The objective was to develop evidence-based recommendations for the management of antiphospholipid syndrome (APS) in adults. Based on evidence from a systematic literature review and expert opinion, ...overarching principles and recommendations were formulated and voted. High-risk antiphospholipid antibody (aPL) profile is associated with greater risk for thrombotic and obstetric APS. Risk modification includes screening for and management of cardiovascular and venous thrombosis risk factors, patient education about treatment adherence, and lifestyle counselling. Low-dose aspirin (LDA) is recommended for asymptomatic aPL carriers, patients with systemic lupus erythematosus without prior thrombotic or obstetric APS, and non-pregnant women with a history of obstetric APS only, all with high-risk aPL profiles. Patients with APS and first unprovoked venous thrombosis should receive long-term treatment with vitamin K antagonists (VKA) with a target international normalised ratio (INR) of 2-3. In patients with APS with first arterial thrombosis, treatment with VKA with INR 2-3 or INR 3-4 is recommended, considering the individual's bleeding/thrombosis risk. Rivaroxaban should not be used in patients with APS with triple aPL positivity. For patients with recurrent arterial or venous thrombosis despite adequate treatment, addition of LDA, increase of INR target to 3-4 or switch to low molecular weight heparin may be considered. In women with prior obstetric APS, combination treatment with LDA and prophylactic dosage heparin during pregnancy is recommended. In patients with recurrent pregnancy complications, increase of heparin to therapeutic dose, addition of hydroxychloroquine or addition of low-dose prednisolone in the first trimester may be considered. These recommendations aim to guide treatment in adults with APS. High-quality evidence is limited, indicating a need for more research.
Objective
End‐stage renal disease (ESRD) is a major consequence of lupus nephritis, but how this risk has changed over time is unknown. We conducted this systematic review to examine changes in ESRD ...among adults with lupus nephritis from 1971 to 2015 and to estimate risks of ESRD among contemporary patients.
Methods
We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for cohort studies and clinical trials on ESRD in adults with lupus nephritis. We analyzed studies from developed and developing countries separately. The outcome was probability of ESRD at 5, 10, and 15 years of lupus nephritis.
Results
We included 187 articles that reported on 18,309 patients. In developed countries, the 5‐year risk of ESRD decreased from 16% (95% confidence interval 95% CI 14–17%) in 1970–1979 to 11% (95% CI 10–12%) in the mid‐1990s and then plateaued. ESRD risks at 10 years and 15 years showed steeper declines in the 1970s and 1980s but also plateaued in 1993–1997, with a notable increase in the late 2000s. The decrease in risk after 1980 coincided with increased use of cyclophosphamide. The 15‐year ESRD risk was higher in developing countries than in developed countries. Patients with class IV lupus nephritis had the greatest risk of ESRD, with a 15‐year risk of 44% during the 2000s.
Conclusion
Risks of ESRD in lupus nephritis improved between the 1970s and the mid‐1990s and then plateaued, with an increase in the late 2000s. This pattern suggests limitations in the effectiveness of, or access to, current treatments.
Objective
To examine health care utilization among patients with knee osteoarthritis (OA) and assess whether utilization differs among residents of regions with high and low rates of total knee ...arthroplasty (TKA).
Methods
This was a retrospective cohort study of US Medicare beneficiaries with knee OA enrolled from 2005 to 2010. Health care utilization data for knee complaints, including rates of physician visits, physical therapy, knee injections, and arthroscopy, were ed from claims files until time of TKA or the end of the study in 2015. Utilization was compared among beneficiaries who lived in regions with high or low rates of TKA.
Results
Among 988,570 beneficiaries with knee OA, 327,499 (33.1%) underwent TKA during follow‐up (median 5.6 years). Higher frequency of visits for knee complaints was associated with increased risk of TKA, whereas physical therapy, specialist care, and intraarticular treatments were associated with lower risk of TKA. Frequency of TKA varied from 26.4% in the lowest regional TKA rate quintile to 42.1% in the highest regional TKA rate quintile. Rates of physician visits, physical therapy, specialist care, and treatment with intraarticular injections varied inversely with regional TKA rate quintile. For example, 32.5% of beneficiaries in the lowest region quintile and 23.6% in the highest region quintile underwent physical therapy. Across all quintiles, physical therapy was associated with lower TKA rates.
Conclusion
Dedicated nonsurgical OA care was infrequently used to treat elderly Americans with knee OA. Nonsurgical care was more common in regions with low TKA rates, suggesting reciprocal emphasis on medical treatment compared to surgical treatment across regions.
