Final Acr

Updates in Improving
Care of Patients With

Rheumatoid Arthritis
Insights from the 2016
ACR/ARHP Annual Meeting
BEGIN
Updates in Improving Care of Patients With Rheumatoid Arthritis
Program Title Target Audience

Updates in Improving Care of Patients This activity has been designed to meet the educational needs of
health care professionals involved in the diagnosis, treatment, or
With Rheumatoid Arthritis
management of patients with RA.
Insights from the 2016 ACR/ARHP Annual Meeting
Course Description Educational Objectives

Rheumatoid arthritis (RA) remains a clinically challenging autoimmune Upon completion of this activity, participants will be better able to:
disorder for rheumatologists to manage. Effective patient care is critical: an •• Describe methodologies and factors that can be used to predict
estimated sixty percent of people with inadequately treated RA are unable disease progression, comorbid disease, response to treatment, and
to work 10 years following onset of the disease. The American College of clinical outcomes in patients with RA
Rheumatology (ACR) has endorsed the use of several quality improvement
measures in RA management, including recommended screening, disease •• Discuss considerations in the expanding clinical use of biosimilars
activity assessment, and treatment guidelines. However, clinical care of as biologic DMARDs in RA treatment
patients with respect to guideline recommendations continues to
•• Explain how and when to stratify patients with low RA disease
be suboptimal.
activity as potential candidates for tapering therapy
A major reason for gaps in care of patients with RA is the ever-increasing
•• Define multimorbidity and how it differs from comorbidity in
amount of data being reported. The management paradigm for RA is
approaches to patient care
evolving; increases in knowledge of RA pathophysiology, enhanced
assessment tools, and the emergence of biologic and nonbiologic therapies
targeted to key pathways in RA result in an overwhelming amount of new
information. Rheumatologists must assess key information and decide Faculty
which to apply in clinical practice.
Robert H. Shmerling, MD
This activity is intended to provide rheumatologists with critical updates Clinical Chief, Division of Rheumatology
in care of patients with RA reported at the 2016 ACR Annual Meeting. Beth Israel Deaconess Medical Center
Areas of focus include tracking and measuring disease progression, as Boston, MA
well as predicting positive outcomes of RA, and updates on integration of
biosimilars into clinical practice. Early use of traditional or biologic disease-
modifying antirheumatic drugs (DMARDs) has now made disease remission
a realistic goal for many patients. The possibility of tapering RA therapy in
patients with low disease activity will be discussed. Finally, the activity will
address multimorbidity, taking the concept of comorbidity in patients with
RA and refining it to focus care upon the patient, rather than the disease.
To claim credit for this activity, please complete the posttest at http://courses.elseviercme.com/acr16/654
2
Disclosure of Conflicts of Interest Provider Information

It is the policy of the Elsevier Office of Continuing Medical Education Jointly provided by the Elsevier Office of Continuing Medical
that all faculty, instructors, and planners disclose any real or apparent Education, Integrated Learning Partners, LLC., and Consultants in
conflicts of interest relating to the topics of this educational activity. Medical Education.
The faculty reported the following financial relationships or
relationships to products or devices they or their spouse/life partner
have with commercial interests related to the content of this CME
activity:
Faculty Relationship Identified With CME Credit (Physicians)

Dr. Shmerling has no financial interest This activity has been planned and implemented in accordance with the
Robert H. Shmerling, MD accreditation requirements and policies of the Accreditation Council for
to disclose.
Continuing Medical Education (ACCME) through the joint providership
of the Elsevier Office of Continuing Medical Education, Integrated
Non-faculty Learning Partners, LLC, and Consultants in Medical Education. The
Sherlyn B. Celone-Arnold; Chris Blagden, PhD; Sandy Breslow; Alison Elsevier Office of Continuing Medical Education is accredited by the
Kemp; and Bernard M. Abrams, MD hereby state that neither they ACCME to provide continuing medical education for physicians.
nor their spouse/life partner have had any financial relationships
The Elsevier Office of Continuing Medical Education designates
to products or devices with any commercial interest related to the
this enduring activity for a maximum of 1.75 AMA PRA Category 1
content of this activity in any amount during the past 12 months.
Credit(s)™. Physicians should claim only the credit commensurate with
Financial Support the extent of their participation in the activity.
This activity has been supported by an independent educational grant CME Inquiries/Special Needs
from Amgen.
For all CME inquiries or special needs, please contact
elsevierCME@elsevier.com.
Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or
investigational uses of agents that are not indicated by the FDA. The
Elsevier Office of Continuing Medical Education, Integrated Learning
Partners, Consultants in Medical Education, and Amgen do not
recommend the use of any agent outside of the labeled indications.
3
Disclaimer Method of Participation

Participants have an implied responsibility to use the newly acquired In order to claim credit, participants must:
information to enhance patient outcomes and their own professional
development. The information presented in this activity is not meant 1. Read the educational objectives, accreditation information, and
to serve as a guideline for patient management. Any procedures, faculty disclosures at the beginning of this activity.
medications, or other courses of diagnosis or treatment discussed 2. Complete the pre-activity questions.
or suggested in this activity should not be used by clinicians without
evaluation of their patient’s conditions and possible contraindications 3. Read or review the activity content.
on dangers in use, review of any applicable manufacturer’s product
4. Complete the post-activity test questions and evaluation.
information, and comparison with recommendations from other
authorities. 5. Physicians who receive a grade of 70% or better on the post-
activity test questions and who complete the evaluation will
receive a CME certificate.
6. All other participants who receive a grade of 70% or better on the

post-activity test questions and who complete the evaluation will
receive a certificate of participation.
Release date: May 15, 2017
Expiration date: May 15, 2018
4
Table of Contents Navigation Key

This interactive eMonograph contains items that are active. These
1. Introduction................................................................................... 6 icons were designed to help you recognize these features as you
navigate through the document.
2. Quantifying Disease Progression and Response to Treatment..... 7
Clickable Item Icon: Click on this icon to view
Biomarkers................................................................................ 7 additional content.
Imaging...................................................................................... 8
Faculty Commentary Icon: Click on this icon to view

3. Predicting Positive Clinical Outcomes in RA................................ 10 additional information from faculty.
4. Biosimilars: Regulatory and Practice Considerations.................. 14
Molecular Engineering of Biosimilars...................................... 14
5. Managing Patients With Low RA Disease Activity:

Can We Taper Therapy?............................................................... 19
6. Treatment of RA When the Patient Is Unwell............................... 23
References ....................................................................................... 27
5
1 •• As more biosimilars enter our disease management toolbox, we

need to understand how these agents are designed to be similar,
Introduction and potentially interchangeable, with the existing, original biologic
therapies, to be able to effectively integrate them into clinical use.
This is a time of exciting changes in the field of rheumatoid arthritis We will discuss the process by which biosimilars are developed
(RA). Unprecedented advances in genomics, molecular biology, and and some of the key issues we should understand as we consider
protein engineering are leading to earlier detection of disease and an their use. One of the most common questions I am asked by
increasing armamentarium of effective treatment options, all of which patients with RA when they attain low disease activity is whether
combine to improve the care of our patients with RA. As the quality they need to stay on their RA medications. We will discuss some
movement has taken hold here in the US and the government has of the arguments for and against tapering or withdrawing disease-
revised policies and payment models with the goal of improving the modifying antirheumatic drug (DMARD) therapy, balancing the risk
quality of healthcare, we, as clinicians, are now almost continuously of relapse with the potential benefits of not taking medications.
advancing the standards by which we deliver care to our patients.
Advancing knowledge to support these efforts is critical. Educational •• Clinical trials are restrictive in the types of patient they enroll, and
activities such as this one are designed to assist us by providing both as such some of the information is difficult to apply to our patients,
scientific updates as well as practical advice for how and when they who often have multiple other diseases managed in tandem in the
can be applied to our patients in the clinic. rheumatology clinic and other practices. We will describe here ideas
on how we shift our focus away from RA as the index disease and
In this activity, some of the salient advances in RA assessment and toward our patient as the focal point of quality care. The concept of
management of the past 2 years will be highlighted, including data multimorbidity is central to this topic, something that doesn’t always
presented at last year’s Annual College of Rheumatology (ACR) align with clinical trial data.
meeting in Washington, DC. For those of you who could not attend, I
believe this information will be educational, and if you did attend as I
did, a useful reinforcement of some of the key issues discussed there.
•• A key question for us continues to be in the area of early detection

of RA. Early intervention leads to better patient outcomes in RA, and
we will discuss some of the latest information on molecular and
cellular biomarkers, imaging approaches that can help us identify
and track RA disease and its progression, and some initial insights
into predicting which patients may respond better to specific
therapeutic approaches.
6
2 calprotectin retained a significant association with ultrasound markers

