RESUMO
OBJECTIVE: To evaluate the relationship between reported coronavirus disease 2019 (COVID-19)-like symptoms and the presence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) antibodies in patients with an immune-mediated inflammatory disorder or post-solid organ transplantation (IMIDT) with and without immunosuppressive medication (imed) and controls. METHOD: The IENIMINI cohort was a prospective cohort study set up in the Netherlands in March 2020, with 2 monthly (paper) or weekly (online) questionnaires about COVID-19-like symptoms. Participants from this cohort who reported these symptoms between March 2020 and November 2020 were approached for this substudy. SARS-CoV-2 antibodies were tested using a total antibody assay. RESULTS: Of the 1203 participants approached, 629 agreed to participate and were sent a fingerprick test; 565 participants collected a capillary blood sample, of which 562 were usable. Analysis showed that 57/202 (28.2%) of the tested IMIDT group with imed, 48/16 3(29.4%) of the IMIDT group without imed, and 69/197 (35.0%) of the control group tested positive for SARS-CoV-2 antibodies. Seroprevalences of SARS-CoV-2 antibodies between males and females, biological disease-modifying anti-rheumatic drug users and non-users, and those who had had a serious disease period (defined as an episode with dyspnoea and fever) and those who had not, were not statistically different between the three groups. CONCLUSIONS: Approximately 30% of patients who had reported COVID-19-like symptoms had SARS-CoV-2 antibodies. The seroprevalence of SARS-CoV-2 antibodies after reported COVID-19-like symptoms was similar in IMIDT patients with and without imed compared to controls.
Assuntos
COVID-19 , Masculino , Feminino , Humanos , COVID-19/epidemiologia , SARS-CoV-2 , Estudos Prospectivos , Estudos Soroepidemiológicos , Fatores de Risco , Anticorpos AntiviraisRESUMO
OBJECTIVES: To compare the cumulative incidence and disease severity of reported SARS-CoV-2 omicron breakthrough infections between patients with immune-mediated inflammatory diseases (IMID) on immunosuppressants and controls, and to investigate determinants for breakthrough infections. METHODS: Data were used from an ongoing national prospective multicentre cohort study on SARS-CoV-2 vaccination responses in patients with IMID in the Netherlands (Target-to-B! (T2B!) study). Patients wih IMID on immunosuppressants and controls (patients with IMID not on immunosuppressants and healthy controls) who completed primary immunisation were included. The observation period was between 1 January 2022 and 1 April 2022, during which the SARS-CoV-2 omicron (BA.1 and BA.2 subvariant) was dominant. A SARS-CoV-2 breakthrough infection was defined as a reported positive PCR and/or antigen test at least 14 days after primary immunisation. A multivariate logistic regression model was used to investigate determinants. RESULTS: 1593 patients with IMID on immunosuppressants and 579 controls were included. The cumulative incidence of breakthrough infections was 472/1593 (29.6%; 95% CI 27% to 32%) in patients with IMID on immunosuppressants and 181/579 (31.3%; 95% CI 28% to 35%) in controls (p=0.42). Three (0.5%) participants had severe disease. Seroconversion after primary immunisation (relative risk, RR 0.71; 95% CI 0.52 to 0.96), additional vaccinations (RR 0.61; 95% CI 0.49 to 0.76) and a prior SARS-CoV-2 infection (RR 0.60; 95% CI 0.48 to 0.75) were associated with decreased risk of breakthrough infection. CONCLUSIONS: The cumulative incidence of reported SARS-CoV-2 omicron breakthrough infections was high, but similar between patients with IMID on immunosuppressants and controls, and disease severity was mostly mild. Additional vaccinations and prior SARS-CoV-2 infections may reduce the incidence of breakthrough infections.
Assuntos
COVID-19 , SARS-CoV-2 , Humanos , Estudos de Coortes , Vacinas contra COVID-19 , Estudos Prospectivos , COVID-19/epidemiologia , Imunossupressores/uso terapêuticoRESUMO
AIM: To assess whether in early (rheumatoid) arthritis (RA) patients, metacarpal bone mineral density (BMD) loss after 4â months predicts radiological progression after 1â year of antirheumatic treatment. METHODS: Metacarpal BMD was measured 4 monthly during the first year by digital X-ray radiogrammetry (DXR-BMD) in patients participating in the IMPROVED study, a clinical trial in 610 patients with recent onset RA (2010 criteria) or undifferentiated arthritis, treated according to a remission (disease activity score<1.6) steered strategy. With Sharp/van der Heijde progression ≥0.5 points after 1â year (yes/no) as dependent variable, univariate and multivariate logistic regression analyses were performed. RESULTS: Of 428 patients with DXR-BMD results and progression scores available, 28 (7%) had radiological progression after 1â year. Independent predictors for radiological progression were presence of baseline erosions (OR (95% CI) 6.5 (1.7 to 25)) and early DXR-BMD loss (OR (95% CI) 1.5 (1.1 to 2.0)). In 366 (86%) patients without baseline erosions, early DXR-BMD loss was the only independent predictor of progression (OR (95% CI) 2.0 (1.4 to 2.9)). CONCLUSIONS: In early RA patients, metacarpal BMD loss after 4â months of treatment is an independent predictor of radiological progression after 1â year. In patients without baseline erosions, early metacarpal BMD loss is the main predictor of radiological progression.
Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/diagnóstico por imagem , Artrite Reumatoide/tratamento farmacológico , Densidade Óssea , Ossos Metacarpais/diagnóstico por imagem , Absorciometria de Fóton , Artrite Reumatoide/patologia , Progressão da Doença , Feminino , Humanos , Hidroxicloroquina/uso terapêutico , Masculino , Metotrexato/uso terapêutico , Pessoa de Meia-Idade , Prednisona/uso terapêutico , Sulfassalazina/uso terapêuticoRESUMO
OBJECTIVES: To assess which treatment strategy is most effective in inducing remission in early (rheumatoid) arthritis. METHODS: 610 patients with early rheumatoid arthritis (RA 2010 criteria) or undifferentiated arthritis (UA) started treatment with methotrexate (MTX) and a tapered high dose of prednisone. Patients in early remission (Disease Activity Score <1.6 after 4 months) tapered prednisone to zero and those with persistent remission after 8 months, tapered and stopped MTX. Patients not in early remission were randomised to receive either MTX plus hydroxychloroquine plus sulfasalazine plus low-dose prednisone (arm 1) or to MTX plus adalimumab (ADA) (arm 2). If remission was present after 8 months both arms tapered to MTX monotherapy; if not, arm 1 changed to MTX plus ADA and arm 2 increased the dose of ADA. Remission rates and functional and radiological outcomes were compared between arms and between patients with RA and those with UA. RESULTS: 375/610 (61%) patients achieved early remission. After 1 year 68% of those were in remission and 32% in drug-free remission. Of the randomised patients, 25% in arm 1 and 41% in arm 2 achieved remission at year 1 (p<0.01). Outcomes were comparable between patients with RA and those with UA. CONCLUSIONS: Initial MTX and prednisone resulted in early remission in 61% of patients with early (rheumatoid) arthritis. Of those, 68% were in remission and 32% were in drug-free remission after 1 year. In patients not in early remission, earlier introduction of ADA resulted in more remission at year 1 than first treating with disease-modifying antirheumatic drug combination therapy plus prednisone.
Assuntos
Anti-Inflamatórios/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Hidroxicloroquina/uso terapêutico , Metotrexato/uso terapêutico , Prednisona/uso terapêutico , Sulfassalazina/uso terapêutico , Adalimumab , Adulto , Idoso , Artrite/diagnóstico por imagem , Artrite/tratamento farmacológico , Artrite Reumatoide/diagnóstico por imagem , Progressão da Doença , Quimioterapia Combinada/métodos , Intervenção Médica Precoce/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Indução de Remissão/métodos , Método Simples-Cego , Resultado do TratamentoRESUMO
OBJECTIVES: To evaluate current (inter)national registers and observational cohorts in Europe, and to compare inclusion criteria, aims, collected data, and participation in the European League Against Rheumatism (EULAR) repository. METHOD: We performed a systematic search strategy in six literature databases for rheumatoid arthritis (RA). Publications reporting European (inter)national prospective registers/cohorts including > 200 RA patients with at least half a year of follow-up were selected. RESULTS: In total, 417 articles and abstracts were included from four international databases and 39 national databases/cohorts. International databases were of similar design, frequency of data collection and selection criteria and are mostly initiated to monitor and compare clinical patient care among countries. National databases/cohorts vary in aims and inclusion criteria. Half of the national registers are connected to the EULAR repository of databases. CONCLUSIONS: Our findings indicate that, among researchers, there is little awareness of guidelines to set up registers or cohorts and of the existence of the database collaboration network of EULAR.
