Treatment Of Rheumatic Diseases Research Articles

Homeopathy for Rheumatological Diseases: A Systematic Review.

Homeopathy has mainly been used to treat several diseases. On the other hand, it has been used in a few rheumatic disorders. The aim of this article is to review the use of homeopathy in rheumatic diseases (RDs). PubMed and Embase databases were examined for literature on homeopathy and RDs between 1966 and April 2023. There are 15 articles found with 811 patients. The diseases treated were osteoarthritis (n=3), followed by rheumatoid arthritis (n=3), ankylosing spondylitis (n=1), hyperuricemia (n=1), and tendinopathy (n=1). Age varied from 31 to 87 years old, and male gender ranged from 56.7% to 100%. Homeopathy changed from a fixed medicine to an individualized homeopathy. Most studies (9/15) demonstrated improvements after homeopathy. Side effects were not seen or minimal and were comparable to placebo groups. In conclusion, this review shows homeopathy is a promising and safe therapy for RD treatment. However, the data needs to be reproduced in future more extensive studies, including other rheumatic conditions.

An integrated approach to the treatment of Rheumatic diseases: the role of psychological interventions.

Rheumatic diseases are chronic conditions that often result in significant physical and psychological challenges, reducing patients' quality of life and increasing the economic burden on healthcare systems. This study examines the vital role of psychological interventions in the comprehensive treatment of rheumatic diseases. The findings reveal a high prevalence of psycho-emotional disorders such as depression, anxiety, and stress among these patients, which can worsen disease progression and hinder treatment adherence. The review highlights the bidirectional relationship between the central nervous and immune systems, showing how psychological stress influences the pathophysiology of inflammatory diseases. Various psychological interventions are explored, including mind-body therapies, cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based practices such as meditation, yoga, and tai chi. These approaches improve emotional well-being, help reduce pain, and enhance overall quality of life. The article emphasizes a holistic treatment model incorporating pharmacological care, physical rehabilitation, and psychological support. This integrated approach fosters more effective management of rheumatic diseases by addressing their complex nature and promoting better functional outcomes. The study advocates for the seamless incorporation of psychological support into routine clinical practice tailored to the biopsychosocial profile of each patient. Future research should focus on identifying the most effective psychological interventions for different patient groups to enhance the quality of life for individuals with rheumatic diseases.

Methotrexate: Use in the Post Dobbs v. Jackson Era.

Methotrexate is one of the most frequently used medications for the treatment of rheumatic diseases. Although initially developed for use as chemotherapy for both solid and hematologic malignancies, it was used as early as the 1960s with success for rheumatoid arthritis (RA) and psoriatic arthritis, ultimately being approved by the US Food and Drug Administration for the treatment of RA in 1988. Beyond RA and psoriatic arthritis, methotrexate is used in the treatment of systemic lupus erythematosus, idiopathic inflammatory myopathies, and other inflammatory conditions. Methotrexate is cytotoxic to the trophoblast and has been used to treat both ectopic pregnancy and gestational trophoblastic neoplasia, leading to studies in the early 1990s that showed it was effective and safe for early abortion in combination with prostaglandin E1 analog misoprostol. Methotrexate is also a teratogen, causing serious birth defects in 6%-10% of patients taking it while pregnant. Additionally, women are more likely to be affected by both RA at SLE, as compared with males, thus worsening the burden of these adverse effects. Both methotrexate's history of use as an abortifacient and its teratogenic properties make its use more complicated in the current era of abortion policy in the United States following the Dobbs v. Jackson Women's Health Organization ruling. Recently published data suggest that this ruling has affected both provider perspectives and patient experiences as it relates to methotrexate use. In the post-Dobbs era, the role of the rheumatologist as it relates to patients' sexual and reproductive health is likely to expand.

Cannabinoids in the Inflamed Synovium Can Be a Target for the Treatment of Rheumatic Diseases.

