ACR Annual Meeting 2019

The VERVE study highlights a crucial topic for rheumatologists treating patients in clinical practice. The traditional thinking is to inform patients never to receive live vaccines when they are using TNF (tumor necrosis factor) inhibitors to treat their autoimmune disease. The VERVE study indicates that in the case of the Zostavax vaccine, patients on this form of biologic therapy for rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis can safely receive this preventive measure. This study scratches the surface on an important topic, and other studies need to follow.

Many patients on biologic therapy want to travel. Many times, international travel requires vaccination that is only in the form of a live vaccine – for example, the yellow fever vaccine. It would be useful for us to better understand whether other live vaccines can safely be administered and better inform our patients who want to travel. In addition, many times mothers with young infants are nervous if they are on biologic therapy and their children need to receive a live vaccine. They are concerned that their children will shed the live virus and they will be in jeopardy. This study highlights that this may be more of an antiquated way of thinking. We need more studies of this kind to better understand and advise our patients properly without instilling unwarranted fear.

Dr. Oberstein is a practicing rheumatologist at the University of Miami Health System and is senior medical director of musculoskeletal at Modernizing Medicine in Boca Raton, Fla. She has no relevant disclosures to report.

The VERVE study highlights a crucial topic for rheumatologists treating patients in clinical practice. The traditional thinking is to inform patients never to receive live vaccines when they are using TNF (tumor necrosis factor) inhibitors to treat their autoimmune disease. The VERVE study indicates that in the case of the Zostavax vaccine, patients on this form of biologic therapy for rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis can safely receive this preventive measure. This study scratches the surface on an important topic, and other studies need to follow.

Many patients on biologic therapy want to travel. Many times, international travel requires vaccination that is only in the form of a live vaccine – for example, the yellow fever vaccine. It would be useful for us to better understand whether other live vaccines can safely be administered and better inform our patients who want to travel. In addition, many times mothers with young infants are nervous if they are on biologic therapy and their children need to receive a live vaccine. They are concerned that their children will shed the live virus and they will be in jeopardy. This study highlights that this may be more of an antiquated way of thinking. We need more studies of this kind to better understand and advise our patients properly without instilling unwarranted fear.

Dr. Oberstein is a practicing rheumatologist at the University of Miami Health System and is senior medical director of musculoskeletal at Modernizing Medicine in Boca Raton, Fla. She has no relevant disclosures to report.

The VERVE study highlights a crucial topic for rheumatologists treating patients in clinical practice. The traditional thinking is to inform patients never to receive live vaccines when they are using TNF (tumor necrosis factor) inhibitors to treat their autoimmune disease. The VERVE study indicates that in the case of the Zostavax vaccine, patients on this form of biologic therapy for rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis can safely receive this preventive measure. This study scratches the surface on an important topic, and other studies need to follow.

Many patients on biologic therapy want to travel. Many times, international travel requires vaccination that is only in the form of a live vaccine – for example, the yellow fever vaccine. It would be useful for us to better understand whether other live vaccines can safely be administered and better inform our patients who want to travel. In addition, many times mothers with young infants are nervous if they are on biologic therapy and their children need to receive a live vaccine. They are concerned that their children will shed the live virus and they will be in jeopardy. This study highlights that this may be more of an antiquated way of thinking. We need more studies of this kind to better understand and advise our patients properly without instilling unwarranted fear.

Dr. Oberstein is a practicing rheumatologist at the University of Miami Health System and is senior medical director of musculoskeletal at Modernizing Medicine in Boca Raton, Fla. She has no relevant disclosures to report.

ATLANTA – Patients with moderate to severe osteoarthritis of the hip and knee who took the investigational anti-nerve growth factor monoclonal antibody tanezumab experienced a significantly higher rate of joint safety events than that of patients who received NSAIDs as part of a recent randomized, double-blind, active-controlled, phase 3 study.

Jeff Craven/MDedge News

Although patients who switched from NSAIDs to 5 mg subcutaneous tanezumab every 8 weeks reported significantly improved Western Ontario and McMaster Universities (WOMAC) index pain and function scores at 16 weeks, the difference was no longer statistically significant at 56 weeks; there was an increase in the number of joint safety events in both low- and high-dose tanezumab groups when compared with patients who continued on NSAIDs, Marc C. Hochberg, MD, of the University of Maryland, Baltimore, said in his presentation at the annual meeting of the American College of Rheumatology.

“Despite prior stable doses of NSAIDs, tanezumab subcutaneously administered every 8 weeks was associated with significantly more joint safety events than NSAIDs in a dose-dependent fashion,” he said.

Dr. Hochberg and colleagues conducted a phase 3 study of tanezumab in response to a Food and Drug Administration hold on the drug in 2010 in response to reports of osteonecrosis in patients taking tanezumab. “An adjudication committee was set up at that time to review all the records of individuals who participated in those studies who had been reported to have adverse joint related events, including osteonecrosis, as well as all the elected total joint replacements,” Dr. Hochberg explained. Only 4-month safety and efficacy data for tanezumab had been reported prior to these new data with at least 1 year of follow-up.

The study comprised 2,996 patients with hip or knee osteoarthritis (OA) from 446 centers in 18 countries, where patients were randomized to receive 2.5 mg of subcutaneous tanezumab (1,002 patients), tanezumab at 5 mg (998 patients) or NSAIDs (996 patients) for up to 80 weeks. Approximately two-thirds of the patients were women, and about 70% were white. About 85% of all patients had knee OA. The most common NSAIDs were celecoxib, diclofenac, and naproxen.

Less than 1% had Kellgren-Lawrence grade 0-1 at baseline, while about 30% had grade 2, 47% grade 3, and 22% grade 4. Patients had a mean 7.0 or 7.1 score on the WOMAC pain and function subscales, and a mean Patient’s Global Assessment of OA (PGA-OA) score of 7.4 or 7.5. Baseline radiographs were taken, as well as at safety follow-ups at 24 weeks, 56 weeks, and 80 weeks.

The researchers examined rapidly progressive OA (RPOA) type 1, classified as loss of 2 mm or more of joint space width within 1 year, and type 2, which was defined as abnormal bone loss or destruction, including limited or total collapse of at least one subchondral surface. Other primary joint safety endpoints examined were primary osteonecrosis, subchondral insufficiency fracture, and pathologic fracture. Each of these was reported individually in addition to the rate of total joint replacement. If an event was discovered, it was sent to an adjudication committee, Dr. Hochberg said. “You have either investigator-reported joint safety events, possible joint safety events or identified from the central raters’ assessment of imaging, or the reported total joint replacement reviewed blindly by the adjudication committee, blinded to treatment allocation, and then the adjudication results are those that are used for the analysis,” he said.

Overall, 447 patients who received tanezumab at 2.5 mg, 419 patients who received tanezumab at 5 mg, and 446 patients who continued receive NSAIDs completed treatment. There were 71 joint safety events in the tanezumab 5-mg group (7.1%) per 1,000 person-years, compared with 39 events per 1,000 person-years in the 2.5-mg group (3.9%), and 15 events per 1,000 person-years in the NSAIDs group (1.5%). The rate of joint safety events was significantly higher in both tanezumab groups, compared with the NSAIDs group (both P less than or equal to .001). Among patients with RPOA type 1, 4.9% of patients in the 5-mg group and 2.9% of patients in the 2.5-mg tanezumab group experienced joint safety events, compared with 1.1% of patients in the NSAIDs group. While RPOA type 2, primary osteonecrosis, and subchondral insufficiency fractures were uncommon in the study, Dr. Hochberg noted there was a statistically significant difference in joint safety events between the 5-mg tanezumab group and the NSAID group for patients with RPOA type 2 (1.4% vs. 0.1%; P less than or equal to .001).

The relationship between total joint replacement and tanezumab was dose-dependent: In the 5-mg group, 8.0% of patients underwent total joint replacement, while 5.3% of patients underwent total joint replacement in the 2.5-mg group, compared with 2.6% of patients in the NSAID group. “Most of the total joint replacements were due to normal progression of osteoarthritis,” Dr. Hochberg said.

When asked if he believed there is a role for tanezumab in the management of patients with OA, Dr. Hochberg said moderate to severe symptomatic hip or knee OA, including polyarticular OA, are potential areas where tanezumab and other nerve growth factor inhibitors could be beneficial.

“There is a tremendous unmet need in this population, and these are patients who have either had an inadequate response to, are intolerant of, or have contraindications to nonsteroidal anti-inflammatory drugs, have not responded well to intra-articular therapy, or have multiple joint involvement,” he said. There is also a role for tanezumab in OA patients who don’t want to take weaker opioid analgesics such as tramadol, he added.

This study was funded by Pfizer and Lilly, and the companies sponsored the summarization of the study. The authors reported various ties with these and other companies.

SOURCE: Hochberg MC et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 1302 and Abstract 2756.

ATLANTA – Patients with moderate to severe osteoarthritis of the hip and knee who took the investigational anti-nerve growth factor monoclonal antibody tanezumab experienced a significantly higher rate of joint safety events than that of patients who received NSAIDs as part of a recent randomized, double-blind, active-controlled, phase 3 study.

Jeff Craven/MDedge News

Although patients who switched from NSAIDs to 5 mg subcutaneous tanezumab every 8 weeks reported significantly improved Western Ontario and McMaster Universities (WOMAC) index pain and function scores at 16 weeks, the difference was no longer statistically significant at 56 weeks; there was an increase in the number of joint safety events in both low- and high-dose tanezumab groups when compared with patients who continued on NSAIDs, Marc C. Hochberg, MD, of the University of Maryland, Baltimore, said in his presentation at the annual meeting of the American College of Rheumatology.

“Despite prior stable doses of NSAIDs, tanezumab subcutaneously administered every 8 weeks was associated with significantly more joint safety events than NSAIDs in a dose-dependent fashion,” he said.

Dr. Hochberg and colleagues conducted a phase 3 study of tanezumab in response to a Food and Drug Administration hold on the drug in 2010 in response to reports of osteonecrosis in patients taking tanezumab. “An adjudication committee was set up at that time to review all the records of individuals who participated in those studies who had been reported to have adverse joint related events, including osteonecrosis, as well as all the elected total joint replacements,” Dr. Hochberg explained. Only 4-month safety and efficacy data for tanezumab had been reported prior to these new data with at least 1 year of follow-up.

The study comprised 2,996 patients with hip or knee osteoarthritis (OA) from 446 centers in 18 countries, where patients were randomized to receive 2.5 mg of subcutaneous tanezumab (1,002 patients), tanezumab at 5 mg (998 patients) or NSAIDs (996 patients) for up to 80 weeks. Approximately two-thirds of the patients were women, and about 70% were white. About 85% of all patients had knee OA. The most common NSAIDs were celecoxib, diclofenac, and naproxen.

Less than 1% had Kellgren-Lawrence grade 0-1 at baseline, while about 30% had grade 2, 47% grade 3, and 22% grade 4. Patients had a mean 7.0 or 7.1 score on the WOMAC pain and function subscales, and a mean Patient’s Global Assessment of OA (PGA-OA) score of 7.4 or 7.5. Baseline radiographs were taken, as well as at safety follow-ups at 24 weeks, 56 weeks, and 80 weeks.

The researchers examined rapidly progressive OA (RPOA) type 1, classified as loss of 2 mm or more of joint space width within 1 year, and type 2, which was defined as abnormal bone loss or destruction, including limited or total collapse of at least one subchondral surface. Other primary joint safety endpoints examined were primary osteonecrosis, subchondral insufficiency fracture, and pathologic fracture. Each of these was reported individually in addition to the rate of total joint replacement. If an event was discovered, it was sent to an adjudication committee, Dr. Hochberg said. “You have either investigator-reported joint safety events, possible joint safety events or identified from the central raters’ assessment of imaging, or the reported total joint replacement reviewed blindly by the adjudication committee, blinded to treatment allocation, and then the adjudication results are those that are used for the analysis,” he said.

Overall, 447 patients who received tanezumab at 2.5 mg, 419 patients who received tanezumab at 5 mg, and 446 patients who continued receive NSAIDs completed treatment. There were 71 joint safety events in the tanezumab 5-mg group (7.1%) per 1,000 person-years, compared with 39 events per 1,000 person-years in the 2.5-mg group (3.9%), and 15 events per 1,000 person-years in the NSAIDs group (1.5%). The rate of joint safety events was significantly higher in both tanezumab groups, compared with the NSAIDs group (both P less than or equal to .001). Among patients with RPOA type 1, 4.9% of patients in the 5-mg group and 2.9% of patients in the 2.5-mg tanezumab group experienced joint safety events, compared with 1.1% of patients in the NSAIDs group. While RPOA type 2, primary osteonecrosis, and subchondral insufficiency fractures were uncommon in the study, Dr. Hochberg noted there was a statistically significant difference in joint safety events between the 5-mg tanezumab group and the NSAID group for patients with RPOA type 2 (1.4% vs. 0.1%; P less than or equal to .001).

The relationship between total joint replacement and tanezumab was dose-dependent: In the 5-mg group, 8.0% of patients underwent total joint replacement, while 5.3% of patients underwent total joint replacement in the 2.5-mg group, compared with 2.6% of patients in the NSAID group. “Most of the total joint replacements were due to normal progression of osteoarthritis,” Dr. Hochberg said.

When asked if he believed there is a role for tanezumab in the management of patients with OA, Dr. Hochberg said moderate to severe symptomatic hip or knee OA, including polyarticular OA, are potential areas where tanezumab and other nerve growth factor inhibitors could be beneficial.

“There is a tremendous unmet need in this population, and these are patients who have either had an inadequate response to, are intolerant of, or have contraindications to nonsteroidal anti-inflammatory drugs, have not responded well to intra-articular therapy, or have multiple joint involvement,” he said. There is also a role for tanezumab in OA patients who don’t want to take weaker opioid analgesics such as tramadol, he added.

This study was funded by Pfizer and Lilly, and the companies sponsored the summarization of the study. The authors reported various ties with these and other companies.

SOURCE: Hochberg MC et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 1302 and Abstract 2756.

ATLANTA – Patients with moderate to severe osteoarthritis of the hip and knee who took the investigational anti-nerve growth factor monoclonal antibody tanezumab experienced a significantly higher rate of joint safety events than that of patients who received NSAIDs as part of a recent randomized, double-blind, active-controlled, phase 3 study.

Jeff Craven/MDedge News

Although patients who switched from NSAIDs to 5 mg subcutaneous tanezumab every 8 weeks reported significantly improved Western Ontario and McMaster Universities (WOMAC) index pain and function scores at 16 weeks, the difference was no longer statistically significant at 56 weeks; there was an increase in the number of joint safety events in both low- and high-dose tanezumab groups when compared with patients who continued on NSAIDs, Marc C. Hochberg, MD, of the University of Maryland, Baltimore, said in his presentation at the annual meeting of the American College of Rheumatology.

“Despite prior stable doses of NSAIDs, tanezumab subcutaneously administered every 8 weeks was associated with significantly more joint safety events than NSAIDs in a dose-dependent fashion,” he said.

Dr. Hochberg and colleagues conducted a phase 3 study of tanezumab in response to a Food and Drug Administration hold on the drug in 2010 in response to reports of osteonecrosis in patients taking tanezumab. “An adjudication committee was set up at that time to review all the records of individuals who participated in those studies who had been reported to have adverse joint related events, including osteonecrosis, as well as all the elected total joint replacements,” Dr. Hochberg explained. Only 4-month safety and efficacy data for tanezumab had been reported prior to these new data with at least 1 year of follow-up.

