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ID PMID Title PublicationDate abstract
17089920 Combination therapy for early rheumatoid arthritis. 2006 Nov Around 1% of adults in the U.K. have rheumatoid arthritis (RA). U.K. national guidelines recommend that such people should receive disease-modifying anti-rheumatic drugs (DMARDs) as soon as possible after diagnosis, as earlier treatment is more effective in reducing disease progression. Also, it has been proposed that combination DMARD therapy may reduce joint damage more than single drugs. In the light of several recently published trials on combination therapy in early RA, here we update our recommendations on such treatment.
17977485 Disease activity measures for rheumatoid arthritis. 2007 Sep Rheumatoid arthritis (RA) is an inflammatory autoimmune and progressive disease. In patients with RA, persistent disease activity ultimately results in irreversible radiographic damage of the joints with persistent functional loss as a consequence. Disease activity measures assess a disease state at a particular time point. In order to evaluate the course of the disease in daily clinical practice or to judge the efficacy of a treatment in a clinical trial, a measure should also comprise the dimension of time. Composite indices provide a comprehensive view of disease activity and include the Disease Activity Score 28, the American College of Rheumatology criteria and newer indices such as the Clinical Disease Activity Index, the Rheumatoid Arthritis Disease Activity Index, and the Simplified Disease Activity Index. The target of RA treatment is to suppress disease activity as completely as possible, with remission being the ultimate goal. The composite index chosen should, therefore, be applicable to the circumstance in which it will be used, with different requirements in clinical practice versus clinical trials. In addition to the choice of an assessment index, novel disease monitoring strategies have been used to optimize treatment and disease control, as in the TICORA and BeST studies. It is clear that the best benefit for the patient can be obtained by combining the optimal treatment strategy and the most appropriate outcome measure. Low disease activity, intensive monitoring, and rapid adjustments in treatment seem to promise the greatest benefit. Further studies are required to better evaluate the clinical relevance of methods for assessing disease activity in patients with RA.
17278922 Outcomes in rheumatoid arthritis: incorporating the patient perspective. 2007 Mar PURPOSE OF REVIEW: As biologics have improved the prognosis for rheumatoid arthritis, the prioritization of outcomes has shifted. Methods of quantifying concerns of particular importance to patients as a basis for better addressing the patient perspective in treatment are being developed. This review aims first to highlight some of the recent research in more traditional outcomes and then to focus on the rapid development of patient-centered outcomes over the last several years. RECENT FINDINGS: Clinical trials with combinations of biologics and other disease-modifying antirheumatic drugs have reported significant improvement in radiographs, inflammatory markers and joint exams in rheumatoid arthritis patients. Concomitantly, several studies have appeared in major journals, reporting that patients are emphasizing outcomes such as fatigue, return to normalcy and mental health that are less easily measured by the traditional outcomes markers. SUMMARY: Recent studies have shown both that rheumatologist and patient approaches to achieving wellness differ and providing patients with a sense of control in reaching that state of wellness leads to better outcomes. Current research is focused on evaluating how best to measure the patient assessments and incorporate the patient voice into the clinic.
18675723 The rheumatoid thumb. 2008 Aug Rheumatoid arthritis of the thumb is a common source of disability. Obtaining an understanding of the underlying biologic and physical manifestations of rheumatoid arthritis is essential in the choice of treatment of the disease. In the early stages of the disease, conservative and less invasive measures can be used. In the more advanced stages, arthrodesis and arthroplasty are often used. Isolated interphalangeal involvement is best managed with arthrodesis. Metacarpophalangeal involvement in low-demand patients can be treated with arthroplasty, whereas arthrodesis can be used in more active patients. Patients who have carpometacarpal joint damage are best treated with trapezium resection arthroplasty.
