Isabel Castrejón

Multinational evidence-based recommendations on how to investigate and follow-up undifferentiated peripheral inflammatory arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative

Objective To develop evidence-based recommendations on how to investigate and follow-up undifferentiated peripheral inflammatory arthritis (UPIA). Methods 697 rheumatologists from 17 countries participated in the 3E (Evidence, Expertise, Exchange) Initiative of 2008–9 consisting of three separate rounds of discussions and modified Delphi votes. In the first round 10 clinical questions were selected. A bibliographic team systematically searched Medline, Embase, the Cochrane Library and ACR/EULAR 2007–2008 meeting abstracts. Relevant articles were reviewed for quality assessment, data extraction and synthesis. In the second round each country elaborated a set of national recommendations. Finally, multinational recommendations were formulated and agreement among the participants and the potential impact on their clinical practice was assessed. Results A total of 39 756 references were identified, of which 250 were systematically reviewed. Ten multinational key recommendations about the investigation and follow-up of UPIA were formulated. One recommendation addressed differential diagnosis and investigations prior to establishing the operational diagnosis of UPIA, seven recommendations related to the diagnostic and prognostic value of clinical and laboratory assessments in established UPIA (history and physical examination, acute phase reactants, autoantibodies, radiographs, MRI and ultrasound, genetic markers and synovial biopsy), one recommendation highlighted predictors of persistence (chronicity) and the final recommendation addressed monitoring of clinical disease activity in UPIA. Conclusions Ten recommendations on how to investigate and follow-up UPIA in the clinical setting were developed. They are evidence-based and supported by a large panel of rheumatologists, thus enhancing their validity and practical use.

Decline of Mean Initial Prednisone Dosage From 10.3 to 3.6 mg/day to Treat Rheumatoid Arthritis Between 1980 and 2004 in One Clinical Setting, With Long‐Term Effectiveness of Dosages Less Than 5 mg/day

To analyze prednisone treatment from 1980–2004 in 308 patients with rheumatoid arthritis (RA), including 75 monitored over 4–8 years and 73 monitored over >8 years, for initial dose, long‐term doses and effectiveness, and adverse events.

MDHAQ/RAPID3 to recognize improvement over 2 months in usual care of patients with osteoarthritis, systemic lupus erythematosus, spondyloarthropathy, and gout, as well as rheumatoid arthritis.

ObjectiveTo analyze whether MDHAQ (Multidimensional Health Assessment Questionnaire) scores for physical function (FN), pain, Patient Global Estimate (PATGL), and RAPID3 (Routine Assessment of Patient Index Data, a composite of these 3 measures) document improvement in patients with osteoarthritis, systemic lupus erythematosus, spondyloarthropathy, and gout, similarly to rheumatoid arthritis. MethodsIn a solo rheumatology practice, every patient completes an MDHAQ/RAPID3 and is assigned a Physician Global Estimate (DOCGL) at every visit. Mean and median FN (0–10 scale), pain (0–10), PATGL (0–10), RAPID3 (0–30), and DOCGL (0–10) were computed at first visit and 2 months later in 141 new patients with 5 diagnoses. Proportions with RAPID3 high (>12), moderate (6.1–12), and low (3.1–6) severity and remission (⩽3) were computed. Differences between baseline and 2-month follow-up for each diagnosis were analyzed using paired t tests. Mean changes over 2 months across 5 diagnoses were compared using analysis of variance. ResultsMean baseline scores for all measures were in narrow ranges for all 5 diagnoses: FN 1.5 to 2.5, pain 4.2 to 5.9, PATGL 4.3 to 5.6, RAPID3 10.1 to 13.7, and DOCGL 2.4 to 4.0. Improvement for FN was 9.4% to 26.8% in all diagnoses but osteoarthritis, for pain 20.2% to 35.3% in all diagnoses, PATGL 11.3% to 30.4%, RAPID3 16.8% to 27.5%, and for DOCGL 23.8% to 36.4%, similar in 5 diagnostic groups. ConclusionsMDHAQ, RAPID3, and DOCGL document similar baseline and improvement scores in patients with 5 diagnoses. These quantitative data may supplement traditional narrative, “gestalt” descriptions in usual care of patients with any rheumatic disease.

