The efficacy of short-term bridging strategies with high- and low-dose prednisolone on radiographic and clinical outcomes in active early rheumatoid arthritis: a double-blind, randomized, placebo-controlled trial

OBJECTIVE

In active early rheumatoid arthritis (RA), glucocorticoids are often used for bridging, due to the delayed action of methotrexate. We compare the effect of three bridging strategies including high-dose and low-dose prednisolone on radiographic and clinical outcomes.

METHODS

Adult RA patients from one rheumatology hospital and 23 rheumatology practices presenting with moderate/high disease activity were randomised (1:1:1) to 60 mg (high-dose, HDP), 10 mg prednisolone (low-dose, LDP) daily (tapered to 0 mg within 12 weeks), or placebo. The 12-week-intervention period was followed by 40 weeks of therapy at physicians' discretion. The primary outcome was radiographic change at 1 year measured by the modified Sharp/van der Heijde (mSvdH) score. Disease activity was assessed by DAS28 (ESR).

RESULTS

Of 395 randomized patients (n=132 HDP, n=131 LDP, n=132 placebo), 375 (95%) remained in the modified intention-to-treat analysis. Mean changes (standard deviation) in mSvdH scores of the 3 groups after one year were comparable: HDP 1.0 (2.0), LDP 1.1 (2.2), placebo 1.1 (1.5) units. The primary analysis showed no superiority of HDP vs. placebo (estimated difference of the mean change -0.04 (95% confidence interval (CI) -0.5; 0.4)). At week 12, mean DAS28 (ESR) differed: HDP vs. placebo: -0.6 (95%CI -1.0; -0.2); LDP vs. placebo: -0.8 (95% CI -1.2; -0.5). At week 52, there was no significant difference in DAS28 (ESR) between the 3 groups (range 2.6-2.8). Serious adverse events occurred similarly often.

CONCLUSION

Short-term glucocorticoid bridging therapy at high dose showed no benefit with regard to progression of radiographic damage at one year.

The Structured Delegation of Medical Care Services for Patients With Inflammatory Rheumatic Diseases

BACKGROUND

In some areas of Germany, there is a shortage of specialist physicians for patients with inflammatory rheumatic diseases. Delegating certain medical care services to qualified, specialized rheumatological assistants (SRAs) might be an effective way to supplement the available capacity for specialized medical care.

METHODS

Patients under stable treatment for rheumatoid arthritis (RA) or psoriatic arthritis (PsA) were included in this trial, which was designed to demonstrate, in a first step, the non-inferiority of a form of care involving delegation of physicians' tasks to SRAs (team-based care), in comparison to standard care, with respect to changes in disease activity at one year. "Non-inferiority," in this context, means either superiority or else an irrelevant extent of inferiority. In a second step, in case non-inferiority could be shown, the superiority of team-based care with respect to changes in patients' health-related quality of life would be tested as well. Disease activity was measured with the Disease Activity Score 28, and health-related quality of life with the EQ-5D-5L. This was a randomized, multicenter, rater-blinded trial with two treatment arms (team-based care and standard care). The statistical analysis was performed with mixed linear models (DRKS00015526).

RESULTS

From September 2018 to June 2019, 601 patients from 14 rheumatological practices and 3 outpatient rheumatological clinics in the German states of North Rhine-Westphalia and Lower Saxony were randomized to either team-based or standard care. Team-based care was found to be non-inferior to standard care with respect to changes in disease activity (adjusted difference = -0.19; 95% confidence interval [-0.36; -0.02]; p <0.001 for non-inferiority). Superiority with respect to health-related quality of life was not demonstrated (adjusted difference = 0.02 [-0.02; 0.05], p = 0.285).

CONCLUSION

Team-based care, with greater integration of SRAs, is just as good as standard care in important respects. Trained SRAs can effectively support rheumatologists in the care of stable patients with RA or PsA.

