Cyprus
| | - Claire Daien
- 5Department of Rheumatology, Montpellier hospital, France and UMR5535, Institut de Génétique Moléculaire de Montpellier, Montpellier University, Montpellier, France
| | - Dieter Wiek
- EULAR PARE, Zurich, Switzerland.,7Deutsche Rheuma-Liga, Bonn, Germany
| | | | - Maurizio Cutolo
- 9Research Laboratory and Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, IRCCS San Martino Polyclinic Hospital, Genoa, Italy
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Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis JN, Cervera R, Doria A, Gordon C, Govoni M, Houssiau F, Jayne D, Kouloumas M, Kuhn A, Larsen JL, Lerstrøm K, Moroni G, Mosca M, Schneider M, Smolen JS, Svenungsson E, Tesar V, Tincani A, Troldborg A, van Vollenhoven R, Wenzel J, Bertsias G, Boumpas DT. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis 2019; 78:736-745. [DOI: 10.1136/annrheumdis-2019-215089] [Citation(s) in RCA: 780] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 12/11/2022]
Abstract
Our objective was to update the EULAR recommendations for the management of systemic lupus erythematosus (SLE), based on emerging new evidence. We performed a systematic literature review (01/2007–12/2017), followed by modified Delphi method, to form questions, elicit expert opinions and reach consensus. Treatment in SLE aims at remission or low disease activity and prevention of flares. Hydroxychloroquine is recommended in all patients with lupus, at a dose not exceeding 5 mg/kg real body weight. During chronic maintenance treatment, glucocorticoids (GC) should be minimised to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn. Appropriate initiation of immunomodulatory agents (methotrexate, azathioprine, mycophenolate) can expedite the tapering/discontinuation of GC. In persistently active or flaring extrarenal disease, add-on belimumab should be considered; rituximab (RTX) may be considered in organ-threatening, refractory disease. Updated specific recommendations are also provided for cutaneous, neuropsychiatric, haematological and renal disease. Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion.
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Alunno A, Studenic P, Nikiphorou E, Balážová P, van Nieuwkoop L, Ramiro S, Carubbi F, Richez C, Caeyers N, Gossec L, Kouloumas M. Person-focused care for young people with rheumatic and musculoskeletal diseases: young rheumatologists' and EULAR Young PARE perspectives. RMD Open 2017; 3:e000514. [PMID: 29018568 PMCID: PMC5623325 DOI: 10.1136/rmdopen-2017-000514] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/03/2017] [Accepted: 08/20/2017] [Indexed: 12/15/2022] Open
Abstract
In recent years, the evolution of healthcare challenged the management of people with rheumatic and musculoskeletal diseases (RMDs). From disease-centred care to person-focused care, a holistic approach along with patient empowerment about their disease, improved the physician-patient relationship and allowed to achieve better outcomes with lower healthcare costs. Nevertheless, RMDs may occur from childhood to the old age and to date very few studies have addressed the needs and priorities of young people with RMDs. However, the image of RMDs is still associated with the elderly population. In this regard, the group of young people with arthritis and rheumatism in Europe (PARE) was recently developed within European League Against Rheumatism to represent the voice of the young affected and to carry out projects aiming for a better understanding of these specific aspects. This viewpoint discusses the needs and priorities of young people compared with adult people with RMDs, based on the available literature and on the results of the PARE Youth research project, aiming to identify the next steps of actions that need to be taken to improve the current situation.
