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OBJECTIVE: Adherence to urate-lowering therapy (ULT) in gout is challenging. This longitudinal study aimed to determine 2 year changes in beliefs about medicines during intervention with ULT. METHOD: Patients with a recent gout flare and increased serum urate received a nurse-led ULT intervention with tight control visits and a treatment target. Frequent visits at baseline and 1, 2, 3, 6, 9, 12, and 24 months included the Beliefs about Medicines Questionnaire (BMQ), and demographic and clinical variables. The BMQ subscales on necessity, concerns, overuse, harm, and the necessity-concerns differential were calculated as a measure of whether the patient perceived that necessity outweighed concerns. RESULTS: The mean serum urate reduced from 500 mmol/L at baseline to 324 mmol/L at year 2. At years 1 and 2, 85.5% and 78.6% of patients, respectively, were at treatment target. The 2 year mean ± sd BMQ scores increased for the necessity subscale from 17.0 ± 4.4 to 18.9 ± 3.6 (p < 0.001) and decreased for the concerns subscale from 13.4 ± 4.9 to 12.5 ± 2.7 (p = 0.001). The necessity-concerns differential increased from 3.52 to 6.58 (p < 0.001), with a positive change independent of patients achieving treatment targets at 1 or 2 years. BMQ scores were not significantly related to treatment outcomes 1 or 2 years later, and achieving treatment targets did not lead to higher BMQ scores. CONCLUSION: Patient beliefs about medicines improved gradually over 2 years, with increased beliefs in the necessity of medication and reduced concerns, but this improvement was unrelated to better outcomes. TRIAL REGISTRATION: ACTRN12618001372279.
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Supresores de la Gota , Gota , Humanos , Gota/tratamiento farmacológico , Supresores de la Gota/uso terapéutico , Estudios Longitudinales , Cumplimiento de la Medicación , Encuestas y Cuestionarios , Brote de los Síntomas , Resultado del Tratamiento , Ácido Úrico/sangre , Conocimientos, Actitudes y Práctica en SaludRESUMEN
OBJECTIVE: To explore the burden of gout in the Nordic region, with a population around 27 million in 2015 distributed across six countries. METHOD: We used the findings of the 2015 Global Burden of Diseases study to report prevalence and disability associated with gout in the Nordic region. RESULTS: From 1990 to 2015, the number of prevalent gout cases rose by 30% to 252 967 [95% uncertainty interval (UI) 223 478â287 288] in the Nordic region. In 2015, gout contributed to 7982 (95% UI 5431â10 800) years lived with disability (YLDs) in the region, an increase of 29% (95% UI 24â35%) from 1990. While the crude YLD rate of gout increased by 12.9% (95% UI 7.8â18.1%) between 1990 and 2015, the age-standardized YLD rate remained stable. Gout was ranked as the 63rd leading cause of total YLDs in the region in 2015, with the highest rank in men aged 55-59 years (38th leading cause of YLDs). The corresponding rank at the global level was 94. Of 195 countries studied, four Nordic countries [Greenland (2nd), Iceland (12th), Finland (14th), and Sweden (15th)] were among the top 15 countries with the highest age-standardized YLD rate of gout. CONCLUSION: The burden of gout is rising in the Nordic region. Gout's contribution to the total burden of diseases in the region is more significant than the global average. Expected increases in gout burden owing to population growth and ageing call for stronger preventive and therapeutic strategies for gout management in Nordic countries.
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Gota/epidemiología , Adolescente , Adulto , Anciano , Evaluación de la Discapacidad , Personas con Discapacidad/estadística & datos numéricos , Femenino , Carga Global de Enfermedades/métodos , Gota/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Países Escandinavos y Nórdicos/epidemiología , Adulto JovenRESUMEN
OBJECTIVES: Rehabilitation is important for people with musculoskeletal diseases (MSDs), and evaluating the effect of rehabilitation on both an individual and group level is advocated. A consensus concerning use of outcome measures will improve collaboration between healthcare providers, and increase the possibility of conducting meta-analyses in future research. The aim of this study was to develop a consensus-based core set of outcome measures for rehabilitation in MSDs, and to test the feasibility and responsiveness of the set. METHOD: The core set was developed through a stepwise process comprising a Delphi consensus procedure, systematic literature searches, and a pilot study, including 386 patients, to test the feasibility and responsiveness of the set. RESULTS: The following aspects and outcome measures were selected: pain [numeric rating scale (NRS)], fatigue (NRS), physical fitness (the 30-second Sit to Stand test), mental health (Hopkins Symptom Checklist 5), daily activities (Hannover Functional Questionnaire), goal attainment (Patient-Specific Functional Scale including motivation score for baseline assessment), quality of life (5-level EuroQol 5 Dimensions), social participation (the social participation item from COOP/WONCA) and coping (Effective Musculoskeletal Consumer Scale-17). All tested outcome measures were found to be feasible, with high completion rates and acceptable score distribution. Standard response means varied from 0.3 to 0.9. CONCLUSIONS: A consensus-based core set of patient reported outcome measures is presented for evaluating rehabilitation in MSDs. The core set is feasible and responsive for use in Norway, but needs further testing in other countries.
