Aggressive Treatment Of Rheumatoid Arthritis Research Articles

COMPARISON OF CONVENTIONAL DISEASE MODIFYING ANTI-RHEUMATIC DRUGS WITH AND WITHOUT INTRA-ARTICULAR PLATELET RICH PLASMA INJECTION IN THE ALTERATION OF DISEASE PROGRESSION OF EARLY RHEUMATOID ARTHRITIS: A RANDOMIZED CONTROLLED TRIAL

Background and Objectives:Rheumatoid arthritis (RA) is a symmetric inflammatory polyarticular arthritis, where autoimmune response causes chronic inflammation and destruction of joints leading to deformities and affecting the activities of daily living. ACR recommends early diagnosis and aggressive treatment of RA with combination disease modifying anti-rheumatic drugs (DMARDs). Although it attenuates disease progression, long-term remissions have not been adequately achieved. Injection of platelet rich plasma(PRP) decrease joint inflammation by modulating synovial cell proliferation, differentiation and inhibition of catabolic pathways. Aim:to compare conventional DMARDs with and without intra-articular platelet rich plasma injection in wrist joint in the alteration of disease progression of early rheumatoid arthritis. Methods:A randomized controlled trial, done among newly diagnosed patients of Rheumatoid Arthritis affecting wrist joint, in Department of PMR, RIMS. Data collected in pretested structured proforma and analysis for Pain, Disease activity, USG grading and hand function done using Chi-square test, students t-test, repeated measure ANOVA test. Results:There is significant improvement in VAS, DAS28, Cochin scale and USG Grade in study group at the end of 8 weeks, however at 20 weeks it is found to be comparable and p-value is not significant. Conclusion:Addition of Intra articular PRP in wrist along with DMARDs has early and better improvement in pain and delay disease progression. Intra-articular PRP injection under USG guidance helps in reduction of synovial inflammation and pain, improvement in function and a safe treatment modality. Early treatment and reduction of disease activity by intervention in targeted joint may delay joint deformity and disability.

Provider Specialty and the Use of Disease‐Modifying Antirheumatic Drugs for Rheumatoid Arthritis Among Older Adults in the 2005‐2016 National Ambulatory Medical Care Survey

ObjectiveWe compared disease‐modifying antirheumatic drug (DMARD) use for older adults with rheumatoid arthritis (RA)‐related ambulatory visits from rheumatologists and primary care providers (PCPs).MethodsIn this study of national sample office visits, we characterized ambulatory visits by older adults 65 years of age or older seen by rheumatologists or PCPs for diagnosis of RA using the 2005‐2016 National Ambulatory Medical Care Survey. We analyzed patterns and trends of DMARD use using descriptive statistics and multivariable analyses by provider specialty.ResultsWe identified 518 observations representing 7,873,246 ambulatory RA visits by older adults over 12 years; 74% were with rheumatologists. Any DMARD use was recorded at 56% of rheumatologist and 30% of PCP visits. Among visits with any DMARD use, 20% of rheumatologist visits had two or more DMARDs compared with 6% of PCP visits. Over the 12‐year study period, there was no statistical difference in trend of any or conventional synthetic DMARD use at visits by provider specialty, adjusted for patient characteristics, non‐DMARD polypharmacy and multimorbidity. However, biologic DMARD use was more likely to incrementally increase with rheumatologist compared with PCP visits (P = 0.003).ConclusionDMARD use for older adults with RA remains low from both rheumatologists and PCPs, including biologic DMARDs, even though American College of Rheumatology guidelines recommend earlier and more aggressive treatment of RA. With predicted shortages in the rheumatology workforce and maldistribution of rheumatology providers, PCPs may play an increasingly important role in caring for older adults with RA. Further research is needed to understand to optimize appropriate use of DMARDs in older patients with RA.

Risk factors associated with initiation of a biologic disease modifying anti-rheumatic drug in patients with rheumatoid arthritis: A nested case-control study on 34,925 patients.