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Affiliation(s)
- Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - Paul Studenic
- Division of Rheumatology, Department of Internal Medicine 3, Medical University Vienna, Vienna, Austria
| | - Elena Nikiphorou
- Department of Academic Rheumatology, King's College London, London, UK.,Department of Rheumatology, Whittington Hospital, London, UK
| | - Petra Balážová
- Patient, EULAR Young PARE, Zurich, Switzerland.,Slovak League Against Rheumatism, Piestany, Slovakia
| | | | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Francesco Carubbi
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.,Department of Medicine, ASL1 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | - Christophe Richez
- Department of Rheumatology, FHU ACRONIM, Pellegrin Hospital and UMR CNRS 5164, Bordeaux University, Bordeaux, France
| | | | - Laure Gossec
- Sorbonne Universités, UPMC Univ Paris 06, Institut Pierre Louis d'Epidémiologie et de Santé Publique (UMRS 1136), Paris, France.,Department of Rheumatology, Hôpital Pitié Salpêtrière, AP-HP, Paris, France
| | - Marios Kouloumas
- Patient, EULAR Young PARE, Zurich, Switzerland.,Cyprus Legue Against Rheumatism, Aglantzia, Cyprus
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9
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Nikiphorou E, Alunno A, Carmona L, Kouloumas M, Bijlsma J, Cutolo M. Patient-physician collaboration in rheumatology: a necessity. RMD Open 2017; 3:e000499. [PMID: 29152329 PMCID: PMC5686831 DOI: 10.1136/rmdopen-2017-000499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/13/2017] [Accepted: 06/14/2017] [Indexed: 02/04/2023] Open
Abstract
Over the past few decades, there has been significant and impressive progress in the understanding and management of rheumatic diseases. One of the key reasons for succeeding in making this progress has been the increasingly stronger partnership between physicians and patients, setting a milestone in patient care. In this viewpoint, we discuss the recent evolution of the physician-patient relationship over time in Europe, reflecting on the 'journey' from behind the clinic walls through to clinical and research collaborations at national and international level and the birth of healthcare professional and 'rheumatic' patient organisations. The role of expert patients and patient advocates in clinical and scientific committees now represents a core part of the decision-making process. In more recent years and following the recognition that the young patients, physicians and academics have a voice and needs of their own, including the need to be educated and instructed, has encouraged the establishment of youth organisations, enabling change and innovation to take place at a uniquely different level.
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Affiliation(s)
- Elena Nikiphorou
- Academic Rheumatology Department, King's College London, London, UK.,Rheumatology Department, Whittington Hospital NHS Trust, London, UK
| | - Alessia Alunno
- Department of Medicine, Rheumatology Unit, University of Perugia, Italy
| | | | | | - Johannes Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, The Netherlands
| | - Maurizio Cutolo
- Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy
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10
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Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, Nam J, Ramiro S, Voshaar M, van Vollenhoven R, Aletaha D, Aringer M, Boers M, Buckley CD, Buttgereit F, Bykerk V, Cardiel M, Combe B, Cutolo M, van Eijk-Hustings Y, Emery P, Finckh A, Gabay C, Gomez-Reino J, Gossec L, Gottenberg JE, Hazes JMW, Huizinga T, Jani M, Karateev D, Kouloumas M, Kvien T, Li Z, Mariette X, McInnes I, Mysler E, Nash P, Pavelka K, Poór G, Richez C, van Riel P, Rubbert-Roth A, Saag K, da Silva J, Stamm T, Takeuchi T, Westhovens R, de Wit M, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017; 76:960-977. [PMID: 28264816 DOI: 10.1136/annrheumdis-2016-210715] [Citation(s) in RCA: 1720] [Impact Index Per Article: 245.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 01/05/2017] [Accepted: 02/09/2017] [Indexed: 02/07/2023]
Abstract
Recent insights in rheumatoid arthritis (RA) necessitated updating the European League Against Rheumatism (EULAR) RA management recommendations. A large international Task Force based decisions on evidence from 3 systematic literature reviews, developing 4 overarching principles and 12 recommendations (vs 3 and 14, respectively, in 2013). The recommendations address conventional synthetic (cs) disease-modifying antirheumatic drugs (DMARDs) (methotrexate (MTX), leflunomide, sulfasalazine); glucocorticoids (GC); biological (b) DMARDs (tumour necrosis factor (TNF)-inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab), abatacept, rituximab, tocilizumab, clazakizumab, sarilumab and sirukumab and biosimilar (bs) DMARDs) and targeted synthetic (ts) DMARDs (Janus kinase (Jak) inhibitors tofacitinib, baricitinib). Monotherapy, combination therapy, treatment strategies (treat-to-target) and the targets of sustained clinical remission (as defined by the American College of Rheumatology-(ACR)-EULAR Boolean or index criteria) or low disease activity are discussed. Cost aspects were taken into consideration. As first strategy, the Task Force recommends MTX (rapid escalation to 25 mg/week) plus short-term GC, aiming at >50% improvement within 3 and target attainment within 6 months. If this fails stratification is recommended. Without unfavourable prognostic markers, switching to-or adding-another csDMARDs (plus short-term GC) is suggested. In the presence of unfavourable prognostic markers (autoantibodies, high disease activity, early erosions, failure of 2 csDMARDs), any bDMARD (current practice) or Jak-inhibitor should be added to the csDMARD. If this fails, any other bDMARD or tsDMARD is recommended. If a patient is in sustained remission, bDMARDs can be tapered. For each recommendation, levels of evidence and Task Force agreement are provided, both mostly very high. These recommendations intend informing rheumatologists, patients, national rheumatology societies, hospital officials, social security agencies and regulators about EULAR's most recent consensus on the management of RA, aimed at attaining best outcomes with current therapies.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.,2nd Department of Medicine, Hietzing Hospital, Vienna, Austria
| | - Robert Landewé
- Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Johannes Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | | | | | - Jackie Nam
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Voshaar
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Ronald van Vollenhoven
- Amsterdam Rheumatology & Immunology Center, Amsterdam, The Netherlands.,Zuyderland Medical Center, Heerlen, The Netherlands
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Martin Aringer
- Division of Rheumatology, Medizinische Klinik und Poliklinik III, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Chris D Buckley
- Birmingham NIHR Wellcome Trust Clinical Research Facility, Rheumatology Research Group, Institute of Inflammation and Ageing (IIA), University of Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Vivian Bykerk
- Department of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA.,Rebecca McDonald Center for Arthritis & Autoimmune Disease, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mario Cardiel
- Centro de Investigación Clínica de Morelia SC, Michoacán, México
| | - Bernard Combe
- Rheumatology Department, Lapeyronie Hospital, Montpellier University, UMR 5535, Montpellier, France
| | - Maurizio Cutolo
- Research Laboratory and Division of Clinical Rheumatology, University of Genoa, Genoa, Italy
| | - Yvonne van Eijk-Hustings
- Department of Patient & Care and Department of Rheumatology, University of Maastricht, Maastricht, The Netherlands
| | - Paul Emery
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Axel Finckh
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Cem Gabay
- Division of Rheumatology, University Hospitals of Geneva, Geneva, Switzerland
| | - Juan Gomez-Reino
- Fundación Ramón Dominguez, Hospital Clinico Universitario, Santiago, Spain
| | - Laure Gossec
- Department of Rheumatology, Sorbonne Universités, Pitié Salpêtrière Hospital, Paris, France
| | - Jacques-Eric Gottenberg
- Institut de Biologie Moléculaire et Cellulaire, Immunopathologie, et Chimie Thérapeutique, Strasbourg University Hospital and University of Strasbourg, CNRS, Strasbourg, France
| | - Johanna M W Hazes
- Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tom Huizinga
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Meghna Jani
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Dmitry Karateev
- V.A. Nasonova Research Institute of Rheumatology, Moscow, Russian Federation
| | - Marios Kouloumas
- European League Against Rheumatism, Zurich, Switzerland.,Cyprus League against Rheumatism, Nicosia, Cyprus
| | - Tore Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Beijing University People's Hospital, Beijing, China
| | - Xavier Mariette
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, INSERM U1184, Center for Immunology of viral Infections and Autoimmune Diseases (IMVA), Le Kremlin Bicêtre, France
| | - Iain McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Eduardo Mysler
- Organización Médica de Investigación, Buenos Aires, Argentina
| | - Peter Nash
- Department of Medicine, University of Queensland, Queensland, Australia
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Gyula Poór
- National Institute of Rheumatology and Physiotherapy, Semmelweis University, Budapest, Hungary
| | - Christophe Richez
- Rheumatology Department, FHU ACRONIM, Pellegrin Hospital and UMR CNRS 5164, Bordeaux University, Bordeaux, France
| | - Piet van Riel
- Department of Rheumatology, Bernhoven, Uden, The Netherlands
| | | | - Kenneth Saag
- Division of Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jose da Silva
- Serviço de Reumatologia, Centro Hospitalar e Universitário de Coimbra Praceta Mota Pinto, Coimbra, Portugal
| | - Tanja Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Keio University School of Medicine, Keio University Hospital, Tokyo, Japan