Assuntos
Artrite Reumatoide , Bases de Dados como Assunto/normas , Bases de Dados Factuais/classificação , Bases de Dados Factuais/normas , Artrite Reumatoide/epidemiologia , Artrite Reumatoide/terapia , Coleta de Dados/classificação , Coleta de Dados/normas , Coleta de Dados/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Europa (Continente) , Objetivos , Humanos , Internacionalidade , Seleção de Pacientes , Sistema de Registros/classificação , Sistema de Registros/normas , Sistema de Registros/estatística & dados numéricosRESUMO
OBJECTIVE: To evaluate if initially starting glucocorticoid (GC) bridging leads to a higher probability of long-term GC and biological (b)DMARD use in rheumatoid arthritis (RA)-patients. METHODS: Electronical health records data from newly diagnosed RA-patients from the Leiden University Medical Center were used. Patients who started GC as part of initial treatment (iGC group) and who did not (niGC group) were compared in terms of GC and bDMARD use later in the disease course. Multivariable adjustment was performed to account for confounding by indication. RESULTS: 465/932 newly diagnosed RA-patients (50 %) were treated with GC as initial treatment step. Patients in the iGC group were older, included fewer females, had a higher disease activity at baseline compared to the niGC group plus a more rapid decrease in DAS28 in the first 6 months. During follow-up, 42 % of the iGC group started a second course of GC and 17 % started a bDMARD, compared to 34 % and 13 % In the niGC group. The hazard to start a bDMARD later in the disease course was not significantly different between the two groups in two time periods (0.34 95 %CI(0.09;1.21) resp. 1.48 95 %CI (0.98;2.22)), but the hazard to (re)start GC later on was higher for the iGC group (aHR 1.37 95 %CI(1.09;1.73)). CONCLUSION: In this daily practice cohort of newly diagnosed RA patients, patients in the iGC group had a more rapid DAS28 decrease and an increased probability of starting GC later on compared to the niGC group. The probability of bDMARD use was not significantly increased.
Assuntos
Antirreumáticos , Artrite Reumatoide , Produtos Biológicos , Feminino , Humanos , Glucocorticoides/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Quimioterapia Combinada , Progressão da Doença , Análise de Dados , Produtos Biológicos/uso terapêutico , Resultado do TratamentoRESUMO
Undifferentiated arthritis (UA) is defined as an inflammatory oligoarthritis or polyarthritis in which no definitive diagnosis can be made. We performed a literature review to assess the efficacy of various drug therapies in patients with UA. The literature search was conducted using electronic databases Pubmed, EMBASE and MEDLINE in adults with UA or early arthritis (not fulfilling the American College of Rheumatology (ACR) 1987 or ACR/European League Against Rheumatism (EULAR) 2010 criteria for rheumatoid arthritis). Drug therapy consisted of disease modifying antirheumatic drugs (DMARDs), biological agents and oral, intramuscular or intra-articular corticosteroids. Nine publications on eight randomised controlled trials (RCTs), two publications on two uncontrolled open-label trials and seven publications on three cohort studies were included. Temporary treatment with methotrexate (MTX), abatacept and intramuscular corticosteroids were demonstrated in RCTs with 12 months to 5 years follow-up to be more effective than placebo in suppressing disease activity or radiological progression. One study suggests that DMARD combination therapy is, at least after 4 months, superior to MTX monotherapy in patients with UA at high risk of developing persistent arthritis. The open-label uncontrolled trials and cohort studies also suggested that early treatment may provide immediate suppression of inflammation. The long-term benefit of early treatment in UA remains unclear. In conclusion, patients with UA benefit from early treatment with MTX. Combining multiple DMARDs or DMARDs with corticosteroids and biological agents may be even more beneficial. However, which treatment may provide the best results or may alter the disease course has still to be determined. More RCTs with longer follow-up time are needed.
Assuntos
Antirreumáticos/uso terapêutico , Artrite/tratamento farmacológico , Fatores Biológicos/uso terapêutico , Glucocorticoides/uso terapêutico , Quimioterapia Combinada , Humanos , Metotrexato/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Indução de RemissãoRESUMO
OBJECTIVE: To evaluate the contribution of joint space narrowing (JSN) and erosions in general and in four different joint groups in relation to physical disability in rheumatoid arthritis (RA). METHODS: 5-year follow-up data from the Behandel Strategieën (BeSt) trial were used, where 508 patients with recent onset RA were treated aiming at a disease activity score≤2.4. Joint damage was assessed annually and scored according to the Sharp-van der Heijde method. Physical disability was measured 3-monthly with the Health Assessment Questionnaire (HAQ). Generalised Estimating Equations analyses were performed to assess the relationship between the HAQ and JSN scores and erosions scores, separately and in joint groups. RESULTS: Overall, damage scores were low, and neither total JSN nor erosions showed a significant effect on HAQ (ß=0.001 95% CI -0.003 to 0.004 and ß=0.002 95% CI -0.001 to 0.006, respectively). Of the total damage scores per joint group, damage in the wrist shows a trend for association with physical disability displaying the largest effect size (ß=0.005 95% CI 0.000 to 0.011). Also in the analysis with erosions per joint group, the wrist was most strongly related with physical functioning (ß=0.016 95% CI 0.003 to 0.029); in the analysis with JSN per joint group no joint group was significantly related to the HAQ. Analysis of all erosion and narrowing scores per joint group in one model reveals only erosions in the wrist to be independently associated with impaired physical functioning (ß=0.017 95% CI 0.003 to 0.030). CONCLUSIONS: Joint damage in the wrist, erosions more than JSN, is associated with impaired physical functioning even in patients with early RA with limited overall damage after 5 years tightly controlled treatment.
