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Reumatoïde artritis: de standaard aanpak

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Baricitinib (Oluminant ®) is een potente, selectieve JAK inhibitor die Janus kinase (JAK) 1 en JAK2 inhibeert. In Europa is baricitinib 4 mg dagelijks geregistreerd voor de behandeling van matige tot ernstige reumatoïde artritis (RA) bij volwassen patiënten die onvoldoende respons vertonen op één of meer Disease Modifying Antirheumatic Drugs (DMARDs) of hier intolerant voor zijn. Verschillende klinische studies van  52 weken toonden aan dat baricitinib monotherapie (als eerste- of tweede lijn behandeling) en combinatie therapie met conventionele synthetische DMARD (csDMARD; als tweede- en derde lijn behandeling) effectief was voor het verminderen van symptomen. Dit gaat gepaard met een verbeterde gezondheids-gerelateerde kwaliteit van leven (HR-QOL). Baricitinib monotherapie inhibeert de structurele schade in methotrexaat-naïve patiënten, geëvalueerd over een behandelingstermijn van 52 weken. Dit is eveneens op te merken bij patiënten die naast baricitinib nog een onderhoudsdosis methotrexaat gebruiken. Baricitinib wordt over het algemeen goed verdragen gedurende de behandelingstermijn van 52 weken, De meeste bijwerkingen waren slechts van milde tot matige ernst. De tolerantie tegenover baricitinib is over het algemeen te vergelijken met die tegenover biological DMARDS (bDMARDs), met infecties als de meest voorkomende bijwerking. Hoewel de incidentie van herpes zoster (HZ) hoger was met baricitinib dan in de algemene RA populatie, waren de infecties goed te behandelen. Behandeling met methotrexaat in combinatie met baricitinib bleek superieur aan de behandeling met methotrexaat en adalimumab. Hoewel nog bijkomende vergelijkende studies nodig zijn om de definitieve positie van baricitinib in de behandeling van RA te bepalen, kunnen we toch al stellen dat baricitinib een goede optie is in de behandeling van patiënten met RA.

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Summary Introduction Rheumatoid Arthritis (RA) is an autoimmune-induced inflammatory disease with a worldwide prevalence of about 5 per 1000 adults. This chronic systemic disease is characterized by inflammation of mainly the small joints of hands and feet with pain, swelling and stiffness. If insufficiently treated, this inflammatory process can lead to worse physical functioning, impaired work and social participation and eventually joint damage through loss of articular cartilage and bone erosions. It is crucial to start an effective treatment in patients with RA as soon as possible to reach the target of remission or at least low disease activity. Treatment should be rapidly adapted in case the target is not yet met, according to the 'treat to target' principle. Objectives This PhD research project is based on data of the 2-year Care in early RA (CareRA) trial and the 3-year observational CareRA plus follow-up study. The overall objective of this thesis was to evaluate the long-term effectiveness of intensive treatment strategies used in CareRA, in order to define an optimal approach for treating patients with early RA. In this perspective, the efficacy, safety, sustainability of treatment response and need for treatment adaptations, associated with these regimes, were assessed up until 2 and 5 years after treatment initiation. Additionally, the applicability of these regimens in clinical practice was investigated, by addressing the following questions: whether presence of significant comorbidities would affect outcomes, which maintenance therapy should be used once patients reach a sufficient clinical response and to what extent do rheumatologists adhere to these strategies in a setting close to daily clinical practice. Results The first chapter explored the effectiveness of initial treatment strategies for patients with early RA on the long term. We concluded that an initial combination of methotrexate (MTX) and a glucocorticoids (GCs) bridging scheme (COBRA Slim) including a subsequent treat-to-target approach, can lead to a good and sustained disease control on the long term, irrespective of patient's prognosis. This COBRA Slim regimen resulted in comparable outcomes after 2 and 5 years as more complex regimens, and showed a more favourable safety profile. Therefore, this strategy with fewer drugs may avoid unnecessary overtreatment in patients sufficiently responding. Furthermore, the COBRA-Slim strategy with its consecutive adaptation steps seemed to result in biologicals being initiated at a later stage, assuming a better cost-effectiveness, which was confirmed in a separate cost-effectiveness analysis by our research group. Therefore, the COBRA Slim scheme was considered as an efficacious, safe and cost-effective treatment strategy for every patient with RA. In the first part of the second chapter we explored how we could further refine the optimal treatment strategy for early RA, by investigating the effectiveness of different maintenance therapies once patients achieved a well-controlled disease state. Firstly, we compared the effectiveness of stepping down treatment to either MTX or to leflunomide (LEF) in a randomized setting, in patients who achieved low disease activity after an initial combination of MTX, LEF and a GCs bridging scheme. Our results indicated that within this setting, it was more beneficial to step down to MTX than to LEF, since this maintenance therapy led to numerically better clinical outcomes after 65 weeks, had a better retention rate with 20% more patients remaining on MTX monotherapy and was tolerated equally well. These findings could also hold true for patients achieving low disease activity after addition of LEF to MTX monotherapy because of an initial insufficient response, although we were unable to formally demonstrate this based on this trial design. In the second part of the second chapter, we evaluated to what extent rheumatologists adhered to the treat-to-target (T2T) approach within the treatment strategies studied. We defined adherence as performing a dose escalation or changing/adding DMARDs in case low disease activity was not achieved. Results indicated that applying T2T strictly during the first 2 years of treatment was challenging, since in only half of visits theoretically requiring a DMARD adaptation, treatment was intensified. The most frequent reason not to intensify treatment, given by rheumatologists during the first study year, was that they considered the disease already well-controlled. Strict application of T2T guidance at every visit was associated with higher remission rates after 2 years, after adjusting for factors known to potentially influence chances at remission. However, an exact cause-effect relationship could not be demonstrated, due to the potential effect of various other factors. Furthermore, stating that T2T should always be applied without restriction, could also lead to a risk for overtreatment in certain cases and hence increased occurrence of (dose related) DMARD side effects. Therefore, we advocate for a flexible tight control, which states that decisions to adapt treatment should not be made blindly based on ambiguous or too ambitious target measures but should be based on the individual clinical picture. In the third chapter, we evaluated the prevalence of comorbidities in early RA patients before initiation of DMARD treatment and the impact of comorbidities on treatment response. We demonstrated that even in this early phase of the disease there was a high prevalence of comorbidities with nearly half of patients in our sample having at least one clinically relevant comorbidity. Additionally, we showed that having a comorbidity, but also the degree of comorbidity before treatment initiation was significantly related to worse functionality, worse disease control and worse physical health related quality of life as well as more hospitalizations. This effect of comorbidity on treatment response, could apparently not be mitigated by using intensive treatment regimens and applying the treat-to-target principle. Because of this impact of comorbidity on clinically important outcomes, the focus of caring for patients with newly diagnosed RA should not only be on controlling disease activity as soon as possible, which is necessary for all patients, but also on the management of comorbidities. Since many comorbidities are amenable to preventive and therapeutic measures, they should be detected and taken care of at an early stage, in order to reduce their impact on the outcomes in RA. Conclusion This doctoral thesis gives indications on how care for patients with early RA can be improved. Firstly, an initial combination of MTX and a GC bridging scheme led to sustained effectiveness and was well tolerated in patients with early RA. Secondly, stepping down treatment to MTX instead of to LEF was more beneficial in patients who achieved a good disease control after an initial intensive combination of both these drugs. Thirdly, it seems that we should be strict in our evaluation of the disease status but flexible in our approach to improve it further. And lastly, comorbidities should be screened for and managed already from disease onset since they affect clinical outcomes despite intensive treatment. These results provide directions to optimize pharmacological treatment and management of early RA, with the overall aim to improve patients' health related quality of life.

