In patients with rheumatic diseases undergoing immunosuppressive treatment, hepatitis B virus reactivation (HBVr) has been long recognized as a major treatment-related adverse event with substantial ...morbidity and mortality. Because HBVr is easily preventable with appropriate screening and monitoring strategies, and, when indicated, prophylactic antiviral treatment, awareness of this complication is of the utmost importance, especially in the era of biologic treatments. As a condition, it continues to be topical, in view of the emergence of novel classes of immunosuppressive drugs (i.e. Janus kinase inhibitors) acquiring licenses for a variety of rheumatic diseases. The class-specific risk of these agents for HBVr has not yet been determined. Moreover, ambiguity still exists for the management of patients planned to be treated with traditional agents, such as cyclophosphamide and glucocorticoids, particularly in the setting of resolved HBV infection. Clinicians in the field of rheumatic diseases should be tailoring their practice according to the host’s profile and treatment-specific risk for HBVr. In this review, the authors attempt to critically review the existing literature and provide practical advice on these issues.
Objectives
To investigate possible associations between rheumatoid arthritis (RA) patient-expressed preferences over anti-tumour necrosis factor (anti-TNF) treatment and clinical and patient-reported ...outcomes.
Methods
PANORAMA was a non-interventional, prospective, multicentre, cohort study of 12 months duration, in patients with moderate-to-severe RA who initiated or switched to anti-TNF treatment. After initiation of anti-TNF, patients completed a preferences questionnaire on attributes related to anti-TNF treatment. Satisfaction with treatment was assessed with the Treatment Satisfaction Questionnaire for Medication (TSQM); compliance and persistence to treatment were recorded via a patient diary. Univariate and multivariate analyses were applied to assess correlations between patients’ preferences over treatment with clinical and patient-reported outcomes.
Results
A total of 254 patients were enrolled; 66.1% (168/254) had highly active disease (DAS28-ESR > 5.1), while 65.4% (166/254) were biological-naïve. The 12-month drug-survival rate was 72.3%, while the respective rates of good EULAR response and remission (DAS28-ESR < 2.6) were 56.5% and 40.8%, respectively. By univariate analysis, fulfilment of patient preferences over treatment was associated with increased probability of remaining on therapy (
p
= 0.019), good EULAR response (
p
< 0.001) and satisfaction with treatment (p < 0.001). By multivariate analysis, fulfilment of patient preferences was the most important predictor for good EULAR response (OR 5.56,
p
< 0.001; finding confirmed and after propensity scoring matching), while seropositivity (HR 1.18,
p
= 0.047) and a high ESR (> 35 mm/h, HR 1.16,
p
= 0.071) predicted drug survival.
Conclusions
In anti-TNF-treated RA patients, fulfilment of treatment preferences was independently associated with a good EULAR response and correlated with drug persistence at 12 months, emphasising the importance of patient preferences in treatment outcomes.
Key Points
• In anti-TNF treated RA patients, fulfilment of patients’ treatment preferences is associated with a good clinical response at 12 months.
• A shared decision-making process can maximise treatment’s outcome in anti-TNF treated patients.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The aim of this study was to assess the patient characteristics, treatment patterns and disease outcomes in patients with psoriatic arthritis (PsA) referred to a combined Dermatology–Rheumatology ...(Derm–Rheum) Clinic. This was a retrospective study of patients seen in a combined Derm–Rheum Clinic (February 2018 to June 2020) in a Tertiary University Hospital. Consecutive patients with suspicious musculoskeletal symptoms or a known diagnosis of PsA referred to the Derm–Rheum Clinic were examined and followed simultaneously by experienced dermatologists and rheumatologists. Among 151 patients with psoriasis (PSO) with suspicious musculoskeletal complaints, 129 (85%) with a final diagnosis of PsA were included (56% females, mean age: 55 years, median disease duration: 14.2 years). In 62% of these patients (
n
= 94), PsA was diagnosed for the 1st time. At initial evaluation, 95% had peripheral arthritis, 45% nail involvement, 23% axial involvement, 12% enthesitis and 6% dactylitis with a median DAPSA and PASI scores of 20.5 and 1.6, respectively. 31% of the patients were not receiving any systemic treatment, 45% were on biologics, 29% on non-biologics and 10% on targeted synthetic agents (apremilast). At last visit (median interval time: 15 months), only 8% did not receive any systemic therapy (
p
< 0.001 compared to 1st visit), 62% were on biologics (
p
= 0.009 compared to 1st visit), 46% on non-biologics (
p
= 0.01 compared to 1st visit) and 10% remained on apremilast. The median DAPSA and PASI scores decreased significantly to 5.3 and 0, respectively. In conclusion, about 2/3 of patients with PSO and musculoskeletal complaints referred to a combined Derm–Rheum Clinic were diagnosed for the 1st time with PsA. During follow-up, the percentage of PsA patients on systemic therapies significantly increased with major improvement of disease activity indices. These data emphasize the value of combined Derm–Rheum Clinics for earlier referral, diagnosis, and more effective treatment of PsA patients.
