Low Rheumatoid Arthritis Activity Research Articles

Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial

Objectives: To compare the cost-effectiveness of three types of follow-up for outpatients with stable low-activity rheumatoid arthritis (RA).Method: In total, 287 patients were randomized to either planned rheumatologist consultations, shared care without planned consultations, or planned nurse consultations. Effectiveness measures included disease activity (Disease Activity Score based on 28 joint counts and C-reactive protein, DAS28-CRP), functional status (Health Assessment Questionnaire, HAQ), and health-related quality of life (EuroQol EQ-5D). Cost measures included activities in outpatient clinics and general practice, prescription and non-prescription medicine, dietary supplements, other health-care resources, and complementary and alternative care. Measures of effectiveness and costs were collected by self-reported questionnaires at inclusion and after 12 and 24 months. Incremental cost-effectiveness rates (ICERs) were estimated in comparison with rheumatologist consultations.Results: Changes in disease activity, functional status, and health-related quality of life were not statistically significantly different for the three groups, although the mean scores were better for the shared care and nurse care groups compared with the rheumatologist group. Shared care and nurse care were non-significantly less costly than rheumatologist care. As both shared care and nurse care were associated with slightly better EQ-5D improvements and lower costs, they dominated rheumatologist care. At EUR 10 000 per quality-adjusted life year (QALY) threshold, shared care and nurse care were cost-effective with more than 90% probability. Nurse care was cost-effective in comparison with shared care with 75% probability.Conclusions: Shared care and nurse care seem to cost less but provide broadly similar health outcomes compared with rheumatologist outpatient care. However, it is still uncertain whether nurse care and shared care are cost-effective in comparison with rheumatologist outpatient care.

Experience with long-term use of certolizumab pegol (Cimzia)

Objective: to establish whether long-term combination therapy with a tumor necrosis factor (TNF) α inhibitor and a disease-modifying antirheumatic drug (DMARD) (methotrexate – MTX) may lead to sustained rheumatoid arthritis (RA) remission and its maintenance even after discontinuation of genetically engineered biological agents (GEBA). Subjects and methods. Moscow City Clinical Hospital Four had been following up 5 patients (4 women and 1 man) receiving certolizumab pegol (CZP, Cimzia) since 2005. Their treatment was performed in the CDP 879-027/28 study until August 2011; thereafter the patients continued to receive the drug at the department until February 2011. The patients’ mean age was 49.2±8.58 years; the average duration of RA was 4.4±2.3 years. The reason for using the medicament was ineffective previous standard DMARD therapy (sulfasalazine, leflunomide; when using CZP, all the patients took MTX in a dose of 10-15 mg/week; 2 patients had it in combination with prednisolone 5-7.5 mg/day). In all the patients, the disease activity remained high (mean DAS28, 6.33±0.52). Quality of life (QL) was also assessed using overall HAQ, EQ-5 questionnaires. The mean EQ-5D and HAQ QL scores were 50±7.9 and 1.825±0.17, respectively. The patients received either CZP 400 or 200 mg, or placebo in a blind study in October to December 2005; in an open-label study they took 400 mg CZP subcutaneously once two weeks since 2006 and 200 mg of this agent subcutaneously once two weeks (the dose was reduced according to the protocol after data on the efficiency of this dosage regimen were accumulated) since February 2008. Results. By the end of CZP treatment, 3 patients achieved sustained (1-year or more) remission (DAS28<2.6); 2 patients had low disease activity (DAS28<3.2), as confirmed by QL indicators according to the HAQ and EQ-5D questionnaires. It was decided that 3 patients would not resume GEBA therapy. They continued to take MTX 12.5-15 mg/week as DMARD therapy. One patient with a maximum DAS28 score of 3.16 by the end of the protocol continued to be treated with CZP (200 mg subcutaneously once two weekly). Another female patient with moderate RA activity at the end of therapy herself completed the treatment with a TNF-α inhibitor. Following a year, 2 patients remained in sustained RA remission and did not need a GEBA. RA activity increased in a female patient who had stopped treatment; she was recommended to resume therapy with the TNF-α inhibitor. Another female patient was stated to have a low RA activity and her follow-up was continued Conclusion. The findings are evidence in favor of the fact that long-term combination therapy with a TNF-α inhibitor in combination with MTX may lead to not only sustained RA remission, but also its maintenance even after a GEBA was discontinued. The use of CZP for 6.5 years induced remission and promoted stability in some patients during a year after drug discontinuation.