Assuntos
Artrite Reumatoide/diagnóstico por imagem , Cartilagem Articular/diagnóstico por imagem , Articulações do Pé/diagnóstico por imagem , Articulação da Mão/diagnóstico por imagem , Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Artrite Reumatoide/fisiopatologia , Estudos de Coortes , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Radiografia , Índice de Gravidade de Doença , Fatores Sexuais , Inquéritos e Questionários , Fatores de TempoRESUMO
OBJECTIVES: Treat-to-target strategies in the management of patients with rheumatoid arthritis (RA) involve intensifying medication as long as low disease activity or remission is not achieved. Our aim was to discuss reasons and opportunities for tapering and discontinuing medication when the target is achieved, in particular of biological agents. METHODS: Data from the Behandel Strategieën (BeSt) study are presented, a multicentre randomised clinical trial comparing 4 treatment strategies in patients with recent onset active RA (1987 criteria): 1. Sequential monotherapy, 2. Step up to combination therapy (both starting with methotrexate (MTX) monotherapy), 3. Initial combination therapy with MTX, sulfasalazine and prednisone and 4. Initial combination therapy with MTX and infliximab. Treatment adjustments involving dose increases, drug changes or expansion to combination therapy occurred based on three-monthly calculations of the Disease Activity Score (DAS), with a target of ≤2.4. If this was achieved for 2 consecutive evaluations, treatment was tapered (combinations to monotherapy, monotherapy to maintenance dose). Prednisone and infliximab (either as part of initial treatment or as delayed treatment after failure on earlier therapies in arms 1, 2 and -for infliximab- 3) were always tapered and discontinued before other drugs. The outcomes of discontinuation of infliximab are presented. RESULTS: 77/120 (64%) of patients who started initial infliximab were able to discontinue infliximab, whereas 27/109 (25%) of patients who started delayed infliximab in arms 1-3 could discontinue infliximab. Discontinuation was independent of previous dose increases in order to achieve low DAS. After discontinuation of infliximab, 16 of 27 patients (59%) in arms 1-3 and 34 of 77 patients (44%) in arm 4 suffered a DAS flare >2.4 and had to restart treatment. Median time without infliximab treatment was 17 (IQR 3-47) months, and 29 of the 61 patients (58%) who needed to restart had been at least 1 year without infliximab. Restarting infliximab resulted in DAS ≤2.4 in all patients, and there was no progression of radiological damage. Presence of shared epitope, smoking, and a long treatment with infliximab were independent predictors of infliximab restart. CONCLUSIONS: Data on infliximab discontinuation in the BeSt study suggest that this possible in 1 in 4 patients, or more if infliximab was the initial treatment, who have had at least 6 consecutive months of low disease activity. While MTX is continued, about 50% of patients can permanently stop infliximab without radiological damage progression, the others regain low disease activity after restarting infliximab. Treat to target strategies using biologic agents should include strategies for discontinuation.
Assuntos
Anticorpos Monoclonais/administração & dosagem , Antirreumáticos/administração & dosagem , Artrite Reumatoide/tratamento farmacológico , Produtos Biológicos/administração & dosagem , Anticorpos Monoclonais/efeitos adversos , Antirreumáticos/efeitos adversos , Artrite Reumatoide/diagnóstico , Artrite Reumatoide/imunologia , Produtos Biológicos/efeitos adversos , Esquema de Medicação , Quimioterapia Combinada , Humanos , Infliximab , Estimativa de Kaplan-Meier , Países Baixos , Seleção de Pacientes , Recidiva , Indução de Remissão , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Anticitrullinated protein antibodies (ACPAs) are suggested to identify different subsets of patients with rheumatoid arthritis (RA). The authors compared the clinical and radiological responses to Disease Activity Score (DAS)-steered treatment in patients with RA positive or RA negative for ACPA. METHODS: In the BehandelStrategieën (BeSt) study, 508 patients with recent-onset RA were randomised to four treatment strategies aimed at a DAS ≤2.4. Risks of damage progression and (drug-free) remission in 8 years were compared for ACPA-positive and ACPA-negative patients using logistic regression analysis. Functional ability and DAS components over time were compared using linear mixed models. RESULTS: DAS reduction was achieved similarly in ACPA-positive and ACPA-negative patients in all treatment strategy groups, with a similar need to adjust treatment because of inadequate response. Functional ability and remission rates were not different for ACPA-positive and ACPA-negative patients. ACPA-positive patients had more radiological damage progression, especially after initial monotherapy. They had a lower chance of achieving (persistent) drug-free remission. CONCLUSION: Clinical response to treatment was similar in ACPA-positive and ACPA-negative patients. However, more ACPA-positive patients, especially those treated with initial monotherapy, had significant radiological damage progression, indicating that methotrexate monotherapy and DAS- (≤2.4) steered treatment might be insufficient to adequately suppress joint damage progression in these patients.