To identify risk factors of biological disease-modifying anti-rheumatic drugs (bDMARDs) initiation in patients with rheumatoid arthritis (RA). Using the 2002-2016 Korea National Health Insurance database, we conducted a nested case-control study on seropositive RA patients. Cases (bDMARD users) and controls (users of conventional synthetic DMARDs only) were 1:4 matched on the calendar year/month of RA diagnosis and index dates (bDMARD initiation dates). Potential risk factors from two time periods, 1-year post-RA-diagnosis and 1-year pre-index, were separately assessed on the association with bDMARD initiation by conditional logistic regression analyses. The study included 6985 cases and 27,940 controls. Older age, female gender, use of methotrexate (MTX), leflunomide, or tacrolimus as a first csDMARD, higher initial MTX dose, and initial csDMARD combination during 1-year post-diagnosis were negatively associated with later bDMARD initiation, while use of sulfasalazine as a first csDMARD, corticosteroid therapy, and higher maximal MTX dose were positively associated. Among covariates from 1-year period before bDMARD initiation, use of leflunomide, sulfasalazine, or tacrolimus, parenteral MTX, higher maximal MTX dose, corticosteroid, and csDMARD combination were positively associated with subsequent bDMARD initiation. Effects of comorbidities on bDMARD initiation were heterogenous across involved systems. In this population-based nationwide study, we identified period-specific risk factors of bDMARD initiation among RA patients in Korea. Overall, initial aggressive RA treatment after diagnosis was associated with less use of later bDMARD, while highly intensive therapy observed just before bDMARD initiation rather reflects refractory nature of RA during this period, and did not prevent bDMARD use.

Nail-bed infarctions as a paradoxical effect of abatacept in rheumatoid arthritis

Objective: Evaluating a group of Rheumatoid Arthritis (RA) patients under abatacept therapy regarding the risk of developing vasculitis. Methods: An exploratory study was conducted on RA patients with ongoing combined methotrexate/ abatacept therapy and reporting a case who developed small-vessel vasculitis. Follow-up visits with thorough clinical examination and routine laboratory investigations were done every 3-6 months. Disease activity was assessed by the Clinical Disease Activity Index (CDAI). Functional assessment was done by Health Assessment Questionnaire (HAQ) score. Results: Sixteen biologic-naive female patients with newly diagnosed moderate-to-severe RA under abatacept therapy (mean age, 44 ± 10.86 years) were enrolled in this study. The mean disease duration was 4.63 ± 2.20, mean duration of methotrexate/abatacept therapy was 22.75 ± 9.40 months. All over the follow-up periods, patients were clinically improved with low disease activity score and within normal laboratory investigations apart from rising titers of Sedimentation Rate (ESR) and C-Reactive Protein (CRP). One patient was presented by nail-bed infarctions after 15 months follow-up of abatacept therapy. Abatacept–induced small-vessel vasculitis was the most likely diagnosis. The remaining 15 patients still clinically free of any manifestations suggesting vasculitis. Conclusion: Abatacept can induce vasculitis in RA patients having risk factors for RV. Combination therapy of methotrexate/abatacept may be a delaying or inhibiting factor in the appearance of RV manifestations. Persistently elevated acute phase reactants despite clinical and laboratory improvement on early aggressive treatment of RA is an alarm for a possibly imminent vasculitis.

Diastolic dysfunction in rheumatoid arthritis: a usual travel-mate?

A high rate of left ventricular diastolic dysfunction (LVDD) has been described in rheumatoid arthritis (RA), compared with general population. A prospective study demonstrated that LVDD occurred in 24% in one year of follow-up in RA patients without cardiac disease. Older age, higher systolic arterial pressure and lower E/A ratio are considered predictive factors. In addition, in RA, LVDD is known to be the only risk factor for the development of cardiovascular (CV) events, also in absence of classical CV risk factors. Some occasional reports suggest that early and aggressive treatment of RA could influence the evolution of LVDD and, accordingly, modify the rate of CV events. Therefore, a correct assessment of diastolic function should be considered of pivotal importance in the routine follow-up of RA patients.

