Dr C Balakrishnan, Consultant Rheumatologist, Hinduja hospital, Mumbai

Factors Associated With Sustained Remission in Rheumatoid Arthritis in Patients Treated With Anti–Tumor Necrosis Factor

Arthritis Care and Research (pages 783–793)

Arthritis Care Res (Hoboken). 2017 Jun;69(6):783-793. doi: 10.1002/acr.23016. Epub 2017 May 8.

Anti–tumor necrosis factor (anti-TNF) antibody has dramatically improved the treatment of rheumatoid arthritis (RA), however to predict which patients are most likely to attain a sustained response remains a challenge. Thus an in-depth analysis to answer this question was undertaken and 6 studies were identified. Concomitant methotrexate use was associated with an increased likelihood of achieving sustained remission. Greater baseline disease activity, tender joint count, age, disease duration, baseline functional impairment, and female sex were associated with reduced likelihood of achieving sustained remission. This evidence supports current recommendations for methotrexate co-prescription and highlights the negative impact of particular clinical and demographic features on the likelihood of achieving optimal response to anti-TNF treatment.

Disease activity trajectories in early axial spondyloarthritis: results from the DESIR cohort

Annals of the Rheumatic Diseases (Pages 1036-1041).

Ann Rheum Dis. 2017 Jun;76(6):1036-1041. doi: 10.1136/annrheumdis-2016-209785. Epub 2016 Nov 25.

Disease activity may change over time in axial spondyloarthritis (ax-SpA). This study was done to identify patterns of disease activity evolution in patients with early ax-SpA (< 3 years) over the 3 years of follow-up. The five distinct trajectories of disease activity over the 3 years were (t1) ‘persistent moderate disease activity’ (36.2%); (t2) ‘persistent inactive disease’ (17.8%); (t3) ‘changing from very high disease activity to inactive disease’ (7.8%); (t4) ‘persistent high disease activity’ (34.1%) and (t5) ‘persistent very high disease activity’ (4.1%). After adjustment for other characteristics, t2 persistent inactive disease- was associated with a white-collar job (OR=2.6 (95% CI 1.0 to 6.7)) and t3 -changing from very high disease activity to inactive disease- with male gender (OR=7.1 (1.6 to 32.2)), higher education level (OR=9.4 (1.4 to 63.4)) and peripheral joint involvement (OR=6.2 (1.23 to 31.32)).

Patients from (t4) and (t5) were more often declared work disabled over follow-up (HR=5.2 (1.5 to 18.0) and HR=8.0 (1.3 to 47.9), respectively).

Thus despite treatment 35% patients had persistently high disease activity. As with RA, male gender and higher education levels were found to predict inactive disease state, although the reasons for this, were not clear.

The Euro-Lupus Low-Dose Intravenous Cyclophosphamide Regimen Does Not Impact the Ovarian Reserve, as Measured by Serum Levels of Anti–Müllerian Hormone

Arthritis and Rheumatology (pages 1267–1271)

Arthritis Rheumatol. 2017 Jun;69(6):1267-1271. doi: 10.1002/art.40079. Epub 2017 May 3.

Cyclophosphamide (CYC) remains cornerstone of threatening severe SLE manifestations, despite of availability of other options. Gonadal toxicity remains a major concern. The Euro-Lupus regimen of low-dose intravenous cyclophosphamide (IV CYC) was developed to reduce gonadal toxicity. To address the effect of low dose CYC on the ovarian reserve, serum titers of anti–Müllerian hormone (AMH) in patients with systemic lupus erythematosus (SLE) treated with the Euro-Lupus regimen and compared them with those measured in patients who were treated with higher doses of IV CYC or were never treated with IV CYC were measured.

Reassuringly, AMH levels measured in SLE patients treated with the Euro-Lupus IV CYC regimen did not differ from those measured in patients never treated with the cytotoxic drug. As expected, patients given >6 gm of IV CYC had significantly lower serum titers of AMH, compared with those never treated with IV CYC. Also the median serum AMH titers did not change before and after treatment with the Euro-Lupus IV CYC regimen in the subset of patients for whom paired samples could be tested. Thus, the low-dose IV CYC does not impact the ovarian reserve of SLE patients and thus can be proposed as a treatment option in young SLE patients.

2016 American College of Rheumatology/European League Against Rheumatism criteria for minimal, moderate, and major clinical response in adult dermatomyositis and polymyositis

Annals of the Rheumatic Diseases (pages 782-791)

Ann Rheum Dis. 2017 May;76(5):792-801. doi: 10.1136/annrheumdis-2017-211400.

With rapid development in the field of idiopathic inflammatory myositis (IIM), is essential to develop response criteria for adult dermatomyositis (DM) and polymyositis (PM), for assessing response to treatment objectively. Consensus was reached for a conjoint analysis-based continuous model using absolute per cent change in core set measures (physician, patient, and extramuscular global activity, muscle strength, Health Assessment Questionnaire, and muscle enzyme levels). A total improvement score (range 0–100), determined by summing scores for each core set measure, was based on improvement in and relative weight of each core set measure. Thresholds for minimal, moderate, and major improvement were ≥20, ≥40, and ≥60 points in the total improvement score. Sensitivity and specificity in DM/PM patient cohorts were 85% and 92%, 90% and 96%, and 92% and 98% for minimal, moderate, and major improvement, respectively. Thus, the response criteria for adult DM/PM consisted of the conjoint analysis model based on absolute per cent change in 6 core set measures, with thresholds for minimal, moderate, and major improvement.

Treat-to-target (T2T) recommendations for gout

Annals of the Rheumatic Diseases (pages-632-638)

Ann Rheum Dis. 2016 Apr;76(4):632-638. doi: 10.1136/annrheumdis-2016-209467. Epub 2016 Sep 22.

Gout is one of the commonest cause of inflammatory arthritis. As the treat to target (T2T) concept has been successfully in other rheumatic diseases, it was essential to develop T2T approach for gout. Although no randomized trial was identified in which a comparison with standard treatment or an evaluation of a T2T approach had been performed in patients with gout, indirect evidence was provided to focus on targets such as normalization of serum urate levels. The expert group developed four overarching principles and nine T2T recommendations. They considered dissolution of crystals and prevention of flares to be fundamental; patient education, ensuring adherence to medications and monitoring of serum urate levels were also considered to be of major importance. However, unmet questions yet need to be answered; in optimal management of gout, these have also been pointed out.

Compiled by :

Dr Taral Parikh, Rheumatologist, Columbia Asia, Ahmedabad

Dr Romi Shah, DNB Resident, Rheumatology, Hindujahosp, Mumbai