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ID PMID Title PublicationDate abstract
22532636 Impact of tumour necrosis factor inhibitor treatment on radiographic progression in rheuma 2013 Jan OBJECTIVES: To compare radiographic progression during treatment with disease-modifying antirheumatic drugs (DMARD) and subsequent treatment with tumour necrosis factor α inhibitors (TNF-I) in rheumatoid arthritis (RA) patients in clinical practice. METHODS: Conventional radiographs (x-rays) of hands and wrists were obtained ∼2 years before start (prebaseline), at baseline and ∼2 years after start (follow-up) of TNF-I. Clinical data were obtained from the DANBIO registry and the patient files. x-Rays were scored blinded to chronology according to the Sharp/van der Heijde method. Annual radiographic progression rates during the DMARD (prebaseline to baseline x-ray) and TNF-I (baseline to follow-up x-ray) periods were calculated. RESULTS: 517 RA patients (76% women, 80% IgM rheumatoid factor positive, 65% anticyclic citrullinated peptide positive, 40% current smokers, age 54 years (range 21-86), median disease duration 5 years (range 0-57)) were included. Patients were treated with infliximab (61%), etanercept (15%) or adalimumab (24%). During the DMARD period 85% of patients received methotrexate, 51% sulphasalazine and 78% prednisolone. The median DMARD period was 733 days (IQR 484-1002) and the median TNF-I period was 562 days (IQR 405-766). The median radiographic progression rate decreased from 0.7 (IQR 0-2.9) total Sharp score units/year (dTSS) in the DMARD period to 0 (0-0.9) units/year in the TNF-I period (p<0.0001, Wilcoxon). Corresponding mean dTSS values were 2.1 (SD 3.7) versus 0.7 (SD 2.3) units/year (p<0.0001, paired t test). 305 patients progressed (dTSS >0) in the DMARD period compared with 158 patients in the TNF-I period (p<0.0001, χ(2)). CONCLUSION: This nationwide observational study of RA patients documented significantly reduced radiographic progression during TNF-I treatment compared with the previous period of DMARD treatment.
23214197 The efficacy and safety of leflunomide in patients with active rheumatoid arthritis. 2012 May OBJECTIVES: The aim of this study was to evaluate the efficacy and safety of leflunomide in patients with active rheumatoid arthritis (RA). MATERIAL AND METHODS: The study included 100 patients (88 women and 12 men) with rheumatoid arthritis (RA). The mean age was 46.5 years and the mean duration of the disease was 10.3 years. The inclusion criteria were a Disease Activity Score (DAS28) of over 3.2, and contraindications to methotrexate or failure of treatment with methotrexate for at least 3 months. The patients that were enrolled in the study had developed lesions of various grades according to the Steinbrocker Radiological Classification. Leflunomide was administered at a dose of 20 mg per day for the whole observation period. During the monitoring appointments the duration of morning stiffness, pain and disease activity were evaluated on a visual analogue scale (VAS), as well as the number of tender and swollen joints and the DAS28 score. In compliance with the leflunomide therapy protocol, the following control tests were performed: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), hematology, creatinine and liver function tests. Safety assessment included monitoring of adverse events and laboratory test results. RESULTS: During the one-year monitoring period significant improvements were noted in 68% of the patients, expressed as a decrease of 1.2 or more in their DAS28 scores. DAS28 > 0 < 1.2 was achieved in a further 18% of the patients. No improvement was reported by 14% of the subjects. In one year of treatment leflunomide was effective in 74% of the patients with active RA. The most marked clinical improvement in the DAS28 index was noted between the third and sixth months of treatment. In the next six months ESR, CRP and DAS28 scores continued to decline steadily, but the differences were not as clear as those recorded in the previous time period. CONCLUSIONS: The most commonly observed adverse events were related to the gastrointestinal tract (i.e. diarrhea and periodic increases in liver function tests), and reported hair loss. Mild to moderate adverse events were observed in 19% of the patients; they resolved spontaneously or in response to medication, and were not a reason for discontinuing therapy in any of the cases.