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Consenso , Medicina Basada en la Evidencia/métodos , Salud Mental , Enfermedades Musculoesqueléticas/rehabilitación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Técnica Delphi , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morbilidad/tendencias , Enfermedades Musculoesqueléticas/epidemiología , Noruega/epidemiología , Proyectos Piloto , Calidad de Vida , Encuestas y Cuestionarios , Adulto JovenRESUMEN
OBJECTIVE: To compare the value that rheumatologists across Europe attach to patients' preferences and economic aspects when choosing treatments for patients with rheumatoid arthritis. METHODS: In a discrete choice experiment, European rheumatologists chose between two hypothetical drug treatments for a patient with moderate disease activity. Treatments differed in five attributes: efficacy (improvement and achieved state on disease activity), safety (probability of serious adverse events), patient's preference (level of agreement), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). A Bayesian efficient design defined 14 choice sets, and a random parameter logit model was used to estimate relative preferences for rheumatologists across countries. Cluster analyses and latent class models were applied to understand preference patterns across countries and among individual rheumatologists. RESULTS: Responses of 559 rheumatologists from 12 European countries were included in the analysis (49% females, mean age 48â years). In all countries, efficacy dominated treatment decisions followed by economic considerations and patients' preferences. Across countries, rheumatologists avoided selecting a treatment that patients disliked. Latent class models revealed four respondent profiles: one traded off all attributes except safety, and the remaining three classes disregarded ICER. Among individual rheumatologists, 57% disregarded ICER and these were more likely from Italy, Romania, Portugal or France, whereas 43% disregarded uncommon/rare side effects and were more likely from Belgium, Germany, Hungary, the Netherlands, Norway, Spain, Sweden or UK. CONCLUSIONS: Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.
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Antirreumáticos/economía , Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Conducta de Elección , Prioridad del Paciente , Reumatólogos/psicología , Adulto , Antirreumáticos/efectos adversos , Análisis Costo-Beneficio , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pautas de la Práctica en Medicina , Encuestas y CuestionariosRESUMEN
BACKGROUND: New drugs and new evidence concerning the use of established treatments have become available since the publication of the first European League Against Rheumatism (EULAR) recommendations for the management of gout, in 2006. This situation has prompted a systematic review and update of the 2006 recommendations. METHODS: The EULAR task force consisted of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients and 3 experts in epidemiology/methodology from 12 European countries. A systematic review of the literature concerning all aspects of gout treatments was performed. Subsequently, recommendations were formulated by use of a Delphi consensus approach. RESULTS: Three overarching principles and 11 key recommendations were generated. For the treatment of flare, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), oral or intra-articular steroids or a combination are recommended. In patients with frequent flare and contraindications to colchicine, NSAIDs and corticosteroids, an interleukin-1 blocker should be considered. In addition to education and a non-pharmacological management approach, urate-lowering therapy (ULT) should be considered from the first presentation of the disease, and serum uric acid (SUA) levels should be maintained at<6â mg/dL (360â µmol/L) and <5â mg/dL (300â µmol/L) in those with severe gout. Allopurinol is recommended as first-line ULT and its dosage should be adjusted according to renal function. If the SUA target cannot be achieved with allopurinol, then febuxostat, a uricosuric or combining a xanthine oxidase inhibitor with a uricosuric should be considered. For patients with refractory gout, pegloticase is recommended. CONCLUSIONS: These recommendations aim to inform physicians and patients about the non-pharmacological and pharmacological treatments for gout and to provide the best strategies to achieve the predefined urate target to cure the disease.
