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den Broeder N, Verhoef L, de Man YA, Kok MR, Thurlings R, van der Weele W, van den Bemt BJ, van den Hoogen FH, van der Maas A, den Broeder AA. Long-term clinical and radiological effectiveness and safety of ultralow doses of rituximab in rheumatoid arthritis: observational extension of the REDO trial. RMD Open 2024; 10:e003659. [PMID: 38599654 PMCID: PMC11015170 DOI: 10.1136/rmdopen-2023-003659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/02/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND The REDO trial (REtreatment with Rituximab in RhEmatoid arthritis: Disease Outcome after Dose Optimisation) showed similar disease activity for retreatment with ultralow doses (200 mg and 500 mg per 6 months) compared with standard low-dose rituximab (RTX, 1000 mg per 6 months). We performed an observational extension study of the REDO trial to assess long-term effectiveness. METHODS Patients from the REDO trial were followed from start of the trial to censoring in April 2021. RTX use was at the discretion of patient and rheumatologist using treat to target. The primary outcome was disease activity (disease activity score in 28 joints C-reactive protein (DAS28-CRP)), analysed using a longitudinal mixed model by original randomisation and time-varying RTX dose. The original DAS28-CRP non-inferiority (NI) margin of 0.6 was used. RTX dose and persistence, safety and radiological outcomes were also assessed. FINDINGS Data from 126 of 142 REDO patients was collected from 15 December 2016, up to 30 April 2021. Drop-outs continued treatment elsewhere (n=3) or did not consent (n=13).Disease activity did not differ by original randomisation group: 1000 mg mean DAS28-CRP (95% CI) of 2.2 (2.0 to 2.5), 500 mg 2.3 (2.1 to 2.4) and 200 mg 2.4 (2.2 to 2.5). Lower time-varying RTX dose was associated with higher DAS28-CRP (0.22 (95% CI 0.05 to 0.40) higher for 200 mg/6 months compared with 1000 mg/6 months), but remained within the NI-margin. RTX persistence was 93%. Median RTX dose was 978 mg (IQR 684-1413) per year, and no association was found between RTX dose and adverse events or radiological damage. INTERPRETATION Long-term use of ultralow doses of RTX is effective in patients with rheumatoid arthritis responding to standard dose RTX.
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Affiliation(s)
| | - Lise Verhoef
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, Netherlands
| | - Yaël A de Man
- Rheumatology, Ziekenhuisgroep Twente, Almelo, Netherlands
| | - Marc R Kok
- Rheumatology, Maasstad Ziekenhuis, Rotterdam, Zuid-Holland, Netherlands
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Ulijn E, den Broeder N, Ten Cate D, van Overdijk K, Demirel H, Landewé R, van Herwaarden N, den Broeder A. Limited Diagnostic and Prognostic Value of Routine Radiographs in Newly Presenting Arthritis Suspected of Rheumatoid Arthritis: A Retrospective Study. Arthritis Care Res (Hoboken) 2024; 76:497-502. [PMID: 37933435 DOI: 10.1002/acr.25271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/12/2023] [Accepted: 11/03/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Current recommendations suggest that patients with newly presenting arthritis suspected of rheumatoid arthritis (RA) should undergo routine radiographs of hands and feet (X-HF) as the presence of RA-associated erosions might be of diagnostic and prognostic value. Our objective was to investigate the prevalence, diagnostic, and prognostic value of RA-associated erosions seen on routine X-HF in a large, recent cohort of patients with newly presenting arthritis. METHODS A retrospective cohort study was performed between 2016 and 2019 in patients with newly presenting arthritis suspected of RA. Patients were included if arthritis was present at diagnosis, rheumatoid factor and anticitrullinated protein antibodies were measured, RA was noted in the differential diagnosis, and routine X-HF were conducted. Outcomes were the prevalence of one or more RA-associated erosion(s), and whether diagnostic or prognostic classification were changed by erosivity. Seronegative patients, patients without acute phase reactants, and patients with longer symptom duration were analyzed as subgroups. RESULTS RA-associated erosions were found in 32 of 724 patients (4.4%, 95% confidence interval [95% CI] 3.1-6.2). Erosions led to a change of diagnostic classification in two patients (0.3%, 95% CI 0.01-1.1) and changed prognostic classification in three patients (0.4%, 95% CI 0.1-1.3). Seronegative patients and patients without elevated acute phase reactants had significantly lower prevalence of erosions (χ2 9.4, P = 0.002, χ2 6.5, P = 0.01). Longer symptom duration was not associated with a different prevalence of erosions (χ2 0.4, P = 0.81). CONCLUSION The recommendation of conducting routine X-HF in patients with newly presenting arthritis suspected of RA might be reconsidered due to low prevalence of early erosive disease and lack of diagnostic and prognostic value.
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Affiliation(s)
- Evy Ulijn
- Sint Maartenskliniek, Nijmegen, the Netherlands
| | | | | | | | | | - Robert Landewé
- Amsterdam Medical Center (AMC), Amsterdam, and Zuyderland Medical Center, Heerlen, the Netherlands
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Te Groen M, Derks M, den Broeder N, Peters C, Dijkstra G, de Vries A, Romkens T, Horjus C, de Boer N, de Jong M, Nagtegaal I, Derikx L, Hoentjen F. Quality of Surveillance Impacts the Colitis-Associated Advanced Neoplasia Risk: A Multicenter Case-Control Study. Clin Gastroenterol Hepatol 2024; 22:357-367.e5. [PMID: 36572110 DOI: 10.1016/j.cgh.2022.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/09/2022] [Accepted: 12/08/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Although colorectal cancer (CRC) surveillance is embedded in clinical inflammatory bowel disease (IBD) practice, a subset of patients still develops advanced neoplasia (AN) (high-grade dysplasia [HGD] and/or CRC). We aimed to assess the impact of surveillance quality on AN risk in IBD. METHODS In this multicenter case-control study, we searched the Dutch nationwide pathology databank to identify IBD cases with AN and controls with indefinite or low-grade dysplasia. The surveillance colonoscopy preceding the index lesion (first indefinite for dysplasia [IND]/low-grade dysplasia [LGD] or AN) was used to assess the impact of surveillance quality. We assessed intervals, bowel preparation, cecal intubation, and absence of inflammation as primary quality indicators. In addition, we assessed chromoendoscopy, endoscopist expertise, hospital setting, and biopsy strategy. Associations of quality indicators with AN risk were determined with multivariable logistic regression analyses with Firth's correction. RESULTS We included 137 cases and 138 controls. Delayed intervals (58.2% vs 39.6%) and active inflammation (65.3% vs 41.8%) were frequently present in cases and controls and were associated with AN (delayed interval: adjusted odds ratio [aOR], 2.00; 95% confidence interval [CI], 1.07-3.81; P = .03; active inflammation: aOR, 2.46; 95% CI, 1.33-4.61; P < .01). Surveillance compliant with primary quality indicators was associated with a reduced AN risk (aOR, 0.43; 95% CI, 0.22-0.91; P = .03), similar to chromoendoscopy (OR, 0.11; 95% CI, 0.01-0.89; P = .01). Other indicators were not significantly associated with AN. CONCLUSIONS Surveillance compliant with primary quality indicators is associated with a reduced colitis-associated AN risk. Delayed surveillance intervals and active inflammation were associated with an increased AN risk. This underlines the importance of procedural quality, including endoscopic remission to optimize the effectiveness of endoscopic surveillance.
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Affiliation(s)
- Maarten Te Groen
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Monica Derks
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nathan den Broeder
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Charlotte Peters
- Department of Gastroenterology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology, Groningen University Medical Center, Groningen, the Netherlands
| | - Annemarie de Vries
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Tessa Romkens
- Department of Gastroenterology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Carmen Horjus
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Nanne de Boer
- Department of Gastroenterology and Hepatology, AGEM Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michiel de Jong
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Iris Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Lauranne Derikx
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Frank Hoentjen
- Inflammatory Bowel Disease Center, Department of Gastroenterology, Radboud University Medical Center, Nijmegen, the Netherlands; Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
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Schapink L, den Broeder N, den Broeder AA, Verhoef LM. Treat-to-target vs fixed interval retreatment strategy with rituximab in rheumatoid arthritis: a retrospective cohort study. Rheumatol Int 2024:10.1007/s00296-023-05524-x. [PMID: 38286887 DOI: 10.1007/s00296-023-05524-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/21/2023] [Indexed: 01/31/2024]
Abstract
To compare the effectiveness of retreatment of rheumatoid arthritis (RA) patients with rituximab (RTX) following the treat-to-target retreatment (TTr) or fixed interval retreatment (FIr) strategy. RA patients starting RTX treatment between January 2008 and June 2016, and receiving at least three infusion cycles were grouped by strategy (TTr, FIr or both). Primary outcome (between strategy difference in DAS28-CRP (Disease Activity Score in 28 joints calculated with C-reactive protein)) and secondary outcomes (flares, use of co-medication and mean yearly dose of RTX) were analyzed by group using linear mixed models to account for different strategies within patients. A total of 213 patients, 59 TTr (of whom 32 switched from TTr to FIr) and 186 FIr were included. No between-group difference in mean DAS28-CRP was found (0.10 DAS28-CRP point (95% CI - 0.07 to 0.26)). The TTr strategy did not result in more flares (IRR 1.13, 95%CI 0.87 to 1.47), conventional synthetic disease-modifying antirheumatic drug use (difference - 11.7%, 95%CI - 26.3% to 2.9%), or lower mean yearly RTX dose (difference 172 mg/yr, 95%CI - 355 to 11.7 mg/yr). RTX retreatment with either a TTr or FIr strategy does not seem to lead to better disease control and/or less drug use when used in a DAS28-CRP treat-to-target context. Choice of either strategy can, therefore, be made based on patient and physician preferences and logistical context.
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Affiliation(s)
- Lisa Schapink
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rheumatic Diseases, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
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Popa CD, Opdam MAA, den Broeder N, van Ballegooijen H, Mulder K, van de Wiel KM, van Herwaarden N, Wientjes MHM, den Broeder AA. Therapy with JAK inhibitors or bDMARDs and the risk of cardiovascular events in the Dutch rheumatoid arthritis population. Rheumatology (Oxford) 2023:kead531. [PMID: 37796830 DOI: 10.1093/rheumatology/kead531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/27/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Caution has been advocated recently when using Janus kinase inhibitors (JAKi) in rheumatoid arthritis (RA) patients with an unfavorable cardiovascular risk profile. We aimed to compare the incidences in cardiovascular events between JAKi or bDMARDs in a large population of RA patients. METHODS RA patients starting a new bDMARD or JAKi between August 1st 2018 and January 31st 2022 have been selected from IQVIA's Dutch Real-World Data Longitudinal Prescription database, covering about 63% of outpatient prescriptions in the Netherlands. Study outcome was a cardiovascular event, defined as the start of platelet aggregation inhibitors during study period. The incidence densities of cardiovascular events were compared between JAKi and bDMARDs using multilevel Poisson regression, adjusted for exposition time and confounders. RESULTS 15 191 unique patients were included, with 28 481 patient-years on treatment with either JAKi (2,373) or bDMARDs (26 108). Most patients were female (72%) and median age was 62 years. We found 36 cardiovascular events (1.52 events/100 patient years) during therapy with JAKi and 383 events (1.47 events/100 patient years) during therapy with bDMARDs, respectively, resulting in an adjusted incidence rate ratio (IRR) of 0.99 for JAKi compared with bDMARDs (95% confidence interval (CI), 0.70-1.41). Sub-analyses in patients >65 years, by sex, or separately for tofacitinib and baricitinib, yielded similar results. CONCLUSION In a large Dutch general RA population, the risk of cardiovascular events seems not different between JAKi users and those using bDMARDs, although a small increase in higher risk patients cannot be excluded.