The management of rheumatic diseases has noticeably changed in recent years with the development of targeted therapeutic agents, namely, biological disease-modifying antirheumatic drugs. Identifying essential signaling pathways and factors crucial for the development and progression of these diseases remains a significant challenge. Therapy could be used to delay the onset or reduce harm. The endocannabinoid system's presence within the synovium can be identified as a suggested target for therapeutic interventions due to its role in modulating pain, inflammation, and joint metabolism. This review brings together the most pertinent information concerning the actions of the endocannabinoid system present in inflamed synovial tissue and its interaction with phytocannabinoids and synthetic cannabinoids, which can be used from a therapeutic perspective to minimize the inflammatory and pain processes typical of osteoarthritis and rheumatoid arthritis.

Therapeutic apheresis treatment in rheumatic diseases: Insights from a single-center experience.

We aimed to evaluate the characteristics of the patients with a rheumatologic disease who underwent TPE. A single-center, retrospective study was conducted between January 2016 and June 2023. Twenty patients with a median age of 51 years received a median of 6 TPE sessions. Concurrently, immunosuppressive therapy was administered to 18 (90%) of them. During the follow-up period, 9 patients (45%) died. Creatinine (p = 0.001), C-reactive protein (p = 0.001), sedimentation rate (p = 0.002), leukocyte (p = 0.003), thrombocyte (p = 0.003), and neutrophil (p = 0.003) counts was decreased after TPE. Similarly, in the ROC analysis of post TPE laboratory parameters, urea, creatinine, CRP, hemoglobin, platelets, and lymphocytes predicted mortality with areas under the curve values ranging from 0.747 to 0.869. In the Cox regression analysis for mortality, creatinine was predictive for mortality (p = 0.030), HR 1.59 (95% CI: 1.05-2.41). In rheumatologic conditions, TPE is beneficial to fill the gap until the effects of immunosuppressants become apparent.

Ocular Adverse Effects of TNF-α Inhibitors in the FDA Adverse Event Reporting System (FAERS)

Autoimmune inflammatory diseases affect 7.6-9.4% of the global population, predominantly women. TNF-α inhibitors (TNFI) have revolutionized rheumatic disease treatment but are associated with serious ocular adverse events (AEs). We analyzed FAERS data for adalimumab, etanercept, and infliximab (1998-2024), documenting patient demographics and the top 10 ocular AEs for each TNFI. Of the 45,445 reported ocular AEs, 66.6% were in females and 50.3% were in adults aged 18-64. The most common AEs included visual impairment (7,093), cataract (5,730), and blurred vision (5,586). There were 2,271 reports of blindness. The distribution of AEs was similar across adult age groups but rare in pediatric patients and those over 85. A review by da Silva et al corroborates our findings, identifying uveitis, optic neuropathy, and retinal toxicity among others. FAERS data showed 1,927 uveitis cases linked to adalimumab, 1,054 to etanercept, and 1,076 to infliximab. These AEs may result from TNF-α binding in ocular tissues, paradoxically causing and treating uveitis. Our study highlights the severity of ocular AEs with TNFI use, suggesting a need for vigilance in monitoring patients, especially given the potential for irreversible blindness. The limitations include voluntary reporting and underreporting in FAERS, underscoring the need for further research to better understand these risks.

Abstract We056: Hydroxychloroquine cures autoimmune myocarditis by inhibiting innate immune via the CXCL16-CXCR6 axis between macrophages and T cells

Background: Myocarditis is a live-threatening inflammatory disease of the heart and is lack of effective treatment measures. Hydroxychloroquine (HCQ), a classic antimalarial drug, has been widely used in the treatment of rheumatic diseases. This study investigated whether HCQ can treat chronic autoimmune myocarditis. Methods and Results: Murine autoimmune myocarditis was induced, and therapeutic effects of oral HCQ on acute and chronic myocarditis were evaluated using echocardiography, cardiac catheterization, and analysis of inflammatory scores in cardiac tissue. Results showed that HCQ treatment significantly improved cardiac function, inhibited ventricle enlargement and reduced cardiac inflammation. Single-cell transcriptomic analysis in the heart showed that HCQ treatment significantly reduced infiltration of macrophage, neutrophiles and T-cells, inhibited inflammatory pathway, especially the secretion of CXCL16 from macrophages, thereby reducing the chemotaxis of T cells, especially NKT cells and Th17 cells. Finally, both in vitro and in vivo experiments confirm the inhibitory effect of HCQ on CXCL16-CXCR6 axis between macrophages and T cells. Additionally, treatment with anti-CXCL16 antibody can also improve cardiac function and attenuate cardiac fibrosis in myocarditis. Conclusions: HCQ treatments clinically cure mice with autoimmune myocarditis through inhibiting innate immune and infiltration of macrophages majorly via CXCL16-CXCR6 axis.

