Network meta-analysis on efficacy and safety of different biological agents in treatment of rheumatoid arthritis / 中国组织工程研究

OBJECTIVE:There are many kinds of biological agents for the treatment of rheumatoid arthritis in clinic,but the differences in therapeutic efficacy and safety are still unclear.The purpose of this study is to compare the differences in effectiveness and safety of different biological agents for the treatment of rheumatoid arthritis. METHODS:CNKI,VIP,WanFang,China Biomedical Literature System,PubMed,Cochrane Library,Web of Science,and Embase databases were searched to collect the randomized controlled trials on biological agents for rheumatoid arthritis that meet the requirements from inception to October 1,2022.The literature was selected by EndNote software,and the quality of the included literature was evaluated by RevMan 5.3 software.The software Stata 14.2 was used for direct meta-analysis and network meta-analysis of ACR20(American College of Rheumatology 20%response),ACR50(American College of Rheumatology 50%response),ACR70(American College of Rheumatology 70%response),erythrocyte sedimentation rate,and adverse reactions. RESULTS:Totally 39 articles were included,including 5 low-risk articles,4 high-risk articles,and the remaining 30 articles contained unknown risk bias,with a total of 13 treatment measures.The results of network meta-analysis:(1)In ACR20,infliximab combined with methotrexate(OR=5.54,95%CI:1.33-23.01,P<0.05),abatacept+methotrexate tablets(OR=3.21,95%CI:1.13-9.10,P<0.05),and tocilizumab(OR=2.95,95%CI:1.61-5.44,P<0.05)were better than methotrexate tablets.The probabilistic ranking of ACR20 was:infliximab+methotrexate tablets>abatacept+methotrexate tablets>tocilizumab>certlizumab>etanercept+methotrexate tablets.(2)In the aspect of ACR50,etanercept combined with methotrexate tablets(OR=4.04,95%CI:2.13-7.66,P<0.05),infliximab combined with methotrexate tablets(OR=4.79,95%CI:1.19-19.26,P<0.05),and tocilizumab combined with methotrexate tablets(OR=3.54,95%CI:1.36-9.22,P<0.05)had better therapeutic effects than methotrexate tablets.The probabilistic ranking of ACR50 was:etanercept+methotrexate tablets>infliximab+methotrexate tablets>tocilizumab+methotrexate tablets>tocilizumab>certlizumab+methotrexate tablets.(3)In terms of ACR70,the therapeutic effects of infliximab combined with methotrexate tablets(OR=8.00,95%CI:2.31-27.69,P<0.05),etanercept combined with methotrexate tablets(OR=4.26,95%CI:2.51-7.21,P<0.05),and tocilizumab combined with methotrexate tablets(OR=3.51,95%CI:1.82-6.80,P<0.05)were better than methotrexate tablets.The probabilistic ranking of ACR70 was infliximab+methotrexate tablets>etanercept+methotrexate tablets>tocilizumab+methotrexate tablets>certlizumab>adalimumab+methotrexate tablets.(4)In erythrocyte sedimentation rate,etanercept combined with methotrexate tablets(SMD=-9.23,95%CI:-16.55 to-1.92,P<0.05)was better than etanercept and methotrexate tablets(SMD=14.59,95%CI:7.28-21.91,P<0.05).The probabilistic ranking of erythrocyte sedimentation rate was etanercept+methotrexate tablets>infliximab+methotrexate tablets>etanercept>adalimumab+methotrexate tablets>methotrexate tablets.(5)In terms of adverse reactions,placebo(OR=0.62,95%CI:0.39-0.99,P<0.05)was better than infliximab and certlizumab(OR=0.44,95%CI:0.25-0.78,P<0.05).The probabilistic ranking of adverse reactions was placebo>infliximab>etanercept+methotrexate tablets>certlizumab>etanercept. CONCLUSION:Based on evidence from 39 randomized controlled trials,infliximab combined with methotrexate tablets(highly recommended)can be the first choice in clinic,and etanercept combined with methotrexate tablets(highly recommended)can be the second choice in terms of good effectiveness and safety.

