Potential role of arthroscopy in the management of inflammatory arthritis.

Despite its advantages in diagnosis, treatment and research, the role of arthroscopy in the management of rheumatic diseases has diminished due to the development of other less invasive means of joint assessment including advances in imaging techniques, e.g. ultrasound and magnetic resonance imaging. However, arthroscopy still provides invaluable information. By direct and precise internal inspection of a joint, arthroscopy allows the collection of synovial membrane samples (biopsies) of excellent quality, notably from the most representative pathological areas. Arthroscopy may also play a therapeutic role in the management of inflammatory arthritis (IA) by providing pain relief (lavage). Here we describe the procedure of knee arthroscopy under local anaesthesia, as well as an in situ visual assessment of synovial inflammation and its correlation with degree of histological and immunological abnormalities. With the emphasis being placed on early diagnosis and treatment initiation in patients with IA and as earlier initiation of targeted biologic therapies becomes more commonplace, the ability to predict which patients will respond to the different therapies available would be invaluable. Assessment of arthroscopic derived synovial biopsies has potential to play an important role in management of early IA in the future.

Decreased CD20 expression in rheumatoid arthritis synovium following 8 weeks of rituximab therapy.

OBJECTIVE: To characterise the effects of rituximab on synovial tissue of patients with refractory rheumatoid arthritis (RA). METHODS: Arthroscopic biopsy of knee joint synovium was performed on 6 patients with seropositive RA prior to commencing rituximab. Four patients underwent repeat biopsy eight weeks following completion of their rituximab infusion schedule. Cryostat sections of synovium were prepared and stained with mouse monoclonal specific antibodies including CD20, plasma cell antibody and CD68. RESULTS: Eight weeks after treatment mean DAS28 fell from 6.6+/-0.43 to 4.7+/-0.49 (p=0.068). Mean CRP fell from 86.7+/-27 mg/L to 20.5+/-7 mg/L (p<0.05). Subsynovial CD20+ B cells were demonstrated in all six patients at baseline. B cells were completely depleted in two patients at follow-up biopsy. Complete depletion was associated with excellent clinical response. No change in subsynovial B cells was seen in one patient. One patient's follow-up arthroscopy yielded inadequate tissue. A reduction was also seen in subsynovial plasma cells and CD68+ cells after treatment. CONCLUSION: B cells were present in synovial tissue of all patients with refractory RA. Complete depletion of B cells was associated with an excellent clinical response. These preliminary results suggest that early depletion of synovial B cells precedes a decrease in local inflammation leading to clinical improvement.

Established rheumatoid arthritis: rationale for best practice: physicians' perspective of how to realise tight control in clinical practice.

Developments in the understanding of the pathogenesis of rheumatoid arthritis (RA) and the introduction of targeted biologic therapies have greatly advanced the management of RA in clinical practice. The management of RA is now aimed at achieving remission, to prevent joint damage and disability. In particular, a critical period early in disease is recognised, in which early aggressive treatment with disease-modifying therapy is advocated. Although a state of remission is the ideal, this chapter discusses the difficulties which may arise in achieving this goal in patients with established disease. The evidence for best management, aimed at achieving clinical remission in established disease, is reviewed. The consequences of incomplete control of chronic inflammation in established disease, including pain, disability and co-morbidities (such as cardiovascular disease and osteoporosis), also pose a significant clinical challenge. The rationale for a multidisciplinary team approach in reducing the associated morbidity and mortality of the disease are examined.

Quality of life and economic impact of switching from established infliximab therapy to adalimumab in patients with rheumatoid arthritis.

OBJECTIVE: To evaluate the quality of life and economic impact of switching therapy from infliximab to adalimumab in patients with rheumatoid arthritis (RA). METHODS: In this open-label study, patients demonstrating a clinical response to infliximab were switched to treatment with adalimumab and followed for 16 weeks. Both generic (Health Assessment Questionnaire and Short Form 36 Physical Component Summary and Mental Component Summary) and specific (Rheumatoid Arthritis Quality of Life questionnaire) assessment instruments of physical function and of quality of life were employed. An economic analysis of treatment-related costs was also performed. Disease activity was assessed by the composite 28-joint count Disease Activity Score (DAS28). C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were measured as acute phase markers. RESULTS: Nineteen patients were enrolled and completed the study. No changes in functional and quality-of-life measures were observed. One-year extrapolation data showed potential reductions in costs following switching to adalimumab that could be attributed primarily to reductions in patient- and staff-related costs. Safety and tolerability were similar for both treatments. Although there was a significant reduction in DAS28 (P < 0.005) and CRP (P < 0.001) after switching to adalimumab, there were no significant changes in individual DAS28 components, including swollen and tender joint counts and ESR. CONCLUSIONS: A switch from infliximab to adalimumab in patients with RA who have responded to infliximab is a feasible, well-tolerated treatment option, with the potential for direct and indirect economic advantages.