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Patient reported outcomes (PRO) are important in assessing rheumatoid arthritis (RA) disease activity and treatment response, both in research and in routine clinical practice. One of the most commonly registered PROs is the patient global assessment (PGA), which is included in the calculation of the 28-joint Disease Activity Score (DAS28), the Simple Disease Activity Index (SDAI) and the American College of Rheumatology (ACR) response criteria. Patient-physician discordance in the assessment of RA disease activity is a common and important issue that can negatively impact patient care, treatment adherence, and outcomes. When patients rate their disease activity higher than their physicians, known as positive discordance, this suggests there may be unmet patient needs that are not being fully addressed. To develop effective care strategies that focus on these unmet needs, it is crucial for the rheumatology community to gain a better understanding of the prevalence, causes, and consequences of patient-physician discordance. -The most widely used approach in the literature is to calculate the absolute difference or gap between the PGA and Physician Global Assessment (PhGA), often measured on 0-10cm or 0-100mm visual analog scales (VAS). However, no guidance is available on how to define significant discordance between these variables. We conducted a scoping review of all available evidence concerning discordance between PGA and PhGA in patients with RA. A literature search was conducted in MEDLINE, EMBASE, Cochrane Controlled Trials Register, Scopus, and Web of Science from inception to December 2023. Peer-reviewed journal articles were considered for inclusion if they (1) included patients with RA aged ≥ 18 years, (2) reported on discordance between patient and physician global assessment, and (3) were available in English. Data concerning the used definitions and determinants of discordance between patients and physicians weresystematically extracted. 1754 studies underwent title and abstract screening, of which 31 studies met the inclusion criteria for the review. The formulation of the PGA question differed across studies. Discordance was most often approached as a binary measure by considering the absolute difference between PGA and PhGA with various cutoff values, ranging from 1 mm to 30 mm on a 100 mm scale. Positive discordance was consistently more prevalent than negative discordance, with prevalence ranging from 14% to 77%. Pain emerges as the most consistent independent determinant across multiple studies. Physical function, fatigue, fibromyalgia, depression, radiographic damage, disease activity state and objective measures of inflammation are also important correlates in some analyses. Our review revealed a lack of standardized definition for discordance between PGA and PhGA, with various approaches employed across studies. The choice of cutoff point to define significant discordance, often appeared arbitrary, lacking empirical justification or validation. A wide range of variables associated with discordance have been identified. A better understanding of this discordance may lead to more effective communication between health professionals and patients, which can improve both patient and physician satisfaction. Further research is needed to establish a standardized and validated definition of discordance that is clinically meaningful and facilitates comparisons across studies.