Switching Arthritis Medication

Earlier this month, the CreakyJoints team attended the annual European Congress of Rheumatology (EULAR), a three-day conference that provides rheumatologists and other health care providers with the latest scientific advances and clinical guidance for treating rheumatic and musculoskeletal diseases.

This year’s conference included nearly 14,000 attendees from more than 130 countries, nearly 5,000 abstracts (which are preliminary research studies), and more than 130 different sessions. The conference brings together clinicians, researchers, biopharmaceutical companies, patient advocacy groups like ours, and other stakeholders to share, discuss, and disseminate research on how to prevent disease; manage symptoms and comorbidities; stop disease progression; provide optimal treatment plans, help patients enter and sustain remission, and improve overall health and quality of life.

There were fascinating sessions centered around topics that patients care deeply about, such as fatigue, exercise, and medical marijuana. There was interesting research on tailoring biologic therapies for psoriatic arthritis, and how and when to taper rheumatoid arthritis patients in remission.

Members of CreakyJoints attended numerous sessions, talked with study authors about their research, read through hundreds of studies, curated coverage of the conference from health care provider media outlets, and asked our medical advisors to share their thoughts on the most impactful research and takeaways for patients. Here’s a sample of what we think you should know from EULAR 2019:

Symptoms and Disease Management

Fatigue Common in Arthritis

Doctors want to help patients manage their fatigue better. In a session at EULAR titled “My Joints Hurt and I’m Overwhelmingly Tired: Fatigue in Rheumatoid Arthritis” doctors reviewed how to recognize, assess, and treat fatigue in inflammatory arthritis patients. “Fatigue remains a difficult-to-address patient concern,” says Maria Danila, MD, a rheumatologist at the University of Alabama Birmingham, who attended the session. Fatigue affects 40 to 80 percent of patients with rheumatic and musculoskeletal diseases, so it was encouraging to see clinicians making this topic front and center at EULAR 2019.

Obesity could be a factor in rheumatoid arthritis (RA) fatigue. Canadian researchers sought to understand which factors led RA patients to experience fatigue during their first year after being diagnosed. They found that obesity was a “major determinant of persistent fatigue” in both men and women with RA and suggested that “lifestyle interventions targeting weight loss may play an important role in reducing persistent fatigue that does not improve with RA treatment.”

Psoriatic arthritis (PsA) patients often have high levels of pain even after inflammation is controlled. Swedish researchers found that even after PsA patients started a biologic, 40 percent still reported unacceptable levels of pain after one year. A similar study on RA patients conducted a year ago found that only 12 percent had unacceptable pain a year after starting a biologic. One hypothesis, according to researcher Tor Olofsson, MD, is that some psoriatic arthritis patients develop a more generalized central sensitization of pain similar to that of fibromyalgia. “If inflammation isn’t treated quickly enough in the beginning of the disease, it could sensitive the central pain system,” he said in EULAR Congress News. Psoriatic arthritis patients may need additional medication or non-drug treatment options to help with this secondary pain management.

Gut microbiome differences may help explain why some RA patients do or don’t respond to methotrexate. Some newly diagnosed RA patients respond well to the disease-modifying drug methotrexate and others do not. Preliminary EULAR research found that there were differences in how bacterial genes functioned in people who did and did not respond to methotrexate. More research is needed to validate this work and to see whether the model applies to other patient populations. But the research does provide “the first step toward predicting methotrexate response in new-onset RA patients,” according to EULAR Congress News.

The doctor-patient relationship could impact whether patients take methotrexate as prescribed. Serbian researchers found that patients were more likely to be “non-adherent” to methotrexate if they reported needing better communication with their doctor about RA treatment. About one-third of patients in the study were considered non-adherent to MTX. Taking methotrexate raises a lot of questions for patients; it may be the case that improving doctor-patient communication could alleviate some patient concerns.

Axial spondyloarthritis (AS) patients who are HLA-B27 positive are more likely to get uveitis. Bouts of uveitis, or eye inflammation, are a common and painful problem for AS patients. Uveitis may influence treatment escalation, such as the decision to start biologic medication. British researchers wanted to understand which factors made AS patients more prone to developing uveitis. They looked at data on more than 2,400 AS patients; nearly one-quarter of them had at least one instance of uveitis. The odds of developing uveitis were higher in patients who were HLA-B27 positive and had the disease for a longer period of time.