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Supresores de la Gota/uso terapéutico , Gota/tratamiento farmacológico , Corticoesteroides/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Técnica Delphi , Consejo Dirigido , Medicina Basada en la Evidencia , Gota/sangre , Gota/terapia , Humanos , Interleucina-1/antagonistas & inhibidores , Estilo de Vida , Educación del Paciente como Asunto , Brote de los Síntomas , Ácido Úrico/sangreRESUMEN
OBJECTIVES: To explore factors related to sleep disturbance in patients with rheumatoid arthritis (RA). METHOD: Cross-sectional data from 986 patients in the Oslo RA Register (ORAR) collected in 2009 were included. Sleep problems were assessed by four measures: the Medical Outcomes Study (MOS) sleep disturbance scale, and the sleep components of the Rheumatoid Arthritis Impact of Disease (RAID) score, the Multi-Dimensional Health Assessment Questionnaire (MDHAQ), and the 15-dimensional quality of life questionnaire (15D). Patient-reported outcomes (PROs) were recorded using standard questionnaires for physical and mental function [the HAQ and the MOS 36-item Short-Form Health Survey (SF-36), disease activity (the RA Disease Activity Index, RADAI), utility (SF-6D), and visual analogue scales (VAS) for pain, fatigue, and disease activity]. Demographics including comorbidity were collected. Information on use of medication for RA and sleep disturbance was obtained using checklists. Multivariate analyses were used to identify factors independently associated with sleep problems by four different measures. RESULTS: The mean (standard deviation, SD) age of the patients was 59.4 (12.5) years, 76.9% were females, and the mean (SD) disease duration was 13.7 (10.7) years. The correlation between the various sleep measures was high (r2 = 0.71-0.78). Sleep disturbance was moderately correlated to pain (r2 = 0.41-0.61), fatigue (r2 = 0.44-0.58), physical function (r2 = 0.33-0.48), RADAI (r2 = 0.42-0.55), and utility (r2 = 0.49-0.61). RAID sleep demonstrated the highest correlation with other PROs. RADAI, fatigue, the mental component score of SF-36, physical function, body mass index (BMI), and use of Z-drugs/benzodiazepines were independently associated with two or more measures of sleep problems (all p < 0.001). CONCLUSIONS: Sleep disturbance measured by four different measures was independently related to other PROs including fatigue, pain, and disease activity in RA patients.
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Artritis Reumatoide/complicaciones , Fatiga/complicaciones , Medición de Resultados Informados por el Paciente , Trastornos del Sueño-Vigilia/etiología , Adulto , Anciano , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/fisiopatologíaRESUMEN
OBJECTIVE: To develop a consensual list of the most important aspects of activity pacing (AP) as an intervention within the context of non-pharmacological rheumatology care. METHOD: An international, multidisciplinary expert panel comprising 60 clinicians and/or healthcare providers experienced in AP across 12 different countries participated in a Delphi survey. Over four Delphi rounds, the panel identified and ranked the most important goals of AP, behaviours of AP (the actions people take to meet the goal of AP), strategies to change behaviour in AP, and contextual factors that should be acknowledged when instructing AP. Additionally, topics for future research on AP were formulated and prioritized. RESULTS: The Delphi panel prioritized 9 goals, 11 behaviours, 9 strategies to change behaviour, and 10 contextual factors of AP. These items were integrated into a consensual list containing the most important aspects of AP interventions in non-pharmacological rheumatology care. Nine topics for future research on AP with the highest ranking were included in a research agenda highlighting that future research should focus on the effectiveness of AP interventions and on appropriate outcome measures to assess its effectiveness, as selected by 64% and 82% of the panellists, respectively. CONCLUSIONS: The diversity and number of items included in the consensual list developed in the current study reflect the heterogeneity of the concept of AP. This study is an important first step in achieving more transparency and homogeneity in the concept of AP in both rheumatology daily clinical practice and research.
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OBJECTIVE: To examine changes in patient reported outcome measures (PROs) over 15â years in a representative population of patients with rheumatoid arthritis (RA), with a particular focus on gender differences. PATIENTS AND METHODS: Patients in the Oslo RA register filled in questionnaires including the Modified Health Assessment Questionnaire (MHAQ), the Short-Form 36 (SF-36) with physical (PCS) and mental component summaries and derived utility (SF-6D), visual analogue scales (VAS) for pain, patient global assessment of disease (PtGA) and fatigue, and checklists of medication commonly used in the treatment of RA. Data were collected at five time points during a 15-year period from 1994. Mixed model analyses were used to analyse longitudinal changes in PROs from 1994 to 1996, 2001, 2004 and 2009. RESULTS: Data were available from 829-1025 RA patients at each time point. PROs were statistically significantly improved from 1994 to 2009 (MHAQ, SF-36 PCS, SF-6D, pain VAS, PtGA VAS and fatigue VAS; all p<0.001), and also with clinically important improvement. Men reported significantly better health status than women in 1994, but women improved significantly more than men over 15â years with a reduction of the gender gap in 2009. Antirheumatic medication was increasingly used over 15â years with no gender differences. CONCLUSIONS: RA patients reported statistically significantly improved health status for most PROs from 1994 to 2009. Women improved most, and although they still reported higher disease impact than men, the gender differences were small at the final data collection in 2009.