of synovitis.5
Quantifying Disease Progression and Other markers of RA disease activity that have been investigated
include metabolites produced as part of bone or cartilage turnover;
Response to Treatment these have the potential to indicate disease activity even in
presymptomatic individuals. Some biomarkers of interest are MMP3
Biomarkers
(a member of the matrix metalloproteinase family), thrombospondin-5
The increasing investigation into biomarkers in RA has been driven (cartilage oligomeric matrix protein, or COMP), and a TNF receptor
primarily by the need to identify patients earlier in the disease course. superfamily member, osteoprotegerin (OPG).7-9 The GREAT study
The 2010 ACR and European League Against Rheumatism (EULAR) looked at 140 patients with DMARD-naïve early RA (symptoms less
criteria attempted to classify RA earlier in the time course and help than 2 years), treated for 6 months with synthetic DMARDs (mostly
clinicians identify patients sooner.1 Follow-up analyses suggest that methotrexate), and looked at markers of bone and cartilage turnover
the 2010 criteria did indeed improve diagnostic performance; however, as potential biomarkers.10 Among the markers studied, only elevated
limitations remain, particularly in their ability to identify patients who baseline MMP-3 and OPG identified a group of patients resistant to
are negative for the autoantibodies anti-citrullinated protein antibody therapy at 6 months, as defined by a Simple Disease Activity Index
(ACPA) and rheumatoid factor (RF).2 Currently, only C-reactive protein (SDAI) score>11, and low baseline levels of OPG predicted better control
(CRP) and erythrocyte sedimentation rate (ESR) are regularly used of disease activity. These types of bone and cartilage biomarkers may
as inflammatory biomarkers clinically. A recent study suggested that prove useful in stratifying patients according to therapy responsiveness,
CRP levels may vary in men or women with RA in different body mass such as patients who may need early intensification of management.
index (BMI) categories. Morbid obesity was associated with increasing
Thinking beyond molecular and toward cellular markers, a recent
CRP in women with RA, as with the control population; however, in
prospective cohort study has identified a potential role for B-cell clonal
men this correlation did not hold true, and in fact in one Veteran’s
development in the onset and progression of RA. Analysis of B-cell clones
Administration population cohort was reversed—a higher CRP level
obtained from 21 patients without RA but defined as at-risk (ACPA+ and
being associated with lower BMI.3 Hence, there is a need for additional
RF+) identified a number of B-cell clones that were expanded beyond
objective biomarkers to support clinically-assessed measures of RA
0.5% of the total population, none of which were isolated from control
diagnostic classification.
groups. Five or more of these dominant clones in peripheral blood from
One of the most promising is calprotectin, a pro-inflammatory an independent prospective cohort of similar patients was associated
leukocyte S100 family protein that has been demonstrated previously with a 5-fold increase in relative risk for developing RA.11 Interestingly, in
to be elevated in RA, and substantially increased in inflamed patients that developed overt RA, these clones were no longer observable
synovium.4 In two separate studies, serum calprotectin outperformed in peripheral blood, but rather were now localized to the inflamed
both CRP and ESR as markers of treatment response as defined by synovium, suggesting a direct role for these cells in disease pathology
swollen joint counts and ultrasound-assessed synovitis.5,6 In the and progression. Another recent pilot implicated T-helper lymphocytes,
ARCTIC study, an intensive treat-to-target trial, all markers were high specifically Th17 types, as potential markers; low levels at baseline were
before treatment onset, but after 12 months of DMARD therapy, only associated with a good response to bDMARDs.12
7
Imaging Roll over the buttons below to see an

In addition to molecular and cellular biomarkers, imaging techniques illustration of each measure.
also continue to be investigated for their utility in quantifying RA
FIGURE 1. Measures Quantifiable Using RAMRIQ.
disease progression and response to treatment. X-ray techniques
to assess joint damage have been in use for many years, but are
limited by needing large numbers of patients to provide a quantitative Methods: RAMRIQ measures
assessment of treatment response even at 12 months from baseline. JOINT SPACE
Imaging techniques such as MRI have become of increasing utility SYNOVITIS OEDEMA EROSION WIDTH
because of the ability to see the joint in 3-D (although typically viewed
as a series of 2-D slices), but limitations in quantitative imaging exist
due to reader interpretation and scoring of images. This can be of
particular concern in analyzing large multi-center trials, where data
has to be pulled together from different machines and can vary based
on the interpretation and scoring of the individual reader. Some recent
automation using newer imaging software and analytic techniques is
helping to overcome this issue, as well as beginning to help us more
fully understand individual patient disease progression. One of these is
RAMRIQ (RA-MRI quantification), an image analysis that builds on the
existing RAMRIS (reader-based scoring system) but removes the need
for subjective scoring (Figure 1).13,14 This analysis software is based
on the same programming used in facial recognition techniques; the
software learns the 3-D shape of all the bones in the hand by reading
a high volume of test data, which allows it to create a fully 3-D image
of the patient’s hand skeleton and surrounding tissue. It is accurate to
around 0.2mm, more sensitive than reader interpretation and scoring of
images, and fully automated, which removes inter-reader variability and
allows high-level statistical analysis.
8
The predictive power of RAMRIQ was investigated using post- 18F-fluorodeoxyglucose (FDG) is a marker of glucose uptake that
hoc data from a study (30 patients per arm) of tofacitinib plus has been used in different diseases to identify sites of abnormal
methotrexate (MTX) versus either tofacitinib or MTX alone, assessed glucose metabolism. This technique has been used in the evaluation
by radiographic and RAMRIS-measured joint damage over a 12-month of cardiomyopathies for almost 20 years. In patients with RA, FDG-
period.13,14 RAMRIQ scoring of synovitis and bone marrow edema/ PET has been used traditionally to identify clinically inflamed joints,
osteitis at months 1 and 3 could effectively predict significant erosion but has the potential to track cardiovascular aspects of RA as well.
progression of the joint at month 12. Although few study patients The RHYTHM study looked at 113 patients with moderate-to-severe
developed radiographic progression at the 12-month mark in the RA, current lower disease activity (Clinical Disease Activity Index
original study, what was measurable radiographically was predictable (CDAI) score<10, mean DAS28=3.78), and no history of cardiovascular
by RAMRIQ. This radiographic progression at 12 months was not disease; 30% of these patients showed myocardial inflammation
predictable using RAMRIS at 1 and 3 months, showing the limitations using FDG-PET.16,17 Higher BMI and higher disease activity positively
of reader-assisted subjective measures with only 30 patients.14 If correlated with myocardial inflammation, and use of tumor necrosis
confirmed in other settings with a larger number of patients, this factor inhibitor (TNFi) therapy was negatively correlated. A small
study could have implications for clinical trials and clinical practice; group of these patients (n=12) enrolled in a 6-month step-up therapy
with the substantial increase in sensitivity and specificity of these trial, and a decrease in mean DAS28 score in these patients (4.57 to
techniques, it is possible that trials could be of shorter duration and 3.51) was paralleled by a decrease in myocardial inflammation.17 This
still be meaningful for regulatory authorities with a smaller number of is an encouraging sign, as it supports the idea that if we treat to target
patients in each study arm. with anti-RA therapy, we may have a positive impact on cardiovascular
disease outcomes.
Another imaging technique that has gained attention is the use
of whole-body positron emission tomography (PET) scanning, in
particular with respect to cardiovascular aspects of RA.15 Click here to read Faculty Commentary
9
3 FIGURE 2. Ability of Peripheral Blood Transcriptional Biomarkers in the ORBIT

Cohort to Predict Subsequent Response/Non-response to Biologic Therapy
Predicting Positive Clinical Outcomes in RA Training Set Test Set
While biomarkers are beginning to provide insight into how we track
General responsiveness 82.0%
and measure disease progression, predicting which patients will 8 genes, baseline DAS28, age (81.1–82.8)
91.1%
respond to a specific class, or mechanism of action, of drug therapy is
still quite unclear. Data from the ORBIT study, in which patients were
Response to TNFi 82.7%
randomized to either rituximab or TNFi therapy and switched to the 88.7%
23 genes, baseline DAS28, age (81.6–83.8)
alternate therapy if they did not respond, showed that roughly 25%
of patients needed to switch in either study arm, and those who did Response to rituximab 95.4%
switch achieved an average DAS28 score reduction of around 1.4 units 91.7%
23 genes, baseline DAS28, gender (94.8–96.0)
on the second treatment.18,19 If we could better identify patients who
would respond to one therapeutic mechanism of action or other, could
we better tailor treatment plans?
The ORBIT study attempted to use gene expression profiles of the