Assuntos
Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Artrite Reumatoide/imunologia , Autoanticorpos/sangue , Peptídeos Cíclicos/imunologia , Adulto , Idoso , Biomarcadores/sangue , Sedimentação Sanguínea , Progressão da Doença , Quimioterapia Combinada , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Indução de Remissão , Resultado do TratamentoRESUMO
OBJECTIVE: Several prediction models for rapid radiological progression (RRP) in the first year of rheumatoid arthritis have been designed to aid rheumatologists in their choice of initial treatment. The association was assessed between RRP and disability and joint damage progression in 8 years. METHODS: Patients from the BeSt cohort were used. RRP was defined as an increase of ≥5 points in the Sharp/van der Heijde score (SHS) in year 1. Functional ability over 8 years, measured with the health assessment questionnaire (HAQ), was compared for patients with and without RRP using linear mixed models. Joint damage progression from years 1 to 8 was compared using logistic regression analyses. RESULTS: RRP was observed in 102/465 patients. Over 8 years, patients with RRP had worse functional ability: difference in HAQ score 0.21 (0.14 after adjustment for disease activity score (over time)). RRP was associated with joint damage progression ≥25 points in SHS in years 1-8: OR 4.6. CONCLUSION: RRP in year 1 is a predictor of worse functional ability over 8 years, independent of baseline joint damage and disease activity. Patients with RRP have more joint damage progression in subsequent years. RRP is thus a relevant outcome on which to base the initial treatment decision.
Assuntos
Artrite Reumatoide/diagnóstico por imagem , Avaliação da Deficiência , Artrite Reumatoide/complicações , Artrite Reumatoide/patologia , Progressão da Doença , Feminino , Humanos , Articulações/patologia , Masculino , Pessoa de Meia-Idade , RadiografiaRESUMO
OBJECTIVES: To determine the prevalence and predictors of influenza and influenza-like symptoms in patients with rheumatoid arthritis (RA). METHOD: Questionnaires were sent to patients registered as having RA and they were asked to fill in per month any period and details of influenza-like symptoms and vaccination. An experienced rheumatologist assessed the level of disease activity and use of anti-rheumatic medication. The prevalence of reported influenza (fever > 38°C, headache, muscle soreness, and coughing and/or dyspnoea) and influenza-like symptoms was determined and risk factors were identified by logistic regression analysis. RESULTS: Of the 1692 patients approached, 783 (46%) patients were eligible for follow-up. Fifty per cent of the patients reported influenza-like symptoms, 5.9% had symptoms suggesting influenza, and 74% reported vaccination. The prevalence of influenza and influenza-like symptoms per month ranged from 0.0% to 2.3% and from 10.4% to 19.7%, respectively. Anti-tumour necrosis factors (anti-TNFs) [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.2-4.8] and body mass index (BMI) (OR 1.06, 95% CI 1.0-1.1) were independently associated with symptoms of influenza. A trend was found for patients not in remission, patients using leflunomide, and patients with previous lung conditions. Independent risk factors of influenza-like symptoms were age (OR 0.98, 95% CI 0.97-0.99), female gender (OR 1.8, 95% CI 1.3-2.5), influenza vaccination (OR 1.6, 95% CI 1.1-2.4), and previous lung condition (OR 1.7, 95% CI 1.2-2.4). CONCLUSIONS: In 2009-2010, the prevalence of reported influenza in patients with RA was 5.9%. Patients using anti-TNFs and with higher BMI seemed to be more at risk for influenza symptoms. Milder upper respiratory tract infections were reported more often by females, younger patients, and those vaccinated against influenza or with previous lung conditions.