Though gout is treatable, management is less than optimal for most patients. An eye-opening survey of 1,100 gout patients across 14 different European countries found that gout is being diagnosed late, is not well controlled, and is not regularly monitored — yet 80 percent of gout patients said they were satisfied with their current treatment. For example, 70 percent of patients had a gout flare in the last year, and one-third of these patients had more than three gout flares. Most patients were diagnosed and treated by general practitioners rather than rheumatologists, which suggests that more patient education is needed to explain the risks of under-treated gout and the importance of getting on a uric acid-lowering therapy that eliminates flares and reduces the risk of gout’s many comorbidities.

Healthy Lifestyle and Wellness

Losing Weight with Arthritis

Many EULAR studies added to the body of evidence that supports the role of physical activity in improved quality of life for patients with lupus and inflammatory arthritis, including RA, PsA, and AS, says rheumatologist and CreakyJoints medical advisor Vinicius Domingues, MD.

Chunks of sedentary time are bad for fibromyalgia symptoms. A Spanish survey of about 400 women with fibromyalgia found that those who spent their days in more bouts of sedentary time reported worse overall disease function, regardless of how much time they also spent exercising. Even though it can be difficult to fight the fatigue and pain that makes daily activities challenging with fibromyalgia, trying to break up your day into little bursts of gentle activity, such as with five or 10-minute walks, may help ease such symptoms.

Doctors want to help patients form an exercise habit. In a session at EULAR called “Exercise: More Than a Wonder Drug” attendees discussed “how to help and motivate patients to make [exercise] a habit so they can reap its long-term rewards.” When patients’ time with doctors is so limited and focused on assessing disease activity and reviewing medication management, it’s encouraging to see health care providers learning about how to encourage physical activity with their patients.

Up to half of patients with axial spondyloarthritis don’t meet physical activity recommendations. University of Massachusetts researchers reviewed 11 different studies to analyze physical activity habits in patients with axial spondyloarthritis. Based on self-reported data from patients, only half to 70 percent met physical activity recommendations. Walking, swimming/pool exercise, and cycling were the most popular types. While it’s known that physical activity and movement can help relieve inflammatory back pain, AxSpA patients need more guidance on finding an exercise plan they can follow despite having pain and fatigue.

Reducing obesity in psoriatic arthritis is critical. “The theme [of EULAR] I found most important was obesity in PsA,” says rheumatologist Alexis Ogdie, MD, MSCE, director of the Penn Psoriatic Arthritis and Spondyloarthritis Program at the University of Pennsylvania. She points to an important study that found that among more than 900 patients, “those who were obese had worse outcomes across the board: more joint swelling, more pain, worse function, worse lipids and cardiovascular endpoints.” Read more about the research.

Dr. Ogdie says her favorite study presented at EULAR was a weight loss intervention for people with psoriatic arthritis. Those who lost significant weight over the course of four months and kept it off at one year has significantly improved disease activity. “This really highlights the importance of managing obesity in PsA,” she says.

Inflammatory arthritis and osteoarthritis patients need tailored weight loss support. In CreakyJoints’ own ArthritisPower research presented at EULAR, we found certain barriers to weight loss are more common among people with osteoarthritis vs. inflammatory arthritis. Depression was a greater barrier to exercise among people with osteoarthritis (47 percent) compared with inflammatory arthritis (34 percent), for example. Disliking exercise was also a more prevalent barrier for OA patients (35 percent) than for those with inflammatory arthritis (21 percent). People with inflammatory arthritis were more likely to use digital weight loss tools compared with patients with osteoarthritis.

“While arthritis patients have some similar needs when it comes to wellness and weight loss resources and support, osteoarthritis and inflammatory arthritis patients shouldn’t necessarily be treated exactly the same,” says study co-author Kelly Gavigan, MPH, manager of research and data science for CreakyJoints. “When developing resources for patients, whether digital tools, patient support groups, or community-based programs, it’s important to think about the specific needs of the patients involved, based on their age, type of arthritis, and other factors, in order to make these resources as useful and effective as possible.”