FRI0111 Body mass index (BMI) is not a surrogate of rheumatoid cachexia

BackgroundRheumatoid cachexia (RC) is a metabolic abnormality defined by a low fat-free mass with a normal or high fat mass in patients with Rheumatoid Arthritis (RA). It is predictor of...

Combination pulse therapy with methotrexate and dexamethasone in patients with early rheumatoid arthritis and poor prognostic factors: an open-label randomized trial

Система комплексной поддержки и сопровождения научного журнала Elpub позволяет запустить двуязычный сайт журнала со встроенной системой электронной редакции в соответствии с лучшими издательскими практиками, а так же предусматривает техническую и методическую поддержку со стороны специалистов НЭИКОН.

The first Russian strategic study of pharmacotherapy for rheumatoid arthritis (REMARCA)

The international recommendations «Treat to target» (T2T) underline the greatest importance of treatment strategy for the success of treating rheumatoid arthritis (RA). Evaluation of the efficiency of this approach obviously requires special strategic studies with an adaptive design, which substantially differ from classical randomized clinical trials and are much closer to clinical practice. To date, there are only single publications on the practical application of the T2T recommendations, there is a problem in the choice of effectiveness criteria and there are a number of other important problems associated with the introduction of these recommendations. The Russian study REMARCA is to answer these questions. Its design focuses on the practical adaptation of the T2T strategy to treat patients with earlyand extended-stage active RA who have poor prognostic factors, by using subcutaneous methotrexate and genetically engineered biological agents (GEBA). Preliminary analysis shows that therapy according to the REMARCA protocol is successful in the majority of patients. The high rate of low RA activity and remission has been achieved during subcutaneous methotrexate monotherapy. The patients who need GEBA to be incorporated may be initially more resistant to therapy. The patients with early RA have better chances of successful T2T therapy than those with extended-stage RA.

Russian registry of Infliximab.Impact of therapy on the functional status of patients with rheumatoid arthritis

Система комплексной поддержки и сопровождения научного журнала Elpub позволяет запустить двуязычный сайт журнала со встроенной системой электронной редакции в соответствии с лучшими издательскими практиками, а так же предусматривает техническую и методическую поддержку со стороны специалистов НЭИКОН.

Preferential reduction of bone mineral density at the femur reflects impairment of physical activity in patients with low-activity rheumatoid arthritis

Bone mineral density (BMD) and factors influencing BMD in rheumatoid arthritis (RA) under good or moderate control were examined to assess management of osteoporosis in RA. BMD of the lumbar spine, femur, and distal radius was measured in 105 female patients with well-controlled RA. Laboratory and clinical variables associated with disease activity were measured in the same subjects, and correlations between these variables and BMD were evaluated. The RA patients showed a greater decrease in BMD of the femoral neck than of the lumbar spine. Age, Health Assessment Questionnaire (HAQ) score, and Larsen damage score had negative correlations with BMD of the femoral neck. In multiple regression analysis of the parameters associated with BMD of the femoral neck in simple regression analysis, an increase in HAQ score showed a negative correlation with BMD of the femoral neck. After initiation of treatment with alendronate (ALN), BMD of the femoral neck increased and correlated with improvement in HAQ score. A decrease in BMD of the femoral neck is a characteristic of RA. This suggests that muscle tonus has more effect than weight-bearing activity on BMD in patients with RA. BMD of the femoral neck is a useful index for general evaluation of RA patients.