Assuntos
Artrite Reumatoide/complicações , Influenza Humana/diagnóstico , Adulto , Idoso , Feminino , Humanos , Vacinas contra Influenza , Influenza Humana/complicações , Influenza Humana/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Inquéritos e Questionários , VacinaçãoRESUMO
OBJECTIVE: Personalized treatment depends on the treatment goals. Current prediction models to guide initial treatment choices focus on radiological damage progression. However, for some patients this outcome is less relevant, whereas short-term functional ability is relevant to all. Do these various treatment goals share the same predictors? METHODS: Data for 497 patients from the Dutch Behandel Strategieen (BeSt) study of treatment strategies for early rheumatoid arthritis (RA), randomized to initial monotherapy or combination therapy, were used. Predictors of short-term functional disability [Health Assessment Questionnaire (HAQ) score ≥ 1 after 3 months of treatment] were identified with logistic regression analyses. Predicted risks of a HAQ score ≥ 1 were determined for each treatment group and for each subpopulation. RESULTS: At baseline, 76% of patients had a HAQ score ≥ 1 (mean 1.7 ± 0.5). After 3 months of treatment this score was achieved by 40% (mean HAQ score 1.5 ± 0.5). Baseline HAQ score, pain, the Ritchie Articular Index (RAI), and treatment group were significant independent predictors for a HAQ score ≥ 1; the presence of rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and baseline radiological damage were not. With cut-offs of 35% and 60%, the risk of a HAQ score ≥ 1 was high for 47% and low for 20% of the patients treated with initial monotherapy. Risks were markedly reduced in the combination therapy groups, also in unfavourable risk profiles. CONCLUSION: In recent-onset active RA, baseline HAQ score, pain, and initial treatment are predictors for a HAQ score ≥ 1 after 3 months. Known predictors of radiological damage were not predictive of short-term functional disability. The choice of the best initial treatment thus depends on the relevance of various outcome measures for an individual patient.
Assuntos
Artrite Reumatoide/fisiopatologia , Avaliação da Deficiência , Progressão da Doença , Índice de Gravidade de Doença , Anticorpos Monoclonais/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/diagnóstico por imagem , Artrite Reumatoide/tratamento farmacológico , Sedimentação Sanguínea/efeitos dos fármacos , Proteína C-Reativa/efeitos dos fármacos , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Infliximab , Modelos Logísticos , Masculino , Metotrexato/uso terapêutico , Medição da Dor/efeitos dos fármacos , Prednisona/uso terapêutico , Prognóstico , Radiografia , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Sulfassalazina/uso terapêutico , Inquéritos e Questionários , Resultado do TratamentoRESUMO
After achieving low disease activity or remission, biological therapy might be stopped in rheumatoid arthritis patients, but information on whether and how this should be done is scarce. Successful discontinuation was highly variable since it was described in 0-97% of patients, in studies with different patient populations and follow-up durations between 12 weeks and over 7 years. In most studies, patients were required to have low disease activity or be in clinical remission for at least 6 months before biological therapy was discontinued. Significant joint damage progression in the first year after discontinuation was rare and functional ability was relatively stable in almost all patients in this year. In patients who had a disease flare, retreatment with biological therapy was successful in 70-100%. Mild infusion reactions after retreatment were described in a small number of patients. In conclusion, in the absence of a guideline for stopping biologicals in RA, we present a preliminary proposal that biological therapy can be stopped in many RA-patients after achieving low disease activity or remission for at least 6 months. Adequate monitoring of disease activity is essential, and retreatment appears to be safe and successful in many patients. Future research may further identify when and/or which patients are most likely to discontinue biological treatment successfully.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Produtos Biológicos/uso terapêutico , Quimioterapia Combinada , Humanos , Metotrexato/uso terapêutico , Guias de Prática Clínica como AssuntoRESUMO
OBJECTIVES: Targeted treatment is effective in the short term in achieving low disease activity or even remission in patients with rheumatoid arthritis (RA). The benefits of long-term targeted treatment are discussed based on the BeSt study results. METHODS: The BeSt study has incorporated 7 years of targeted treatment, aiming at low disease activity (DAS =<2.4), and including both treatment intensification when DAS is high and treatment tapering and discontinuation if DAS is persistently low. Functional ability over time, (drug free) remission percentages, treatment adjustments and radiological outcomes over 7 years are discussed. RESULTS: Targeted treatment resulted in stabilisation of functional ability after initial improvement, minimal radiological damage progression after the first year, and tapering of medication. Drug free remission was achieved in 15% of completers in year 7. Patients who lost drug free remission (46% up to year 5) restarted treatment and mostly regained remission without radiological deterioration. Patients treated with initial combination therapy responded earlier and had less damage progression that remained evident up to five years follow up. CONCLUSIONS: Early and maintained targeted treatment has functional and radiological benefits over the first 7 years of the BeSt study and can include drug tapering and (partial, temporary or permanent) discontinuation.