Vitamin D deficiency is linked to higher disease activity in spondyloarthritis patients. Vitamin D plays a role in bone health, so it stands to reason that having low levels of vitamin D could exacerbate symptoms in different joint diseases. Spanish researchers reviewed data on 100 spondyloarthritis patients (diseases included non-radiographic axial spondyloarthritis, ankylosing spondylitis, psoriatic arthritis, and other types) and found that those with low levels of vitamin D had higher disease activity scores. “Inflammation along with increased bone turnover and low levels of vitamin D could be related to the pathophysiology of osteoporosis related to spondyloarthritis, and may adversely affect the patient’s functional status and quality of life,” the authors concluded. Some rheumatologists recommend taking vitamin D supplements; ask your doctor about whether this is right for you.

Mediterranean diet shows promise, but more research is needed. There’s scant evidence to support specific diet recommendations to prevent or manage inflammatory arthritis, but many nutrition experts advise patients to follow a Mediterranean-style diet because of other data that links this style of eating to lower risks of heart disease, type 2 diabetes, and certain cancers. One French study from EULAR found that following a Mediterranean diet helped lower the risk of developing rheumatoid arthritis in women who used to smoke. An Italian study found that among people already diagnosed with RA, there was a correlation between following a Mediterranean diet and lower disease activity, although it was not statistically significant. Adhering to the Mediterranean diet was linked with lower rates of high blood pressure and better general health.

Smoking cessation for arthritis patients was a notable topic. A EULAR session called “How Not to Smoke Like a Chimney” addressed the importance of rheumatologists working on smoking cessation more consistently with patients. The session outlined key reasons that it’s critical to quit smoking when you’re diagnosed with a rheumatic disease, including: better chances of responding to medication or being able to take a lower dose, lower risks of infection while on immunosuppressive therapy, fewer comorbidities and complications, and a lower overall risk of death.

Mental Health

Suidical Thoughts from Chronic Pain

Suicidal thoughts are common among people with rheumatic or musculoskeletal disease. In a recent survey of more than 900 European patients, one in 10 said that their pain led them to have suicidal thoughts within the prior month. The survey revealed that 58 percent of respondents felt that pain had made things unmanageable for them. Sleep was a major issue, too: 69 percent said the poor quality of their sleep made their pain worse. If you’re in pain and are experiencing depression or suicidal thoughts, don’t ignore your physical or mental health. Read more about the study and how to get help.

Depression could affect how well patients respond to methotrexate. When U.S. researchers looked at data from RA patients in the Veterans Affairs Rheumatoid Arthritis registry, they found that depression was linked with a less robust short-term response to MTX and more persistent and severe pain. The study authors concluded that depression in RA patients may be a risk factor for not responding to medication and suggested treating depression could lead to better RA disease control.

Lupus patients who *don’t* use social media are more prone to anxiety and depression. While we often hear that social media usage is linked with more mental health issues such as stress, anxiety, and depression, interesting data from Chinese researchers found the opposite in a survey of about 400 lupus patients. Rates of anxiety (41 percent) and depression (28 percent) were common, but people who were more active on social media were actually less likely to experience these issues. More research is needed to understand why, but it may be the case that patients who utilize support communities via social media platforms find that this helps alleviate depression and anxiety.

Medical Marijuana and CBD

A majority of arthritis patients use marijuana and CBD to help their symptoms. According to CreakyJoints data on more than 1,000 patients presented at EULAR, more than half of people surveyed (57 percent) said they tried marijuana or CBD for a medical reason, and nearly all said that it helped: 97% of people who tried marijuana said it improved symptoms; 93% of people who tried CBD said it improved symptoms. However, our data also revealed that more clinical information about how these products affect patients’ health is needed. Only two-thirds of patients who use marijuana or CBD for medical reasons said they told their doctor; of those, nearly 60 percent said they didn’t get any advice on safety, effectiveness, or dosing. About half of people said wanted to get more information on marijuana and CBD from their doctor. Read more about our marijuana and CBD research.

