Arthritis Medication Research Articles

Neutrophil-lymphocyte and platelet-lymphocyte rate and their seasonal differences in ankylosing spondylitis and rheumatoid arthritis patients using anti-TNF medication.

In recent years, neutrophil-lymphocyte rate (NLR) and platelet-lymphocyte rate (PLR) are reported to be increasing in plenty of rheumatological diseases and the latter rates to be disease activity indicators. In our study, we aimed to search for the difference in NLR and PLR before and after the treatment, their relationship with the disease activity and their seasonal differences in patients using anti-TNF medication for rheumatoid arthritis (RA) and ankylosing spondylitis (AS) while. Sixty-eight RA and 203 AS patients using anti-TNF medication for at least 6 months were included in the study. Patients with acute infection, diabetes, hypertension, cancer, renal failure and liver failure were excluded from the study. NLR, PLR, seasonal differences and the disease activities of the patients were evaluated retrospectively. We determined that NLR and PLR are strongly correlated with disease activity, erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP). In addition, we determined that disease activity, thrombocytes and PLR are increased in spring and winter, especially in patients with RA. NLR and PLR are simple, cheap, and easily accessible parameters which can be used to evaluate disease activity and treatment response before and after anti-TNF treatment. Further studies are needed to enlighten the effect of seasonal differences on disease activity (Tab. 2, Fig. 2, Ref. 43).

Imaging of the Temporomandibular Joint in Juvenile Idiopathic Arthritis: How Does Quantitative Compare to Semiquantitative MRI Scoring?

Contrast-enhanced magnetic resonance imaging (MRI) is commonly used to evaluate temporomandibular joint (TMJ) disease in patients with juvenile idiopathic arthritis (JIA). However, MRI assessments have been limited by qualitative reporting, the presence of enhancement in normal joints, and a lack of standardized protocols. The purpose of the present study was to compare a quantitative MRI analysis using an enhancement ratio (ER) to a new semiquantitative system developed by Outcome Measures in Rheumatology and Clinical Trials (OMERACT). We performed a retrospective cross-sectional study of children with JIA who had undergone TMJ MRI with gadolinium enhancement at Boston Children's Hospital. The predictor variables were demographic data (sex, age at MRI) and disease-related findings (JIA subtype and arthritis medication at MRI). The outcome variables were OMERACT scores and ER (ratio of TMJ synovium and longus capitis muscle pixel intensities). The ER was compared with the OMERACT total, inflammatory, and damage scores using Pearson's correlation analysis and multivariable linear regression. Statistical significance was evaluated using the Student t test and analysis of variance with significance set at P<.05. Inter- and intraexaminer reliability were evaluated using intraclass correlation coefficients (ICCs). The sample included 50 subjects (84% female) with a mean age of 12.7±3.9years and 124 MRI scans. The mean ER was 2.5±0.9 (normal, <1.55). The mean OMERACT total was 4.9±3.3. Controlling for age, sex, JIA subtype, and medication, for every 1-U increase in ER, the OMERACT increased by 3.11 for the total (P<.001), 1.01 for the inflammatory (P<.001), and 0.86 for the damage (P<.001) scores. The intra- and interrater consistency was better for the ER (ICC, 0.83 and 0.96, respectively) than for OMERACT (ICC, 0.77 and 0.35, respectively). Quantitative evaluation of TMJ synovial enhancement using the ER is easier to score and has superior intra- and interrater agreement; however, it can only assess inflammation. Semiquantitative assessment of TMJ using the OMERACT adds data about chronic changes. Using both systems might provide the most accurate assessment of JIA status.

Refinements to captive chimpanzee (Pan troglodytes) care: a self-medication Paradigm.

