Rheumatoid Arthritis Medication Research Articles

Autoimmune and Atopic Disorders and Risk of Classical Hodgkin Lymphoma.

Results from previous investigations have shown associations between the risk of Hodgkin lymphoma (HL) and a history of autoimmune and atopic diseases, but it remains unknown whether these associations apply to all types of HL or only to specific subtypes. We investigated immune diseases and the risk of classical HL in a population-based case-control study that included 585 patients and 3,187 controls recruited from October 1999 through August 2002. We collected information on immune diseases through telephone interviews and performed serological analyses of specific immunoglobulin E reactivity. Tumor Epstein-Barr virus (EBV) status was determined for 498 patients. Odds ratios with 95% confidence intervals were calculated using logistic regression analysis. Rheumatoid arthritis was associated with a higher risk of HL (odds ratio (OR) = 2.63; 95% confidence interval (CI): 1.47, 4.70), especially EBV-positive HL (OR = 3.18; 95% CI: 1.23, 8.17), and with mixed-cellularity HL (OR = 4.25; 95% CI: 1.66, 10.90). HL risk was higher when we used proxies of severe rheumatoid arthritis, such as ever having received daily rheumatoid arthritis medication (OR = 3.98; 95% CI: 2.08, 7.62), rheumatoid arthritis duration of 6-20 years (OR = 3.80; 95% CI: 1.72, 8.41), or ever having been hospitalized for rheumatoid arthritis (OR = 7.36; 95% CI: 2.95, 18.38). Atopic diseases were not associated with the risk of HL. EBV replication induced by chronic inflammation in patients with autoimmune diseases might explain the higher risk of EBV-positive HL.

Understanding the information needs of women with rheumatoid arthritis concerning pregnancy, post-natal care and early parenting: A mixed-methods study.

BackgroundAlthough women with rheumatoid arthritis (RA) face a number of challenges in negotiating the journey to parenthood, no studies have explored the information needs of women with RA in relation to their childbearing years. This study aimed to determine the need for (and preferred mode/s of delivery of) information regarding pregnancy, post-natal care and early parenting among women with RA.MethodsInterviews and focus groups were conducted with 27 women with RA who were pregnant in the last 5 years, currently pregnant or planning pregnancy. Verbatim transcripts were analysed using both inductive and deductive approaches. Two validated instruments were used to quantify information needs and preferences: the Educational Needs Assessment Tool (ENAT, range 0-156, higher scores indicate higher educational needs) and the Autonomy Preference Index (API, range 0-100, higher scores indicate stronger preferences).ResultsLack of information about medication safety, access to physical/emotional support services and practical strategies for coping with daily challenges related to parenting were the most prominent of the six key themes identified. Rheumatologists were the primary source for information regarding treatment decisions while arthritis consumer organisations were perceived as critical ‘resource hubs’. There was strong preference for information delivered electronically, especially among rural participants. Quantitative outcomes supported the qualitative findings; on average, participants reported high educational needs (mean ENAT score 97.2, SD 30.8) and API scores indicated that desire for information (mean 89.8, SD 5.6) was greater than the need for involvement in treatment decision-making (mean 68.4, SD 8.2).ConclusionsMany women with RA struggle to find adequate information on pregnancy planning, pregnancy and early parenting in relation to their chronic condition, and there is a clear need to develop accessible information that is consumer-focused and evidence-based. Although most participants trusted their rheumatologist as their primary information source, there was consistent demand for more information, particularly regarding the safety of RA medications during pregnancy and breastfeeding, and the importance of learning from other women’s personal experiences was strongly emphasised.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-015-0657-4) contains supplementary material, which is available to authorized users.

PMS64 - Evaluation of disease activity in patients diagnosed with rheumatoid arthritis: how often and to what detail are assessments documented?