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Affiliation(s)
- Calin D Popa
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, The Netherlands
- Department of Rheumatology, Radboudumc Nijmegen, The Netherlands
| | - Merel A A Opdam
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, The Netherlands
| | | | | | | | | | - Maike H M Wientjes
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, The Netherlands
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Savelkoul EHJ, Thomas PWA, Derikx LAAP, den Broeder N, Römkens TEH, Hoentjen F. Systematic Review and Meta-analysis: Loss of Response and Need for Dose Escalation of Infliximab and Adalimumab in Ulcerative Colitis. Inflamm Bowel Dis 2023; 29:1633-1647. [PMID: 36318229 PMCID: PMC10547237 DOI: 10.1093/ibd/izac200] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Loss of response to infliximab or adalimumab in ulcerative colitis occurs frequently, and dose escalation may aid in regaining clinical benefit. This study aimed to systematically assess the annual loss of response and dose escalation rates for infliximab and adalimumab in ulcerative colitis. METHODS A systematic search was conducted from August 1999 to July 2021 for studies reporting loss of response and dose escalation during infliximab and/or adalimumab use in ulcerative colitis patients with primary response. Annual loss of response, dose escalation rates, and clinical benefit after dose escalation were calculated. Subgroup analyses were performed for studies with 1-year follow-up or less. RESULTS We included 50 unique studies assessing loss of response (infliximab, n = 24; adalimumab, n = 21) or dose escalation (infliximab, n = 21; adalimumab, n = 16). The pooled annual loss of response for infliximab was 10.1% (95% confidence interval [CI], 7.1-14.3) and 13.6% (95% CI, 9.3-19.9) for studies with 1-year follow-up. The pooled annual loss of response for adalimumab was 13.4% (95% CI, 8.2-21.8) and 23.3% (95% CI, 15.4-35.1) for studies with 1-year follow-up. Annual pooled dose escalation rates were 13.8% (95% CI, 8.7-21.7) for infliximab and 21.3% (95% CI, 14.4-31.3) for adalimumab, regaining clinical benefit in 72.4% and 52.3%, respectively. CONCLUSIONS Annual loss of response was 10% for infliximab and 13% for adalimumab, with higher rates during the first year. Annual dose escalation rates were 14% (infliximab) and 21% (adalimumab), with clinical benefit in 72% and 52%, respectively. Uniform definitions are needed to facilitate more robust evaluations.
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Affiliation(s)
- Edo H J Savelkoul
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Pepijn W A Thomas
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Lauranne A A P Derikx
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Nathan den Broeder
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, ‘s-Hertogenbosch, the Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
- Division of Gastroenterology, University of Alberta, Edmonton, Canada
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den Broeder N, den Broeder AA, Verhoef LM, van den Hoogen FHJ, van der Maas A, van den Bemt BJF. Non-Medical Switching from Tocilizumab to Sarilumab in Rheumatoid Arthritis Patients with Low Disease Activity, an Observational Study. Clin Pharmacol Ther 2023; 114:810-814. [PMID: 37429827 DOI: 10.1002/cpt.2999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/29/2023] [Indexed: 07/12/2023]
Abstract
Tocilizumab and sarilumab are IL-6-receptor antagonists registered for rheumatoid arthritis (RA), with equal effectiveness and safety. Switching from tocilizumab to sarilumab could be a strategy to reduce injection burden, in case of drug shortages, and to reduce costs. This study therefore aims to investigate the effectiveness and safety of switching patients with RA with well-controlled disease under tocilizumab treatment to sarilumab. Patients with RA with low Disease Activity Score 28 (DAS28;-CRP < 2.9 or < 3.5 with clinical judgment), on stable dose tocilizumab (> 6 months) were offered to switch to sarilumab. Patients who switched and consented were followed for 6 months. Sarilumab was started at 200 mg and double the last tocilizumab interval. Co-primary outcomes at 6 months were (i) the 90% confidence interval (CI) of DAS28-CRP change from baseline compared with the non-inferiority margin of 0.6 and (ii) the 90% CI of the proportion of patients persisting with sarilumab, compared with a prespecified minimum of 70%. Of 50 invited patients, 25 agreed to switch to sarilumab, and 23 patients switched and were included. One patient was lost to follow-up immediately after inclusion, therefore 22 patients are included in the analyses. At 6 months, mean change in DAS28-CRP was 0.48 (90% CI: 0.11-0.87), compared with the non-inferiority margin of 0.6. Sarilumab persistence was 68% (90% CI: 51-82%, 15 out of 22 patients), compared with the prespecified minimum of 70%. Non-medical switching from tocilizumab to sarilumab in patients doing well on tocilizumab failed to show non-inferiority regarding disease activity and drug persistence.
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Affiliation(s)
- Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
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Jansen FM, den Broeder N, Lubeek SFK, Savelkoul EHJ, Marcus CM, Hoentjen F, van Dop WA. Cumulative thiopurine dosing and keratinocyte skin cancer in inflammatory bowel disease: a case-control study. Eur J Gastroenterol Hepatol 2023; 35:1123-1130. [PMID: 37665613 DOI: 10.1097/meg.0000000000002617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
BACKGROUND AND AIM Patients with inflammatory bowel disease (IBD) treated with thiopurines are at increased risk of keratinocyte skin cancer (KSC). Most international guidelines recommend yearly dermatological screening of thiopurine-treated patients. Whether the association between the development of KSC and the use of thiopurines is dose-dependent remains unclear. The aim of this study was to investigate the association between the cumulative thiopurine dose and KSC development in patients with IBD which can be helpful to assist in further skin cancer risk stratification and personalization of screening recommendations in patients with IBD. METHODS We performed a single-center case-control study, including patients with IBD with and without a history of KSC (cases and controls, respectively). The primary outcome was the association of cumulative azathioprine, mercaptopurine and thioguanine dose with KSC development. Univariable and multivariable logistic regression analyses were performed, the latter corrected for age and smoking, known risk factors of KSC. RESULTS We included 50 cases and 150 controls, predominantly white population. Age and current azathioprine use were univariably significantly associated with KSC development. In multivariable logistic regression analyses, age at inclusion remained significantly associated. Cumulative doses of thiopurines (separate or combined) or duration of thiopurine use did not impact KSC risk, also after correcting for age and smoking. CONCLUSION Cumulative thiopurine dose and duration did not show an association with KSC development. Future KSC risk stratification, based on all available KSC risk factors, may aid in selecting individuals who can benefit most from dermatologic screening programs.
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Affiliation(s)
- Fenna M Jansen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
| | - Nathan den Broeder
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
| | - Satish F K Lubeek
- Department of Dermatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Edo H J Savelkoul
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
| | - Carlijne M Marcus
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Willemijn A van Dop
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences
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Wientjes MHM, Ulijn E, Kievit W, Landewé RBM, Meek I, den Broeder N, van Herwaarden N, van den Bemt BJF, Verhoef LM, den Broeder AA. The added value of predictive biomarkers in treat-to-target strategies for rheumatoid arthritis patients: a conceptual modelling study. Rheumatology (Oxford) 2023; 62:2700-2706. [PMID: 36538875 DOI: 10.1093/rheumatology/keac709] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/08/2022] [Accepted: 12/13/2022] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVES To quantify the additional value of a hypothetical biomarker predicting response to treatment for RA regarding efficacy and costs by using a modelling design. METHODS A Markov model was built comparing a usual care T2T strategy with a biomarker-steered strategy for RA patients starting biologic therapy. Outcome measures include time spent in remission or low disease activity (LDA) and costs. Four additional scenario analyses were performed by varying biomarker or clinical care characteristics: (i) costs of the biomarker; (ii) sensitivity and specificity of the biomarker; (iii) proportion of eligible patients tapering; and (iv) medication costs. RESULTS In the base model, patients spent 2.9 months extra in LDA or remission in the biomarker strategy compared with usual care T2T over 48 months. Total costs were €43 301 and €42 568 for, respectively, the usual care and biomarker strategy, and treatment costs accounted for 91% of total costs in both scenarios. Cost savings were driven due to patients in the biomarker strategy experiencing remission or LDA earlier, and starting tapering sooner. Cost-effectiveness was not so much driven by costs or test characteristics of the biomarker (scenario 1/2), but rather by the level of early and proactive tapering and drug costs (scenarios 3/4). CONCLUSIONS The use of a biomarker for prediction of response to b/tsDMARD treatment in RA can be of added value to current treat-to-target clinical care. However, gains in efficacy are modest and cost gains are depending on a combination of early proactive tapering and high medication costs.
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Affiliation(s)
- Maike H M Wientjes
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Evy Ulijn
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Wietske Kievit
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert B M Landewé
- Department of Clinical Immunology and Rheumatology, Amsterdam Rheumatology and Clinical Immunology Center, Amsterdam, The Netherlands
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Inger Meek
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Noortje van Herwaarden
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
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Jansen FM, Smits LJT, Thomas PWA, de Jong DJ, Kreijne JE, van Dop WA, den Broeder N, Hoentjen F. Feasibility of Reduced Clinical Monitoring in Patients with Inflammatory Bowel Disease Treated with Thiopurine Therapy. Dig Dis Sci 2023:10.1007/s10620-023-07950-0. [PMID: 37131100 DOI: 10.1007/s10620-023-07950-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 04/06/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Outpatient visits and laboratory assessments are routinely scheduled every 3 to 4 months in thiopurine-treated patients with inflammatory bowel disease (IBD) to timely detect thiopurine-related adverse events (AEs). AEs that require therapy adjustment beyond 12 months of treatment are rare. AIM AND METHODS This single-center prospective cohort study evaluated the safety of a reduced 6-monthly monitoring strategy in steroid-free patients with quiescent IBD on stable dose of azathioprine, mercaptopurine, or thioguanine monotherapy. The primary outcome was thiopurine-related AEs requiring therapy adjustments during a follow-up period of 24 months. Secondary outcomes included all AEs including laboratory toxicity, disease flares until 12 months, and the net monetary benefit from this strategy concerning IBD-related health care use. RESULTS We enrolled 85 patients with IBD (median age 42 years, 61% Crohn's disease, 62% female), with a median disease duration of 12.5 years and median thiopurine treatment duration of 6.7 years. During follow-up, 3 patients (4%) ceased thiopurines due to AEs: recurrent infections, non-melanoma skin cancer, and gastrointestinal complaints (nausea, vomiting). At 12 months, 25 laboratory toxicities were observed (including 13% myelotoxicity, 17% hepatotoxicity); none required therapy adjustments and all were transient. A reduced monitoring strategy had a net benefit of €136 per patient. CONCLUSION Three patients (4%) ceased thiopurine therapy due to thiopurine-related AEs, while no laboratory toxicity required therapy adjustments. Monitoring frequency of every 6 months seems feasible in patients with stable IBD on long-term (median duration > 6 years) maintenance thiopurine therapy and may contribute to reduced patient-burden and health care costs.