Identification of lignans as selective cyclooxygenase-2 inhibitors from the extract of Acanthopanacis cortex

Acanthopanacis cortex (the dried root bark of Acanthopanax gracilistylus W. W. Smith) has been used for the treatment of rheumatic diseases in China for over 2000 years. Four previously undescribed lignans (1–4) and 12 known lignans (5–16) were isolated from Acanthopanacis cortex. In this study, the inhibitory activities of compounds 1–16 against neutrophil elastase (NE), cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) are reported. The results show that compounds 1–16 exhibit weak inhibitory activities against NE and COX-1. However, compounds 2, 6–8 and 13–16 demonstrate better COX-2 inhibitory effects with IC50 values from 0.75 to 8.17 μΜ. These findings provide useful information for the search for natural selective COX-2 inhibitors.

Pharmacological evidence regarding medicinal plants used for the treatment of rheumatoid arthritis and osteoarthritis (osteoarthrosis)

Rheumatoid arthritis (RA) and osteoarthritis (OA) are social impact disorders that lead to intense pain, deformities, and inability to perform daily and work-related activities. In Brazil, despite the National Policies for Integrative and Complementary Practices (PNPIC) and Medicinal Plants and Phytotherapies (PNPMF) that have expanded access to Phytotherapy, the incorrect dissemination of the use of medicinal plants remains common, often without any scientific evidence of efficacy. The aim of this study was to select some plants popularly recommended on the internet for treating RA and OA and to gather data on their efficacy and safety. These plants include Harpagophytum procumbens, Hypericum perforatum, Miconia albicans, Uncaria tomentosa, and Varronia curassavica. A literature review covering in vitro, preclinical, and clinical trials revealed promising results regarding the action of these plants on RA and OA. Most studies emphasize the anti-inflammatory, anti-arthritic, and analgesic effects of these species. However, as the mechanisms are not yet fully understood, further studies, particularly clinical trials, are necessary to reach a more definitive conclusion. This literature review can contribute to and alert healthcare professionals and patients seeking these products for the treatment of rheumatic diseases.

Methotrexate toxicity in patients with rheumatic diseases: A 10-year evaluation of manifestations, risk factors, and mortality

Methotrexate (MTX) is a commonly used medication in the treatment of rheumatic diseases. MTX toxicity is a serious and at times fatal complication. In this 10-year cohort, we retrospectively evaluated the cases of MTX toxicity among rheumatic patients to identify demographic, clinical, and laboratory characteristics and risk factors of mortality. Through 10 years, patients older than 17 years with a rheumatic disease and at least one major manifestation of MTX toxicity (mucositis, myelosuppression, pneumonitis) were enrolled in the study. Demographic, clinical, and laboratory data were collected. Comparisons were made between patients who recovered and those who passed away. Of the 66 patients, most had rheumatoid arthritis, followed by systemic lupus erythematous. Most patients were females, and their mean age was 63.3±12.4 years. The most common comorbidity was hypertension followed by diabetes mellitus. Most patients were on polypharmacy and were taking MTX incorrectly. Other potential risk factors of toxicity were hypoalbuminemia, decreased renal function, and infection. The outcome of six patients was death and the predictors of mortality were severe leukopenia at admission, infection, especially sepsis, and severe renal impairment. In this study, we observed some potential risk factors for toxicity, namely incorrect MTX use, polypharmacy, renal impairment, hypoalbuminemia, infection, and comorbid conditions such as diabetes mellitus, hypertension, and ischemic heart disease. We also identified the risk factors of mortality, including infection, sepsis, severe leukopenia, high creatinine levels, and severe renal impairment.