Preferential reduction of bone mineral density at the femur reflects impairment of physical activity in patients with low-activity rheumatoid arthritis

Bone mineral density (BMD) and factors influencing BMD in rheumatoid arthritis (RA) under good or moderate control were examined to assess management of osteoporosis in RA. BMD of the lumbar spine, femur, and distal radius was measured in 105 female patients with well-controlled RA. Laboratory and clinical variables associated with disease activity were measured in the same subjects, and correlations between these variables and BMD were evaluated. The RA patients showed a greater decrease in BMD of the femoral neck than of the lumbar spine. Age, Health Assessment Questionnaire (HAQ) score, and Larsen damage score had negative correlations with BMD of the femoral neck. In multiple regression analysis of the parameters associated with BMD of the femoral neck in simple regression analysis, an increase in HAQ score showed a negative correlation with BMD of the femoral neck. After initiation of treatment with alendronate (ALN), BMD of the femoral neck increased and correlated with improvement in HAQ score. A decrease in BMD of the femoral neck is a characteristic of RA. This suggests that muscle tonus has more effect than weight-bearing activity on BMD in patients with RA. BMD of the femoral neck is a useful index for general evaluation of RA patients.

Rheumatoid cachexia, central obesity and malnutrition in patients with low-active rheumatoid arthritis: feasibility of anthropometry, Mini Nutritional Assessment and body composition techniques

The concurrent decrease in fat free mass (FFM) and increase in fat mass (FM), including central obesity, in patients with rheumatoid arthritis (RA) may be related to increased cardiovascular morbidity as well as to functional decline. The objectives of this study were to evaluate body composition and nutritional status in patients with RA and the feasibility of bioelectrical impedance (BIA) to detect rheumatoid cachexia. Eighty RA outpatients (76% women), mean age 61 (range 22-80) years and with mean disease duration of 6 (range 1-52) years, were assessed by body mass index (BMI), waist circumference (WC), whole-body dual-energy X-ray absorptiometry (DXA), BIA and the Mini Nutritional Assessment (MNA). Fat free mass index (FFMI; kg/m(2)) was low in 26% of the women and in 21% of the men. About every fifth patient displayed concomitant low FFMI and elevated fat mass index (FMI; kg/m(2)), i.e. rheumatoid cachexia. BMI and MNA were not able to detect this condition. Sixty-seven percent had increased WC. Reduced FFM was independently related to age (p = 0.022), disease duration (p = 0.027), ESR (p = 0.011) and function trendwise (p = 0.058). There was a good relative agreement between DXA and BIA (FM r (2) = 0.94, FFM r (2) = 0.92; both p < 0.001), but the limits of agreement were wide for each variable, i.e. for FM -3.3 to 7.8 kg; and for FFM -7.9 to 3.7 kg. Rheumatoid cachexia and central obesity were common in patients with RA. Neither BMI nor MNA could detect this properly. There was a good relative agreement between DXA and BIA, but the limits of agreement were wide, which may restrict the utility of BIA in clinical practice.

Prevalence of thyroid diseases and antithyroid antibodies in women with rheumatoid arthritis

Thyroid abnormal function and and/or autoimmune thyroid disease (ATD) are observed in 6% to 33.8% patients with rheumatoid arthritis (RA). The aim of the study was to determine whether ATD is more prevalent in patients with RA compared to the control group involving age and sex-matched subjects without RA and whether these patients should be screened for thyroid disease. In 100 patients with RA and 55 patients without RA (control group) hormonal thyroid function and antithyroid antibodies were assessed. ATD was more prevalent (16%) in patients with RA than in the control group (9%). The difference was no statistically significant. The RA patients with concomitant ATD had lower RA activity than non-ATD RA patients. Antithyreoglobulin (anti-TG) and antithyroid peroxidase (anti-TPO) antibodies were present in similar percentage of patients with RA (12% and 15%, respectively) and in the control group (9% and 18%, respectively). The most common thyroid dysfunction observed in both groups was subclinical hypothyroidism. An association between thyroid dysfunction and clinical symptoms suggestive of thyroid disease in RA patients was not demonstrated. In patients with RA low free triiodothyronine concentrations were significantly more common. A higher prevalence of ATD in female RA patients compared with controls indicates the need for screening not only of thyroid function, but also of the presence of anti-TPO antibodies as the ATD marker in RA patients. Their presence does not correlate with the occurrence of thyroid disorders in RA patients. Monitoring of thyroid function is of particular importance since as already shown the course of thyroid disease in RA patients is often asymptomatic.