Objective
To update evidence‐based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA).
Methods
We conducted updated ...systematic literature reviews for 20 clinical questions on pharmacologic treatment addressed in the 2015 guidelines, and for 26 new questions on pharmacologic treatment, treat‐to‐target strategy, and use of imaging. New questions addressed the use of secukinumab, ixekizumab, tofacitinib, tumor necrosis factor inhibitor (TNFi) biosimilars, and biologic tapering/discontinuation, among others. We used the Grading of Recommendations, Assessment, Development and Evaluation methodology to assess the quality of evidence and formulate recommendations and required at least 70% agreement among the voting panel.
Results
Recommendations for AS and nonradiographic axial SpA are similar. TNFi are recommended over secukinumab or ixekizumab as the first biologic to be used. Secukinumab or ixekizumab is recommended over the use of a second TNFi in patients with primary nonresponse to the first TNFi. TNFi, secukinumab, and ixekizumab are favored over tofacitinib. Co‐administration of low‐dose methotrexate with TNFi is not recommended, nor is a strict treat‐to‐target strategy or discontinuation or tapering of biologics in patients with stable disease. Sulfasalazine is recommended only for persistent peripheral arthritis when TNFi are contraindicated. For patients with unclear disease activity, spine or pelvis magnetic resonance imaging could aid assessment. Routine monitoring of radiographic changes with serial spine radiographs is not recommended.
Conclusion
These recommendations provide updated guidance regarding use of new medications and imaging of the axial skeleton in the management of AS and nonradiographic axial SpA.
Objective
Advances in treatment over the past 20 years have resulted in improved control of rheumatoid arthritis (RA). The objective of our study was to investigate whether there has been a decrease ...in permanent work disability associated with RA in the US.
Methods
Medicare data from 1999 to 2015 were used to identify beneficiaries age 20–59 years with RA who became eligible for Medicare coverage under Social Security Disability Insurance. Diagnosis of RA was based on physician claims in the first year of enrollment. Annual rates of enrollment were sex‐ and age‐standardized to the 2000 US population.
Results
The study included 97,787 beneficiaries with RA and Social Security Disability Insurance across all years. Medicare enrollment was 26.0 per million in 1999 and 26.0 per million in 2015. Rates increased following the Great Recession of 2008–2009 before returning to prerecession levels. There was no linear trend over time after adjusting for the annual national unemployment rate (relative risk 0.99 per year 95% confidence interval 0.99–1.00; P = 0.69). Risks of work disability were much higher among workers over age 50 years.
Conclusion
Based on Medicare enrollment by recipients of Social Security Disability Insurance, there was no decrease in permanent work disability among young and middle‐age workers with RA in the US between 1999 and 2015.
The 30-item disabilities of the arm, shoulder and hand (DASH) questionnaire is increasingly used in clinical research involving upper extremity musculoskeletal disorders. From the original DASH a ...shorter version, the 11-item QuickDASH, has been developed. Little is known about the discriminant ability of score changes for the QuickDASH compared to the DASH. The aim of this study was to assess the performance of the QuickDASH and its cross-sectional and longitudinal validity and reliability.
The study was based on extracting QuickDASH item responses from the responses to the full-length DASH questionnaire completed by 105 patients with a variety of upper extremity disorders before surgery and at follow-up 6 to 21 months after surgery. The DASH and QuickDASH scores were compared for the whole population and for different diagnostic groups. For longitudinal construct validity the effect size and standardized response mean were calculated. Analyses with ROC curves were performed to compare the ability of the DASH and QuickDASH to discriminate among patients classified according to the magnitude of self-rated improvement. Cross-sectional and test-retest reliability was assessed.
The mean DASH score was 34 (SD 22) and the mean QuickDASH score was 39 (SD 24) at baseline. For the different diagnostic groups the mean and median QuickDASH scores were higher than the corresponding DASH scores. For the whole population, the mean difference between the QuickDASH and DASH baseline scores was 4.2 (95% CI 3.2-5.3), follow-up scores was 2.6 (1.7-3.4), and change scores was 1.7 (0.6-2.8). The overall effect size and standardized response mean measured with the DASH and the QuickDASH were similar. In the ROC analysis of change scores among patients who rated their arm status as somewhat or much better and those who rated it as unchanged the difference in the area under the ROC curve for the DASH and QuickDASH was 0.01 (95% CI -0.05-0.07) indicating similar discriminant ability.Cross-sectional and test-retest reliability of the DASH and QuickDASH were similar.
The results indicate that the QuickDASH can be used instead of the DASH with similar precision in upper extremity disorders.
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