TNF blockade in daily practice

In conclusion, this thesis describes different clinical aspects on the use of anti-TNF. Initial combination treatment with infliximab and methotrexate seems very promising in early RA and may even alter the course of the disease. In patients with intolerance or inadequate response to infliximab, a second TNF-blocking agent can be successful, although, the introduction of new biologicals such as rituximab and abatacept provides other therapeutic options. Further research is needed to answer the question which drugs are indicated after failing a first TNF-blocking agent, or even as initial therapy. The use of intra-articular infliximab is inferior to intra-articular depomedrol in chronic and/or recurrent gonartrtitis and this expensive treatment should not have benefit of the doubt in these patients. In contrast, the use of infliximab in rheumatoid vasculitis seems promising in patients who have contra-indication for the recommended immunosupression. Influenza- and pneumococcal vaccinations result in less and lower antibody titers during treatment with anti-TNF, however, antibodies were formed and it remains unclear whether the lower laboratory outcomes are clinically relevant. To date, most guidelines recommend vaccination in patients using immunosuppressive therapy. During the use of anti-TNF neurological symptoms comparable to those of multiple sclerosis (MS) have been described and MR changes have been detected. The use of anti-TNF should be considered as contra-indicated in patients with signs and symptoms compatible with MS.Shering-Plough BV, Teva Pharma Nederland BV, Wyeth Pharmaceuticals BV, Abbott BV, Roche Nederland BV, UCB Pharma BV, Bristol-Myers Squibb BV, Sanofi-Aventis Netherlands BV, ,Pfizer BVUBL - phd migration 201

Onset of rheumatoid arthritis after COVID-19: coincidence or connected?

Immunogenetics and cellular immunology of bacterial infectious disease

How do patients with systemic sclerosis experience currently provided healthcare and how should we measure its quality?

Objectives. To gain insight into SSc patients' perspective on quality of care and to survey their preferred quality indicators.Methods. An online questionnaire about healthcare setting, perceived quality of care (CQ index) and quality indicators, was sent to 2093 patients from 13 Dutch hospitals.Results. Six hundred and fifty patients (mean age 59 years, 75% women, 32% limited cutaneous SSc, 20% diffuse cutaneous SSc) completed the questionnaire. Mean time to diagnosis was 4.3 years (s.d. 6.9) and was longer in women compared with men (4.8 (s.d. 7.3) vs 2.5 (s.d. 5.0) years). Treatment took place in a SSc expert centre for 58%, regional centre for 29% or in both for 39% of patients. Thirteen percent of patients was not aware of whether their hospital was specialized in SSc. The perceived quality of care was rated with a mean score of 3.2 (s.d. 0.5) (range 1.0-4.0). There were no relevant differences between expert and regional centres. The three prioritized process indicators were: good patient-physician interaction (80%), structural multidisciplinary collaboration (46%) and receiving treatment according to SSc guidelines (44%). Absence of disease progression (66%), organ involvement (33%) and digital ulcers (27%) were the three highest rated outcome indicators.Conclusion. The perceived quality of care evaluated in our study was fair to good. No differences between expert and regional centres were observed. Our prioritized process and outcome indicators can be added to indicators suggested by SSc experts in earlier studies and can be used to evaluate the quality of care in SSc.Pathophysiology and treatment of rheumatic disease

TNF blockade in daily practice

In conclusion, this thesis describes different clinical aspects on the use of anti-TNF. Initial combination treatment with infliximab and methotrexate seems very promising in early RA and may even alter the course of the disease. In patients with intolerance or inadequate response to infliximab, a second TNF-blocking agent can be successful, although, the introduction of new biologicals such as rituximab and abatacept provides other therapeutic options. Further research is needed to answer the question which drugs are indicated after failing a first TNF-blocking agent, or even as initial therapy. The use of intra-articular infliximab is inferior to intra-articular depomedrol in chronic and/or recurrent gonartrtitis and this expensive treatment should not have benefit of the doubt in these patients. In contrast, the use of infliximab in rheumatoid vasculitis seems promising in patients who have contra-indication for the recommended immunosupression. Influenza- and pneumococcal vaccinations result in less and lower antibody titers during treatment with anti-TNF, however, antibodies were formed and it remains unclear whether the lower laboratory outcomes are clinically relevant. To date, most guidelines recommend vaccination in patients using immunosuppressive therapy. During the use of anti-TNF neurological symptoms comparable to those of multiple sclerosis (MS) have been described and MR changes have been detected. The use of anti-TNF should be considered as contra-indicated in patients with signs and symptoms compatible with MS

Efficacy of intraarticular infliximab administration in patients with recurrent gonarthritis: comment on the article by van der Bijl et al Reply

Pathophysiology and treatment of rheumatic disease

Long-term disease and patient-reported outcomes of a continuous treat-to-target approach in patients with early rheumatoid arthritis in daily clinical practice

Patients in real life may differ from those in clinical trials. The aim of this study is to report 5-year outcomes of a continuous treat-to-target (T2T) approach in patients with rheumatoid arthritis (RA) in daily clinical practice. In the Dutch RhEumatoid Arthritis Monitoring cohort, all patients with a clinical diagnosis of RA were treated according to a protocolled T2T strategy, aimed at 28-joint Disease Activity Score (DAS28)  3.2 and ≤ 5.1 (moderate disease activity) and DAS28 > 5.1 (high disease activity) were 63, 16, 18 and 3%, respectively. Sustained remission (DAS28 < 2.6 during ≥ 6 months) was observed at least once in 84% of the patients and drug-free remission (DAS28 < 2.6 during ≥ 6 months after withdrawal of all disease-modifying anti-rheumatic drugs) in 36% of the patients. Functional disability and health-related quality of life significantly improved during the first 24 weeks. Continuous application of T2T in real-life RA patients leads to favourable disease- and patient-related outcomes

Early radiological progression remains associated with long-term joint damage in real-world rheumatoid arthritis patients treated to the target of remission

Objective: To evaluate radiological damage and to explore characteristics associated with radiological progression in rheumatoid arthritis (RA) treated to the target of remission in a real-world setting. Method: Baseline to 6 year follow-up data were used from an observational early RA cohort. Radiographs of hands and feet at baseline, 6 months, and 1, 3, and 6 years were scored using the modified Sharp/van der Heijde score (SHS). The threshold for rapid radiological progression (RRP) after 6 months was based on the calculated smallest detectable change of 3.95. Negative binomial generalized linear mixed model and logistic regression analyses were performed to examine which variables were associated with RRP and 6 year radiological progression. Results: Most radiological damage occurred in the first year of treatment [median 2.0 interquartile range (IQR) 1.0–4.0 SHS points] compared to the subsequent 5 years of follow-up (median 3.0 IQR 1.0–5.0 SHS points). While low disease activity was achieved within 6 months on average, 18.8% of the patients developed RRP. Anti-cyclic citrullinated peptide (anti-CCP) positivity [incidence rate ratio (IRR) 1.42, p = 0.03], baseline erosive disease (IRR 1.60, p = 0.02), and RRP (IRR 3.28, p < 0.001) were associated with 6 year radiological progression. Erosive disease was the strongest predictor of RRP (odds ratio 8.8, p < 0.001). Conclusion: Long-term radiological outcome is limited in most real-world RA patients treated to the target of remission, but RRP still occurs. Anti-CCP positivity, baseline erosive disease, and RRP remain associated with long-term radiological outcome