In an effort to enhance welfare, behavioural management continually refines methods of non-human primate (NHP) care. Chimpanzees (Pan troglodytes) are one of the most cognitively complex captive NHPs and they have been observed to self-medicate in the wild. The population of captive chimpanzees in the US is aged (due to a breeding moratorium instituted in 1998) and will progressively require more medical care as they get older. To functionally simulate natural self-medication behaviour, provide chimpanzees with the opportunity to voluntarily participate in their own healthcare, and open new avenues of communication between caregivers and chimpanzees, we used a medication choice paradigm that allowed chimpanzees to choose their daily arthritis medication. We provided four arthritic, mobility-impaired chimpanzees with meloxicam or ibuprofen in blue or green Gatorade® to establish associations between the coloured drinks and the effects of the medications. We subsequently gave each chimpanzee a choice between the two medications. Behaviour was recorded using 15-min focal animal observations. Mobility was assessed using interactive mobility tests and a caregiver-rating system. One chimpanzee showed a medication preference (ibuprofen over meloxicam). The chimpanzees exhibited no significant behavioural or mobility differences over time, suggesting that ibuprofen and meloxicam may not differ significantly in their ability to alleviate arthritic symptoms. Whether or not the chimpanzees show a medication preference, the opportunity to make meaningful choices and the functional simulation of a complex behaviour, self-medication, is present when using this medication choice technique. Furthermore, the paradigm itself could have potential applications for additional medication options and treatment regimens.

TAILA DHARA IN NIDRANASHA W.S.R. TO INSOMNIA

ABSTRACT Ayurveda says Nidra yuktam Sukham Dukkham, In fact, it says that sleep is one of the three pillars of health. Insomnia or Nidranasha, is not just about being not getting proper sleep but it means that the nervous system has been weakened and reduces our ability to cope up with daily sleep. Insomnia is named as Nidranasha, happens due to vitiation of Kapha, Pitta and Vata dosha. Proper and deep sleep helps the person keep Energetic, Enthusiastic, does Brumhana, increases the Bala, increases vigour and vitality and most it keeps the Mind in stable state for gaining knowledge. Insomnia means inability to get sleep at night or inability to have a restful and sound sleep. Insomnia is typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. Insomnia can be short term, lasting for days or weeks, or long term, lasting more than a month. Insomnia can occur independently or as a result of another problem. Conditions that can result in insomnia include psychological stress, chronic pain, heart failure, hyperthyroidism, heartburn, Alzheimer’s disease and Parkinson’s disease, Arthritis, menopause, and certain medications, and drugs such as caffeine, nicotine, and alcohol. Treatment of Insomnia:- Panchakarma – Taila dhara a type of Shirodhara is very much useful in combacting the Insomnia caused due to various above said disorders. So its a demand of time to know about the real sleep and the disturbed sleep according to Ayurveda and Mordern medicines also and effect of Taila Dhara Brahmi,Jatamamsi siddha) in treating Insomnia.

Patients' and nurses' preferences for autoinjectors for rheumatoid arthritis: results of a European survey.

PurposeThis survey investigated patients’ and nurses’ preferences among four different autoinjectors used for subcutaneous delivery of medication for rheumatoid arthritis (RA).MethodsIn a multinational survey in five countries, 200 patients with RA and 100 nurses training patients on the use of autoinjectors participated in face-to-face interviews. Respondents were asked to rate the importance of eleven autoinjector attributes and to compare the autoinjectors for etanercept (Enbrel®, MyClic® autoinjector), adalimumab (Humira®, Humira pen), and an etanercept biosimilar (Benepali®, Molly® autoinjector) with a demonstration autoinjector for a new etanercept biosimilar – Erelzi® (SensoReady® autoinjector).ResultsEasy grip and ease of performing self-injection were the most important attributes identified by both groups. Overall, 79% of the patients rated the SensoReady autoinjector easier to use than their currently used injection device (86% of MyClic users, 84% of Humira pen users, and 63% of Molly users). In the patient survey, the SensoReady performed better than the other autoinjectors on the attributes visual feedback after completion of injection, easy to grip, and convenient shape. Nurses also rated the SensoReady easier to use than the MyClic (95%), Humira pen (97%), or Molly (91%). When asked which autoinjector they would recommend to a patient with RA who had not used an autoinjector before, 81% of patients and 90% of nurses selected the SensoReady.ConclusionBoth patients and nurses perceived the SensoReady to be easier to use compared with other available injection devices. The main reasons for this preference were the buttonless injection, 360° viewing window for feedback (visual confirmation of dose injection), and convenient triangular shape making the injection device easy to grip. Patients and nurses were most likely to recommend the SensoReady autoinjector over other autoinjectors to patients with RA.