Objectives: Rheumatoid arthritis (RA) is a chronic inflammatory disorder that affects the lining of joints, causing painful swelling that can result in bone erosion and joint deformity. Patient adherence to medications can help reduce or lessen inflammation; however, non-adherence and frequent switching are recognized problems in patients with RA. The objectives of this study are to better understand patients’ reason(s) for being non-adherent and/or switching and physicians’ reasons for recommending a switch. Methods: We extracted 300 records for RA patients from a unique database of physicianpatient interactions (RealHealthData). Using Atlas.ti, we analyzed these records to analyze trends for medication switches and/or nonadherence, i.e., when, why and how patients stopped or switched their medication. In addition, we analyzed physicians’ noted reasons for switching. Results: On average, patients were 53 years old (±10). Patients’ functional disability was similar to the general RA population, with a noted variability of swelling and joint pain. The medications prescribed to the patients included: methotrexate (22%), Orencia (18%), Remicade (14%), Plaquenil (14%), Humira (13%) Enbrel (8%), Acterma (6%) and CellCept (5%). Patients’ reported reasons for switching and/or non-adherence included: increased pain/swelling (34%), feeling the medication is not working and/or continual progression of symptoms (35%) and adverse reaction to medication such as itching (11%) and GI complications (11%). Of the physicians who recommended switching, reasons for switching their patients’ medications included potential toxicities associated with drugs (46%) and observed disease progression (34%). Conclusions: It is critical to better understand patients’ and physicians’ reasons for switching medication for chronic disease like RA. The more we know about reasons for behavior, the more we can actively plan and organize research, development and outreach that is patient-centric and clinically meaningful. Our results demonstrate that using physician-patient interaction data can add tremendous value to outcomes researchers and healthcare decision makers. Results On average, patients were 59 years old and Figure 2 presents the breakdown of medications prescribed. Patients’ reported reasons for switching and/or non-adherence included: increased pain/swelling (34%), feeling the medication is not working and/or continual progression of symptoms (35%) and adverse reaction to medication such as itching (11%) and GI complications (11%) (Figure 3). Of the physicians who recommended switching, reasons for switching their patients’ medications included potential toxicities associated with drugs (46%) and observed disease progression (34%) (Figure 4). Methods We extracted 300 patient records that were identified for people diagnosed with RA from a unique database of physician-patient interactions: RealHealthData (http://www.realhealthdata.com/). RealHealthData works with medical transcription companies across the country to build a database of detailed narrative medical records, providing a unique perspective on patient conditions and physician interaction. (Figure 1). In order to be included in the database, patients needed to be at least 18 years of age, diagnosed with Rheumatoid Arthritis and had an office visit with at least one physician in the past 12 months. Using Atlas.ti and Excel, we analyzed these patient records to evaluate how often the recommended assessments of disease activity was documented by physicians during office visits.

Factors associated with the initiation of biologic disease-modifying antirheumatic drugs in Texas Medicaid patients with rheumatoid arthritis.

Rheumatoid arthritis (RA) is a progressive autoimmune disorder of joints that is associated with high health care costs, yet guidance is lacking on how early to initiate biologic disease-modifying antirheumatic drugs (DMARDs), a class of medications that is the major cost driver in RA management. Few studies have examined the factors associated with the transition from nonbiologic DMARDs, the first-line therapy for RA, to biologic DMARDs in RA patients. To examine patient sociodemographics, medication use patterns, and clinical characteristics associated with initiation of biologic DMARDs. This was a retrospective study using the Texas Medicaid prescription and medical claims database from July 1, 2003-December 31, 2010. Adults (aged 18-63 years) with an RA diagnosis (ICD-9-CM code 714.xx), no nonbiologic DMARD or biologic DMARD use during the 6-month pre-index period, and a minimum of 2 prescription claims for the same nonbiologic DMARD during the post-index period were included in the study. The index date was defined as the date when the first nonbiologic DMARD claim was made. Predictors of initiation of biologic DMARDs were age, gender, race, adherence (proportion of days covered), persistence to nonbiologic DMARDs, comorbidity (Charlson Comorbidity Index [CCI]), pain medication use, glucocorticoid use, and rheumatologist visit. Logistic regression was used to examine the factors associated with the initiation of biologic DMARDs. A total of 2,714 patients were included. After controlling for patient characteristics, logistic regression showed, that compared with methotrexate (MTX) users, sulfasalazine (SSZ) and hydroxychloroquine (HCQ) users were less likely to initiate biologic DMARDs by 69.0% (OR = 0.310, 95% CI = 0.221-0.434, P less than 0.0001) and 79.9% (OR = 0.201, 95% CI = 0.152-0.265, P less than 0.0001), respectively. Nonbiologic DMARD dual therapy users were 39.1% less likely to initiate biologic DMARDs compared with nonbiologic DMARD monotherapy users (OR = 0.609, 95% CI = 0.463-0.803, P = 0.0004). With each year increase in age, patients were 1.6% less likely to start biologic DMARDs (OR = 0.984, 95% CI = 0.975-0.993, P = 0.0006). Compared with glucocorticoid users, glucocorticoid nonusers were 53.8% less likely to start on biologic DMARDs (OR = 0.462, 95% CI = 0.372-0.573, P less than 0.0001). Patients with CCI scores of ≥ 3 were approximately 1.6 times more likely to initiate biologic DMARDs than those with CCI scores of 1 (OR = 1.618, 95% CI = 1.228-2.132, P = 0.0006). Younger age, CCI scores ≥3, glucocorticoid use, MTX users (vs. SSZ and HCQ users), and nonbiologic DMARD monotherapy users (vs. dual therapy users) were significantly associated with higher likelihood to initiate biologic DMARDs. Recognizing these potential factors that drive the initiation of biologic DMARDs in this patient population, health care providers and Texas Medicaid should take measures to achieve optimal therapy for RA patients through thorough RA medication evaluation, well-structured RA monitoring programs, and patient education.