21704234 Use of biologics in rheumatoid arthritis: current and emerging paradigms of care. 2011 Jun BACKGROUND: Improved understanding of rheumatoid arthritis (RA) pathogenesis has led to the development of new biologic treatments that target specific elements of RA inflammatory response. OBJECTIVE: Our aim was to provide a comprehensive review of biologic therapies currently used for the treatment of RA. METHODS: A search of MEDLINE (up to October 2010) was conducted. Preference for article inclusion was given to English language meta-analyses and large, Phase III, randomized controlled trials (RCTs) of biologic treatments in patients with RA. RESULTS: In large RCTs, significantly more patients treated with tumor necrosis factor-α (TNF-α) antagonists (as monotherapy, or as an adjunct to methotrexate) versus controls (35%-67% vs 9%-33% of patients; P ≤ 0.01) achieved an American College of Rheumatology 20 response as a primary study end point. However, safety concerns-especially the potential for serious infections and malignancy-remain for TNF-α blockade. For example, 1 meta-analysis (>5000 patients) reported a 2-fold increase (95% CI, 1.3-3.1) in the risk of serious infections and a 3.3-fold increase (95% CI, 1.2-9.1) in the risk of malignancy. Abatacept and rituximab (given in combination with methotrexate) may be useful clinical alternatives for RA patients with an inadequate response to TNF-α antagonists. These agents do not appear to increase the risk of serious infections (OR, 1.35-1.45; 95% CI, 0.56-3.73), although rituximab may rarely cause progressive multifocal leukoencephalopathy (0.4 cases per 100,000 hospitalizations). CONCLUSIONS: Over the last decade, targeted biologic agents have transformed RA treatment. Although relatively expensive in the short term, the direct costs of these biologics may be offset by slowed disease progression and significant improvements in RA symptoms, physical function, and quality of life.
22990336 Depression is improved when low-dose tacrolimus is given to rheumatoid arthritis patients 2013 Sep PURPOSE: Depression in rheumatoid arthritis (RA) patients is more severe than in healthy people. Herein, we report improved depression in RA patients using biologic agents. We examined whether depression was improved by tacrolimus combination therapy when biologic agents were ineffective. METHOD: The study included 13 RA patients who used biologic agents. The following methods were used before the initiation of tacrolimus combination therapy and at 14 and 30 weeks after treatment initiation: the Zung self-rating depression scale (SDS) to evaluate depression state, disease activity score 28/erythrocyte sedimentation rate (DAS28), tender joint counts, swollen joint counts, a patient global assessment to evaluate RA disease activity, and the modified health assessment questionnaire (mHAQ) to evaluate quality of life. RESULTS: The SDS scores before the initiation of tacrolimus combination therapy and at 14 and 30 weeks after treatment initiation were 45.2 ± 10.6, 44.8 ± 12.8, and 41.6 ± 11.2 (p = 0.047), respectively, indicating significant improvement. The DAS28 was 5.0 ± 1.3 prior to treatment, 3.8 ± 1.3 at 14 weeks, and 3.5 ± 0.9 at 30 weeks, demonstrating significant improvement at both 14 and 30 weeks (p < 0.001). The mHAQ score changed from 0.60 ± 0.45 at baseline to 0.54 ± 0.52 and 0.38 ± 0.43 at 14 and 30 weeks, respectively. The mHAQ score was significantly lower at 30 weeks when compared to baseline (p = 0.013). CONCLUSION: Tacrolimus combination therapy does not directly improve depression in RA patients, but it is possible that the observed improvement in depression accompanies the improvement in the secondary failure of RA.