PSY148 - PRIMARY NON-ADHERENCE AMONG NEWLY DIAGNOSED RHEUMATOID ARTHRITIS PATIENTS

To describe the prescription and use of conventional and biologic disease modifying anti-rheumatic drugs (DMARD) use within one year following a new rheumatoid arthritis (RA) diagnosis. The IBM MarketScan Explorys Claims-EMR Data Set was used to identify adult patients with newly diagnosed RA from 2012-2017; the new diagnosis of RA was the index event. Patients were required to have two RA diagnoses at least 14 days apart, continuous enrollment for one year pre- and post-index, and EMR activity during the one-year follow-up period. Patients with prior RA diagnosis or use of an RA biologic were excluded. The primary outcomes were presence and timing of a prescription claim and/or physician order for a conventional or biologic DMARD. A total of 2,732 adults met the study inclusion criteria. Overall, 58.1% of patients received a conventional or biologic DMARD within one year of their new RA diagnosis. An additional 4.7% of newly diagnosed patients had a physician order for a DMARD but no corresponding fill or treatment receipt. Overall, 279 (10.2%) patients started a new biologic within one year post-index and an additional 32 patients (1.2%) had a physician order for a biologic DMARD but no corresponding fill. Put differently, 10.3% of newly diagnosed RA patients with a new physician prescription for an RA biologic do not receive that biologic. Of these patients, approximately two-thirds (62.5%) did receive a conventional DMARD, driven by methotrexate (70.0%). Overall, 56.8% of patients used a conventional DMARD and an additional 4.9% had a physician order for a conventional DMARD but no corresponding fill; non-fill rates were similar between methotrexate and the other conventional DMARDs. Clinical treatment guidelines recommend early and aggressive treatment of RA, however, one-in-ten patients prescribed a biologic DMARD and one-in-twelve prescribed a conventional DMARD do not receive one.

Preliminary study for predicting better methotrexate efficacy in Japanese patients with rheumatoid arthritis.

BackgroundRheumatoid arthritis (RA) is a chronic autoimmune disease characterized by systemic inflammatory status, joint destruction, disability, and pain. Methotrexate (MTX) has been confirmed to reduce disease activity and delay or stabilize the development of bone erosions. However, major drawbacks are that patients show great interindividual variability in response to MTX and the unpredictable occurrence of side effects. A strategy for personalized MTX treatment to predict its efficacy and toxicity has not yet been determined.To establish personalized MTX therapy in Japanese patients with rheumatoid arthritis, we performed a preliminary study for predicting better methotrexate efficacy including single-nucleotide polymorphisms (SNPs) for MTX-related transporters/enzymes.MethodsDisease control status (good or poor) was judged by the number of Disease Activity Scores (DAS28) of <2 for 6–12 months. The response index R was calculated by the improved area under the curve (AUC) of the DAS28 score for 0–3 or 0–6 months by dividing the cumulative dose of MTX during 0–3 or 0–6 months, respectively. Genotyping of alleles of RFC1 80G > A, RFC1 –43 T > C, FPGS 1994G > A, GGH 401C > T, MTHFR 1298A > C, and TYMS 3'-UTR (−6/+6) was performed using the real-time PCR system.ResultsSeven of 21 patients were judged as good responders in terms of disease control, and the remainder as poor responders. For 0–3 months after starting MTX administration, the median cumulative dose and improved DAS28 AUC in the good and poor response groups were 96.0 mg and 25.4 and 118.0 mg and 23.4, respectively. For 0–6 months, the median cumulative dose and improved DAS28 AUC in the good and poor response groups were 192.0 mg and 51.0 and 214.0 mg and 47.6, respectively. Statistically significant differences between the 2 groups in the 0–6-month period were observed in DAS28 AUC improvement and index R. A slight tendency for a correlation between G/G genotypes and A allele genotypes in RFC1 80 genotypes was observed, although it did not reach statistical significance.ConclusionThis study suggested that aggressive RA treatment with MTX from the early period of administration is necessary to obtain a good response after 6 months, although no SNPs predicting a better treatment response to MTX were identified.