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Actividades Cotidianas , Artritis Reumatoide/fisiopatología , Estado de Salud , Evaluación del Resultado de la Atención al Paciente , Sistema de Registros , Factores Sexuales , Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Noruega , Calidad de Vida , Índice de Severidad de la Enfermedad , Encuestas y CuestionariosRESUMEN
OBJECTIVES: Patient reported outcomes (PROs) are relevant in rheumatology. Variable accessibility and validity of commonly used PROs are obstacles to homogeneity in evidence synthesis. The objective of this project was to provide a comprehensive library of "validated PROs". METHODS: A launch meeting with rheumatologists, PROs methodological experts, and patients, was held to define the library's aims and scope, and basic requirements. To feed the library we performed systematic reviews on selected diseases and domains. Relevant information on PROs was collected using standardised data collection forms based on the COSMIN checklist. RESULTS: The EULAR Outcomes Measures Library (OML), whose aims are to provide and to advise on PROs on a user-friendly manner albeit based on scientific grounds, has been launched and made accessible to all. PROs currently included cover any domain and, are generic or specifically target to the following diseases: rheumatoid arthritis, osteoarthritis, spondyloarthritis, low back pain, systemic lupus erythematosus, gout, osteoporosis, juvenile idiopathic arthritis, and fibromyalgia. Up to 236 instruments (106 generic and 130 specific) have been identified, evaluated, and included. The systematic review for SLE, which yielded 10 specific instruments, is presented here as an example. The OML website includes, for each PRO, information on the construct being measured and the extent of validation, recommendations for use, and available versions; it also contains a glossary on common validation terms. CONCLUSIONS: The OML is an in progress library led by rheumatologists, related professionals and patients, that will help to better understand and apply PROs in rheumatic and musculoskeletal diseases.
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Lupus Eritematoso Sistémico , Evaluación de Procesos y Resultados en Atención de Salud/normas , Manejo de Atención al Paciente , Práctica Clínica Basada en la Evidencia , Humanos , Desarrollo de la Colección de Bibliotecas , Lupus Eritematoso Sistémico/diagnóstico , Lupus Eritematoso Sistémico/terapia , Manejo de Atención al Paciente/métodos , Manejo de Atención al Paciente/normas , Reproducibilidad de los ResultadosRESUMEN
OBJECTIVE: To understand how handling of missing data influences the statistical power and bias of treatment effects in randomised controlled trials of painful knee osteoarthritis (OA). METHODS: We simulated trials with missing data (withdrawals) due to lack-of-efficacy. Outcome measures were response/non-response according to the Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) set of responder criteria, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function from the WOMAC questionnaire, and patient global assessment. We used five methods for managing missing data: ignoring the missing data, last and baseline observation carried forward (LOCF and BOCF), and multiple imputation with two different strategies. The treatment effect was then analysed by appropriate univariate and longitudinal statistical methods, and power, bias and mean squared error (MSE) was assessed by comparing the estimated treatment effect in the trials with missing data with the estimated treatment effect on the trials without missing data. RESULTS: The best imputation method in terms of high power and low bias/MSE was our implementation of regression multiple imputation. The most conservative method was the data augmentation Markov chain Monte Carlo (MCMC) multiple imputation. The LOCF, BOCF and the complete-case methods were not particularly conservative and gave relatively low power and high bias. The analysis on the WOMAC pain scale gave less bias and higher power than the OMERACT-OARSI responder outcome measure. CONCLUSIONS: Multiple imputation of missing data may be used to decrease bias/MSE and increase power in OA trials. These results can guide investigators in the choice of outcome measures and especially how missing data can be handled.
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Interpretación Estadística de Datos , Osteoartritis de la Rodilla/tratamiento farmacológico , Ensayos Clínicos Controlados Aleatorios como Asunto/estadística & datos numéricos , Proyectos de Investigación/estadística & datos numéricos , Sesgo , Celecoxib , Sulfatos de Condroitina/uso terapéutico , Inhibidores de la Ciclooxigenasa 2/uso terapéutico , Glucosamina/uso terapéutico , Humanos , Dimensión del Dolor/métodos , Pirazoles/uso terapéutico , Sulfonamidas/uso terapéutico , Resultado del TratamientoRESUMEN
OBJECTIVES: To provide a thorough description of team rehabilitation care and compare the structure, process, and outcomes in two specialized arthritis rehabilitation settings. METHODS: Patients with inflammatory arthritis scheduled for inpatient rehabilitation in seven specialized rehabilitation centres and three rheumatology hospital departments in Norway were included consecutively in a prospective cohort study. Patients completed questionnaires at admission, at discharge, and at a 6-month follow-up, and kept a diary regarding structure and process variables during the rehabilitation stay. RESULTS: Eighty patients in rehabilitation centres and 73 in hospital departments were included and 80% responded to the 6-month follow-up questionnaire. The two clinical settings differed significantly with regard to structure variables such as cost, referral of patients, length of stay, and number of health professionals involved, and most process variables reflecting treatment modalities. The most remarkable difference was in the amount of individual intervention compared with group intervention. Despite significant improvements in most outcomes at discharge, the scores deteriorated towards baseline level 6 months later. There was a trend towards more significant improvement during rehabilitation for patients at rehabilitation centres whereas patients at hospitals had more prolonged improvement. CONCLUSIONS: Team rehabilitation for inflammatory arthritis in two different clinical settings differed across most variables for structure and process, but few significant differences in outcome were found. Considering the substantial differences in cost, there is an urgent need for consensus concerning which patients should receive rehabilitation in which setting. Future research on the development and evaluation of methods for prolonging the beneficial effects of rehabilitation is needed.