Doctors were eager to learn more about using cannabis for rheumatologic diseases. One of the most popular EULAR sessions — titled “Cannabis for Arthritis: Hype or Hope?” — featured researchers who spoke about the science that currently exists on cannabinoid use for rheumatologic and musculoskeletal conditions. According to the lecturers, there is not yet evidence to support massive use of cannabis in rheumatology, but it may be useful in some cases. The proof of efficacy for pain is very weak, said Serge Perrot, MD, PhD, professor of clinical pharmacology at Paris and Descartes University and a rheumatologist and head of the pain center at Cochin-Hotel Dieu Hospital, Paris, in EULAR Congress News. However, there is data that cannabis can be helpful for sleep and anxiety, which are common issues for rheumatology patients. “We know there’s a broader story and it’s not just pain itself — it’s all the ancillary things that go alongside it, such as the anxiety, depression, comorbidities, and so on,” Steve Alexander, BSc, PhD, FBPhS, associate professor in molecular pharmacology at the University of Nottingham Medical School, told the paper. “So I think the messages is one of tentative hope.”

Vaccines

Live, weakened vaccines can be safe for children with rheumatic diseases. Most people with inflammatory arthritis take medication that suppresses the immune system and are therefore advised not to get vaccines made with live viruses. But this could be problematic for young children who need certain live vaccines (such as measles mumps rubella), especially in light of worldwide disease outbreaks. Reassuring Israeli research on more than 200 pediatric rheumatology patients who had received an MMR or MMRV (which includes varicella) booster found that none experienced a disease flare or developed any serious infections. While more research is needed, this promising data indicates that live vaccines may be used in children with rheumatic diseases and is worth discussing with your child’s pediatrician and rheumatologist. Read more about the research.

Flu vaccine doesn’t cause side effects or disease flares. British researchers looked at what happened to nearly 15,000 patients with autoimmune rheumatic diseases after they received the influenza vaccine: Did they experience more joint pain or disease flares? The results showed no association and supports the use of the flu vaccine in rheumatic patients. The study findings “should dispel any fears people have about reported links to disease activity or vasculitis,” rheumatologist Georgina Nakafero, MD, said in a press release.

Inflammatory arthritis patients need more information about the importance of flu and pneumonia vaccinations. Irish researchers sought to study why vaccination rates for flu and pneumonia are low among people with inflammatory arthritis, who are more susceptible to these infections. Patients said the most common reason was lack of awareness. The study also found that most patients were informed about vaccines and were vaccinated by their primary care doctors. The authors suggest that more collaboration between primary care doctors and rheumatologists on patient education on the importance of vaccines could help.

Rheumatoid Arthritis Treatment

“Patients should be on the lookout for more JAK inhibitors and other drugs in this family that are pills,” says rheumatologist Gwenesta Melton, MD, vice president of the Association of Women in Rheumatology (AWIR). These can be easier to take, she added.

New JAK inhibitor gets closer to rheumatoid arthritis approval. JAK inhibitors are targeted oral medications that can treat inflammatory autoimmune diseases. Two are currently FDA approved — baricitinib (Olumiant) and tofacitinib (Xeljanz) — to treat RA. Another JAK medication, filgotinib, could become the third drug in its class to be approved, Medscape reported. This is based on results from a phase III clinical trial presented at EULAR. The data showed that filgotinib helped prevent radiographic progression and improved physical function among RA patients who didn’t respond to methotrexate. More patients who took filgotinib achieved an improvement of at least 20 percent in American College of Rheumatology criteria (ACR20) after three months compared with patients on a placebo. “Its effectiveness and ease of use makes it a potential monotherapy,” investigator Bernard Combe, MD, PhD, from Montpellier University in France told Medscape. He predicted that the drug could be on the market within two years.

Another forthcoming JAK, upadacitinib, performed better than adalimumab (Humira) at preventing radiographic damage in RA patients. In new data presented at EULAR, more than 1,600 RA patients were randomized to take upadacitinib once a day, take adalimumab every other week, or take a placebo (along with also taking methotrexate). Patients could switch therapies between 14 and 26 weeks if their disease activity was not improving. Of the patients on upadacitinib, 39 percent were switched during that period; of those who stayed on the drug, 86 percent completed week 48 of the study. For those on adalimumab, 49 percent of patients on adalimumab switched medication; of those who stayed on it, 76 percent completed week 48 of the study. “These data continue to support the potential of upadacitinib to help maintain consistent disease control for patients living with moderately to severely active rheumatoid arthritis,” said Professor Ronald van Vollenhoven, MD, PhD, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands, in a statement from AbbVie. The biopharmaceutical company makes both of the drugs studied.