21998113 Multiple adverse pregnancy outcomes before symptom onset are associated with a worse disea 2012 Apr OBJECTIVE: Previous evidence suggests that women with a history of adverse pregnancy outcomes (APOs) may be at greater risk of developing rheumatoid arthritis. Additionally, one study reported that female patients with rheumatoid arthritis with a history of preonset APOs showed a worse 2-year radiographic outcome than did patients with no APOs. The authors' aim was to investigate the relationship between preonset APOs (spontaneous abortion or stillbirth) and disease outcome in women with inflammatory polyarthritis (IP). METHODS: The Norfolk Arthritis Register (NOAR) is a primary-care-based cohort of patients with recent-onset IP; 1586 gravid women who joined NOAR during 1990-2004 were included in this analysis. The authors examined the relationship between patient-reported preonset APOs and disease outcome, measured using the Health Assessment Questionnaire (HAQ) and disease activity score in 28 joints (DAS28(CRP)) (for a subgroup of patients), using linear random effects analysis, adjusted for age and other factors. RESULTS: In a predominantly parous cohort (99%), 397 (25%) women reported ≥1 APO before symptom onset. The rates of APOs in NOAR were comparable to the general population. On average, women with a history of ≥2 APOs had significantly higher HAQ and DAS28 scores over time than women with no APOs (mean difference in HAQ 0.13 (95% CI 0.002 to 0.26); DAS28, 0.56 (95% CI 0.01 to 1.11)). This relationship was more pronounced in women with ≥3 APOs (mean difference in HAQ 0.23 (95% CI 0.02 to 0.43); DAS28, 0.98 (95% CI 0.23 to 1.74)). CONCLUSION: Women with two or more APOs before IP onset had a worse disease outcome than women with no APOs.
22162339 "They didn't tell us, they made us work it out ourselves": patient perspectives of a cogni 2012 Apr OBJECTIVE: Fatigue is an overwhelming rheumatoid arthritis (RA) symptom caused by interacting clinical and psychosocial factors. Cognitive-behavioral therapy (CBT) addresses links between thoughts, feelings, and behaviors and uses cognitive restructuring to facilitate behavior changes. In a randomized controlled trial, a group CBT program for RA fatigue improved fatigue impact, severity, and perceived coping, as well as mood and quality of life. The aim of this study was to explore the patient perspective of the program and the impact of behavior changes. METHODS: Ten exit focus groups were held (38 patients). Transcripts were analyzed by an independent researcher using a hybrid thematic approach, with a subset analyzed by a team member and patient partner. RESULTS: Three overarching themes were identified. In "they made us work it out ourselves" (program factors facilitating changes), patients spontaneously identified elements of group CBT as pivotal, including guided discovery, the impact of metaphors, and working as a group. In "feeling much better about yourself and coping much better" (the nature of changes), patients described cognitive changes, including enhanced self-efficacy and problem solving, and emotional changes, including being less volatile and fearful of fatigue. In "my life has changed so much it's unbelievable" (benefits beyond fatigue), patients reengaged in previously abandoned activities, were more active, and enjoyed greater social participation. CONCLUSION: Patients highlighted that CBT elements were key to making behavior changes and that these had far-reaching impacts on their lives. This suggests it could be beneficial in clinical practice to incorporate cognitive-behavioral approaches into patient education programs that aim to enhance self-management.
21931342 Rheumatoid arthritis: Repair of erosion in RA--shifting the balance to formation. 2011 Sep 20 Repair of bone erosions in rheumatoid arthritis has been considered a difficult goal to achieve. However—with better therapies at hand to control synovial inflammation—sensitive μCT imaging techniques now available confirm that repair of bone erosion is possible, and begins at the base of erosive lesions.