18045811 MRI of rheumatoid arthritis image quantitation for the assessment of disease activity, pro 2008 Jan Magnetic resonance imaging (MRI) allows the direct visualization of many bone and soft tissue changes in rheumatoid arthritis. Synovitis volume, bone marrow oedema and bone erosions are suitable for serial measurement. The outcome measures in rheumatoid arthritis clinical trials (OMERACT) rheumatoid arthritis magnetic resonance imaging (RAMRIS) system is designed to allow straightforward, reproducible scoring of all these features. Alternatively, synovial volumes may be directly and quickly measured using semi-automated techniques. There is the potential for similar systems for measuring erosions. Dynamic contrast enhanced MRI depends on the rate of enhancement of the synovium after intravenous contrast agent. Measurements depend on the underlying physiology of the inflamed synovium, in particular the vascularity and capillary permeability which are expected to closely mirror inflammatory activity in the joint. Measurements from MRI have been shown to correlate with clinical, laboratory, imaging and histological measures of inflammation, predict erosive progression and respond rapidly to various types of treatment. They are, therefore, expected to be good measures of disease activity, progression and response to therapy.
16817941 Aspects of early arthritis. What determines the evolution of early undifferentiated arthri 2006 Over 3500 patients with recent onset inflammatory polyarthritis (IP) have been recruited by the Norfolk Arthritis Register (NOAR) since 1990. Longitudinal data from this cohort have been used to examine the prevalence and predictors of remission, functional disability, radiological outcome, cardiovascular mortality and co-morbidity and the development of non-Hodgkin's lymphoma. Rheumatoid factor titre, high baseline C-reactive protein and high baseline HAQ score are all predictors of a poor outcome. There is a strong association between possession of the shared epitope and the development of erosions. Patients who satisfy the American College of Rheumatology criteria for rheumatoid arthritis (RA) have a worse prognosis than those who do not. However, it appears that these patients are a poorly defined subset of all those with IP rather than having an entirely separate disease entity. New statistical techniques offer exciting possibilities for using longitudinal datasets such as NOAR to explore the long-term effects of treatment in IP and RA.
16925504 InforMatrix: treatment of rheumatoid arthritis using biologicals. 2006 Sep This article offers an interactive decision matrix technique (InforMatrix), in which a group of experts in rheumatology determine an order of merit within the various biologicals used for rheumatoid arthritis. In this order of merit, six criteria (efficacy, safety, tolerance, ease of use, applicability and costs) are weighed against each other. Data necessary for this weighing process are derived from both literature, as well as clinical practice experience. This article provides an overview of the most relevant clinical trials on the biologicals, as well as a description of the interactive decision matrix technique. Using this interactive matrix technique makes rational consideration of the treatment options for rheumatoid arthritis possible.
16496075 [Activity-score based therapy in rheumatoid arthritis]. 2006 Mar Disease activity scores for rheumatoid arthritis have been developed and validated in recent years. They allow the longitudinal documentation of the effectiveness of treatment. Application of these scores in routine daily practice could significantly improve the effectiveness of therapy with relatively little effort. This review presents evidence for the benefits of the application disease activity scores in clinical routine.
17133760 Rheumatoid arthritis: A review. 2006 Sep Rheumatoid arthritis (RA) is a systemic autoimmune disease with primary manifestations in the diarthrodial (movable) joints. Methotrexate in weekly doses is the most widely used disease modifying agent. The recent development of biologic agents designed to shut off disease activity can be of great benefit to individuals who fail methotrexate therapy. New treatments such as tumor necrosis factor suppressants are effective in up to 80% of patients. It is extremely important to diagnose RA in its earliest stages so that patients may benefit from antimetabolites and biologics before permanent joint damage takes place.
17083763 Remission of rheumatoid arthritis: should we care about definitions? 2006 Nov A state of remission can be achieved in more and more rheumatoid arthritis (RA) patients. The combination of several RA disease activity measures seems to be important to provide an overall view of disease activity. Remission can be defined by two different approaches: one using a categorical model, requiring criteria for multiple variables to be fulfilled, each with its own threshold value (remission "criteria"); the other using a dimensional model, providing single measures of activity, which allow definition of remission by a single cut point (remission cut points for composite indices). The face validity of remission as defined by composite indices surpasses the one for the "criteria". Likewise, the ones that are not weighted seem to surpass the weighted ones, as can be seen by the significant proportion of patients that continues to have considerable swollen joint counts despite being in Disease Activity Score (DAS)-28 remission. All composite indices seem to perform similarly well as tests for remission using expert judgments as the gold standard.