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium.,Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten de Wit
- Department Medical Humanities, VU Medical Centre, Amsterdam, The Netherlands
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11
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Baillet A, Gossec L, Carmona L, Wit MD, van Eijk-Hustings Y, Bertheussen H, Alison K, Toft M, Kouloumas M, Ferreira RJO, Oliver S, Rubbert-Roth A, van Assen S, Dixon WG, Finckh A, Zink A, Kremer J, Kvien TK, Nurmohamed M, van der Heijde D, Dougados M. Points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic diseases in daily practice: a EULAR initiative. Ann Rheum Dis 2016; 75:965-73. [DOI: 10.1136/annrheumdis-2016-209233] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/27/2016] [Indexed: 01/15/2023]
Abstract
In chronic inflammatory rheumatic diseases, comorbidities such as cardiovascular diseases and infections are suboptimally prevented, screened for and managed. The objective of this European League Against Rheumatism (EULAR) initiative was to propose points to consider to collect comorbidities in patients with chronic inflammatory rheumatic diseases. We also aimed to develop a pragmatic reporting form to foster the implementation of the points to consider. In accordance with the EULAR Standardised Operating Procedures, the process comprised (1) a systematic literature review of existing recommendations on reporting, screening for or preventing six selected comorbidities: ischaemic cardiovascular diseases, malignancies, infections, gastrointestinal diseases, osteoporosis and depression and (2) a consensus process involving 21 experts (ie, rheumatologists, patients, health professionals). Recommendations on how to treat the comorbidities were not included in the document as they vary across countries. The literature review retrieved 42 articles, most of which were recommendations for reporting or screening for comorbidities in the general population. The consensus process led to three overarching principles and 15 points to consider, related to the six comorbidities, with three sections: (1) reporting (ie, occurrence of the comorbidity and current treatments); (2) screening for disease (eg, mammography) or for risk factors (eg, smoking) and (3) prevention (eg, vaccination). A reporting form (93 questions) corresponding to a practical application of the points to consider was developed. Using an evidence-based approach followed by expert consensus, this EULAR initiative aims to improve the reporting and prevention of comorbidities in chronic inflammatory rheumatic diseases. Next steps include dissemination and implementation.
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12
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Smolen JS, Breedveld FC, Burmester GR, Bykerk V, Dougados M, Emery P, Kvien TK, Navarro-Compán MV, Oliver S, Schoels M, Scholte-Voshaar M, Stamm T, Stoffer M, Takeuchi T, Aletaha D, Andreu JL, Aringer M, Bergman M, Betteridge N, Bijlsma H, Burkhardt H, Cardiel M, Combe B, Durez P, Fonseca JE, Gibofsky A, Gomez-Reino JJ, Graninger W, Hannonen P, Haraoui B, Kouloumas M, Landewe R, Martin-Mola E, Nash P, Ostergaard M, Östör A, Richards P, Sokka-Isler T, Thorne C, Tzioufas AG, van Vollenhoven R, de Wit M, van der Heijde D. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis 2016; 75:3-15. [PMID: 25969430 PMCID: PMC4717393 DOI: 10.1136/annrheumdis-2015-207524] [Citation(s) in RCA: 941] [Impact Index Per Article: 117.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 04/10/2015] [Accepted: 04/13/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Reaching the therapeutic target of remission or low-disease activity has improved outcomes in patients with rheumatoid arthritis (RA) significantly. The treat-to-target recommendations, formulated in 2010, have provided a basis for implementation of a strategic approach towards this therapeutic goal in routine clinical practice, but these recommendations need to be re-evaluated for appropriateness and practicability in the light of new insights. OBJECTIVE To update the 2010 treat-to-target recommendations based on systematic literature reviews (SLR) and expert opinion. METHODS A task force of rheumatologists, patients and a nurse specialist assessed the SLR results and evaluated the individual items of the 2010 recommendations accordingly, reformulating many of the items. These were subsequently discussed, amended and voted upon by >40 experts, including 5 patients, from various regions of the world. Levels of evidence, strengths of recommendations and levels of agreement were derived. RESULTS The update resulted in 4 overarching principles and 10 recommendations. The previous recommendations were partly adapted and their order changed as deemed appropriate in terms of importance in the view of the experts. The SLR had now provided also data for the effectiveness of targeting low-disease activity or remission in established rather than only early disease. The role of comorbidities, including their potential to preclude treatment intensification, was