Can Remission in Rheumatoid Arthritis Be Assessed Without Laboratory Tests or a Formal Joint Count? Possible Remission Criteria Based on a Self-report RAPID3 Score and Careful Joint Examination in the ESPOIR Cohort

Objective. To explore 5 possible criteria for remission in rheumatoid arthritis (RA) based on a patient self-report index, the Routine Assessment of Patient Index Data (RAPID3), with a careful joint examination and possible physician global estimate (DOCGL), but without a formal joint count or laboratory test. Methods. The ESPOIR early RA cohort of 813 French patients recruited in 2002–2005 was analyzed to identify patients in remission 6 months after enrollment, according to 2 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria: Boolean ≤ 1 for total tender joint count-28, swollen joint count-28, C-reactive protein, and patient global estimate (PATGL), and Simplified Disease Activity Index (SDAI) ≤ 3.3. Agreement with 7 other remission criteria was analyzed — Disease Activity Score-28 (DAS28) ≤ 2.6, Clinical Disease Activity Index (CDAI) ≤ 2.8, and 5 candidate criteria based on RAPID3, joint examination, and DOCGL: “RAPID3R” (RAPID3 ≤ 3.0); “RAPID3R+SJ1” (RAPID3 ≤ 3.0, ≤ 1 swollen joint); “RAPID3R+SJ1+D1” (RAPID3 ≤ 3.0, ≤ 1 swollen joint, DOCGL ≤ 1); “RAPID3R+SJ0” (RAPID3 ≤ 3.0, 0 swollen joints); and “RAPID3R+SJ0+D1” (RAPID3 ≤ 3.0, 0 swollen joints, DOCGL ≤ 1), according to kappa statistics, sensitivity, and specificity. Residual global, articular, and questionnaire abnormalities according to each criteria set were analyzed. Results. Among 813 ESPOIR patients, 720 had complete data to compare all 9 possible criteria. Substantial agreement with the Boolean criteria was seen for SDAI, CDAI, RAPID3R+SJ1, RAPID3R+SJ1+D1, RAPID3R+SJ0, and RAPID3R+SJ0+D1 (92.2%–94.7%, kappa 0.67–0.79), versus only moderate agreement for DAS28 or RAPID3R (79.9%–85.8%, kappa 0.46–0.55). Conclusion. Remission according to CDAI and RAPID3R+SJ1, but not DAS28 or RAPID3R, is similar to that of the ACR/EULAR criteria. RAPID3 scores require a complementary careful joint examination for clinical decisions, do not preclude formal joint counts or other indices, and may be useful in busy clinical settings.

Quantitative Data for Care of Patients with Systemic Lupus Erythematosus in Usual Clinical Settings: A Patient Multidimensional Health Assessment Questionnaire and Physician Estimate of Noninflammatory Symptoms

Objective. To analyze quantitative data in patients with systemic lupus erythematosus (SLE), seen in usual care, from a patient Multidimensional Health Assessment Questionnaire (MDHAQ) with routine assessment of patient index data (RAPID3) scores and from a physician global estimate of noninflammatory symptoms; and to compare results to self-report Systemic Lupus Activity Questionnaire (SLAQ) scores and 4 SLE indices: SLE Disease Activity Index-2K (SLEDAI-2K), British Isles Lupus Assessment Group (BILAG), Systemic Lupus Activity Measure (SLAM), and European Consensus Lupus Activity Measurement (ECLAM). Methods. Fifty consecutive patients with SLE were studied in usual care of one rheumatologist. All patients completed an MDHAQ/RAPID3 in this setting. Each patient also completed a SLAQ. The rheumatologist scored SLEDAI-2K, BILAG, SLAM, ECLAM, and 2 physician global estimates, one for overall status and one for noninflammatory symptoms. Patients were classified into 2 groups: “few” or “many” noninflammatory symptoms. Scores and indices were compared using correlations, cross-tabulations and t tests. Results. The patients included 45 women and 5 men. MDHAQ/RAPID3 and SLAQ scores were significantly correlated. RAPID3 scores were significantly higher in patients with SLE index scores above median levels, and in 34 patients scored by the rheumatologist as having “few” noninflammatory symptoms. MDHAQ/RAPID3 and SLAQ were significantly higher in 16 patients scored as having many noninflammatory symptoms. Conclusion. MDHAQ/RAPID3 and SLAQ subscale scores appear to reflect disease activity in patients with SLE, but not in patients with many noninflammatory symptoms. A physician scale for noninflammatory symptoms is useful to interpret MDHAQ/RAPID3, SLAQ, and SLE index scores.

