Rheumatoid arthritis

Posted on Rheumatoid arthritis

Black Patients with RA Less Likely to Receive a Biologic, More Likely to Be Treated with Glucocorticoids Than Whites

Black Patients with RA Less Likely to Receive a Biologic, More Likely to Be Treated with Glucocorticoids Than Whites
Black Patients with RA Less Likely to Receive a Biologic, More Likely to Be Treated with Glucocorticoids Than Whites


A new study reveals that Black patients with rheumatoid arthritis (RA) were less likely to be prescribed a biologic treatment and more likely to use glucocorticoids, which carry a risk of serious long-term side effects. This study highlights ongoing racial disparities in the care of patients with rheumatic disease. Details of the study was shared at ACR Convergence, the ACR’s annual meeting (abstract #0044).

RA is the most common type of autoimmune arthritis. It is caused when the immune system (the body’s defense system) is not working properly. RA may cause pain and swelling in the joints as well as affect multiple organ systems such as the lung and eye. RA is treated with disease modifying anti rheumatic drugs, including biologics, to help stop joint pain and swelling, and also prevent joint damage. “

Racial disparities in access to care and effective treatment regimens are poorly understood in the RA population, but past research shows that non-white RA patients have a lower frequency of biologic use versus white patients, even when accounting for comparable disease activity and access to treatment. This new study looked at racial disparities in RA treatment and emergency department use in patients with RA at a single, tertiary academic center in Pennsylvania.

“With the explosion of effective therapies for rheumatoid arthritis, it is particularly important to make sure that we are treating patients in the best way possible,” says the study’s co-author, Michael George, MD, MSCE, Assistant Professor of Medicine at the Hospital of the University of Pennsylvania. “Variability in practice, and disparities in treatment, suggest that there is room for significant improvement. We hope that this study will add to the existing literature about disparities in rheumatoid arthritis care–understanding why they exist and finding ways to address them are key to improving the health of patients with RA.”

The study used electronic health record data from 1,831 patients with RA from 2010 to 2018. Patients had at least two RA diagnoses from a rheumatology outpatient encounter and at least one prescription of a disease-modifying antirheumatic drug (DMARD) during the follow-up period, or from their first to their last clinic visit. The researchers also measured patient demographic information, medication use and comorbidities at the baseline visit and at any point during the follow-up period.

The researchers then compared the differences in patient characteristics and visits between Black and white patients. Of the 1,831 patients in the study, 82% were female, 35% were Black, 54% were white and the mean age was 55. The average follow-up period for all patients was 6.97 years. Black patients were more likely to be older, have a higher body-mass index (BMI), were former or current smokers and had higher rates of cardiovascular disease and diabetes.

The researchers found racial disparities in how RA was treated with prednisone and conventional synthetic DMARD treatments used significantly more often in Black patients than whites: 79.3% of Black patients used prednisone compared to 69.1% of whites, and 96.7% of Black patients used a conventional DMARD compared to 93.5% of whites.

Additionally, white patients in the study were significantly more likely to use a biologic, a more advanced, expensive, and effective treatment for controlling RA disease activity and preventing joint damage. According to the data, 74% of whites and 67% of Blacks were prescribed a biologic drug. Black patients also had significantly more visits to the hospital emergency department (ED) over the eight-year period.

“This project supports prior work showing reduced use of biologics and a greater use of prednisone in patients who were Black – which could potentially mean worse outcomes or increased steroid side effects in this group,” says Dr. George. “A key next step that many are working on is understanding the key drivers of these disparities – understanding why they exist (e.g., access to medications, insurance, patient-provider communication, health beliefs, etc.) is important so we know how to address these disparities.”

Posted on Rheumatoid arthritis

Study Finds Statins Lower CVD and Mortality in People with RA, Only Modestly Increase Diabetes Risk

Sober curious


 New research presented this week at ACR Convergence, the American College of Rheumatology’s annual meeting, shows that statins are associated with reduced rates of cardiovascular disease (CVD) and mortality in people with rheumatoid arthritis, but only modestly increase risk of type-2 diabetes, suggesting that statins’ benefits outweigh the risks in these patients (Abstract #1427). 