Evaluation of the degree of clinical rheumatoid arthritis activity based on the concentrations of cytokines TNF-alpha, IL-12, IL-15, and IL-18 in serum and synovial fluid

Experimental in vitro and in vivo investigations in a mouse model have proved that TNF-alpha, IL12, IL-15 and IL18 participate in the pathogenesis of erosive inflammatory arthritis. The aim of this research was to determine the clinical significance of cytokines in the evaluation of the activity of rheumatoid arthritis (RA). Inside a 4-year period we followed-up 64 patients with RA as newly ocurred or in the phase of worsening. We observed the clinical manifestation of the disease upon which we divided the patients in to 3 groups: the patients with low active RA, patients with moderate active RA, and the patients with wild active RA. The control group (n=25 patients) included the patients with osteoarthrosis (OA), and arthritis of the knee. In the samples of serum of all of the patients the concentratin of cytokines TNF-alpha, IL-12, IL-15, and IL-18 were determined using the immunoenzymatic methods in mice for human interleukines. By comparing the concentrations in 30 patients with the high, 14 patiens with moderate, and 20 patiens with the mild activity of RA it was determined that the patients with the high degree of the disease activity, had significantly high (p < 0.01; p < 0.05) concentrations of the examined cytokines in blood and synovial fluid as compared to the patients with the moderate and mild active disease. There was a relationship (p < 0.01) between the concentrations of cytokines in blood and synovial fluid with the quantity of the Disease Activity Score in 28 joints. Cytokines concentrations could be good indicators of the degree of the general activity of RA. This research could contribute to the interpretation of insufficiently well known views of the pathogenesis role and significance of citokines in an active disease.

Leptin serum levels are not correlated with disease activity in patients with rheumatoid arthritis

Leptin, the ob gene product, has been proposed as a mediator of inflammatory cytokine—dependent decreased food intake and cachexia in rodents. In humans, leptin serum levels increase after administration of tumor necrosis factor-alpha (TNF-α) or interleukin-2 or during septicemia. However, the effect of human chronic inflammatory disease on serum leptin is unknown. We therefore determined the serum leptin level (radioimmunoassay), body mass index (BMI), percent body fat ([%BF] bioelectrical impedance analysis), and disease activity (Disease Activity Score [DAS]) in 58 patients with rheumatoid arthritis (RA) and 16 controls. The BMI, %BF, serum leptin, and ratio of leptin to %BF (leptin/%BF) did not differ significantly in 25 patients with moderate RA activity (DAS, 3.6 ± 0.5), 33 patients with low RA activity (DAS, 1.8 ± 0.5), and controls. A positive correlation for serum leptin and %BF was detected in all groups. Our data indicate that in RA, a human chronic cytokine-mediated inflammatory disease, the serum leptin level is directly related to %BF but not to disease activity.

Monoreactive and Polyreactive Rheumatoid Factors Produced by in Vitro Epstein‐Barr Virus‐Transformed Peripheral Blood and Synovial B Lymphocytes from Rheumatoid Arthritis Patients

The CD5 membrane molecule, initially identified as an exclusive T-cell marker, also defines a phenotypically and functionally distinct B-lymphocyte population. In normal individuals, CD5+ B cells are committed to secrete 'natural' polyreactive (auto)antibodies, that is antibodies, mainly IgM, endowed with multiple antigen-binding capabilities, including rheumatoid factor (RF) activity. At variance with this, in rheumatoid arthritis (RA) as well as in other autoimmune conditions, monoreactive autoantibodies binding with high affinity and specificity to a given self antigen have been isolated and the cells from which they originate differently related to the CD5+ B-lymphocyte subset. Here, we studied the proportions of CD5+ B cells and the characteristics, in terms of polyreactivity and monoreactivity, of RF produced by B lymphocytes in RA patients with classified disease activity. Our results suggest that patients with a more severe disease activity have higher proportions of CD5+ B cells and higher frequencies of B lymphocytes committed to secrete RF, with the characteristics of polyreactive antibodies. On the other hand, we did not find a significant difference between the proportions of peripheral B cells producing monoreactive RF in patients with high- versus patients with low-activity RA. However, in two highly active RA patients, we found that synovial fluid, compared with peripheral blood, was significantly enriched for (IgG and IgA) monoreactive RF-producing B cells.