The study comprised 2,996 patients with hip or knee osteoarthritis (OA) from 446 centers in 18 countries, where patients were randomized to receive 2.5 mg of subcutaneous tanezumab (1,002 patients), tanezumab at 5 mg (998 patients) or NSAIDs (996 patients) for up to 80 weeks. Approximately two-thirds of the patients were women, and about 70% were white. About 85% of all patients had knee OA. The most common NSAIDs were celecoxib, diclofenac, and naproxen.

Less than 1% had Kellgren-Lawrence grade 0-1 at baseline, while about 30% had grade 2, 47% grade 3, and 22% grade 4. Patients had a mean 7.0 or 7.1 score on the WOMAC pain and function subscales, and a mean Patient’s Global Assessment of OA (PGA-OA) score of 7.4 or 7.5. Baseline radiographs were taken, as well as at safety follow-ups at 24 weeks, 56 weeks, and 80 weeks.

The researchers examined rapidly progressive OA (RPOA) type 1, classified as loss of 2 mm or more of joint space width within 1 year, and type 2, which was defined as abnormal bone loss or destruction, including limited or total collapse of at least one subchondral surface. Other primary joint safety endpoints examined were primary osteonecrosis, subchondral insufficiency fracture, and pathologic fracture. Each of these was reported individually in addition to the rate of total joint replacement. If an event was discovered, it was sent to an adjudication committee, Dr. Hochberg said. “You have either investigator-reported joint safety events, possible joint safety events or identified from the central raters’ assessment of imaging, or the reported total joint replacement reviewed blindly by the adjudication committee, blinded to treatment allocation, and then the adjudication results are those that are used for the analysis,” he said.

Overall, 447 patients who received tanezumab at 2.5 mg, 419 patients who received tanezumab at 5 mg, and 446 patients who continued receive NSAIDs completed treatment. There were 71 joint safety events in the tanezumab 5-mg group (7.1%) per 1,000 person-years, compared with 39 events per 1,000 person-years in the 2.5-mg group (3.9%), and 15 events per 1,000 person-years in the NSAIDs group (1.5%). The rate of joint safety events was significantly higher in both tanezumab groups, compared with the NSAIDs group (both P less than or equal to .001). Among patients with RPOA type 1, 4.9% of patients in the 5-mg group and 2.9% of patients in the 2.5-mg tanezumab group experienced joint safety events, compared with 1.1% of patients in the NSAIDs group. While RPOA type 2, primary osteonecrosis, and subchondral insufficiency fractures were uncommon in the study, Dr. Hochberg noted there was a statistically significant difference in joint safety events between the 5-mg tanezumab group and the NSAID group for patients with RPOA type 2 (1.4% vs. 0.1%; P less than or equal to .001).

The relationship between total joint replacement and tanezumab was dose-dependent: In the 5-mg group, 8.0% of patients underwent total joint replacement, while 5.3% of patients underwent total joint replacement in the 2.5-mg group, compared with 2.6% of patients in the NSAID group. “Most of the total joint replacements were due to normal progression of osteoarthritis,” Dr. Hochberg said.

When asked if he believed there is a role for tanezumab in the management of patients with OA, Dr. Hochberg said moderate to severe symptomatic hip or knee OA, including polyarticular OA, are potential areas where tanezumab and other nerve growth factor inhibitors could be beneficial.

“There is a tremendous unmet need in this population, and these are patients who have either had an inadequate response to, are intolerant of, or have contraindications to nonsteroidal anti-inflammatory drugs, have not responded well to intra-articular therapy, or have multiple joint involvement,” he said. There is also a role for tanezumab in OA patients who don’t want to take weaker opioid analgesics such as tramadol, he added.

This study was funded by Pfizer and Lilly, and the companies sponsored the summarization of the study. The authors reported various ties with these and other companies.

SOURCE: Hochberg MC et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 1302 and Abstract 2756.

ATLANTA – New guidelines for management of osteoarthritis of the hand, knee, and hip from the American College of Rheumatology and the Arthritis Foundation lay out a wide range of treatment options without an algorithm or hierarchy, making strong recommendations for nondrug interventions and for tailoring plans to individual patient-level factors.

Jeff Craven/MDedge News

Since the ACR last released OA management guidelines in 2012, a number of recommendations have been added, changed, and removed, and the structure of the guidelines has also changed. For instance, the new OA guidelines include a broad list of management options, Sharon L. Kolasinski, MD, chair of the ACR guidelines panel and professor of clinical medicine in the division of rheumatology at the University of Pennsylvania, Philadelphia, said in a presentation at the annual meeting of the American College of Rheumatology.

“The new guideline emphasizes comprehensive management of patients with OA, rather than a stepwise algorithm in a linear manner,” she said.

There is also no hierarchy to the recommendations, apart from the strength of the recommendation. “For any individual patient, a single option may be chosen at a particular time point, perhaps with or without other options, and may be reused in the future. For a given intervention, there might be a period of time over which it’s useful, and then the option might be changed,” Dr. Kolasinski noted.

Dr. Kolasinski advised making treatment decisions based on a patient’s disease severity, whether the patient uses medical devices, and in consideration of patient risk factors. “A history of injuries, surgical history, access to care, personal beliefs and preferences should all be brought to bear on decision making for osteoarthritis management,” she said.

The guidelines also advise considering a patient’s overall well-being and factors related to a patient’s perception of pain and function, such as mood disorders, altered sleep, chronic pain, impaired coping measures, and stress level. “Comprehensive management requires a broad assessment of how pain and function are affecting the patient with OA as a whole and recognizing that multiple options are available. They might be used in combination or change over time,” Dr. Kolasinski said.

The new guidelines place a strong emphasis on educational, behavioral, psychosocial, mind-body, and physical approaches. There are strong recommendations for the use of exercise, including aerobic, strengthening, neuromuscular, and aquatic exercise. Weight loss also carries a strong recommendation for patients with hip and knee OA, with a focus on group-based exercise, education, fitness and exercise goals, and a multidisciplinary approach using self-efficacy and self-management programs. The panels made a strong recommendation for tai chi to improve hip and knee OA. There are also strong recommendations for orthoses; aids and assistive devices such as canes, first carpometacarpal (CMC) orthoses, and tibiofemoral knee braces. Other interventions, such as Kinesio tape for first CMC joint and knee OA, hand orthoses, and patellofemoral knee braces, carried a conditional recommendation. Other conditional recommendations made by the panel were for acupuncture, thermal interventions, and radiofrequency ablation for patients with knee OA. Balance training for hip and knee OA, yoga for knee OA, and cognitive-behavioral therapy all were conditionally recommended by the panel.

The panel strongly recommended against the use of transcutaneous nerve stimulation for hip and knee OA, Dr. Kolasinski noted. The panel also conditionally recommended against use of modified shoes and pulsed vibration therapy in knee OA; lateral or medial wedged insoles, massage, and manual therapy with exercise in hip or knee OA; and iontophoresis in first CMC OA.

Jeff Craven/MDedge News

Recommendations for, against pharmacologic approaches

The ACR has changed conditional recommendations for topical NSAIDs for knee and hand OA, oral NSAIDs, and intra-articular steroids for knee and hip OA into strong recommendations for the 2019 guidelines, Dr. Kolasinski said. While the 2012 guidelines conditionally recommended against topical capsaicin for knee OA, the new guidelines conditionally recommend it.

Other pharmacologic conditional recommendations included topical NSAIDs, chondroitin sulfate, and intra-articular corticosteroid injections for hand OA, acetaminophen, and duloxetine for knee OA.

With the new recommendations come changes that some rheumatologists and health care providers may find controversial. “I think that the practicing rheumatologist may be surprised that we have a recommendation against the use of hyaluronic acid in the knee as a conditional recommendation,” Dr. Kolasinski said. “The assessment of the literature at this point really reveals that there is equivalence between intra-articular hyaluronic acid injection and intra-articular saline injection, and so it was the feeling of the panel that, really, this was worth changing the recommendation from the 2012 guideline.”

The panel made strong recommendations against use of the following pharmacologic interventions:

• Bisphosphonates.
• Glucosamine sulfate.
• Combination glucosamine sulfate-chondroitin sulfate products.
• Hydroxychloroquine.
• Methotrexate.
• Intra-articular hyaluronic acid injections in hip OA.
• Chondroitin sulfate, platelet-rich plasma injections, and stem cell injections in hip and knee OA.
• Tumor necrosis factor (TNF) inhibitors.
• Interleukin-1–receptor antagonists.

Additionally, the panel made a conditional recommendation against topical capsaicin on the hand, colchicine, fish oil, vitamin D, intra-articular hyaluronic acid injections in the first CMC, and intra-articular botulinum toxin and prolotherapy in hip and knee OA.

The panel did not recommend for or against use of yoga for hip and hand OA, topical lidocaine, pregabalin, gabapentin, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors apart from duloxetine, tricyclic antidepressants, and anti-nerve growth factor agents.

While the panel conditionally recommended against use of opioids, they made a conditional recommendation for use of tramadol opioids, and there was “a heated discussion about that distinction,” Dr. Neogi noted in a discussion session at the meeting. “There was a recent observational study that indicated that tramadol may have an increased risk of [all-cause] mortality, but there are lots of issues of confounding by indication in that study.”

The patient panel also raised strong concerns about the ACR and the Arthritis Foundation coming out against opioids for OA management in their guidelines. “They don’t want to damn opioids, but they’re also concerned about a specialty society coming out strongly against opioids in the concern that their physicians may limit their access to opioids if they’re in a situation where nothing else is helping them,” Dr. Neogi said.

Dr. Kolasinski noted the guidelines will be published online in Arthritis & Rheumatology in December, and will appear in print in February of next year.

Dr. Kolasinski reported no relevant financial disclosures. Dr. Neogi reported relationships with EMD Serono, Merck, and Pfizer.

ATLANTA – New guidelines for management of osteoarthritis of the hand, knee, and hip from the American College of Rheumatology and the Arthritis Foundation lay out a wide range of treatment options without an algorithm or hierarchy, making strong recommendations for nondrug interventions and for tailoring plans to individual patient-level factors.

Jeff Craven/MDedge News

Since the ACR last released OA management guidelines in 2012, a number of recommendations have been added, changed, and removed, and the structure of the guidelines has also changed. For instance, the new OA guidelines include a broad list of management options, Sharon L. Kolasinski, MD, chair of the ACR guidelines panel and professor of clinical medicine in the division of rheumatology at the University of Pennsylvania, Philadelphia, said in a presentation at the annual meeting of the American College of Rheumatology.

“The new guideline emphasizes comprehensive management of patients with OA, rather than a stepwise algorithm in a linear manner,” she said.

There is also no hierarchy to the recommendations, apart from the strength of the recommendation. “For any individual patient, a single option may be chosen at a particular time point, perhaps with or without other options, and may be reused in the future. For a given intervention, there might be a period of time over which it’s useful, and then the option might be changed,” Dr. Kolasinski noted.

Dr. Kolasinski advised making treatment decisions based on a patient’s disease severity, whether the patient uses medical devices, and in consideration of patient risk factors. “A history of injuries, surgical history, access to care, personal beliefs and preferences should all be brought to bear on decision making for osteoarthritis management,” she said.

The guidelines also advise considering a patient’s overall well-being and factors related to a patient’s perception of pain and function, such as mood disorders, altered sleep, chronic pain, impaired coping measures, and stress level. “Comprehensive management requires a broad assessment of how pain and function are affecting the patient with OA as a whole and recognizing that multiple options are available. They might be used in combination or change over time,” Dr. Kolasinski said.

The new guidelines place a strong emphasis on educational, behavioral, psychosocial, mind-body, and physical approaches. There are strong recommendations for the use of exercise, including aerobic, strengthening, neuromuscular, and aquatic exercise. Weight loss also carries a strong recommendation for patients with hip and knee OA, with a focus on group-based exercise, education, fitness and exercise goals, and a multidisciplinary approach using self-efficacy and self-management programs. The panels made a strong recommendation for tai chi to improve hip and knee OA. There are also strong recommendations for orthoses; aids and assistive devices such as canes, first carpometacarpal (CMC) orthoses, and tibiofemoral knee braces. Other interventions, such as Kinesio tape for first CMC joint and knee OA, hand orthoses, and patellofemoral knee braces, carried a conditional recommendation. Other conditional recommendations made by the panel were for acupuncture, thermal interventions, and radiofrequency ablation for patients with knee OA. Balance training for hip and knee OA, yoga for knee OA, and cognitive-behavioral therapy all were conditionally recommended by the panel.

The panel strongly recommended against the use of transcutaneous nerve stimulation for hip and knee OA, Dr. Kolasinski noted. The panel also conditionally recommended against use of modified shoes and pulsed vibration therapy in knee OA; lateral or medial wedged insoles, massage, and manual therapy with exercise in hip or knee OA; and iontophoresis in first CMC OA.

Jeff Craven/MDedge News

Recommendations for, against pharmacologic approaches

The ACR has changed conditional recommendations for topical NSAIDs for knee and hand OA, oral NSAIDs, and intra-articular steroids for knee and hip OA into strong recommendations for the 2019 guidelines, Dr. Kolasinski said. While the 2012 guidelines conditionally recommended against topical capsaicin for knee OA, the new guidelines conditionally recommend it.

Other pharmacologic conditional recommendations included topical NSAIDs, chondroitin sulfate, and intra-articular corticosteroid injections for hand OA, acetaminophen, and duloxetine for knee OA.

With the new recommendations come changes that some rheumatologists and health care providers may find controversial. “I think that the practicing rheumatologist may be surprised that we have a recommendation against the use of hyaluronic acid in the knee as a conditional recommendation,” Dr. Kolasinski said. “The assessment of the literature at this point really reveals that there is equivalence between intra-articular hyaluronic acid injection and intra-articular saline injection, and so it was the feeling of the panel that, really, this was worth changing the recommendation from the 2012 guideline.”

The panel made strong recommendations against use of the following pharmacologic interventions:

• Bisphosphonates.
• Glucosamine sulfate.
• Combination glucosamine sulfate-chondroitin sulfate products.
• Hydroxychloroquine.
• Methotrexate.
• Intra-articular hyaluronic acid injections in hip OA.
• Chondroitin sulfate, platelet-rich plasma injections, and stem cell injections in hip and knee OA.
• Tumor necrosis factor (TNF) inhibitors.
• Interleukin-1–receptor antagonists.

Additionally, the panel made a conditional recommendation against topical capsaicin on the hand, colchicine, fish oil, vitamin D, intra-articular hyaluronic acid injections in the first CMC, and intra-articular botulinum toxin and prolotherapy in hip and knee OA.

The panel did not recommend for or against use of yoga for hip and hand OA, topical lidocaine, pregabalin, gabapentin, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors apart from duloxetine, tricyclic antidepressants, and anti-nerve growth factor agents.

While the panel conditionally recommended against use of opioids, they made a conditional recommendation for use of tramadol opioids, and there was “a heated discussion about that distinction,” Dr. Neogi noted in a discussion session at the meeting. “There was a recent observational study that indicated that tramadol may have an increased risk of [all-cause] mortality, but there are lots of issues of confounding by indication in that study.”