SAT0135 COMPARISON OF THE EFFICACY AND SAFETY OF TWO BRIDGING SCHEDULES OF PREDNISOLONE IN EARLY ACTIVE RHEUMATOID ARTHRITIS (CORRA): A DOUBLE-BLIND, RANDOMISED, PLACEBO-CONTROLLED TRIAL

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory joint disease potentially leading to disability, impaired functioning, and premature death. Most treatment strategies include the early use of disease-modifying antirheumatic drugs (DMARDs) such as methotrexate (MTX) which is considered as an established ‘anchor’ therapy. Since it takes some weeks until MTX shows clinical efficacy, glucocorticoids (GC) are widely used for bridging.

Objectives:

The aim of the study “Comparison of the efficacy and safety of two starting dosages of prednisolone in early active RA” (CORRA) is to compare the efficacy and safety of two standard GC bridging schedules vs. placebo in addition to MTX, following a treat-to-target regimen, in early RA.

Methods:

CORRA is an investigator-initiated, randomised, multi-center, double-blind, placebo-controlled trial. Adult RA patients who were eligible for inclusion in the trial if they had a disease duration of less than 3 years and moderate or high disease activity were recruited in one hospital and 18 rheumatology practices in Germany. Patients were randomised (1:1:1) to receive 60 mg or 10 mg prednisolone (Pred) orally once daily (tapered down to 5 mg Pred within 8 weeks) or placebo. The duration of the intervention was 12 weeks, followed by an open observational phase for another 40 weeks. All patients were also treated with MTX (usually starting with 15mg/week followed by a treat-to target scheme). The primary efficacy endpoint was the progression of the radiographic joint damage after one year compared to baseline as determined by the van der Heijde modification of the Sharp score (SHS). Patients, physicians and readers of radiographs were unaware of the treatment assignments. For the comparison of the two GC groups, a non-inferiority margin of 1.3 points of the SHS was set. This trial was registered at ClinicalTrials.gov, numberNCT02000336.

Results:

Between February 2014 and February 2017, 395 patients were included in the trial, 381 of which had sufficient data also of follow-up visits. A total of 129 patients were assigned to the 60 mg Pred group, 124 to 10 mg Pred and 128 to the placebo group. At baseline, mean age was 58 years, 58% were female, 55% were rheumatoid factor and 52% ACPA positive. The mean number of swollen joints was 12.8 out of 28, mean ESR was 33.6 mm/h, mean CRP 2.2 mg/dL, mean DAS 28 6.0. Radiographic damage was 4.9 as measured by the SHS. In the 60 mg, 10 mg Pred group and in the placebo group, the DAS 28 was 2.6, 3.1, 4.5 at week 4 (p<0.001), 3.1, 2.8, 3.6 at week 12 (p<0.001), and 2.7, 2.6, 2.8 at week 52 (p=0.411), respectively. After 12 months the radiographic progression could be determined in 375 patients. In the 60 mg, 10 mg Pred group, and in the placebo group, the mean progression after 1 year was 1.0, 1.0, 1.1 for the total SHS and 0.5, 0.6, 0.7 for the erosion score of the SHS, respectively. Statistical analysis showed non-inferiority of the 10 mg Pred and of the placebo group in comparison to the 60 mg Pred group. Regarding safety issues, there were 10, 5, 6 serious adverse events and 31, 16, 20 adverse events in the MedDRA system organ class “infections and infestations” for the 60 mg Pred, 10 mg Pred, and the placebo group, respectively.

Conclusion:

The bridging schedule starting with 60 mg Pred reduced disease activity better than the 10 mg schedule or placebo only for a short time. The primary outcome structural damage was non-inferior in the 10 mg Pred and the placebo group in comparison to the 60 mg Pred group. Initial advantages of the higher dose may have been compromised by the long follow-up with the possible escalation of therapy due to the treat-to-target regimen.