enrolled patients to answer this question. RNA analysis of patient
blood gene expression at baseline versus 3 months identified groups
of genes which could predict general or class-specific responsiveness
with high sensitivity and specificity (Figure 2).19 Rituximab Both TNFi
Responders Responders
33 % 41 %
16 %
Non-responders
10%
10
The ability of these gene expression profiles to predict response to Outside of genetic or biomarker predictors, other recent studies have
therapy was modest at 3 months. By 12 months this expression profile provided some insight into factors that may predict response to therapy
predictor had lost a significant amount of its power, possibly due to and thereby drive our clinical decision-making. A combined post-
the switching that took place in the study over that 12-month period. hoc analysis of two adalimumab/MTX trials, OPTIMA and PREMIER,
However, if we look at stratification of the data at 3 months, the profiles attempted to identify factors predicting poor response and rapid
can identify the 10% of patients who will not respond to either therapy, radiographic progression in patients taking MTX. Health Assessment
and for these patients, one might consider pharmacologic agents Questionnaire (HAQ) score at baseline, along with time-averaged HAQ
with alternate mechanisms of action. The profiles can also identify and DAS28 scores through 12 weeks, were the biggest predictors of
the roughly 40% of patients who would respond to either therapeutic MTX-IR (insufficient responders) and rapid radiographic progression.22
approach used in ORBIT as well as those who would respond best to SIRROUND-D was a phase 3 trial of sirukumab, an anti-IL-6 biologic, in
either rituximab or TNFi therapy. patients refractory to other DMARDs; a post-hoc analysis to identify
predictors of radiographic nonprogression showed that patients with
This technology is still several years away from clinical utility; however, poor prognostic factors at baseline, including high baseline radiographic
it is encouraging as a clinician to note that a significant group of damage and ACPA seropositivity, were the strongest predictors of
patients will respond to either one or both of these classes of therapy. radiographic nonprogression for sirukumab over placebo.23 The ESPOIR
Starting from this positive baseline, we could be more aggressive cohort is a prospective observational multicenter study conducted in
sooner and switch therapies if patients do not attain early response, France in the early 2000s including early RA patients in an attempt
maximizing our chances of response. Support for this hypothesis to better understand disease progression and response to treatment.
comes from an analysis of data from the CORRONA patient registry, Data from recent analyses of these patients’ treatment response with
in which the authors attempted to understand how poor prognosis at conventional synthetic DMARDs suggests that, rather than conventional
baseline may influence treatment decisions. The use of a high number prognostic factors, the most significant parameter affecting response to
of poor prognostic factors as a guide to treatment was previously treatment was a delay in treatment initiation.24 Treating patients within 3
removed from the ACR guidelines.20 Data was collected from patients months of first joint swelling was 2.5-times more likely to result in good
with baseline prognostic factors, who were biologic-naïve, and who had or moderate response at 1 year.
a follow-up visit at 12 months.21 Their data suggested that currently
the presence of 3 or more poor prognostic factors at baseline does not
influence clinical decision-making, as determined by initiation of any
DMARD at 12 months. However, an increased number of poor prognostic
factors was strongly correlated with a lower responsiveness to initial
therapy by CDAI scores. This suggests that patients with more advanced
disease at treatment initiation are less likely to respond to first-line
therapy, supporting an argument for more aggressive treatment in
these patients, including switching earlier to DMARDs with an alternate
mechanism of action.
11
Clinically suspect arthralgia (CSA) is a term recently defined by EULAR to TABLE 1. (A) EULAR-defined characteristics of clinically suspect arthralgia;
describe patients without clinically apparent synovitis but with arthralgia (B) Sensitivity and specificity for clinically suspect arthralgia for the number
symptoms suggestive of RA (Table 1).25 Patients with CSA are among of positive characteristics
those considered at high risk of progressing to overt RA. Two recent
(A) EULAR defined characteristics describing arthralgia at risk for RA
reports in this population of patients are of interest. First, there appears
to be only minimal, if any, correlation of ACPA and RF autoantibodies These parameters are to be used in patients with arthralgia without
in this patient population with those who will go on to develop RA, clinical arthritis and without other diagnosis or other explanation for
extending and reinforcing the theme that autoantibodies alone are the arthralgia.
insufficient to predict which patients will develop RA.26 Second, and History taking: Physical examination:
of more interest, in patients with CSA who progressed to RA, only • Joint symptoms of recent onset
(duration <1 year) • Difficulty with making a fist
a HAQ>1.0 correlated positively with progression, suggesting that
• Symptoms located in MCP joints • Positive squeeze test
patients in the early phases of RA already have functional limitations.27
• Duration of morning stiffness of MCP joints
≥60 min
EULAR, European League Against
Click here to read Faculty Commentary • Most severe symptoms present Rheumatism; RA, rheumatoid arthritis.
in the early morning
• Presence of a first-degree relative
with RA
(B) Sensitivities and specificities for the presence of arthralgia at risk