23124814 Biomechanical analysis of the wrist arthroplasty in rheumatoid arthritis: a finite element 2013 Feb The total replacement of wrists affected by rheumatoid arthritis (RA) has had mixed outcomes in terms of failure rates. This study was therefore conducted to analyse the biomechanics of wrist arthroplasty using recently reported implants that have shown encouraging results with the aim of providing some insights for the future development of wrist implants. A model of a healthy wrist was developed using computed tomography images from a healthy volunteer. An RA model was simulated based on all ten general characteristics of the disease. The ReMotion â„¢ total wrist system was then modelled to simulate total wrist arthroplasty (TWA). Finite element analysis was performed with loads simulating the static hand grip action. The results show that the RA model produced distorted patterns of stress distribution with tenfold higher contact pressure than the healthy model. For the TWA model, contact pressure was found to be approximately fivefold lower than the RA model. Compared to the healthy model, significant improvements were observed for the TWA model with minor variations in the stress distribution. In conclusion, the modelled TWA reduced contact pressure between bones but did not restore the stress distribution to the normal healthy condition.
21972762 Outcomes following pantalar arthrodesis in rheumatoid arthritis. 2011 Jul BACKGROUND: We report a consecutive series of pantalar arthrodeses in patients with rheumatoid arthritis, using a single laterally based incision and autologous bone graft. MATERIALS AND METHODS: All operations were performed by a single surgeon and were assessed preoperatively and at 6 and 12 months postoperatively. The levels of patient satisfaction, functional improvement and pain scores of the foot following surgery were recorded along with radiological parameters. Seventeen patients (two male and 15 female) underwent 18 hindfoot surgeries and were assessed preoperatively using the SF-12 General Health survey questionnaire, Manchester-Oxford Foot Survey and pain scores. RESULTS: We found a significant improvement in pain levels and SF-12 scores. In addition the patients reported a high level of satisfaction with the outcome of surgery and improvement in function. CONCLUSION: The results show that pantalar arthrodesis is a very effective operative treatment for severe ankle and concomitant hindfoot disease. The treatment period is prolonged and patients should be counselled appropriately. LEVEL OF EVIDENCE: IV, Retrospective Case Series
23228398 HLA-G may predict the disease course in patients with early rheumatoid arthritis. 2013 Apr The current management of early rheumatoid arthritis (ERA) is to start an intensive treatment as soon as possible. To avoid under/overtreatment, it is important to identify reliable ERA evolution biomarkers. HLA-G molecules has been associated with rheumatoid arthritis, suggesting a role in disease regulation. HLA-G antigens are expressed as membrane bound and soluble isoforms (mHLA-G, sHLA-G) that act as ligand for immune-inhibitory receptors (ILT2, ILT4, KIR2DL4). Expression of HLA-G is influenced by a 14 bp insertion/deletion polymorphism in exon 8 of the gene, where the deletion is associated with mRNA stability. We analyzed 23 ERA patients during a 12 months follow-up disease treatment for sHLA-G, IL-1beta, IL-6, IL-10 and TNF-alpha levels in plasma samples by ELISA, mHLA-G and ILT2 expression on peripheral blood CD14 positive cells by flow cytometry and typed HLA-G 14 bp deletion/insertion polymorphism by Real-Time PCR. Disease status (DAS28), ultrasonography with power Doppler and laboratory data were checked. Cytokine levels confirmed the anti-inflammatory effect of the treatment. sHLA-G, mHLA-G and ILT2 expression inversely correlated with DAS28 disease scores. The frequency of 14 bp deletion allele increased in patients with disease remission. Based on these results, HLA-G may be a candidate biomarker to evaluate early prognosis and disease activity in ERA patients.
21439276 Inhibition of IL6 in rheumatoid arthritis and juvenile idiopathic arthritis. 2011 May 15 A number of clinical trials have been done to investigate the role of interleukin-6 (IL-6) as a potential therapeutic target in rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA). Most of the data testing this comes from trials of the humanized anti Il-6 receptor antibody tocilizumab. Results from clinical trials worldwide have been promising so far. Additional study will define the ultimate role of tocilizumab and Il6 inhibitors in the treatment paradigms for RA and JIA.