It may be safe to taper prednisone in RA patients doing well on tociluzumab (Actemra). A new trial found that more than two-thirds of RA patients in remission or with low disease activity who tapered prednisone down to 0 mg/day over the course of six months while taking tociluzumab did not experience disease flares or experience adrenal issues (which can happen while weaning off steroid medication). “Tapering glucocorticoid treatment with an aim for complete discontinuation is worth considering for all patients once they achieve disease control in line with treat-to-target recommendations,” Gerd R. Burmester, MD, director of the department of rheumatology and clinical immunology at Charité-Universitätsmedizin Berlin and Humboldt University of Berline, said in the EULAR Congress News.

It may be safe to taper methotrexate in RA patients doing well on tofacitinib (Xeljanz). RA patients taking the JAK inhibitor tofacitinib (Xeljanz) plus methotrexate who achieved low disease activity may be able to stop taking MTX without worsening their disease activity. “These results may be used to inform treatment guidelines regarding optimal approaches for discontinuation of methotrexate in patients with rheumatoid arthritis,” study author Stanley Cohen, MD, of the University of Texas Southwestern Medical Center in Dallas, told MedPage Today.

Psoriatic Arthritis Treatment

EULAR data was very promising for biologic IL-17 inhibitors such as ixekizumab (Taltz) and secukinumab (Cosentyx), says Dr. Domingues. He says the jury is still out, but thinks there will be a shift in using these therapies earlier in the disease journey. “This will impact the approach from rheumatologists and likely payers down the road,” he says.

Ixekizumab (Taltz) improved outcomes for psoriatic arthritis patients compared with adalimumab (Humira). In a head to head trial, more than 500 psoriatic arthritis patients were randomly assigned to receive either ixekizumab, which is a biologic that inhibits the immune system protein interleukin-17 or adalimumab, which is an anti-TNF biologic. After six months, more patients on Taltz (36 percent) achieved a greater than 50 percent reduction of disease activity than those on Humira (28 percent). Taltz was particularly more effective when it came to measures of skin clearance: 60 percent of patients on Taltz showed complete skin clearance compared with just 47 percent of those on Humira. The two drugs may work just as well on patients’ joints, but Taltz is better for the skin, so “overall patients felt a little better on Taltz,” says Dr. Ogdie.

Psoriatic arthritis patients on secukinumab (Cosentyx) saw little radiographic damage after two years. Longer-term data presented at EULAR indicated that patients taking the biologic drug secukinumab (Cosentyx) continued to do well on the medication over the course of two years: 77 percent to 79 percent of patients achieved an American College of Rheumatology 20 (ACR20) improvement in their joint and pain symptoms after two years of treatment; roughly 60 to 70 percent of patients achieved a Psoriasis Area and Severity Index (PASI90) score (which means a 90 percent reduction in skin symptoms); and the majority of patients also experienced improvements in other PsA symptoms such as dactylitis and enthesitis. “It is reassuring that treatment with secukinumab continues to be effective,” John Isaacs, MBBS, PhD, chair of the EULAR Abstract Selection Committee, told MedPage Today.

Secukinumab (Cosentyx) helped hard-to-treat psoriatic arthritis patients. In a study of 177 PsA patients who had previously tried multiple disease-modifying drugs, almost half (47 percent) achieved remission or low disease activity after taking secukinumab (Cosentyx) for six months. “This was a very heavily pretreated patient population,” study author Augustin Latourte, MD, of Hôpital Lariboisière, Paris, told MedPage Today, “so the ability to get 47 percent of these patients into remission or achieving low disease activity means that this is a good result.”

A new class of medications looks positive for treating psoriatic arthritis. New data on tildrakizumab, which is a biologic drug that affects the immune system protein interleukin 23 (IL-23), showed that it is safe and effective in treating psoriatic arthritis. The results look similar to preliminary research on other biologics that target the same immune system pathway, such as rizankizumab (SKYRIZI) and guselkumab (Tremfya), which suggests “this class of medicines may be good for peripheral psoriatic arthritis,” says Dr. Ogdie.