of RA with the clinical expertise on CSA as reference
Number of
Sensitivity (%) Specificity (%)
parameters present
≥1 100.0 14.1
≥2 98.4 53.8
≥3 90.2 74.4
≥4 70.5 93.6
≥5 32.8 100.0
≥6 16.4 100.0
≥7 1.6 100.0
12
Left-ventricular diastolic dysfunction (LVDD), or the lack of ventricular Prednisone use >10 mg per day was also associated with higher rates
filling due to increasing myocardial stiffness and inadequate of infection in patients with RA and interstitial lung disease in one
myocardial relaxation during diastole, underlies many cases of study.31 This data highlights some of the potentially significant risks
heart failure in patients with RA. A 5-year study of patients using associated with corticosteroid use, which must be carefully balanced
echocardiography attempted to identify factors predicting LVDD against their benefits in clinical use.
progression. Major factors correlated with echocardiographic
evidence of LVDD progression included high disease activity and Viewed together, the take-home message from these and other studies
severity at baseline, and use of prednisone.28 This correlates well with is a clear benefit of early treatment initiation on disease prognosis,
a recently developed expanded risk score calculator for cardiovascular particularly prior to overt functional limitations, in patients with
disease (CVD) in patients with RA (ERS-RA), which identified disease RA. Of course, this is not a new concept; multiple previous studies
activity, disability (HAQ score), prednisone use, and disease duration have shown a similar benefit from early treatment initiation.32,33 As
>10 years as modifiable factors which may lower CVD risk in patients biomarkers and other methods to earlier identify those patients at
with RA when reduced.29,30 It is worth noting, however, that these risk for developing RA emerge and move in to clinical use, the time to
factors are not entirely independent of one another: high disease treatment initiation may be reduced and patients can receive effective
activity may lead to corticosteroid therapy and corticosteroid therapy treatments with appropriate intensity to achieve optimal outcomes.
may reduce disease activity. This points out the challenge of relying
on these variables to assess cardiovascular disease risk and the
importance of controlling disease activity with therapies other than
corticosteroids.
13
4
FIGURE 3: Antibody Structure and Naming Conventions for Different
Biosimilars: Regulatory and Practice Biologic Therapies
Considerations A B
VARIABLE REGION HIGH
Molecular Engineering of Biosimilars
Over the past 30 years, improved understanding of the molecular
detail of immunoglobulins and the function of the immune system Murine
have been the primary drivers for the antibody engineering that has CDRs
underpinned biologic therapy in RA. Notably, the modular domains Light
of both the light and heavy chains in monoclonal antibodies, each chain
of which are encoded by separate exons at the DNA level, has
facilitated rapid advancements in antibody engineering. Initial Chimeric
work with mouse-generated antibodies to specific therapeutic InfliXIMAB
Heavy
targets has given way to therapies that are either chimeric, in chain RituXIMAB
which entire domains are replaced with human ones; humanized,
in which only the hypervariable complementarity-determining CONSTANT REGION IMMUNOGENICITY
regions (CDRs) are remaining from the original mouse antibody;
and fully-human antibodies, generated by more modern molecular
engineering techniques.34 Each of these antibody types has its
Humanised
own conventional nomenclature in biologic therapy (Figure 3).
TociliZUMAB
AlemtuZUMAB
`Fully Human´
AdaliMUMAB LOW
GoliMUMAB
(continued on next page)
14
Much of this molecular engineering has focused on the variable region These living cells modify the protein product by various mechanisms,
(Fv) of the antibody, which confers specific binding to a target such as including glycosylation, methylation, deamidation, and oxidation,
TNF. Keeping this region specific to the target while maintaining a low which are only partly determined by the amino acid sequence of
immunogenicity is critical for an effective biologic. Antibody molecules the antibody. One well studied example is Asparagine-297 of the
also have a second function, however, and that is the linkage of these immunoglobulin heavy chain; glycosylation at this residue has a fairly
targets to an effector function, such as complement activation or cell- consistently structured backbone of glucosamine and mannose,
mediated cytotoxicity. This is accomplished via the constant region but can also have fucose, galactose, and sialic acid moieties
(Fc), which is also known to play a role in prolonging antibody half- attached in different cell types and lineages (Figure 4). When all
life; the neonatal Fc receptor is a ubiquitously expressed cell surface potential glycosylation sites in any particular antibody are taken into
protein that rescues antibodies from lysosomal degradation when they account, a large number of possible structural conformations and
are endocytosed from the blood.35 Selectively mutating specific amino heterogeneity in the pool of antibody species can be obtained from
acids within these regions can improve binding or reduce unwanted any given cell type.36 These post-translational modifications matter
effector function activation; for example, RA biologic therapies have no clinically, as they can impact effector function, structural stability, and
need for activating natural killer cells via the complement pathway, and pharmacokinetics. There are also many steps along the pathway to
so molecules such as abatacept have these binding regions mutated development and generation of a final clinical product in which post-
to reduce the likelihood of unwanted cell death.34 translational modifications may impact the outcome and molecular
properties, and they are not always predictable; as such, regulatory
One of the major complexities with biologics, as well as biosimilars, agencies mandate control of the post-translational modification profile
is that these are large, complicated molecules produced by living in biologic agents.
cells rather than an in vitro chemical synthesis, as is the case with
manufactured pharmacologics.
FIGURE 4: Variation in Glycosylation Patterns of Asparagine-297 of the Immunoglobulin Heavy Chain
-Gln-Tyr-Asn297-Ser-Thr-Tyr-Arg-
α(1-6) α(1-3)
Legend
GOF G1F G1F G2F N-acetylglucosamine (GlcNAc) Galactose
Fucose Sialic acid (SA)
Mannose
GO G1 G1 G2
15
The development and integration of biosimilars into clinical practice The biosimilar and the bio-originator data should be superimposable,
presents new challenges for the rheumatologist. The processes at the levels of:
of antibody engineering to create biologics and biosimilars is very
different from that associated with small-molecule pharmacologics. •• Primary amino acid sequence
With the knowledge of these processes, the challenges of producing •• Higher order folding structures, including secondary, tertiary,
biosimilars, as well as obtaining regulatory approval, become clear. quaternary structure, and aggregation
The consensus definition of a biosimilar is a biotherapeutic product
which is similar in terms of quality, safety, and efficacy to an already •• Enzymatic post-translational modifications
licensed reference biotherapeutic product, or bio-originator.37 The
•• Other potential variants, including protein deamidation and oxidation
phrase “similar to” defines the absence of a clinically relevant difference
in the parameter of interest; the US Food and Drug Administration FIGURE 5. Approval Processes for Bio-originators versus Biosimilars
(FDA) refers to safety, purity, and potency as the parameters of interest.
Small-molecule pharmacologics are chemically synthesized, easily Conventional Approval Pathway
replicated, and their identity is able to be readily confirmed; as a result,
regulatory approval of generic versions requires demonstrating only
an identical structure in vitro, by mass spectrometry for example, Clinical studies
and identical pharmacokinetics using healthy volunteers. A typical
monoclonal antibody is over 1000-times larger and more complex than
a small molecule such as aspirin, and as such, determining similarity
Clin Pharm
becomes significantly more challenging. Starting with the same amino
acid sequence, post-translational modifications and a heterogeneous
Pre-clinical
antibody product can result in a markedly different biologic from
Analytical
the bio-originator. These can be affected by the cell line, any genetic
modifications the cell line may have, the culture medium in which
the cells are grown, or specific growth conditions; and much of this
information for the bio-originator is either proprietary or commercially
Biosimilar Approval Pathway
sensitive. The challenge with producing a biosimilar is therefore two- Clinical studies
fold; comprehensive analysis of the bio-originator, and subsequent Clin Pharm
replication of that development process. Pre-clinical
When demonstrating similarity between products to the FDA, the first
item is an extensive physicochemical and biological characterization
of the product, described as a “fingerprint-like” analysis (Figure 5).38
Analytical
16
Following this, the binding and function of the two products must be Beyond the antibody engineering process itself, which can produce
compared non-clinically and in a side-by-side approach. It is important glycosylation events recognizable by our immune systems and
to demonstrate that the biosimilar binds to its antigenic target as thereby have immunogenic potential, patient factors including
well as the bio-originator, and that the Fc domain binds to all relevant underlying genetics, comorbid disease and concomitant medications,
receptors and complement, along with any appropriate activation of dosing schedule, and route of administration all can influence
downstream signaling cascades and functions. In vivo non-clinical immunogenicity. Since biosimilars are licensed with relatively few
animal testing of the biosimilar is usually not required, unless there patient exposures as compared to the bio-originator, registries and
are clear and significant differences from the bio-originator, such as surveillance are required to monitor not only immunogenicity, but rare
use of a different cell expression system, incompletely characterized adverse events and long-term safety and efficacy data, which will be
impurities, or formulation differences. Following this, there must lacking with the shortened regulatory process.
be at least one pharmacokinetic study in healthy volunteers to
demonstrate that the body handles the biosimilar in the same way Another issue under debate is that of interchangeability, which defines
as the bio-originator, and at least one randomized controlled trial to the situation in which a pharmacist may substitute a biosimilar for
demonstrate clinical equivalence; the margins of similarity are defined the bio-originator. A biosimilar product is interchangeable if it is
using meta-analysis data from the bio-originator clinical trials. Safety expected to produce the same clinical result as the bio-originator in
and immunogenicity must be comparable for the biosimilar, and it any given patient, and the FDA’s draft guidance has required at least
is a regulatory requirement that immunogenicity continues to be one suitably designed switching study to effectively demonstrate
monitored using post-marketing surveillance programs.38 interchangeability.40 Similar to the process whereby a patient may
receive a generic small-molecule pharmaceutical instead of a
Immunogenicity is a concern for both biosimilar and bio-originator branded product at their pharmacy (unless the prescribing physician
products. Even with fully humanized antibodies, immunogenicity can specifically requests the brand name version), and with the same
arise in about a third of patients, as seen in studies of adalimumab.39 cost considerations (as biosimilars are predicted to be significantly
Fortunately, immunogenicity does not always lead to side effects or less expensive than bio-originators), if a biosimilar has demonstrated
loss of efficacy. interchangeability with the bio-originator, substitution with a biosimilar
will not specifically require the prescribing physician’s approval. None
of the biosimilars approved to date in the US have demonstrated
interchangeability.
17
The naming convention for biosimilars is important for prescribers The final issue in ongoing discussion of biosimilars is that of
to understand. With the amount of ongoing post-marketing extrapolating indications. The operating principle is that if the bio-
surveillance, the ability to accurately identify a product is critical, originator was efficacious and safe in multiple diseases, and the
and the International Non-proprietary Name (INN) will be insufficient biosimilar has been determined to be clinically equivalent for one of
for that task. The FDA currently requires a four-letter suffix for the those diseases, it should be equivalent for them all.38 However, for
INN to distinguish different products; for example, the biosimilar this to hold true, clinical efficacy must rely on a similar mechanism
of infliximab (Remicade) is infliximab-dyab (Inflectra). A concern of action in the extrapolated indication. For example, infliximab in
is that this naming difference implies these products are not RA and psoriatic arthritis works by neutralizing TNF in the joint; this
interchangeable (which is currently true), when they may be in has led to the extrapolated indication for infliximab-dyab to both
the future. In Europe currently, the INN is used identically for both diseases. For the clinician, it is therefore important to understand
products, which may inappropriately imply interchangeability. Both that biosimilars have not been extensively characterized clinically
of these scenarios emphasize the importance of understanding the as much as chemically. As far as we know, they should perform
current nomenclature used for biosimilars, and the degree to which identically to the bio-originator, but we should be aware that they
interchangeability is appropriate now and in the future. have not been tested as extensively in patients, and so increased
vigilance on our part is worthwhile.
Click here to read Faculty Commentary
18
5 Pilot data has suggested early remission is a prerequisite for successful

therapy withdrawal (Figure 6).43 This small study (47 patients) also
suggested a basis for assessing patients’ ability to regain low disease
Managing Patients With Low RA Disease activity following flare.
Activity: Can We Taper Therapy? FIGURE 6: Early Remission May be a Prerequisite for Successful TNFi
For patients with RA who have low disease activity, it makes sense to Therapy Withdrawal
consider reducing the dose of a medication or to stop it altogether.
Perhaps disease control will be just as good with a lower dose; EARLY (MTX NAÏVE) DELAYED (MTXIR)
in addition, there may be cost savings and safety advantages to
Treatment group Treatment group
consider. Cytokine levels in the target organ may also justify reducing
N = 27 N = 20
medication dosage. When TNFi therapy is initiated, TNF levels in the
joint synovium are usually high, as disease activity is high. These
local levels of TNF tend to fall as therapy proceeds successfully, and it
therefore stands to reason that the amount of agent needed to inhibit TNF BLOCKER THERAPY STOPPED
specific cytokines may be reduced.41 Another important reason to
taper therapy is patient preference. Patients in remission rarely see
why they may need to continue aggressive therapy when they feel well, FLARE SUSTAINED FLARE SUSTAINED
and as clinicians we often err on the side of continuing treatment lest N = 11 REMISSION N = 17 REMISSION
the patient flare. But this is only logical if the patient actually needs Time to flare: N = 16 Time to flare: N=3
continued exposure to therapy to maintain disease control, and this is median median
the crux of the discussion around whether to taper. 14 months 4 weeks
DMARD tapering/withdrawal studies can shed some light on