Prevalence of polypharmacy and drug interaction in older adults with rheumatic disease

Introduction/AimOlder people with rheumatic diseases tend to have a greater number of associated comorbidities, which will require the use of more drugs, increasing the risk of hospitalizations, complications, and drug interactions. In Mexico, there has been an estimated prevalence of polypharmacy of up to 55%, however there are scarce reports on the topic in our elderly population with rheumatic diseases. We aimed to determine the prevalence of polypharmacy and the association of drug interactions in patients treated for rheumatic disease. MethodsA retrospective observational study was conducted on patients undergoing treatment for rheumatic diseases who were treated in geriatrics and rheumatology clinics from January to December 2021. The presence of polypharmacy and drug interactions was evaluated using the BOT Plus Pharmacological Surveillance System. The prevalence of polypharmacy and the association of drug interactions were estimated. ResultsWe evaluated 320 patients, with a mean age of 67.05±5.8 years, predominantly female (85%). The prevalence of polypharmacy was 68.1% (n=218), of which 214 (98.1%) patients had related drug interactions; 27.1% were severe and 53.2% as moderate interactions. Factors related with increased risk of drug interactions were being exposed to hypertension increased the risk of drug interactions (POR 1.75, 95% CI 1.44–2.14; P<0.001), having osteoarthritis (POR 1.21, 95% CI 1.04–1.42; P=0.032) and thyroid disease (POR 1.45, 95% CI 1.28–1.65; P=0.001). The most prevalent serious interactions were leflunomide–methotrexate in 27 (46.5%) patients and buprenorphine–tramadol in 8 (13.7%). ConclusionsA high prevalence of polypharmacy and drug interactions was observed in elderly patients with rheumatic diseases. The main associated factors were comorbidities, particularly high blood pressure, osteoarthritis and thyroid diseases.

Clinical observation of hypofibrinogenemia induced by the treatment of tocilizumab in rheumatic diseases and exploration of risk factor for hypofibrinogenemia.

The objective of this study was to analyze the changes in plasma fibrinogen (FIB) levels during tocilizumab (TCZ) treatment in patients with rheumatic diseases, to clarify the incidence of hypofibrinogenemia and its possible risk factors, and toestablish a nomogram model for predicting the probability of hypofibrinogenemia in rheumatoid arthritis (RA) patients treated with TCZ. Clinical data of patients treated with TCZ at the Department of Rheumatology and Immunology, the First Affiliated Hospital of Xi'an Jiaotong University from January 2014 to October 2021 were retrospectively analyzed to observe the incidence of hypofibrinogenemia in several rheumatic diseases at different time points. The risk factor of hypofibrinogenemia in RA patients treated with TCZ was determined by using Cox regression analysis. Based on the results of Cox regression analysis, a nomogram for predicting the probability of hypofibrinogenemia in rheumatoid arthritis (RA) patients treated with TCZ was established and validated through RStudio software. A total of 83 TCZ-treated patients were enrolled in this study, and 32 (38.55%) patients developed hypofibrinogenemia during TCZ treatment. There were 8 males and 24 females in the FIB-reduced group, with an average age of 44.88 ± 18.39years. Hypofibrinogenemia was most common in TCZ-treated patients with takayasu arteritis (TA) and RA. Hypofibrinogenemia typically occured within 3months after TCZ treatment. In RA patients treated with TCZ, platelet distribution width, parathyroid hormone, bone mineral density, tender joint count, and swollen joint count were independent risk factors for the occurrence of hypofibrinogenemia. The nomogram based on the above risk factors could effectively predict the probability of hypofibrinogenemia in RA patients receiving TCZ. Although bleeding symptoms were not observed in this study, the incidence of hypofibrinogenemia remained high after TCZ treatment, usually occurring within 3months of treatment. Therefore, it is necessary to monitor FIB levels during TCZ treatment. In addition, clinicians can use the nomogram model developed from this study to predict the incidence of hypofibrinogenemia after TCZ treatment in RA patients. Key Points • Hypofibrinogenemia often occurs during TCZ treatment for rheumatic diseases. • PDW, PTH, BMD, tender joint count, and swollen joint count are risk factors for the occurrence of hypofibrinogenemia. • It is necessary to monitor FIB levels during TCZ treatment to avoid bleeding tendency.

