Selected Immune Disorders and Disability (2022) / Chapter Skim
Currently Skimming:
6 Inflammatory Arthritis
6 Inflammatory Arthritis
Pages 159-208
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 159... ...
The types of inflammatory arthritis include immune-related arthritis and crystal-induced arthritis. Immune-related arthritis is a category that includes rheumatoid arthritis (RA)
|
From page 160... ...
. Clinical Diagnosis and Professionally Accepted Classification Criteria for Rheumatoid Arthritis The diagnosis of RA is based on a patient's clinical history, physical examination, and laboratory findings.
|
From page 161... ...
Adults TABLE 6-1 Classification Criteria for Rheumatoid Arthritis Score Target population: Patients (1) who have at least one joint with definite clinical synovitis (2)
|
From page 162... ...
. We review the major measures used to assess treatment response below, noting that while these measures are widely used in research and clinical trials, their application in routine clinical practice by U.S.
|
From page 163... ...
Specifically, ACR-endorsed instruments to measure RA disease activity and to define remission include: DAS and its variants such as DAS28-CRP and 1 The DAS28 is a measure of disease activity in rheumatoid arthritis. DAS stands for "disease activity score," and the number 28 refers to the 28 joints that are examined in this assessment.
|
From page 164... ...
. Treatment and Management of Rheumatoid Arthritis The goal of RA treatment is to attain and maintain control of disease activity in an effort to reduce the symptoms of joint pain and swelling, prevent deformity, maintain quality of life and function, and limit
|
From page 165... ...
Patients who are not in clinical remission and who have any degree of disease activity as measured using validated scales are considered candidates for therapy; indeed, it is recommended that therapy for RA be initiated as soon as possible after the diagnosis is established, as there is evidence that earlier DMARD therapy is associated with better outcomes. The specific agents recommended are determined by the degree of disease activity, the prior treatments used, the TABLE 6-2 Medications Used to Treat Rheumatoid Arthritis Type of Medication Examples Conventional synthetic DMARDs Methotrexate, leflunomide, hydroxychloroquine, sulfasalazine Targeted biologic DMARDs Anti-tumor necrosis factor Adalimumab, certolizumab pegol, etanercept, golimumab, infliximab, several biosimilars Inhibitor of T-cell activation Abatacept Anti-CD20 (B-cell depletion)
|
From page 166... ...
The 2019 EULAR recommendations for RA treatment are largely similar to the 2021 ACR guidelines: notably, conventional DMARDs (and specifically methotrexate) are recommended as the initial therapy for RA; the addition of, or switch to, an alternate DMARD is recommended if improvement is not achieved, and if patients do not respond to a biologic DMARD, the guidelines recommend switching to a different biologic DMARD or tofacitinib.
|
From page 167... ...
. While there is no universally accepted definition of refractory RA, the term is often used to refer to patients who have not responded to at least two different targeted DMARDs or to two different targeted biologic DMARDs with different mechanisms of action (Buch, 2018; de Hair et al., 2018; KearsleyFleet et al., 2018; Roodenrijs et al., 2018)
|
From page 168... ...
A EULAR task force (Smolen et al., 2020) suggests the following factors as predictive of poor prognosis: • Persistently moderate or high disease activity despite conventional synthetic DMARD therapy according to composite measures including joint counts • Failure of two or more conventional DMARDs • High acute-phase reactant levels • High swollen joint count • Presence of a rheumatoid factor (RF)
|
From page 169... ...
Oral candidiasis Neutropenia Inflammatory bowel disease JAK inhibitors Infections (tofacitinib, baricitinib, upadacitinib) Reactivation of tuberculosis Reactivation of herpes zoster Cytopenias Bowel perforation Elevated lipids Cardiovascular/thrombotic events NOTE: DMARD = disease-modifying anti-rheumatic drug; JAK = janus kinase; NSAID = nonsteroidal anti-inflammatory drug; TNF = tumor necrosis factor.
|
From page 170... ...