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Affiliation(s)
- Fenna M Jansen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lisa J T Smits
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pepijn W A Thomas
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dirk J de Jong
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joany E Kreijne
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willemijn A van Dop
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
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11
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Peeters IR, den Broeder AA, Taylor WJ, den Broeder N, Flendrie M, van Herwaarden N. Urate-lowering therapy following a treat-to-target continuation strategy compared to a treat-to-avoid-symptoms discontinuation strategy in gout patients in remission (GO TEST Finale): study protocol of a multicentre pragmatic randomized superiority trial. Trials 2023; 24:282. [PMID: 37072799 PMCID: PMC10114395 DOI: 10.1186/s13063-023-07242-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/01/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Long-term gout treatment is based on reducing serum urate levels using urate-lowering therapy (ULT). Most guidelines recommend using a lifelong continuation treat-to-target (T2T) strategy, in which ULT is dosed or combined until a serum urate target has been reached and maintained. However, a frequently used alternative strategy in clinical practice is a treat-to-avoid-symptoms (T2S) ULT discontinuation strategy, with the possibility of restarting the medication. This latter strategy aims at an acceptable symptom state, regardless of serum urate levels. High-quality evidence to support either strategy for patients in prolonged remission while using ULT is lacking. METHODS We developed an investigator-driven pragmatic, open-label, multicentre, randomized, superiority treatment strategy trial (GO TEST Finale). At least 278 gout patients using ULT who are in remission (>12 months, preliminary gout remission criteria) will be randomized 1:1 to a continued T2T strategy (treatment target serum urate < 0.36 mmol/l) or switched to a T2S discontinuation strategy in which ULT is tapered to stop and restarted in case of (persistent or recurrent) flaring. The primary outcome is the between-group difference in the proportion of patients not in remission during the last 6 months of 24 months follow-up and will be analyzed using a two proportion z test. Secondary outcomes are group differences in gout flare incidence, reintroduction or adaptation of ULT, use of anti-inflammatory drugs, serum urate changes, occurrence of adverse events (with a special interest in cardiovascular and renal events), and cost-effectiveness. DISCUSSION This study will be the first clinical trial comparing two ULT treatment strategies in patients with gout in remission. It will contribute to more specific and unambiguous guideline recommendations and improved cost-effectiveness of long-term gout treatment. It also paves the way (exploratory) to individualized long-term ULT treatment. In this article, we elaborate on some of our trial design choices and their clinical and methodological consequences. TRIAL REGISTRATION International Clinical Trial Registry Platform (ICTRP) NL9245. Registered on 2 February 2021 (METC Oost-Nederland NL74350.091.20); EudraCT EUCTR2020-005730-15-NL. Registered on 11 January 2021.
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Affiliation(s)
- Iris Rose Peeters
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, the Netherlands.
- Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, the Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - William J Taylor
- Department of Medicine, University of Otago Wellington, Newtown, Wellington, New Zealand
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, the Netherlands
- Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marcel Flendrie
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, the Netherlands
| | - Noortje van Herwaarden
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, the Netherlands
- Department of Pharmacology, Radboud University Medical Center, Nijmegen, the Netherlands
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12
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Bolhuis TE, Marsman DE, den Broeder AA, den Broeder N, van der Maas A. 1-year results of treatment with rituximab in polymyalgia rheumatica: an extension study of a randomised double-blind placebo-controlled trial. Lancet Rheumatol 2023; 5:e208-e214. [PMID: 38251523 DOI: 10.1016/s2665-9913(23)00032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Rituximab was effective for patients with polymyalgia rheumatica in the 21-week BRIDGE-PMR randomised controlled trial. Here, we aimed to assess rates of glucocorticoid-free remission up to 1 year after infusion in an extension of this trial. METHODS BRIDGE-PMR was a randomised controlled proof-of-concept trial that enrolled participants with polymyalgia rheumatica according to 2012 European League Against Rheumatism-American College of Rheumatology classification criteria at the Sint Maartenskliniek, Nijmegen, Netherlands. Patients were randomly allocated in a 1:1 ratio to receive one intravenous dose of 1000 mg rituximab or placebo, with identical pre-medication and accelerated glucocorticoid tapering over 17 weeks. After the 21-week study, patients were followed in a double-blind extension until 1 year after infusion during which standard-of-care treatment was provided. The primary outcome after 52 weeks was between-group difference in glucocorticoid-free remission (ie, polymyalgia rheumatica activity score [PMR-AS] <10), assessed in all randomly allocated participants, with data imputed using a predictive mean matching model (provided data were missing at random). A sensitivity analysis restricted to patients with complete data (complete case analysis) was also done. This trial is registered with EudraCT (2018-002641-11) and the Dutch trial database (NL7414). FINDINGS Between Dec 18, 2019 and June 8, 2021, 47 patients enrolled in the BRIDGE-PMR were followed up in this extension study (23 [11 women and 12 men] allocated rituximab and 24 [13 women and 11 men] allocated placebo), of who 38 had recently diagnosed polymyalgia rheumatica and nine had relapsing polymyalgia rheumatica. Mean (SD) age was 64 (10) years in the rituximab group and 66 (9) years in the placebo group. All participants were White. Missing data were imputed for six participants (four rituximab, two placebo); because the data were probably missing at random, a complete case analysis was added as sensitivity analyses. In the imputed analysis, the between-group absolute difference reached statistical significance (12 [52%] of 23 in the rituximab group in glucocorticoid-free remission vs five [21%] of 24 participants in the placebo group; absolute difference 31% [95% CI 5 to 57], RR 2·5 [1·0 to 6·0]; p=0·04). In the complete case analysis, nine (47%) of 19 patients in the rituximab group were in glucocorticoid-free remission 1 year after infusion compared with five (23%) of 22 in the placebo group (absolute difference 25% [95% CI -4 to 53], relative risk (RR) 2·1 [95% CI 0·8 to 5·2]; p=0·12). Eight (33%) patients in the placebo group and six (26%) in the rituximab group had adverse events. INTERPRETATION After a single dose of rituximab (1000 mg), the proportion of patients with polymyalgia rheumatica in glucocorticoid-free remission remained stable at 1 year after infusion, and a glucocorticoid sparing effect was evident. A larger trial including possibility for retreatment is warranted to confirm these results. FUNDING Sint Maartenskliniek.
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Affiliation(s)
- Thomas E Bolhuis
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Diane E Marsman
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, Netherlands.
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13
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Opdam MAA, de Leijer JH, den Broeder N, Thurlings RM, van der Weele W, Nurmohamed MT, Kok MR, van Bon L, Ten Cate DF, Verhoef LM, den Broeder AA. Rituximab dose-dependent infection risk in rheumatoid arthritis is not mediated through circulating immunoglobulins, neutrophils or B cells. Rheumatology (Oxford) 2022; 62:330-334. [PMID: 35686851 DOI: 10.1093/rheumatology/keac318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 12/16/2021] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Rituximab (RTX) is a safe and effective treatment for RA. A dose-dependent infection risk was found in the REDO trial. Some studies associate RTX use with higher infection risks, possibly explained by low immunoglobulin levels and/or neutropenia. Additionally, a higher infection risk shortly after RTX infusion is reported. The objectives of this study were (i) to compare incidence rates of infections between doses and over time, and (ii) to assess B-cell counts, immunoglobulin levels, neutrophil counts and corticosteroid/disease modifying rheumatic drug use as mediating factors between RTX study dose and infection risk. METHODS Post hoc analyses of the REDO trial were performed. Infection incidence rates between RTX dosing groups and between time periods were compared using Poisson regression. A step-wise mediation analysis was performed to investigate if any of the factors mentioned above act as a mediator in the observed dose-dependent difference in infection risk. RESULTS The potential mediators that were investigated (circulating B-cell counts, immunoglobulin levels, neutrophil counts and drug use) did not explain the dose-dependent infection risk observed in the REDO trial. Additionally, a trend towards a time-dependent infection risk was found, with higher infection rates shortly after RTX infusion. CONCLUSIONS These secondary analyses of the REDO trial confirmed the observed dose-dependent infection risk. Additionally, we found that infection risks were higher shortly after RTX infusion. However, a mediating pathway was not found.
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Affiliation(s)
- Merel A A Opdam
- Department of Rheumatology, Sint Maartenskliniek.,Department of Rheumatology, Radboud Institute for Health Sciences, Radboudumc
| | | | | | | | | | | | - Marc R Kok
- Department of Rheumatology & Clinical Immunology, Maasstad Ziekenhuis, Rotterdam
| | - Lenny van Bon
- Department of Rheumatology, Hospital Group Twente, Almelo, the Netherlands
| | | | | | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek.,Department of Rheumatic Diseases, Radboudumc, Nijmegen
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14
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van der Togt CJ, Verhoef LM, van den Bemt BJ, den Broeder N, ter Heine R, den Broeder AA. Pharmacokinetic boosting to enable a once-daily reduced dose of tofacitinib in patients with rheumatoid arthritis and psoriatic arthritis (the PRACTICAL study). Ther Adv Musculoskelet Dis 2022; 14:1759720X221142277. [PMCID: PMC9749037 DOI: 10.1177/1759720x221142277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Tofacitinib is a Janus Kinase (JAK) inhibitor used for the treatment of rheumatoid arthritis (RA) and psoriatic arthritis (PsA), dosed as 5 mg twice daily (BID). It is primarily metabolized by the cytochrome P-3A (CYP3A) enzyme, and therefore, the manufacturer recommends to halve the dose when using CYP3A-inhibiting co-medication. Combining half-dose tofacitinib with a registered CYP3A inhibitor (cobicistat) could reduce costs and improve patient experience. Objectives: Primary: bioequivalence of tofacitinib 5 mg combined with cobicistat once daily (QD; intervention) to tofacitinib 5 mg BID (control). Secondary: safety, patient preference (7-point Likert scale at study end) and predicted differences in disease activity (DAS28-CRP and probability of ACR20 response) using a validated exposure-response model. Design: Open-label, cross-over pharmacokinetic study. Methods: We included patients with RA or PsA, treated with tofacitinib 5 mg BID for ⩾14 days without co-medication affected by CYP3A inhibition. Pharmacokinetic sampling was performed at baseline and after 2–6 weeks of intervention treatment. Bioequivalence was defined as 90% CI of the average tofacitinib concentration (Cavg,ss; intervention to control) falling between 80% and 125%, assessed by non-linear mixed-effects modelling. Results: Between 16 September 2019 and 15 January 2021, 30 patients were included, of whom 25 completed both PK measurements. The tofacitinib Cavg,ss was 85% (90% CI: 75–96%). No serious adverse events occurred. Patient preference was 56% for intervention versus 18% for control. No relevant differences in median predicted disease activity were found (DAS28-CRP: 0.03, 95% CI: −0.16 to 0.22; ACR20: −0.01, −0.07 to 0.05). Conclusion: Due to slightly lower tofacitinib concentrations during intervention treatment, pharmacokinetic bioequivalence could not formally be established. However, pharmacokinetic boosting may be an attractive strategy for cost reduction of tofacitinib because of its safety, similar predicted pharmacodynamics and patient preference. Registration: This study was registered on 29 May 2019 in the Netherlands Trial Register (register number: NL7766).