Methotrexate can play a role in some patients with psoriatic arthritis. One clinical trial compared patients taking methotrexate alone versus a TNF biologic (etanercept/Enbrel) with methotrexate versus the biologic alone. Patients who took the biologic alone or who took the biologic with methotrexate had a greater reduction in disease activity than those who took methotrexate alone. The big question for doctors is whether patients need both the biologic and methotrexate at the same time, or whether they can take the biologic alone. “This data showed that MTX still has some role in a subset of patients with psoriatic arthritis,” says Dr. Domingues, which is very important given the lack of overall data on methotrexate and treating psoriatic arthritis. Based on this research, “I will persevere a bit longer with methotrexate and push for a combination with a biologic,” he says.

Spondyloarthritis Treatment

Seeing a Rheumatologist for Ankylosing Spondylitis

Biologic bimekizumab improved pain and functionality in ankylosing spondylitis patients. Study data presented at EULAR looked at how various doses of the biologic, which targets two versions of the immune system protein interleukin 17 (IL-17A and IL-17F), performed relative to a placebo. Improvements in functionality ranged from nearly 25 percent to 50 percent across different bimekizumab dosages, compared to about 12 percent for those on the placebo. “Bimekizumab may deliver results that improve disease activity and outcomes that are most important from the patient perspective, like pain, fatigue, stiffness, mobility, and function,” Emmanuel Caeymaex, head of immunology and executive vice president of the Immunology Patient Value Unit at UCB, which manufactures the drug, said in a press release.

‘Treat to target’ may become more popular in treating axial spondyloarthritis. “Treat to target” is frequently discussed in rheumatoid arthritis disease management. It refers to picking a target, such as remission or low disease activity, and adjusting a patient’s medications until the target is hit and sustained. While there’s no firm agreement yet on what a target in AxSpA should look like, Pedro Machado, MD, of University College London said in the EULAR Congress News that “treat to target is an emerging management strategy” because of increasing evidence that “achieving inactive disease may improve structural outcomes and stop the development of radiographic damage of the spine.”

There are new quality standards for managing axial spondyloarthritis. Quality standards identify priority areas that need to be improved to optimize patient care. New AxSpA quality standards from the Assessment of Spondyloarthritis International Society (ASAS) call for such changes as reducing the time it takes for patients to get referred to a rheumatologist and a diagnostic work-up; monitoring disease activity every six months; standardizing when to escalate treatment; providing fast access to a rheumatologist during AS disease flare-ups; and providing patient education on self-management and exercise benefits.

Osteoarthritis Treatment

Prednisolone Helps Treat Hand OA

Expect to see innovation in treatment for osteoarthritis, says Australian rheumatologist Hedley Griffiths, MD. A session on what’s new in OA called for the need to innovate drugs that reduce cartilage breakdown, drugs that enhance cartilage growth, and targeted pain therapies. “Therapies involving these mechanisms are currently being studied and may give new avenues to actively treat this significant problem,” says Dr. Griffiths.

Oral steroid medication improves hand OA pain and functioning. Researchers took 92 patients with painful hand OA and swelling in the lining of the joint (synovial inflammation) and randomly assigned them to two groups: One group took 10 mg of prednisolone daily; the other got a placebo. After six weeks, those in the medication group fared substantially better in terms of pain and functioning. Oral steroid medication is commonly used to help manage flares of inflammatory arthritis. This data indicates that inflammation processes also play a role in osteoarthritis, which might explain why a drug such as prednisolone could have an impact. Read more about the findings.

The biologic tanezumab may improve pain and function in patients with severe hip or knee OA pain. Nearly 300 patients received injections of 2.5 mg or 5 mg tanezumab or a placebo at the start of the study, then again at weeks 8 and 16, and then were followed for 24 weeks. Patients on both doses reported improvements in pain and function compared with those on the placebo, though more patients on tanezumab reported serious adverse events, reported RheumatologyAdvisor. The drug also had positive results in research presented at the 2018 annual meeting of the American College of Rheumatology.

MRI changes can predict future knee osteoarthritis. X-rays, or radiographs, are the standard imaging tool for doctors to look for osteoarthritic changes in a joint. But by the time damage shows up on an X-ray, it’s already done. It’s interesting, then, that researchers from the University of Arizona, Tucson, found that MRI could identify a number of different kinds of structural changes in the knee that could predict who would go on to have radiographic knee OA (osteoarthritis damage that shows up on an X-ray) up to 10 years later. “Identification of [these abnormalities] may highlight potential targets for disease-modifying osteoarthritis drugs,” according to C. Kent Kwoh, MD, in EULAR Congress News.