management strategies in patients with low RA disease activity.42 TNF BLOCKER
However, heterogeneity of patient populations, definitions of RESTARTED
remission, and low disease activity across many studies make it
REMISSION TNF BLOCKER
REGAINED RESTARTED N = 17
difficult to come up with clear take-home recommendations. One WITH DMARD N = 3 (11%) (85%)
group of patients who might have the best success with tapering are ESCALATION All regained
those who reach remission early in the disease course. remission
N=8
REMISSION
REGAINED
N = 15
19
For patients early in the RA disease course (MTX-naïve in this study), more Based on these initial trial results with different therapeutics, a case
than half sustained remission over the 2-year study period after TNFi can be made that, if a patient in early stages of the disease can attain
therapy was stopped; all patients continued MTX therapy. The patients remission on pharmacotherapy for a sustained period of time (e.g.,
in this arm who relapsed did so with a significantly longer median time 3 months), dose reduction of the biologic may be possible with little
to flare than the control group of MTX inadequate responders (MTXIR), risk of adverse impact. Additional data comes from the PRESERVE
and most also re-attained remission with escalation of a DMARD study, in which patients had persistent, moderate disease activity
alone, rather than having to restart TNFi therapy. For MTXIR patients, (rather than being early in the disease course); after reaching low
substantially fewer patients maintained remission once TNFi therapy was disease activity with full-dose etanercept plus methotrexate, they
stopped, and all of those flared needed to restart TNFi therapy to have a were randomized to either continued full-dose etanercept, half-dose
chance of regaining remission; even with TNFi therapy, not all of these etanercept, or placebo.47 At the conclusion of the 88-week study, there
patients regained remission. In conclusion, this pilot study suggested was little difference by disease activity measures between patients
that successful cessation of TNFi therapy is achievable if remission is in the full-dose versus the half-dose etanercept arms. Data from
achieved quickly following early treatment initiation. these studies therefore suggests that dose reduction in patients with
sustained low RA disease activity is feasible and well-tolerated among
Looking at data from some studies that have considered dose reduction, patients with either early or well-controlled disease.
rather than withdrawal of therapy, in early disease, a pattern appears
(Table 2):
TABLE 2: Studies of dose reduction in patients with RA early in the disease course.
Study Study Information Outcome Following Dose Reduction
Randomized, double-blind study extension following patients who reached remission

(DAS<2.6) Relapse (flare) over time and proportion of patients
AGREE44
Evaluated maintenance of response to half-dose (5mg/kg) versus continuation on full relapsing were similar in both groups (31% vs 34%)
dose (10mg/kg) of intravenous abatacept
Patients with 12 weeks of sustained, low disease activity (DAS<2.6) on etanercept

and methotrexate following 52 weeks of treatment were randomized to: Patients who maintained combination therapy through
PRIZE45 • Half-dose etanercept plus full-dose methotrexate the full 92 weeks of the trial showed sustained remission
• Full-dose methotrexate alone, or through the final 40 weeks on half-dose etanercept
• Placebo for a further 40 weeks
Patients with sustained low disease activity (DAS28≤3.2) during weeks 40–52 Patients who maintained combination therapy through the full
while taking standard dose certolizumab pegol were randomized to either continue 104 weeks of the trial showed sustained remission through
C-EARLY 46
standard dose certolizumab, a reduced frequency of dosing, or placebo for a further the final 52 weeks on reduced-dose certolizumab, comparable
52 weeks to that observed in the full-dose patient group
20
The studies discussed previously all considered dose reduction; On the other hand, there are some valid reasons to not taper therapy.
additional data is available on stopping therapy altogether. In the From an immunopathologic standpoint, we know that endothelial
2-year TNF-20 trial, researchers showed sustained benefit of 1 year of cells of the affected synovium have altered morphology and gene
infliximab treatment followed by withdrawal of therapy, as measured expression patterns that persist across the disease course, implying
by quality-of-life and HAQ scores.48 Long-term follow-up of these disease processes and inflammatory processes may still be present,
patients over 8 years showed maintained low disease activity in even for patients treated to low disease activity.52 One longitudinal
the infliximab-treated cohort versus placebo (DAS28 score 2.7 vs real-world study using patients in the CORRONA Registry who
4.3) and 44% of infliximab patients were in remission versus none voluntarily decided to discontinue their TNFi therapy found that
in the placebo group.49 Patients who stopped etanercept therapy in roughly 50% of patients had restarted their TNFi by around the
the second arm of the PRIZE study (Table 2, previous page) did not 18-month mark, and at the end of the study over 90% of participants
maintain remission as well as those patients who remained on half- had flared.53
dose etanercept, but still about 80% maintained remission.45 It is of
note that the PRIZE study had a third phase, during which patients Flares have long-term consequences for patient health and quality-of-
in all three study arms who were still in remission went completely life. Ten-year data from the BeST study, in which patients were treated
drug-free for a further 28 weeks, including stopping MTX. Fifty percent to target DAS≤2.4 and then tapered to maintain MTX monotherapy54
of patients who took etanercept through the first two phases and demonstrated that the more flares a patient experienced, the higher
then went completely drug-free were still in remission at the end the HAQ score at year 10, and the greater the radiographic disease
of this phase.45 Applying this study to clinical practice may be met progression from baseline to year 10. Flares were also associated
with resistance, however, as the ACR guidelines recommend against with patient-scored factors, including perception of pain and disease
discontinuation of all therapy.50 In C-EARLY, patients who stopped activity, morning stiffness, and functional deterioration, suggesting
therapy in the second phase did show some increase in disease that treatment intensification may outweigh the possible risks in
activity compared to patients continuing on certolizumab, but their select patients. Other studies have also suggested that patients on
mean DAS score was still rather low (around 3.0) after 104 weeks.46 tapered regimens experience more adverse events, including infections,
and require more corticosteroid, DMARD, and pain medications as a
The OPTIMA study was a complex multi-arm study over 78 weeks; for result.55,56 Hence, if we consider an economic argument for tapering, we
the purposes of discussing termination of therapy only two arms are must balance the reduced cost of primary pharmacologic therapy with
relevant. Patients in the first phase were given full-dose adalimumab the potential increased costs of using other agents, as well as indirect
plus MTX, and if they had sustained DAS28≤2.8 at weeks 22 and costs including those associated with side effects, increased office
26, they were randomized blindly to either continue on the same visits, or other contact with the healthcare system.
therapy or to withdraw adalimumab.51 Using DAS and SDAI scores,
roughly 90% of patients maintained remission when adalimumab was
continued, and there were around 10% fewer patients maintaining
low disease activity when the agent was stopped. Given an estimated
recapture rate in excess of 75% (P Emery, pers. comm.), the risk of
potential harm to patients with low disease activity from tapering
therapy seems quite low.
21
Key issues in considering tapering or termination of therapy are the FIGURE 7: Differences in Clinical Outcomes for Patients Sustaining
definitions of remission and determining how to predict who will Adalimumab Versus Those Discontinuing in the OPTIMA Trial
tolerate less medical therapy. Patients with the same low disease
activity score are often quite different in terms of their global RA ACR
disease state, their overall health and wellness, their serologic status for 100
ACR20
certain biomarkers, their RA disease and treatment history, and different
dimensions of remission, including imaging, immunologic measures,
and clinical status. In OPTIMA, for example, when the patients who 80 ACR50
Patients (%)
continued adalimumab were compared to those who stopped it, there
were small but discernable differences in radiographic progression ACR70
and ACR-70 scores (Figure 7).51 Among these patient groups, the only
predictor of maintaining remission after stopping adalimumab was a 60
lower HAQ score at baseline. Patients in the early stages of disease
typically have less functional impairment, and based on these data may
have an increased likelihood of maintaining remission when therapy is 40
stopped; but this needs to be evaluated on a case-by-case basis, and 26 30 34 38 42 46 50 54 58 62 66 70 74 78
dose reduction would present a lower-risk scenario. In order to be better Weeks
able to predict who would tolerate termination of therapy, data samples
that analyze outcomes for predictive factors must be larger; so, while
these data are helpful, it is worth remembering that current guidelines 100 89.0 88.0 89.0
recommend caution when tapering and recommend that patients with
Patients ∆mTSS ≤0.5 (%)

RA not stop all therapy.50 80 89.0
85.0 81.0
60 X-ray progression: % pts
Click here to read Faculty Commentary
40
20
0
26 52 78
Weeks
ADA+MTX/MTX (n = 88) Sustained ADA+MTX (n = 94)
22
6 The concept of multimorbidity considers how all identified disease

states may interrelate, with the focus on the patient as the center of
care.58 This requires adding an extra dimension to our thinking: beyond
Treatment of RA When the Patient Is Unwell measures of RA disease activity as our primary outcomes, with the
Multimorbidity is the term used to describe patients with two or more patient as the primary treatment focus we should include more global
chronic medical conditions. Multimorbidity differs from comorbidity in measures such as overall quality of life (Figure 8).
that comorbidity involves the relation of an index disease (in this case
RA), to one other specified disease such as diabetes or heart disease.
As rheumatologists, we have traditionally focused on treating RA with
the hope that at least some comorbidities (such as heart disease)
might benefit as well.
FIGURE 8: Refocusing Treatment to Patient-centered Outcomes Is the Key Principle of Managing Multimorbidity
Click on the figure to see Multimorbidity
Comorbidity
Peptic ulcer Secondary
Primary treatment focus
treatment focus
Osteoporosis RA Cardiovascular disease
Assess effectiveness by evaluating