The patient panel also raised strong concerns about the ACR and the Arthritis Foundation coming out against opioids for OA management in their guidelines. “They don’t want to damn opioids, but they’re also concerned about a specialty society coming out strongly against opioids in the concern that their physicians may limit their access to opioids if they’re in a situation where nothing else is helping them,” Dr. Neogi said.

Dr. Kolasinski noted the guidelines will be published online in Arthritis & Rheumatology in December, and will appear in print in February of next year.

Dr. Kolasinski reported no relevant financial disclosures. Dr. Neogi reported relationships with EMD Serono, Merck, and Pfizer.

ATLANTA – New guidelines for management of osteoarthritis of the hand, knee, and hip from the American College of Rheumatology and the Arthritis Foundation lay out a wide range of treatment options without an algorithm or hierarchy, making strong recommendations for nondrug interventions and for tailoring plans to individual patient-level factors.

Jeff Craven/MDedge News

Since the ACR last released OA management guidelines in 2012, a number of recommendations have been added, changed, and removed, and the structure of the guidelines has also changed. For instance, the new OA guidelines include a broad list of management options, Sharon L. Kolasinski, MD, chair of the ACR guidelines panel and professor of clinical medicine in the division of rheumatology at the University of Pennsylvania, Philadelphia, said in a presentation at the annual meeting of the American College of Rheumatology.

“The new guideline emphasizes comprehensive management of patients with OA, rather than a stepwise algorithm in a linear manner,” she said.

There is also no hierarchy to the recommendations, apart from the strength of the recommendation. “For any individual patient, a single option may be chosen at a particular time point, perhaps with or without other options, and may be reused in the future. For a given intervention, there might be a period of time over which it’s useful, and then the option might be changed,” Dr. Kolasinski noted.

Dr. Kolasinski advised making treatment decisions based on a patient’s disease severity, whether the patient uses medical devices, and in consideration of patient risk factors. “A history of injuries, surgical history, access to care, personal beliefs and preferences should all be brought to bear on decision making for osteoarthritis management,” she said.

The guidelines also advise considering a patient’s overall well-being and factors related to a patient’s perception of pain and function, such as mood disorders, altered sleep, chronic pain, impaired coping measures, and stress level. “Comprehensive management requires a broad assessment of how pain and function are affecting the patient with OA as a whole and recognizing that multiple options are available. They might be used in combination or change over time,” Dr. Kolasinski said.

The new guidelines place a strong emphasis on educational, behavioral, psychosocial, mind-body, and physical approaches. There are strong recommendations for the use of exercise, including aerobic, strengthening, neuromuscular, and aquatic exercise. Weight loss also carries a strong recommendation for patients with hip and knee OA, with a focus on group-based exercise, education, fitness and exercise goals, and a multidisciplinary approach using self-efficacy and self-management programs. The panels made a strong recommendation for tai chi to improve hip and knee OA. There are also strong recommendations for orthoses; aids and assistive devices such as canes, first carpometacarpal (CMC) orthoses, and tibiofemoral knee braces. Other interventions, such as Kinesio tape for first CMC joint and knee OA, hand orthoses, and patellofemoral knee braces, carried a conditional recommendation. Other conditional recommendations made by the panel were for acupuncture, thermal interventions, and radiofrequency ablation for patients with knee OA. Balance training for hip and knee OA, yoga for knee OA, and cognitive-behavioral therapy all were conditionally recommended by the panel.

The panel strongly recommended against the use of transcutaneous nerve stimulation for hip and knee OA, Dr. Kolasinski noted. The panel also conditionally recommended against use of modified shoes and pulsed vibration therapy in knee OA; lateral or medial wedged insoles, massage, and manual therapy with exercise in hip or knee OA; and iontophoresis in first CMC OA.

Jeff Craven/MDedge News

Recommendations for, against pharmacologic approaches

The ACR has changed conditional recommendations for topical NSAIDs for knee and hand OA, oral NSAIDs, and intra-articular steroids for knee and hip OA into strong recommendations for the 2019 guidelines, Dr. Kolasinski said. While the 2012 guidelines conditionally recommended against topical capsaicin for knee OA, the new guidelines conditionally recommend it.

Other pharmacologic conditional recommendations included topical NSAIDs, chondroitin sulfate, and intra-articular corticosteroid injections for hand OA, acetaminophen, and duloxetine for knee OA.

With the new recommendations come changes that some rheumatologists and health care providers may find controversial. “I think that the practicing rheumatologist may be surprised that we have a recommendation against the use of hyaluronic acid in the knee as a conditional recommendation,” Dr. Kolasinski said. “The assessment of the literature at this point really reveals that there is equivalence between intra-articular hyaluronic acid injection and intra-articular saline injection, and so it was the feeling of the panel that, really, this was worth changing the recommendation from the 2012 guideline.”

The panel made strong recommendations against use of the following pharmacologic interventions:

• Bisphosphonates.
• Glucosamine sulfate.
• Combination glucosamine sulfate-chondroitin sulfate products.
• Hydroxychloroquine.
• Methotrexate.
• Intra-articular hyaluronic acid injections in hip OA.
• Chondroitin sulfate, platelet-rich plasma injections, and stem cell injections in hip and knee OA.
• Tumor necrosis factor (TNF) inhibitors.
• Interleukin-1–receptor antagonists.

Additionally, the panel made a conditional recommendation against topical capsaicin on the hand, colchicine, fish oil, vitamin D, intra-articular hyaluronic acid injections in the first CMC, and intra-articular botulinum toxin and prolotherapy in hip and knee OA.

The panel did not recommend for or against use of yoga for hip and hand OA, topical lidocaine, pregabalin, gabapentin, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors apart from duloxetine, tricyclic antidepressants, and anti-nerve growth factor agents.

While the panel conditionally recommended against use of opioids, they made a conditional recommendation for use of tramadol opioids, and there was “a heated discussion about that distinction,” Dr. Neogi noted in a discussion session at the meeting. “There was a recent observational study that indicated that tramadol may have an increased risk of [all-cause] mortality, but there are lots of issues of confounding by indication in that study.”

The patient panel also raised strong concerns about the ACR and the Arthritis Foundation coming out against opioids for OA management in their guidelines. “They don’t want to damn opioids, but they’re also concerned about a specialty society coming out strongly against opioids in the concern that their physicians may limit their access to opioids if they’re in a situation where nothing else is helping them,” Dr. Neogi said.

Dr. Kolasinski noted the guidelines will be published online in Arthritis & Rheumatology in December, and will appear in print in February of next year.

Dr. Kolasinski reported no relevant financial disclosures. Dr. Neogi reported relationships with EMD Serono, Merck, and Pfizer.

ATLANTA – Gout is associated with an increased risk of both fatal and nonfatal cardiovascular disease events, according to a large population-based health data linkage study in New Zealand.

Sharon Worcester/MDedge News

“Overall, the survival was quite good within both cohorts, but ... there is a clear and statistically significant difference in the survival between the people with gout and those without gout,” Ken Cai, MBBS, reported at the annual meeting of the American College of Rheumatology, noting that a similarly “significant and clear” difference was seen in nonfatal CVD events between the groups.

Of 968,387 individuals included in the analysis, 34,056 had gout, said Dr. Cai, a rheumatology clinical fellow at the University of Auckland (New Zealand). After adjusting for population-level estimated 5-year CVD risk for cardiovascular death, nonfatal myocardial infarction, stroke, or other vascular event, the adjusted hazard ratios were 1.20 for fatal and 1.32 for nonfatal first CVD events in patients with gout. The CVD risk score used in the analysis accounted for age, gender, ethnicity, level of social deprivation, diabetes status, previous hospitalization for atrial fibrillation, and baseline dispensing of blood pressure–lowering, lipid-lowering, and antiplatelet/anticoagulant medications.

“To allow for any other differences between the gout and nongout cohorts with respect to gender, age, ethnicity, and social deprivation, we further adjusted for these factors again, even though they had been accounted for within our CVD risk score,” he said, noting that “gout continued to demonstrate an increased adjusted hazard ratio” for fatal and nonfatal events after that adjustment (HRs, 1.40 and 1.35, respectively)

Additional analysis in the gout patients showed that CVD risk was similarly increased both in those who had been dispensed allopurinol at least once in the prior 5 years and those who had not (adjusted HRs for fatal events, 1.41 and 1.33; and for nonfatal, first CVD events, 1.34 and 1.38, respectively), and “there was no significant difference between these two groups, compared to people without gout,” he said.

Adjustment for serum urate levels in gout patients also showed similarly increased risk for fatal and nonfatal events for those with levels less than 6 mg/dL and those with levels of 6 mg/dL or greater (adjusted HRs of 1.32 and 1.42 for fatal events, and 1.27 and 1.43 for nonfatal first CVD events, respectively).

Again, no significant difference was seen in the risk of events between these two groups and those without gout, Dr. Cai said, noting that patients with no serum urate monitoring also had an increased risk of events (adjusted HR of 1.41 for fatal events and 1.29 for nonfatal, first CVD events).

Gout and hyperuricemia have previously been reported to be independent risk factors for CVD and CVD events, and urate-lowering therapy such as allopurinol have been thought to potentially be associated with reduced risk of CVD, he said, noting that the relationships are of particular concern in New Zealand, where gout affects more than 4% of the adult population.

“Maori, who are the indigenous people of New Zealand, and Pasifika people are disproportionately affected by gout; 8.5% of Maori, and 13.9% of Pasifika adults have gout,” he said, adding that an estimated one-third of Maori and Pasifika adults over age 65 years have gout.

To further assess the relationships between gout and CVD risk, he and his colleagues used validated population-level risk-prediction equations and linked National Health Identifier (NHI) data, he said.

National registries of medicines dispensing data, hospitalization, and death were linked to the Auckland/Northland regional repository of laboratory results from Jan. 1, 2012 to Dec. 31, 2016.

“We included all New Zealand residents aged 20 years or older who were in contact with publicly funded services in 2011 and were alive at the end of December, 2011,” he said, adding that those with a previous hospitalization for CVD or heart failure prior to the end of December 2011 were excluded, as were those with primary residence outside of the region for the prior 3 years and those missing predictor variable data.

Although the findings are limited by an inability to adjust for smoking status, body mass index, and blood pressure – as such data are not collected at the national level, and by the population-based nature of the study, which does not allow determination about causation, they nevertheless reinforce the association between gout and an increased estimated risk of CVD events, Dr. Cai said.

“Even after adjustment for estimated 5-year CVD risk and the additional weighting of risk factors within it, gout independently increased the hazard ratio for fatal and nonfatal events,” he said. “In our study, this effect was not ameliorated by allopurinol use or serum urate lowering to treatment target.”

Similar studies are needed in other populations, he said.

Dr. Cai reported grant support from Arthritis Australia.

sworcester@mdedge.com

SOURCE: Cai K et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 2732.

ATLANTA – Gout is associated with an increased risk of both fatal and nonfatal cardiovascular disease events, according to a large population-based health data linkage study in New Zealand.

Sharon Worcester/MDedge News

“Overall, the survival was quite good within both cohorts, but ... there is a clear and statistically significant difference in the survival between the people with gout and those without gout,” Ken Cai, MBBS, reported at the annual meeting of the American College of Rheumatology, noting that a similarly “significant and clear” difference was seen in nonfatal CVD events between the groups.

Of 968,387 individuals included in the analysis, 34,056 had gout, said Dr. Cai, a rheumatology clinical fellow at the University of Auckland (New Zealand). After adjusting for population-level estimated 5-year CVD risk for cardiovascular death, nonfatal myocardial infarction, stroke, or other vascular event, the adjusted hazard ratios were 1.20 for fatal and 1.32 for nonfatal first CVD events in patients with gout. The CVD risk score used in the analysis accounted for age, gender, ethnicity, level of social deprivation, diabetes status, previous hospitalization for atrial fibrillation, and baseline dispensing of blood pressure–lowering, lipid-lowering, and antiplatelet/anticoagulant medications.

“To allow for any other differences between the gout and nongout cohorts with respect to gender, age, ethnicity, and social deprivation, we further adjusted for these factors again, even though they had been accounted for within our CVD risk score,” he said, noting that “gout continued to demonstrate an increased adjusted hazard ratio” for fatal and nonfatal events after that adjustment (HRs, 1.40 and 1.35, respectively)

Additional analysis in the gout patients showed that CVD risk was similarly increased both in those who had been dispensed allopurinol at least once in the prior 5 years and those who had not (adjusted HRs for fatal events, 1.41 and 1.33; and for nonfatal, first CVD events, 1.34 and 1.38, respectively), and “there was no significant difference between these two groups, compared to people without gout,” he said.

Adjustment for serum urate levels in gout patients also showed similarly increased risk for fatal and nonfatal events for those with levels less than 6 mg/dL and those with levels of 6 mg/dL or greater (adjusted HRs of 1.32 and 1.42 for fatal events, and 1.27 and 1.43 for nonfatal first CVD events, respectively).

Again, no significant difference was seen in the risk of events between these two groups and those without gout, Dr. Cai said, noting that patients with no serum urate monitoring also had an increased risk of events (adjusted HR of 1.41 for fatal events and 1.29 for nonfatal, first CVD events).

Gout and hyperuricemia have previously been reported to be independent risk factors for CVD and CVD events, and urate-lowering therapy such as allopurinol have been thought to potentially be associated with reduced risk of CVD, he said, noting that the relationships are of particular concern in New Zealand, where gout affects more than 4% of the adult population.

“Maori, who are the indigenous people of New Zealand, and Pasifika people are disproportionately affected by gout; 8.5% of Maori, and 13.9% of Pasifika adults have gout,” he said, adding that an estimated one-third of Maori and Pasifika adults over age 65 years have gout.

To further assess the relationships between gout and CVD risk, he and his colleagues used validated population-level risk-prediction equations and linked National Health Identifier (NHI) data, he said.

National registries of medicines dispensing data, hospitalization, and death were linked to the Auckland/Northland regional repository of laboratory results from Jan. 1, 2012 to Dec. 31, 2016.

“We included all New Zealand residents aged 20 years or older who were in contact with publicly funded services in 2011 and were alive at the end of December, 2011,” he said, adding that those with a previous hospitalization for CVD or heart failure prior to the end of December 2011 were excluded, as were those with primary residence outside of the region for the prior 3 years and those missing predictor variable data.

Although the findings are limited by an inability to adjust for smoking status, body mass index, and blood pressure – as such data are not collected at the national level, and by the population-based nature of the study, which does not allow determination about causation, they nevertheless reinforce the association between gout and an increased estimated risk of CVD events, Dr. Cai said.

“Even after adjustment for estimated 5-year CVD risk and the additional weighting of risk factors within it, gout independently increased the hazard ratio for fatal and nonfatal events,” he said. “In our study, this effect was not ameliorated by allopurinol use or serum urate lowering to treatment target.”

Similar studies are needed in other populations, he said.

Dr. Cai reported grant support from Arthritis Australia.

sworcester@mdedge.com

SOURCE: Cai K et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 2732.

ATLANTA – Gout is associated with an increased risk of both fatal and nonfatal cardiovascular disease events, according to a large population-based health data linkage study in New Zealand.