066. Are Clinicians Following Guidance for Combination Therapy in Recent-Onset Rheumatoid Arthritis? Results from a Nationwide Observational Study (RAMS)

Background: NICE guidance recommends the use of a combination of DMARDs, to include MTX, in the initial management of patients presenting with RA. Monotherapy is only recommended where there are contraindications or multiple comorbidities. However, it is not clear how frequently different treatment strategies are used in routine practice. The aim of this study was to identify, in a national observational cohort, the frequency of MTX monotherapy and examine factors associated with its prescription. Methods: The Rheumatoid Arthritis Medications Study (RAMS) recruited patients with RA starting MTX for the first time since 2008 across the UK. Patients included in this study presented within 2 years of symptom onset. Data, including demographics, comorbidity, medication history, smoking history, CRP, RF, DAS for 28 joints (DAS28) and HAQ were recorded at start of therapy. Subsequent medication changes were detailed at 3and 6-month follow up. Patients were classified as being on MTX monotherapy if they did not meet either of the following criteria: currently on another DMARD or another DMARD started within 90 days of MTX start date; and currently on oral steroids (for at least 30 days) or started on oral steroids within 30 days of MTX start date. Univariate and multivariate logistic regression analysed the association of MTX monotherapy with baseline age, gender, disease duration, CRP, RF, tender and swollen joint counts, HAQ, DAS28, smoking status and comorbidity. Results: A total of 731 patients were included, baseline characteristics are shown in Table 1. MTX monotherapy was prescribed in 493 (67%) patients, of those on combination treatment 193 (80%) were treated in combination with another DMARD, 48 (20%) with steroids. Older age was associated with increased odds of monotherapy and RF positivity with combination therapy (Table 1). Conclusion: MTX appears to be more commonly prescribed as monotherapy than in combination with other DMARDs, despite NICE guidance. In our study, older patients were more frequently treated with monotherapy; however no association was seen with the presence of multiple comorbidities. Others factors not currently incorporated within the guidance, such as patient preference, may be contributing to these prescribing practices. Disclosure statement: K.L.H. has received honoraria from AbbVie and Pfizer. All other authors have declared no conflicts of interest.

Repigmentation of hair following adalimumab therapy

Repigmentation of canities, or age-related grey or white hair, is a rare occurrence. Generalized repigmentation of grey-white hair has been reported following inflammatory processes, and heterochromia (localized patches of hair repigmentation) is even more unusual, reported in association with medication use and malignancy. Tumor necrosis factor (TNF) inhibitors are increasingly utilized medications for inflammatory disorders, including psoriasis, rheumatoid arthritis, and inflammatory bowel disease. Hair loss, or alopecia, has been described among the side effects of these medications, but changes in hair pigmentation in association with this class of drugs have not previously been reported. We describe a patient with hair repigmentation associated with adalimumab therapy.