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Affiliation(s)
| | | | - Bart J.F. van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Ubbergen, The Netherlands,Department of Pharmacy, Radboudumc, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands,Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Rob ter Heine
- Department of Pharmacy, Radboudumc, Nijmegen, The Netherlands
| | - Alfons A. den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands,Department of Rheumatic Diseases, Radboudumc, Ubbergen, The Netherlands
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15
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van der Togt CJT, Ten Cate DF, van den Bemt BJF, Rahamat-Langendoen J, den Broeder N, den Broeder AA. Seroconversion after a third COVID-19 vaccine is affected by rituximab dose but persistence is not in patients with rheumatoid arthritis. Rheumatology (Oxford) 2022; 62:1627-1630. [PMID: 36000861 PMCID: PMC9452149 DOI: 10.1093/rheumatology/keac486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/24/2022] [Revised: 08/05/2022] [Accepted: 08/16/2022] [Indexed: 12/02/2022] Open
Abstract
Objectives In patients with rheumatoid arthritis (RA) treated with (ultra-)low dose rituximab (RTX), we investigated (1) the association of dosing and timing of rituximab (RTX) on seroconversion after third COVID-19 vaccination, and (2) persistence of humoral response after two-dose vaccination. Methods In this monocentre observational study, patients from the COVAC-cohort were included in the third vaccine analysis if humoral response was obtained 2-6 weeks after third vaccination in previous non-responders, and in the persistence analysis if a follow-up humoral response was obtained before third vaccination in previous responders. Dichotomization between ‘positive’ and ‘negative’ response was based on the assay cut-off. The association between latest RTX dose before first vaccination, timing between latest rituximab and vaccination, and response was analysed with univariable logistic regression. Results Of the 196 patients in the cohort, 98 were included in the third vaccine analysis and 23 in the persistence analysis. Third vaccination response was 19/98 (19%) and higher for 200 mg RTX users (5/13, 38%) than 500 and 1000 mg (7/37, 19% and 7/48, 15%). Non-significant trends were seen for higher response with lower dosing (200 versus 1000 mg: OR 3.66, 95% CI 0.93-14.0) and later timing (per month since infusion: OR 1.16, 0.97-1.35). Humoral response persisted in 96% (22/23) and in 89% (8/9) of patients who received RTX between the two measurements. Conclusion Repeated vaccination as late as possible after the lowest RTX dose possible seems the best vaccination strategy. A once positive humoral response after COVID-19 vaccination persists irrespective of intercurrent rituximab infusion. Trial registration Netherlands Trial Register, https://www.trialregister.nl/, NL9342
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Affiliation(s)
- Céleste J T van der Togt
- Radboud Institute for Health Sciences, Department of Rheumatology, Radboud university medical center, Nijmegen, The Netherlands.,Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - David F Ten Cate
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Ubbergen, The Netherlands.,Department of Clinical Pharmacy, Radboudumc, Nijmegen, The Netherlands
| | | | - Nathan den Broeder
- Radboud Institute for Health Sciences, Department of Rheumatology, Radboud university medical center, Nijmegen, The Netherlands.,Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Department of Rheumatic Diseases, Radboudumc, Nijmegen, The Netherlands
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16
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Bolhuis TE, Marsman D, van den Hoogen FHJ, Broeder AAD, Broeder ND, van der Maas A. (Dis)agreement of polymyalgia rheumatica relapse criteria, and prediction of relapse in a retrospective cohort. BMC Rheumatol 2022; 6:45. [PMID: 35915465 PMCID: PMC9344672 DOI: 10.1186/s41927-022-00274-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background To develop and assess a prediction model for polymyalgia rheumatica (PMR) relapse within the first year of glucocorticoid (GC) treatment. Methods A retrospective PMR cohort (clinical diagnosis) from a rheumatology department was used. All visits > 30 days after starting GC treatment and with > 2.5 mg/day oral prednisolone were used as potential relapse visits. Often used relapse criteria (1) rheumatologist judgement, (2) treatment intensification-based relapse) were assessed for agreement in this cohort. The proportion of patients with treatment-based relapse within 1 and 2 years of treatment and the relapse incidence rate were used to assess unadjusted associations with candidate predictors using logistic and Poisson regression respectively. After using a multiple imputation method, a multivariable model was developed and assessed to predict the occurrence (yes/no) of relapse within the first year of treatment. Results Data from 417 patients was used. Relapse occurred at 399 and 321 (of 2422) visits based on the rheumatologist judgement- and treatment-based criteria respectively, with low to moderate agreement between the two (87% (95% CI 0.86–0.88), with κ = 0.49 (95% CI 0.44–0.54)). Treatment-based relapse within the first two years was significantly associated with CRP, ESR, and pre-treatment symptom duration, and incidence rate with only CRP and ESR. A model to predict treatment intensification within the first year of treatment was developed using sex, medical history of cardiovascular disease and malignancies, pre-treatment symptom duration, ESR, and Hb, with an AUC of 0.60–0.65. Conclusion PMR relapse occurs frequently, although commonly used criteria only show moderate agreement, underlining the importance of a uniform definition and criteria of a PMR specific relapse. A model to predict treatment intensification was developed using practical predictors, although its performance was modest. Supplementary Information The online version contains supplementary material available at 10.1186/s41927-022-00274-y.
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Affiliation(s)
- Thomas E Bolhuis
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands. .,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Diane Marsman
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
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17
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Michielsens CA, den Broeder N, van den Hoogen FH, Mahler EA, Teerenstra S, van der Heijde D, Verhoef LM, den Broeder AA. Treat-to-target dose reduction and withdrawal strategy of TNF inhibitors in psoriatic arthritis and axial spondyloarthritis: a randomised controlled non-inferiority trial. Ann Rheum Dis 2022; 81:1392-1399. [PMID: 35701155 DOI: 10.1136/annrheumdis-2022-222260] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/30/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Tumour necrosis factor inhibitors (TNFi) are effective in psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), but are associated with a small (0.6%) increase in serious infection risk, patient burden due to need for self-injection and high costs. Treat-to-target (T2T) tapering might ameliorate these drawbacks, but high-quality evidence on T2T tapering strategies is lacking in PsA and axSpA. METHODS We performed a pragmatic open-label, monocentre, randomised controlled non-inferiority (NI) trial on T2T tapering of TNFi. Patients with PsA and axSpA using a TNFi with ≥6 months stable low disease activity (LDA) were included. Patients were randomised 2:1 to disease activity-guided T2T with or without tapering until withdrawal and followed-up to 12 months. Primary endpoint was the difference in proportion of patients having LDA at 12 months between groups, compared with a prespecified NI margin of 20%, estimated using a Bayesian prior. RESULTS 122 patients (64 PsA and 58 axSpA) were randomised to a T2T strategy with (N=81) or without tapering (N=41). The proportion of patients in LDA at 12 months was 69% for the tapering and 73% for the no-tapering group: adjusted difference 5% (Bayesian 95% credible interval: -10% to 19%) which confirms NI considering the NI margin of 20%. The mean percentage of daily defined dose was 53% for the tapering and 91% for the no-tapering group at month 12. CONCLUSIONS A T2T TNFi strategy with tapering attempt is non-inferior to a T2T strategy without tapering with regard to the proportion of patients still in LDA at 12 months, and results in a substantial reduction of TNFi use. TRIAL REGISTRATION NUMBER NL 6771.
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Affiliation(s)
- Celia Aj Michielsens
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands .,Department of Rheumatic Diseases, Radboudumc Radboud Institute for Health Sciences, Nijmegen, Gelderland, The Netherlands
| | - Nathan den Broeder
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands.,Department of Rheumatic Diseases, Radboudumc Radboud Institute for Health Sciences, Nijmegen, Gelderland, The Netherlands
| | | | - Elien Am Mahler
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands
| | - Steven Teerenstra
- Radboud Institute for Health Sciences, Department for Health Evidence, group Biostatistics, Radboudumc, Nijmegen, Gelderland, The Netherlands
| | | | - Lise M Verhoef
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands
| | - Alfons A den Broeder
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands.,Department of Rheumatic Diseases, Radboudumc Radboud Institute for Health Sciences, Nijmegen, Gelderland, The Netherlands
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18
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Marsman DE, Bolhuis TE, den Broeder N, den Broeder AA, van der Maas A. PolyMyalgia Rheumatica treatment with Methotrexate in Optimal Dose in an Early disease phase (PMR MODE): study protocol for a multicenter double-blind placebo controlled trial. Trials 2022; 23:318. [PMID: 35428320 PMCID: PMC9012047 DOI: 10.1186/s13063-022-06263-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease affecting people older than 50, resulting in pain and stiffness of the neck, shoulder, and pelvic girdle. To date, glucocorticoids (GC) remain the cornerstone of treatment, but these have several drawbacks. Firstly, a large proportion of patients do not achieve GC-free remission within either the first (over 70%) or second year of treatment (over 50%). Secondly, GC-related adverse events (AE) occur in up to 65% of patients and can be severe. The current EULAR/ACR guidelines for PMR recommend early introduction of methotrexate (MTX) as a GC sparing agent in patients at risk for worse prognosis. However, earlier trials of low to medium quality only studied MTX dosages of 7.5–10 mg/week with no to modest effect. These doses may be suboptimal as MTX is recommended in higher doses (25 mg/week) for other inflammatory rheumatic diseases. The exact role, timing, and dose of MTX in PMR remain unclear, and therefore, our objective is to study the efficacy of MTX 25 mg/week in recently diagnosed PMR patients. Methods We set up a double-blind, randomized, placebo-controlled superiority trial (PMR MODE) to assess the efficacy of MTX 25 mg/week versus placebo in a 1:1 ratio in 100 recently diagnosed PMR patients according to the 2012 EULAR/ACR criteria. All patients will receive prednisolone 15 mg/day, tapered to 0 mg over the course of 24 weeks. In case of primary non-response or disease relapse, prednisolone dose will be temporarily increased. Assessments will take place at baseline, 4, 12, 24, 32, and 52 weeks. The primary outcome is the difference in proportion of patients in GC-free remission at week 52. Discussion No relapsing PMR patients were chosen, since the possible benefits of MTX may not outweigh the risks at low doses and effect modification may occur. Accelerated tapering was chosen in order to more easily identify a GC-sparing effect if one exists. A composite endpoint of GC-free remission was chosen as a clinically relevant endpoint for both patients and rheumatologist and may reduce second order (treatment) effects. Trial registration Dutch Trial Registration, NL8366. Registered on 10 February 2020
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19
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van der Togt CJT, Ten Cate DF, den Broeder N, Rahamat-Langendoen J, van den Bemt BJF, den Broeder AA. Humoral response to Coronavirus Disease-19 vaccines is dependent on dosage and timing of rituximab in patients with rheumatoid arthritis. Rheumatology (Oxford) 2022; 61:SI175-SI179. [PMID: 35377422 PMCID: PMC8992349 DOI: 10.1093/rheumatology/keac206] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/28/2022] [Indexed: 11/12/2022] Open
Abstract
Objectives Humoral response to vaccines in RA patients treated with rituximab (RTX) in standard dosages (≥1000 mg) is decreased. Ultra-low dosages (500 or 200 mg) may have better response. Also, timing after latest RTX infusion may be an important variable. We aimed to investigate the influence of RTX dosage and timing on response to COVID-19 vaccination in RA patients. Methods A single-centre observational study (n = 196) investigated the humoral response, measured by total Ig anti-COVID-19 assay (positive response ≥1.1), 2–6 weeks after complete COVID-19 vaccination. A multivariable logistic regression model was built to study the effect of RTX dosage and time between latest rituximab and vaccination on response, adjusting for age and methotrexate use. Results After two-dose vaccination, the response rate was significantly better for patients receiving 200 mg (n = 31, 45%) rituximab compared with 1000 mg (n = 98, 26%; odds ratio 3.07, 95% CI 1.14–8.27) and for each additional month between latest rituximab and vaccination (OR 1.67, 1.39–2.01). Conclusion Both increased time between latest rituximab infusion and complete vaccination, and 200 mg as latest dose were associated with a better response to COVID-19 vaccination and should be considered when trying to increase vaccine response after rituximab in RA patients. Trial registration Netherlands Trial Register, https://www.trialregister.nl/, NL9342.