Sharon Worcester/MDedge News

“Overall, the survival was quite good within both cohorts, but ... there is a clear and statistically significant difference in the survival between the people with gout and those without gout,” Ken Cai, MBBS, reported at the annual meeting of the American College of Rheumatology, noting that a similarly “significant and clear” difference was seen in nonfatal CVD events between the groups.

Of 968,387 individuals included in the analysis, 34,056 had gout, said Dr. Cai, a rheumatology clinical fellow at the University of Auckland (New Zealand). After adjusting for population-level estimated 5-year CVD risk for cardiovascular death, nonfatal myocardial infarction, stroke, or other vascular event, the adjusted hazard ratios were 1.20 for fatal and 1.32 for nonfatal first CVD events in patients with gout. The CVD risk score used in the analysis accounted for age, gender, ethnicity, level of social deprivation, diabetes status, previous hospitalization for atrial fibrillation, and baseline dispensing of blood pressure–lowering, lipid-lowering, and antiplatelet/anticoagulant medications.

“To allow for any other differences between the gout and nongout cohorts with respect to gender, age, ethnicity, and social deprivation, we further adjusted for these factors again, even though they had been accounted for within our CVD risk score,” he said, noting that “gout continued to demonstrate an increased adjusted hazard ratio” for fatal and nonfatal events after that adjustment (HRs, 1.40 and 1.35, respectively)

Additional analysis in the gout patients showed that CVD risk was similarly increased both in those who had been dispensed allopurinol at least once in the prior 5 years and those who had not (adjusted HRs for fatal events, 1.41 and 1.33; and for nonfatal, first CVD events, 1.34 and 1.38, respectively), and “there was no significant difference between these two groups, compared to people without gout,” he said.

Adjustment for serum urate levels in gout patients also showed similarly increased risk for fatal and nonfatal events for those with levels less than 6 mg/dL and those with levels of 6 mg/dL or greater (adjusted HRs of 1.32 and 1.42 for fatal events, and 1.27 and 1.43 for nonfatal first CVD events, respectively).

Again, no significant difference was seen in the risk of events between these two groups and those without gout, Dr. Cai said, noting that patients with no serum urate monitoring also had an increased risk of events (adjusted HR of 1.41 for fatal events and 1.29 for nonfatal, first CVD events).

Gout and hyperuricemia have previously been reported to be independent risk factors for CVD and CVD events, and urate-lowering therapy such as allopurinol have been thought to potentially be associated with reduced risk of CVD, he said, noting that the relationships are of particular concern in New Zealand, where gout affects more than 4% of the adult population.

“Maori, who are the indigenous people of New Zealand, and Pasifika people are disproportionately affected by gout; 8.5% of Maori, and 13.9% of Pasifika adults have gout,” he said, adding that an estimated one-third of Maori and Pasifika adults over age 65 years have gout.

To further assess the relationships between gout and CVD risk, he and his colleagues used validated population-level risk-prediction equations and linked National Health Identifier (NHI) data, he said.

National registries of medicines dispensing data, hospitalization, and death were linked to the Auckland/Northland regional repository of laboratory results from Jan. 1, 2012 to Dec. 31, 2016.

“We included all New Zealand residents aged 20 years or older who were in contact with publicly funded services in 2011 and were alive at the end of December, 2011,” he said, adding that those with a previous hospitalization for CVD or heart failure prior to the end of December 2011 were excluded, as were those with primary residence outside of the region for the prior 3 years and those missing predictor variable data.

Although the findings are limited by an inability to adjust for smoking status, body mass index, and blood pressure – as such data are not collected at the national level, and by the population-based nature of the study, which does not allow determination about causation, they nevertheless reinforce the association between gout and an increased estimated risk of CVD events, Dr. Cai said.

“Even after adjustment for estimated 5-year CVD risk and the additional weighting of risk factors within it, gout independently increased the hazard ratio for fatal and nonfatal events,” he said. “In our study, this effect was not ameliorated by allopurinol use or serum urate lowering to treatment target.”

Similar studies are needed in other populations, he said.

Dr. Cai reported grant support from Arthritis Australia.

sworcester@mdedge.com

SOURCE: Cai K et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 2732.

ATLANTA – Ixekizumab (Taltz) provided significantly greater improvement in joint and skin symptoms, compared with adalimumab (Humira), in biologic-naive patients with active psoriatic arthritis (PsA), according to final 52-week safety and efficacy results from the randomized SPIRIT-H2H study.

The high-affinity monoclonal antibody against interleukin-17A also performed at least as well as the tumor necrosis factor (TNF)–inhibitor adalimumab across multiple PsA domains and regardless of methotrexate use, Josef Smolen, MD, reported during a late-breaking abstract session at the annual meeting of the American College of Rheumatology.

Multiple biologic disease-modifying antirheumatic drugs (bDMARDs) are available for the treatment of PsA, but few studies have directly compared their efficacy and safety, said Dr. Smolen of the Medical University of Vienna. He noted that the SPIRIT-H2H study aimed to compare ixekizumab and adalimumab and also to address “one of the most clinically relevant questions for clinicians,” which relates to the efficacy of bDMARDs with and without concomitant methotrexate.

Ixekizumab is approved for adults with active PsA and moderate to severe plaque psoriasis, but TNF inhibitors like adalimumab have long been considered the gold standard for PsA treatment, he explained.

Of 283 patients with PsA randomized to receive ixekizumab and 283 randomized to receive adalimumab, 87% and 84%, respectively, completed week 52 of the head-to-head, open-label study comparing the bDMARDs. Treatment with ixekizumab achieved the primary endpoint of simultaneous improvement of 50% on ACR response criteria (ACR50) and 100% on the Psoriasis Area and Severity Index (PASI100) in 39% of patients, which was significantly higher than the rate of 26% with adalimumab, Dr. Smolen said.

Ixekizumab also performed at least as well as adalimumab for the secondary outcome measures of ACR50 response (50% in both groups) and PASI100 response (64% vs. 41%), as well as for all other outcomes measures, including multiple musculoskeletal PsA domains, he said.

“Remarkably ... at 1 year, more than one-third of the patients achieved an ACR70 in both groups, and half of the patients achieved an ACR50,” he added, noting that the ACR100 responses were in line with previous investigations.

Stratification by methotrexate use showed that the simultaneous ACR50 and PASI100 response rates were improved with ixekizumab versus adalimumab both in users and nonusers of methotrexate (39% vs. 30% and 40% vs. 20%, respectively). This finding highlights the ongoing debate about whether TNF inhibitors should or should not be used with methotrexate for PsA.

“This study was not adequately powered to say that, but there is some indication, and I think that this is food for thought for future further analysis because the data in the literature are discrepant in this respect,” Dr. Smolen said.

In non-methotrexate users in SPIRIT-H2H, the ACR20 responses were 53% with ixekinumab vs. 40% with adalimumab, ACR50 responses were 72% vs. 60%, and ACR70 responses were 41% vs. 27%, respectively, he said noting that the difference for ACR70 was statistically significant, and that the ACR70 response with ixekinumab was about the same as the ACR50 for adalimumab.

As for ACR20, ACR50, and ACR70 responses in methotrexate users, “the lines criss-crossed” early on, he said, but all were “slightly superior” with adalimumab than with ixekizumab at 52 weeks (75% vs. 68%, 56% vs. 48%, and 39% vs. 32%, respectively).

Study participants had a mean age of 48 years and had active PsA with at least 3/66 tender joints, at least 3/68 swollen joints, at least 3% psoriasis body surface area involvement, no prior treatment with bDMARDs, and prior inadequate response to one or more conventional synthetic DMARDs. Treatment was dosed according to drug labeling through 52 weeks.

The safety profiles of both agents were consistent with previous reports; treatment-emergent adverse events occurred in 73.9% of ixekizumab and 68.6% of adalimumab patients, and serious adverse events occurred in 4.2% and 12.4%, respectively.

“On the other hand, ixekizumab had more injection site reactions: 11% vs. close to 4%,” he said, noting that 4.2% of the ixekizumab patients and 7.4% of the adalimumab patients discontinued treatment because of adverse events. No deaths occurred in either group.

As reported previously in Annals of the Rheumatic Diseases, ixekizumab was superior to adalimumab for simultaneous achievement of ACR50 and PASI100 at 24 weeks, and these final 52-week results confirm those results, he said.

The study was funded by Eli Lilly, which markets ixekizumab. Dr. Smolen reported research grants and/or honoraria from Eli Lilly and AbbVie, which markets adalimumab, as well as many other pharmaceutical companies.

sworcester@mdedge.com

SOURCE: Smolen J et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract L20.

ATLANTA – Ixekizumab (Taltz) provided significantly greater improvement in joint and skin symptoms, compared with adalimumab (Humira), in biologic-naive patients with active psoriatic arthritis (PsA), according to final 52-week safety and efficacy results from the randomized SPIRIT-H2H study.

The high-affinity monoclonal antibody against interleukin-17A also performed at least as well as the tumor necrosis factor (TNF)–inhibitor adalimumab across multiple PsA domains and regardless of methotrexate use, Josef Smolen, MD, reported during a late-breaking abstract session at the annual meeting of the American College of Rheumatology.

Multiple biologic disease-modifying antirheumatic drugs (bDMARDs) are available for the treatment of PsA, but few studies have directly compared their efficacy and safety, said Dr. Smolen of the Medical University of Vienna. He noted that the SPIRIT-H2H study aimed to compare ixekizumab and adalimumab and also to address “one of the most clinically relevant questions for clinicians,” which relates to the efficacy of bDMARDs with and without concomitant methotrexate.

Ixekizumab is approved for adults with active PsA and moderate to severe plaque psoriasis, but TNF inhibitors like adalimumab have long been considered the gold standard for PsA treatment, he explained.

Of 283 patients with PsA randomized to receive ixekizumab and 283 randomized to receive adalimumab, 87% and 84%, respectively, completed week 52 of the head-to-head, open-label study comparing the bDMARDs. Treatment with ixekizumab achieved the primary endpoint of simultaneous improvement of 50% on ACR response criteria (ACR50) and 100% on the Psoriasis Area and Severity Index (PASI100) in 39% of patients, which was significantly higher than the rate of 26% with adalimumab, Dr. Smolen said.

Ixekizumab also performed at least as well as adalimumab for the secondary outcome measures of ACR50 response (50% in both groups) and PASI100 response (64% vs. 41%), as well as for all other outcomes measures, including multiple musculoskeletal PsA domains, he said.

“Remarkably ... at 1 year, more than one-third of the patients achieved an ACR70 in both groups, and half of the patients achieved an ACR50,” he added, noting that the ACR100 responses were in line with previous investigations.

Stratification by methotrexate use showed that the simultaneous ACR50 and PASI100 response rates were improved with ixekizumab versus adalimumab both in users and nonusers of methotrexate (39% vs. 30% and 40% vs. 20%, respectively). This finding highlights the ongoing debate about whether TNF inhibitors should or should not be used with methotrexate for PsA.

“This study was not adequately powered to say that, but there is some indication, and I think that this is food for thought for future further analysis because the data in the literature are discrepant in this respect,” Dr. Smolen said.

In non-methotrexate users in SPIRIT-H2H, the ACR20 responses were 53% with ixekinumab vs. 40% with adalimumab, ACR50 responses were 72% vs. 60%, and ACR70 responses were 41% vs. 27%, respectively, he said noting that the difference for ACR70 was statistically significant, and that the ACR70 response with ixekinumab was about the same as the ACR50 for adalimumab.

As for ACR20, ACR50, and ACR70 responses in methotrexate users, “the lines criss-crossed” early on, he said, but all were “slightly superior” with adalimumab than with ixekizumab at 52 weeks (75% vs. 68%, 56% vs. 48%, and 39% vs. 32%, respectively).

Study participants had a mean age of 48 years and had active PsA with at least 3/66 tender joints, at least 3/68 swollen joints, at least 3% psoriasis body surface area involvement, no prior treatment with bDMARDs, and prior inadequate response to one or more conventional synthetic DMARDs. Treatment was dosed according to drug labeling through 52 weeks.

The safety profiles of both agents were consistent with previous reports; treatment-emergent adverse events occurred in 73.9% of ixekizumab and 68.6% of adalimumab patients, and serious adverse events occurred in 4.2% and 12.4%, respectively.

“On the other hand, ixekizumab had more injection site reactions: 11% vs. close to 4%,” he said, noting that 4.2% of the ixekizumab patients and 7.4% of the adalimumab patients discontinued treatment because of adverse events. No deaths occurred in either group.

As reported previously in Annals of the Rheumatic Diseases, ixekizumab was superior to adalimumab for simultaneous achievement of ACR50 and PASI100 at 24 weeks, and these final 52-week results confirm those results, he said.

The study was funded by Eli Lilly, which markets ixekizumab. Dr. Smolen reported research grants and/or honoraria from Eli Lilly and AbbVie, which markets adalimumab, as well as many other pharmaceutical companies.

sworcester@mdedge.com

SOURCE: Smolen J et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract L20.

ATLANTA – Ixekizumab (Taltz) provided significantly greater improvement in joint and skin symptoms, compared with adalimumab (Humira), in biologic-naive patients with active psoriatic arthritis (PsA), according to final 52-week safety and efficacy results from the randomized SPIRIT-H2H study.

The high-affinity monoclonal antibody against interleukin-17A also performed at least as well as the tumor necrosis factor (TNF)–inhibitor adalimumab across multiple PsA domains and regardless of methotrexate use, Josef Smolen, MD, reported during a late-breaking abstract session at the annual meeting of the American College of Rheumatology.

Multiple biologic disease-modifying antirheumatic drugs (bDMARDs) are available for the treatment of PsA, but few studies have directly compared their efficacy and safety, said Dr. Smolen of the Medical University of Vienna. He noted that the SPIRIT-H2H study aimed to compare ixekizumab and adalimumab and also to address “one of the most clinically relevant questions for clinicians,” which relates to the efficacy of bDMARDs with and without concomitant methotrexate.

Ixekizumab is approved for adults with active PsA and moderate to severe plaque psoriasis, but TNF inhibitors like adalimumab have long been considered the gold standard for PsA treatment, he explained.

Of 283 patients with PsA randomized to receive ixekizumab and 283 randomized to receive adalimumab, 87% and 84%, respectively, completed week 52 of the head-to-head, open-label study comparing the bDMARDs. Treatment with ixekizumab achieved the primary endpoint of simultaneous improvement of 50% on ACR response criteria (ACR50) and 100% on the Psoriasis Area and Severity Index (PASI100) in 39% of patients, which was significantly higher than the rate of 26% with adalimumab, Dr. Smolen said.

Ixekizumab also performed at least as well as adalimumab for the secondary outcome measures of ACR50 response (50% in both groups) and PASI100 response (64% vs. 41%), as well as for all other outcomes measures, including multiple musculoskeletal PsA domains, he said.

“Remarkably ... at 1 year, more than one-third of the patients achieved an ACR70 in both groups, and half of the patients achieved an ACR50,” he added, noting that the ACR100 responses were in line with previous investigations.

Stratification by methotrexate use showed that the simultaneous ACR50 and PASI100 response rates were improved with ixekizumab versus adalimumab both in users and nonusers of methotrexate (39% vs. 30% and 40% vs. 20%, respectively). This finding highlights the ongoing debate about whether TNF inhibitors should or should not be used with methotrexate for PsA.

“This study was not adequately powered to say that, but there is some indication, and I think that this is food for thought for future further analysis because the data in the literature are discrepant in this respect,” Dr. Smolen said.