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Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Granulocyte monocyte colony-stimulating factor (GM-CSF) is currently considered a crucial inflammatory mediator and a novel therapeutic target in rheumatoid arthritis (RA), despite the fact that its ...precise cellular sources remain uncertain. We studied the expression of GM-CSF in peripheral lymphocytes from RA patients and its change with antirheumatic therapies.
Intracellular GM-CSF expression was assessed by flow cytometry in stimulated peripheral B (CD19+) and T (CD3+) cells from RA patients (
= 40), disease (
= 31 including osteoarthritis
= 15, psoriatic arthritis
= 10, and systemic rheumatic diseases
= 6) and healthy (
= 16) controls. The phenotype of GM-CSF+ B cells was assessed as well as longitudinal changes in GM-CSF+ lymphocytes during methotrexate (MTX,
= 10) or anti-tumor necrosis factor (anti-TNF,
= 10) therapy.
Among untreated RA patients with active disease (Disease Activity Score 28-C-reactive protein = 5.6 ± 0.89) an expanded population of peripheral GM-CSF+ B (4.1 ± 2.2%) and T (3.4 ± 1.6%) cells was detected compared with both disease (1.7 ± 0.9%,
< 0.0001 and 1.7 ± 1.3%,
< 0.0001, respectively) and healthy (0.3 ± 0.2%,
< 0.0001 and 0.6 ± 0.6%,
< 0.0001) controls. RA GM-CSF+ B cells displayed more commonly a plasmablast or transitional phenotype (37.12 ± 18.34% vs. 14.26 ± 9.46%,
= 0.001 and 30.49 ± 15.04% vs. 2.45 ± 1.84%,
< 0.0001, respectively) and less a memory phenotype (21.46 ± 20.71% vs. 66.99 ± 16.63%,
< 0.0001) compared to GM-CSF- cells. GM-CSF expression in RA patients did not correlate to disease duration, activity or serological status. Anti-TNF treatment led to a statistically significant decrease in GM-CSF+ B and T cells while MTX had no significant effect.
This is the first study showing an expanded population of GM-CSF+ B and T lymphocytes in patients with active RA which declined after anti-TNF therapy.
Recurrent pericarditis is a problematic clinical condition that impairs the quality of life of the affected patients due to the need for repeated hospital admissions, emergency department visits, and ...complications from medications, especially glucocorticoids. Unfortunately, available treatments for recurrent pericarditis are very limited, including only a handful of medications such as aspirin/NSAIDs, glucocorticoids, colchicine, and immunosuppressants (such as interleukin-1 (IL-1) blockers, azathioprine, and intravenous human immunoglobulins). Until recently, the clinical experience with the latter class of medications was very limited. Nevertheless, in the last decade, experience with IL-1 blockers has consistently grown, and valid clinical data have emerged from randomized clinical trials. Accordingly, IL-1 blockers are a typical paradigm shift in the treatment of refractory recurrent pericarditis with a clearly positive cost/benefit ratio for those unfortunate patients with multiple recurrences. A drawback related to the above-mentioned medications is the absence of universally accepted and established treatment protocols regarding the full dose administration period and the need for a tapering protocol for individual medications. Another concern is the need for long-standing treatments, which should be discussed with the patients. The above-mentioned unmet needs are expected to be addressed in the near future, such as further insights into pathophysiology and an individualized approach to affected patients.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
To determine the conversion and reversion rates of tuberculosis (TB) screening tests (Tuberculin Skin Test-TST, Interferon Gamma Release Assay-IGRA: T-SPOT.TB) during biologic treatment in patients ...with rheumatic diseases and negative baseline screening.
This was a long-term, longitudinal cohort study of 50 patients with rheumatic diseases and negative baseline TB screening (TST: < 5 mm, negative T-SPOT.TB) treated with tumor necrosis factor inhibitors (TNFi) or other non-TNFi biologics. Patients were rescreened at a mean time of 1.4 (first rescreening) and 6.9 (second rescreening) years from baseline, with both assays. The conversion (negative to positive) and reversion (positive to negative) rate was calculated for each TB screening test.