Assessment of specificity of immunologic tests for detection of tuberculosis infection in children with juvenile idiopathic arthritis

Introduction. The use of genetic engineering biological agents (GEBA) in the treatment of rheumatic diseases over the past decades has led to a significant improvement in the prognosis in this group of patients. However, against the background of anti-tumor necrosis factor α therapy (anti TNF-α), the risk of developing tuberculosis increases tenfold.Aim. To evaluate the specificity and safety of Mantoux test, recombinant tuberculosis allergen (RTA) test, IGRA tests: TB-Feron IGRA, T-SPOT.TB, QuantiFERON-TB GIT in patients from 5 to 18 years of age, who are at risk for the development of tuberculosis, due to the use of immunosuppressive therapy, including GEBP.Materials and methods. This clinical trial is a prospective single-center open-label study with 120 patients under observation. Girls predominated among the patients – 71 (59.2%), the average age was 12 years (95% CI [5.2–17.4]). As part of the treatment of the underlying disease, patients in the vast majority of cases (78.3%) received iFNO-α drugs: etanercept (67 people), adalimumab (25 people), golimumab (2 people).Results and discussion. According to the results of a comprehensive medical examination, including CT scan of the chest organs, the presence of active tuberculosis was not established in any of the patients. A positive result of the RTA sample was registered in 0.8% of the subjects, Mantoux test in 46.6%, T-SPOT.TB – 1.7%, TB-Feron IGRA and QuantiFERON-TB GIT – 0.8% each. During the safety assessment, it was noted that within 28 days after the study, none of the 120 patients had any adverse events. Patients need appropriate screening before starting treatment and regular follow-up examinations.Conclusions. The Mantoux test with 2 TE has low specificity (0.49), and the sample with RTA (0.99), TB-Feron IGRA (0.99), T-SPOT.TB (0.98) and QuantiFERON-TB GIT (0.99) are highly specific and safe as tests for detecting tuberculosis infection in children with juvenile idiopathic arthritis.

Patient self-reported experience and satisfaction with golimumab and etanercept treatments for rheumatic diseases: A cohort study.

Golimumab and etanercept both exhibit good efficacy in treating rheumatic diseases, while the patient self-reported measurement of treatment improvement and injection experience lacks sufficient evidence. Hence, this study aimed to compare the satisfaction with disease improvement and injection experience and the level of injection site reactions (ISRs) between golimumab-treated and etanercept-treated patients with rheumatic diseases. A total of 312 patients with rheumatic diseases were serially enrolled. Among them, 158 patients received golimumab (golimumab group); the other 154 patients were treated with etanercept (etanercept group) according to the actual disease status, physician advice, and patient willingness. Satisfaction with disease improvement was assessed using the 7-point Likert scale; satisfaction with injection experience and level of ISRs were both determined by the 5-point Likert scale. Satisfaction degrees with global injection experience (P = .025), injection device (P = .008), injection frequency (P = .010), and injection convenience (P = .003) were superior in the golimumab group to the etanercept group, while satisfaction degrees with global disease improvement, symptom relief, and speed of action did not vary (all P > .050) between the 2 groups. Discomfort (P = .005), swelling (P < .001), pain (P = .028), and burning (P = .035) levels were lower in the golimumab group than in the etanercept group. In addition, among 56 patients with a history of tumor necrosis factor inhibitor treatment before golimumab, 40 (71.4%) patients preferred golimumab to other tumor necrosis factor inhibitor. After switching to golimumab treatment, the level of ISRs in most patients was reduced or comparable. Golimumab achieves a satisfying injection experience and relieves the level of ISRs over etanercept in patients with rheumatic diseases.