highlighted more strongly than before. The treatment aim was again defined as remission with low-disease activity being an alternative goal especially in patients with long-standing disease. Regular follow-up (every 1-3 months during active disease) with according therapeutic adaptations to reach the desired state was recommended. Follow-up examinations ought to employ composite measures of disease activity that include joint counts. Additional items provide further details for particular aspects of the disease, especially comorbidity and shared decision-making with the patient. Levels of evidence had increased for many items compared with the 2010 recommendations, and levels of agreement were very high for most of the individual recommendations (≥9/10). CONCLUSIONS The 4 overarching principles and 10 recommendations are based on stronger evidence than before and are supposed to inform patients, rheumatologists and other stakeholders about strategies to reach optimal outcomes of RA.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Hietzing Hospital, Vienna, Austria
| | - Ferdinand C Breedveld
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerd R Burmester
- Department of Rheumatology, Clinical Immunology Free University and Humboldt University, Charité-University Medicine, Berlin, Germany
| | - Vivian Bykerk
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, Cornell University, New York, USA
| | - Maxime Dougados
- Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital,Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | | | | | - Monika Schoels
- 2nd Department of Medicine, Hietzing Hospital, Vienna, Austria
| | - Marieke Scholte-Voshaar
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Tanja Stamm
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Michaela Stoffer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Jose Louis Andreu
- Rheumatology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain
| | - Martin Aringer
- Department of Medicine III, University Medical Center TU Dresden, Dresden, Germany
| | - Martin Bergman
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Neil Betteridge
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Hans Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, and VU University Medical Center, Amsterdam, The Netherlands
| | - Harald Burkhardt
- Division of Rheumatology, Department of Medicine, Johann-Wolfgang-Goethe University Frankfurt, German
| | - Mario Cardiel
- Centro de Investigación Clínica de Morelia, Morelia, Michoacán, Mexico
| | - Bernard Combe
- Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
| | - Patrick Durez
- Pôle de Recherche en Rhumatologie, Institut de Recherche Experimentale et Clinique, Université Catholique de Louvain and Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Joao Eurico Fonseca
- Rheumatology Research Unit, Instituto de de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Rheumatology Department, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Alan Gibofsky
- Weill Medical College, Cornell University Hospital for Special Surgery, New York, USA
| | - Juan J Gomez-Reino
- Rheumatology Unit, Santiago University Clinical Hospital, Santiago de Compostela, Spain
| | | | - Pekka Hannonen
- Department of Medicine, Central Hospital, Jyväskylä, Finland
| | | | - Marios Kouloumas
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Robert Landewe
- Academic Medical Center, University of Amsterdam, Amsterdam, and Atrium Medical Center, Heerlen, The Netherlands
| | | | - Peter Nash
- University of Queensland, Brisbane, Queensland, Australia
| | - Mikkel Ostergaard
- Department of Clinical Medicine, Faculty of Health Sciences, Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet and Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Andrew Östör
- Rheumatology Clinical Research Unit, School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge University Hospitals, NHS Foundation Trust, Cambridge, UK
| | - Pam Richards
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | | | - Carter Thorne
- Division of Rheumatology, Southlake Regional Health Centre, Newarket, Ontario, Canada
| | | | | | - Martinus de Wit
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Desirée van der Heijde
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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13
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van der Heijde D, Aletaha D, Carmona L, Edwards CJ, Kvien TK, Kouloumas M, Machado P, Oliver S, de Wit M, Dougados M. 2014 Update of the EULAR standardised operating procedures for EULAR-endorsed recommendations. Ann Rheum Dis 2014; 74:8-13. [PMID: 25261577 PMCID: PMC4283681 DOI: 10.1136/annrheumdis-2014-206350] [Citation(s) in RCA: 201] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this article, the European League Against Rheumatism (EULAR) standardised operating procedures for the elaboration, evaluation, dissemination and implementation of recommendations endorsed by the EULAR standing committees published in 2004 have been updated. The various steps from the application to implementation have been described in detail.