Disclosure of Interests:

Dietmar Krause Grant/research support from: Pfizer and AbbVie (Abbott), Anna Mai: None declared, Nina Timmesfeld: None declared, Ulrike Trampisch: None declared, Renate Klaassen-Mielke: None declared, Henrik Rudolf: None declared, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Elmar Schmitz: None declared, Claas Fendler: None declared, Claudia Klink: None declared, Stephanie Boeddeker: None declared, Ertan Saracbasi: None declared, Jochen Christoph: None declared, Manfred Igelmann: None declared, Hans Juergen Menne: None declared, Albert Schmid: None declared, Hans J Trampisch: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

Chronic but not inflammatory changes at the Achilles' tendon differentiate patients with peripheral spondyloarthritis from other diagnoses - Results from a prospective clinical trial

Background

Imaging has an essential role in the new spondyloarthritis (SpA) classification criteria for axial but not for peripheral manifestations. We evaluated the impact of imaging findings for identification and treatment decisions in patients with peripheral spondyloarthritis (pSpA) and controls (non-SpA).

Methods

Patients with pSpA (Assessment of SpA international Society criteria, n=30) and non-SpA (n=30), aged <45 years, with painful heels or knees, were recruited. Conventional radiography, grey-scale ultrasound including power Doppler (US/PDUS) and MRI of symptomatic areas were performed to assess inflammatory and structural changes. Mann-Whitney U test was used for group comparisons.

Results

In total, 105 painful entheses (71 heels, 34 knees) in 60 patients were examined. Differences between diagnoses were found for symptom duration (pSpA: 17.2±27.5 vs non-SpA: 4.4±4.3 months), human leucocyte antigen B27 prevalence (67% vs 13%) and gender distribution (53.3% vs 20% male, respectively), all P<0.05. Logistic regression analysis for baseline differences showed that chronic changes (erosions and calcification) in the heel were more frequent in pSpA versus non-SpA by US/PDUS (62.5% vs 28.6% patients and 59.5% vs 26.5% entheses, P<0.05). Inflammatory changes in heel or knee by US/PDUS and MRI could not differentiate between non-SpA and pSpA.

Conclusions

Differentiation between pSpA and non-SpA was only possible based on structural but not inflammatory changes in the heels and knees of symptomatic patients. US/PDUS was superior to MRI for this purpose. These findings imply that pSpA is associated with erosive changes at enthesitic sites, while inflammation and susceptibility are of minor influence for the development of erosions and calcification to pSpA.

Quantification of Bone Marrow Edema by Magnetic Resonance Imaging Only Marginally Reflects Clinical Neck Pain Evaluation in Rheumatoid Arthritis and Ankylosing Spondylitis

OBJECTIVE

Neck pain is common in rheumatoid arthritis (RA) and ankylosing spondylitis (AS). We investigated the correlation of bone marrow edema (BME) on magnetic resonance imaging (MRI) in RA and AS and its association with clinical complaints of neck pain.

METHODS

Cervical spine short-tau inversion recovery-MRI and T1w-MRI of 34 patients with RA and 6 patients with AS complaining about neck pain were obtained. Clinical and laboratory data were available. BME was scored by 2 blinded readers using a modification of a published score, including various cervical sites. Degenerative changes were also quantified.

RESULTS

Patients were predominantly women (82.5%), and mean ± SD age was 57.5 ± 11.8 years, C-reactive protein (CRP) was 0.8 ± 1.3 mg/dl, and pain score was 46.0 ± 17.5. BME was detected in 24/40 patients (60%) involving the atlantoaxial region (21%), vertebral bodies (75%), facet joints (29%), and spinous processes (46%). Degenerative changes were identified in 21/40 patients (52.5%), 13 (62%) of whom also had BME in vertebral bodies. No differences were found between patients with versus without cervical BME for clinical assessments: numeric rating scale pain (median ± interquartile range) 5.5 ± 3.0 vs 6.0 ± 4.0 (p = 0.69), Funktionsfragebogen Hannover 68.2 ± 41.0 vs 42.0 ± 55.5 (p = 0.19), Northwick pain score 44.4 ± 21.8 vs 47.2 ± 27.0 (p = 0.83), or CRP 0.40 ± 0.80 vs 0.60 ± 0.66 (p = 0.94). For patients with degenerative changes, symptom duration was longer than for patients without (10 ± 12.5 vs 5.0 ± 18.0 yrs, p = 0.73).