21882799 Case management in care of Turkish rheumatoid arthritis patients. 2011 Sep This study examined the effectiveness of a case management (CM) intervention in the care of patients with rheumatoid arthritis (RA) as a pilot study in a teaching hospital in Turkey. Two groups were compared with respect to disability, quality of life, cost, and patient satisfaction: RA patients who received CM plus usual nursing care and RA patients who received usual nursing care alone. All patients underwent follow-up interviews at 3 and 6 months after being discharged from the hospital. Disability scores were significantly better in the RA group receiving CM, but there were no significant differences between the two groups with regard to quality of life, patient satisfaction, and total healthcare costs. Using CM in the care of patients with RA may favorably affect disease-related outcomes.
23077939 [Identification of bone mass and bone turnover in patients with rheumatoid arthritis treat 2012 Apr Corticosteroids (CS) are currently used in Rheumatoid Arthritis (RA) in conjunction with either synthetic remissive or biologic drugs. AIM: In our study we used have focused on bone mineral density assessment (BMD) in RA patients with and without low doses of CS in order to elaborate an optimal therapeutic approach. MATERIAL AND METHODS: prospective observational study on 55 consecutive patients with RA (1987, ACR diagnostic criteria) classified in two groups based on CS use: group A--23 RA receiving CS and subgroup B--32 RA without CS. All patients have been evaluated according to a predefined protocol including demographics, clinical, biological and therapeutic RA characteristics, BMD and T-score assessment by DXA (Hologique QDR) (1994, WHO classification). Subgroup analysis was done in SPSS-12 software, p < 0.05. RESULTS: No significant differences in demographics and RA related parameters (p > 0.05) have been demonstrated between subgroups. However, significant changes in BMD and T-score have been reported in RA receiving CS as follows (p < 0.05): up to 74% cases with osteoporosis, 13% with fracture and 8.7% with osteopenia (A) versus 31.3% with osteoporosis, 28.1% with fracture and 15.6% with osteopenia (B). Moreover, 90% of RA under 7.5 mg CS daily and all receiving > 10 mg daily presented with osteoporosis; also, osteoporosis has been demonstrated all postmenopausal RA in group A (75%) and only 68% of group B (76%). CONCLUSIONS: concomitant CS use in RA, even low doses, is commonly associated with low BMD, irrespective of other risk factors.
22316079 Brazilian propolis inhibits the differentiation of Th17 cells by inhibition of interleukin 2012 Oct Propolis is a resinous substance collected by honeybees from leaf buds and cracks in the bark of various plants. It has been reported to show immunomodulatory activity. Previously, we reported the protective effect of Brazilian propolis ethanolic extract against the pathogenesis of collagen-induced arthritis (CIA), an experimental animal model of rheumatoid arthritis (RA). Moreover, we found that the protective effect against CIA was involved in suppression of the production of interleukin-17 (IL-17) in CIA mice. In the present study, we demonstrated for the first time that propolis inhibited IL-6 plus transforming growth factor-β induced Th17 differentiation in vitro. Propolis also suppressed the IL-6-induced phosphorylation of signal transducer and activator of transcription 3 (STAT3), a cytokine-activated essential transcription factor in Th17 development, concomitantly with the enhanced suppressor of cytokine signaling 3 expression involved in the downregulation of STAT3 phosphorylation. These data suggest that the suppressive effect of propolis on Th17 differentiation might be useful for controlling unbalanced cytokine networks in autoimmune diseases.