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Affiliation(s)
| | - Daniel Aletaha
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | - Christopher J Edwards
- NIHR Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Marios Kouloumas
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Pedro Machado
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands Coimbra University Hospital, Coimbra, Portugal
| | - Sue Oliver
- Independent Nurse Consultant, North Devon, UK
| | - Maarten de Wit
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Maxime Dougados
- Rheumatology Department, Paris Descartes University, Cochin Hospital, Paris, France INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
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14
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Kouloumas M. SP0102 Raising Awareness - the Perspective of Pare. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.6308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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15
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Smolen JS, Landewé R, Breedveld FC, Buch M, Burmester G, Dougados M, Emery P, Gaujoux-Viala C, Gossec L, Nam J, Ramiro S, Winthrop K, de Wit M, Aletaha D, Betteridge N, Bijlsma JWJ, Boers M, Buttgereit F, Combe B, Cutolo M, Damjanov N, Hazes JMW, Kouloumas M, Kvien TK, Mariette X, Pavelka K, van Riel PLCM, Rubbert-Roth A, Scholte-Voshaar M, Scott DL, Sokka-Isler T, Wong JB, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Ann Rheum Dis 2014; 73:492-509. [PMID: 24161836 PMCID: PMC3933074 DOI: 10.1136/annrheumdis-2013-204573] [Citation(s) in RCA: 1430] [Impact Index Per Article: 143.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 10/05/2013] [Accepted: 10/11/2013] [Indexed: 02/07/2023]
Abstract
In this article, the 2010 European League against Rheumatism (EULAR) recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (sDMARDs and bDMARDs, respectively) have been updated. The 2013 update has been developed by an international task force, which based its decisions mostly on evidence from three systematic literature reviews (one each on sDMARDs, including glucocorticoids, bDMARDs and safety aspects of DMARD therapy); treatment strategies were also covered by the searches. The evidence presented was discussed and summarised by the experts in the course of a consensus finding and voting process. Levels of evidence and grades of recommendations were derived and levels of agreement (strengths of recommendations) were determined. Fourteen recommendations were developed (instead of 15 in 2010). Some of the 2010 recommendations were deleted, and others were amended or split. The recommendations cover general aspects, such as attainment of remission or low disease activity using a treat-to-target approach, and the need for shared decision-making between rheumatologists and patients. The more specific items relate to starting DMARD therapy using a conventional sDMARD (csDMARD) strategy in combination with glucocorticoids, followed by the addition of a bDMARD or another csDMARD strategy (after stratification by presence or absence of adverse risk factors) if the treatment target is not reached within 6 months (or improvement not seen at 3 months). Tumour necrosis factor inhibitors (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, biosimilars), abatacept, tocilizumab and, under certain circumstances, rituximab are essentially considered to have similar efficacy and safety. If the first bDMARD strategy fails, any other bDMARD may be used. The recommendations also address tofacitinib as a targeted sDMARD (tsDMARD), which is recommended, where licensed, after use of at least one bDMARD. Biosimilars are also addressed. These recommendations are intended to inform rheumatologists, patients, national rheumatology societies and other stakeholders about EULAR's most recent consensus on the management of RA with sDMARDs, glucocorticoids and bDMARDs. They are based on evidence and expert opinion and intended to improve outcome in patients with RA.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria
| | - Robert Landewé
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Atrium Medical Center, Heerlen, The Netherlands
| | - Ferdinand C Breedveld
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maya Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Maxime Dougados
- Department of Rheumatology B, Cochin Hospital, René Descartes University, Paris, France
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Cécile Gaujoux-Viala
- Department of Rheumatology, Nîmes University Hospital, Montpellier I University, Nimes, France
| | - Laure Gossec
- Rheumatology Department, Paris 06 UPMC University, AP-HP, Pite-Salpetriere Hospital, Paris, France
| | - Jackie Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sofia Ramiro
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Hospital Garcia de Orta, Almada, Portugal
| | - Kevin Winthrop
- Oregon Health and Science University, Portland, Oregon, USA
| | - Maarten de Wit
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Neil Betteridge
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten Boers
- VU University Medical Center, Amsterdam, The Netherlands
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine, Free University and Humboldt University, Berlin, Germany
- Clinical Immunology Free University and Humboldt University, Berlin, Germany
| | - Bernard Combe
- Service d'Immuno-Rhumatologie, Montpellier University, Lapeyronie Hospital, Montpellier, France
| | - Maurizio Cutolo
- Academic Clinical Unit of Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Nemanja Damjanov