Discontinuation of tumour necrosis factor inhibitors in patients with rheumatoid arthritis in low-disease activity: persistent benefits. Data from the Corrona registry.

There is increasing interest in discontinuing biological therapies for patients with rheumatoid arthritis (RA) achieving good clinical responses, provided patients maintain clinical benefit. We assessed patients with RA from the Corrona registry who discontinued treatment with their first tumour necrosis factor inhibitor (TNFi) while in low-disease activity (LDA) or lower levels of disease activity. Patients were followed until they lost clinical benefit, defined as increased disease activity or change in RA medications. Duration of maintenance of clinical benefit was estimated using the Kaplan-Meier method. Cox proportional hazard models were assessed to identify factors related to maintenance of benefit. We identified 717 eligible patients with RA from 35,656 in the Corrona registry. At discontinuation, patients had a median RA duration of 8 years, mean clinical disease activity score of 4.3±0.11; 41.8% were using TNFi as monotherapy. 73.4% of patients maintained benefit for >12 months after discontinuing therapy and 42.2% did so through 24 months. Factors predictive of maintaining clinical benefit in multivariate analysis included lower disease activity, less pain and better functional status at the time of TNFi discontinuation. Among 301 patients initiating their first TNFi within the registry, faster responders (ie, those who achieved LDA in 4 months or less) did better than slower responders (HR 1.54 (95% CI 1.17 to 2.04)). RA disease duration did not affect maintenance of clinical benefit. Discontinuation of a first course of TNFi may be associated with persistent clinical benefit. Half of patients maintained response through 20 months. Several patient characteristics may help predict persistent benefit.

The design of a low literacy decision aid about rheumatoid arthritis medications developed in three languages for use during the clinical encounter.

BackgroundShared decision-making in rheumatoid arthritis (RA) care is a priority among policy makers, clinicians and patients both nationally and internationally. Demands on patients to have basic knowledge of RA, treatment options, and details of risk and benefit when making medication decisions with clinicians can be overwhelming, especially for those with limited literacy or limited English language proficiency. The objective of this study is to describe the development of a medication choice decision aid for patients with rheumatoid arthritis (RA) in three languages using low literacy principles.MethodsBased on the development of a diabetes decision aid, the RA decision aid (RA Choice) was developed through a collaborative process involving patients, clinicians, designers, decision-aid and health literacy experts. A combination of evidence synthesis and direct observation of clinician-patient interactions generated content and guided an iterative process of prototype development.ResultsThree iterations of RA Choice were developed and field-tested before completion. The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations. The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians.ConclusionsThe process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool. The use of RA Choice in the clinical encounter has the potential to enhance communication for RA patients, including those with limited health literacy and limited English language proficiency.

Delayed wound healing after forefoot surgery in patients with rheumatoid arthritis

Objective. To elucidate the systemic and local risk factors and the effect of surgical procedures for delayed wound healing after forefoot surgery in patients with rheumatoid arthritis (RA).Methods. Fifty forefoot surgeries were performed in 39 patients using resection arthroplasty or a joint-preserving procedure (25 feet for each procedure). The associations between the occurrence of delayed wound healing and clinical variables, radiological assessment, or surgical procedures were analyzed.Results. Delayed wound healing was recorded in nine feet of eight patients. The duration of RA was significantly longer in the delayed healing group than that in the healed group. Age, sex, smoking history, concomitant diabetes, and RA medication did not differ between the groups. Radiological evaluation showed significant differences between groups in metatarsophalangeal dorsal flexion angle. The shortened length of the fourth and the fifth metatarsal bones affected the occurrence of the complication. The joint-preserving procedure had significantly less delayed wound healing compared with resection arthroplasty.Conclusions. Preoperative dorsoplantar deformity and perioperative tissue damage can cause delayed wound healing after forefoot surgery in RA patients.