In non-methotrexate users in SPIRIT-H2H, the ACR20 responses were 53% with ixekinumab vs. 40% with adalimumab, ACR50 responses were 72% vs. 60%, and ACR70 responses were 41% vs. 27%, respectively, he said noting that the difference for ACR70 was statistically significant, and that the ACR70 response with ixekinumab was about the same as the ACR50 for adalimumab.

As for ACR20, ACR50, and ACR70 responses in methotrexate users, “the lines criss-crossed” early on, he said, but all were “slightly superior” with adalimumab than with ixekizumab at 52 weeks (75% vs. 68%, 56% vs. 48%, and 39% vs. 32%, respectively).

Study participants had a mean age of 48 years and had active PsA with at least 3/66 tender joints, at least 3/68 swollen joints, at least 3% psoriasis body surface area involvement, no prior treatment with bDMARDs, and prior inadequate response to one or more conventional synthetic DMARDs. Treatment was dosed according to drug labeling through 52 weeks.

The safety profiles of both agents were consistent with previous reports; treatment-emergent adverse events occurred in 73.9% of ixekizumab and 68.6% of adalimumab patients, and serious adverse events occurred in 4.2% and 12.4%, respectively.

“On the other hand, ixekizumab had more injection site reactions: 11% vs. close to 4%,” he said, noting that 4.2% of the ixekizumab patients and 7.4% of the adalimumab patients discontinued treatment because of adverse events. No deaths occurred in either group.

As reported previously in Annals of the Rheumatic Diseases, ixekizumab was superior to adalimumab for simultaneous achievement of ACR50 and PASI100 at 24 weeks, and these final 52-week results confirm those results, he said.

The study was funded by Eli Lilly, which markets ixekizumab. Dr. Smolen reported research grants and/or honoraria from Eli Lilly and AbbVie, which markets adalimumab, as well as many other pharmaceutical companies.

sworcester@mdedge.com

SOURCE: Smolen J et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract L20.

ATLANTA – Adding ixekizumab (Taltz) to conventional background medications significantly improved the signs and symptoms of nonradiographic axial spondyloarthritis (axSpA) in the randomized, double-blind, placebo-controlled phase 3 COAST-X trial.

Sharon Worcester/MDedge News

The high-affinity interleukin-17A monoclonal antibody ixekizumab “has shown efficacy in ankylosing spondylitis – also called radiographic axial spondyloarthritis – [and] it recently was approved by the [Food and Drug Administration] for the treatment of active ankylosing spondylitis,” said Atul Deodhar, MD, explaining that COAST-X sought to assess its efficacy in patients with active nonradiographic axSpA and objective evidence of inflammation. He presented the results of the trial at the annual meeting of the American College of Rheumatology.

Of 303 adults with an established diagnosis of axSpA who met Assessment of Spondyloarthritis International Society (ASAS) classification criteria and who were enrolled in the 52-week trial, 105 were randomized to receive background medications plus placebo, and 102 and 96 received background medications plus ixekizumab every 2 or 4 weeks, respectively. The primary endpoint of a 40% improvement in ASAS response criteria (ASAS 40) was reached at week 16 by 19% of the placebo-group patients and by 35% and 40% of the 2- and 4-week ixekizumab-group patients, and at week 52 by 13%, 30%, and 31% of the patients in the groups, respectively, Dr. Deodhar reported.

Additionally, “all major secondary endpoints were met for each ixekizumab regimen, both at week 16 and week 52,” said Dr. Deodhar, professor of medicine in the division of arthritis and rheumatic diseases at Oregon Health & Science University, Portland.

For example, Ankylosing Spondylitis Disease Activity Score (ASDAS) at week 16 declined by 0.6 with placebo, 1.3 with 2-week ixekizumab dosing, and 1.1 points with 4-week ixekizumab dosing; Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Functional Index changes were –1.5, –2.5, and –2.2, and –1.3, –2.3 and –2.0; Short Form–36 physical component score changes were 5.3, 8.0, and 8.1 points; and MRI sacroiliac joint Spondyloarthritis Research Consortium of Canada score changes were –0.3, –4.5 and –3.4, in the groups, respectively.

“ASDAS less than 2.1 – low disease activity – was achieved by 32% and 27% [in the 2- and 4-week ixekizumab groups] versus 12% in the placebo [group],” he said, noting that similarly significant results were seen at week 52.

Notably, the differences in ASAS 40 response rates between the treatment and placebo groups were observed beginning at week 1, and “a notable proportion” of patients who escaped to the open-label 2-week ixekizumab group, as allowed per study protocol starting at week 16, had an ASAS 40 response at the time of escape; the ASAS 40 response rates at that time were 6.5%, 16.7%, 25% in the groups, respectively, and the rates increased further on open-label ixekizumab, he said.

Study participants were adults diagnosed with axSpA by a physician and treated for at least 3 months. Inclusion criteria also included BASDAI score of at least 4, back pain score of at least 4, inflammation as evidenced by sacroiliitis on MRI or elevated C-reactive protein levels of greater than 5 mg/L, and inadequate response or intolerance to at least two NSAIDs.

Ixekizumab in both treatment groups was given at a dose of 80 mg, and changes to conventional background medications, including NSAIDs, conventional synthetic disease-modifying antirheumatic drugs, analgesics, and low-dose corticosteroids, were allowed, as was escape to open-label ixekizumab given every 2 weeks at investigators’ discretion after week 16.

Ixekizumab treatment was well tolerated; the frequency of serious adverse events and AEs leading to treatment discontinuation was low and similar across all arms, Dr. Deodhar said.

For example, treatment-emergent AEs occurred in 55.7%, 77.5%, and 65.6% of patients, serious AEs occurred in 1.0%, 1.0%, and 2.1%, and AE-related discontinuations occurred in 1.9%, 1.0%, and 1.0% or patients in the groups, respectively.

No deaths occurred and no new safety signals were identified.

“The results demonstrate, for the first time, that blocking IL-17A is a potential treatment option for patients with nonradiographic axSpA,” he concluded.

COAST-X was sponsored by Eli Lilly. Dr. Deodhar and most coauthors reported receiving research grants and/or honoraria for consulting or speaking from Eli Lilly and other pharmaceutical companies. Four authors are current employees and shareholders of Eli Lilly.

sworcester@mdedge.com

SOURCE: Deodhar A et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 2729.

ATLANTA – Adding ixekizumab (Taltz) to conventional background medications significantly improved the signs and symptoms of nonradiographic axial spondyloarthritis (axSpA) in the randomized, double-blind, placebo-controlled phase 3 COAST-X trial.

Sharon Worcester/MDedge News

The high-affinity interleukin-17A monoclonal antibody ixekizumab “has shown efficacy in ankylosing spondylitis – also called radiographic axial spondyloarthritis – [and] it recently was approved by the [Food and Drug Administration] for the treatment of active ankylosing spondylitis,” said Atul Deodhar, MD, explaining that COAST-X sought to assess its efficacy in patients with active nonradiographic axSpA and objective evidence of inflammation. He presented the results of the trial at the annual meeting of the American College of Rheumatology.

Of 303 adults with an established diagnosis of axSpA who met Assessment of Spondyloarthritis International Society (ASAS) classification criteria and who were enrolled in the 52-week trial, 105 were randomized to receive background medications plus placebo, and 102 and 96 received background medications plus ixekizumab every 2 or 4 weeks, respectively. The primary endpoint of a 40% improvement in ASAS response criteria (ASAS 40) was reached at week 16 by 19% of the placebo-group patients and by 35% and 40% of the 2- and 4-week ixekizumab-group patients, and at week 52 by 13%, 30%, and 31% of the patients in the groups, respectively, Dr. Deodhar reported.

Additionally, “all major secondary endpoints were met for each ixekizumab regimen, both at week 16 and week 52,” said Dr. Deodhar, professor of medicine in the division of arthritis and rheumatic diseases at Oregon Health & Science University, Portland.

For example, Ankylosing Spondylitis Disease Activity Score (ASDAS) at week 16 declined by 0.6 with placebo, 1.3 with 2-week ixekizumab dosing, and 1.1 points with 4-week ixekizumab dosing; Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Functional Index changes were –1.5, –2.5, and –2.2, and –1.3, –2.3 and –2.0; Short Form–36 physical component score changes were 5.3, 8.0, and 8.1 points; and MRI sacroiliac joint Spondyloarthritis Research Consortium of Canada score changes were –0.3, –4.5 and –3.4, in the groups, respectively.

“ASDAS less than 2.1 – low disease activity – was achieved by 32% and 27% [in the 2- and 4-week ixekizumab groups] versus 12% in the placebo [group],” he said, noting that similarly significant results were seen at week 52.

Notably, the differences in ASAS 40 response rates between the treatment and placebo groups were observed beginning at week 1, and “a notable proportion” of patients who escaped to the open-label 2-week ixekizumab group, as allowed per study protocol starting at week 16, had an ASAS 40 response at the time of escape; the ASAS 40 response rates at that time were 6.5%, 16.7%, 25% in the groups, respectively, and the rates increased further on open-label ixekizumab, he said.

Study participants were adults diagnosed with axSpA by a physician and treated for at least 3 months. Inclusion criteria also included BASDAI score of at least 4, back pain score of at least 4, inflammation as evidenced by sacroiliitis on MRI or elevated C-reactive protein levels of greater than 5 mg/L, and inadequate response or intolerance to at least two NSAIDs.

Ixekizumab in both treatment groups was given at a dose of 80 mg, and changes to conventional background medications, including NSAIDs, conventional synthetic disease-modifying antirheumatic drugs, analgesics, and low-dose corticosteroids, were allowed, as was escape to open-label ixekizumab given every 2 weeks at investigators’ discretion after week 16.

Ixekizumab treatment was well tolerated; the frequency of serious adverse events and AEs leading to treatment discontinuation was low and similar across all arms, Dr. Deodhar said.

For example, treatment-emergent AEs occurred in 55.7%, 77.5%, and 65.6% of patients, serious AEs occurred in 1.0%, 1.0%, and 2.1%, and AE-related discontinuations occurred in 1.9%, 1.0%, and 1.0% or patients in the groups, respectively.

No deaths occurred and no new safety signals were identified.

“The results demonstrate, for the first time, that blocking IL-17A is a potential treatment option for patients with nonradiographic axSpA,” he concluded.

COAST-X was sponsored by Eli Lilly. Dr. Deodhar and most coauthors reported receiving research grants and/or honoraria for consulting or speaking from Eli Lilly and other pharmaceutical companies. Four authors are current employees and shareholders of Eli Lilly.

sworcester@mdedge.com

SOURCE: Deodhar A et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 2729.

ATLANTA – Adding ixekizumab (Taltz) to conventional background medications significantly improved the signs and symptoms of nonradiographic axial spondyloarthritis (axSpA) in the randomized, double-blind, placebo-controlled phase 3 COAST-X trial.

Sharon Worcester/MDedge News

The high-affinity interleukin-17A monoclonal antibody ixekizumab “has shown efficacy in ankylosing spondylitis – also called radiographic axial spondyloarthritis – [and] it recently was approved by the [Food and Drug Administration] for the treatment of active ankylosing spondylitis,” said Atul Deodhar, MD, explaining that COAST-X sought to assess its efficacy in patients with active nonradiographic axSpA and objective evidence of inflammation. He presented the results of the trial at the annual meeting of the American College of Rheumatology.

Of 303 adults with an established diagnosis of axSpA who met Assessment of Spondyloarthritis International Society (ASAS) classification criteria and who were enrolled in the 52-week trial, 105 were randomized to receive background medications plus placebo, and 102 and 96 received background medications plus ixekizumab every 2 or 4 weeks, respectively. The primary endpoint of a 40% improvement in ASAS response criteria (ASAS 40) was reached at week 16 by 19% of the placebo-group patients and by 35% and 40% of the 2- and 4-week ixekizumab-group patients, and at week 52 by 13%, 30%, and 31% of the patients in the groups, respectively, Dr. Deodhar reported.

Additionally, “all major secondary endpoints were met for each ixekizumab regimen, both at week 16 and week 52,” said Dr. Deodhar, professor of medicine in the division of arthritis and rheumatic diseases at Oregon Health & Science University, Portland.

For example, Ankylosing Spondylitis Disease Activity Score (ASDAS) at week 16 declined by 0.6 with placebo, 1.3 with 2-week ixekizumab dosing, and 1.1 points with 4-week ixekizumab dosing; Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Functional Index changes were –1.5, –2.5, and –2.2, and –1.3, –2.3 and –2.0; Short Form–36 physical component score changes were 5.3, 8.0, and 8.1 points; and MRI sacroiliac joint Spondyloarthritis Research Consortium of Canada score changes were –0.3, –4.5 and –3.4, in the groups, respectively.

“ASDAS less than 2.1 – low disease activity – was achieved by 32% and 27% [in the 2- and 4-week ixekizumab groups] versus 12% in the placebo [group],” he said, noting that similarly significant results were seen at week 52.

Notably, the differences in ASAS 40 response rates between the treatment and placebo groups were observed beginning at week 1, and “a notable proportion” of patients who escaped to the open-label 2-week ixekizumab group, as allowed per study protocol starting at week 16, had an ASAS 40 response at the time of escape; the ASAS 40 response rates at that time were 6.5%, 16.7%, 25% in the groups, respectively, and the rates increased further on open-label ixekizumab, he said.

Study participants were adults diagnosed with axSpA by a physician and treated for at least 3 months. Inclusion criteria also included BASDAI score of at least 4, back pain score of at least 4, inflammation as evidenced by sacroiliitis on MRI or elevated C-reactive protein levels of greater than 5 mg/L, and inadequate response or intolerance to at least two NSAIDs.

Ixekizumab in both treatment groups was given at a dose of 80 mg, and changes to conventional background medications, including NSAIDs, conventional synthetic disease-modifying antirheumatic drugs, analgesics, and low-dose corticosteroids, were allowed, as was escape to open-label ixekizumab given every 2 weeks at investigators’ discretion after week 16.

Ixekizumab treatment was well tolerated; the frequency of serious adverse events and AEs leading to treatment discontinuation was low and similar across all arms, Dr. Deodhar said.

For example, treatment-emergent AEs occurred in 55.7%, 77.5%, and 65.6% of patients, serious AEs occurred in 1.0%, 1.0%, and 2.1%, and AE-related discontinuations occurred in 1.9%, 1.0%, and 1.0% or patients in the groups, respectively.

No deaths occurred and no new safety signals were identified.

“The results demonstrate, for the first time, that blocking IL-17A is a potential treatment option for patients with nonradiographic axSpA,” he concluded.

COAST-X was sponsored by Eli Lilly. Dr. Deodhar and most coauthors reported receiving research grants and/or honoraria for consulting or speaking from Eli Lilly and other pharmaceutical companies. Four authors are current employees and shareholders of Eli Lilly.

sworcester@mdedge.com

SOURCE: Deodhar A et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 2729.

ATLANTA – Patients with systemic sclerosis aged 44 years and younger in the United States now have mortality comparable to that of the general population in that age group, according to recent results presented at the annual meeting of the American College of Rheumatology.

“Mortality for scleroderma has steadily decreased in younger ages for the last 5 decades,” Ram R. Singh, MD, professor of medicine, pathology, and laboratory medicine at the University of California, Los Angeles, said in his presentation.