Prediction of primary non-response to methotrexate therapy using demographic, clinical and psychosocial variables: results from the UK Rheumatoid Arthritis Medication Study (RAMS)

BackgroundMethotrexate (MTX) remains the disease-modifying anti-rheumatic drug of first choice in rheumatoid arthritis (RA) but response varies. Predicting non-response to MTX could enable earlier access to alternative or additional medications and control of disease progression. We aimed to identify baseline predictors of non-response to MTX and combine these into a prediction algorithm.MethodsThis study included patients recruited to the Rheumatoid Arthritis Medication Study (RAMS), a UK multi-centre prospective observational study of patients with RA or undifferentiated polyarthritis, commencing MTX for the first time. Non-response to MTX at 6 months was defined as “no response” using the European League Against Rheumatism (EULAR) response criteria, discontinuation of MTX due to inefficacy or starting biologic therapy. The association of baseline demographic, clinical and psychosocial predictors with non-response was assessed using logistic regression. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC) and calibration plots.ResultsOf 1050 patients, 449 (43%) were classified as non-responders. Independent multivariable predictors of MTX non-response (OR (95% CI)) were rheumatoid factor (RF) negativity (0.62 (0.45, 0.86) for RF positivity versus negativity), higher Health Assessment Questionnaire score (1.64 (1.25, 2.15)), higher tender joint count (1.06 (1.02, 1.10)), lower Disease Activity score in 28 joints (0.29 (0.23, 0.39)) and higher Hospital Anxiety and Depression Scale anxiety score (1.07 (1.03, 1.12)). The optimism-corrected AUC was 0.74.ConclusionsThis is the first model for MTX non-response to be developed in a large contemporary study of patients commencing MTX in which demographic, clinical and psychosocial predictors were considered. Patient anxiety was a predictor of non-response and could be addressed at treatment commencement.

Gout prevalence and predictors of urate-lowering therapy use: results from a population-based study

BackgroundGout has an increasing global prevalence. Underutilization of urate-lowering therapy (ULT) is thought to be common, via both suboptimal dosing and poor medication adherence. The aims of this study were to determine the prevalence of self-reported gout and the key predictors of ULT use in those with gout in a representative population survey in South Australia.MethodsData were obtained from the Spring 2015 South Australian Health Omnibus Survey, a multilevel, systematic, survey in a representative population sample involving face-to-face interviews (n = 3005). This study analyzed responses from respondents aged ≥ 25 years (n = 2531) about self-reported gout, ULT use, sociodemographic factors, lifestyle factors, and comorbidities, using survey weighting. Univariate and subsequent adjusted logistic regression analyses on self-reported gout were performed. ULT use was divided into three categories (never use, prior use, and current use) and these data were analyzed using a multinomial logistic regression model.ResultsSelf-reported gout prevalence was 6.8% (95% CI 5.8, 7.9). The mean age of respondents with gout was 64 years (standard deviation 16) and 82% were male. As expected, older age, male gender, lower socioeconomic status (SES), and higher body mass index (BMI) were associated with gout, as were high alcohol consumption, current smoking, other forms of arthritis, and hypertension or hypercholesterolemia medication, after adjustment for sociodemographic variables. Two thirds of respondents with gout reported ULT use (36% current; 29% previous) with only 55% continuing treatment. Predictors of ULT use included male gender, low SES, and concomitant cholesterol-lowering therapy. Respondents with gout with a higher BMI were more likely to remain on ULT.ConclusionsDespite gout being a common, potentially disabling joint disease, only 55% of respondents with gout in this study adhered to ULT. Identification of key predictors of ULT use will provide guidance on prescribing strategy in clinical practice and on the quality of gout care in the community.

089 The association between poor prognostic factors at methotrexate initiation and disease activity and disability over one year: results from the Rheumatoid Arthritis Medication Study

089 The association between poor prognostic factors at methotrexate initiation and disease activity and disability over one year: results from the Rheumatoid Arthritis Medication Study

The Efficacy and Safety of Mainstream Medications for Patients With cDMARD-Naïve Rheumatoid Arthritis: A Network Meta-Analysis.

