Real-World Use and Effectiveness Outcomes in Patients with Rheumatoid Arthritis Treated with Upadacitinib: An Analysis from the CorEvitas Registry

INTRODUCTION

Data assessing longer-term real-world effectiveness and treatment patterns with upadacitinib (UPA), a Janus kinase inhibitor, in rheumatoid arthritis (RA) are lacking. We assessed improvement in clinical and patient-reported outcomes and treatment patterns for up to 12 months among adult patients with RA initiating UPA.

METHODS

Data were collected from the CorEvitas® RA Registry (08/2019-04/2022). Eligible patients had moderate to severe RA (Clinical Disease Activity Index [CDAI] > 10) and follow-up visits at 6 or 12 months after UPA initiation. Outcomes were mean change from baseline, percentage achieving minimal clinically important differences (MCID) in clinical and patient-reported outcomes, and disease activity at follow-up. We evaluated clinical outcomes and therapy changes among patients with tumor necrosis factor inhibitor (TNFi) experience and among those receiving UPA as first-line therapy, as well as those receiving UPA as monotherapy versus as part of combination therapy. We further evaluated whether outcomes were similar among those that remained on therapy.

RESULTS

Patients treated with UPA (6-month cohort, N = 469; 12-month cohort, N = 263) had statistically significant improvements (p < 0.001) in mean CDAI, tender/swollen joint counts, pain, and fatigue at follow-up. At 12 months, 46.0% achieved MCID in CDAI and 40.0% achieved low disease activity/remission. Overall, 43.0% discontinued UPA at 12 months; of those receiving combination treatment (N = 90) with conventional therapies and UPA, 42.2% (N = 38) discontinued conventional therapy. Findings were similar in the 6-month cohort and among subgroups. Changes from baseline and proportions of patients achieving MCID or clinical outcomes tended to be numerically lower among patients with TNFi experience and numerically higher among those receiving UPA as first-line therapy.

CONCLUSIONS

UPA initiation was associated with improvements in clinical and patient-reported outcomes, with meaningful clinical improvements regardless of prior TNFi experience, line of therapy, or concomitant use of conventional therapies. Further research is needed to better understand sustained response of UPA over longer treatment periods.

Effect of Visit Frequency of Pharmacist-Led Diabetes Medication Management Program

BACKGROUND

Pharmacists have a positive effect on clinical outcomes in chronic disease state management, however, few studies have evaluated the effect that frequency of visits may have on diabetes biomarkers such as hemoglobin A1c and blood pressure readings.

METHODS

Under the medication management program (MMP), patients with diabetes were seen monthly by pharmacists until early 2015, when time between visits was increased to every 3 months. A retrospective chart review was conducted to evaluate the primary outcome of the percent change in hemoglobin A1c and blood pressure after the change in visit frequency.

RESULTS

In the 303 patients enrolled, no statistical difference existed between the pre and post average A1c (p-value = 0.10). The intermediate average A1c was statistically lower from the preintervention mean A1c (p-value = 0.001) but not from the postintervention mean A1c (p-value = 0.30). No statistical differences were seen between systolic blood pressure and diastolic blood pressure.

CONCLUSION

Patients who have been seen by a clinical pharmacist more frequently (every month or every other month) for several years may be able to maintain their reduction in A1c with less-frequent visits (every 3 to 6 months).

Efficacy of Liposomal Bupivacaine Compared with Multimodal Periarticular Injections for Postoperative Pain Control following Total Knee Arthroplasty

Single-dose long-acting periarticular anesthetics have been shown to be an effective method of postoperative analgesia in total knee arthroplasty (TKA). This study retrospectively compares the efficacy of multimodal periarticular injection consisting of a combination of ropivacaine, duramorph, epinephrine, and toradol (HC) with liposomal bupivacaine (LB) periarticular injection in TKA. This study was a retrospective matched comparative chart review of two cohorts of patients who underwent TKA within a single health care system and cared for by one provider. We compared 22 patients who were treated with LB intraoperatively (LBG) with 41 matched controls who were treated with HC periarticular injection (HCG). These cases were retrospectively reviewed at 0 to 6, 6 to 12, 12 to 24, 24 to 48, and 48 to 72 hours. We reviewed pain scores and opioid use per the preceding time period, total opioid use, length of stay (LOS), and wound complications between the two groups. The two groups showed no statistical difference in total opioids used. In both the 6- to 12-hour and 12- to 24-hour intervals, the LBG required significantly more opioids than the HCG, with p-values of 0.0039 and 0.0061, respectively. Pain scores were not significantly different for any time period. We found no difference in LOS. The LBG tended to have lower doses of antiemetics than the HCG. No significant difference was found in postoperative pain scores and total opioid use between LB and multimodal periarticular intraoperative injections in TKA. Our data demonstrated decreased opioid consumption in the HC group compared with the LB group in both the 6- to 12-hour and 12- to 24-hour time intervals postoperatively. At our institution, LB costs US$314.99, whereas HC costs US$95.