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Affiliation(s)
- Céleste J T van der Togt
- Radboud Institute for Health Sciences, Department of Rheumatology, Radboud university medical center, Nijmegen, The Netherlands.,Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - David F Ten Cate
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Nathan den Broeder
- Radboud Institute for Health Sciences, Department of Rheumatology, Radboud university medical center, Nijmegen, The Netherlands.,Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | | | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Ubbergen, The Netherlands.,Department of Clinical Pharmacy, Radboudumc, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands.,Department of Rheumatic Diseases, Radboudumc, Nijmegen, The Netherlands
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20
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Ulijn E, den Broeder AA, Boers N, Gotthardt M, Bouman CAM, Landewé R, den Broeder N, van Herwaarden N. Extra-articular findings with FDG-PET/CT in rheumatoid arthritis patients: more harm than benefit. Rheumatol Adv Pract 2022; 6:rkac014. [PMID: 35311064 PMCID: PMC8924972 DOI: 10.1093/rap/rkac014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/15/2022] [Indexed: 11/14/2022] Open
Abstract
ABSTRACT
Objective
Whole-body Positron Emission Tomography with CT-scanning using fluorine-18 fluorodeoxyglucose (18F-FDG) is occasionally used in rheumatoid arthritis (RA) patients to detect arthritis. FDG-PET/CT might also detect malignancies, but the amount of incidental findings and the number of relevant malignant disease that could be missed are currently unknown. We aimed to study the malignancy screening performance of whole-body FDG-PET/CT in longstanding RA patients with low disease activity.
Methods
FDG-PET/CT-scanning was done in the intervention arm of the Dose REduction Strategy of Subcutaneous TNF-inhibitors (DRESS) study, a randomized controlled trial on dose-tapering of biological Disease Modifying Anti-Rheumatic Drugs (bDMARDs). The reference standard was clinical diagnosis of malignancy during the 3 year follow-up of the study. Prevalence of extra-articular abnormalities, follow-up, and treatments were summarized post-hoc.
Results
121 scans were made in 79 patients. Extra-articular abnormalities were found in 59/121 (49%) scans, resulting in additional diagnostic procedures in 21/79 (26.6%) patients. Nine patients (7.4%) were suspected of malignancy, none turned out to be malignant. Six clinical malignancies that developed during follow-up were all negative on baseline FDG-PET/CT.
Conclusion
Whole-body FDG-PET/CT-scanning used in RA patients for imaging of arthritis results in frequent incidental extra-articular findings, while some who apparently had normal scans also developed malignancies.
Trial registration
Netherlands Trial Register, www.trialregister.nl, NL6771
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Affiliation(s)
- Evy Ulijn
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Martin Gotthardt
- Radiology Nuclear Medicine, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Chantal A M Bouman
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Robert Landewé
- Department of Rheumatology and Clinical immunology, Amsterdam Medical Center, Amsterdam, the Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Noortje van Herwaarden
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
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21
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Thomas PWA, den Broeder N, Derikx M, Kievit W, West RL, Russel MGVM, Jansen JM, Römkens TEH, Hoentjen F. Impact of Biological Therapies and Tofacitinib on Real-world Work Impairment in Inflammatory Bowel Disease Patients: A Prospective Study. Inflamm Bowel Dis 2022; 28:1813-1820. [PMID: 35134917 PMCID: PMC9713499 DOI: 10.1093/ibd/izac002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND There are limited real-world data on the change in total work impairment (TWI) in biological-treated patients with inflammatory bowel disease (IBD). This study aimed to evaluate the real-world effects of initiating biological therapy or tofacitinib on change in TWI in IBD patients. METHODS This multicenter prospective cohort study enrolled IBD patients who started treatment with biological therapy or tofacitinib. Subjects completed the work productivity and activity impairment (WPAI) questionnaire and short inflammatory bowel disease questionnaire at therapy initiation and at week 26. Total work impairment comprises working hours missed due to sick leave and impact of disease during working hours (range 0%-100%). Clinical disease activity was assessed using the Harvey-Bradshaw Index and Simple Clinical Colitis Activity Index (SCCAI). RESULTS We included 137 IBD patients for analyses (median age 38 years, 58% Crohn's disease [CD]). The median baseline TWI was 50% and decreased by a median of 10%-points of points after 26 weeks. Patients with continued biological therapy or tofacitinib use, clinical disease activity at baseline, and clinical response or remission at week 26 showed a greater median TWI reduction (22%-points) than the remaining study patients (7%-points; P = .014). Ulcerative colitis (UC) and IBD-unclassified (IBD-U) patients showed a greater median TWI reduction (26%-points) than CD patients (6%-points); P = .041. Correlations were observed between decrease in TWI and decrease in SCCAI, decrease in fatigue and increase in quality of life. CONCLUSIONS Work impairment in IBD patients decreased following biological therapy or tofacitinib initiation. Patients achieving clinical remission or response showed the greatest improvement, especially UC and IBD-U patients.
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Affiliation(s)
- Pepijn W A Thomas
- Address correspondence to: Pepijn W.A. Thomas, MD, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, PO Box 9101, code 455, 6500 HB Nijmegen, The Netherlands ()
| | - Nathan den Broeder
- Department of Gastroenterology and Hepatology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Monique Derikx
- Occupational Medicine, Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wietske Kievit
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre, The Netherlands
| | - Rachel L West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Maurice G V M Russel
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Tessa E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands
| | - Frank Hoentjen
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands and Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
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Wientjes MHM, Gijzen TMG, den Broeder N, Bloem K, de Vries A, van den Bemt BJF, den Broeder AA, Verhoef LM. Drug levels, anti-drug antibodies and B-cell counts were not predictive of response in rheumatoid arthritis patients on low dose rituximab. Rheumatology (Oxford) 2022; 61:3974-3980. [PMID: 35022672 DOI: 10.1093/rheumatology/keac024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 09/16/2021] [Revised: 01/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The REDO trial showed that ultra-low dose rituximab (500 mg or 200 mg) was similarly effective in the majority of rheumatoid arthritis (RA) patients. This pre-planned secondary analysis investigates 1) associations between rituximab dosage, drug levels, anti-drug antibodies (ADA) and B cell counts and 2) the predictive value of pharmacokinetic and -dynamic parameters, patient, disease and treatment characteristics in relation to response to ultra-low dose rituximab. METHODS For 140 RA patients from the REDO trial, differences in drug levels, ADA and B cell counts were examined at baseline, three and six months after dosing. Treatment response was defined as absence of flare and no extra rituximab or > 1 glucocorticoid injection received during follow-up. The association between potential predictors and response was investigated using logistic regression analyses. RESULTS Lower doses of rituximab resulted in lower drug levels but did not significantly affect ADA levels and B cell counts. 3 (10.7%), 12 (20.7%) and 7 (13.0%) patients failed to meet response-criteria in respectively the 1000 mg, 500 mg and 200 mg group. Drug levels, ADA and B cell counts as well as patient, disease and treatment characteristics were not predictive for response to ultra-low dose rituximab. CONCLUSION Results of this study further support that continued treatment with 500 or 200 mg rituximab is similarly effective as 1000 mg in RA patients doing well on rituximab. These results, combined with absence of clinical dose response relation in the original REDO study, suggest that 200 mg rituximab is not yet the lowest effective rituximab retreatment dose in RA.
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Affiliation(s)
- Maike H M Wientjes
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Titia M G Gijzen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Karien Bloem
- Biologics Lab, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Annick de Vries
- Biologics Lab, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands.,Department of Pharmacy, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands.,Department of Rheumatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
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23
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Marsman DE, den Broeder N, van den Hoogen FHJ, den Broeder AA, van der Maas A. Efficacy of rituximab in patients with polymyalgia rheumatica: a double-blind, randomised, placebo-controlled, proof-of-concept trial. The Lancet Rheumatology 2021. [DOI: 10.1016/s2665-9913(21)00245-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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24
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Michielsens CAJ, den Broeder N, Mulder MLM, van den Hoogen FHJ, Verhoef LM, den Broeder AA. Tumour necrosis factor inhibitor dose adaptation in psoriatic arthritis and axial spondyloarthritis (TAPAS): a retrospective cohort study. Rheumatology (Oxford) 2021; 61:2307-2315. [PMID: 34599803 PMCID: PMC9157113 DOI: 10.1093/rheumatology/keab741] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 07/08/2021] [Revised: 09/20/2021] [Indexed: 02/07/2023] Open
Abstract
Objectives We investigated the effect of disease activity-guided dose optimization (DAGDO) of TNF inhibitor (TNFi) on disease activity and TNFi dose in PsA and axial spondyloarthritis (axSpA) patients with low disease activity (LDA). Methods A retrospective cohort study was conducted in PsA and axSpA patients doing well on TNFi and eligible for TNFi DAGDO. Three different treatment periods were defined: (i) full dose continuation period, (ii) TNFi DAGDO period, and (iii) period with stable TNFi dose after DAGDO. A mixed-model analysis was used to estimate mean Disease Activity Score 28-joint count CRP (DAS28-CRP) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) during these periods, and a mean percentage of the daily defined dose (%DDD) was calculated as secondary outcome. Results Three hundred and twenty-four patients (153 PsA and 171 axSpA) were included, with a mean of 6.5 DAS28-CRP and 6.4 BASDAI measurements and a median follow-up duration of 46 and 44 months, respectively. A corrected difference of 0.06 (95% CI: −0.09, 0.21) in mean DAS28-CRP was found for the TNFi DAGDO period and 0.03 (95% CI: −0.14, 0.20) for the period with stable TNFi dose, compared with full dose continuation period. Differences for BASDAI were 0.03 (95% CI: −0.21, 0.27) and 0.05 (95% CI: −0.24, 0.34), respectively. The mean %DDD for the three treatment periods was for PsA 108%, 62% and 78%, and for axSpA 108%, 62% and 72%, respectively. Conclusion DAGDO of TNFi reduces drug exposure and has no negative effects on disease activity in PsA and axSpA patients compared with full dose continuation.