Estimated Cutoff Points for the 28-Joint Disease Activity Score Based on C-reactive Protein in a Longitudinal Register of Early Arthritis

Objective. To estimate the cutoff points for the 28-joint Disease Activity Score (DAS28) calculated using C-reactive protein (CRP) measurements from patients with early arthritis. Methods. We analyzed data from 568 visits of 207 patients enrolled in our prospective longitudinal register of early arthritis. Six rheumatologists evaluated the degree of disease activity at each visit on the basis of the available clinical data, and the final degree of disease activity was established by consensus. DAS28 values were calculated for each visit using CRP or erythrocyte sedimentation rate (ESR). Through a ROC analysis, cutoff points for both indices, as well as for minimal disease activity (MDA), were selected on the basis of the best tradeoff values between sensitivity and specificity. Results. The cutoff values to classify disease activity with the DAS28-CRP were 2.3, 3.8, and 4.9, considering remission at < 2.3, low disease activity 2.3–3.8, moderate disease activity 3.8–4.9, and high disease activity > 4.9. The cutoff value for MDA when calculated with CRP was 2.6. The area under the ROC curves was always greater for DAS28-CRP than for DAS28-ESR, reaching statistical significance for low/moderate activity and for the MDA. Conclusion. Our study confirms that the cutoff points for DAS28-CRP are lower than those described for DAS28-ESR, suggesting that DAS28-CRP may be more accurate to assess disease activity in our population.

Discordance of global estimates by patients and their physicians in usual care of many rheumatic diseases: association with 5 scores on a Multidimensional Health Assessment Questionnaire (MDHAQ) that are not found on the Health Assessment Questionnaire (HAQ).

To analyze discordance between global estimates by patients (PATGL) and their physicians (DOCGL) according to demographic and self‐report variables on a Multidimensional Health Assessment Questionnaire (MDHAQ) in patients with many rheumatic diseases seen in usual care.

The EULAR Outcome Measures Library: an evolutional database of validated patient-reported instruments

Multiple instruments to assess the patients perception of disease activity and other critical domains are used in rheumatology to evaluate treatment response and guide clinical decisions. These instruments, known as patient-reported outcomes (PROs), allow to incorporate the patients perspective.1 Despite PROs being increasingly recognised as important measures, there is great heterogeneity in their use.2 In order to overcome the difficulty in accessing validated PROs and the heterogeneity in its use,3 an initiative to generate a repository of the main cross-culturally validated PROs in rheumatic and musculoskeletal diseases (RMDs) was endorsed by the European League Against Rheumatism (EULAR). The main idea was to develop a structured Outcome Measures Library (OML) that would include a comprehensive database of validated PROs. The international taskforce defined …

GUEPARD treat-to-target strategy is significantly more efficacious than ESPOIR routine care in early rheumatoid arthritis according to patient-reported outcomes and physician global estimate

Objective. To analyse seven RA Core Data Set measures and three indices for their capacity to distinguish treatment results in early RA in the GUEPARD treat-to-target clinical trial vs ESPOIR routine care. Methods. Post hoc analyses compared 65 GUEPARD and 130 matched control ESPOIR patients over 6 and 12 months for mean changes in measures, relative efficiencies and standardized response means (SRM). Three indices—28-joint disease activity score (DAS28), clinical disease activity index (CDAI) and routine assessment of patient index data (RAPID3)—were compared for mean changes and numbers of patients with high, moderate or low activity or remission using κ values. Results. Greater improvement was seen for GUEPARD vs ESPOIR, statistically significant for physician and patient global estimates and pain and health assessment questionnaire physical function (HAQ-FN), but not joint counts and laboratory tests. Relative efficiencies with tender joint count as the referent measure indicated that pain (2.57) and global estimates by patient (3.13) and physician (2.31) were most efficient in distinguishing GUEPARD from ESPOIR. Mean improvements in GUEPARD vs ESPOIR were −3.4 vs −2.6 for DAS28 (0–10) (24%), −29.8 vs −23.1 for CDAI (0–76) (23%) and −13.0 vs −7.8 for RAPID3 (0–30) (40%) (all P < 0.01); agreement was moderate between CDAI vs DAS28 (κ = 0.56) and vs RAPID3 (κ = 0.48), and fair between DAS28 vs RAPID3 (κ = 0.26). Conclusion. Patient and global measures indicate greater efficacy than joint counts or laboratory measures in detecting difference between GUEPARD treat-to-target and ESPOIR routine care. A RAPID3 of only patient measures may help guide treat-to-target in busy clinical settings.

Patient self‐report RADAI (Rheumatoid Arthritis Disease Activity Index) joint counts on an MDHAQ (Multidimensional Health Assessment Questionnaire) in usual care of consecutive patients with rheumatic diseases other than rheumatoid arthritis

To analyze a patient self‐report joint count from the Rheumatoid Arthritis Disease Activity Index (RADAI) on a Multidimensional Health Assessment Questionnaire (MDHAQ) in a cohort of consecutive patients seen in usual rheumatology care with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoarthritis (OA), psoriatic arthritis (PsA), and gout.