17350543 Management of established rheumatoid arthritis with an emphasis on pharmacotherapy. 2007 Feb The goals for the management of established rheumatoid arthritis (RA) differ slightly from the goals for the management of early RA. In established RA, in most cases, joint damage will be present, therefore the main goals are aimed at keeping the disease activity as low as possible to prevent joint damage progression. Furthermore, patients with RA have a reduced life expectancy, mainly due to co-morbid conditions such as cardiovascular disease. As in early disease, pharmacotherapy is the cornerstone of the management of patients with established RA. In this article we will discuss the characteristic manifestations of established RA, the pharmacological treatment strategies available for reaching the management goals of established RA, the role of prognostic factors and the measurements available for evaluating the outcomes of the management of individual patients with established RA in daily clinical practice.
17765841 Total ankle replacement for rheumatoid ankle arthritis. 2007 Sep This article reviews total ankle replacement for rheumatoid ankle arthritis. The benefits of preserving the mobility of the ankle joint for the patient who has rheumatoid arthritis are undisputed. Recent reports have consistently shown that patient satisfaction following ankle replacement is high and prosthetic survival is more than 90% at five years and in many instances more than 80% at 10 years. Ankle replacement is contraindicated when there is severe coronal plane deformity.
17870036 Economic consequences of established rheumatoid arthritis and its treatment. 2007 Oct Recent years have witnessed tremendous progress in the therapeutic approach to rheumatoid arthritis (RA). The introduction of novel biologic agents, in particular TNF inhibitors, has allowed clinicians to achieve improved outcomes for their patients. An important factor that has affected the utilization of novel therapies is their acquisition costs, which far exceed those for older antirheumatic drugs. Nevertheless, RA is a serious chronic condition which can cause substantial morbidity and even accelerated mortality for affected individuals. The notable sequelae of uncontrolled rheumatoid synovitis include joint damage and functional disability, which in turn, cause severe economic consequences not only to patients and their families, but also to society. Therefore, it is appropriate for pharmacoceconomic analyses to take into account all relevant costs, not only of the treatments, but of the disease itself. In this way, the value of therapies can be correctly estimated.
17765839 Management of hindfoot disease in rheumatoid arthritis. 2007 Sep There is a wide variety of hindfoot disease seen in patients with rheumatoid arthritis. Initial treatment is conservative including optimizing medical management to control the disease process. Should symptoms persist, surgical treatment may be performed, although there is an increased complication rate related to both the disease and the side effects of the medications used to treat it.
16980723 The heart and cardiovascular manifestations in rheumatoid arthritis. 2006 Oct Cardiovascular features in rheumatoid arthritis (RA) are common. Among those are the classical extra-articular features that not only include pericarditis, cardiomyopathy/myocarditis, cardiac amyloidosis, coronary vasculitis, arrhythmia and valve diseases, but also congestive heart failure and ischaemic heart disease which are found more frequently and are associated with an increased mortality compared with the general population. This overview discusses the epidemiological aspects of these cardiovascular diseases and their relevance for diagnosis and treatment of RA.
17343248 Health economic issues in rheumatoid arthritis. 2006 Nov The objectives of treatment in rheumatoid arthritis (RA) are to reduce temporary symptoms due to inflammatory activity and, more importantly, to preserve function. The introduction of potent disease-modifying anti-rheumatic drugs (DMARDs) in recent years has increased the opportunities for effective treatment. However, these treatments come at a substantially higher cost than traditional DMARDs and therefore compete with other essential interventions for limited resources. They have triggered a debate on whether they represent an efficient use of resources, which patients should be treated, when, and for how long. Cost-effectiveness analysis attempts to estimate the trade-offs involved in these decisions and to provide information that can help in making them. However, in chronic progressive diseases, health gains and any potential associated economic benefits are often most evident in the long-term. As a consequence, the impact of new treatments has to be estimated using models that can project available knowledge, such as results from clinical trials or short-term follow-up studies in clinical practice, into the future. These models also allow scenarios to be explored that provide the best value for money, for example by defining subgroups for which treatment is most effective, or criteria that define when treatment should be stopped. Economic evaluation in RA has a long tradition, with the first study performed about 20 years ago. However, with the recent drug introductions, the field has witnessed an explosion of economic studies. Modelling techniques have become more sophisticated to overcome concerns about their validity. At the same time, they may appear less transparent, making it difficult for non-specialists to understand the details. This article, rather than reviewing all published models and comparing them, attempts to illustrate the inputs required for such studies, and the influence that different approaches and datasets can have on the results.