Glucocorticoids in rheumatology: myths vs. reality

Glucocorticoids (GC) have been the mainstay of practicing rheumatologists since the Nobel Prize was awarded for the discovery of cortisone in 1950. It has been proven that GC have highly effective anti-inflammatory and immunosuppressive properties. Identification of genomic and non-genomic effects, which directly affect most pathogenetic processes in the course of rheumatic diseases, served as the basis for the implementation of GC in routine rheumatological therapy. The further widespread introduction of GC into rheumatology practice is due to low cost, high availability, quick onset of action, and activity aimed at preventing organ damage. The optimal choice for the use of GC in the treatment of rheumatic diseases is a specific and individual approach in dosage and routine monitoring. To date, there are no reliable tools for determining the toxicity of GC, which is associated with poor compliance, acute onset or chronic course of adverse events AE, variability in the duration of GC use, and the need for the different dosages to control diseases.

Evidence of the interactions between immunosuppressive drugs used in autoimmune rheumatic diseases and Chinese herbal medicine: A scoping review

ObjectivesChinese herbal medicine (CHM) has been shown to be effective in autoimmune rheumatic diseases, but harmful herb-drug interactions might be inherent. We aim to review the evidence regarding herb-drug interactions between immunosuppressive drugs used in autoimmune rheumatic diseases and CHM. MethodsWe searched PubMed, EMBASE and CINAHL from inception till 30 April 2023 using keywords that encompassed ‘herb-drug interactions’, ‘herbs’ and ‘immunosuppressants’. Articles were included if they contained reports about interactions between immunosuppressive drugs used in the treatment of rheumatic diseases with CHM. Level of evidence for each pair of interaction was graded using the algorithm developed by Colalto. ResultsA total of 65 articles and 44 unique pairs of interactions were identified. HDIs were reported for cyclophosphamide, cyclosporine, tacrolimus, methotrexate, mycophenolic acid, glucocorticoids, sulfasalazine, tofacitinib and biologic disease-modifying antirheumatic drugs. Among these, cyclosporine (n = 27, 41.5%) and tacrolimus (n = 19, 29.2%) had the highest number of documented interactions. Hypericum perforatum had the highest level of evidence of interaction with cyclosporine and tacrolimus. Consumption reduced the bioavailability and therapeutic effects of the drugs. Schisandra sphenanthera had the highest level of evidence of interaction with tacrolimus and increased the bioavailability of the drug. Majority of the articles were animal studies. ConclusionOverall level of evidence for the included studies were low, though interactions between cyclosporine, tacrolimus, Hypericum perforatum and Schisandra sphenanthera were the most and well-documented. Healthcare professionals should actively enquire about the concurrent use of CHM in patients, especially when drugs with a narrow therapeutic index are consumed.

Exploring the potential molecular mechanism of Gualou Guizhi decoction in the treatment of rheumatoid arthritis based on network pharmacology and molecular docking.

Traditional Chinese medicine (TCM) has been used in China for a long time and is gradually gaining more and more recognition worldwide. Gualou Guizhi Decoction (GGD) has long been used as a folk medicine for the treatment of rheumatic diseases, but its bioactive components and therapeutic mechanisms are still unclear. An integrated approach using network pharmacology and molecular docking and using methotrexate as a positive control drug. We obtained 157 active ingredients of GGD, 7542 RA disease targets and 49 intersecting targets. GO and KEGG enrichment analysis revealed that their functions were mainly related to cytokine active metal ion binding, enzyme binding and DNA binding, and enriched in TNF signaling pathway, T cell receptor signaling pathway, Toll-like receptor signaling pathway, RA pathway and other signaling pathways that are closely related to RA. The molecular docking results show that the effector components of GGD bind better to the core targets of RA, and some are even better than methotrexate. The therapeutic effect of GGD for RA is achieved by affecting the core targets such as VEGFA, IL-1β, IL6, CXCL8, CCL2, and JUN, which together interfere with the tumor necrosis factor signaling pathway and RA pathway to treat RA. The above study provides new ideas for further exploration of this classic formula in the future.