TABLE 6-4 Novel Agents in Clinical Trials for Rheumatoid Arthritis and Psoriatic Arthritis Mechanism of Clinical Trial Drug(s) Action Phase Registration Sponsor Rheumatoid Arthritis PF-06650833 IRAK-4 inhibitor 2 NCT04413617 Pfizer PF-06651600 JAK-3 inhibitor (ritlecitinib)
|
From page 171... ...
HAQ scores are predictive of work disability, and the HAQ is commonly used as a secondary outcome measure in clinical trials testing RA therapies. Among pharmacologic agents, a range of medications including conventional synthetic DMARDs (e.g., methotrexate, leflunomide)
|
From page 172... ...
, with the exception of two recent trials that found sarilumab to be superior to adalimumab in its impact on physical functioning as measured using the HAQ (Strand et al., 2018)
|
From page 173... ...
. Clinical Diagnosis and Professionally Accepted Classification Criteria for Psoriatic Arthritis The diagnosis of PsA is based on the clinical history, a physical examination, laboratory findings, and radiography.
|
From page 174... ...
Other treatment response criteria developed specifically for PsA include the Psoriatic Arthritis Response Criteria (PsARC) and the Minimal Disease Activity (MDA)
|
From page 175... ...
The DAS, for example, may not be appropriate for patients who have predominantly lower extremity or distal interphalangeal joint disease since these joints are not included as part of the standard DAS 28-joint count. Measures of disease activity that have been developed and validated specifically for PsA include the Disease Activity Index for Psoriatic Arthritis, the Psoriatic Arthritis Joint Activity Index, the Composite Psoriatic Disease Activity Index, and the Psoriatic Arthritis Disease Activity Score (Gladman, 2010; Mease et al., 2005; Ogdie et al., 2020; Schoels et al., 2016; Wong et al., 2012)
|
From page 176... ...
The indications for surgical intervention are the same as in RA patients. Clinical Practice Guidelines for Receiving Treatments Evidence-based treatment guidelines for the pharmacologic management of PsA include the 2018 ACR/National Psoriasis Foundation (NPF)
|
From page 177... ...
Fourth, for enthesitis or axial disease that is not responsive to conventional DMARDs, a biologic DMARD is recommended; usually this will be a TNF inhibitor, but an IL-17 may be used if there is also skin involvement. Finally, phosphodiesterase-4 inhibitors are reserved for patients with mild disease who have had an inadequate response to one or more conventional DMARDs and for whom a biologic DMARD or a JAK inhibitor is not appropriate.
|
From page 178... ...
. Accordingly, as with RA, many clinical trials of PsA therapeutics assess treatment response at both 3 and 6 months, and the EULAR treatment guidelines for PsA recommend changing therapy if no improvement is seen after 3–6 months (Gossec et al., 2016)
|
From page 179... ...
. JUVENILE IDIOPATHIC ARTHRITIS JIA, formerly known as juvenile rheumatoid arthritis (JRA)
|
From page 180... ...
As several of the groups resemble a type of adult inflammatory arthritis, many think that the age cutoff should be removed and childhood arthritis described as per adult designations. Age cutoffs imply a biologic relevance that is not existent -- i.e., many children do not "outgrow" JIA (Glerup et al., 2020)
|
From page 181... ...
Extra-synovial manifestations of RF-positive JIA are similar to those seen in adult-type RA, including interstitial lung disease and nodulosis. Enthesitis-Related Arthritis and Juvenile Psoriatic Arthritis Enthesitis-related arthritis (ERA)
|
From page 182... ...
Juvenile psoriatic arthritis (PsJIA) generally presents in a bimodal distribution, with younger patients resembling oligoarticular JIA and older patients presenting with disease reminiscent of adult psoriatic arthritis (Stoll et al., 2006)
|
From page 183... ...
Measures that can be considered include ACR provisional criteria for inactive disease (Wallace Criteria) , the Juvenile Arthritis Disease Activity Score (JADAS)
|
From page 184... ...
To be in complete remission, patients must have had inactive disease for a continuous period of at least 12 months during which they do not receive any antiarthritis or antiuveitis medication. Articular damage and extra-articular damage may be scored according to the two parts of the Juvenile Arthritis Damage Index (JADI)
|
From page 185... ...