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Artritis/rehabilitación , Costos de la Atención en Salud , Hospitales , Grupo de Atención al Paciente/normas , Centros de Rehabilitación , Adolescente , Adulto , Anciano , Artritis/tratamiento farmacológico , Artritis/fisiopatología , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Derivación y Consulta , Encuestas y Cuestionarios , Resultado del Tratamiento , Adulto JovenRESUMEN
A gout attack may evolve after a purine-rich diet or alcohol and after starting urate-lowering therapy (ULT). The relationships between fluctuation and change in serum urate (SU) with the occurrence of flares were investigated in this study. In the prospective NOR-Gout study, gout patients with increased SU and a recent flare were treated to target with ULT over 1 year, with follow-up at year 2 with SU and flare as outcomes. SU and flares were assessed at both monthly and 3-monthly intervals until target SU was reached. Fluctuation over periods and changes in SU between two time points were assessed and compared in patients with and without flares. At year 1, 186 patients completed follow-up (88.2%) and 173 (82.0%) at year 2. Mean age (SD) at baseline was 56.4 (13.7) years, disease duration was 7.8 (7.6) years, and 95.3% were men. The first-year SU fluctuation and change were related to flare occurrence during year 1 (both p < 0.05). High fluctuation with an absolute sum of all SU changes during the first 9 months was related to flares over 3-month periods (all p < 0.05), and high fluctuation during the first 3 months was related to flares in months 3-6 (p = 0.04). Monthly and high SU changes or again reaching higher SU levels > 360 µmol/l were not related to flares. Fluctuation and change in SU were related to flare occurrence during the first year of ULT, while changes between visits and reaching SU levels > 360 µmol/L were not related to flares. Key Points ⢠Urate-lowering therapy seeks to achieve a treatment target and prevent gout flares, and changes in serum urate are related to gout flares. ⢠Fluctuation and changes in serum urate were associated with gout flares, suggesting that fluctuation in serum urate is unfavourable during gout treatment. ⢠During urate-lowering therapy in gout in clinical practice, fluctuation of serum urate, for example, due to lack of adherence, should be observed and avoided.
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Supresores de la Gota , Gota , Masculino , Humanos , Persona de Mediana Edad , Femenino , Supresores de la Gota/uso terapéutico , Ácido Úrico , Estudios Prospectivos , Gota/tratamiento farmacológico , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To assess the effectiveness of switching to a second tumour necrosis factor inhibitor (TNFi) in patients with ankylosing spondylitis (AS). METHODS: Data were extracted from an ongoing longitudinal observational multicentre study in Norway. This study included anti-TNF naïve patients with AS starting treatment with a TNFi as well as treatment with a second TNFi in these same patients. Effectiveness data and 2-year drug survival were compared between switchers and non-switchers and within switchers (first and second TNFi). RESULTS: 514 anti-TNF naïve patients with AS were included; 77 patients switched to a second TNFi while 437 patients did not switch. The percentages of non-switchers using etanercept, infliximab or adalimumab were 53%, 32% and 15%, and the percentages of first and second TNFi in the switchers were 42%, 53% and 5% and 40%, 23% and 36%, respectively. The reason for switching was insufficient response (IR) in 30, adverse events (AEs) in 44 and not reported in 3 patients. Baseline disease activity was similar between the groups. Three-month BASDAI 50 and ASAS 40 responses were achieved by 49% and 38% of non-switchers, by 25% and 30% of switchers after the first TNFi and by 28% and 31% after the second TNFi. The 3-month disease activity level was higher for switchers on the second TNFi than for non-switchers. Drug withdrawal rate was higher during the second TNFi among switchers than for non-switchers (p=0.001). No difference was found in the effectiveness of the second TNFi between switchers due to IR and AE. CONCLUSION: This study confirms that switching to a second TNFi can be effective in AS and can be as useful as in rheumatoid arthritis, although overall effectiveness seems to be somewhat lower than in non-switchers.
