The State of Patient Reported Outcome Measures in Rheumatology.

OBJECTIVE: No prior studies in rheumatology have evaluated the quality or timeliness of patient reported outcome (PRO) measure reporting. METHODS: Clinical trials that informed new Food and Drug Administration (FDA) approvals for the first rheumatological indication between 1995-2021 were identified. Whether collected PROs were published, met minimal clinically important (MCID) difference or statistical significance (p < 0.05) thresholds, or were consistent with CONSORT-PRO reporting standards was recorded. Hazard ratios and the Kaplan-Meier estimate were used to assess the time from FDA approval to PRO publication. RESULTS: Thirty one FDA approvals corresponded with 110 pivotal trials and 262 reported patient reported outcome measures (PROs). One of the included studies (1.1%) met all five recommended items, 10/90 (11.1%) met 4 items, 17/90 (18.9%) met 3 items, 21/90 (23.3%) met 2 items, 26/90 (28.9%) met 1 item, and 15/90 (16.7%) met none of the reporting standards. Most PROs met MCID thresholds (149/262, 56.9%) and were statistically significant (223/262, 85.1%). Of our subset analysis, one third of PROs were not published upfront (70/212, 33.0%) and one of nine (22/212, 10.4%) remained unpublished four or more years after initial trial reporting. Publication rates were highest for HAQ-DI (97.4%) and lowest for SF-36 (81.8%). Less than half of these published PROs met MCID and statistical significance thresholds (94/212, 44.3%). CONCLUSION: One in nine PROs remained unpublished for more than 4 years after initial trial reporting, and compliance with CONSORT PRO reporting guideline was poor. Efforts should be made to ensure PROs are adequately reported and expeditiously published.

Twenty-five years of novel drug approvals in rheumatology.

The field of rheumatology has experienced dozens of novel drug approvals in the past two and a half decades, but the regulatory mechanisms underpinning these decisions are not well understood. In the USA, the Food and Drug Administration (FDA) evaluates the safety and efficacy of novel drugs through the New Drug Application (NDA) process. When additional content expertise is required to evaluate scientific or technical matters, the FDA may convene Human Drug Advisory Committees. To better understand the landscape of rheumatology NDAs and the FDA use of advisory committees, we performed a review of all rheumatic disease drug applications from 1996 to 2021 that were granted approval by the FDA. Our review identified 31 NDAs, seven of which utilized an advisory committee. The indications for using advisory committees and their influence on ultimate approvals was not clear. Recommendations to improve transparency and increase public trust in FDA decisions are provided.

Is there a role for Pneumocystis jiroveci pneumonia prophylaxis in giant cell arteritis or polymyalgia rheumatica?

BACKGROUND: Pneumocystis jiroveci pneumonia (PJP) is an opportunistic fungal infection that affects immunocompromised patients. The objective of this study was to describe the incidence of PJP among patients with giant cell arteritis (GCA) or polymyalgia rheumatica (PMR). METHODS: A retrospective cohort study of incident cases of GCA and PMR was conducted using claims data from the TriNetX database to describe the incidence of PJP during the first 6 months of therapy. Additionally, a systematic review was performed to identify other publications describing PJP among patients with GCA or PMR. RESULTS: During 547 patient-years of follow-up time, no cases of PJP were identified among 1,168 cases of GCA (incident rate 0 per 1,000 person-years); during 7,446 patient-years of follow up time, one case of PJP was identified out of 15,575 cases of PMR (incident rate 0.07 cases per 1,000 patient-years). This patient was alive at last follow up. Our systematic review identified 1 case-control study, 4 cohort studies, and 18 case series / case reports of PJP among patients with GCA or PMR. The incident rate of PJP was reported from one additional study for GCA and was estimated at 0.08 cases per 1,000 person years; no additional cohort studies were identified for patients with PMR. Over the entirety of the published literature, the total number of cases identified among case series and case reports was 33, from which 4 total deaths were identified. CONCLUSIONS: Patients with newly diagnosed GCA or PMR rarely develop PJP. Existing data does not support routine prescribing of PJP prophylaxis for either group of patients.

Recurrent Pericardial Effusion in a Patient With Delayed Progression of Melanoma Treated With Immune Checkpoint Inhibitors.

Two commonly used immune checkpoint inhibitors (ICIs) utilized in the treatment of metastatic melanoma are nivolumab, a programmed death (PD-1) checkpoint inhibitor, and ipilimumab, a cytotoxic T-lymphocyte antigen (CTLA-4) checkpoint inhibitor. However, due to the activation of the immune system, ICIs have been associated with cardiotoxic immune-related adverse events (irAEs). Here, we present a 40-year-old male with stage 4 metastatic melanoma treated with nivolumab and ipilimumab who developed recurrent pericardial effusions and subsequent constrictive pericarditis 10 months after initiation of treatment. He initially received a total of four cycles and was started on maintenance nivolumab on 8/2022. On 3/23/2023, he complained of chest pain and was found to be hypotensive. He subsequently underwent an emergent pericardiocentesis where 330cc of serosanguinous fluid was drained. Repeat echo on 3/24 demonstrated a re-accumulation of a moderate-sized pericardial effusion, and a subxiphoid pericardial window was placed. He again presented on 5/24/2023 with similar complaints, and a CT scan of chest showed enlarged pericardial effusion with new bilateral pleural effusions.  To our knowledge, this is one of few case reports discussing pericardial effusions in the setting of nivolumab and ipilimumab ICI immunotherapy.