Rheumatoid Arthritis During Pregnancy and Postnatal Catch‐Up Growth in the Offspring

Active rheumatoid arthritis (RA) during pregnancy and the presence of rheumatoid factor (RF) or anti-citrullinated protein antibodies (ACPAs) are associated with lower birth weight of the child. Moreover, treatment of the mothers with prednisone may shorten the gestational age at birth. Rapid catch-up in weight for length during the first year of life has been related to a worse cardiovascular and metabolic profile in early adulthood. This study was therefore undertaken to assess the influence of RA disease activity, medication use, and presence of RF or ACPAs during pregnancy on the growth of the child in the first year of life. Among 180 children born to mothers with RA, the tempo of catch-up in weight during the first year of life was studied. Independent variables were the extent of RA disease activity (according to the Disease Activity Score in 28 joints [DAS28]), medication use, and presence of RF or ACPAs during pregnancy. Of 167 children with available data, 52 (31%) showed catch-up in weight in the first year of life, of whom 90% (47 of 52) showed rapid catch-up. An elevated DAS28 score in the mother was associated with rapid catch-up in weight of the offspring, independent of maternal medication use or the presence of RF or ACPAs during pregnancy (odds ratio 1.44 [95% confidence interval 1.07-1.95] per 1-point increase in the DAS28). Use of medications during pregnancy had no influence on postnatal growth. Elevated RA disease activity during pregnancy should be avoided because it is associated with rapid postnatal catch-up in weight, a risk factor for a worse cardiovascular and metabolic profile in adults. Medication for RA during pregnancy, including prednisone, had no effect on growth. Continuation or extension of medication will not only improve maternal health during pregnancy, but could be beneficial for the future health of the unborn child.

OP0123 Can We Use Ultrasound to Identify Rheumatoid Arthritis Patients in Remission Who Can Taper Their Medication?

BackgroundTapering of medication in rheumatoid arthritis (RA) patients is becoming increasingly important due to the effectiveness of both biological therapy and tight-controlled treatment. Patients are able to reach the state...

FRI0194 Identifying Patients with Rheumatoid Arthritis in Primary Care Electronic Medical Records

BackgroundRheumatology research in primary care populations has been hampered by an inability to efficiently identify rheumatology patients. Electronic medical records (EMRs) are a rich data source that can be used...

FRI0074 Renal Dysfunction in Patients with Rheumatoid Arthritis: Results from the Comedra Study

BackgroundPatients with rheumatoid arthritis (RA) are at increased risk of renal dysfunction.ObjectivesTo assess the prevalence and associations of renal dysfunction in patients with RA.MethodsCOMEDRA is a French nation-wide cross-sectional multicentric...

OP0004 Assessing Methotrexate Compliance in Rheumatoid Arthritis

BackgroundWorldwide, methotrexate (MTX) is considered the first-line disease-modifying antirheumatic drug treatment for patients with rheumatoid arthritis (RA). MTX compliance among patients with RA may be influenced by MTX response, adverse...

OP0276 Efficacy of Daily Teriparatide for Two Years on Osteoporosis in Patients with Rheumatoid Arthritis – is IT Appropreate to Combine Daily Teriparatide and Biological Agents?

BackgroundAlthough medication of rheumatoid arthritis (RA) has been improved by early intensive treatment using MTX and biological agents (BIO) for decades, treatment of concomitant disease in RA patients, such as...

SAT0095 Control of Disease Activity is Associated with Improvement in Physical Activity in Patients with Rheumatoid Arthritis

BackgroundIt is well-known that patients with rheumatoid/undifferentiated arthritis (RA/UA) experience reduced functioning in daily tasks. Less is known about changes in physical activity over time and the association with disease...

THU0487 Identification of 131 Differential Gene Expression Profiles in Good Responders in the First Few Weeks after MTX Commencement: Results from the Rheumatoid Arthritis Methotrexate Study (RAMS)

BackgroundMethotrexate (MTX) is the DMARD of first choice in most patients with rheumatoid arthritis (RA). However, a significant minority (30-40%) of patients do not respond to MTX therapy. Gene expression...