RA disease activity
Secondary
treatment focus Diabetes mellitus
23
Regardless of the disease states, multimorbidity is associated with diseases are common. Considering that disease activity and treatment
poorer patient outcomes,59,60 including: can trigger or worsen other medical conditions, early decisions in RA
management are among the most critical.
•• Reduced quality of life
Even when in remission, individuals with RA may experience functional
•• Reduced socioeconomic status
impairment. Patients with 4 or more multimorbidities, who were in
•• Increased mortality rates remission according to the CDAI, had a significantly higher HAQ score
than those without any comorbid disease. In patients with higher
•• Increased rates of polypharmacy and high treatment burden disease activity, increasing multimorbidity also correlated strongly
with increasing HAQ scores, indicating that patients with RA and
•• Increased rates of treatment-emergent adverse events
multimorbidity have worse function regardless of current RA disease
•• Increased health system utilization, including emergency room visits activity.59
The number of multimorbid conditions increases with age; in one When thinking about managing patients with multimorbidity, we as
large analysis, by the median age of onset of RA (45 to 49 years), clinicians should offer an approach that maximizes quality of life. The
43.2% of the population had 1 or more chronic morbidity, and 23.2% 2016 National Institute for Health and Care Excellence (NICE) guidelines
had 2 or more.61 By ages 50 to 60, more patients will have 2 or more offer useful items for a clinician to focus on:
diseases than those with 1 or none, and these make up a substantial
•• How the patient’s health conditions and their treatments interact and
proportion of the patients with RA that we treat. The number of
how this affects quality of life
comorbid conditions also increases for any given age with reducing
socioeconomic status, adding an extra dimension of burden to the •• The patient’s individual needs, preferences for treatments, health
management and the potential for poorer patient outcomes.61 priorities, lifestyle and goals
Yet, due to exclusion criteria, these are not patients represented in •• The benefits and risks of following recommendations from guidance
clinical trial populations. Therefore, we face challenging treatment on single health conditions
decisions on a daily basis. When considering RA, it is not one clearly
defined disease as studied in clinical trials, but an amalgamation •• Improving quality of life by reducing treatment burden, adverse
of complex chronic diseases, all of which we should be considering events, and unplanned care
in our management approach. Multimorbidity is present in almost •• Improving coordination of care across services
two-thirds of patients with RA, as compared with around 20% of the
general population.58 Currently it is unclear why there is such an In addition, these guidelines offer some practical advice for the clinician
increased prevalence; shared genetic or lifestyle factors (such as when delivering an approach to patient care that takes account of
smoking or a sedentary lifestyle) could be contributors. multimorbidity:
Time plays an important role for patients with RA and multimorbidity. •• Discuss with your patients the purpose of an approach to their care
We may treat a patient with RA over many decades and over that period that takes account of their multimorbidity
of time, development of new conditions or exacerbations of existing
24
•• Establish patient (and caregiver) disease burden and treatment burden TABLE 3: Recommendations for Improving CVD Care in Patients With RA
•• Establish patient goals, values, and priorities Click on the red Evidence buttons in Table 3 to view
Recommendations for Care
•• Conduct comprehensive medical management, along with other
treatments, taking into account evidence of likely benefits and harms Evidence Evidence
for the individual patient, and their important goals and outcomes
Changes in cholesterol levels and
•• Agree on an individualized management plan with the patient other metabolic markers are to
RA patients are more likely to have be expected when inflammatory
In essence, the guidelines recommend having a conversation with a silent MI, or sudden cardiac death processes are modulated, either due
the patient, documenting what their concerns and priorities are, and on admission to coronary care, than to RA disease activity or through the
establishing a set of goals which can be operationalized and consulted. patients without RA.62 use of pharmacologic treatments.
The major domains for which comorbidity becomes multimorbidity RA disease activity generally reduces
in patients with RA are ones with which we are all familiar: available cholesterol molecules.
cardiovascular risk factors and CVD, infections and vaccinations,
osteoporosis, gastrointestinal disease, lymphomas and other cancers, Evidence Evidence
and mental health.
Treat-to-target approaches in RA CVD risk can be quickly and easily
have demonstrated a 21% reduction calculated based upon a number of
in CVD risk with a 10-point reduction well-investigated parameters.65
in CDAI score.64
Evidence Evidence
RA pharmacotherapies have shown Clinical trials have demonstrated an

elevations in low-density lipoprotein increased risk of heart failure with
cholesterol (LDL-C), a key marker of TNF inhibitor therapy.
elevated CVD risk.66
25
Click on the red Evidence buttons in Tables 4 and 5 to view Recommendations for Care
TABLE 4: Recommendations for Patients With RA With a History of Malignancy TABLE 5 (CONTINUED)
Evidence Evidence Evidence
There is a lack of clear data and

Response to some inactivated vaccines, including hepatitis B, may be reduced
knowledge on the mechanism of
following rituximab or other biologic therapy.68
action of biologic therapies and
Rituximab is an approved therapy for
tofacitinib, which may contribute to
many lymphoproliferative cancers.
an increased cancer risk. DMARDs
are considered generally less
immunosuppressive.50 When we look at domains such as cardiovascular disease, serious
infectious diseases, and cancer, considering the evidence base and
guidelines we have currently, some useful clinical recommendations
TABLE 5: Recommendations for Infectious Disease Screening, and Use of appear. While this is not truly considering multimorbidity yet, it still
Vaccinations in Patients With RA
works from the perspective of CVD being comorbid to RA. This is likely
Evidence Evidence the most reasonable current starting point as we have no clinical
trials specifically addressing multimorbid patient groups. As we move
forward, more effectiveness studies, real-world experience, and open-
label trials may help to provide us with more practical strategies not
only regarding management of RA, but for the whole patient who is
Patients with RA treated with biologics The Centers for Disease Control more reflective of the people visiting our practices.
or tofacitinib are at 3-to 4-fold (CDC) recommends herpes zoster
increased risk of tuberculosis. vaccination for people aged 60
or older. Click here to read Faculty Commentary
Please click here to complete the posttest