Rheumatoid arthritis is still expensive in the new decade: a comparison between two early RA cohorts, diagnosed 1996–98 and 2006–09

Objectives: To calculate total costs during the first year after diagnosis in 463 patients with early rheumatoid arthritis (RA) included during 2006–09 (T2) and compare the results with a similar cohort included in 1996–98 (T1).Method: Clinical and laboratory data were collected regularly in both cohorts, and patients completed biannual questionnaires reporting health care utilization and number of days lost from work.Results: Disease activity was similar in both cohorts T1 and T2 at inclusion. Significant improvements were seen during the first year in both cohorts but were more pronounced in T2. Outpatient care increased and hospitalization decreased in T2 compared with T1. Almost 3% of patients had surgery in both cohorts, but in T2, only women had surgery. Drug costs were higher in T2 than in T1 (EUR 689 vs. EUR 435). In T2, 12% of drug costs were direct costs and 4% were total costs. The corresponding values for T1 were 9% and 3%. In T1, 50% were prescribed disease-modifying anti-rheumatic drugs (DMARDs) at inclusion, compared to T2, where prescription was > 90%. Direct costs were EUR 5716 in T2 and EUR 4674 in T1. Costs for sick leave were lower in T2 than in T1 (EUR 5490 vs. EUR 9055) but disability pensions were higher (EUR 4152 vs. EUR 2139), resulting in unchanged total costs. In T1, direct costs comprised 29% and indirect costs 71% of the total costs. The corresponding values for T2 were 37% and 63%.Conclusions: The earlier and more aggressive treatment of RA with traditional DMARDs in T2 resulted in better outcomes compared to T1. Direct costs were higher in T2, partly offset by decreased sick leave, but total costs remained unchanged.

AB0346 Renal Insufficiency in Rheumatoid Arthritis – A Retrospective Clinicopathologic Study of 161 Autopsy Patients

BackgroundRenal insufficiency and/or uremia are one of the most important causes of death in rheumatoid arthritis (RA) due to AA amyloidosis (AAa), glomerulonephritis, pyelonephritis, interstitial nephritis or other reasons.ObjectivesThe aim...

Possible Association of Etanercept, Venous Thrombosis, and Induction of Antiphospholipid Syndrome

Tumor necrosis factor α (TNF α) inhibitors are commonly used for treatment of aggressive rheumatoid arthritis and other rheumatic diseases. Etanercept is one of the medications approved for treatment of rheumatoid arthritis. Though many studies have documented the safety and efficacy of these medications, evidence for adverse effects is emerging including cancer, infections, and cardiovascular disease. There have been studies showing that these medications induce autoantibody production, including antinuclear antibodies and anti-dsDNA antibodies. Limited data exists, however, regarding induction of antiphospholipid antibodies (APLs) by TNF α inhibitors, including anticardiolipin antibodies (ACLs), lupus anticoagulant (LAC), and anti-β 2-glycoprotein I (anti-β 2 GPI), or an association between antibody development and clinical manifestations. In this case series, we describe five patients who developed venous thromboembolism (VTE) and APLs while receiving etanercept therapy. All five of our patients met the criteria for diagnosis of APS after receiving etanercept. Our case series supports the association between etanercept, APLs, and VTE. We believe that testing for APLs prior to initiation of anti-TNF therapy is reasonable, given this relationship and the risks associated with VTE.

FRI0060 Trends in baseline disease activity, response and remission rates in rheumatoid arthritis (RA) during the last decade: Results from the nor-DMARD register

BackgroundDuring the past decade there has been an increasing focus on early, aggressive treatment, and combined with the availability of biologicals this will likely lead to improved outcomes in patients...

The new European League Against Rheumatism/American College of Rheumatology diagnostic criteria for rheumatoid arthritis

This era of early aggressive treatment of rheumatoid arthritis (RA) calls for criteria that allow timely classification of patients at risk of persistent erosive disease. We review how the new American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria meet up to this challenge. The new 2010 ACR/EULAR classification criteria for RA were developed using initiation of methotrexate as anchor in a population with undifferentiated arthritis. Many studies from different countries have now been published that have addressed the performances of these new criteria. The goal of earlier classification of RA seems to be met with the new criteria, but exclusion of other diagnoses is essential. Increased sensitivity comes at the price of loss of specificity and indiscriminate use of these classification criteria as a diagnostic tool carries the risk of overtreatment.