Relationship Between Hemoglobin A1c Value and Bone Healing in Diabetic Ankle Fractures Treated Operatively versus Non-operatively

Category:

Ankle

Introduction/Purpose:

Diabetic ankle fractures create unique challenges to fracture management, such as impaired wound / bone healing and increased infection rate. There is inconclusive evidence regarding a specific hemoglobin A1c (A1c) value or glucose level at which the risk of adverse outcomes increases. The aim of this study was to evaluate the A1c level at which the rate of nonunion and other major complications significantly increased in diabetic ankle fractures treated operatively (Op) and non-operatively (Nonop).

Methods:

This is a retrospective cohort study of diabetic ankle fractures treated Op or NonOp with at least 3 months follow up and a hemoglobin A1c value within 90 days of injury. A query of electronic medical records was performed to identify all patients 18 years of age or older with a diagnosis of diabetes and who underwent Op or NonOp management as the initial treatment of an ankle fracture between January 1, 2004 and December 31, 2014 within a single health system. Union was defined as callus formation at 3 of 4 cortices on radiographs, while nonunion was defined as lack of fracture healing at 6 months based on radiographs of the injured ankle. Multivariable logistic regression analysis was performed to explore demographic, injury-related, and management-related risk factors that influence nonunion and major complications.

Results:

A total of 243 ankle fractures (130 Op, 113 NonOp) were identified. Nine patients in the NonOp group failed nonoperative management and required surgical fixation. There were 51 patients that developed nonunion/malunions (19 Op, 32 NonOp). Patients with diabetic neuropathy or nephropathy had significantly higher risk of nonunion. In both groups, length of immobilization greater than 12 weeks was a significant predictor of nonunion. There was no A1c level nor preinjury glucose level at which there was significantly increased rate of nonunion or deep infections in either treatment group. However, A1c was a predictor of wound complications at 3 months postoperative in the Op group with an odds ratio of 1.26. There was no significant difference in wound complications at 3 months between treatment groups.

Conclusion:

While no specific A1c value or glucose level demonstrated a significant rise in fracture nonunion, this study found that diabetic neuropathy and diabetic nephropathy play a significant role in fracture healing. However, hemoglobin A1c was found to be a predictor of wound complications at 3 months postoperative. Additionally, the data suggested a longer duration of immobilization may negatively impact fracture union. These results highlight the complexity of treating diabetic ankle fractures and suggest prolonged immobilization may not be beneficial for this subpopulation.

Rate of contralateral hip fracture after dynamic hip screw vs intramedullary nail for treatment of pertrochanteric hip fractures

A retrospective, comparative study was performed reviewing the electronic medical records and digital radiographs of patients who underwent treatment for intertrochanteric and pertrochanteric hip fractures with either a hip screw and side plate (HSSP) or intramedullary nail. A total of 430 patients were treated with HSSP, and 725 were managed with a cephalomedullary nail (CMN). Of these, 103 sustained a contralateral hip fracture. Fixation technique was not associated with a significant difference in the rate of contralateral fracture. Among the patients with a contralateral fracture, the median time to contralateral fracture was 119.28 months following HSSP and 81.97 months following CMN. Bisphosphonate use was found to be a significant predictor of contralateral fracture for all patients, but when matching using propensity scores, its use was found to be insignificant. In conclusion, there was no difference in the rate of subsequent contralateral hip fracture when comparing HSSP with CMN. Additionally, the time to second surgery between the two treatment modalities was found to be statistically insignificant. It is unclear if bisphosphonate use increased the odds of having a contralateral fracture, regardless of the surgical intervention. The difference in the bisphosphonate effect using propensity score matching suggests that the results may be due to confounding variables and bias.