PMS76 - Drug Utilization Patterns For Rheumatoid Arthritis

Various medications are commonly used to manage Rheumatoid Arthritis (RA). This study examined drug utilization patterns and factors associated with the use of medications by RA patients. Data from the 2006-2010 National Ambulatory Care Survey (NAMCS) and the outpatient department component of the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to examine the RA related ambulatory visits. RA medications were classified as NSAIDS and analgesics, corticosteroids, and disease modifying Anti-rheumatic drugs (DMARDs). Bivariate chi-square analysis and multiple logistic regression analysis were performed to evaluate the factors associated with prescribing of RA medications. SAS survey procedures that adjust for the complex sampling procedure of national surveys were used to conduct bivariate and multivariate analyses. An average of 3.57 million (0.33%) visits was made by patients with RA from 2006 to 2010. Majority of these visits were made by females (76.75%), Whites (88.50%) and individuals aged 18-64 years old (61.53%). More than two third of the RA patients were prescribed anti-rheumatic drugs (70.75%). The most commonly prescribed anti-rheumatic drugs were NSAIDs and Analgesics (75.60%), DMARDs (20.40%) and Corticosteroids (4.00%). Multiple logistic regression analysis showed that females (OR: 0.55; 95% CI: 0.32-0.95), individuals aged group 18 to 64 years (OR: 0.48; 95% CI: 0.29-0.78) were less likely to receive anti-rheumatic drugs, whereas those seeking care from rheumatologists (OR: 4.38; 95% CI: 2.19-8.77) and those with multiple previous visits (OR: 1.43; 95% CI: 1.26-1.62) were more likely to receive anti rheumatic drugs. Most (7 out of 10) visits for the RA involved use of anti-rheumatic drugs. Drug use patterns varied across age, gender, physician specialty, and previous use of health care. Further research is needed to evaluate the variation across drug classes for RA.

Rheumatoid arthritis medications and lactation

In contrast to the disease remission enjoyed by a majority of rheumatoid arthritis (RA) patients during pregnancy, the immediate postpartum period is generally characterized by flare. Managing symptoms during this time is challenging because the potential transfer of medication into the breast milk of nursing mothers may limit which antirheumatic drugs can be safely used. The benefits of breastfeeding are significant, however, so an understanding of how to adjust medications to permit lactation and nursing is important for rheumatologists. Although nonsteroidal antiinflammatory drugs (NSAIDs) in general are passed into milk in low doses, shorter acting NSAIDs are preferred, with caution for premature infants. Prednisone can be taken by nursing mothers, although when used at doses higher than 20 mg/day an interval of 4 h after dosing and prior to breastfeeding is recommended. Hydroxychloroquine and sulfasalazine are compatible with nursing. Cyclosporine is generally allowed in lactating women, although a single infant was reported to develop therapeutic drug levels. Azathioprine (AZA) and tissue necrosis factor-α-inhibitors have little to no transfer into breast milk, with negligible levels measured in infant sera, and thus may be considered for use in lactating mothers. Methotrexate and leflunomide should not be used. Other biological RA medications have not been evaluated, and are, therefore, best avoided by breastfeeding patients. Many but not all RA medications may be used during lactation with low risk to the nursing infant; this review summarizes the available data for commonly used medications in order to help guide therapy during the postpartum period.

Rheumatoid arthritis and pregnancy

Tumour necrosis factor inhibitors (TNFi) and other biologic response modifiers are being increasingly used for the treatment of rheumatoid arthritis (RA) among women of childbearing age, raising concerns regarding the potential safety of inadvertent or intentional exposure of these agents to the developing fetus. TNFi and other biologics whose constructs contain a functional IgGFc piece are actively transported across the placenta during the second and third trimesters of pregnancy. Very little drug passively diffuses to the fetal circulation during the first trimester, when organogenesis occurs. Cumulative data from both the rheumatology and gastroenterology literature suggest that the rate of birth defects following antenatal TNFi exposure does not appear to be higher than that seen in the general population. There are very little data available on pregnancy outcomes following antenatal exposure to other biologic medications for RA. Cumulative evidence suggests that TNFi use during pregnancy carries low risk for teratogenicity. A single case of fatal BCG infection in an exposed neonate following live virus vaccination highlights the potential need to defer live virus vaccines for at least 6 months in exposed neonates until more data of risk factors for infection susceptibility are available.