Rheumatoid Arthritis: 3 New Things

November 5, 2018

What’s new: biologic tapering, high-dose influenza vaccine, real-time patient input.

References1. Dierckx S, Lauwerys BR, Sokolova T, et al. Tapering of biological antirheumatic drugs in rheumatoid arthritis patients is achievable and cost effective in daily clinical practice: DATA from the Brussels UCL RA Cohort. [abstract]. Arthritis Rheumatol. 2018;70(suppl 10). Accessed November 2, 2018.2. Colmegna I, Useche M, Rodriguez K, et al. Efficacy of high-dose versus standard-dose influenza vaccine in seropositive rheumatoid arthritis patients. [abstract]. Arthritis Rheumatol. 2018;70(suppl 10). Accessed November 2, 2018.3. Forman M, Leatherwood C, Xu C, et al. Implementation of a treat-to-target quality improvement program for rheumatoid arthritis management using real-time patient reported outcome measures [abstract]. Arthritis Rheumatol. 2018;70(suppl 10). Accessed November 2, 2018.

The highlights of three new studies in rheumatoid arthritis (RA) include: (1) patients who achieve low disease activity or remission may successfully taper their biologics; (2) a high-dose vaccine enhances production of antibodies against influenza virus in patients with RA; and (3) real-time patient input enhances RA management.^1-3 Scroll through the slides for the latest findings and their clinical implications.

A retrospective study evaluated the proportion of patients for whom biologic disease-modifying anti-rheumatic drugs (DMARDs) can be tapered in daily clinical practice. The study included data from 332 eligible patients with rheumatoid arthritis (RA), including 140 patients who received a tapered biologic DMARD regimen and 192 patients who received the full dose.

There were no differences between the two groups in terms of anti-citrullinated protein antibody, erosions, the number of previous biologic DMARDs, the time to first conventional synthetic DMARD and biologic DMARD, baseline disease activity, or C-reactive protein (CRP) scores and glucocorticoid use. As expected, current disease activity and CRP scores were lower in the tapered dose group. Only 15 patients had a flare during the follow-up.¹

Clinical Implications: “Tapering of biologics is essential in daily care. The unmet needs for this research are numerous, including the physician’s decision not to follow guidelines addressed by the industry,” said co-author Patrick Durez, MD, Head of Clinic, Division of Rheumatology, UniversitÃ© Catholique de Louvain in Brussels.

Because patients with RA have a 2.75-fold increased risk of influenza compared with healthy patients in the same age group, annual influenza vaccination is a high priority for them. A treatment-stratified, randomized, modified double-blind, active-controlled trial in 279 adult seropositive RA patients assessed antibody responses to either a high-dose trivalent inactivated influenza vaccine or a standard-dose quadrivalent inactivated influenza vaccine.

Overall responses to vaccination were consistently higher with the high-dose vaccine. Patients who received the high-dose vaccine were 2.8 times more likely to H3N2 seroconvert, 2 times more likely to B/Bris seroconvert, and 2.3 times more likely to H1N1 seroconvert.²

Clinical Implications: “The burden of influenza among people with RA is disproportionally high, and interventions to improve responses to influenza vaccination are urgently needed. Strategies to optimize protection in the elderly, another vulnerable group, include the use of quadrivalent vaccines, higher antigen doses and adjuvants. Like the elderly, RA patients have reduced vaccine-induced protection that limits the impact of vaccination in reducing morbidity and mortality associated with influenza,” said lead author Ines Colmegna, MD, Associate Professor, Division of Rheumatology, McGill University. She added: “Influenza vaccines are safe, effective and associated with significant reductions in the number of physician visits, hospitalizations for pneumonia or influenza, and deaths among high-risk adults. The study shows that the high-dose vaccine provides better seroprotection against influenza in RA patients. These results together with the fact that the high-dose vaccine was as safe as the standard-dose vaccine may lead to changes in practice: that is, recommendation to use the high-dose instead of the standard-dose influenza vaccine in RA.”

A non-randomized, quality improvement study assessed the success of a program to collect disease activity scores from 2549 patients with rheumatoid arthritis (RA) via iPad tablets in the waiting room or an online patient portal. The patients completed a RAPID3 survey, and these scores were uploaded to their electronic medical records in real-time and made available for their physicians to review during the office visit. Rheumatologists in the study were non-randomly allocated to either intervention (9 rheumatologists) or control (13 rheumatologists) groups.

Mean treat-to-target scores among the intervention group were 15% higher than among controls. Of 104 completed phone calls to patients with RA in the intervention group, there was median Treatment Satisfaction Questionnaire for Medication scores of 73 for effectiveness, 85 for side effects, 89 for convenience, and 77 for global satisfaction. There was a median Shared Decision Making Questionnaire score of 91 for the patients of the intervention group physicians.³

Clinical Implications: “One of the strongest characteristics of our study is that it is based on a real-life clinic model and reflects our experience in an everyday setting. We hope our experience can exemplify that it is possible to pursue routine implementation of patient-reported outcome measures in daily clinical practice. We were able to achieve buy-in at all levels of our clinic staff, including the front desk personnel, medical assistants, and clinic management. This was an essential part of incorporating the surveys into routine workflow. Additionally, we learned from initial patient focus groups that shared decision-making was an important facet of RA management and medication adherence,” said co-author Cianna Leatherwood, MD, a rheumatologist now at Kaiser Permanente Oakland Medical Center.