Background: The mainstream medications for rheumatoid arthritis (RA) include conventional disease-modifying antirheumatic drugs (cDMARDs), which mostly are methotrexate (MTX), and biologic agents such as adalimumab (ADA), certolizumab (CZP), etanercept (ETN), golimumab (GOL), infliximab (IFX), and tocilizumab (TCZ). This network meta-analysis was aimed at evaluating the efficacy and safety of the medications above and interventions combining cDMARDs and biologic agents for patients with RA.Methods: PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov were searched systematically for eligible randomized controlled trials (RCTs). Outcomes concerning efficacy and safety were evaluated utilizing odds ratios (ORs) and 95% credible intervals (CrI). The outcomes of efficacy would be evaluated through remission and American College of Rheumatology (ACR) scores. The surface under the cumulative ranking curve (SUCRA) was calculated to rank each treatment on each index.Results: A total of 20 RCTs with 9,047 patients were included, and the efficacy and safety of the concerning interventions for RA were evaluated. Compared with cDMARDs alone, TCZ+MTX, ETN+MTX, IFX+MTX, TCZ, and ADA+MTX showed significant statistical advantage on ACR20, ACR50, and ACR70. Apart from that, as for remission, TCZ+MTX, IFX+MTX, TCZ, and CZP+MTX performed better compared to cDMARDs alone. The SUCRA ranking also indicated that TCZ+MTX was the intervention with best ranking in the entire four efficacy indexes followed by ETX+MTX and IFX+MTX. However, there was no obvious difference among these medications compared with cDMARDs when it comes to safety, which need more specific studies on that.Conclusion: TCZ+MTX was potentially the most recommended combination of medications for RA due to its good performance in all outcomes of efficacy. ETX+MTX and IFX+MTX, which also performed well, could be introduced as alternative treatments. However, considering the adverse events, the treatments concerning should be introduced with caution.

Oral Therapies for Multiple Sclerosis.

Multiple sclerosis treatment faces tremendous changes owing to the approval of new medications, some of which are available as oral formulations. Until now, the four orally available medications, fingolimod, dimethylfumarate (BG-12), teriflunomide, and cladribine have received market authorization, whereas laquinimod is still under development. Fingolimod is a sphingosine-1-phosphate inhibitor, which is typically used as escalation therapy and leads to up to 60% reduction of the annualized relapse rate, but might also have neuroprotective properties. In addition, there are three more specific S1P agonists in late stages of development: siponimod, ponesimod, and ozanimod. Dimethylfumarate has immunomodulatory and cytoprotective functions and is used as baseline therapy. Teriflunomide, the active metabolite of the rheumatoid arthritis medication leflunomide, targets the dihydroorotate dehydrogenase, thus inhibiting the proliferation of lymphocytes by depletion of pyrimidines. Here we will review the mechanisms of action, clinical trial data, as well as data about safety and tolerability of the compounds.

Association between physical health and cardiovascular diseases: Effect modification by chronic conditions.

Objectives:This study assessed whether the physical component summary score of the RAND-36 health-related quality-of-life survey was associated with incidence of coronary heart disease, stroke, congestive heart failure, angina, or peripheral arterial disease, and whether baseline chronic conditions modified these associations.Methods:Analysis was limited to 69,155 postmenopausal women (50–79 years) in the Women’s Health Initiative Study who had complete data on the RAND-36, the outcomes, and covariates. Chronic conditions were defined as blood pressure ⩾140/90 mm or self-reported heart disease, diabetes, hypertension, arthritis, asthma, emphysema, cancer, and/or cholesterol-reducing medication use. Outcomes data were ascertained during follow-up (1993–2005) with medical records.Results:There were 2451 coronary heart disease, 1896 stroke, 1533 congestive heart failure, 1957 angina, and 502 peripheral arterial disease events during follow-up (median 8.2 years). Participants in the lowest physical component summary quintile, compared to the highest, had a significantly higher risk of developing coronary heart disease (hazard ratio (95% confidence interval) 2.0 (1.7, 2.3)), stroke (1.8 (1.5, 2.2)), angina (2.4(2.0, 2.9)), and peripheral arterial disease (3.0 (2.0, 4.4)), irrespective of chronic conditions. Interactions between physical component summary and existing chronic conditions were not significant for any outcome except congestive heart failure (p = 0.005); after adjustment, participants in the lowest physical component summary quintile and with any chronic condition had nearly a twofold higher risk of congestive heart failure (Yes = 4.4 (3.3, 5.8) vs No = 2.4 (1.2, 4.3)).Conclusion:We found a low physical component summary score was a significant risk factor for individual cardiovascular disease incidence in postmenopausal women.