(2020) recently published 18 years of follow-up for the Population-Based Nordic Juvenile Idiopathic Arthritis Cohort.
|
From page 186... ...
and indirect costs (productivity loss due to sick leave and work disability) remain high into adulthood.
|
From page 187... ...
. The treatment of JIA-related eye disease has improved since the introduction of conventional synthetic DMARDs (csDMARDs)
|
From page 188... ...
Treatment choice varies not only by subgroup but by severity as well. The Childhood Arthritis and Rheumatology Research Alliance (CARRA)
|
From page 189... ...
Mortality in people with RA is 1.5 to 2 times higher than in age- and gender-matched non-RA controls, a difference that is due predominantly to accelerated cardiovascular disease and interstitial lung disease. The arthritis of RA, as with any inflammatory arthritis, typically presents with joint pain and swelling along with prolonged stiffness in the early morning.
|
From page 190... ...
JIA, formerly known as JRA, is an umbrella term for several types of inflammatory arthritis in childhood. The subtypes of JIA share the common features of joint pain and inflammation with the adult inflammatory arthropathies.
|
From page 191... ...
2008. Reporting disease activity in clinical trials of patients with rheumatoid arthritis: EULAR/ACR collaborative recommendations.
|
From page 192... ...
2017. Assessment of muscle mass relative to fat mass and associations with physical functioning in rheumatoid arthritis.
|
From page 193... ...
2019. Persistence rates of abatacept and TNF inhibitors used as first or second biologic DMARDs in the treatment of rheumatoid arthritis: 9 years of experience from the Rhumadata® clinical database and registry.
|
From page 194... ...
2011. The lifetime risk of adult-onset rheumatoid arthritis and other inflammatory autoimmune rheumatic diseases.
|
From page 195... ...
2018. Effectiveness of foot orthoses in patients with rheumatoid arthritis related to disability and pain: A systematic review and meta-analysis.
|
From page 196... ...
2009. Evaluation of composite measures of treatment response without acute-phase reactants in patients with rheumatoid arthritis.
|
From page 197... ...
in rheumatoid arthritis patients with an inadequate response to conventional DMARDs -- A systematic review and network meta-analysis. Health and Quality of Life Outcomes 12(1)
|
From page 198... ...
2018. Rheumatoid arthritis patients treated in trial and real world set tings: Comparison of randomized trials with registries.
|
From page 199... ...
2021. Optimizing the start time of biologics in polyarticular juvenile idiopathic arthritis: A comparative effectiveness study of Childhood Arthritis and Rheumatology Research Alliance consensus treatment plans.
|
From page 200... ...
2021. Biologic switching among nonsystemic juvenile idiopathic arthritis patients: A cohort study in the Childhood Arthritis and Rheumatology Research Alliance registry.
|
From page 201... ...
U.S. trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis.
|
From page 202... ...
2014. Health Assessment Questionnaire dis ability progression in early rheumatoid arthritis: Systematic review and analysis of two inception cohorts.
|
From page 203... ...
2021. Improved disease course associated with early initiation of biologics in polyarticular juvenile idiopathic arthritis: Trajectory analysis of a Childhood Arthritis and Rheumatology Research Alliance consensus treatment plans study.
|
From page 204... ...
2014. Safety of synthetic and biological DMARDs: A sys tematic literature review informing the 2013 update of the EULAR recommendations for management of rheumatoid arthritis.
|
From page 205... ...
2017. Education and employment in patients with juvenile idiopathic arthritis -- A standardized comparison to the German general population.
|
From page 206... ...
2015a. Tofacitinib with methotrexate in third-line treatment of patients with active rheumatoid arthritis: Patient-reported outcomes from a phase III trial.
|
From page 207... ...
2020. Outcome measures for juvenile idiopathic arthritis disease activity.
|
From page 208... ...
2007. The prevalence and incidence of work dis ability in rheumatoid arthritis, and the effect of anti-tumor necrosis factor on work disability.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.