for this activity.
26
References
1. van der Linden MP, Knevel R, Huizinga TW, van der Helm-van Mil AH. Classification 11. Tak PP, Doorenspleet ME, de Hair M, et al. Dominant B-Cell Receptor Clones in
of rheumatoid arthritis: comparison of the 1987 American College of Rheumatology Peripheral Blood Predict Onset of Arthritis in Individuals at Risk for Rheumatoid
criteria and the 2010 American College of Rheumatology/European League Against Arthritis. Abstract #1036. Presented at American College of Rheumatology 2016
Rheumatism criteria. Arthritis Rheum. 2011;63:37-42. Annual Meeting. Washington, DC.
2. Boeters DM, Gaujoux-Viala C, Constantin A, van der Helm-van Mil AHM. The 2010 12. Salomon S, Guignant C, Morel P, Gubler B, Fardellone P, Marolleau JP, Goeb V. The
ACR/EULAR Criteria Are Not Sufficiently Accurate in the Early Identification of Baseline Th17 Lymphocytes Level Is a Predictive Marker of Good Response to
Autoantibody-Negative Rheumatoid Arthritis. Abstract #493. Presented at American Biologics in Rheumatoid Arthritis. Abstract #2929. Presented at American College
College of Rheumatology 2016 Annual Meeting. Washington, DC. of Rheumatology 2016 Annual Meeting. Washington, DC.
3. George MD, Giles JT, Katz PP, et al. C-Reactive Protein and Disease Activity in 13. Conaghan PG, Østergaard M, Bowes MA, et al. (a) Comparing the effects of
Rheumatoid Arthritis: Impact of Obesity and Adiposity. Abstract #510. Presented at tofacitinib, methotrexate and the combination, on bone marrow oedema, synovitis
American College of Rheumatology 2016 Annual Meeting. Washington, DC. and bone erosion in methotrexate-naive, early active rheumatoid arthritis: results
of an exploratory randomised MRI study incorporating semiquantitative and
4. Abildtrup M, Kingsley GH, Scott DL. Calprotectin as a biomarker for rheumatoid quantitative techniques. Ann Rheum Dis. 2016;75:1024-33.
arthritis: a systematic review. J Rheumatol. 2015;42:760-70.
14. Conaghan PG, Bowes MA, Østergaard M, et al. (b) Inflammation Detected with
5. Jonsson MK, Hammer HB, Nordal HH, et al. Calprotectin Levels Correlate with Modern Sensitive MRI Analysis Demonstrates That Therapeutic Response As Early
Inflammation in Early Rheumatoid Arthritis before Disease-Modifying Antirheumatic As One Month Predicts 12-Month Radiographic Progression: Data from a Study
Drug Treatment and after 12 Months of Treatment. Abstract #492. Presented at Using Tofacitinib and Methotrexate in Early RA. Abstract #3090. Presented at
American College of Rheumatology 2016 Annual Meeting. Washington, DC. American College of Rheumatology 2016 Annual Meeting. Washington, DC.
6. Nordal HH, Brokstad KA, Solheim M, Halse AK, Kvien TK, Hammer HB. Calprotectin 15. Yamashita H, Kubota K and Mimori A. Clinical value of whole-body PET/CT in
(S100A8/A9) has the strongest association with ultrasound-detected synovitis and patients with active rheumatic diseases. Arthritis Res Ther. 2014;16:423.
predicts response to biologic treatment: results from a longitudinal study of patients
with established rheumatoid arthritis. Arthritis Res Ther. 2017;19:3. 16. Amigues I, Giles JT, Zartoshti A, Morgenstern R, Flores R, Bokhari S, Bathon J. (a)
Moderate to Severe Disease Activity in Rheumatoid Arthritis Is Associated with
7. Ally MM, Hodkinson B, Meyer PW, Musenge E, Tikly M, Anderson R. Serum matrix Myocardial 18f-Fluorodeoxyglucose (18F-FDG) Uptake. Abstract #1470. Presented at
metalloproteinase-3 in comparison with acute phase proteins as a marker of disease American College of Rheumatology 2016 Annual Meeting. Washington, DC.
activity and radiographic damage in early rheumatoid arthritis. Mediators Inflamm.
2013;2013:183653. 17. Amigues I, Giles JT, Zartoshti A, Morgenstern R, Flores R, Bokhari S, Bathon J.
(b) Myocardial 18f-Fluorodeoxyglucose (18F-FDG) Uptake in RA Patients without
8. Sun S, Bay-Jensen AC, Karsdal MA, et al. The active form of MMP-3 is a marker of Clinical Cardiovascular Disease Is Higher Than in Controls and Decreases with
synovial inflammation and cartilage turnover in inflammatory joint diseases. BMC Treatment. Abstract #1471. Presented at American College of Rheumatology 2016
Musculoskelet Disord. 2014;15:93. Annual Meeting. Washington, DC.
9. van Steenbergen HW, van der Helm-van Mil AH. Osteoprotegerin as biomarker for 18. Porter D, van Melckebeke J, Dale J, et al. (a) Tumour necrosis factor inhibition
persistence of rheumatoid arthritis. Rheumatology (Oxford). 2016;55:949-50.
versus rituximab for patients with rheumatoid arthritis who require biological
10. Meyer P, Ally MM, Hodkinson B, Musenge E, Becker P, Tikly M, Anderson R. Serum treatment (ORBIT): an open-label, randomised controlled, non-inferiority, trial. Lancet.
MMP-3 and OPG As Predictors of Response to Traditional DMARDs in a Treatment 2016;388:239-47
Naïve Early Rheumatoid Arthritis Cohort. Abstract #2585. Presented at American
College of Rheumatology 2016 Annual Meeting. Washington, DC.
27
References (continued)
19. Porter D, Goodyear CS, Nijjar JS, Messow M, Siebert S, Mudaliar M, McInnes IB. 27. ten Brinck RM, van Steenbergen HW, Mangnus L, Burgers LE, Reijnierse M, Huizinga TW,
(b) Predicting the Response to TNF Inhibition or B Cell Depletion Therapy from van der Helm-van Mil AH. (b) Functional Disability in Patients Presenting with Clinically
Peripheral Whole Blood Gene Expression Profiles in Patients with Rheumatoid Suspect Arthralgia and Progression to Clinical Arthritis. Abstract #1038. Presented at
Arthritis. Abstract #3089. Presented at American College of Rheumatology 2016 American College of Rheumatology 2016 Annual Meeting. Washington, DC.
Annual Meeting. Washington, DC.
28. Davis JM III, Lin G, Oh J, et al. Diastolic Dysfunction in Patients with Rheumatoid Arthritis:
20. Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 Predictors of Longitudinal Progression over Five Years. Abstract #1476. Presented at
recommendations for the use of nonbiologic and biologic disease-modifying American College of Rheumatology 2016 Annual Meeting. Washington, DC.
antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum. 2008;59:762-84.
29. Solomon DH, Greenberg J, Curtis JR, Liu M, Farkouh ME, Tsao P, Kremer JM, Etzel CJ.
21. Harrold LR, Alemao E, Litman HJ, et al. Impact of Poor Prognostic Factors on (a) Derivation and internal validation of an expanded cardiovascular risk prediction
Treatment Decisions in Clinical Practice in Patients with Rheumatoid Arthritis: score for rheumatoid arthritis: a Consortium of Rheumatology Researchers of North
Findings from a US Observational Cohort. Abstract #2478. Presented at American America Registry Study. Arthritis Rheumatol. 2015;67:1995-2003.
30. Liao K, Etzel CJ, Greenberg JD, Guan H, Kremer J, Solomon DH. Modifiable Rheumatoid
22. Kavanaugh A, van Vollenhoven RF, Wolfe BA, Florentinus S, Chen S, Suboticki JL, Arthritis Factors and Impact on Cardiovascular Risk. Abstract #24. Presented at
Smolen JS. Predictors of Inadequate Response and Rapid Radiographic Progression in American College of Rheumatology 2016 Annual Meeting. Washington, DC.
Patients with Early Rheumatoid Arthritis Receiving Methotrexate: a Post Hoc Analysis
of 2 Randomized, Controlled Trials of Adalimumab. Abstract #2651. Presented at 31. Zamora-Legoff A, Krause M, Crowson CS, Ryu JH, Matteson EL. Risk for Serious
American College of Rheumatology 2016 Annual Meeting. Washington, DC. Infection in Rheumatoid Arthritis Associated Interstitial Lung Disease. Abstract #1496.
Presented at American College of Rheumatology 2016 Annual Meeting. Washington, DC.
23. Karpouzas G, Takeuchi T, Thorne C, Sheng S, Li X, Rao R, Fei K, Hsu B. Prediction
of Inhibition of Radiographic Progression By Sirukumab, an Anti–IL-6 Cytokine 32. Lard LR, Visser H, Speyer I, et al. Early versus Delayed Treatment in Patients with
Monoclonal Antibody, in Patients with Active Rheumatoid Arthritis Despite Disease- Recent-onset Rheumatoid Arthritis: Comparison of Two Cohorts Who Received
Modifying Anti-Rheumatic Drug Treatment: Results of a Global, Phase 3 Trial. Abstract Different Treatment Strategies. Am J Med. 2001;111:446-51.
#2650. Presented at American College of Rheumatology 2016 Annual Meeting.
Washington, DC. 33. Nell VPK, Machold KP, Ebert G, Stamm TA, Uffmam M, Smolen JS. Benefit of very early
referral and very early therapy with disease-modifying anti-rheumatic drugs in patients
24. Mary J, Combe B, Lukas C, De Bandt M. Predictive Factors of Good Response to with early rheumatoid arthritis. Rheumatology 2004;43:906-914
Conventional DMARDs in Patients with Early Seronegative Rheumatoid Arthritis:
Data from the Espoir Cohort Abstract #2460. Presented at American College of 34. Isaacs JD. Antibody engineering to develop new antirheumatic therapies. Arthritis Res
Rheumatology 2016 Annual Meeting. Washington, DC. Ther. 2009;11:225.
25. van Steenbergen HW, Aletaha D, Beaart-van de Voorde LJ, et al. EULAR definition 35. Junghans RP, Anderson CL. The protection receptor for IgG catabolism is the beta2-
of arthralgia suspicious for progression to rheumatoid arthritis. Ann Rheum Dis. microglobulin-containing neonatal intestinal transport receptor. Proc Natl Acad Sci
2017;76:491-496. USA. 1996;93:5512-6.
26. ten Brinck RM, van Steenbergen HW, Verheul MK, Trouw LA, van der Helm-van Mil 36. Sha S, Agarabi C, Brorson K, Lee DY, Yoon S. N-Glycosylation Design and Control of
AH. (a) The Prognostic Value of Different Auto-Antibodies for Arthritis Development Therapeutic Monoclonal Antibodies. Trends Biotechnol. 2016;34:835-46.
in Patients with Clinically Suspect Arthralgia. Abstract #1035. Presented at American
28
37. World Health Organization. Expert committee on biological standardization. Geneva, 47. Smolen JS, Nash P, Durez P, et al. Maintenance, reduction, or withdrawal of etanercept
19 to 23 October 2009. Guidelines on evaluation of similar biotherapeutic products after treatment with etanercept and methotrexate in patients with moderate rheumatoid
(SBPs). http://who.int/biologicals/biotherapeutics/en/ arthritis (PRESERVE): a randomised controlled trial. Lancet. 2013;381:918-29.
38. Food and Drug Administration. Scientific Considerations in Demonstrating 48. Quinn MA, Conaghan PG, O’Connor PJ, et al. Very early treatment with infliximabin
Biosimilarity to a Reference Product. Guidance for Industry. U.S. Department of Health addition to methotrexate in early, poor-prognosis rheumatoid arthritis reduces magnetic
and Human Services. April 2015. http://www.fda.gov/ resonance imaging evidence of synovitis and damage, with sustained benefit after
infliximab withdrawal: results from a twelve-month randomized, double-blind, placebo-
39. Kneepkens EL, Wei JC, Nurmohamed MT, et al. Immunogenicity, adalimumab levels and
controlled trial. Arthritis Rheum. 2005;52:27-35
clinical response in ankylosing spondylitis patients during 24 weeks of follow-up. Ann
Rheum Dis. 2015;74:396-401. 49. Bejarano V, Conaghan PG, Quinn MA, Saleem B, Emery P. Benefits 8 years after a
remission induction regime with an infliximab and methotrexate combination in early
40. Food and Drug Administration. Considerations in Demonstrating Interchangeability With
rheumatoid arthritis. Rheumatology (Oxford). 2010;49:1971-4.
a Reference Product. Guidance for Industry. U.S. Department of Health and Human
Services. January 2017. http://www.fda.gov/ 50. Singh JA, Saag KG, Bridges SL Jr., et al. 2015 American College of Rheumatology
Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken).
41. Buch MH, Reece RJ, Quinn MA, et al. The value of synovial cytokine expression in
2016;68:1-25.
predicting the clinical response to TNF antagonist therapy (infliximab). Rheumatology
(Oxford). 2008;47:1469-75 51. Smolen JS, Emery P, Fleischmann R, et al. Adjustment of therapy in rheumatoid
arthritis on the basis of achievement of stable low disease activity with adalimumab
42. Schett G, Emery P, Tanaka Y, et al. Tapering biologic and conventional DMARD therapy
plus methotrexate or methotrexate alone: the randomised controlled OPTIMA trial.
in rheumatoid arthritis: current evidence and future directions. Ann Rheum Dis.
Lancet. 2014;383:321-32.
2016;75:1428-37.
52. Middleton J, Americh L, Gayon R, Julien D, Aguilar L, Amalric F, Girard JP. Endothelial
43. Saleem B, Keen H, Goeb V, et al. Patients with RA in remission on TNF blockers: when
cell phenotypes in the rheumatoid synovium: activated, angiogenic, apoptotic and
and in whom can TNF blocker therapy be stopped? Ann Rheum Dis. 2010;69:1636-42.
leaky. Arthritis Res Ther. 2004;6:60-72.
44. Westhovens R, Robles M, Ximenes AC, et al. Maintenance of remission following 2
53. Kavanaugh A, Lee SJ, Curtis JR, et al. Discontinuation of tumour necrosis factor
years of standard treatment then dose reduction with abatacept in patients with early
inhibitors in patients with rheumatoid arthritis in low-disease activity: persistent
rheumatoid arthritis and poor prognosis. Ann Rheum Dis. 2015;74:564-8.
benefits. Data from the Corrona registry. Ann Rheum Dis. 2015;74:1150-5.
45. Emery P, Hammoudeh M, FitzGerald O, et al. Sustained remission with etanercept
54. Markusse IM, Dirven L, Gerards AH, et al. Disease flares in rheumatoid arthritis are
tapering in early rheumatoid arthritis. N Engl J Med. 2014;371:1781-92 associated with joint damage progression and disability: 10-year results from the
BeSt study. Arthritis Res Ther. 2015;17:232.
46. Weinblatt M, Bingham C III, Burmester GR, et al. A Randomized, Double-Blind, Placebo-
Controlled Phase 3 Study Evaluating Treatment Strategies (Continuation Versus 55. van Herwaarden N, van der Maas A, Minten MJ, et al. Disease activity guided dose
Withdrawal) for Maintaining Low Disease Activity after 1 Year of Certolizumab Pegol in reduction and withdrawal of adalimumab or etanercept compared with usual care
DMARD-Naïve Patients with Early and Progressive, Active RA. Abstract #952. Presented in rheumatoid arthritis: open label, randomised controlled, non-inferiority trial. BMJ.
at American College of Rheumatology 2016 Annual Meeting. Washington, DC. 2015;350:h1389.
29
56. Ghiti Moghadam M, Vonkeman HE, Ten Klooster PM, et al. Stopping tumor necrosis 67. Rollefstad S, Ikdahl E, Hisdal J, Kvien TK, Pedersen TR, Holme I, Semb AG. Systemic
factor inhibitor treatment in patients with established rheumatoid arthritis in inflammation in patients with inflammatory joint diseases does not influence statin
remission or with stable low disease activity: a pragmatic multicenter, open-label dose needed to obtain LDL cholesterol goal in cardiovascular prevention. Ann
randomized controlled trial. Arthritis Rheumatol. 2016;68:1810-7. Rheum Dis. 2015;74:1544-50.
57. Yazdany J, Bansback N, Clowse M, Collier D, Law K, et al. Rheumatology Informatics 68. Bingham CO III, Looney RJ, Deodhar A, Halsey N, Greenwald M, et al. Immunization
System for Effectiveness: A National Informatics-Enabled Registry for Quality responses in rheumatoid arthritis patients treated with rituximab: results from a
Improvement. Arthritis Care Res (Hoboken). 2016;68:1866-1873. controlled clinical trial. Arthritis Rheum 2010;62:64–74.
58. Radner H, Yoshida K, Smolen JS, Solomon DH. Multimorbidity and rheumatic 69. Centers for Disease Control and Prevention. Recommended adult immunization
conditions—enhancing the concept of comorbidity. Nat Rev Rheumatol. schedule, United States 2014. http://www.cdc.gov/vaccines/schedules/downloads/
2014;10:252-6. adult/adultschedule.pdf.
59. Radner H. Multimorbidity in rheumatic conditions. Wien Klin Wochenschr.