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Affiliation(s)
- Celia A J Michielsens
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands.,Department of Rheumatic diseases, Radboud Institute for Health Sciences, Radboudumc Nijmegen, the Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands
| | - Michelle L M Mulder
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands.,Department of Rheumatic diseases, Radboud Institute for Health Sciences, Radboudumc Nijmegen, the Netherlands
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands.,Department of Rheumatic diseases, Radboud Institute for Health Sciences, Radboudumc Nijmegen, the Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek Nijmegen, the Netherlands.,Department of Rheumatic diseases, Radboud Institute for Health Sciences, Radboudumc Nijmegen, the Netherlands
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25
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Heuvelmans J, den Broeder N, van den Elsen GAH, den Broeder AA, van den Bemt BJF. Effectiveness and tolerability of oral versus subcutaneous methotrexate in patients with rheumatoid arthritis. Rheumatology (Oxford) 2021; 61:331-336. [PMID: 33788911 DOI: 10.1093/rheumatology/keab313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to compare the effectiveness and tolerability between oral methotrexate (MTX) and subcutaneous MTX in a large group of rheumatoid arthritis (RA) patients in a real-life setting. METHODS In this retrospective cohort study, adult patients with clinical diagnosis of RA who started MTX treatment (monotherapy or combined with hydroxychloroquine), either started with oral or subcutaneous MTX. The primary outcome was superiority testing of between group difference in change in DAS28CRP between baseline and 3-6 months, and subsequent non inferiority testing (NI margin 0.6) analyses in case of non-superiority. Secondary outcomes included MTX dose, side effects, laboratory abnormalities, and use of comedication. RESULTS 640 RA patients were included: 259 started with oral MTX and 381 with subcutaneous. There was no significant difference in ΔDAS28CRP, after adjusting for confounding, 0.13 (95%-CI: -0.14, 0.40), and oral MTX strategy was non inferior to subcutaneous. The mean MTX dose was slightly lower for the oral strategy (18.0 SD6.9 vs 19.9 SD8.2, p= 0.002), which was accompanied by a lower cumulative incidence of adverse events (41% vs 52%, p= 0.005). No differences were seen in use of other comedication. CONCLUSIONS Starting with oral MTX in RA in a real-life setting is non inferior to a subcutaneous MTX treatment with regard to disease activity control, at least when used in dosages up to 25 mg and on a background of HCQ cotreatment and a treat-to-target approach. In addition, tolerability was better. This supports the strategy of starting with oral MTX.
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Affiliation(s)
- Janne Heuvelmans
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, Netherlands
| | | | - Geke A H van den Elsen
- Department of pharmacology and toxicology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
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den Broeder AA, den Broeder N, Verhoef LM. (Ultra-)low dosing of rituximab in rheumatoid arthritis: chances and challenges. Rheumatol Adv Pract 2021; 5:rkab007. [PMID: 33693305 PMCID: PMC7931796 DOI: 10.1093/rap/rkab007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/21/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Ubbergen, The Netherlands
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27
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Marsman DE, den Broeder N, Boers N, van den Hoogen FH, den Broeder AA, van der Maas A. Polymyalgia rheumatica patients with and without elevated baseline acute phase reactants: distinct subgroups of polymyalgia rheumatica? Clin Exp Rheumatol 2021; 39:32-37. [DOI: 10.55563/clinexprheumatol/gdps1r] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 02/04/2020] [Indexed: 11/13/2022]
Affiliation(s)
- Diane E. Marsman
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Frank H.J. van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, and Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Alfons A. den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, and Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
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28
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Marsman D, Bolhuis T, Broeder ND, van den Hoogen F, den Broeder A, van der Maas A. Effect of add-on methotrexate in polymyalgia rheumatica patients flaring on glucocorticoids tapering: a retrospective study. Rheumatol Int 2021; 41:611-616. [PMID: 33486552 DOI: 10.1007/s00296-020-04783-2] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/30/2020] [Indexed: 11/25/2022]
Abstract
Guidelines on management of polymyalgia rheumatica (PMR) recommend early introduction of methotrexate (MTX), especially in patients with worse prognosis, although evidence on clinical efficacy of MTX in PMR is limited. Our objective was to assess MTX efficacy in real-world PMR care. Retrospective data of newly diagnosed PMR patients who started MTX were compared to control patients in whom MTX was not started at the first flare. Main outcomes were number of flares per year (Poisson regression) and weighted daily glucocorticoid (GC)-dose (linear regression), and flare incidence rate ratio in the MTX group only. 240 patients were selected; 39 patients in the MTX group and 201 in the control group. The yearly incidence rate ratio of flares in the MTX versus control group was 0.80 (95% CI 0.45-1.42). The yearly flare rate was 1.22 before and 0.43 after MTX initiation, resulting in an incidence ratio of 0.35 (95% CI 0.23-0.52). Adjusted time weighted daily GC dose was higher in the MTX versus control group (ratio 1.37, 95% CI 1.04-1.80). No clear effect of MTX on flares was found and time weighted daily GC dose was higher, possibly due to residual confounding by indication. However, the clearly reduced flare rate after MTX start might be suggestive for a beneficial effect of MTX.
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Affiliation(s)
- Diane Marsman
- Department of Rheumatology, Sint Maartenskliniek, PO box 9011, 6500 GM, Nijmegen, The Netherlands.
| | - Thomas Bolhuis
- Department of Rheumatology, Sint Maartenskliniek, PO box 9011, 6500 GM, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, PO box 9011, 6500 GM, Nijmegen, The Netherlands
| | - Frank van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, PO box 9011, 6500 GM, Nijmegen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Alfons den Broeder
- Department of Rheumatology, Sint Maartenskliniek, PO box 9011, 6500 GM, Nijmegen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, PO box 9011, 6500 GM, Nijmegen, The Netherlands
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29
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Marsman DE, den Broeder N, Popa CD, den Broeder AA, van der Maas A. Seasonal influence on incidence of polymyalgia rheumatica: winter might be coming. Clin Exp Rheumatol 2021; 39 Suppl 128:19-20. [PMID: 33634778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/13/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Diane E Marsman
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Calin D Popa
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, and Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, and Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
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Groen MT, den Broeder N, Hoentjen F. Noninferiority or Nonsuperiority? Gastroenterology 2020; 159:2248. [PMID: 32433982 DOI: 10.1053/j.gastro.2020.02.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/03/2020] [Indexed: 12/02/2022]
Affiliation(s)
| | | | - Frank Hoentjen
- Radboud University Medical Centre, Nijmegen, the Netherlands
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31
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Kersten BE, den Broeder N, van den Hoogen FHJ, Knaapen-Hans HAK, van den Ende CHM, Vonk MC. Treatment with cyclophosphamide i.v. pulse therapy is an option for effective treatment of skin fibrosis in patients with early systemic sclerosis. Rheumatology (Oxford) 2020; 59:1793. [PMID: 32040189 PMCID: PMC7310099 DOI: 10.1093/rheumatology/keaa047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brigit E Kersten
- Department of Rheumatic Diseases, Radboud University Medical Center
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | | | | | - Madelon C Vonk
- Department of Rheumatic Diseases, Radboud University Medical Center
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32
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Kersten BE, den Broeder N, van den Hoogen FHJ, Knaapen-Hans HAK, van den Ende CHM, Vonk MC. Treatment with cyclophosphamide i.v. pulse therapy is an option for effective treatment of skin fibrosis in patients with early systemic sclerosis. Rheumatology (Oxford) 2020; 59:1550-1555. [PMID: 31628802 PMCID: PMC7310100 DOI: 10.1093/rheumatology/kez487] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 06/24/2019] [Revised: 09/18/2019] [Indexed: 01/10/2023] Open
Abstract
Objectives SSc is a autoimmune disease characterized by fibrosis of the skin and internal organs. There is a lack of evidence for the efficacy of i.v. CYC pulse therapy on skin thickening. We aimed to examine the response of i.v. CYC pulse therapy on skin thickening in our cohort of SSc patients and analysed factors that predict this response. Methods We retrospectively evaluated the data for 143 patients with SSc from baseline to 12, 24 and 36 months. All patients were treated with at least 6 i.v. CYC pulses (750 mg/m2/month). We applied the modified Rodnan Skin Score (mRSS) to assess skin thickening. A clinically relevant response was defined as a decrease in mRSS of 5 points and 25% from baseline. Different baseline variables for predicting response on month 12 were tested in logistic regression analyses. Results Baseline characteristics of the patients with dcSSc and lcSSc were collected. Forty-three percent (n = 42) of dcSSc patients had a clinically relevant response on month 12. Non-responding on month 6 predicts non-response on month 12 (odds ratio 37.1; 95% CI 4.5, 306.4). Conclusion We concluded that i.v. CYC pulse therapy should be considered as an effective treatment option for skin thickening in dcSSc patients, because 43% of this group of patients were found to have a clinically relevant response. Of the dcSSC patients who did not respond by month 6, only 29% had a response by month 12. This finding can help the physician and patient in shared decision making about whether or not to continue therapy.
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Affiliation(s)
- Brigit E Kersten
- Department of Rheumatic Diseases, Radboud University Medical Center
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | | | | | - Madelon C Vonk
- Department of Rheumatic Diseases, Radboud University Medical Center
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33
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Ulijn E, den Broeder N, Wientjes M, van Herwaarden N, Meek I, Tweehuysen L, van der Maas A, van den Bemt BJ, den Broeder AA. Therapeutic drug monitoring of adalimumab in RA: no predictive value of adalimumab serum levels and anti-adalimumab antibodies for prediction of response to the next bDMARD. Ann Rheum Dis 2020; 79:867-873. [PMID: 32317314 DOI: 10.1136/annrheumdis-2020-216996] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND After adalimumab treatment failure, tumour necrosis factor inhibition (TNFi) and non-TNFi biological disease-modifying anti-rheumatic drugs (bDMARDs) are equally viable options on a group level as subsequent treatment in rheumatoid arthritis (RA) based on the current best evidence synthesis. However, preliminary data suggest that anti-adalimumab antibodies (anti-drug antibodies, ADA) and adalimumab serum levels (ADL) during treatment predict response to a TNFi as subsequent treatment. OBJECTIVE To validate the association of presence of ADA and/or low ADL with response to a subsequent TNFi bDMARD or non-TNFi bDMARD. Sub-analyses were performed for primary and secondary non-responders. METHODS A diagnostic test accuracy retrospective cohort study was done in consenting RA patients who discontinued adalimumab after >3 months of treatment due to inefficacy and started another bDMARD. Inclusion criteria included the availability of (random timed) serum samples between ≥8 weeks after start and ≤2 weeks after discontinuation of adalimumab, and clinical outcome measurements Disease Activity Score in 28 joints - C-reactive protein (DAS28-CRP) between 3 to 6 months after treatment switch. Test characteristics for EULAR (European League Against Rheumatism) good response (DAS28-CRP based) after treatment with the next (non-)TNFi bDMARD were assessed using area under the receiver operating characteristic and sensitivity/specificity. RESULTS 137 patients were included. ADA presence was not predictive for response in switchers to a TNFi (sensitivity/specificity 18%/75%) or a non-TNFi (sensitivity/specificity 33%/70%). The same was true for ADL levels in patients that switched to a TNFi (sensitivity/specificity 50%/52%) and patients that switched to a non-TNFi (sensitivity/specificity 32%/69%). Predictive value of ADA and ADL were similar for both primary and secondary non-responders to adalimumab. CONCLUSIONS In contrast to earlier research, we could not find predictive value for response to a second TNFi or non-TNFi for either ADA or random timed ADL.