Rheumatoid arthritis (RA) is the most common type of autoimmune arthritis. It is caused when the immune system (the body’s defense system) is not working properly. RA can cause pain, swelling, and damage in the joints, including the small joints of the hands, wrists, and feet. Additionally, RA can cause inflammatory damage in other body systems such as the heart, lungs, skin, eyes, and kidney. In people with RA, chronic inflammation can increase the risk and accelerate the onset of both CVD and type-2 diabetes. Statins are widely prescribed treatments that lower blood cholesterol and triglycerides to prevent heart attacks and strokes, but they slightly increase type-2 diabetes risk. Researchers set to find out if the benefits of statins are worth the risks in people with RA who are already at risk for diabetes.

To find out, they analyzed medical records of thousands of people with RA in the United Kingdom to compare rates of CVD, mortality and type-2 diabetes in both statin users and non-users. “We know that statins have been extensively studied in the general population, but our understanding of statins’ effects in RA patients are limited and mostly based on a few studies. Given that RA patients are already at higher risk for CVD and type-2 diabetes compared to general population, it is important to know the overall benefits and risks of statins,” says Gulsen Ozen, MD, a rheumatologist at University of Nebraska Medical Center in Omaha and a co-author of the study. The study included patients who were 18 or older, diagnosed with RA with no other alternative diagnoses, and were prescribed one or more disease-modifying antirheumatic drugs (DMARDs) between 1989 and 2018. Anyone with prior diabetes was excluded for type-2 diabetes risk assessment.

The study included 1,768 statin users and 3,528 non-users followed for rates of CVD and mortality, and 3,608 statin users and 7,208 non-users followed for rates of type-2 diabetes. Investigators tracked rates of CVD outcomes such as heart attack, stroke, hospitalization for heart failure and CVD-related death, as well as all-cause mortality and type-2 diabetes. Researchers found that 63 of the 1,768 statin users developed CVD compared to 340 out of the 3,528 non-users.

They also found incident type-2 diabetes in 128 of 3,608 statin users compared to 518 of the 7,208 non-users. Statin use was associated with a 32% reduction in CVD, a 54% reduction in all-cause mortality and a 33% reduction in type-2 diabetes risks. Patients with and without any prior CVD had similar reductions in both CVD (36% and 34%) and mortality (62% and 54%) risks if they took statins, the study showed. Researchers also found that the number needed to treat to prevent CVD and mortality in one year was 102 and 42, respectively, while the number needed to harm for a new diagnosis of type-2 diabetes was 127 in one year of statin treatment. 

“We know that RA patients are at higher risk for the development of CVD and death and type-2 diabetes compared to the general population. Moreover, RA patients are less frequently treated with statins than the general population, which is also concerning,” says Dr. Ozen. “We found that statins reduce both CVD and all-cause mortality, which were similar in magnitude. This may suggest that statins may have other beneficial effects in RA patients beyond lipid reduction. As rheumatologists, besides optimal disease activity control, we need to work on addressing the traditional CVD risk factors in our patients in conjunction with their primary-care providers. We believe that our findings emphasize the benefits of statins in patients with RA.”

Posted on Rheumatoid arthritis

Fear of Side Effects, Including Rheumatic Disease Flares, Driving COVID-19 Vaccine Hesitancy Among Some Patients

New research presented this week at ACR Convergence, the American College of Rheumatology’s annual meeting, shows that in Alabama, one in 10 racial or ethnic minority patients with a rheumatic disease in a large rheumatology clinic said they were unlikely to get vaccinated against COVID-19 (Abstract #0617). COVID-19 is the disease caused by the novel SARS-CoV-2 coronavirus.

Research presented at ACR Convergence 2020 showed that people of color with rheumatic disease have worse health outcomes from COVID-19 infection, are more likely to be hospitalized to treat their coronavirus infection and are more likely to require invasive ventilator treatment. While COVID-19 vaccines are now available in the U.S., hesitancy to receive them persists. Alabama lags behind other U.S. states in COVID-19 vaccine uptake. According to researchers, people in racial and ethnic minority groups also face disparities in access to the vaccines.

In addition, many in Alabama’s large Black population mistrust the medical establishment due to past abuses like the Tuskegee Syphilis study. Researchers at the University of Alabama at Birmingham (UAB) launched this new study to find out more about vaccine hesitancy and uptake among racial and ethnic minority patients at a large academic center’s rheumatology clinic. “Many patients seen in rheumatology clinics are immunosuppressed or have comorbidities that put them at risk for higher morbidity and mortality due to COVID-19,” says Maria I. Danila, MD, MSc, MSPH, Associate Professor of Medicine, Division of Clinical Immunology and Rheumatology at UAB and the study’s corresponding author. “Early during the rollout of the COVID-19 vaccination program in our region, it became apparent that vaccination among some minority communities was lagging. We conducted this study to take ‘the pulse’ of vaccine uptake in our area and to understand the top reasons why some patients had not been vaccinated. Our goal was to inform the development of communication strategies to ensure equitable access to vaccination among our patients.” 