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Antirreumáticos/uso terapéutico , Sustitución de Medicamentos , Espondilitis Anquilosante/tratamiento farmacológico , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Adalimumab , Adulto , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Monoclonales Humanizados , Antirreumáticos/efectos adversos , Métodos Epidemiológicos , Etanercept , Femenino , Humanos , Inmunoglobulina G/efectos adversos , Inmunoglobulina G/uso terapéutico , Infliximab , Masculino , Persona de Mediana Edad , Receptores del Factor de Necrosis Tumoral/uso terapéutico , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
OBJECTIVES: To agree terminology and to develop recommendations for the diagnosis of calcium pyrophosphate deposition (CPPD). METHODS: The European League Against Rheumatism (EULAR) CPPD Task Force, comprising 15 experts from 10 countries, agreed the terms and recommendations for diagnosis of CPPD using a Delphi consensus approach. Evidence was systematically reviewed and presented in terms of sensitivity, specificity and positive likelihood ratio (LR) to support diagnosis; ORs were used for association. Strength of recommendation (SOR) was assessed by the EULAR visual analogue scale. RESULTS: It was agreed that 'CPPD' should be the umbrella term that includes acute calcium pyrophosphate (CPP) crystal arthritis, osteoarthritis (OA) with CPPD and chronic CPP crystal inflammatory arthritis. Chondrocalcinosis (CC) defines cartilage calcification, most commonly due to CPPD and detected by imaging or histological examination. A total of 11 key recommendations were generated on the topics of clinical features, synovial fluid (SF) examination, imaging, comorbidities and risk factors. Definitive diagnosis of CPPD relies on identification of SF CPP crystals. Rapid onset inflammatory symptoms and signs are suggestive but not definitive for acute CPP crystal arthritis. Radiographic CC is not highly sensitive or specific, whereas ultrasonography appears more useful (LR=24.2, 95% CI 3.51 to 168.01) for peripheral joints. Recognised risk factors for CPPD include ageing, OA and metabolic conditions such as primary hyperparathyroidism, haemochromatosis and hypomagnesaemia; familial forms are rare. SORs varied from 53 to 99 (maximum 100). CONCLUSION: New terms for CPPD were agreed and 11 key recommendations for diagnosis of CPPD were developed using research evidence and expert consensus.
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Condrocalcinosis/diagnóstico , Terminología como Asunto , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Condrocalcinosis/epidemiología , Condrocalcinosis/etiología , Comorbilidad , Técnica Delphi , Medicina Basada en la Evidencia/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Factores de Riesgo , Distribución por SexoRESUMEN
OBJECTIVES: To develop evidence-based recommendations for management of calcium pyrophosphate deposition (CPPD). METHODS: A multidisciplinary guideline development group of 15 experts, representing 10 European countries, generated key propositions for management of CPPD using a Delphi consensus approach. For each recommendation research evidence was searched systematically. Whenever possible, the effect size and number needed to treat for efficacy and RR or OR for side effects were calculated for individual treatment modalities. Strength of recommendation was assessed by the European League Against Rheumatism visual analogue scale. RESULTS: Nine key recommendations were generated, including topics for general management, treatment of acute attacks, prophylaxis against recurrent acute attacks and management of chronic symptoms. It was recommended that optimal treatment requires both non-pharmacological and pharmacological treatments. For acute CPP crystal arthritis, cool packs, temporary rest and joint aspiration combined with steroid injection are often sufficient. For prophylaxis or chronic inflammatory arthritis with CPPD, oral non-steroidal anti-inflammatory drugs with gastroprotective treatment and/or low-dose colchicine 0.5-1.0 mg daily may be used. Other recommendations included parenteral or oral corticosteroid for acute CPP arthritis in those unresponsive or unsuited to other measures, and low-dose corticosteroid, methotrexate or hydroxychloroquine for chronic inflammatory arthritis with CPPD. Asymptomatic CPPD requires no treatment. Strength of recommendations varies from 79% to 95%. CONCLUSION: Nine key recommendations for management of CPP crystal associated arthritis were developed using both research evidence and expert consensus. Strength of recommendations was provided to assist the application of these recommendations.