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Affiliation(s)
- Evy Ulijn
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, Netherlands
| | | | - Maike Wientjes
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, Netherlands
| | - Noortje van Herwaarden
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, Netherlands.,Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Inger Meek
- Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lieke Tweehuysen
- Rheumatology, Sint Maartenskliniek, Nijmegen, Gelderland, Netherlands
| | | | - Bart Jf van den Bemt
- Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands.,Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
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Mulder MLM, Vriezekolk JE, den Broeder N, Mahler EAM, Helliwell PS, van den Hoogen FHJ, den Broeder AA, Wenink MH. Comparing methotrexate monotherapy with methotrexate plus leflunomide combination therapy in psoriatic arthritis: protocol of a randomized, placebo-controlled, double-blind clinical trial (COMPLETE-PsA). Trials 2020; 21:155. [PMID: 32041657 PMCID: PMC7011519 DOI: 10.1186/s13063-020-4097-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 10/15/2019] [Accepted: 01/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Both methotrexate (MTX) and leflunomide (LEF) are registered and regularly prescribed as first-line treatments for the use in patients with psoriatic arthritis (PsA) and they are occasionally used in combination. However, evidence about their individual, and especially combined efficacy, in PsA is lacking. The aim of this study is to compare the effectiveness and safety of MTX and LEF combination therapy to MTX monotherapy in patients with PsA. Methods COMPLETE-PsA is a randomized, placebo-controlled, double-blind clinical trial. Disease-modifying antirheumatic drug (DMARD)-untreated patients (n = 78) with clinical diagnosis of active (i.e. ≥2 swollen joints) PsA will be randomized 1:1 (stratified for high disease activity, Psoriatic Arthritis Disease Activity Score [PASDAS] ≥ 5.4) to the combination or monotherapy. The intervention group receives MTX 25 mg (oral or subcutaneous) once weekly plus LEF 20 mg daily, and the control group receives the same but with placebo instead of LEF daily. Primary endpoint is between-group difference in PASDAS at 16 weeks, adjusted for baseline PASDAS. Key secondary parameters include between-group comparisons in change in Disease Activity in Psoriatic Arthritis (DAPSA) score, skin score, enthesitis score, dactylitis score, and swollen/tender joint count, as well as the proportion of patients fulfilling minimal disease activity (MDA), American College of Rheumatology (ACR) 20/50/70 response criteria at week 16. Furthermore, safety, function and quality of life (Health Assessment Questionnaire [HAQ], Psoriatic Arthritic Impact of Disease [PSAID], Short Form 12 [SF-12]) will be assessed. Discussion This is, to our knowledge, the first randomized, placebo-controlled, double-blind clinical trial assessing the effectiveness of MTX and LEF combination therapy in patients with PsA. The study will provide important information for treatment strategies and treatment recommendations. Trial registration Dutch Trial Register NTR7632 (3 December 2018). CMO NL66544.091.18 (19 November 2018).
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Affiliation(s)
- Michelle L M Mulder
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands. .,Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Johanna E Vriezekolk
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands
| | - Elien A M Mahler
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands
| | - Philip S Helliwell
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands.,Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands.,Department of Rheumatic Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mark H Wenink
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, Nijmegen, 6500 GM, The Netherlands
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Michielsens CAJ, Boers N, den Broeder N, Wenink MH, van der Maas A, Mahler EAM, Mulder MLM, van der Heijde D, van den Hoogen FHJ, Verhoef LM, den Broeder AA. Dose reduction and withdrawal strategy for TNF-inhibitors in psoriatic arthritis and axial spondyloarthritis: design of a pragmatic open-label, randomised, non-inferiority trial. Trials 2020; 21:90. [PMID: 31941544 PMCID: PMC6964104 DOI: 10.1186/s13063-019-4000-5] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/16/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Tumour necrosis factor inhibitors (TNFi) are effective in the treatment of patients with spondyloarthritis (SpA), including psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA). However, these drugs come with some disadvantages such as adverse events, practical burden for patients and high costs. Dose optimisation of TNFi after patients have reached low disease activity (LDA) has been shown feasible and safe in rheumatoid arthritis (RA). However, data on TNFi dose optimisation in PsA and axSpA are scarce, especially pragmatic, randomised strategy studies. METHODS We developed an investigator-driven, pragmatic, open-label, randomised, controlled, non-inferiority trial (DRESS-PS) to compare the effects of a disease activity-guided treat-to-target strategy with or without a tapering attempt in patients with SpA (PsA and axSpA combined), ≥ 16 years of age, who are being treated with TNFi, and have had at least 6 months of low disease activity. The primary outcome is the percentage of patients in LDA after 12 months of follow up. Patients are assessed at baseline, 3, 6, 9, and 12 months of follow up. Bayesian power analyses with a weakened prior based on a similar study performed in RA resulted in a sample size of 95 patients in total. DISCUSSION More knowledge on disease activity-guided treatment algorithms would contribute to better treatment choices and cost savings and potentially decrease the risk of side effects. In this article we elucidate some of our design choices on TNFi dose optimisation and its clinical and methodological consequences. TRIAL REGISTRATION Dutch Trial Register, NL6771. Registered on 27 November 2018 (CMO NL66181.091.18, 23 October 2018).
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Affiliation(s)
- Celia A J Michielsens
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands. .,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Mark H Wenink
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Elien A M Mahler
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Michelle L M Mulder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Hengstdal 3, 6574 NA, Nijmegen, The Netherlands.,Department of Rheumatic Diseases, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
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Verhoef LM, den Broeder N, Thurlings RM, van der Laan WH, van der Weele W, Kok MR, Bernelot Moens HJ, Woodworth TG, van den Bemt BJF, van den Hoogen FHJ, den Broeder AA. Ultra-low doses of rituximab for continued treatment of rheumatoid arthritis (REDO study): a randomised controlled non-inferiority trial. Lancet Rheumatol 2019; 1:e145-e153. [PMID: 38229391 DOI: 10.1016/s2665-9913(19)30066-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Rituximab is an effective treatment for rheumatoid arthritis, given as either two doses of 1000 mg (2 weeks apart) every 6 months (the dose recommended by the US Food and Drug Administration and European Medicines Agency) or two doses of 500 mg (2 weeks apart) or one dose of 1000 mg (a standard low dose) every 6 months. Findings of several small uncontrolled studies suggest that doses lower than the recommended dose or standard low dose might be sufficient for maintenance treatment, potentially improving safety and reducing costs. Therefore, we aimed to compare the efficacy of ultra-low doses of rituximab (one dose of 500 mg or 200 mg) with a standard low dose of rituximab (one dose of 1000 mg) for patients with rheumatoid arthritis who respond to standard doses of rituximab. METHODS The REDO study is a randomised, double-blind, non-inferiority trial done at five centres in the Netherlands. Adults (aged ≥18 years) with rheumatoid arthritis responding well to rituximab were randomly allocated (1:2:2) to receive intravenous rituximab as one dose of either 1000 mg, 500 mg, or 200 mg, respectively. Volumes of all doses were equal to achieve masking. Randomisation lists were computer-generated and stratified by rheumatoid factor or anti-citrullinated protein antibody status (positive or negative) and concomitant use of conventional synthetic disease modifying antirheumatic drugs (yes or no). The primary analysis was a per-protocol hierarchical testing procedure comparing ultra-low doses with a standard low dose (500 mg vs 1000 mg at 3 months, followed by 500 mg vs 1000 mg at 6 months, 200 mg vs 1000 mg at 3 months, and 200 mg vs 1000 mg at 6 months), using a non-inferiority margin of 0·60 on change from baseline in the 28-joint disease activity score based on C-reactive protein levels (DAS28-CRP). The study is registered at www.trialregister.nl, NTR6117. FINDINGS Between Dec 15, 2016, and Sept 20, 2018, 142 patients were randomly allocated to either 1000 mg rituximab (n=29), 500 mg rituximab (n=58), or 200 mg rituximab (n=55). The 500 mg dose was non-inferior to 1000 mg at 3 months (mean change from baseline in DAS28-CRP, -0·07, 95% CI -0·41 to 0·27) but not at 6 months (0·29, -0·08 to 0·65). Because of the hierarchical testing procedure, non-inferiority could not be tested for the 200 mg dose. 13 patients had serious adverse events, three (10%) in the 1000 mg group, six (10%) in the 500 mg group, and four (7%) in the 200 mg group. The most frequently reported serious adverse events were cardiovascular. No deaths occurred during the study. A significantly lower incidence of infections was seen in the ultra-low-dose groups compared with the standard dose group (1·10 infections per patient-year with the 1000 mg dose vs 0·52 per patient-year with the 500 mg dose and 0·51 per patient-year with the 200 mg dose; rate ratio 0·47, 95% CI 0·21-0·83; p=0·013 for 500 mg vs 1000 mg; 0·44, 0·22-0·88; p=0·019 for 200 mg vs 1000 mg). INTERPRETATION Our study did not show non-inferiority of ultra-low doses of rituximab for continued treatment of patients with rheumatoid arthritis. Nonetheless, in clinical practice, a strategy with an ultra-low dose of rituximab might be considered after evaluation of risks and benefits, although further studies are needed to establish non-inferiority. Further analyses and a 2-year observational extension are ongoing and should provide further insight into efficacy and safety. FUNDING Menzis and Centraal Ziekenfonds.
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Affiliation(s)
- Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, Netherlands.
| | | | | | | | | | - Marc R Kok
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, Netherlands
| | | | - Thasia G Woodworth
- Department of Medicine/Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Bart J F van den Bemt
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, Netherlands; Department of Pharmacy, Radboudumc, Nijmegen, Netherlands
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, Netherlands; Department of Rheumatic Diseases, Radboudumc, Nijmegen, Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, Netherlands; Department of Rheumatic Diseases, Radboudumc, Nijmegen, Netherlands
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Mahler EAM, den Broeder AA, den Broeder N, Bijlsma JWJ, Snijders GF, van den Hoogen FHJ, van den Ende CHM. Short-term clinical worsening is a clear predictor for worsening at 2 years in established knee and hip osteoarthritis. Clin Exp Rheumatol 2019; 37:414-421. [PMID: 30299244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 07/02/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Our aim was to estimate the proportion of knee and hip OA patients showing worsening at 2 years, and to examine the additional predictive value of failure of optimised non-surgical treatment during 3 months for worsening at 2 years. METHODS Data of patients participating in the longitudinal CONTROL-PRO study (patients fulfilling clinical ACR criteria for knee or hip OA) were used. Measurements of pain, functioning and patient global assessments were performed at baseline, 3 months and 2 years. Worsening at 2 years was defined as fulfilling the recently validated clinical worsening criteria for knee and hip OA, or total joint replacement (TJR). Logistic regression was performed with worsening at 2 years as the dependent variable. RESULTS The 297 included patients were predominantly women (66%) with a mean age of 55 years. At 2 years, 61% showed worsening (knee 59%; hip 71%) and 24% had undergone a TJR (knee 19%; hip 51%). Clinical worsening at 3 months appeared to be a clear independent predictor for worsening at 2 years (OR 2.8 95% CI 1.5-5.2) with a moderate discriminative ability (AUC 0.68 95% CI 0.57-0.70). Similar results were obtained when only TJR at 2 years was used as the outcome measure (OR 4.1 95% CI 2.0-8.4) with good AUC (0.82 95% CI 0.76-0.87). CONCLUSIONS Our findings suggest that re-assessment of symptoms after optimised non-surgical treatment could be meaningful in clinical decision making for TJR. Furthermore, this information could be used to identify subgroups of patients potentially eligible for novel and advanced treatment options.