2016;128:786-90.
60. National Institute for Health and Care Excellence (NICE). Multimorbidity: clinical
assessment and management. NICE Guideline. Published 21 Sept 2016.
61. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of

multimorbidity and implications for health care, research, and medical education: a
cross-sectional study. Lancet. 2012;380:37-43.
62. Prasad M, Hermann J, Gabriel SE, et al. Cardiorheumatology: cardiac involvement in

systemic rheumatic disease. Nat Rev Cardiol. 2015;12:168-76.
63. Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular
disease risk management in patients with rheumatoid arthritis and other forms of
inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017;76:17-28.
64. Solomon DH, Reed GW, Kremer JM, et al. (b) Disease activity in rheumatoid arthritis
and the risk of cardiovascular events. Arthritis Rheumatol. 2015;67:1449-55.
65. Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations
for patient-centered management of dyslipidemia: part 1-executive summary. J Clin
Lipidol. 2014;8:473–488.
66. Choy E, Sattar N. Interpreting lipid levels in the context of high-grade inflammatory
states with a focus on rheumatoid arthritis: a challenge to conventional
cardiovascular risk actions. Ann Rheum Dis. 2009;68:460-9.
30

Final Acr

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Final Acr

Transféré par

Droits d'auteur :

Formats disponibles

Updates in Improving

Care of Patients With

Program Title Target Audience

Course Description Educational Objectives

Disclosure of Conflicts of Interest Provider Information

Faculty Relationship Identified With CME Credit (Physicians)

Disclosure of Unlabeled Use

Disclaimer Method of Participation

6. All other participants who receive a grade of 70% or better on the

Release date: May 15, 2017

Expiration date: May 15, 2018

Table of Contents Navigation Key

Faculty Commentary Icon: Click on this icon to view

4. Biosimilars: Regulatory and Practice Considerations.................. 14

Molecular Engineering of Biosimilars...................................... 14

5. Managing Patients With Low RA Disease Activity:

6. Treatment of RA When the Patient Is Unwell............................... 23

1 •• As more biosimilars enter our disease management toolbox, we

•• A key question for us continues to be in the area of early detection

2 calprotectin retained a significant association with ultrasound markers

Imaging Roll over the buttons below to see an

3 FIGURE 2. Ability of Peripheral Blood Transcriptional Biomarkers in the ORBIT

The ORBIT study attempted to use gene expression profiles of the

(B) Sensitivities and specificities for the presence of arthralgia at risk

Biosimilars: Regulatory and Practice Biologic Therapies

(continued on next page)

Click here to read Faculty Commentary

5 Pilot data has suggested early remission is a prerequisite for successful

DMARD tapering/withdrawal studies can shed some light on

Study Study Information Outcome Following Dose Reduction

Randomized, double-blind study extension following patients who reached remission

Patients with 12 weeks of sustained, low disease activity (DAS<2.6) on etanercept

Patients ∆mTSS ≤0.5 (%)

6 The concept of multimorbidity considers how all identified disease

Click on the figure to see Multimorbidity

Osteoporosis RA Cardiovascular disease

Assess effectiveness by evaluating

RA pharmacotherapies have shown Clinical trials have demonstrated an

Evidence Evidence Evidence

There is a lack of clear data and

Please click here to complete the posttest

59. Radner H. Multimorbidity in rheumatic conditions. Wien Klin Wochenschr.

61. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of

62. Prasad M, Hermann J, Gabriel SE, et al. Cardiorheumatology: cardiac involvement in

Vous aimerez peut-être aussi