Dr. Favalli, et al. reply

We thank Dr. So, et al1 for the interest in our letter2 and for sharing the results about the coronavirus disease 2019 (COVID-19) in patients with systemic lupus erythematosus (SLE) in Hong Kong1 We agree that the quantification of the risk of infection with severe acute respiratory coronaviruses-2 (SARS-CoV-2) in patients with SLE is a major concern

COVID-19 infection and rheumatoid arthritis: Faraway, so close!

The outbreak of the new coronavirus infections COVID-19 in December 2019 in China has quickly become a global health emergency. Given the lack of specific anti-viral therapies, the current management of severe acute respiratory syndrome coronaviruses (SARS-CoV-2) is mainly supportive, even though several compounds are now under investigation for the treatment of this life-threatening disease. COVID-19 pandemic is certainly conditioning the treatment strategy of a complex disorder as rheumatoid arthritis (RA), whose infectious risk is increased compared to the general population because of an overall impairment of immune system typical of autoimmune diseases combined with the iatrogenic effect generated by corticosteroids and immunosuppressive drugs. However, the increasing knowledge about the pathophysiology of SARS-CoV-2 infection is leading to consider some anti-rheumatic drugs as potential treatment options for the management of COVID-19. In this review we will critically analyse the evidences on either positive or negative effect of drugs commonly used to treat RA in this particular scenario, in order to optimize the current approach to RA patients

Treatment comparison in rheumatoid arthritis : head-to-head trials and innovative study designs

Over the last decades, the increasing knowledge in the area of rheumatoid arthritis has progressively expanded the arsenal of available drugs, especially with the introduction of novel targeted therapies such as biological disease modifying antirheumatic drugs (DMARDs). In this situation, rheumatologists are offered a wide range of treatment options, but on the other side the need for comparisons between available drugs becomes more and more crucial in order to better define the strategies for the choice and the optimal sequencing. Indirect comparisons ormeta-analyses of data coming fromdifferent randomised controlled trials (RCTs) are not immune to conceptual and technical challenges and often provide inconsistent results. In this review we examine some of the possible evolutions of traditional RCTs, such as the inclusion of active comparators, aimed at individualising treatments in real-life conditions. Although head-to-head RCTs may be considered the best tool to directly compare the efficacy and safety of two different DMARDs, surprisingly only 20 studies with such design have been published in the last 25 years. Given the recent advent of the first RCTs truly comparing biological DMARDs, we also review the state of the art of head-to-head trials in RA

Biologic therapy and spinal radiographic progression in patients with axial spondyloarthritis : a structured literature review

We aimed to perform a structured literature review of spinal radiographic progression, as assessed by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), in patients with ankylosing spondylitis (AS) or nonradiographic axial spondyloarthritis (nr-axSpA) treated with biologic therapy. Searches were limited to English language manuscripts published in the 11 years prior to 9 July 2019. Randomized controlled trials, open-label extensions (OLEs) and observational studies reporting mSASSS progression in patients with AS or nr-axSpA treated with biologics were eligible for inclusion. Bias was assessed using the methodological index for nonrandomized studies (MINORS) tool. Among the 322 studies identified in the literature search, 23 (11 OLEs and 12 cohort studies) met the eligibility criteria and were selected for inclusion. Most studies reported mSASSS progression in patients with AS receiving tumor necrosis factor inhibitor (TNFi) treatment. One study reported mSASSS progression in patients with AS treated with secukinumab, an interleukin-17A inhibitor. The mean (range) MINORS score was 11.3 (7\u201315) for the 15 noncomparative studies and 15 (12\u201322) for the 8 comparative studies. Although results of the individual studies were variable, mSASSS progression in patients with AS was generally minimal and slow with long-term TNFi therapy. Moreover, odds ratios for the likelihood of mSASSS progression with/without TNFi favoured TNFi therapy in several of the cohort studies. The rate of mSASSS progression following continuous secukinumab treatment was low and remained stable over 4 years. Of two studies reporting progression in patients with nr-axSpA treated with TNFis, one showed no mSASSS progression; however, the lack of control limited comparative conclusions

Eight-year retention rate of first-line tumor necrosis factor inhibitors in spondyloarthritis : A multi-center retrospective analysis

Objective. To evaluate the 8-year survival of the first TNF inhibitor (TNFi) in patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA), identify the predictive factors for withdrawal, and compare the discontinuation rates for infliximab, etanercept, and adalimumab. Methods. We evaluated PsA and axSpA patients treated with a first-line TNFi between 2005 and 2015 at four Italian tertiary centres. 8-year drug survival was calculated by Kaplan-Meier method and risk for discontinuation among treatment groups compared by stratified log-rank test. Univariate and multivariate Cox proportional hazard models were developed to examine predictors of withdrawal. Results. Out of 614 patients (316 axSpA, 298 PsA), 203 received adalimumab, 131 etanercept, and 280 infliximab, with similar frequencies in axSpA and PsA subgroups. The cumulative 8-year retention rate in the whole population was 55.1% (57.2 and 51.9% and for axSpA and PsA, respectively; p=NS). No significant differences were observed in drug persistence among individual TNFi in either group. Male sex (HR 0.595, 95% CI 0.405-0.875; p=0.008) and concomitant methotrexate use (HR 0.648, 95% CI 0.426-0.985; p=0.042) were associated with a lower risk of withdrawal in PsA and high baseline BASDAI (HR 0.9842 95% CI 0.9708-0.9980; p=0.028) in axSpA. No difference was found in the comparative analysis of reasons for discontinuation between PsA and axSpA. Conclusion. We reported that the real-life 8-year retention rate of the first TNFi in axSpA and PsA is over 50%, with no significant differences between axSpA and PsA and irrespective of the individual TNFi

Eight-year retention rate of first-line tumor necrosis factor inhibitors in spondyloarthritis : A multi-center retrospective analysis

Objective. To evaluate the 8-year survival of the first TNF inhibitor (TNFi) in patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA), identify the predictive factors for withdrawal, and compare the discontinuation rates for infliximab, etanercept, and adalimumab. Methods. We evaluated PsA and axSpA patients treated with a first-line TNFi between 2005 and 2015 at four Italian tertiary centres. 8-year drug survival was calculated by Kaplan-Meier method and risk for discontinuation among treatment groups compared by stratified log-rank test. Univariate and multivariate Cox proportional hazard models were developed to examine predictors of withdrawal. Results. Out of 614 patients (316 axSpA, 298 PsA), 203 received adalimumab, 131 etanercept, and 280 infliximab, with similar frequencies in axSpA and PsA subgroups. The cumulative 8-year retention rate in the whole population was 55.1% (57.2 and 51.9% and for axSpA and PsA, respectively; p=NS). No significant differences were observed in drug persistence among individual TNFi in either group. Male sex (HR 0.595, 95% CI 0.405-0.875; p=0.008) and concomitant methotrexate use (HR 0.648, 95% CI 0.426-0.985; p=0.042) were associated with a lower risk of withdrawal in PsA and high baseline BASDAI (HR 0.9842 95% CI 0.9708-0.9980; p=0.028) in axSpA. No difference was found in the comparative analysis of reasons for discontinuation between PsA and axSpA. Conclusion. We reported that the real-life 8-year retention rate of the first TNFi in axSpA and PsA is over 50%, with no significant differences between axSpA and PsA and irrespective of the individual TNFi