Alice Klinkhoff

Biological agents for rheumatoid arthritis: targeting both physical function and structural damage.

Rheumatoid arthritis (RA) is a chronic progressive inflammatory disease of multifactorial aetiology. The pivotal role of proinflammatory cytokines in the pathogenesis and perpetuation of synovitis has been demonstrated in basic research since the late 1980s and in clinical research since the early 1990s. Biological agents are monoclonal antibodies or recombinant forms of natural inhibitory molecules which selectively interact with molecules or cell receptors affecting immune or inflammatory processes. In RA, etanercept, infliximab and adalimumab are currently available to target tumour necrosis factor (TNF) and an interleukin (IL)-l receptor antagonist is available to target IL-1 activity. Trials have shown benefits as monotherapy, although the best results for disease control are seen when biological agents are coadministered with methotrexate.The use of these agents in clinical trials and in practice has resulted in dramatic improvements in RA disease control, and delay and prevention of radiographic damage. The remarkable benefits to patients in well-being, quality of life and function, and the speed of onset of action are reminiscent of the early days of corticosteroid use. Ten years after the first clinical trials of anti-TNF therapies, the adverse effect profile is evolving and includes, for anti-TNF therapy, an increased risk of infections associated with immune suppression, injection and infusion reactions, and a risk of drug induced autoimmune syndromes such as systemic lupus erythematosus. Where these drugs are affordable, the prognosis of individuals for control of severe RA is better than ever before. This manuscript summarises the clinical trial results and post-marketing information regarding the biological agents currently in use for RA.

Readiness to Manage Arthritis: A Pilot Study Using a Stages-of-Change Measure for Arthritis Rehabilitation

&NA; The purpose of this pilot study was to evaluate the Readiness to Manage Arthritis Questionnaire (RMAQ), a new multibehavior measure of readiness for change in arthritis management. Data were obtained from 46 patients with chronic inflammatory arthritis admitted for intensive treatment. Test‐retest reliability, correlations with clinical variables and theoretically related constructs, and responsiveness to change were assessed. Test‐retest reliability indicated reasonable stability, with intraclass correlation coefficients ranging from 0.30 to 0.75. A significant association was observed between psychological well‐being and readiness status. Clinical variables of disease duration, disease severity, pain, and function were not related to readiness status. Correlations between stages‐of‐change scores and self‐efficacy for managing arthritis symptoms were mostly nonsignificant, with the exception of modest agreement between readiness to engage in physical activity and exercise self‐efficacy (0.43). Significant changes were observed in mean RMAQ scores from initial assessment to 12 weeks post‐treatment for the behaviors of using joint protection, dealing with frustration, learning about arthritis, engaging in physical activity, and stress management. Findings from this pilot study suggest that the RMAQ has adequate psychometric properties in patients with chronic inflammatory arthritis and can be used to assess an individuals readiness to adopt important arthritis self‐management behaviors.

Current and emerging therapies for rheumatoid arthritis, with a focus on infliximab: clinical impact on joint damage and cost of care in canada.

BACKGROUND Rheumatoid arthritis (RA) is a physically debilitating disease that places an enormous burden not only on individuals and their families but also on the economy. Affecting -1% of the Canadian population, RA is characterized by pain and swelling of joints. Without effective treatment, RA results in joint destruction that often requires surgery. OBJECTIVE This review summarizes the effect of current and new RA treatments on joint damage, with a focus on infliximab. The health-economic repercussions and potential impact of arresting the joint destruction of RA are discussed. METHODS Information for inclusion in this review was identified through searches of the MEDLINE and HealthStar databases from 1995 to 2000. Search terms included rheumatoid arthritis, treatment guidelines, economics, and individual drug names. RESULTS Standard initial RA drug therapy has been aimed at reducing pain and inflammation, whereas use of the more potent disease-modifying antirheumatic drugs (DMARDs) has been reserved for later stages of disease. More aggressive RA treatment involves introducing DMARDs at the earliest stage. The largest single direct cost of RA involves hospital admissions for the correction of joint deformities. Among newer therapies, the anti-tumor necrosis factor-alpha agent infliximab has been shown to arrest radiographic measures of disease progression. CONCLUSIONS With early and aggressive treatment involving new drugs and drug combinations, it may be possible to ameliorate the physical, social, and economic effects of RA.

Characterization of Patients with Arthritis Referred for Gold Therapy in the Era of Biologics

Objective. To describe the clinical characteristics of patients referred for gold therapy and determine the reason for referral. Methods. We conducted a chart review of patients referred for gold at the Mary Pack Arthritis Program, Vancouver, Canada, from July 2007 to July 2009. Results. The sample included 69 female and 12 male patients. Diagnosis was rheumatoid arthritis (RA) in 71/81, psoriatic arthritis in 5, juvenile idiopathic arthritis (JIA) in 2, Sjögren syndrome in 1, undifferentiated polyarthritis in 1, and spondyloarthritis in 1. Twenty of 81 patients had received gold before: 15 were referred for a second course, 4 a third course, and 1 a fourth course. Ten of 81 patients were referred for gold as their first disease-modifying antirheumatic drug (DMARD). Seventy-one had received prior DMARD: 1 prior DMARD in 22 patients, 2 in 24 patients, 3 in 15 patients, and > 3 in 6 patients. Four patients had received prior biologic therapy plus 2 to 4 prior DMARD. Twelve of 71 received gold monotherapy, 56/71 received gold/DMARD combinations, and 3 received gold/biologic/DMARD combinations. Reasons for referral included failure of other DMARD in 54 patients, limited DMARD options in 50 (chronic liver disease in 34, sulfa allergy in 7, high alcohol consumption in 5, and planning pregnancy in 4), physician choice in 12, previous benefit from gold in 10, benefit of clinic support in 10, inappropriate for biologics in 7, patient choice in 4, and failure of biologics in 3. Conclusion. The most common reasons for referral to gold clinic in 2007 to 2009 are failure of other DMARD and limited DMARD options due to underlying liver disease.