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Affiliation(s)
- Elien A M Mahler
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek and Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Johannes W J Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Gijs F Snijders
- Department of Rheumatology, Sint Maartenskliniek and Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek and Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelia H M van den Ende
- Department of Rheumatology, Sint Maartenskliniek and Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
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den Broeder N, Bouman CAM, Kievit W, van Herwaarden N, van den Hoogen FHJ, van Vollenhoven RF, Bijlsma HWJ, van der Maas A, den Broeder AA. Three-year cost-effectiveness analysis of the DRESS study: protocolised tapering is key. Ann Rheum Dis 2018; 78:141-142. [PMID: 30150367 DOI: 10.1136/annrheumdis-2018-213547] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/28/2018] [Accepted: 08/01/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Chantal A M Bouman
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Wietske Kievit
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Rheumatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ronald F van Vollenhoven
- Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Rheumatology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Hans W J Bijlsma
- Department of Rheumatology & Clinical Immunology, Utrecht University Medical Centre, Utrecht, The Netherlands
| | - Aatke van der Maas
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands .,Department of Rheumatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Tweehuysen L, den Broeder N, van Herwaarden N, Joosten LAB, van Lent PL, Vogl T, van den Hoogen FHJ, Thurlings RM, den Broeder AA. Predictive value of serum calprotectin (S100A8/A9) for clinical response after starting or tapering anti-TNF treatment in patients with rheumatoid arthritis. RMD Open 2018; 4:e000654. [PMID: 29657832 PMCID: PMC5892754 DOI: 10.1136/rmdopen-2018-000654] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/03/2018] [Accepted: 03/15/2018] [Indexed: 01/01/2023] Open
Abstract
Objectives Calprotectin (S100A8/A9) has been correlated with disease activity in rheumatoid arthritis (RA). The aim of this study was to investigate the predictive value of serum calprotectin for clinical response after starting and tapering anti-tumour necrosis factor treatment in RA. Methods Serum samples and clinical outcomes were derived from two longitudinal RA studies. At baseline (starting or tapering of adalimumab or etanercept), calprotectin levels were determined by ELISA. In the Biologic Individual Optimised Treatment Outcome Prediction (BIO-TOP) study, treatment effect was assessed after 6 months using the European League Against Rheumatism (EULAR) response criteria. In the Dose Reduction Strategies of Subcutaneous TNF Inhibitors (DRESS) study, patients were classified at 18 months as being successfully dose reduced, discontinued or not able to reduce the dose. Area under the receiver operating characteristic curves (AUC) were generated to evaluate the predictive value of calprotectin and logistic prediction models were created to assess its added value. Results In the BIO-TOP study, calprotectin levels were higher in responders (n=50: 985 ng/mL (p25–p75: 558–1417)) compared with non-responders (n=75: 645 ng/mL (p25–p75: 415–973), p=0.04). AUC for predicting EULAR good response was 0.61 (95% CI 0.50 to 0.71). The prediction model with calprotectin (AUC 0.77, 95% CI 0.68 to 0.85) performed similarly to the baseline model (AUC 0.74, 95% CI 0.65 to 0.82, p=0.29). In the DRESS study, calprotectin levels were similar between the three groups (n=47; n=19; n=36) and calprotectin was not predictive for clinical response after tapering. Conclusions Serum calprotectin has some predictive value for clinical response after starting anti-TNF treatment, although it has no added value to other clinical factors. In patients with low disease activity, serum calprotectin is not predictive for clinical response after tapering anti-TNF treatment. Trial registration number NTR4647 (BIO-TOP study) and NTR3216 (DRESS study); Pre-results.
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Affiliation(s)
- Lieke Tweehuysen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | | | - Leo A B Joosten
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter L van Lent
- Department of Experimental Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thomas Vogl
- Department of Immunology, University of Münster, Münster, Germany
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rogier M Thurlings
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
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den Broeder AA, Verhoef LM, Fransen J, Thurlings R, van den Bemt BJF, Teerenstra S, Boers N, den Broeder N, van den Hoogen FHJ. Ultra-low dose of rituximab in rheumatoid arthritis: study protocol for a randomised controlled trial. Trials 2017; 18:403. [PMID: 28854956 PMCID: PMC5577818 DOI: 10.1186/s13063-017-2134-x] [Citation(s) in RCA: 16] [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: 02/06/2017] [Accepted: 08/03/2017] [Indexed: 01/08/2023] Open
Abstract
Background A standard low-dosing schedule of rituximab (RTX; 2 × 500 mg or 1 × 1000 mg) is as effective for active rheumatoid arthritis (RA) as the registered dose (2 × 1000 mg). Moreover, several small uncontrolled studies suggest that even lower-dosed treatment with RTX also leads to good treatment response in patients with RA. Retreatment with such an ‘ultra-low’ dose RTX in patients who responded well to RTX induction treatment is of special interest, as long-term use of lower RTX doses may lead to shorter infusion duration, lower risk of adverse events and lower costs. However, the effect of ultra-low dose of RTX has not been investigated using a controlled trial of proper design and dimensions. Methods/Design REDO is an investigator driven six-month pragmatic, double-blind, randomised controlled non-inferiority trial on the effects of ultra-low-dose RTX (1 × 500 or 1 × 200 mg) compared to standard low dose (1 × 1000 mg) in RA patients who are being retreated with RTX. A total of 140 RA patients, having reached low disease activity (DAS28CRP < 2.9) after the previous RTX infusion and DAS28CRP < 3.5 at moment of retreatment, are randomised in a ratio of 1:2:2 to 1 × 1000 mg, 1 × 500 mg or 1 × 200 mg. The primary objective is testing non-inferiority of the ultra-low-dose vs. standard low-dose RTX, by comparing mean change in DAS28CRP from baseline to six months to the non-inferiority margin of 0.6. Secondary outcomes over the same period are: function; quality of life; safety; costs; and pharmacokinetics and dynamics as process measures. Discussion This study protocol shares characteristics of both early dose finding trials as well as late pragmatic clinical studies. Several choices in the design of this trial are described and possible consequences for RA treatment and expected biosimilar introduction are discussed. Trial registration Dutch Trial Register, NTR6117. Registered on 15 November 2016 (CMO NL57520.091.16, 8 November 2016) Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2134-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alfons A den Broeder
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, The Netherlands. .,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands.
| | - Lise M Verhoef
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, The Netherlands
| | - Jaap Fransen
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Rogier Thurlings
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands.,Department of Pharmacy, Radboudumc, Nijmegen, The Netherlands
| | - Steven Teerenstra
- Department of for Health Evidence, Section of biostatistics, Radboudumc, Nijmegen, The Netherlands
| | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, The Netherlands
| | - Nathan den Broeder
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, The Netherlands
| | - Frank H J van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, The Netherlands.,Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
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Lesuis N, den Broeder N, Boers N, Piek E, Teerenstra S, Hulscher M, van Vollenhoven R, den Broeder AA. The effects of an educational meeting and subsequent computer reminders on the ordering of laboratory tests by rheumatologists: an interrupted time series analysis. Clin Exp Rheumatol 2017; 35:379-383. [PMID: 28339354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 07/04/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To examine the effects of an educational meeting and subsequent computer reminders on the number of ordered laboratory tests. METHODS Using interrupted time series analysis we assessed whether trends in the number of laboratory tests ordered by rheumatologists between September 2012 and September 2015 at the Sint Maartenskliniek (the Netherlands) changed following an educational meeting (September 2013) and the introduction of computer reminders into the Computerised Physician Order Entry System (July 2014). The analyses were done for the set of tests on which both interventions had focussed (intervention tests; complement, cryoglobulins, immunoglobins, myeloma protein) and a set of control tests unrelated to the interventions (alanine transferase, anti-cyclic citrullinated peptide, C-reactive protein, creatine, haemoglobin, leukocytes, mean corpuscular volume, rheumatoid factor and thrombocytes). RESULTS At the start of the study, 101 intervention tests and 7660 control tests were ordered per month by the rheumatologists. After the educational meeting, both the level and trend of ordered intervention and control tests did not change significantly. After implementation of the reminders, the level of ordered intervention tests decreased by 85.0 tests (95%-CI -133.3 to -36.8, p<0.01), the level of control tests did not change following the introduction of reminders. CONCLUSIONS In summary, an educational meeting alone was not effective in decreasing the number of ordered intervention tests, but the combination with computer reminders did result in a large decrease of those tests. Therefore, we recommend using computer reminders in addition to education if reduction of inappropriate test use is aimed for.
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Affiliation(s)
- Nienke Lesuis
- Department of Rheumatology and Laboratory, Sint Maartenskliniek, Nijmegen, the Netherlands.
| | - Nathan den Broeder
- Department of Rheumatology and Laboratory, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Nadine Boers
- Department of Rheumatology and Laboratory, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Ester Piek
- Department of Rheumatology and Laboratory, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Steven Teerenstra
- Department for Health Evidence, Biostatistics Section, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marlies Hulscher
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ronald van Vollenhoven
- Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institute, Stockholm, Sweden
| | - Alfons A den Broeder
- Department of Rheumatology and Laboratory, Sint Maartenskliniek, Nijmegen, the Netherlands
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Lesuis N, van Vliet J, Boers N, den Broeder N, Cats H, Hulscher MEJL, Verrips A, den Broeder AA. The value of routine creatine kinase and thyroid stimulating hormone testing in patients with suspected fibromyalgia: a cross-sectional study. Rheumatology (Oxford) 2016; 55:1273-6. [PMID: 27032423 DOI: 10.1093/rheumatology/kew046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The aim was to examine the prevalence of abnormal creatine kinase (CK) and thyroid stimulating hormone (TSH) values and previously unknown myopathy or thyroid disease in patients with suspected FM syndrome (FMS). METHODS All adult patients with suspected FMS referred to the study hospital between November 2011 and April 2014 could participate. Patients with a history of myopathy or a previous diagnosis of thyroid disorder were excluded. Outcome measures were the percentages of abnormal CK and TSH values and the final diagnosis in those patients. RESULTS Three hundred and seventy-three patients were included in this study (94% female, mean age 42 years). Of these patients, 7.5% (95% CI: 5.2, 10.6%) had an abnormal CK according to the local reference values. Applying the European Federation of the Neurological Societies guideline, this changed to 0.5% (95% CI: 0.2, 1.9%). In none of these patients was hyperCKaemia-related myopathy diagnosed, and the final diagnosis was FMS in 89% of the patients. Of the total number of patients, 3.5% (95% CI: 2.1, 5.9%) had an elevated TSH and 1.4% (95 CI: 0.6, 3.1%) a lowered TSH, with one patient having a somewhat lowered free thyroid hormone level. The final diagnosis was FMS in all these patients. CONCLUSION Abnormal CK and TSH values are rare in patients with suspected FMS and do not result in an alternative diagnosis. Therefore, it seems that routine testing of CK and TSH levels in patients with suspected FMS referred to secondary care does not contribute to the diagnostic process.
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Affiliation(s)
| | | | - Nadine Boers
- Department of Rheumatology, Sint Maartenskliniek
| | | | - Hans Cats
- Department of Rheumatology, Sint Maartenskliniek
| | - Marlies E J L Hulscher
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Aad Verrips
- Department of Neurology, Canisius Wilhelmina Ziekenhuis and
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