New imaging techniques in reumathology: MRI, scintigraphy and PET

SummaryThe first-line imaging technique for diagnosis inflammation in musculo-skeletal organs in rheumatoid arthritis (RA) is planar X-ray examination, which was for many years the first and the only single tool for RA diagnostics and response evaluation. Today, in the era of more aggressive RA treatment, ultrasound examination (US) and magnetic resonance imaging (MRI) are also frequently used. US is used to detect early signs of inflammation within the soft tissue. MRI allows to assess the soft tissue and bone marrow involvement in case of inflammation and/or infection. MRI is capable of detecting more inflammatory lesions and erosions than US, X-ray, or CT. Standard scintigraphy plays a crucial role, and data from positron emission tomography (PET) are also promising. These functional imaging techniques are used in detection of inflammation and/or infection in case of ambiguous results being obtained by other techniques or at other clinics. In patients with RA, scintigraphy plays a key role in the differential diagnosis of hip, knee, etc. endoprosthesis disorders, including mechanical or septic loosening.

Incorporating the treat-to-target concept in rheumatoid arthritis.

Recent publications have proposed revisions to disease classification criteria, new definitions of remission, and guidelines for implementing treat-to-target strategies for the management of patients with rheumatoid arthritis (RA). Despite developments leading to this practice-changing approach, the concept of treat to target has not yet been widely accepted or implemented in managed care. At the 24th Annual Meeting Expo of the Academy of Managed Care Pharmacy (AMCP), held in San Francisco on April 18, 2012, a 4-hour activity titled Incorporating New Treat-to-Target Guidance and Strategies in RA: What Managed Care Needs to Know was conducted in association with AMCP's Continuing Professional Education Partner Program. The practicum featured didactic presentations, a roundtable session, and an expert panel discussion detailing research evidence, ideas, and discussion topics central to the treat-to target concept in RA and its applications to managed care. To (a) discuss recent advances in RA management, (b) evaluate strategies to optimize the use of disease-modifying antirheumatic drugs(DMARDs), and (c) explain how to incorporate the treat-to-target paradigm in contemporary clinical practice and clinical care models in order to improve outcomes for patients. The past decade has seen a tremendous amount of change in the field of rheumatology. The early and aggressive treatment of RA, including the use of novel biologic agents, has been shown to have favorable patient outcomes in reducing synovial inflammation, delaying joint damage,and maintaining functional status, leading to the recently published revisions in classification criteria and updated recommendations for the utilization of conventional DMARDs and biologic agents in the treatment of RA. The revised classification criteria can be used to diagnose RA patients at an earlier point in the disease course by placing greater emphasis on clinical features that manifest early in the disease process. The concept of achieving tight control of RA and treating to target has been well established and utilizes early diagnosis, aggressive treatment, and regular monitoring,leading to positive outcomes in a significant number of patients with RA who achieve current treatment goals of low levels of disease activity or clinical remission.