Access to biologics and Janus kinase inhibitors for treatment of rheumatic diseases in the biosimilars era in Poland: a nation-level study.

By reducing treatment costs, biosimilars provide an opportunity to improve accessibility to highly effective drugs. This study aimed to evaluate access to biologic disease-modifying antirheumatic drugs (bDMARDs) and Janus kinase inhibitors (JAKis) among patients with rheumatic musculoskeletal diseases within a 10 year timeframe in Poland. We performed a retrospective analysis using a nationwide public payer database. By 2022, 11 102, 6602, and 4400 patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (axSpA) were treated with bDMARDs or JAKis. Peak drug utilization was observed for adalimumab, followed by etanercept and tocilizumab. Within the study timeframe, the estimated access to innovative drugs increased from 0.8%, 1.4%, and 0.8% to 3.2%, 8.7%, and 3.5% for RA, PsA, and axSpA patients, respectively. Affordable tumor necrosis factor inhibitors (TNFis) still predominate among innovative therapeutics, but their market share declined from 87% to 46%. The number of patients treated with other bDMARDs/JAKis almost doubled within the prespecified timeframe. Overall, the average annual treatment cost per patient decreased by 60%, from 7315 EUR to 2886 EUR. Despite recent safety warnings, JAKis appear to be increasingly utilized. Additional analyses regarding the COVID‑19 pandemic showed impaired access to intravenous therapies, but not subcutaneous or oral formulations. In Poland, biosimilars‑related savings improved availability of higher‑priced innovative drugs rather than less costly TNFis. Data‑driven resource allocation and dedicated policy solutions facilitating access to affordable biologics are recommended.

Pharmacists' perception about efficacy, safety, and quality of dietary supplements that used for rheumatic disorders in the Iraqi pharmaceutical market.

Rheumatic diseases are common progressive diseases that associated with chronic pain. Most patients seek to reduce the pain of these diseases by using dietary supplements (DS). Yet, most DS have limited benefits to reduce pain and/or disease progression. Therefore, this study aimed to explore the perceptions of community pharmacists about the efficacy, safety, and quality of the DS for treatment of rheumatic diseases (DSTRD) in the Iraqi pharmaceutical market. A qualitative study was conducted during February-2023 through face-to-face interview with community pharmacists with ≥6 months of working experience. The interviews were guided through semi-structured open-ended questions. The interviews were recorded using iPhone-11. A hybrid framework-model was used to analyze the data. Interviews were performed with 20 pharmacists. Only 30% of pharmacists considered DSTRD to be effective, whereas 75% of them perceived DSTRD to be safe. One-quarter of the participants considered the quality of DSTRD to be good. All interviewed pharmacists reported that prescribing DSTRD become a common practice. Eleven participants reported that deals with pharmaceutical companies are the main trigger for prescribing DSTRD. Three-quarter of participating pharmacists mentioned that they educate their patient about the dispensed DSTRD. However, only 10% of them educate patients about the possible side effects and interactions of DSTRD. In conclusion, most of the participating pharmacists have doubts about the efficacy, safety, and quality of DSTRD in the Iraqi market. The prescribing of such products by physicians is common and usually triggered by deals with pharmaceutical companies. Pharmacist-education to the patient on these supplements is poor.

Why most (but perhaps not all) DMARDs work equally well

Biological- or targeted-synthetic DMARD-responses reported in randomized clinical trials, placebo-controlled or head-to-head, in patients with rheumatoid arthritis, psoriatic arthritis or spondyloarthritis are unbelievably similar, when looking across trials performed in the same disease and applying the same primary outcome measures. The exception to this rule may be the response to Janus-kinase-inhibitors, which seem to work 10 % better in all trials (JAK-bonus) This article provides a potential explanation for this remarkable phenomenon, including an explanation for the JAK-bonus. It seems as if JAK-inhibitors exert some inflammation-independent effects on pain, fatigue and wellbeing, and that drug treatment of rheumatic diseases is more than the inhibition of inflammation alone.