16496073 [Measuring disease activity for rheumatoid arthritis]. 2006 Mar Rheumatoid arthritis (RA) is the most common systemic inflammatory joint disease. It can be treated effectively with disease modifying antirheumatic drugs, and the currently propagated treatment strategy is to treat RA consequently, and revise the therapeutic approach frequently on the basis of proper disease activity evaluation. In the current review, we focus on the instruments and measures used in the assessment of RA disease activity. We will first consider the so-called core set measures of activity, prividing comprehensive overviews on joint count scales, global scales, pain scales, biomarkers, and functional assessment instruments. The second part of the review focuses on the value of composite measures of disease activity; a term under which we subsume activity indices using various formulae, self-assessment tools of disease activity, and response criteria. Among the inflammatory rheumatic diseases, RA is the one for which the most intensive research is done, and usually instruments that work for RA are further tested for other joint diseases. However, there is still a research agenda for the assessment of disease activity, even for RA. One important aspect is to assess the reliability and utility of all available instruments, including the very low end of disease activity, since remission has become an achievable goal. Another focus of disease activity assessment is to derive measures that work in clinical trials and in daily practice, but are also well understood by patients and physicians. This will further improve our ability to care for patients with RA consequently.
18817645 Current status of gene therapy for rheumatoid arthritis. 2008 Oct Gene therapy offers great possibilities for treating rheumatoid arthritis (RA). Traditional surgical and pharmaceutical methods of treating RA have met with limited therapeutic success and have failed to produce a cure, but the past several years have seen extensive progress toward development of a gene therapy for arthritis. Numerous vectors and therapeutic genes have been investigated in animal models of arthritis, and the potential of gene therapy to treat or manage RA has been demonstrated in several clinical studies. Gene therapy offers the possibility of overcoming many of the limitations of current biologic therapies by providing long-term, high-level localized expression of therapeutic genes, potentially in as little as a single dose. In this review, we explore the advances in gene therapy for RA and summarize the recent preclinical and clinical data. In addition, we provide an overview of vectors and targets for RA gene therapy.
17122688 Emerging new therapies in rheumatoid arthritis: what's next for the patient? 2006 Nov Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by an inflammation of the synovial membranes and progressive joint destruction, leading to significant impairment of physical function and quality of life. Rheumatoid arthritis imposes a substantial economic burden on both patients and society. The recent introduction of new biologic therapies for the treatment of RA reflects the application of knowledge obtained from advancements in the understanding of disease immunopathology. This article reviews emerging new therapies for RA, focusing on those that will be administered by infusion, and highlights the important role of the infusion nurse in providing optimal patient care.
16909710 Cytokine network and its manipulation in rheumatoid arthritis. 2006 Jun Studies of the inflammatory process in the inflamed synovium from rheumatoid arthritis patients have shown an intricate network of molecules involved in its initiation, perpetuation and regulation trial balances the pro- and anti-inflammatory process. This system is self-regulating though the action of anti-inflammatory and pro-inflammatory cytokines cytokine receptor antagonists and naturally occurring antibodies cytokines. Inflammatory synovitis in rheumatoid arthritis (and possibly in other inflammatory arthritidies) appears to be the result of an imbalance in the cytokine network with either an excess production of pro-inflammatory cytokines or from inadequacy of the natural anti-inflammatory mechanisms. Using this knowledge the newer therapeutic approaches to RA and other inflammatory arthritides are being aimed at correcting this imbalance. Monoclonal antibodies to INF-alpha (humanised form of this is called infliximab), soluble TNF-alpha receptors (etanercept) are already in clinical use and adalimumab (humanised TNF-alpha antibody). IL-1Ra is undergoing clinical trials. Other promising therapeutic agents that could regulate the cytokine network are in various stages of laboratory and clinical evaluation. These studies promise to yield therapeutic targets that could dramatically change the way inflammatory diseases would he treated in the future. The now established efficacy of infliximab and etanercept in inflammatory arthritides could be considered just a glimpse of the exciting scenario of the future.