Prevalence and Associated Factors for Non-adherence in Patients with Rheumatoid Arthritis

Objective. To estimate the prevalence of non-adherence to rheumatoid arthritis (RA) medication and identify the associated factors for non-adherence in RA patients. Methods. Among the KORean Observational study Network for Arthritis 3,523 patients who completed a questionnaire about the adherence to RA medication were analyzed. The patients were divided into two groups: 1) adherent group, patients who skipped medication ≤5 days within the past 2 months; and 2) non-adherent group, patients who skipped ≥6 days of medication. The baseline characteristics were compared, and multivariable regression analysis was performed to identify the associated factors for non-adherence. Results. The non-adherent group had 339 patients (9.6%). The common causes of non-adherence were forgetfulness (45.8%), absence of RA symptoms (24.7%), and discomfort with RA medication (13.1%). Younger age (odds ratio [OR] 1.02, p＜0.01) and higher income (OR 1.70, p＜0.01) were associated with an increased risk of non-adherence. Whereas higher functional disability (OR 0.68, p＜0.01) and oral corticosteroid use (OR 0.73, p=0.02) were associated with a decreased risk of non-adherence. The associated factors differed according to cause of non-adherence. Having adverse events (OR 2.65, p=0.02) was associated with the risk of non-adherence due to discomfort with RA medication while a higher level of education (OR 2.37, p=0.03) was associated with the risk of non-adherence due to an absence of RA symptoms. Conclusion. The 9.6% of Korean RA patients were non-adherent to RA medication. The associated factors differed according to the cause of non-adherence. Therefore, an individualized approach will be needed to improve the adherence to RA medication. (J Rheum Dis 2018;25:47-57)

In vivo anti-arthritic and anti-nociceptive effects of ethanol extract of Moringa oleifera leaves on complete Freund's adjuvant (CFA)-induced arthritis in rats

BackgroundThe medicinal uses of plants are in many cases based exclusively on traditional knowledge without enough scientific evidences. Different parts of Moringa oleifera were traditionally used for the treatment of wide variety of ailments including arthritis and joints pain. The present study had been designed to evaluate the anti-arthritic and anti-nociceptive activities of ethanol extract of Moringa leaves, this being the most abundant plant part suitable for commercial mass production of botanical medicinal products. MethodsComplete Freund's adjuvant (CFA)-induced arthritis in rats was used as disease model. CFA-induced inflammatory paw edema, body weight, arthritic index, X-ray radiography, hematological parameters, and walk track and locomotion analysis were all evaluated for the assessment of disease progression. In addition to that, anti-nociceptive activity was examined at different dose levels in both normal and arthritic-induced rats using Eddy's hot plate and tail flick thermal analgesia. ResultsThe analysis of various arthritic assessment parameters used in this study revealed that Moringa extract has a considerable effect in preventing development or ameliorate arthritis disease severity. Moreover, the ethanol extract of Moringa leaves revealed significant anti-nociceptive activity at in both normal and CFA-induced arthritis rats in a dose-dependent manner. ConclusionEthanol extract of Moringa leaves appears to be a really promising as analgesic and arthritis medication, but a larger and more detailed preclinical and clinical studies especially in human is highly recommended.

Flipping moxibustion of Hui medicine combined with western medication for rheumatoid arthritis with cold dampness bi syndrome

To compare the effects of flipping moxibustion of Hui medicine combined with western medication and simple western medication for rheumatoid arthritis with cold dampness bi syndrome. Eighty patients were randomly assigned into an observation group and a control group, 40 cases in each group. Oral methotrexate (1 time a week) and sulfasalazine (twice a day except the day for methotrexate) were used in the two groups. Patients in the observation group were treated with flipping moxibustion of Hui medicine, twice a week. The main acupoints were Shenshu (BL 23), Guanyuan (CV 4), Zusanli (ST 36), Yinlingquan (SP 9), and the matching acupoints were in the meridians related to the disease location. All the treatment was given for continuous 4 weeks. The TCM symptom score, visual analogue scale (VAS) score, blood sedimentation (ESR), rheumatoid factor (RF) and C-reactive protein (CRP) were observed before and after treatment. The effect was evaluated. The total effect rate in the observation group was 95.0% (38/40), which was better than 77.5% (31/40) in the control group (P<0.05). After treatment, the VAS score, TCM symptom score, RF, ESR, CRP levels decreased in the two groups (all P<0.05), with better effects in the observation group (all P<0.05). The adverse reactions in the observation group were lower than those in the control group. Flipping moxibustion of Hui medicine combined with western medication for rheumatoid arthritis with cold dampness bi syndrome are better than simple western medication, which are safer and more effective.