Managed Care Strategies for Improving Patient Outcomes in Rheumatoid Arthritis

BACKGROUND: Rheumatoid arthritis (RA) is a chronic, systemic autoimmune inflammatory disease that affects approximately 1% of the population. Initial symptoms include joint swelling, stiffness, and tenderness, which are all causes of disability. The diagnosis of RA is based on patient history of joint pain and stiffness, the documentation of symmetric polyarticular joint synovitis, and laboratory measures including radiographs, inflammatory markers, and autoantibodies. As the disease progresses, synovial inflammation leads to cartilage damage, bone erosions, and joint destruction, the major causes of long-term disability. RA is associated with many comorbidities and complications, including cardiovascular disease, which is responsible for higher rates of mortality among patients compared with the general population. Over the past 2 decades, advances in the development of synthetic disease-modifying antirheumatic drugs (DMARDs) and biologic agents for RA have markedly changed treatment goals and management strategies. OBJECTIVES: To review recent updates in the diagnosis and treatment of RA, as well as the importance of early and aggressive treatment and management strategies. SUMMARY: Borrowing from other medical fields, a paradigm of “tight control” of RA has been supported by evidence and is gaining wide acceptance in rheumatology. In 2010, the American College of Rheumatology and the European League Against Rheumatism (EULAR) published revised classification criteria for RA, which will assist in the diagnosis of early RA and facilitate appropriate treatment intervention. Over the last decade, many patients on biologic agents have demonstrated that early and aggressive treatment of RA is beneficial in treating synovial inflammation, delaying joint damage, and improving patient outcomes. Contemporary management strategies based on early diagnosis, aggressive treatment, and regular monitoring have helped a significant number of patients with RA achieve current treatment goals of low levels of disease activity and, in some cases, clinical remission. J Manag Care Pharm. 2011;17(9-b):S3-S8 Copyright © 2011, Academy of Managed Care Pharmacy. All rights reserved. Rheumatoid arthritis (RA) is a chronic, systemic autoimmune inflammatory arthritis that affects approximately 1% of the population.1 The disease affects people of all ages but is most common from the ages of 40-70 years.1 Initially polyarticular synovial inflammation, leading to joint swelling, stiffness, and tenderness, is the major cause of disability. Over time synovial inflammation leads to cartilage damage, bone erosions, and joint destruction, the major causes of long-term disability. In addition, patients with RA have increased mortality compared with the general population, largely attributed to an increased risk of cardiovascular disease.2 The burden of illness of RA not only impacts patients and families but also society through sick leave, loss of work productivity, and utilization of health care, stressing the importance of effective management of RA.3 Over the past 2 decades, optimal use of synthetic diseasemodifying antirheumatic drugs (DMARDs) and/or biologic agents has proven highly effective in treating inflammation, delaying joint damage, and improving patient outcomes. The goals of treatment have expanded from the treatment of inflammation and achievement of a low disease activity state, to the realistic goal of achieving and maintaining clinical remission in a significant number of patients. In addition to treating inflammation, the inhibition of progressive joint destruction is also an important goal. Finally, by using DMARDs and biologic agents, physicians and their patients are striving to decrease pain and stiffness associated with inflammation, retard progressive structural joint damage, reduce RA comorbidities, restore function and quality of life, and help patients to maintain their societal roles. It is commonly accepted that early intervention leads to improved patient outcomes. This paradigm is supported by a number of clinical trials. Therefore, it is critical that patients with symptoms of RA are identified early and referred to specialists with experience in treating RA, which will facilitate initiation of disease-modifying therapy that can be systematically modified in the pursuit of the treatment goals. In this article, we will review recent updates in the diagnosis and treatment of RA as well as the importance of early and aggressive treatment. Diagnosing Rheumatoid Arthritis The diagnosis of RA is a clinical diagnosis that combines the patient history of joint pain and stiffness, the physical examination documentation of symmetric polyarticular joint swelling (synovitis), and the laboratory tests including radiographs, inflammatory markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]), and autoantibodies (rheumatoid factor [RF] and anti-cyclic citrullinated peptide antibodies

Cost-effectiveness of Adding Magnetic Resonance Imaging to Rheumatoid Arthritis Management

Early, aggressive treatment of rheumatoid arthritis (RA) improves outcomes but confers increased risk. Risk stratification to target aggressive treatment of high-risk individuals with early RA is considered important to optimize outcomes while minimizing clinical and monetary costs. Some advocate the addition of magnetic resonance imaging (MRI) to standard RA risk stratification with clinical markers for patients early in the disease course. Our objective was to determine the incremental cost-effectiveness of adding MRI to standard risk stratification in early RA. Using a decision analysis model of standard risk stratification with or without MRI, followed by escalated standard treatment protocols based on treatment response, we estimated 1-year and lifetime quality-adjusted life-years, RA-related costs, and incremental cost-effectiveness ratios (with MRI vs without MRI) for RA patients with fewer than 12 months of disease and no baseline radiographic erosions. Inputs were derived from the published literature. We assumed a societal perspective with 3.0% discounting. One-year and lifetime incremental cost-effectiveness ratios for adding MRI to standard testing were $204,103 and $167,783 per quality-adjusted life-year gained, respectively. In 1-way sensitivity analyses, model results were insensitive to plausible ranges for every variable except MRI specificity, which published data suggest is below the threshold for MRI cost-effectiveness. In probabilistic sensitivity analyses, most simulations produced lifetime incremental cost-effectiveness ratios in excess of $100,000 per quality-adjusted life-year gained, a commonly cited threshold. Under plausible clinical conditions, adding MRI is not cost-effective compared with standard risk stratification in early-RA patients.