22492784 Preliminary evaluation of the first international reference preparation for anticitrullina 2012 Aug BACKGROUND: A lyophilised reference serum from one patient with rheumatoid arthritis (RA) diluted with serum samples from healthy subjects was evaluated as a possible first international standard for anticitrullinated peptide antibodies (ACPAs). METHODS: The authors used 12 commercial ELISAs for ACPA detection in the reference serum and for testing the linearity of the assays by studying twofold serial dilutions. To test the effectiveness of the standardisation, sera from 20 RA patients with variable antibody concentrations were analysed, and the relative concentrations were calculated using both the kit's own curve and the six dilutions of the reference serum as a calibration curve. Fifty sera from normal healthy subjects were used to calculate cut-off values for the reference serum using each commercial kit. RESULTS: The calibration curve obtained for each of the 12 methods using the reference sample dilutions as calibrator allowed harmonisation of the ACPA concentration of the 20 RA serum samples, significantly reducing the dispersion of the values. The mean coefficient of variation (CV) was reduced from 76.4% to 27.9% (p=0.018) and from 85.9% to 33.5% (p=0.028) for the medium/high and negative samples, respectively. Low positive sera CV was also reduced, but to a smaller degree, from 82.5% to 55.5% (p=0.043). CONCLUSION: This first evaluation of the behaviour of the ACPA reference serum demonstrated that it tested positive in all the assays and that it may be used as a reference standard for establishing calibration curves, reducing the dispersion of antibody values and better comparing results obtained from different methods/laboratories.
22177660 Homeopathy enables rheumatoid arthritis patients to cope with their chronic ill health: a 2012 Dec OBJECTIVE: The role of the consultation in mediating improved clinical outcomes has been demonstrated in both conventional and complementary medicine but to date no depth study has explored how complementary medical consultations achieve such benefits. This study explored rheumatoid arthritis (RA) patients' perceptions of the homeopathic consultation including any perceived benefit. METHODS: Qualitative study nested within a placebo-controlled multi-centre trial assessing adjunctive homeopathic intervention for RA. In-depth face to face interviews (with 16 participants) were analysed using interpretative phenomenological analysis. RESULTS: RA participants perceived homeopathic consultations helped them cope better through either enabling improved physical health, wellbeing and/or illness management. Four themes associated with improved coping were: receiving emotional support; exploring the illness; exploring self; and gaining advice. Exploring the wider narrative of their illness, enabled participants to address their individual needs and for some, this process of increased awareness changed their perception resulting in the perceived benefits. CONCLUSION: Homeopathic consultations enable RA patient to cope better. PRACTICE IMPLICATIONS: Homeopathic consultations may provide an additional resource for RA patients. Identifying and employing the "active ingredients" that confer benefit may be appropriate for other clinicians to maximise patient benefits from consultations.
23058179 Gallic acid, a natural polyphenolic acid, induces apoptosis and inhibits proinflammatory g 2013 May OBJECTIVES: To investigate whether gallic acid (3, 4, 5-trihydroxybenzoic acid), a natural polyphenolic acid found in gall nuts, sumac, oak bark, tea leaves, grapes and wine, has pro-apoptotic and anti-inflammatory effects on fibroblast-like synoviocytes (FLS) from patients with rheumatoid arthritis (RA). METHODS: Viability of RA FLS was assessed using a MTT assay after gallic acid treatment. Apoptosis was assessed by TUNEL assay and caspase-3 activity was determined by a colorimetric assay. The levels of apoptosis-related proteins including Bcl-2, p-Akt, p53, and Bax were determined using western blot analyses, and the mRNA expressions of various pro-inflammatory mediators were measured using quantitative real-time PCR. RESULTS: Cell viability of RA FLS was significantly decreased by treatment with 10 or more μM of gallic acid. Gallic acid treatment at the concentrations that do not affect cell viability (0.1 and 1 μM) induced cellular apoptosis of RA FLS. Treatment with 0.1 and 1 μM of gallic acid also resulted in a significant increase in caspase-3 activity and regulated the productions of Bcl-2, Bax, p53 and pAkt. The mRNA expression levels of pro-inflammatory cytokines (IL-1β, IL-6), chemokines (CCL-2/MCP-1, CCL-7/MCP-3), cyclooxygenase-2, and matrix metalloproteinase-9 from RA FLS were suppressed by the gallic acid treatment in dose-dependent manners. CONCLUSION: Gallic acid treatment was found to induce apoptosis of RA FLS through regulation of apoptosis-related protein expressions and to reduce the expression of pro-inflammatory genes in RA FLS. These data suggest that pro-apoptotic and anti-inflammatory activities of gallic acid may be used as a possible therapeutic option for RA.