Assuntos
Anti-Inflamatórios/uso terapêutico , Anticorpos Monoclonais/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/tratamento farmacológico , Metotrexato/uso terapêutico , Prednisona/uso terapêutico , Sulfassalazina/uso terapêutico , Progressão da Doença , Quimioterapia Combinada , Feminino , Humanos , Infliximab , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Indução de Remissão , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: To determine the prevalence of vertebral fractures (VFs) after 5 years of disease activity score (DAS)-steered treatment in patients with early rheumatoid arthritis (RA) and to investigate the association of VFs with disease activity, functional ability and bone mineral density (BMD) over time. METHODS: Five-year radiographs of the spine of 275 patients in the BeSt study, a randomized trial comparing four treatment strategies, were used. Treatment was DAS-steered (DAS ≤ 2.4). A height reduction >20% in one vertebra was defined a vertebral fracture. With linear mixed models, DAS and Health Assessment Questionnaire (HAQ) scores over 5 years were compared for patients with and without VFs. With generalized estimating equations the association between BMD and VFs was determined. RESULTS: VFs were observed in 41/275 patients (15%). No difference in prevalence was found when stratified for gender, prednisone use and menopausal status. Disease activity over time was higher in patients with VFs, mean difference 0.20 (95% CI: 0.05-0.36), and also HAQ scores were higher, independent of disease activity, with a mean difference of 0.12 (95% CI: 0.02-0.2). Age was associated with VFs (OR 1.06, 95% CI: 1.02-1.09), mean BMD in spine and hip over time were not (OR 95% CI, 0.99: 0.78-1.25 and 0.94: 0.65-1.36, respectively). CONCLUSION: After 5 years of DAS-steered treatment, 15% of these RA patients had VFs. Higher age was associated with the presence of VFs, mean BMD in hip and spine were not. Patients with VFs have greater functional disability over time and a higher disease activity, suggesting that VFs may be prevented by optimal disease activity suppression.
Assuntos
Artrite Reumatoide/terapia , Vértebras Lombares/lesões , Fraturas da Coluna Vertebral/epidemiologia , Adulto , Fatores Etários , Idoso , Artrite Reumatoide/diagnóstico , Artrite Reumatoide/epidemiologia , Densidade Óssea , Estudos Transversais , Avaliação da Deficiência , Feminino , Humanos , Modelos Lineares , Modelos Logísticos , Vértebras Lombares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Países Baixos , Razão de Chances , Prevalência , Radiografia , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fraturas da Coluna Vertebral/diagnóstico , Inquéritos e Questionários , Fatores de TempoRESUMO
OBJECTIVE: To study the association between metacarpal bone mineral density (BMD) loss and progressive hand osteoarthritis (OA) over 2 years. METHODS: Using the Kellgren-Lawrence (KL) grading scale and the Osteoarthritis Research Society International Atlas, standardised hand radiographs of 181 patients with primary OA at multiple sites (mean age 60 years, 80% women, mean body mass index 27 kg/m(2)) were assessed for hand OA at baseline (KL ≥ 2 in two or more hand joints) and progressive hand OA over 2 years (≥ 1 point increase in total osteophyte and joint space narrowing score in patients with hand OA at baseline). Changes in BMD were measured over 2 years in metacarpals 2-4 by digital x-ray radiogrammetry. Accelerated BMD loss was defined as loss of >3 mg/cm(2)/year. Logistic regression analyses were performed to assess the associations between BMD loss and progressive hand OA. RESULTS: The baseline prevalence of hand OA was 68% and, after 2 years, 32% of these patients had progressive hand OA. Accelerated BMD loss was present in 79% of the patients with progressive hand OA compared with 60% and 57% of the patients with non-progressive hand OA and no hand OA, respectively. BMD loss was independently associated with progressive hand OA compared with non-progressive hand OA with a RR (95% CI) of 2.1 (1.1 to 4.3). CONCLUSION: Accelerated metacarpal BMD loss is associated with progressive hand OA over a period of 2 years; knowledge of common mechanisms may lead to development of therapeutic interventions for hand OA.
Assuntos
Articulação da Mão/diagnóstico por imagem , Ossos Metacarpais/fisiopatologia , Osteoartrite/complicações , Osteoporose/complicações , Idoso , Biomarcadores/sangue , Densidade Óssea/fisiologia , Proteína C-Reativa/análise , Progressão da Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite/diagnóstico por imagem , Osteoartrite/fisiopatologia , Osteoporose/fisiopatologia , Radiografia , Índice de Gravidade de Doença , Fatores SexuaisRESUMO
OBJECTIVE: To describe the disease course after the cessation of infliximab in early rheumatoid arthritis patients with disease activity score (DAS)-steered treatment and to identify predictors of persistent low disease activity. METHODS: In a post-hoc analysis of the BeSt study, disease activity and joint damage progression were observed in patients treated with methotrexate plus infliximab, who discontinued infliximab after achieving low disease activity (DAS ≤2.4) for 6 months. Predictors were identified using Cox regression analysis. RESULTS: 104 patients discontinued infliximab, of whom 77 had received infliximab plus methotrexate as initial treatment. Mean DAS at the time of infliximab cessation was 1.3, median symptom duration was 23 months and median Sharp/van derHeijde score was 5.5. The median follow-up was 7.2 years. Infliximab was re-introduced after loss of low disease activity in 48%, after a median of 17 months. The joint damage progression rate did not increase in the year after cessation, regardless of flare. After re-introduction of infliximab, 84% of these patients again achieved a DAS ≤2.4. In the multivariable model, smoking, infliximab treatment duration ≥18 months and shared epitope (SE) were independently associated with the re-introduction of infliximab: 6% of the non-smoking, SE-negative patients treated <18 months needed infliximab re-introduction. CONCLUSION: Cessation of infliximab was successful in 52%, with numerically higher success rates in patients initially treated with infliximab. Of the 48% who flared, 84% regained low disease activity. The joint damage progression rate did not increase in the year after cessation. Smoking, long infliximab treatment duration and SE were independently associated with re-introduction of infliximab.