Using the Centers for Disease Control and Prevention’s National Vital Statistics System database, Dr. Singh and colleagues analyzed data of adults with systemic sclerosis (SSc) and identified 46,798 adults who died between 1968 and 2015. They divided the adults with and without SSc into three different age groups: 44 and younger, 45-64, and 65 and older. The researchers performed a joinpoint trend analysis, calculating the annual percent change (APC) and average APC as well as the age-standardized mortality rate (ASMR) in each age group.

In 1968, 466 deaths were attributed to SSc, compared with 1,195 deaths in 2015. Between 1968 and 2015, there was a 19% cumulative percentage increase in SSc-related deaths, compared with a 44% decrease in mortality not attributed to SSc; when the researchers analyzed the ratio of SSc-related ASMR to non-SSc-related ASMR, there was an increase of 112%, Dr. Singh said.

When analyzing the mortality of adults with SSc by age group during 1968-2015 using the CDC’s database, Dr. Singh and colleagues found 5,457 deaths in adults 44 and younger (11.7%), 18,395 deaths in adults aged 45-64 (39.3%), and 22,946 deaths in adults aged 65 and older (49.0%), compared with totals for the general population of 10.3 million deaths in adults aged 44 and younger (9.7%), 20.8 million deaths in adults 45-64 years (19.6%), and 74.8 million deaths in adults aged 65 and older (70.6%).

Over the 48-year period, there were three major trends in SSc-related ASMR, Dr. Singh noted. In the first trend period between 1968 and 1988, there was a 1.0% increase per year (95% confidence interval, 0.6%-1.4%). The second trend period, lasting until 2000, saw a 2.2% increase per year (95% CI, 1.6%-2.7%), while the SSc-related ASMR declined by 2.6% per year in the third trend period from 2001 to 2015 (95% CI, –3.1% to –2.2%).

The percentage of annual deaths for adults with SSc decreased between 1968 and 2015, from 23.4% to 5.7%, and the average APC was greater among adults aged 44 and younger with SSc (–2.2%; 95% CI, –2.4% to –2.0%) than for adults without SSc in the same age group (–1.5%; 95% CI, –1.9% to –1.1%).

There was a cumulative 60% decrease in the ASMR of adults with SSc aged 44 and younger between 1968 and 2015 from an ASMR of 1.0 per million (95% CI, 0.8%-1.2%) to an ASMR of 0.4 per million (0.3-0.5). Adults aged 45-64 years with SSc had a cumulative 20.3% decrease in ASMR over the same time period, with an ASMR of 5.9 per million in 1968 (95% CI, 5.2-6.7) and an ASMR of 4.7 per million in 2015 (95% CI, 4.2-5.2). However, adults aged 65 and older with SSc had a 187% cumulative increase in ASMR, with an ASMR of 5.4 per million in 1968 (95% CI, 4.4-6.5) and an ASMR of 15.5 per million in 2015 (95% CI, 14.3-16.6). Adults with non-SSc-related deaths between 1968 and 2015 had a 50.0% cumulative decrease in ASMR in the group aged 44 and under, a 48.0% cumulative decrease in the 45-year to 64-year-old group, and a 42.1% decrease in the 65-year-old or older group.

The ratio of SSc to non-SSc ASMRs between 1968 and 2015 in the group aged 44 and younger declined 20.0%, whereas there was a 53.1% cumulative increase in the 45- to 64-year-old group and a 395.4% cumulative increase in the 65-year-old and older group. In the oldest group, the APC increased by 3.9% each year for 33 years (95% CI, 3.7%-4.1%) before declining by 1.6% until 2015 (95% CI, –2.0 to –1.3). In contrast, the APC for adults 44 and younger never significantly increased over the 48 years, Dr. Singh noted.

“Increasing scleroderma mortality in older age could be due to improving survival and/or increasing age of onset of scleroderma,” he said.

Dr. Singh reported no conflicts of interest.

SOURCE: Yen E et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 825.

ATLANTA – Patients with systemic sclerosis aged 44 years and younger in the United States now have mortality comparable to that of the general population in that age group, according to recent results presented at the annual meeting of the American College of Rheumatology.

“Mortality for scleroderma has steadily decreased in younger ages for the last 5 decades,” Ram R. Singh, MD, professor of medicine, pathology, and laboratory medicine at the University of California, Los Angeles, said in his presentation.

Using the Centers for Disease Control and Prevention’s National Vital Statistics System database, Dr. Singh and colleagues analyzed data of adults with systemic sclerosis (SSc) and identified 46,798 adults who died between 1968 and 2015. They divided the adults with and without SSc into three different age groups: 44 and younger, 45-64, and 65 and older. The researchers performed a joinpoint trend analysis, calculating the annual percent change (APC) and average APC as well as the age-standardized mortality rate (ASMR) in each age group.

In 1968, 466 deaths were attributed to SSc, compared with 1,195 deaths in 2015. Between 1968 and 2015, there was a 19% cumulative percentage increase in SSc-related deaths, compared with a 44% decrease in mortality not attributed to SSc; when the researchers analyzed the ratio of SSc-related ASMR to non-SSc-related ASMR, there was an increase of 112%, Dr. Singh said.

When analyzing the mortality of adults with SSc by age group during 1968-2015 using the CDC’s database, Dr. Singh and colleagues found 5,457 deaths in adults 44 and younger (11.7%), 18,395 deaths in adults aged 45-64 (39.3%), and 22,946 deaths in adults aged 65 and older (49.0%), compared with totals for the general population of 10.3 million deaths in adults aged 44 and younger (9.7%), 20.8 million deaths in adults 45-64 years (19.6%), and 74.8 million deaths in adults aged 65 and older (70.6%).

Over the 48-year period, there were three major trends in SSc-related ASMR, Dr. Singh noted. In the first trend period between 1968 and 1988, there was a 1.0% increase per year (95% confidence interval, 0.6%-1.4%). The second trend period, lasting until 2000, saw a 2.2% increase per year (95% CI, 1.6%-2.7%), while the SSc-related ASMR declined by 2.6% per year in the third trend period from 2001 to 2015 (95% CI, –3.1% to –2.2%).

The percentage of annual deaths for adults with SSc decreased between 1968 and 2015, from 23.4% to 5.7%, and the average APC was greater among adults aged 44 and younger with SSc (–2.2%; 95% CI, –2.4% to –2.0%) than for adults without SSc in the same age group (–1.5%; 95% CI, –1.9% to –1.1%).

There was a cumulative 60% decrease in the ASMR of adults with SSc aged 44 and younger between 1968 and 2015 from an ASMR of 1.0 per million (95% CI, 0.8%-1.2%) to an ASMR of 0.4 per million (0.3-0.5). Adults aged 45-64 years with SSc had a cumulative 20.3% decrease in ASMR over the same time period, with an ASMR of 5.9 per million in 1968 (95% CI, 5.2-6.7) and an ASMR of 4.7 per million in 2015 (95% CI, 4.2-5.2). However, adults aged 65 and older with SSc had a 187% cumulative increase in ASMR, with an ASMR of 5.4 per million in 1968 (95% CI, 4.4-6.5) and an ASMR of 15.5 per million in 2015 (95% CI, 14.3-16.6). Adults with non-SSc-related deaths between 1968 and 2015 had a 50.0% cumulative decrease in ASMR in the group aged 44 and under, a 48.0% cumulative decrease in the 45-year to 64-year-old group, and a 42.1% decrease in the 65-year-old or older group.

The ratio of SSc to non-SSc ASMRs between 1968 and 2015 in the group aged 44 and younger declined 20.0%, whereas there was a 53.1% cumulative increase in the 45- to 64-year-old group and a 395.4% cumulative increase in the 65-year-old and older group. In the oldest group, the APC increased by 3.9% each year for 33 years (95% CI, 3.7%-4.1%) before declining by 1.6% until 2015 (95% CI, –2.0 to –1.3). In contrast, the APC for adults 44 and younger never significantly increased over the 48 years, Dr. Singh noted.

“Increasing scleroderma mortality in older age could be due to improving survival and/or increasing age of onset of scleroderma,” he said.

Dr. Singh reported no conflicts of interest.

SOURCE: Yen E et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 825.

ATLANTA – Patients with systemic sclerosis aged 44 years and younger in the United States now have mortality comparable to that of the general population in that age group, according to recent results presented at the annual meeting of the American College of Rheumatology.

“Mortality for scleroderma has steadily decreased in younger ages for the last 5 decades,” Ram R. Singh, MD, professor of medicine, pathology, and laboratory medicine at the University of California, Los Angeles, said in his presentation.

Using the Centers for Disease Control and Prevention’s National Vital Statistics System database, Dr. Singh and colleagues analyzed data of adults with systemic sclerosis (SSc) and identified 46,798 adults who died between 1968 and 2015. They divided the adults with and without SSc into three different age groups: 44 and younger, 45-64, and 65 and older. The researchers performed a joinpoint trend analysis, calculating the annual percent change (APC) and average APC as well as the age-standardized mortality rate (ASMR) in each age group.

In 1968, 466 deaths were attributed to SSc, compared with 1,195 deaths in 2015. Between 1968 and 2015, there was a 19% cumulative percentage increase in SSc-related deaths, compared with a 44% decrease in mortality not attributed to SSc; when the researchers analyzed the ratio of SSc-related ASMR to non-SSc-related ASMR, there was an increase of 112%, Dr. Singh said.

When analyzing the mortality of adults with SSc by age group during 1968-2015 using the CDC’s database, Dr. Singh and colleagues found 5,457 deaths in adults 44 and younger (11.7%), 18,395 deaths in adults aged 45-64 (39.3%), and 22,946 deaths in adults aged 65 and older (49.0%), compared with totals for the general population of 10.3 million deaths in adults aged 44 and younger (9.7%), 20.8 million deaths in adults 45-64 years (19.6%), and 74.8 million deaths in adults aged 65 and older (70.6%).

Over the 48-year period, there were three major trends in SSc-related ASMR, Dr. Singh noted. In the first trend period between 1968 and 1988, there was a 1.0% increase per year (95% confidence interval, 0.6%-1.4%). The second trend period, lasting until 2000, saw a 2.2% increase per year (95% CI, 1.6%-2.7%), while the SSc-related ASMR declined by 2.6% per year in the third trend period from 2001 to 2015 (95% CI, –3.1% to –2.2%).

The percentage of annual deaths for adults with SSc decreased between 1968 and 2015, from 23.4% to 5.7%, and the average APC was greater among adults aged 44 and younger with SSc (–2.2%; 95% CI, –2.4% to –2.0%) than for adults without SSc in the same age group (–1.5%; 95% CI, –1.9% to –1.1%).

There was a cumulative 60% decrease in the ASMR of adults with SSc aged 44 and younger between 1968 and 2015 from an ASMR of 1.0 per million (95% CI, 0.8%-1.2%) to an ASMR of 0.4 per million (0.3-0.5). Adults aged 45-64 years with SSc had a cumulative 20.3% decrease in ASMR over the same time period, with an ASMR of 5.9 per million in 1968 (95% CI, 5.2-6.7) and an ASMR of 4.7 per million in 2015 (95% CI, 4.2-5.2). However, adults aged 65 and older with SSc had a 187% cumulative increase in ASMR, with an ASMR of 5.4 per million in 1968 (95% CI, 4.4-6.5) and an ASMR of 15.5 per million in 2015 (95% CI, 14.3-16.6). Adults with non-SSc-related deaths between 1968 and 2015 had a 50.0% cumulative decrease in ASMR in the group aged 44 and under, a 48.0% cumulative decrease in the 45-year to 64-year-old group, and a 42.1% decrease in the 65-year-old or older group.

The ratio of SSc to non-SSc ASMRs between 1968 and 2015 in the group aged 44 and younger declined 20.0%, whereas there was a 53.1% cumulative increase in the 45- to 64-year-old group and a 395.4% cumulative increase in the 65-year-old and older group. In the oldest group, the APC increased by 3.9% each year for 33 years (95% CI, 3.7%-4.1%) before declining by 1.6% until 2015 (95% CI, –2.0 to –1.3). In contrast, the APC for adults 44 and younger never significantly increased over the 48 years, Dr. Singh noted.

“Increasing scleroderma mortality in older age could be due to improving survival and/or increasing age of onset of scleroderma,” he said.

Dr. Singh reported no conflicts of interest.

SOURCE: Yen E et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 825.

ATLANTA – Rituximab (Rituxan) is superior to azathioprine (Imuran) for preventing ANCA-associated vasculitis relapses in patients with histories of previous relapses, according to a randomized trial of 170 patients presented at the annual meeting of the American College of Rheumatology.

Rituximab has been previously shown to be the superior remission maintenance option in the French MAINRITSAN trial (N Engl J Med. 2014 Nov 6;371[19]:1771-80), but mostly in newly diagnosed patients after cyclophosphamide induction. The results expand the finding to those with relapsing disease who previously had remission induced with rituximab, said lead investigator Rona Smith, MD, a clinical lecturer at Cambridge (England) University.

Subjects in the RITAZAREM trial (rituximab versus azathioprine as therapy for maintenance of remission for antineutrophil cytoplasmic antibody [ANCA]–associated vasculitis) were enrolled during a relapse of either granulomatosis with polyangiitis or microscopic polyangiitis and underwent remission induction with rituximab 375 mg/m² per week for 4 weeks coupled with prednisone, either 1 or 0.5 mg/kg per day at provider discretion.

After successful induction – defined as a Birmingham Vasculitis Activity Score for Wegener’s Granulomatosis of 1 point or less on no more than 10 mg/day prednisone – 85 patients were randomized to rituximab 1 g every 4 months for 20 months and 85 to azathioprine 2 mg/kg per day for 20 months, followed by a taper. Prednisone was tapered per protocol to discontinuation at 20 months.

Eleven rituximab patients (13%) relapsed during the 20-month maintenance phase; two relapses were major. There were 32 relapses (38%) in the azathioprine group, 12 of them (38%) major (hazard ratio for rituximab versus azathioprine, 0.3; 95% CI, 0.15-0.60; P less than .001). ANCA type, glucocorticoid induction regimen, and severity of the enrollment relapse did not affect the outcomes.

Also, “there was an increase in the proportion of patients who became ANCA negative” in the rituximab arm, while “there was really no change” with azathioprine. In short, “rituximab is superior to azathioprine for prevention of disease relapse,” Dr. Smith said.

Her audience had a few questions about the rituximab regimen. The French MAINRITSAN trial dosed rituximab every 6 months instead of every 4, for a cumulative dose of 2.5 g, not 5 g, which an audience member said is the standard approach.

Dr. Smith explained that she and her colleagues have seen relapses with rituximab maintenance at 5 and 6 months, so they wanted to move to a shorter schedule. As for the higher dose, they wanted to “achieve complete B-cell depletion for the duration of the treatment period” to see if it translates into longer lasting remissions. “We will hopefully be able to address that question” with further analysis, she said.

There were no new safety signals; 19 rituximab patients (22%) and 31 azathioprine subjects (36%) had at least one serious adverse event; an infection requiring hospitalization occurred in 7 rituximab patients (8%) and 11 azathioprine patients (13%). Twenty-five (29%) rituximab and 21 (25%) azathioprine subjects developed hypogammaglobulinemia (IgG less than 5 g/L), and about half of each group developed an infection that required antibiotics, but not hospitalization.