Fifty patients (mean age = 60 years) with various rheumatic diseases (rheumatoid arthritis: n = 24, spondyloarthropathies: n = 23, other: n = 3) were enrolled. During the first phase (baseline to first rescreening), all patients were treated with TNFi while during the second phase (first to second rescreening), TNFi (54%) and non-TNFi (46%) were used. Fifteen patients (30%) displayed conversion of at least 1 screening assay during follow-up (10 at the first and 5 at the second rescreening). This conversion rate was higher with TST (n = 11, 22% or 3.47/100 patient-years) compared to T-SPOT.TB (n = 4, 8% or 1.74/100 patient-years). Among the 10 converters at the first rescreening, 5 received isoniazid (INH) preventive therapy and 5 did not; an equal number of patients (3/5, 60%) reverted to negative with or without INH therapy. None of the patients developed active TB during follow-up (6.9 ± 1.0 years).
Approximately one-third of patients with rheumatic diseases and negative baseline TB screening developed conversion of at least 1 screening test during long-term biologic treatment. This occurred most often with TST and was usually a transient event. These findings do not support routine serial TB retesting in biologic-treated patients with rheumatic diseases in the absence of TB risk factors.
Hepatitis B virus (HBV) reactivation (HBVr) has been an increasingly recognized and appreciated risk of immunosuppressive therapies in rheumatic patients. Despite its potential for significant ...morbidity and mortality, HBVr is a fully preventable complication with appropriate pretreatment screening and close monitoring of susceptible patients. Better knowledge of the risk for HBVr with the different antirheumatic agents and the establishment of the new-generation oral antivirals in clinical practice has greatly improved the design of screening and therapeutic algorithms. In this review, all available data regarding HBVr in rheumatic patients are critically presented and a screening and therapeutic algorithm is proposed.
Abstract
Background/Aims
Ultrasound (US) imaging has become established in clinical Rheumatology practice to aid diagnosis and monitoring of inflammatory arthritis (IA). We firstly wanted to explore ...the utility of US in the assessment for active synovitis in subjects with known IA, but clinically uncertain disease control. Secondly we set out to compare this with the diagnostic contribution of US in patients presenting with new inflammatory joint symptoms and uncertain clinical synovitis.
Methods
Two contemporaneous samples of subjects were selected from consecutive, pre-Covid, Rheumatology Consultant-delivered Ultrasound Clinic lists in our department: (i) subjects with known IA where clinical disease activity was uncertain, and (ii) subjects without know IA who had symptoms with inconclusive signs of suspected IA. Both grey scale and power Doppler US imaging was used to determine a sonographic conclusion of active IA being present, absent or equivocal. Treatment changes/ decisions were ascertained from the next available clinic letter to explore diagnostic consequences following US.
Results
(i) In the sample of subjects with known IA (n = 30, mean age 53.9 years, 63% female, RA 76.7%, all on DMARDs 20% biologics), 43.3%(n = 13) had US evidence of active IA, and 50% of inactive IA (and the remainder reported as equivocal). At clinic review (n = 30) only 6 of 13 subjects with active US IA had their DMARD treatment escalated (all within same DMARD) and 5 out of 15 subjects with inactive US IA their DMARD de-escalated. (ii) In the sample of subjects with suspected IA (n = 30, mean age 51.5 years, 73% female): 16.7% (n = 5) had US evidence of IA and 77.7% not (and remainder reported as equivocal). At the next clinic review seven patients were commenced on DMARDs: three patients with IA on US, and 4 without.
Conclusion
In our department, Rheumatology clinicians appear to be referring for diagnostic US in known IA from a situation approaching clinical equipoise which would suggest optimum referral practice. If we assume that this clinical equipoise also applies to the assessment and referral practice of new patients with arthralgia but uncertain clinical synovitis, our diagnostic sensitivity of US is approximately 16.7%, meaning: six patients with suspected IA need referral for US to identify one with sonographic IA. Irrespective of this, we observed that the sonographic diagnosis in known or suspected IA is commonly not followed by a concordant treatment decision, suggesting that the US diagnosis forms only part of the diagnostic ‘jigsaw’ decision process.
Disclosure
M. Adikari: None. C. Koutsianas: None. H. John: None. R. Klocke: None.
As the worldwide burden of COVID-19 increases exponentially, healthcare systems are plagued by unprecedented pressure. In this setting, many rheumatologists across the globe have been recruited to ...support the front line, facing several unexpected challenges, but also providing valuable skills in combating COVID-19. At the same time, the rheumatic disease patient population may be especially vulnerable to such a rapidly contagious infectious disease, and thus needs care and support that has to be provided quickly and efficiently. Clear advice on viral spread mitigation, precise guidelines on immunosuppressive treatment use, and alternative methods of providing care, such as telemedicine, are a few of the rheumatologists’ new challenges in caring for their patients in the COVID-19 era. Finally, among other specialties, rheumatologists hold a unique place in the fight against the hyperinflammatory state caused by severe SARS-CoV-2 infection, leading to increased morbidity and mortality. Given their vast experience in the use of biologic and targeted therapies, rheumatologists should lead the way in developing reliable scientific evidence for the optimal treatment of severe COVID-19.
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