CONCLUSION

In this small study of patients with RA and AS complaining about neck pain, BME was found in many different cervical sites, including the facet joints and the spinous processes. However, the occurrence and severity of BME did not correlate with the severity of neck pain.

Do patients with non-radiographic axial spondylarthritis differ from patients with ankylosing spondylitis?

OBJECTIVE

Patients with axial spondylarthritis (SpA) who have structural changes in the sacroiliac joints and/or the spine have been classified as having ankylosing spondylitis (AS), while those without such changes are now classified as having nonradiographic axial SpA (nr-axSpA). The differentiating features are incompletely understood.

METHODS

Data from 100 consecutive patients with axial SpA not treated with tumor necrosis factor antagonists were compared clinically and with laboratory parameters, spinal radiographs, and magnetic resonance imaging (MRI) of the spine. Standardized clinical assessment tools were used to assess health status.

RESULTS

AS was diagnosed in 56 patients and nr-axSpA in 44 patients. Signs of inflammation were significantly higher in patients with AS than in patients with nr-axSpA, with a median C-reactive protein level of 8.0 versus 3.8 mg/liter, a median Ankylosing Spondylitis Disease Activity Score of 2.2 versus 2.8, respectively, and a median amount of spinal inflammatory lesions on MRI of 2.0 versus 0.0, respectively. Significant differences between these 2 groups were seen in sex (76.8% male AS patients versus 31.8% male nr-axSpA patients). Clinical variables did not differ between patients with AS and nr-axSpA (Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, Ankylosing Spondylitis Quality of Life questionnaire, Short Form 36 health survey).

CONCLUSION

Patients with nr-axSpA were characterized by the low proportion of male patients and the low burden of inflammation compared to patients with AS. While both groups did not differ regarding health status, disease activity, and physical function, they did differ in signs of inflammation; all were higher in patients with AS. Since many patients with nr-axSpA had not developed structural changes after years of symptoms, we propose that those patients should not be regarded as having preradiographic AS but rather as having nr-axSpA.

The degree of spinal inflammation is similar in patients with axial spondyloarthritis who report high or low levels of disease activity: a cohort study

BACKGROUND

The threshold for disease activity required to start antitumour necrosis factor (TNF) therapy has been arbitrarily set in patients with axial spondyloarthritis (axSpA) at Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) ≥ 4. How this relates to spinal inflammation is unknown.

OBJECTIVE

To systematically compare the clinical, laboratory and imaging data of patients with axSpA with respect to their BASDAI level.

METHODS

A total of 100 consecutive patients with axSpA who had never been treated with TNF blockers were included. Laboratory parameters, spinal MRI and x-rays were quantified. Data were stratified according to BASDAI ≥ 4.

RESULTS

44 patients were diagnosed as non-radiographic axSpA (nraxSpA) and 56 patients as ankylosing spondylitis (AS): median age 40.3 ± 10.4 years; 57% male, mean disease duration since diagnosis 6.4 ± 8.4 years, 88% HLA-B27+, mean modified Stokes Ankylosing Spondylitis Spinal Score 8.3 ± 16.4. 60% of patients had spinal inflammation by MRI. The stratification based on BASDAI ≥ 4 disclosed significant differences in most clinical parameters but not for inflammation: patients with nraxSpA and BASDAI < 4 versus ≥ 4 had 0.9 ± 1.4 and 0.5 ± 0.6 inflammatory lesions/patient, respectively (p=0.6), while patients with AS had 3.6 ± 3.7 and 2.7 ± 3.0 inflammatory lesions/patient, respectively (p=0.4).