Effect of Obesity on Bone Healing After Foot and Ankle Long Bone Fractures

As obesity has become more common, fractures in the obese population have become more frequent. Concern exists regarding alterations in bone health and healing in obese patients. A matched case-control study was performed at 1 institution to evaluate whether an association exists between nonunion and a high body mass index in metatarsal and ankle fractures. A total of 48 patients with nonunion were identified, and control patients matched 2 to 1 (n = 96) were selected. The control patients were matched for age, sex, and fracture type. No association was identified between nonunion and the continuous body mass index (p = .23) or morbid obesity, with a body mass index of ≥40 kg/m² (p = .51). However, the results from both univariate and multivariate analysis suggested that patients with a current alcohol problem or a history of an alcohol problem might have a greater risk of nonunion. The odds ratio of a patient with a history of alcohol use experiencing nonunion was 2.7 (95% confidence interval 1.2 to 6.2). Further studies are warranted to confirm these findings.

High- versus low-dose leucovorin in the modified FOLFOX6 regimen for first-line treatment of metastatic colorectal cancer

Background In response to the national leucovorin shortage in 2008, our institution adjusted the modified FOLFOX6 (leucovorin, fluorouracil, and oxaliplatin) protocol to utilize a lower dose of leucovorin (20 mg/m²). This adjustment was based on prospective studies suggesting that lower doses of leucovorin may be equally effective in other fluorouracil containing regimens. This retrospective study evaluates outcomes in metastatic colorectal cancer (mCRC) patients treated with low- (20 mg/m²) vs. high-dose (400 mg/m²) leucovorin in the FOLFOX6 regimen for mCRC. Methods This retrospective analysis included consecutive mCRC patients from 2004 to 2011 if they received at least one cycle of modified FOLFOX6 as first line therapy. Patients who received an initial leucovorin dose other than 20 mg/m² or 400 mg/m² on their first cycle were excluded. Patient characteristics included demographics, metastatic site at initial diagnosis, and treatment history including chemotherapy and surgery. Primary outcome was date of death or last contact. Cox proportional hazards regression analysis and Kaplan-Meier survival curves were utilized to evaluate the effect of leucovorin dose on overall survival. Log-rank tests were used to compare median survival times by dose group. Results Of the 93 mCRC patients who received first line modified FOLFOX6, leucovorin 400 mg/m² was administered to 47 (51%) patients and 20 mg/m² to 46 (49%) patients. There were no differences of baseline characteristics between the groups with exception of primary site of cancer ( p = 0.038). The overall survival time was 22.5 months (95% CI 16.6-29.6). The median survival time in the leucovorin 400 mg/m² group was 23.1 months (95% CI 16.2-35.7) compared to leucovorin 20 mg/m² which was 20.5 months (95% CI 14.2-34.2); p = 0.573. The median survival times in patients with one versus two or more sites with metastasis were statistically different (26.9 vs. 16.2 months, p = 0.009). Metastatic site removal or ablation showed differences in the median survival, 34.2 months (95% CI 20.8-50.9) vs. 16.6 months (95% CI 14.1-23.6) without metastatic disease removal ( p = 0.004). The odds of dying for patients with two metastatic sites was higher compared with the odds of those patients with one site, HR 1.8 (95% CI 1.08-3.0). Patients without metastatic site removal or ablation had higher odds of dying compared to those patients without this procedure, HR 0.47 (95% CI 0.27-0.81). Conclusion In this single center retrospective study, there was no difference in overall survival for mCRC patients treated with first line FOLFOX6 with low- vs. high-dose leucovorin.

Initiating BMI prevalence studies in Vietnamese children: changes in a transitional economy

BACKGROUND

Rapid changes in dietary patterns and lifestyles in Vietnam warrant monitoring trends of weight, height and body mass index (BMI) among children.

OBJECTIVE

To determine the trends of weight, height and BMI classification of Vietnamese children, 6-15 years of age, from 1992 to 2000 with reference to socioeconomic, urban and rural differences.

METHODS

Data in the Vietnam Living Standard Survey (1992-1993) and the General Nutrition Survey (2000) were collected from representative samples of children. Body mass index classification was determined using the International Obesity Task Force criteria to calculate the prevalence and trends in each survey, and in a pooled survey analysis.

RESULTS

Statistically significant increases were seen in children's mean weight, height and BMI between the two surveys: 2.1 kg for weight, 4 cm for height, and 0.28 kg/m2 for BMI. Increases in height were greater in rural than urban areas, and BMI increases were smaller in rural than urban areas.

CONCLUSIONS

The rising prevalence of children at risk of overweight in urban Vietnam is a concern that must be monitored to guide policy changes. The unchanging prevalence of rural underweight boys requires attention. A national nutrition program to address under- and overweight for children throughout primary school is needed.