Other Treatment News

Lupus Butterfly Rash on Face

Maintenance therapy with the immunosuppressive drug cyclosporine helps lupus nephritis patients. How to best implement maintenance therapy (treatment to keep patients free of flares for a long period of time) among patients with lupus nephritis with is an ongoing area of research. In an Italian study that followed more than 100 lupus patients for more than 10 years, patients received one of three drugs as maintenance therapy: cyclosporine, mycophenolate mofetil, or azathioprine. While all three drugs helped patients enter and stay in remission, cyclosporine helped more patients achieve complete response rates over time. At the start of the study, cyclosporine was associated with just a 28 percent complete response rate (compared with about 50 percent for mycophenolate mofetil and 39 percent for azathioprine). However, the 10-year complete response rates were 85 percent for cyclosporine, 72 percent for mycophenolate mofetil, and 70 percent for azathioprine.

“Lupus nephritis is a serious condition requiring early aggressive therapy to achieve remission, however, the type and duration of immunosuppression after achieving response remain a matter of controversy,” John Isaacs, MBBS, PhD, chair of the EULAR Abstract Selection Committee, said in a press release. “It is great to see these long-term data which will help further our understanding in this complex area.”

Combination of rituximab and belimumab can help severe systemic lupus erythematosus (SLE). In a small and preliminary study of 15 patients with hard-to-treat lupus, two-thirds showed a good response to receiving a combination of these two drugs after six months. Previous research had shown that this drug combination helped reduce the production of certain autoantibodies that play a role in lupus development and progression. Patients on this combination therapy were also able to successfully stop using steroids and the immune-suppressing drug mycophenolate mofetil. The results indicate that larger, randomized trials should be done.

Treating giant cell arteritis (GCA) with IL-6 biologics looks promising. Dr. Griffiths also pointed out preliminary research on the safety and effectiveness of an IL-6 inhibitor (sirukumab) in treating patients with giant cell arteritis, an inflammatory disease of the blood vessels that is primarily treated with corticosteroids. Because long-term use of steroids has a long list of potentially dangerous side effects (from elevated blood sugar to osteoporosis), alternative medication options that can reduce the reliance on steroid therapy is important. More research is needed, but initial results suggest this medication class could “give us an ability to significantly reduce steroid toxicity in this vulnerable group of patients,” says Dr. Griffiths.

Managing Comorbidities

Heart Disease Risk with Rheumatoid Arthritis Remission

Achieving RA remission reduces heart disease risk. RA patients who are in remission are 80 percent less likely than those with active RA to have a heart attack or stroke or develop congestive heart failure, according to new Italian research that analyzed data on nearly 900 patients. This is very encouraging news for patients who hear and worry about various RA complications because it indicates that controlling disease activity can reduce the impact of systemic inflammation on other organs. It also highlights the importance and the challenge of getting more RA patients into remission in the first place. Read more about the research.

Heart and kidney complications are common in gout patients. U.S. hospitalizations among gout patients have increased dramatically (by 410 percent) over the past two decades. To understand why, researchers compared the reasons for hospitalization among gout patients with similarly aged patients who did not have gout. They found that kidney failure was twice as common in gout as in the general population; hospitalization for high blood pressure and GI bleeding was also much more common among people with gout. “This calls for an increased awareness and management of serious comorbid conditions in patients with gout,” said the study investigators, according to Rheumatology Advisor.

Anti-TNF drugs don’t increase overall cancer risk in psoriatic arthritis patients. A common reason patients worry about taking biologic drugs is the potential long-term increased cancer risk. Now a new study largely puts those fears to rest for psoriatic arthritis patients, though some questions remain. The study analyzed data from more than 8,000 PsA patients from Sweden, Denmark, Iceland, and Finland who had used TNFi biologics and found that there was no overall increase in cancer cases versus what’s expected in the general population. The one exception was lymphoma: PsA patients using these medications were more likely to develop lymphoma than the general population, but more research is needed to understand why. Read more about the research.

