From patients with arthralgia, pre-RA and recently diagnosed RA: What is the current status of understanding RA pathogenesis?

It is believed that therapy for rheumatoid arthritis (RA) is the most effective and beneficial within a short time frame around RA diagnosis. This insight has caused a shift from research in patients with established RA to patients at risk of developing RA and recently diagnosed patients. it is important for improvement of RA therapy to understand when and what changes occur in patients developing RA. This is true for both seropositive and seronegative patients. Activation of the immune system as presented by autoantibodies, increased cytokine and chemokine production, and alterations withi

Work outcome in yet undiagnosed patients with non-radiographic axial spondyloarthritis and ankylosing spondylitis; results of a cross-sectional study among patients with chronic low back pain

Background: To understand the impact of yet undiagnosed non-radiographic axial spondyloarthritis (nr-axSpA) and ankylosing spondylitis (AS) on work outcomes in a cohort of patients with long-lasting chronic low back pain (CLBP). Methods: Data were used from a primary care CLBP cohort that was established to understand the prevalence of nr-axSpA and AS. Clinical characteristics comprised measures of back pain (visual analogue scale), inflammation (C-reactive protein) and physical functioning (Roland Morris Disability Questionnaire (RMDQ)). Worker outcomes comprised a question on employment and the Work Productivity and Activity Impairment (WPAI) questionnaire, distinguishing absenteeism, presenteeism, and overall work impairment in those employed and activity impairment in all patients. For each disease subgroup, employment ratio compared to the general population was assessed by indirect standardization. Factors associated with work productivity were explored by zero inflated negative binomial (ZINB) regression models. Results: Patients with CLBP (n = 579) were included (41% male, mean age 36 years), of whom 71 (12%) were identified as having nr-axSpA and 24 (4%) as having AS. The standardized employment ratios were 0.89 (95% CI 0.84-0.94), 0.97 (95% CI 0.85-1.09) and 0.81 (95% CI 0.56-1.06) for patients with CLBP, nr-axSpA and AS, respectively. Scores for the WPAI subdomains were not significantly different between patients with CLBP, nr-axSpA or AS. The ZINB models showed significant associations between visual analog scale (VAS) score for pain and RMDQ and work productivity. Conclusion: The impact of yet undiagnosed nr-axSpA and AS on patients' work outcomes was substantial but was not significantly different from those of patients with long-standing CLBP. Variables significantly associated with reduced work productivity were VAS for pain and RMDQ score

Subfertility in Women With Rheumatoid Arthritis and the Outcome of Fertility Assessments

_Objective:_ Subfertility is frequently encountered among female rheumatoid arthritis (RA) patients and has been associated with disease activity and antirheumatic drugs. However, little is known about the results of the fertility assessments in these women. Our aim was to study the outcome of fertility assessments in subfer

Doctors' preferences in de-escalating DMARDs in rheumatoid arthritis: A discrete choice experiment

Background: Current guidelines suggest reduction of DMARDs can be considered in RA patients in remission. Objectives were (1) to estimate the relative importance of patient characteristics rheumatologists consider in their decision to de-escalate (2) to assess whether heterogeneity exists among rheumatologists with respect to de-escalation and (3) to identify the preferred de-escalation strategy. Methods: A discrete choice experiment (DCE) was conducted. All rheumatologists and trainees in The Netherlands were invited to participate. A conditional logit model was estimated to assess overall preference for de-escalation and its determinants. Heterogeneity was estimated by latent class analysis. Results: The DCE questionnaire was completed by 156 doctors. This questionnaire was constructed using the results of semi-structured interviews with 12 rheumatologists that identified five patient characteristics relevant for de-escalation: number of swollen joints (SJC), presence of DAS remission/low disease activity (LDA), patient history, duration of remission/LDA and patient willingness to de-escalate DMARDs. Overall SJC and patient history were most important. Latent class analysis revealed five subgroups of doctors, showing differences regarding willingness to de-escalate and relative importance of patient characteristics. De-escalation of the TNF inhibitor rather than methotrexate first was the most preferred strategy. Conclusions: Rheumatologists are not uniform in their decision on whom to de-escalate. Differences emerged in which characteristics they traded off resulting in five subgroups: those that taper (1) always, (2) in absence of swollen joints, (3) in absence of swollen joints and presence of favorable patient history, (4) in DAS remission and favorable patient history, and (5) taking into account all factors

Focus group interviews reveal reasons for differences in the perception of disease activity in rheumatoid arthritis