Between April 19 and May 6, 2021, researchers invited patients from racial and ethnic minority communities in Alabama to complete a survey during their in-person visits to the rheumatology clinic. They assessed patients’ vaccination confidence using a standard psychological scale. They analyzed patients’ attitudes and beliefs about COVID-19 vaccines and determined the potential factors associated with getting a vaccine: such as age, sex, education level, vaccine confidence, safety concerns about the vaccine, medical mistrust and receipt of a flu vaccine in the past. There were 150 patients who agreed to complete the survey. They had a mean age of 54, 86.9% were women, 94% identified as Black or African American, 69% had some college, and 22% said they believed that they would get better medical care if they belonged to a different racial or ethnic group. Although 81% of people who completed the survey had received the flu vaccine in the past, only two-thirds said they had received a COVID-19 vaccine. Of 50 people who remained unvaccinated, only half said they had been offered a COVID-19 shot. One third said they did not plan to be vaccinated. 

The participants who did not plan on receiving a vaccine listed several reasons why. More than half said they had concerns about vaccine side effects, 53% feared a rheumatic disease flare, 32% said they knew someone who had a bad experience with the vaccine, 21% said they worried about getting COVID-19 from the vaccine, and 18% were concerned that the vaccine would “modify my DNA.” Unvaccinated patients also expressed their desire to have more information about the safety and efficacy of the vaccine in people with a rheumatic disease. After multivariable adjustment, researchers found that patients of an older age, not having safety concerns about the new vaccine, having gotten a flu shot in the past, and having higher vaccine confidence overall were associated with receipt of a COVID-19 vaccine. There was no association between reporting medical mistrust and vaccine receipt. 

“Our findings suggest that a one-size-fits-all approach is not a viable solution to help inform COVID-19 vaccine decisions among people with rheumatic disease,” says Dr. Danila. “To build trust, it is important to listen to understand why people may be reluctant to become vaccinated, and to address their specific concerns in an empathic and non-judgmental.

Posted on Rheumatoid arthritis

Ultra-Low Dose Rituximab Controls Disease Activity for Most RA Patients in New Study

Women wearing suits shirt & tie 162 - YouTube

 New research presented this week at ACR Convergence, the American College of Rheumatology’s annual meeting, shows that in one study, the majority of rheumatoid arthritis patients on an ultra-low dose of the drug rituximab maintained low disease activity for up to four years, and rarely needed to switch to other biologic drugs or glucocorticoids to control their disease (Abstract #1443). 

Rheumatoid arthritis (RA) is the most common type of autoimmune arthritis. It is caused when the immune system (the body’s defense system) is not working properly. RA causes pain and swelling in the wrist and small joints of the hands and feet.The optimal dose of rituximab for RA treatment remains unclear, and both 1,000 and 2,000 milligram doses every six months have been shown to be equally effective in previous studies. In another recent trial, six-month efficacy of ultra-low rituximab doses of 200 mg and 500 mg were compared to the 1,000 mg dose. Patients in that trial were invited to participate in this new extension trial to follow their progress on ultra-low doses of rituximab for up to four years. “We conducted this extension (study) to build on the results of the original trial. In that study, the effects of 200 and 500 mg appeared to be similar to those of 1,000 mg, but we could not yet show that statistically,” says Nathan den Broeder, MSc, a PhD student at Sint Maartenskliniek in the Netherlands and the study’s co-author. “There was also a concern that the lower doses might work for a limited time, but then lose their effect on a longer time frame.” Data was collected on patients’ disease activity through April 2021 measured by disease activity scores, or DAS-28, and C-reactive protein levels, and their use of RA medications, including biologic or targeted disease-modifying anti-rheumatic drugs (DMARDs), conventional synthetic DMARDs and glucocorticoids. The primary outcome for the study was disease activity, and secondary outcomes included rituximab persistence, doses and intervals, as well as use of other RA medications. 