There was one death in the azathioprine arm from malignancy, and three in the rituximab group, one from infection and two as of yet unclassified.

The groups were well balanced. Subjects were a median of 59 years old, with a median disease duration of 5.3 years. Refractory patients – those who had not achieved remission during a previous relapse – were excluded, as were patients who had received a B cell–depleting treatment in the previous 6 months and those with eosinophilic granulomatosis with polyangiitis or a malignancy in the past 5 years. Among patients in the study, 72% had tested positive for anti–proteinase 3 ANCA, and 28% for myeloperoxidase ANCA.

The work was funded by Versus Arthritis (formerly Arthritis Research UK), the National Institutes of Health, and the makers of rituximab, Roche/Genentech. Dr. Smith reported ties to Roche, Sanofi, and MedImmune.

aotto@mdedge.com

SOURCE: Smith R et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 806.

ATLANTA – Rituximab (Rituxan) is superior to azathioprine (Imuran) for preventing ANCA-associated vasculitis relapses in patients with histories of previous relapses, according to a randomized trial of 170 patients presented at the annual meeting of the American College of Rheumatology.

Rituximab has been previously shown to be the superior remission maintenance option in the French MAINRITSAN trial (N Engl J Med. 2014 Nov 6;371[19]:1771-80), but mostly in newly diagnosed patients after cyclophosphamide induction. The results expand the finding to those with relapsing disease who previously had remission induced with rituximab, said lead investigator Rona Smith, MD, a clinical lecturer at Cambridge (England) University.

Subjects in the RITAZAREM trial (rituximab versus azathioprine as therapy for maintenance of remission for antineutrophil cytoplasmic antibody [ANCA]–associated vasculitis) were enrolled during a relapse of either granulomatosis with polyangiitis or microscopic polyangiitis and underwent remission induction with rituximab 375 mg/m² per week for 4 weeks coupled with prednisone, either 1 or 0.5 mg/kg per day at provider discretion.

After successful induction – defined as a Birmingham Vasculitis Activity Score for Wegener’s Granulomatosis of 1 point or less on no more than 10 mg/day prednisone – 85 patients were randomized to rituximab 1 g every 4 months for 20 months and 85 to azathioprine 2 mg/kg per day for 20 months, followed by a taper. Prednisone was tapered per protocol to discontinuation at 20 months.

Eleven rituximab patients (13%) relapsed during the 20-month maintenance phase; two relapses were major. There were 32 relapses (38%) in the azathioprine group, 12 of them (38%) major (hazard ratio for rituximab versus azathioprine, 0.3; 95% CI, 0.15-0.60; P less than .001). ANCA type, glucocorticoid induction regimen, and severity of the enrollment relapse did not affect the outcomes.

Also, “there was an increase in the proportion of patients who became ANCA negative” in the rituximab arm, while “there was really no change” with azathioprine. In short, “rituximab is superior to azathioprine for prevention of disease relapse,” Dr. Smith said.

Her audience had a few questions about the rituximab regimen. The French MAINRITSAN trial dosed rituximab every 6 months instead of every 4, for a cumulative dose of 2.5 g, not 5 g, which an audience member said is the standard approach.

Dr. Smith explained that she and her colleagues have seen relapses with rituximab maintenance at 5 and 6 months, so they wanted to move to a shorter schedule. As for the higher dose, they wanted to “achieve complete B-cell depletion for the duration of the treatment period” to see if it translates into longer lasting remissions. “We will hopefully be able to address that question” with further analysis, she said.

There were no new safety signals; 19 rituximab patients (22%) and 31 azathioprine subjects (36%) had at least one serious adverse event; an infection requiring hospitalization occurred in 7 rituximab patients (8%) and 11 azathioprine patients (13%). Twenty-five (29%) rituximab and 21 (25%) azathioprine subjects developed hypogammaglobulinemia (IgG less than 5 g/L), and about half of each group developed an infection that required antibiotics, but not hospitalization.

There was one death in the azathioprine arm from malignancy, and three in the rituximab group, one from infection and two as of yet unclassified.

The groups were well balanced. Subjects were a median of 59 years old, with a median disease duration of 5.3 years. Refractory patients – those who had not achieved remission during a previous relapse – were excluded, as were patients who had received a B cell–depleting treatment in the previous 6 months and those with eosinophilic granulomatosis with polyangiitis or a malignancy in the past 5 years. Among patients in the study, 72% had tested positive for anti–proteinase 3 ANCA, and 28% for myeloperoxidase ANCA.

The work was funded by Versus Arthritis (formerly Arthritis Research UK), the National Institutes of Health, and the makers of rituximab, Roche/Genentech. Dr. Smith reported ties to Roche, Sanofi, and MedImmune.

aotto@mdedge.com

SOURCE: Smith R et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 806.

ATLANTA – Rituximab (Rituxan) is superior to azathioprine (Imuran) for preventing ANCA-associated vasculitis relapses in patients with histories of previous relapses, according to a randomized trial of 170 patients presented at the annual meeting of the American College of Rheumatology.

Rituximab has been previously shown to be the superior remission maintenance option in the French MAINRITSAN trial (N Engl J Med. 2014 Nov 6;371[19]:1771-80), but mostly in newly diagnosed patients after cyclophosphamide induction. The results expand the finding to those with relapsing disease who previously had remission induced with rituximab, said lead investigator Rona Smith, MD, a clinical lecturer at Cambridge (England) University.

Subjects in the RITAZAREM trial (rituximab versus azathioprine as therapy for maintenance of remission for antineutrophil cytoplasmic antibody [ANCA]–associated vasculitis) were enrolled during a relapse of either granulomatosis with polyangiitis or microscopic polyangiitis and underwent remission induction with rituximab 375 mg/m² per week for 4 weeks coupled with prednisone, either 1 or 0.5 mg/kg per day at provider discretion.

After successful induction – defined as a Birmingham Vasculitis Activity Score for Wegener’s Granulomatosis of 1 point or less on no more than 10 mg/day prednisone – 85 patients were randomized to rituximab 1 g every 4 months for 20 months and 85 to azathioprine 2 mg/kg per day for 20 months, followed by a taper. Prednisone was tapered per protocol to discontinuation at 20 months.

Eleven rituximab patients (13%) relapsed during the 20-month maintenance phase; two relapses were major. There were 32 relapses (38%) in the azathioprine group, 12 of them (38%) major (hazard ratio for rituximab versus azathioprine, 0.3; 95% CI, 0.15-0.60; P less than .001). ANCA type, glucocorticoid induction regimen, and severity of the enrollment relapse did not affect the outcomes.

Also, “there was an increase in the proportion of patients who became ANCA negative” in the rituximab arm, while “there was really no change” with azathioprine. In short, “rituximab is superior to azathioprine for prevention of disease relapse,” Dr. Smith said.

Her audience had a few questions about the rituximab regimen. The French MAINRITSAN trial dosed rituximab every 6 months instead of every 4, for a cumulative dose of 2.5 g, not 5 g, which an audience member said is the standard approach.

Dr. Smith explained that she and her colleagues have seen relapses with rituximab maintenance at 5 and 6 months, so they wanted to move to a shorter schedule. As for the higher dose, they wanted to “achieve complete B-cell depletion for the duration of the treatment period” to see if it translates into longer lasting remissions. “We will hopefully be able to address that question” with further analysis, she said.

There were no new safety signals; 19 rituximab patients (22%) and 31 azathioprine subjects (36%) had at least one serious adverse event; an infection requiring hospitalization occurred in 7 rituximab patients (8%) and 11 azathioprine patients (13%). Twenty-five (29%) rituximab and 21 (25%) azathioprine subjects developed hypogammaglobulinemia (IgG less than 5 g/L), and about half of each group developed an infection that required antibiotics, but not hospitalization.

There was one death in the azathioprine arm from malignancy, and three in the rituximab group, one from infection and two as of yet unclassified.

The groups were well balanced. Subjects were a median of 59 years old, with a median disease duration of 5.3 years. Refractory patients – those who had not achieved remission during a previous relapse – were excluded, as were patients who had received a B cell–depleting treatment in the previous 6 months and those with eosinophilic granulomatosis with polyangiitis or a malignancy in the past 5 years. Among patients in the study, 72% had tested positive for anti–proteinase 3 ANCA, and 28% for myeloperoxidase ANCA.

The work was funded by Versus Arthritis (formerly Arthritis Research UK), the National Institutes of Health, and the makers of rituximab, Roche/Genentech. Dr. Smith reported ties to Roche, Sanofi, and MedImmune.

aotto@mdedge.com

SOURCE: Smith R et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 806.

ATLANTA – Elderly-onset and young-onset rheumatoid arthritis patients initiating treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) respond similarly with respect to clinical improvement at 48 weeks and adverse events, data from a large registry in Japan suggest.

Sharon Worcester/MDedge News

The findings have important implications – particularly for elderly-onset rheumatoid arthritis (RA) patients, who tend to present with higher disease activity levels and increased disability, but who nevertheless receive biologics less frequently, compared with young-onset RA patients, according to Sadao Jinno, MD, of the department of rheumatology and clinical immunology, Kobe University Graduate School of Medicine, Osaka, Japan, and colleagues.

The findings were presented in a poster at the annual meeting of the American College of Rheumatology.

Of 7,183 participants in the multicenter observational registry, 989 who initiated bDMARDs and who had a DAS28-erythrocyte sedimentation rate score of at least 3.2 at the time of initiation were included in the current analysis. The proportion of elderly-onset RA patients in the registry was 36.8%, and the proportion of elderly-onset RA patients using bDMARDs was significantly lower than that among young-onset RA patients (18.3% vs. 28.0%; P less than .001), Dr. Jinno and colleagues reported.

However, after adjustment for differences in baseline characteristics between the two age groups, no significant difference was seen in Clinical Disease Activity Index (CDAI) score at 48 weeks (odds ratio, 1.01), Dr. Jinno said during a press conference highlighting the findings.

A trend toward lower remission rates was observed in the early-onset patients (OR, 0.52; P = 1.10). The low-disease activity/remission rate was similar in the groups after adjustment for multiple confounders (OR, 0.86; P = 0.77), he said, adding that drug maintenance rates and adverse event–related discontinuation rates also were similar in the groups (hazard ratio, 0.95; P = 0.78 for drug maintenance; HR, 0.78; P = 0.22 for discontinuation).

Patients were enrolled in the multicenter observational registry between September 2009 and December 2017, and those with onset at age 60 years or older were considered to have elderly-onset RA.

“In my daily practice, I see a lot of patients with elderly-onset RA who are treated with biologics very effectively and safely,” he said. “So we wanted to see if there really is any difference [in outcomes] between the elderly-onset patients and the young-onset patients.”

The findings suggest they can be treated as effectively and safely as younger patients, he said.

In a press release, he further stated that clinicians should “choose wisely which patients with elderly-onset RA are safely treated with biologics given that they are still at risk of developing adverse events, especially infections.”

Conversely, it is important to keep in mind that dysfunction in elderly-onset RA patients may worsen without timely biologic treatment, he noted.

Future investigation will focus on whether elderly-onset RA patients respond differently to “various modes of biologics,” he said.

Dr. Jinno and colleagues reported having no relevant disclosures.

sworcester@mdedge.com

SOURCE: Jinno S et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 1345.

ATLANTA – Elderly-onset and young-onset rheumatoid arthritis patients initiating treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) respond similarly with respect to clinical improvement at 48 weeks and adverse events, data from a large registry in Japan suggest.

Sharon Worcester/MDedge News

The findings have important implications – particularly for elderly-onset rheumatoid arthritis (RA) patients, who tend to present with higher disease activity levels and increased disability, but who nevertheless receive biologics less frequently, compared with young-onset RA patients, according to Sadao Jinno, MD, of the department of rheumatology and clinical immunology, Kobe University Graduate School of Medicine, Osaka, Japan, and colleagues.

The findings were presented in a poster at the annual meeting of the American College of Rheumatology.

Of 7,183 participants in the multicenter observational registry, 989 who initiated bDMARDs and who had a DAS28-erythrocyte sedimentation rate score of at least 3.2 at the time of initiation were included in the current analysis. The proportion of elderly-onset RA patients in the registry was 36.8%, and the proportion of elderly-onset RA patients using bDMARDs was significantly lower than that among young-onset RA patients (18.3% vs. 28.0%; P less than .001), Dr. Jinno and colleagues reported.

However, after adjustment for differences in baseline characteristics between the two age groups, no significant difference was seen in Clinical Disease Activity Index (CDAI) score at 48 weeks (odds ratio, 1.01), Dr. Jinno said during a press conference highlighting the findings.

A trend toward lower remission rates was observed in the early-onset patients (OR, 0.52; P = 1.10). The low-disease activity/remission rate was similar in the groups after adjustment for multiple confounders (OR, 0.86; P = 0.77), he said, adding that drug maintenance rates and adverse event–related discontinuation rates also were similar in the groups (hazard ratio, 0.95; P = 0.78 for drug maintenance; HR, 0.78; P = 0.22 for discontinuation).

Patients were enrolled in the multicenter observational registry between September 2009 and December 2017, and those with onset at age 60 years or older were considered to have elderly-onset RA.

“In my daily practice, I see a lot of patients with elderly-onset RA who are treated with biologics very effectively and safely,” he said. “So we wanted to see if there really is any difference [in outcomes] between the elderly-onset patients and the young-onset patients.”

The findings suggest they can be treated as effectively and safely as younger patients, he said.

In a press release, he further stated that clinicians should “choose wisely which patients with elderly-onset RA are safely treated with biologics given that they are still at risk of developing adverse events, especially infections.”

Conversely, it is important to keep in mind that dysfunction in elderly-onset RA patients may worsen without timely biologic treatment, he noted.

Future investigation will focus on whether elderly-onset RA patients respond differently to “various modes of biologics,” he said.

Dr. Jinno and colleagues reported having no relevant disclosures.

sworcester@mdedge.com

SOURCE: Jinno S et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 1345.

ATLANTA – Elderly-onset and young-onset rheumatoid arthritis patients initiating treatment with biologic disease-modifying antirheumatic drugs (bDMARDs) respond similarly with respect to clinical improvement at 48 weeks and adverse events, data from a large registry in Japan suggest.

Sharon Worcester/MDedge News

The findings have important implications – particularly for elderly-onset rheumatoid arthritis (RA) patients, who tend to present with higher disease activity levels and increased disability, but who nevertheless receive biologics less frequently, compared with young-onset RA patients, according to Sadao Jinno, MD, of the department of rheumatology and clinical immunology, Kobe University Graduate School of Medicine, Osaka, Japan, and colleagues.

The findings were presented in a poster at the annual meeting of the American College of Rheumatology.

Of 7,183 participants in the multicenter observational registry, 989 who initiated bDMARDs and who had a DAS28-erythrocyte sedimentation rate score of at least 3.2 at the time of initiation were included in the current analysis. The proportion of elderly-onset RA patients in the registry was 36.8%, and the proportion of elderly-onset RA patients using bDMARDs was significantly lower than that among young-onset RA patients (18.3% vs. 28.0%; P less than .001), Dr. Jinno and colleagues reported.

However, after adjustment for differences in baseline characteristics between the two age groups, no significant difference was seen in Clinical Disease Activity Index (CDAI) score at 48 weeks (odds ratio, 1.01), Dr. Jinno said during a press conference highlighting the findings.