Objective: Doctors frequently see patients who have difficulties coping with their disease and rate their disease activity high, despite the fact that according to the doctors, the disease activity is low. This study explored the patients’ perspectives on this discordance that may help to understand why for some patients, usual care seems to be insufficient. Methods: In our qualitative study we conducted focus group interviews where questions were used as a guideline. Transcripts were analyzed using inductive thematic analysis. Findings: Twenty-nine patients participated in four focus groups. Participants could not put their finger exactly on why doctors estimated that their disease activity was low, while they experienced high levels of disease activity. During the in-depth focus interviews, seven themes emerged that appeared related to high experienced disease activity: (1) perceived stress, (2) balancing activities and rest, (3) medication intake, (4) social stress, (5) relationship with professionals, (6) comorbidity, and (7) physical fitness. Conclusion: When patients were asked why their view of their disease activity was different from that of their physician, seven themes emerged. The way participants coped with these themes seemed to be the predominant concept. Specific interventions that focus on one or more of the reported themes and on coping may improve not only the quality of life of these patients but also the satisfaction with the patient–doctor relationship for both parties

A five-year model to assess the early cost-effectiveness of new diagnostic tests in the early diagnosis of rheumatoid arthritis

__Background:__ There is a lack of information about the sensitivity, specificity and costs new diagnostic tests should have to improve early diagnosis of rheumatoid arthritis (RA). Our objective was to explore the early cost-effectiveness of various new diagnostic test strategies in the workup of patients with inflammatory arthritis (IA) at risk of having RA. __Methods:__ A decision tree followed by a patient-level state transition model, using data from published literature, cohorts and trials, was used to evaluate diagnostic test strategies. Alternative tests were assessed as add-on to or replacement of the ACR/EULAR 2010 RA classification criteria for all patients and for intermediate-risk patients. Tests included B-cell gene expression (sensitivity 0.60, specificity 0.90, costs €150), MRI (sensitivity 0.90, specificity 0.60, costs €756), IL-6 serum level (sensitivity 0.70, specificity 0.53, costs €50) and genetic assay (sensitivity 0.40, specificity 0.85, costs €750). Patients with IA at risk of RA were followed for 5 years using a societal perspective. Guideline treatment was assumed using tight controlled treatment based on DAS28; if patients had a DAS28 >3.2 at 12 months or later patients could be eligible for starting biological drugs. The outcome was expressed in incremental cost-effectiveness ratios (€2014 per quality-adjusted life year (QALY) gained) and headroom. __Results:__ The B-cell test was the least expensive strategy when used as an add-on and as replacement in intermediate-risk patients, making it the dominant strategy, as it has better health outcomes and lower costs. As add-on for all patients, the B-cell test was also the most cost-effective test strategy. When using a willingness-to-pay threshold of €20,000 per QALY gained, the IL-6 and MRI

Two-year follow-up of a randomized controlled trial of a clinical nurse specialist intervention, inpatient, and day patient team care in rheumatoid arthritis

Aim. To compare the long-term effectiveness of care delivered by a clinical nurse specialist (CNS) with inpatient team care and day patient team care in patients with rheumatoid arthritis and increasing functional limitations. Background. The role of CNSs in the management of patients with rheumatoid art

How to study determinants related to medication adherence in newly diagnosed polyarthritis patients for the development of a prediction instrument

Introduction: For patients with a chronic disease, the appropriate use of medication is the key to manage their illness

Intrauterine Exposure to Biologics in Inflammatory Autoimmune Diseases: A Systematic Review

Background: Inflammatory autoimmune diseases are chronic diseases that often affect women of childbearing age. Therefore, detailed knowledge of the safety profile of medications used for management of inflammatory autoimmune diseases during pregnancy is important. However, in many cases the potential harmful effects of medications (especially biologics) during pregnancy (and lactation) on mother and child have not been fully identified. Objective: Our aim was to update the data on the occurrence of miscarriages and (major) congenital malformations when using biologics during pregnancy based on newly published articles. Additionally, we selected several different secondary outcomes that may be of interest for clinicians, especially information on adverse events in the use of a specific biologic during pregnancy. Material and Methods: A search was conducted from 1 January 2015 until 4 July 2019 in Embase.com, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar with specific search terms for each database. Selection of publications was based on title/abstract and followed by full text (double blinded, two researchers). An overview was made based on outcomes of interest. References of the included publications were reviewed to include and minimize the missing publications. Results: A total of 143 publications were included. The total number of cases ranged from nine for canakinumab to 4276 for infliximab. The rates of miscarriages and major congenital malformations did not show relevant differences from those rates in the general population. Conclusion: Despite limitations to our study, no major safety issues were reported and no trend could be identified in the reported malformations

What support is needed to self-manage a rheumatic disorder: a qualitative study

__Background:__ Today, patients are expected to take an active role in the form of self-management. Given the burden of a rheumatic disorder, the patients cannot be expected to self-manage on their own. In order to develop self-management interventions that fit patients' needs and preferences, it is essential to examine patients' perspective on how support can be optimized. This study aimed to identify support needs of outpatients with rheumatic disorders and preferences for who should provide self-management support. __Methods:__ A qualitative study was conducted using focus groups and individual interviews with outpatients with rheumatic disorders treated in a Dutch university hospital. Interview data was analysed with Directed Content Analysis and coded with predetermined codes derived from our model about support needs of chronically ill patients. This model distinguished three types of support: instrumental, psychosocial and relationa