- 2nd Hospital Department, Institute of Rheumatology, University of Belgrade Medical School, Belgrade, Serbia
| | - Johanna M W Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center, Dr Molewaterplein, Rotterdam, The Netherlands
| | - Marios Kouloumas
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Xavier Mariette
- Hopitaux Universitaires Paris Sud, AP-HP, and Université Paris-Sud, Le Kremlin Bicetre, France
| | - Karel Pavelka
- Institute of Rheumatology and Clinic of Rheumatology, Charles University, Prague, Czech Republic
| | - Piet L C M van Riel
- Department of Rheumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Marieke Scholte-Voshaar
- EULAR Standing Committee of People with Arthritis/Rheumatism in Europe (PARE), Zurich, Switzerland
| | - David L Scott
- King's College School of Medicine, Weston Education Centre, London, UK
| | | | - John B Wong
- Division of Clinical Decision Making, Informatics and Telemedicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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16
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Smolen JS, Landewé R, Breedveld FC, Dougados M, Emery P, Gaujoux-Viala C, Gorter S, Knevel R, Nam J, Schoels M, Aletaha D, Buch M, Gossec L, Huizinga T, Bijlsma JWJW, Burmester G, Combe B, Cutolo M, Gabay C, Gomez-Reino J, Kouloumas M, Kvien TK, Martin-Mola E, McInnes I, Pavelka K, van Riel P, Scholte M, Scott DL, Sokka T, Valesini G, van Vollenhoven R, Winthrop KL, Wong J, Zink A, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis 2010; 69:964-75. [PMID: 20444750 PMCID: PMC2935329 DOI: 10.1136/ard.2009.126532] [Citation(s) in RCA: 1077] [Impact Index Per Article: 76.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2010] [Indexed: 02/06/2023]
Abstract
Treatment of rheumatoid arthritis (RA) may differ among rheumatologists and currently, clear and consensual international recommendations on RA treatment are not available. In this paper recommendations for the treatment of RA with synthetic and biological disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs) that also account for strategic algorithms and deal with economic aspects, are described. The recommendations are based on evidence from five systematic literature reviews (SLRs) performed for synthetic DMARDs, biological DMARDs, GCs, treatment strategies and economic issues. The SLR-derived evidence was discussed and summarised as an expert opinion in the course of a Delphi-like process. Levels of evidence, strength of recommendations and levels of agreement were derived. Fifteen recommendations were developed covering an area from general aspects such as remission/low disease activity as treatment aim via the preference for methotrexate monotherapy with or without GCs vis-à-vis combination of synthetic DMARDs to the use of biological agents mainly in patients for whom synthetic DMARDs and tumour necrosis factor inhibitors had failed. Cost effectiveness of the treatments was additionally examined. These recommendations are intended to inform rheumatologists, patients and other stakeholders about a European consensus on the management of RA with DMARDs and GCs as well as strategies to reach optimal outcomes of RA, based on evidence and expert opinion.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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17
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Gorter SL, Bijlsma JW, Cutolo M, Gomez-Reino J, Kouloumas M, Smolen JS, Landewé R. Current evidence for the management of rheumatoid arthritis with glucocorticoids: a systematic literature review informing the EULAR recommendations for the management of rheumatoid arthritis. Ann Rheum Dis 2010; 69:1010-4. [PMID: 20448288 DOI: 10.1136/ard.2009.127332] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Glucocorticoids (GCs) rapidly reduce disease activity in early and advanced rheumatoid arthritis (RA). This systematic review on behalf of the task force on recommendations for the management of RA addresses the efficacy of GCs in RA. A literature search was performed in Medline, Embase, the Cochrane database, and the ACR/EULAR abstracts 2007 and 2008 on a set of questions relating to the use of GCs in RA. Eleven publications (including three Cochrane reviews comprising 33 trials) that met the criteria for detailed assessment were found. Robust evidence that GCs are effective as bridging therapy was obtained. The addition of GCs, to either standard synthetic disease-modifying antirheumatic drug (DMARD) monotherapy or combinations of synthetic DMARDs, yields clinical benefits and inhibition of radiographic progression that may extend over many years. In early RA, the addition of low-dose GCs (<7.5 mg/day) to DMARDs leads to a reduction in radiographic progression; in longstanding RA, GCs (up to 15 mg/day) improve disease activity. There is some evidence that appropriate timing of GC administration may result in less morning stiffness. Only indirect information was found on the best tapering strategy, supporting the general view that GCs should be tapered slowly in order to avoid clinical relapses. GCs are effective in relieving signs and symptoms and inhibiting radiographic progression, either as monotherapy or in combination with synthetic DMARD monotherapy or combination therapy.
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Affiliation(s)
- S L Gorter
- Division of Internal Medicine, Subdivision of Rheumatology, Maastricht University Hospital, P Debeyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
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