Agreement Between Maternal Report and Medical Records During Pregnancy: Medications for Rheumatoid Arthritis and Asthma.

There are limited data regarding the comparability of medication exposure information during pregnancy from maternal report and medical records, including for rheumatoid arthritis and asthma-related medications. This study included pregnant women with rheumatoid arthritis (n = 216) and asthma (n = 172) enrolled in the MothertoBaby Pregnancy Studies (2009-2014). Women reported types and dates of medications used through semi-structured telephone interviews up to three times during pregnancy and once after delivery, and medical records were obtained. We calculated Cohen's kappa coefficients and 95% confidence intervals (CIs) and per cent agreement for agreement between report and records. For rheumatoid arthritis, prednisone was reported most frequently (53%). During pregnancy, kappa coefficients for rheumatoid arthritis medications ranged from 0.32 (95% CI 0.15, 0.50) for ibuprofen, with 84.3% agreement, to 0.90 (95% CI 0.84, 0.96) for etanercept with 95.4% agreement, and was 0.44 (95% CI 0.33, 0.55) for prednisone, with 71.3% agreement. For asthma, albuterol was reported most frequently (77.9%). During pregnancy, kappa coefficients for asthma medications ranged from 0.21 (95% CI 0.08, 0.35), with 64.5% agreement for albuterol to 0.84 (95% CI 0.71, 0.96) for budesonide/formoterol, with 96.5% agreement. Where kappas for any use during pregnancy were less than excellent (i.e. ≤0.80), medication use was more frequently captured by report than record. Agreement was higher for medications typically used continuously than sporadically. Information on medication use from medical records alone may not be adequate when studying the impact of intermittently used medications during pregnancy on perinatal outcomes.

Beneficial effects of a probiotic blend on gastrointestinal side effects induced by leflunomide and amlodipine in a rat model.

Patients with metabolic disorders frequently suffer from side effects induced by long-term oral medications. The present study using a rat model system indicated that leflunomide (LF) and amlodipine (AMD), the active ingredients contained in the medications for rheumatoid arthritis and hypertension, respectively, appeared to induce various bowel problems including constipation and inflammation. In the small and large intestine, LF increased the expression of tumour necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 compared to the null control and AMD increased the expression of both TNF-α and IL-1β, although its effect on IL-6 was only increased in the large intestine. It is noteworthy that the probiotic blend tested was found to alleviate intestinal complications caused by LF and AMD. Analysis of the gut microbiota revealed that AMD induced compositional changes in the gut microbiota. Namely, members of the phylum Bacteroidetes, which constituted only about 0.3% of the microbiota in the null control, made up more than 10% of the total composition in the AMD-administered rats. Interestingly, the probiotic blend was also found to normaliSe the gut microbiota.

Insilico design of colchicine-based bioisosteric inhibitors of tubulin for the treatment of rheumatoid arthritis.

The super-saturation of serum with monosodium urate due to hyperuricemia is the core metabolic disorder of rheumatoid arthritis. When the serum urate concentration is ≥7mg/dl, this results in the crystallization of monosodium urate in serum at body temperature (37˚C/98.6˚F). Colchicine (COL) is considered to be a first‑line medication for acute arthritis when NSAIDs are contraindicated. COL causes severe side effects, including diarrhea, nausea, cramping, abdominal pain and vomiting, in humans. Experimental studies have additionally demonstrated the presence of mutagenic and reproductive effects in humans. In the present study, molecular docking simulation techniqueswere used to design COL‑derived bioisosteric inhibitors, with the aim of designing an alternative treatment that exhibitedpotent anti‑arthritic activity and was free from the side effects associated with COL.