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Condrocalcinosis/terapia , Antiinflamatorios no Esteroideos/uso terapéutico , Condrocalcinosis/complicaciones , Condrocalcinosis/tratamiento farmacológico , Colchicina/uso terapéutico , Medicina Basada en la Evidencia/métodos , Glucocorticoides/uso terapéutico , Humanos , Osteoartritis/etiología , Osteoartritis/terapiaRESUMEN
UNLABELLED: A 5-year follow-up study was performed in female RA patients with established disease looking at vertebral fractures, scored on spinal X-rays, and non-vertebral fractures. We found a high incidence rate of vertebral and non-vertebral fractures in these patients compared to population-based studies. INTRODUCTION: The aim of this study is to investigate the incidence of vertebral and non-vertebral fractures over a 5-year period in a cohort of postmenopausal patients with established rheumatoid arthritis (RA). METHODS: One hundred and fifty female patients with established RA were included into the OSTRA cohort. The cohort was assessed at baseline and at 5 years for incident vertebral and non-vertebral fractures. Spinal X-rays were taken at baseline and at follow-up and scored using the semi-quantitative method according to Genant. RESULTS: At 5 years, 102 patients (68%) were examined and included in the present analysis. At baseline, the mean age was 61 years, disease duration 17 years, body mass index 25.5 kg/m(2) and 65% of the patients were rheumatoid factor positive. Fifteen percent were treated with bisphosphonates, 25% received calcium supplementation and 20% vitamin-D supplementation at baseline. During the 5-year follow-up, a total of 16 patients out of 102 patients (16%) had a new non-vertebral fracture [annual incidence of 3.2 (95% CI 1.8-5.5) per 100 patients/year]. In 18 patients out of 97 patients (19%), new vertebral fractures were identified on spinal X-ray [annual incidence of 3.7 (95% C.I. 2.2-5.8) per 100 patients/year]. CONCLUSIONS: We found a high incidence of vertebral and non-vertebral fractures in a cohort of women with established RA compared to population-based studies.
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Fracturas Óseas/epidemiología , Fracturas de la Columna Vertebral/epidemiología , Artritis Reumatoide/complicaciones , Estudios de Cohortes , Inglaterra/epidemiología , Femenino , Estudios de Seguimiento , Fracturas Óseas/etiología , Humanos , Incidencia , Persona de Mediana Edad , Países Bajos/epidemiología , Noruega/epidemiología , Osteoporosis Posmenopáusica/complicaciones , Factores de Riesgo , Fracturas de la Columna Vertebral/etiologíaRESUMEN
BACKGROUND: Plasma levels of calprotectin, a major S100 leucocyte protein, are cross-sectionally associated with clinical and laboratory markers of inflammation and with radiographic damage in rheumatoid arthritis (RA). High amounts of calprotectin are found in synovial fluid from patients with RA. OBJECTIVE: To examine whether calprotectin might be an independent predictor of joint destruction over time. METHODS: 124 patients with RA were assessed at baseline and after 10 years with inflammatory markers (calprotectin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR)), serological variables (antibodies to cyclic citrullinated peptide (anti-CCP), IgA rheumatoid factor (RF) and IgM RF) and radiographic and clinical assessments of joint damage (hand radiographs and Rheumatoid Arthritis Articular Damage (RAAD) score). Progression of radiographic damage was assessed according to the van der Heijde modified Sharp score. RESULTS: At both examinations the highest calprotectin levels were found in patients positive for anti-CCP, IgA and IgM RF. Calprotectin had moderate to good correlations with inflammatory and serological markers (r = 0.41-0.67). Patients with normal baseline calprotectin levels had a lower degree of joint damage. High univariate associations were found between baseline calprotectin levels and progression in the Sharp score as well as the RAAD score. Baseline calprotectin was independently associated with progression in the Sharp score and with the RAAD score in multiple linear regression analyses, including baseline levels of CRP, ESR, anti-CCP in addition to demographic variables. CONCLUSION: Calprotectin was an independent predictor of clinical and radiographic joint damage after 10 years. These findings support the proposal that calprotectin may be a prognostic biomarker for erosive disease in patients with RA.