A trend toward lower remission rates was observed in the early-onset patients (OR, 0.52; P = 1.10). The low-disease activity/remission rate was similar in the groups after adjustment for multiple confounders (OR, 0.86; P = 0.77), he said, adding that drug maintenance rates and adverse event–related discontinuation rates also were similar in the groups (hazard ratio, 0.95; P = 0.78 for drug maintenance; HR, 0.78; P = 0.22 for discontinuation).

Patients were enrolled in the multicenter observational registry between September 2009 and December 2017, and those with onset at age 60 years or older were considered to have elderly-onset RA.

“In my daily practice, I see a lot of patients with elderly-onset RA who are treated with biologics very effectively and safely,” he said. “So we wanted to see if there really is any difference [in outcomes] between the elderly-onset patients and the young-onset patients.”

The findings suggest they can be treated as effectively and safely as younger patients, he said.

In a press release, he further stated that clinicians should “choose wisely which patients with elderly-onset RA are safely treated with biologics given that they are still at risk of developing adverse events, especially infections.”

Conversely, it is important to keep in mind that dysfunction in elderly-onset RA patients may worsen without timely biologic treatment, he noted.

Future investigation will focus on whether elderly-onset RA patients respond differently to “various modes of biologics,” he said.

Dr. Jinno and colleagues reported having no relevant disclosures.

sworcester@mdedge.com

SOURCE: Jinno S et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract 1345.

ATLANTA – Patients with nonradiographic axial spondyloarthritis who received secukinumab with or without loading doses showed improvements in physical function, quality of life, inflammation, and other disease signs and symptoms, according to results from a phase 3 study presented at the annual meeting of the American College of Rheumatology.

Jeff Craven/MDedge News

For patients with nonradiographic axial spondyloarthritis in the double-blind, randomized, placebo-controlled PREVENT trial, these benefits persisted up to 52 weeks, Atul A. Deodhar, MD, professor of medicine in the division of arthritis and rheumatic diseases at Oregon Health & Science University, Portland, said in his presentation.

“This is the largest study done for a biologic agent in nonradiographic axial spondyloarthritis,” Dr. Deodhar said. The trial enrolled 185 patients who received subcutaneous secukinumab (Cosentyx) at a dose of 150 mg, 184 patients who received the medication without a loading dose, and 186 patients who received placebo.

Patients were included if they were aged at least 18 years with 6 months or more of inflammatory back pain, had objective signs of inflammation (sacroiliitis on MRI and/or C-reactive protein [CRP] at 5.0 mg/dL or higher), had active disease and spinal pain according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), had total back pain with a visual analog scale of 40 mm or greater, and had not received a tumor necrosis factor inhibitor (TNFi) or had an inadequate response to no more than one TNFi. Patients were also stratified by inflammation measured on MRI and CRP. A little more than half of the patients in each group were women, and at baseline their mean age was 39 years, with a mean symptom duration of more than 8 years and mean Ankylosing Spondylitis Disease Activity Score of 3.5-3.7.

The primary endpoint was at least 40% improvement in Assessment of Spondyloarthritis International Society response criteria (ASAS40) at 16 weeks to meet European Union regulatory requirements and at 52 weeks for the Food and Drug Administration. Escape to open-label secukinumab or standard of care was permitted any time after week 20 for patients deemed to have inadequate response based on clinical judgment of disease activity by the investigator and patient; at 52 weeks, the trial became open label and patients in the placebo group could begin secukinumab or standard of care. The U.S. and European Union analyses were performed independently, with the European analysis including only secukinumab with loading doses and the U.S. analysis including secukinumab without loading.

At 16 weeks, an analysis of the overall population showed that 40.8% of patients in the secukinumab nonloading group had an ASAS40 response, compared with 40.0% in those who got a loading dose and 28.0% with placebo (P less than .05 for both). Among the 90% of patients who were TNFi naive, ASAS40 responses occurred in 42.2% of patients in the nonloading group, 41.5% who received a loading dose, and 29.2% with placebo (P less than .05 for both). ASAS40 response rates persisted at 52 weeks for patients in the nonloading (39.8%), loading (35.4%), and placebo (19.9%) groups (P less than .05).

Over the same time period, the least-square mean changes in total BASDAI score improved from baseline by 2.43 in the nonloading group, 2.35 in the loading group, and 1.46 in the placebo group (P less than .05). The percentage of patients who had 50% or greater improvement in BASDAI was 37% in both treatment groups, compared with 21% with placebo (P less than .05).

Function score as measured by the Bath Ankylosing Spondylitis Functional Index also showed significantly greater improvements at 16 weeks for both loading and nonloading patients versus placebo (–1.75 and ­–1.64 vs. –1.01; P less than .05). Treatment with or without a loading dose led to significant reductions in sacroiliac joint edema on MRI and high-sensitivity CRP. The percentage patients who met ASAS partial remission criteria were significantly higher in the loading (21.6%) and nonloading (21.2%) groups, compared with placebo (7.0%; P less than .05).

Physical function and quality of life assessments at 16 weeks using the 36-item Short Form Health Survey physical component score and the Ankylosing Spondylitis Quality of Life questionnaire showed significant improvements both with and without a loading dose.

There were no new safety concerns with secukinumab that arose in the trial, Dr. Deodhar said.

Dr. Deodhar admitted the placebo effect was high in the PREVENT study, but noted that this was a reoccurring problem in other areas of rheumatology. “The rates are going up in several studies, including in RA, so [in terms of] axial spondyloarthritis and why that happens, we really don’t know.”

When asked about the effect of the loading dose, Dr. Deodhar said that “the load is not really going to take over or have different response by 52 weeks; the load would have a response by 8 weeks or maybe 12 weeks, but then beyond that, I don’t think the load would have any response at all.

“In my clinical experience, speaking outside this trial, load obviously helps the patient quickly to feel better, and so that’s the way I practice my medicine,” he added.

The PREVENT study was sponsored by Novartis, which markets secukinumab. Some of the authors reported relationships with Novartis and many other pharmaceutical companies. Four authors were employees of Novartis.

SOURCE: Deodhar AA et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract L21.

ATLANTA – Patients with nonradiographic axial spondyloarthritis who received secukinumab with or without loading doses showed improvements in physical function, quality of life, inflammation, and other disease signs and symptoms, according to results from a phase 3 study presented at the annual meeting of the American College of Rheumatology.

Jeff Craven/MDedge News

For patients with nonradiographic axial spondyloarthritis in the double-blind, randomized, placebo-controlled PREVENT trial, these benefits persisted up to 52 weeks, Atul A. Deodhar, MD, professor of medicine in the division of arthritis and rheumatic diseases at Oregon Health & Science University, Portland, said in his presentation.

“This is the largest study done for a biologic agent in nonradiographic axial spondyloarthritis,” Dr. Deodhar said. The trial enrolled 185 patients who received subcutaneous secukinumab (Cosentyx) at a dose of 150 mg, 184 patients who received the medication without a loading dose, and 186 patients who received placebo.

Patients were included if they were aged at least 18 years with 6 months or more of inflammatory back pain, had objective signs of inflammation (sacroiliitis on MRI and/or C-reactive protein [CRP] at 5.0 mg/dL or higher), had active disease and spinal pain according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), had total back pain with a visual analog scale of 40 mm or greater, and had not received a tumor necrosis factor inhibitor (TNFi) or had an inadequate response to no more than one TNFi. Patients were also stratified by inflammation measured on MRI and CRP. A little more than half of the patients in each group were women, and at baseline their mean age was 39 years, with a mean symptom duration of more than 8 years and mean Ankylosing Spondylitis Disease Activity Score of 3.5-3.7.

The primary endpoint was at least 40% improvement in Assessment of Spondyloarthritis International Society response criteria (ASAS40) at 16 weeks to meet European Union regulatory requirements and at 52 weeks for the Food and Drug Administration. Escape to open-label secukinumab or standard of care was permitted any time after week 20 for patients deemed to have inadequate response based on clinical judgment of disease activity by the investigator and patient; at 52 weeks, the trial became open label and patients in the placebo group could begin secukinumab or standard of care. The U.S. and European Union analyses were performed independently, with the European analysis including only secukinumab with loading doses and the U.S. analysis including secukinumab without loading.

At 16 weeks, an analysis of the overall population showed that 40.8% of patients in the secukinumab nonloading group had an ASAS40 response, compared with 40.0% in those who got a loading dose and 28.0% with placebo (P less than .05 for both). Among the 90% of patients who were TNFi naive, ASAS40 responses occurred in 42.2% of patients in the nonloading group, 41.5% who received a loading dose, and 29.2% with placebo (P less than .05 for both). ASAS40 response rates persisted at 52 weeks for patients in the nonloading (39.8%), loading (35.4%), and placebo (19.9%) groups (P less than .05).

Over the same time period, the least-square mean changes in total BASDAI score improved from baseline by 2.43 in the nonloading group, 2.35 in the loading group, and 1.46 in the placebo group (P less than .05). The percentage of patients who had 50% or greater improvement in BASDAI was 37% in both treatment groups, compared with 21% with placebo (P less than .05).

Function score as measured by the Bath Ankylosing Spondylitis Functional Index also showed significantly greater improvements at 16 weeks for both loading and nonloading patients versus placebo (–1.75 and ­–1.64 vs. –1.01; P less than .05). Treatment with or without a loading dose led to significant reductions in sacroiliac joint edema on MRI and high-sensitivity CRP. The percentage patients who met ASAS partial remission criteria were significantly higher in the loading (21.6%) and nonloading (21.2%) groups, compared with placebo (7.0%; P less than .05).

Physical function and quality of life assessments at 16 weeks using the 36-item Short Form Health Survey physical component score and the Ankylosing Spondylitis Quality of Life questionnaire showed significant improvements both with and without a loading dose.

There were no new safety concerns with secukinumab that arose in the trial, Dr. Deodhar said.

Dr. Deodhar admitted the placebo effect was high in the PREVENT study, but noted that this was a reoccurring problem in other areas of rheumatology. “The rates are going up in several studies, including in RA, so [in terms of] axial spondyloarthritis and why that happens, we really don’t know.”

When asked about the effect of the loading dose, Dr. Deodhar said that “the load is not really going to take over or have different response by 52 weeks; the load would have a response by 8 weeks or maybe 12 weeks, but then beyond that, I don’t think the load would have any response at all.

“In my clinical experience, speaking outside this trial, load obviously helps the patient quickly to feel better, and so that’s the way I practice my medicine,” he added.

The PREVENT study was sponsored by Novartis, which markets secukinumab. Some of the authors reported relationships with Novartis and many other pharmaceutical companies. Four authors were employees of Novartis.

SOURCE: Deodhar AA et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract L21.

ATLANTA – Patients with nonradiographic axial spondyloarthritis who received secukinumab with or without loading doses showed improvements in physical function, quality of life, inflammation, and other disease signs and symptoms, according to results from a phase 3 study presented at the annual meeting of the American College of Rheumatology.

Jeff Craven/MDedge News

For patients with nonradiographic axial spondyloarthritis in the double-blind, randomized, placebo-controlled PREVENT trial, these benefits persisted up to 52 weeks, Atul A. Deodhar, MD, professor of medicine in the division of arthritis and rheumatic diseases at Oregon Health & Science University, Portland, said in his presentation.

“This is the largest study done for a biologic agent in nonradiographic axial spondyloarthritis,” Dr. Deodhar said. The trial enrolled 185 patients who received subcutaneous secukinumab (Cosentyx) at a dose of 150 mg, 184 patients who received the medication without a loading dose, and 186 patients who received placebo.

Patients were included if they were aged at least 18 years with 6 months or more of inflammatory back pain, had objective signs of inflammation (sacroiliitis on MRI and/or C-reactive protein [CRP] at 5.0 mg/dL or higher), had active disease and spinal pain according to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), had total back pain with a visual analog scale of 40 mm or greater, and had not received a tumor necrosis factor inhibitor (TNFi) or had an inadequate response to no more than one TNFi. Patients were also stratified by inflammation measured on MRI and CRP. A little more than half of the patients in each group were women, and at baseline their mean age was 39 years, with a mean symptom duration of more than 8 years and mean Ankylosing Spondylitis Disease Activity Score of 3.5-3.7.

The primary endpoint was at least 40% improvement in Assessment of Spondyloarthritis International Society response criteria (ASAS40) at 16 weeks to meet European Union regulatory requirements and at 52 weeks for the Food and Drug Administration. Escape to open-label secukinumab or standard of care was permitted any time after week 20 for patients deemed to have inadequate response based on clinical judgment of disease activity by the investigator and patient; at 52 weeks, the trial became open label and patients in the placebo group could begin secukinumab or standard of care. The U.S. and European Union analyses were performed independently, with the European analysis including only secukinumab with loading doses and the U.S. analysis including secukinumab without loading.

At 16 weeks, an analysis of the overall population showed that 40.8% of patients in the secukinumab nonloading group had an ASAS40 response, compared with 40.0% in those who got a loading dose and 28.0% with placebo (P less than .05 for both). Among the 90% of patients who were TNFi naive, ASAS40 responses occurred in 42.2% of patients in the nonloading group, 41.5% who received a loading dose, and 29.2% with placebo (P less than .05 for both). ASAS40 response rates persisted at 52 weeks for patients in the nonloading (39.8%), loading (35.4%), and placebo (19.9%) groups (P less than .05).

Over the same time period, the least-square mean changes in total BASDAI score improved from baseline by 2.43 in the nonloading group, 2.35 in the loading group, and 1.46 in the placebo group (P less than .05). The percentage of patients who had 50% or greater improvement in BASDAI was 37% in both treatment groups, compared with 21% with placebo (P less than .05).

Function score as measured by the Bath Ankylosing Spondylitis Functional Index also showed significantly greater improvements at 16 weeks for both loading and nonloading patients versus placebo (–1.75 and ­–1.64 vs. –1.01; P less than .05). Treatment with or without a loading dose led to significant reductions in sacroiliac joint edema on MRI and high-sensitivity CRP. The percentage patients who met ASAS partial remission criteria were significantly higher in the loading (21.6%) and nonloading (21.2%) groups, compared with placebo (7.0%; P less than .05).

Physical function and quality of life assessments at 16 weeks using the 36-item Short Form Health Survey physical component score and the Ankylosing Spondylitis Quality of Life questionnaire showed significant improvements both with and without a loading dose.

There were no new safety concerns with secukinumab that arose in the trial, Dr. Deodhar said.

Dr. Deodhar admitted the placebo effect was high in the PREVENT study, but noted that this was a reoccurring problem in other areas of rheumatology. “The rates are going up in several studies, including in RA, so [in terms of] axial spondyloarthritis and why that happens, we really don’t know.”

When asked about the effect of the loading dose, Dr. Deodhar said that “the load is not really going to take over or have different response by 52 weeks; the load would have a response by 8 weeks or maybe 12 weeks, but then beyond that, I don’t think the load would have any response at all.

“In my clinical experience, speaking outside this trial, load obviously helps the patient quickly to feel better, and so that’s the way I practice my medicine,” he added.

The PREVENT study was sponsored by Novartis, which markets secukinumab. Some of the authors reported relationships with Novartis and many other pharmaceutical companies. Four authors were employees of Novartis.

SOURCE: Deodhar AA et al. Arthritis Rheumatol. 2019;71(suppl 10), Abstract L21.