CONCLUSION

The burden of inflammation is quite comparable in patients with axSpA-regardless of disease activity. These data clearly challenge the concept of the recommended cut-off point of BASDAI ≥ 4.

Treatment algorithm for postoperative upper gastrointestinal fistulas and leaks using combined vicryl plug and fibrin glue

The incidence of clinically significant anastomotic leaks after upper gastrointestinal surgery is approximately 4 % - 20 %, and the associated mortality can be as high as 80 %. Depending on the clinical presentation, the treatment options are surgery, conservative treatment with external drainage, or endoscopic treatment. This report presents 39 cases of clinically apparent anastomotic leaks or fistulas after surgery for upper gastrointestinal cancers that were treated by endoscopy with insertion of fibrin glue alone (n = 24) or with a combination of Vicryl plug and fibrin glue (n = 15). Thirteen of the 15 patients who underwent Vicryl/fibrin treatments showed complete healing of the anastomotic leak or fistula after one to four sessions. Long-term follow-up results are presented. Postoperative upper gastrointestinal fistulas or anastomotic leaks can be managed successfully with low morbidity by means of endoscopic insertion of Vicryl mesh with fibrin glue, thereby avoiding repeated major surgery and its associated risks.

The Gist of literature on pediatric GIST: review of clinical presentation

AIM/BACKGROUND

To provide a review of existing literature on pediatric GIST with focus on clinical presentation.

METHODS

A MEDLINE search was conducted in July 2007 to give an overview on literature concerning pediatric gastrointestinal stromal tumors (GISTs) with a focus on clinical presentation, using keywords "gastrointestinal stromal tumor" and one of the following "young/boy/girl/child/children/pediatric." Two of the authors sorted the resulting abstracts by relevance for a review on clinical aspects of pediatric GIST if they were in English language, not explicitly only reporting of adults and describing clinical features of patients.

RESULTS

One hundred and six articles were found, 43 of which were excluded because they did not match the criteria mentioned above. We found 97 patients in the articles meeting our criteria, of which 38 cases had to be excluded, because of lacking clinical data, negative staining for CD117 or syndromal occurrence. This left 59 patients for analysis of clinical symptoms in the presentation of nonsyndromal CD117-positive GIST in children.

DISCUSSION

Clinical feature most frequent was anemia in 86.4% (n=51) symptomatic either through acute or subacute bleeding. There was no palpable tumor in 88.1% (n=52), no abdominal pain in 84.7% (n=50), and no vomiting in 88.1% (n=52). Girls tend to show more high-grade tumors and existing case reports show a 2.7-fold higher incidence in females. Altogether epithelioid cell tumors are most frequent, although in boys spindle-cell tumors are reported more often. On the basis of National Institute of Health criteria (6) tumors were low grade in 22% (n=13), medium grade in 37.3% (n=22), and high grade in 35.6% (n=21). There were more high-grade tumors in girls than in boys (40.5% vs. 28.6%). Local excision was the operation most often performed, but details of surgery were missing in most cases.

CONCLUSIONS

Pediatric GIST is a rare but considerable diagnosis in chronic anemia, which is the most frequent clinical finding with this tumor entity. Recent review articles focus on histopathologic criteria but omit clinical features and course of disease. In nonsyndromal CD117-positive GIST, girls tend to show more high-grade tumors and existing literature on pediatric GIST shows a 2.7-fold higher incidence in females. Altogether epithelioid cell tumors are most frequent, although in boys spindle-cell tumors are reported more often. Together with known differences in molecular changes and local as well as systemic tumor behavior this strongly suggests that pediatric GIST represents a different entity than adult GIST. After establishment of clear-cut pathologic features in the past, reports on preoperative diagnostic findings, long-term follow-up, and therapy have to be emphasized to clarify the relationship of these entities.