Preventing gum disease in RA patients may help manage arthritis symptoms. A large Japanese survey of rheumatoid arthritis patients found that those with periodontitis (inflammation of the gums) had significantly higher disease activity scores, worse physical function, and greater rates of infection than patients without gum disease. “Oral care is important for patients with rheumatoid arthritis because it appears to improve disease outcomes in clinical settings,” according to Ryoko Sakai, MD, of Tokyo Women’s Medical University, in EULAR Congress News.

Surgery & Procedures

Vagus Nerve Stimulation for Rheumatoid Arthritis

Partial knee replacement is less likely to cause serious complications than total knee replacement. British researchers analyzed insurance claims data on more than 32,000 patient who had undergone partial knee replacement and more than 250,000 who had had total knee replacement. They determined that those who had the partial procedure were 25 to 50 percent less likely to suffer a dangerous blood clot (venous thromboembolism) within two months of surgery. They were also 15 to 30 percent less likely to report persistent post-surgical pain. However, those who had partial knee replacement were also more likely to require additional surgery within five years. Read more about the research.

Stimulating the vagus nerve in your neck could help treat rheumatoid arthritis in patients who aren’t responding to biologics. Vagus nerve stimulation entails sending mild electrical impulses to this long nerve that connects the brain to the digestive tract. In a pilot study, 14 RA patients (who had previously tried at least two biologic or targeted drugs but did not respond well to them) had a neurostimulator device implanted under their skin. After 12 weeks, the researchers found that two-thirds of patients who received vagus nerve stimulation once a day had significant improvements in their disease activity scores (DAS28-CRP). Those in the placebo group did not improve. Read more about the research.

Inflammatory arthritis patients have more complications after hip and knee replacement surgery. Russian researchers looked at data on more than 2,400 hip and knee operations performed on patients with osteoarthritis and rheumatoid arthritis. RA patients had significantly more local complications than did OA patients, which could be due to a number of factors, including the inflammatory process and side effects of immune-suppressing DMARD and corticosteroid medication. The researchers concluded that “operative treatment of patients with RA requires a special approach and more gentle management … in cooperation with rheumatologist and careful treatment of the bone with surrounding tissues during the surgery.”

Understanding Risk Factors

Arthritis and the GI Tract

IBD and type 1 diabetes could be a rheumatoid arthritis risk factor. When researchers surveyed more than 800 people with rheumatoid arthritis about whether they had been diagnosed with any other diseases (and, if so, when), they found a close link between RA and IBD (which includes Crohn’s disease and ulcerative colitis) and type 1 diabetes. RA patients were significantly more likely than those without RA to also have IBD or type 1 diabetes, and they were diagnosed with these diseases *prior* to developing RA. It’s possible that these autoimmune diseases could predispose people to get RA in the future. Read more about the research.

Biomarkers could predict which psoriasis patients will develop psoriatic arthritis. In most cases of psoriatic arthritis, the autoimmune skin disease psoriasis shows up first. An interesting area of research, then, is how to predict which psoriasis patients are most at risk for developing PsA in the future. Canadian researchers from the University Health Network, Toronto observed the start of certain DNA changes in psoriasis patients about four years before they were diagnosed with psoriatic arthritis. “We may one day be able to use molecular marks … as prognostic markers of future onset of arthritis in psoriasis patients,” says study coauthor Remy Pollock, PhD.

Workplace exposure to inorganic dust can increase the risk of developing gout. A large Swedish study found that people exposed to such dust components as asbestos, silica, and coal were significantly more likely to develop gout (though alcohol use and obesity appeared to be much stronger gout risk factors). Inorganic dust has been previously linked with the onset of other diseases like RA, but “this was the first time occupational exposure to inorganic dust has been shown to be associated with the development of gout,” Valgerdur Sigurdardottir, MD, of the department of rheumatology and inflammation research at the University of Gothenburg, Sahlgrenska Academy in Sweden, said in a press release.

Get Involved in Arthritis Research

If you are diagnosed with arthritis or another musculoskeletal condition, we encourage you to participate in future studies by joining CreakyJoints’ patient research registry, ArthritisPower. ArthritisPower is the first-ever patient-led, patient-centered research registry for joint, bone, and inflammatory skin conditions. Learn more and sign up here.

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