22044028 The C677T polymorphism in the MTHFR gene is associated with the toxicity of methotrexate i 2012 Feb OBJECTIVE: Methotrexate (MTX) is the first-choice drug for the treatment of rheumatoid arthritis (RA) patients. However, 30% of RA patients discontinue therapy within 1 year, usually because of adverse effects. Previous studies have reported conflicting results on the association of polymorphisms in the MTHFR gene with the toxicity of MTX in RA. The aim of this study was to assess the involvement of the C677T and A1298C polymorphisms in the MTHFR gene in the toxicity of MTX in a Spanish RA population. METHODS: The study included retrospectively 468 Spanish RA patients treated with MTX. Single nucleotide polymorphism (SNP) genotyping was performed using the oligonucleotide microarray technique. Allele and genotype association analyses with regard to MTX toxicity and a haplotype association test were also performed. RESULTS: Eighty-four out of the 468 patients (18%) had to discontinue therapy due to adverse effects or MTX toxicity. The C677T polymorphism (rs1801133) was associated with increased MTX toxicity [odds ratio (OR) 1.42, 95% confidence interval (CI) 1.01-1.98, p = 0.0428], and the strongest association was shown in the recessive model (OR 1.95, 95% CI 1.08-3.53, p = 0.0246). The A1298C polymorphism (rs1801131) was not associated with increased MTX toxicity (OR 0.94, 95% CI 0.65-1.38, p = 0.761). A borderline significant risk haplotype was found: 677T-1298A (OR 1.40, 95% CI 1.00-1.96, p = 0.0518). CONCLUSION: These results demonstrate that the C677T polymorphism in the MTHFR gene is associated with MTX toxicity in a Spanish RA population.
23052553 [Is treat to target compatible with health insurance and health insurance funds?]. 2012 Oct Can treat to target (T2T) evidence-based recommendations of the T2T initiative in routine outpatient care be implemented in Germany? Regional selective agreements were made with individual health insurance companies, which included among others structured assessment, target-oriented basic therapy and tight control. A federal universal implementation seems, however, to be distant. A substantial deficit is the poor availibility of rheumatological care. In the currently implemented routine care by health insurance institutions a realization of the T2T recommendations is not only impossible but even impeded. Selective agreements and outpatient specialist treatment of the new treatment structure act make allowances for rheumatological treatment but only the practical implementation will reveal the true possibilities. The current situation needs a national action plan for rheumatological care by which the content of T2T can be implemented.
22849354 The role of tocilizumab in the management of rheumatoid arthritis. 2012 Sep INTRODUCTION: The introduction of biological treatments has improved the outlook for patients diagnosed with rheumatoid arthritis. There are now a range of different agents, targeting various pathways involved in the inflammatory process. Tocilizumab , a fully humanised anti-interleukin-6 receptor monoclonal antibody is licensed for the treatment of rheumatoid arthritis and systemic juvenile idiopathic arthritis. AREAS COVERED: This article reviews and appraises the available evidence regarding the efficacy and safety of tocilizumab in rheumatoid arthritis, as identified in PubMed and Embase searches. EXPERT OPINION: Clinical trial data suggest that tocilizumab has similar efficacy both clinically and in reducing structural progression to that seen with the TNF inhibitors. Patients who might be particularly suitable for tocilizumab are those who have failed multiple TNF inhibitors, those with a high inflammatory response as part of their disease and those unable to tolerate methotrexate, given the good responses seen with monotherapy.