Design and implementation of a decision aid for juvenile idiopathic arthritis medication choices

BackgroundRandomized trials have demonstrated the efficacy of patient decision aids to facilitate shared decision making in clinical situations with multiple medically reasonable options for treatment. However, little is known about how best to implement these tools into routine clinical practice. In addition, reliable implementation of decision aids has been elusive and spread within pediatrics has been slow. We sought to develop and reliably implement a decision aid for treatment of children with juvenile idiopathic arthritis.MethodsTo design our decision aid, we partnered with patient, parent, and clinician stakeholders from the Pediatric Rheumatology Care and Outcomes Improvement Network. Six sites volunteered to use quality improvement methods to implement the decision aid. Four of these sites collected parent surveys following visits to assess outcomes. Parents reported on clinician use of the decision aid and the amount of shared decision making and uncertainty they experienced. We used chi-square tests to compare eligible visits with and without use of the decision aid on the experience of shared decision making and uncertainty.ResultsAfter 18 rounds of testing and revision, stakeholders approved the decision aid design for regular use. Qualitative feedback from end-users was positive. During the implementation project, the decision aid was used in 35% of visits where starting or switching medication was discussed. Clinicians used the decision aid as intended in 68% of these visits. The vast majority of parents reported high levels of shared decision making following visits with (64/76 = 84%) and without (80/95 = 84%) use of the decision aid (p = 1). Similarly, the vast majority of parents reported no uncertainty following visits with (74/76 = 97%) and without (91/95 = 96%) use of the decision aid (p = 0.58).ConclusionsAlthough user acceptability of the decision aid was high, reliable implementation in routine clinical care proved challenging. Our parsimonious approach to outcome assessment failed to detect a difference between visits with and without use of our aid. Innovative approaches are needed to facilitate use of decision aids and the assessment of outcomes.

Patient experiences, attitudes and expectations towards receiving information about anti-TNF medication: a quantitative study

The objective of the study was to measure patient attitudes and experience of information received during drug counselling for rheumatoid arthritis (RA) medications. This is a cross-sectional UK postal questionnaire study. Three RA patient groups—disease-modifying antirheumatic drugs (DMARDs) only, first anti-tumour necrosis factor (anti-TNF) and failed anti-TNF—were sent postal questionnaires. Data on patient history/demographics, drug counselling experience, knowledge of drug side effects, attitudes to vaccinations, cancer screening and blood borne virus testing was collected; 264/679 (39%) patients responded (median age 65 years, 66% female, median disease duration 15 years). Drug information from rheumatology nurses, rheumatology doctors and information leaflets was most useful. Thirty-eight percent of respondents felt reassured by information received, but 37% felt more worried. Forty percent of participants were aware of important drug side effects. Although 42–65% of patients understood they should temporarily halt anti-TNF therapy with concurrent infection, 75% of patients recalled continuing therapy despite infection. Thirteen percent believed that all vaccinations (including travel vaccinations) were safe while taking anti-TNF. Uptake of UK cancer screening programmes was between 87 and 94%, except prostate screening (47%). Most participants were not aware that they may need to discontinue their anti-TNF if they developed cancer. The majority of participants felt neutral/reassured by the prospect of viral hepatitis (95%) and HIV (91%) testing. Although drug counselling is a well-established part of clinical care, there is potential for further improvement to ensure that patients’ knowledge empowers them to act safely. Particular areas for improvement included the following: patients halting DMARDs/anti-TNF therapy during infections, knowledge regarding vaccinations and prostate cancer screening uptake.

Causes and consequences of fatigue in rheumatoid arthritis.

To review current information on the causes, treatments, and consequences of fatigue in rheumatoid arthritis. Disease activity (inflammation, pain, joint symptoms) is associated with greater fatigue. However, disease activity per se accounts for only a small portion of fatigue, and rheumatoid arthritis medications that reduce disease activity have small effects on fatigue. Instead, factors outside the direct effects of rheumatoid arthritis, such as obesity, physical inactivity, sleep disturbance, and depression, explain the majority of variation in fatigue. Some of these factors may be indirect effects of disease (e.g. pain can lead to sleep disturbance). Rheumatoid arthritis has significant effects on the quality of life of individuals with rheumatoid arthritis. The most effective approaches to reducing rheumatoid arthritis fatigue appear to be behavioral, such as increasing physical activity, or cognitive, such as cognitive behavioral interventions. Fatigue in rheumatoid arthritis appears to be largely because of factors outside the direct effects of the disease, such as behavioral and psychological factors. In spite of the tremendous impact of fatigue on patient health and quality of life, effective treatments remain elusive, but existing data show that behavioral and cognitive approaches may be most effective.