The value of early intervention in RA—a window of opportunity

Rheumatoid arthritis (RA) is associated with progressive joint destruction, with functional status influenced by both disease activity and radiographic progression. The case for early aggressive treatment of RA is based on large amounts of good data in many countries. Studies with conventional disease-modifying anti-rheumatic drugs in early RA have shown improved outcomes compared with later treatment, especially if an aggressive approach with combinations of drugs is used. Early intervention with tumour necrosis factor (TNF) inhibitors has been shown to improve clinical outcomes, induce remission and prevent radiographic progression. It also improves patients' functional status, health-related quality of life, and reduces fatigue. Patients with RA have reduced productivity, an increased number of lost work days and retire early; enabling patients to work should be at the core of a therapy's cost-effectiveness. Introduction of anti-TNF therapy early in RA has been shown to decrease job loss and reduce the amount of working time missed. Although the drug costs of initial treatment with combination therapy including a TNF inhibitor are high, these may be compensated by the reduction in lost productivity, making such a strategy cost-effective overall. In addition, some patients who respond well to combination therapy may be able to stop the TNF inhibitor. It is important to assess the benefits of any intervention not just to healthcare costs but to society as a whole, and physicians should be advocates for optimal access to effective therapies for their patients.

Immunologic rheumatic disorders

We provide the basics for clinicians who might be called on to consider the diagnosis of diseases such as systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) in their practice. We will emphasize clinical recognition and first-line laboratory testing. Only characteristics of the classic rheumatic inflammatory diseases (ie, RA, seronegative spondyloarthropathy, SLE, antiphospholipid syndrome, Sjögren syndrome, scleroderma, and polymyositis/dermatomyositis) will be covered. In the past decade, treatment for RA and seronegative spondyloarthropathy has substantially improved. Their treatment has been revolutionized by the use of methotrexate and, more recently, TNF inhibitors, T-cell costimulation modulators, and B-cell depletion. The goal of RA treatment today is to induce a complete remission as early as possible in the disease process, with the mantra being "elimination of synovitis equals elimination of joint destruction." The hope is that if the major mediators of Sjögren syndrome, SLE, or scleroderma can be identified and then blocked, as in the example of TNF inhibitors in patients with RA, more specific treatments will become available. Thus RA has become an excellent model of this evolving paradigm. Through the identification of major mediators in its pathogenesis, novel and highly efficacious therapeutic agents have been developed.

Should neurologists wait and see or see and treat RRMS?

AbstractEarly and aggressive treatment of rheumatoid arthritis (RA) is now regarded as best practice to limit irreversible joint damage. However, in the case of relapsing remitting multiple sclerosis (RRMS), current guidelines recommend that disease modifying therapy should only be initiated in patients with evidence of actively progressing disease. Here, the authors present the key findings of the Programme Identifying and Observing Novel Therapy Adoption in Chronic Diseases (PIONEER) study to examine the reasons for these different management approaches. Copyright © 2009 Wiley Interface Ltd

Permanent renal loss following tumor necrosis factor α antagonists for arthritis

Tumor necrosis factor alpha (TNF-alpha) antagonists are now widely used in the treatment of aggressive rheumatoid arthritis and are generally well tolerated. Although rare, they could induce systemic lupus erythematosus, glomerulonephritis, and antineutrophil cytoplasmic antibody associated systemic vasculitis. Tumor necrosis factor alpha antagonists associated glomerulonephritis usually subsides after discontinuation of the therapy and subsequent initiation of corticosteroids and immunosuppressive agents. Here we describe crescentic glomerulonephritis progression to end-stage renal disease in a patient following two doses of TNF-alpha antagonists for the treatment of reactive arthritis. To our knowledge, dialysis dependent permanent renal loss after TNF-alpha antagonists has not yet been reported. We suggest the renal function should be closely monitored in patients treated with TNF-alpha antagonists by rheumatologists.