Assuntos
Anticorpos Monoclonais/administração & dosagem , Antirreumáticos/administração & dosagem , Artrite Reumatoide/tratamento farmacológico , Anticorpos Monoclonais/uso terapêutico , Antirreumáticos/uso terapêutico , Artrite Reumatoide/fisiopatologia , Progressão da Doença , Esquema de Medicação , Monitoramento de Medicamentos/métodos , Quimioterapia Combinada , Feminino , Humanos , Infliximab , Masculino , Metotrexato/uso terapêutico , Pessoa de Meia-Idade , Prognóstico , Índice de Gravidade de Doença , Método Simples-Cego , Resultado do Tratamento , Suspensão de TratamentoRESUMO
OBJECTIVE: To compare nine disease activity indices and the new American College of Rheumatology (ACR)/European League against Rheumatism (EULAR) remission criteria in rheumatoid arthritis (RA) and to relate these to physical function and joint damage progression. METHODS: Five-year data from the BeSt study were used, a randomised clinical trial comparing four treatment strategies in 508 patients with recent-onset RA. Every three months disease activity was assessed with nine indices (Disease Activity Score (DAS), DAS-C reactive proteine (DAS-CRP), Disease Activity Score in 28 joints (DAS-28), DAS28-CRP, Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI) and three DAS versions with adjusted tender joint scores) and categorized into remission, low, moderate and high disease activity (LDA, MDA, HDA). In addition, the recent ACR/EULAR clinical trial and practice remission was assessed 3-monthly with 28 and 68/66 joint counts. For each index, Generalized Estimating Equations analyses were performed to relate disease activity levels and the absence/presence of remission to 3-monthly assessments of physical functioning and annual radiological progression. RESULTS: From the composite indices, CDAI and SDAI were the most stringent definitions of remission and classified more patients as LDA. DAS28 and DAS28-CRP had the highest proportions of remission and MDA and a smaller proportion of LDA. ACR/EULAR remission percentages were comparable to CDAI/SDAI: remission percentages. The variant including CRP and 68/66 joint counts was the most stringent. For all indices, higher levels of disease activity were associated with decreased physical functioning and more radiological damage progression. Despite differences in classification between the indices, no major differences in relation to the two outcomes were observed. CONCLUSION: The associations of nine composite indices and ACR/EULAR remission criteria with functional status and joint damage progression showed high accordance, whereas the proportions of patients classified in the disease activity levels differed.
Assuntos
Artrite Reumatoide/tratamento farmacológico , Índice de Gravidade de Doença , Adulto , Idoso , Antirreumáticos/uso terapêutico , Artrite Reumatoide/fisiopatologia , Artrite Reumatoide/reabilitação , Biomarcadores/sangue , Proteína C-Reativa/metabolismo , Progressão da Doença , Quimioterapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Indução de Remissão , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate three disease activity score (DAS) alternatives without the Ritchie articular index (RAI). To compare the use of patient global assessment (PGA) of disease activity versus global assessment of health (GH) in DAS, DAS alternatives and DAS28. METHODS: Data from the BeSt study were used, a treatment strategy trial in early rheumatoid arthritis patients aiming at a DAS ≤2.4. DAS alternatives were DAS 0-1, with the RAI (0-3) reduced to a no-yes (0-1) score, DAS tender joint count 53 (DAS TJC53), with a 0-1 TJC in 53 separate joints and DAS TJC44 in 44 joints. Correlation patterns, mean difference from original DAS, classification differences in disease activity level and patient percentages with radiological damage progression per level were determined for all scores. RESULTS: In the majority of patients the scores were equal and correlation was high. Mean difference with the DAS at year 1 was -0.03 for DAS 0-1, 0.18 for DAS TJC53 and 0.11 for DAS TJC44. Classification agreement between scores was high (κ year 1 0.76-0.98). Patient percentages with joint damage progression were similar for all scores. DAS, DAS alternative and DAS28 perform similarly using either PGA or GH. CONCLUSION: DAS without the RAI perform comparably to the original DAS and may be chosen as alternatives. PGA can replace GH in the DAS, the alternatives and DAS28.