Asunto(s)
Artritis Reumatoide/diagnóstico , Complejo de Antígeno L1 de Leucocito/sangre , Adulto , Artritis Reumatoide/sangre , Artritis Reumatoide/diagnóstico por imagen , Biomarcadores/sangre , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Mediadores de Inflamación/sangre , Masculino , Persona de Mediana Edad , Pronóstico , Radiografía , Factor Reumatoide/sangre , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVES: Anti-citrullinated peptide antibodies (ACPAs) are established as useful predictors of radiographic progression in rheumatoid arthritis (RA). The main objective of this study was to test the prognostic capacity of the recently developed test for anti-mutated citrullinated vimentin (anti-MCV). METHODS: A cohort of 238 patients with RA was followed longitudinally for 10 years; 125 patients with complete x ray sets were included in the main analyses. Radiographs were scored according to the van der Heijde modified Sharp score (SHS). Patients were analysed for anti-MCV and anti-cyclic citrullinated peptide (CCP), and were genotyped for human leukocyte antigen (HLA)-DRB1 "shared epitope" (SE) and protein tyrosine phosphatase, non-receptor type 22 (PTPN22) 1858T. RESULTS: Anti-MCV and anti-CCP were strongly associated with regard to status and level. Both antibodies were associated with SE, but only anti-MCV was significantly associated with PTPN22 1858T. A positive anti-MCV test increased the odds of radiographic progression by 7.3 (95% confidence interval (CI) 3.2 to 16.5) compared to 5.7 (95% CI 2.6 to 12.5) for a positive anti-CCP. Presence of MCV antibodies gave an average increase in the total SHS of 30 U compared to an average increase of 25 U for the presence of CCP antibodies. Anti-MCVs were more strongly associated to progression in erosions than joint space narrowing. Associations remained after adjustment for other predictors of radiographic progression. The odds of progression increased with increasing anti-MCV level. CONCLUSIONS: Presence of anti-MCV predicted joint damage, and the strength of this prediction was at least as strong as for anti-CCP. Antibody status showed a stronger association to bone than to cartilage destruction. This study also indicates that higher anti-MCV levels add prognostic information compared to their mere presence or absence.
Asunto(s)
Artritis Reumatoide/diagnóstico por imagen , Autoanticuerpos/sangre , Citrulina/inmunología , Vimentina/inmunología , Adulto , Anciano , Artritis Reumatoide/genética , Artritis Reumatoide/inmunología , Autoantígenos/inmunología , Biomarcadores/sangre , Progresión de la Enfermedad , Femenino , Antígenos HLA-DR/genética , Cadenas HLA-DRB1 , Articulaciones de la Mano/diagnóstico por imagen , Articulaciones de la Mano/patología , Humanos , Masculino , Persona de Mediana Edad , Péptidos Cíclicos/inmunología , Pronóstico , Estudios Prospectivos , RadiografíaRESUMEN
Objective: Fluorescence Optical Imaging (FOI) demonstrates indocyanine green (ICG)-enhanced microcirculation in wrist and finger joints, as a sign of inflammation. We wanted to assess the reliability of three FOI scoring methods from Berlin, Stockholm, and Copenhagen, to assess the validity of FOI with MRI as reference and to compare enhancement in hand joints in erosive hand osteoarthritis (OA) vs. rheumatoid arthritis (RA). Design: Five readers scored all finger and wrist joints of 26 patients with erosive hand OA and RA on semi-quantitative 0-3 scales using three different FOI scoring methods. To evaluate inter-reader reliability, we calculated the intraclass correlation coefficients (ICC) for sum scores and prevalence and bias adjusted kappa values for ordinal scales (Pabak-OS) on joint level. Enhancement in joint groups in erosive hand OA vs. RA was compared using Mann-Whitney test. Sensitivities and specificities of FOI was calculated with MRI as reference for hand OA patients only. Results: We found moderate to good inter-reader reliability for all FOI scoring methods (Pabak-OS: 0.50-0.78, ICC: 0.43-0.85) and different patterns of enhancement in erosive hand OA vs. RA with significantly more FOI enhancement in DIP joints in erosive hand OA across all methods. With MRI as reference the different FOI scoring methods reached similar sensitivities (63-65%) and specificities (76-91%). Conclusion: FOI enhancement can be measured reliably in erosive hand OA and RA using three different scoring methods. More DIP enhancement in erosive hand OA patients and good agreement with MRI support the diagnostic performance of FOI.
RESUMEN
AIM: To examine the test-retest reliability of the rheumatoid arthritis (RA) core disease activity measures and derived composite indices. METHODS: A total of 28 stable patients with RA had 2 complete assessments within 1 week, which included the 7 RA core disease activity measures and derived disease activity indices (28-joint Disease Activity Score (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), RA Disease Activity Index (RADAI) and Routine Assessment of Patient Index Data (RAPID3)). The intraclass correlations (ICC), the smallest detectable difference (SDD) and minimal detectable change as percentage of the maximum score (MDC%) were estimated as measures of test-retest reliability. RESULTS: Correlations for the disease activity indices were high. SDDs (MDC%) to detect a true improvement or deterioration with 95% confidence were: DAS28 1.32 (14.4%), SDAI 8.26 (9.6%), CDAI 8.05 (10.6%), RAPID3 1.48 (14.8%) and RADAI 1.49 (14.9%). Thus, SDDs were rather high, and the MDC% values were of a similar magnitude of 10% to 15% for all seven core data set measures. CONCLUSIONS: SDDs of the DAS28, SDAI and CDAI were close to limits to detect important improvement. Clinicians should be aware of measurement error. Nonetheless, RA core data set measures and indices obtained from a health professional, laboratory and patient self-report had similar reliability.