Out of 142 patients in the previous trial, 118 were included in this new extension study, with a mean follow-up period of 3.2 years. Seven patients switched to another biologic or targeted synthetic DMARD and were then removed from the disease activity analyses. Researchers found that patients taking either ultra-low dose rituximab had non-inferior disease activity compared to those on 1,000 mg. The median yearly rituximab dose was 978 mg. The final rituximab dose per infusion was 200 mg in 37 patients, 500 mg in 47 patients, and 1,000 mg in 34 patients. The median final interval between infusions was 6.0 months for those on 200 mg, 6.2 months for those on 500 mg, and 6.4 months for those on 1,000 mg. The need for glucocorticoid treatment, typically required with patients’ disease flares, was low: 0.38 steroid injections per patient-year and 0.05 initiations or dose increases of oral glucocorticoids per patient year. The study’s results show that most patients in the trial who were treated with ultra-low dose rituximab remained on these doses, in some cases for up to four years, maintained low disease activity, and their disease activity did not differ in any relevant way between doses. Patients on ultra-low doses of rituximab rarely needed to switch to other disease-modifying drugs or use glucocorticoids. 

“Ultra-low dose rituximab is effective in many patients who already responded well to higher doses. The benefits are significant: we showed in the original trial that ultra-low dose rituximab results in fewer infections compared to the standard 1,000 mg dose, something that is especially relevant in the current pandemic,” says den Broeder. “Another benefit is that the duration of the infusion, which can normally take several hours, can be shortened with administering these lower doses. Finally, there are important cost-savings with using ultra-low dose rituximab, a relatively expensive drug. In short, by using ultra-low dose rituximab, patients can expect fewer infections as side effects, shorter infusion times, and lower treatment costs.”

Posted on Rheumatoid arthritis

New biomarkers could predict rheumatoid arthritis susceptibility

New biomarkers could predict rheumatoid arthritis susceptibility
New biomarkers could predict rheumatoid arthritis susceptibility


Cells from a cheek swab revealed biomarkers for rheumatoid arthritis that could lead to a way to diagnose and begin treatment before the disease develops, according to a study published in Scientific Reports.

In the study, researchers from Washington State University and Arthritis Northwest in Spokane, Washington identified a set of epimutations in cells from women who had rheumatoid arthritis that were distinct from those without the joint-damaging autoimmune disease. Epimutations are molecular factors and processes around DNA that regulate genome activity, independent of DNA sequence.

The discovery could advance treatment for rheumatoid arthritis, said Michael Skinner, the senior author on the paper.

“If we can identify these patients ten years earlier before the disease develops, it opens up a whole arena of preventative medicine that we did not have access to before,” said Skinner, a professor in WSU’s School of Biological Sciences.

Rheumatoid arthritis affects about 200,000 people in the U.S. each year with a higher prevalence in women than in men. While current drug treatments have limited efficacy in many patients who have already developed the disease, some studies have shown that treatments begun in early stages of the disease can cause remission of symptoms.

Having biomarkers could allow treatment to begin even earlier before the first signs of it start, Skinner said.

For the study, researchers collected buccal, or cheek, cells using a swab from two cohorts of women: a group of 26 Caucasian women from Spokane and a group of 23 African-American women from Los Angeles. In each group, about half of the women had rheumatoid arthritis with the other half serving as a control.

Even though they are taken from the cheek, buccal cells allowed the researchers to conduct an epigenome-wide analysis. Translating literally as “above” the genome, an epigenome consists of chemical factors that can modify the genome and change its behavior. While not part of DNA itself, epimutations can still be passed down to subsequent generations.

In this study, the researchers found epimutations in areas called DNA methylation regions, among the women in both groups who had rheumatoid arthritis. The study was designed to see if there were differences between racial groups since African Americans have shown some signs of increased prevalence of rheumatoid arthritis. However, while some differences were noted, the researchers found a large overlap in epimutations among women with rheumatoid arthritis of both races, meaning the identified biomarkers hold a strong signal for the disease.

“Surprisingly, most of the DNA methylation sites we found that were consistent among patients with the disease were associated with genes previously known to be involved in rheumatoid arthritis,” said Skinner.

The findings add evidence that the disease is likely systemic, Skinner said, meaning it was found not just in immune system cells involved in rheumatoid arthritis development but in many different cells throughout the body.

The research team also tested an immune-related monocyte cell type in blood samples from a portion of the women, but the buccal cells showed the epimutations as well, indicating that a relatively non-invasive diagnostic cheek swab test could be developed to screen for the disease.