Flare during tapering of biological DMARDs in patients with rheumatoid arthritis in routine care: characteristics and predictors.

OBJECTIVE: To identify predictors of flare in a 2-year follow-up study of patients with rheumatoid arthritis (RA) in sustained clinical remission tapering towards withdrawal of biological disease-modifying anti-rheumatic drugs (bDMARDs). METHODS: Sustained clinical remission was defined as Disease Activity Score for 28 joints (DAS28)-C reactive protein (CRP) ≤2.6 without radiographic progression for >1 year. bDMARDs were tapered according to a mandatory clinical guideline to two-thirds of standard dose at baseline, half of dose at week 16 and discontinuation at week 32. Prospective assessments for 2 years included clinical evaluation, conventional radiography, ultrasound and MRI for signs of inflammation and bone changes. Flare was defined as DAS28-CRP ≥2.6 with ∆DAS28-CRP ≥1.2 from baseline. Baseline predictors of flare were assessed by logistic regression analyses. RESULTS: Of 142 included patients, 121 (85%) flared during follow-up of which 86% regained remission within 24 weeks after flare. Patients that flared were more often rheumatoid factor positive, had tried more bDMARDs and had higher baseline ultrasound synovitis sum scores than those not flaring. For patients on standard dose, predictors of flare within 16 weeks after reduction to two-thirds of standard dose were baseline MRI-osteitis (OR 1.16; 95% CI 1.03 to 1.33; p=0.014), gender (female) (OR 6.71; 95% CI 1.68 to 46.12; p=0.005) and disease duration (OR 1.06; 95% CI 1.01 to 1.11; p=0.020). Baseline predictors for flare within 2 years were ultrasound grey scale synovitis sum score (OR 1.19; 95% CI 1.02 to 1.44; p=0.020) and number of previous bDMARDs (OR 4.07; 95% CI 1.35 to 24.72; p=0.007). CONCLUSION: The majority of real-world patients with RA tapering bDMARDs flared during tapering, with the majority regaining remission after stepwise dose increase. Demographic and imaging parameters (MR-osteitis/ultrasound greyscale synovitis) were independent predictors of immediate flare and flare overall and may be of importance for clinical decision-making in patients eligible for tapering.

Preferences of patients and health professionals for route and frequency of administration of biologic agents in the treatment of rheumatoid arthritis.

OBJECTIVES: To examine the preferences of rheumatoid arthritis (RA) patients and health professionals (HPs) for the route and frequency of administration of biologic drugs. METHODS: One hundred and seven RA patients treated with biological agents for intravenous or subcutaneous use, 35 biologic-naïve RA patients treated with a disease-modifying antirheumatic drug and 30 rheumatology HPs (physicians and nurses) were recruited from two outpatient clinics in Copenhagen, Denmark. All subjects filled out a questionnaire interrogating their choice of preferred route and frequency of administration of a biologic corresponding to current available options, given that effects, adverse effects, and financial costs were identical for the different choices. The subjects were also asked to justify their preferences. The chi-square goodness-of-fit test was used to examine the distributions over different preferences. Proportions were compared using Fisher's exact test. RESULTS: Forty-one patients were currently treated with subcutaneous self-injections at home (SCH) and 66 intravenously at the clinic (IVC). IVC was preferred by 85% of patients currently treated with IVC (P<0.0001). SCH was preferred by 71% of patients currently treated with SCH (P<0.001), by 77% of the biologic-naïve patients (P<0.01), and by 87% of HPs (P<0.0001). The proportion of patients favoring SCH was significantly higher for patients currently receiving SCH and for biologic-naïve RA patients than for those currently on IVC (P<0.0001). SCH once a month and IVC every 8 weeks were the most appealing treatment frequencies (P<0.01). The most frequent reason among patients for choosing IVC or SCH was a wish for safety, and a wish to minimize the time of transportation and treatment, respectively. CONCLUSION: The majority of RA patients treated with biologics preferred their current route of administration. Most patients, those inexperienced with biologics, and HPs favored SCH. Low treatment frequencies were generally preferred.

Return to work following spinal cord injury: a review.

PURPOSE: To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), and present employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtain and sustain productive work. METHODS: A systematic review for 2000 - 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science, EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords 'spinal cord injuries', 'spinal cord disorder', 'spinal cord lesion' or 'spinal cord disease' were cross-indexed with 'employment', 'return to work', 'occupation' or 'vocational'. RESULTS: Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals with SCI working at the time of injury 21 - 67% returned to work after injury. RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Persons with SCI employed ranged from 11.5% to 74%. Individuals who sustained SCI during childhood or adolescence had higher adult employment rates. Most common reported barriers to employment were problems with transportation, health and physical limitations, lack of work experience, education or training, physical or architectural barriers, discrimination by employers, and loss of benefits. Individuals with SCI discontinue working at younger age. CONCLUSIONS: This review confirmed low employment rates after SCI. Future research should explore interventions aimed at helping people with SCI to obtain and sustain productive work.