Comparative effectiveness of abatacept versus TNF inhibitors in rheumatoid arthritis patients who are ACPA and shared epitope positive

Abstract Background The HLA-DRB1 shared epitope (SE) is a risk factor for the development of rheumatoid arthritis (RA) and the production of anti-citrullinated protein antibodies (ACPAs) in RA patients. Our objective was to examine the real-world effectiveness of abatacept versus tumor necrosis factor inhibitors (TNFi) in patients with RA who were SE and anti-cyclic citrullinated peptide antibody (anti-CCP3) positive. Methods Abatacept or TNFi initiators who were SE + and anti-CCP3+ (> 20 U/mL) at or prior to treatment and had moderate or high CDAI score (> 10) at initiation were identified. The primary outcome was mean change in CDAI score over six months. Analyses were conducted in propensity score (PS)-trimmed and -matched populations overall and a biologic-experienced subgroup. Mixed-effects models were used. Results In the overall PS-trimmed (abatacept, n = 170; TNFi, n = 157) and PS-matched cohorts (abatacept, n = 111; TNFi, n = 111), there were numerically greater improvements in mean change in CDAI between abatacept and TNFi but were not statistically significant. Similar trends were seen for biologic-experienced patients, except that statistical significance was reached for mean change in CDAI in the PS-trimmed cohort (abatacept, 12.22 [95% confidence interval (95%CI) 10.13 to 14.31]; TNFi, 9.28 [95%CI 7.08 to 11.48]; p = 0.045). Conclusion In this real world cohort, there were numerical improvements in efficacy outcomes with abatacept over TNFi in patients with RA who were SE + and ACPA+, similar to results from a clinical trial population The only statistically significant finding after adjusting for covariates was greater improvement in CDAI with abatacept versus TNFi in the bio-experienced PS-trimmed cohort. .

Signal mining and analysis of adverse drug events of abatacept based on FAERS database / 中国药房

OBJECTIVE To provide a reference for the safe use of abatacept in clinic. METHODS Based on the United States FDA Adverse Event Reporting System （FAERS） database， the generic name of the drug “abatacept” and the trade name “Orencia” were used as the search keywords to retrieve drug adverse event （ADE） signal of abatacept as primary suspected drug. The reported odds ratio method and proportional reporting ratio method in the proportional imbalance method and Excel 2020 software were used to mine and analyze the signals. RESULTS A total of 93 189 abatacept-induced ADE reports were retrieved， mainly female cases （75.98%）， and the age was mainly concentrated in 18-64 years old （35.17%）； main countries reporting data were the United States （47.41%） and Canada （30.59%）， and the number of reports was generally increasing year by year. A total of 3 092 ADE signals were screened， of which the signals associated with the primary disease were similar to those described in the drug instruction of abatacept， such as rheumatoid arthritis， arthralgia， joint swelling， etc.； followed by ADE signals related to infusion reactions， including pain， fatigue， rash， etc. All selected ADE signals involved 27 system organ classes， mainly involved systemic diseases and drug site conditions， musculoskeletal and connective tissue diseases， injury， poisoning and surgical complications， infections and invasive diseases， gastrointestinal diseases， neurological diseases， respiratory， thoracic and mediastinal diseases， heart diseases， benign， malignant and unspecified tumors and reproductive system and breast diseases， etc. A total of 22 ADE signals were not included in the drug instructions of abatacept among the top 50 ADE signals in the number list of reported cases， including fatigue， drug intolerance， abdominal discomfort， swelling， lupus erythematosus， peripheral swelling， cell sores， diarrhea， elevated liver enzymes and lower respiratory tract infection， etc. CONCLUSIONS In the process of clinical use of abatacept， special attention should be paid to infection and its carcinogenicity， while assessing the risk of respiratory and cardiovascular system diseases in patients； when patients suffer from these two underlying diseases， the pros and cons should be weighed carefully before selecting drug； in addition， the drug-induced ADE in the neurological， gastrointestinal and reproductive system cannot be ignored.

Compared efficacy of rituximab, abatacept, and tocilizumab in patients with rheumatoid arthritis refractory to methotrexate or TNF inhibitors agents: a systematic review and network meta-analysis

Abstract Background Our aim was to compare the efficacy of rituximab, tocilizumab, and abatacept in individuals with rheumatoid arthritis (RA) refractory to treatments with MTX or TNFi agents. Methods We searched 6 databases until January 2023 for phase 2-4 RCTs evaluating patients with RA refractory to MTX or TNFi therapy treated with rituximab, abatacept, and tocilizumab (intervention arm) compared to controls. Study data were independently assessed by two investigators. The primary outcome was considered as achieving ACR70 response. Results The meta-analysis included 19 RCTs, with 7,835 patients and a mean study duration of 1.2 years. Hazard ratios for achieving an ACR70 response at six months were not different among the bDMARDs, however, we found high heterogeneity. Three factors showing a critical imbalance among the bDMARD classes were identified: baseline HAQ score, study duration, and frequency of TNFi treatment in control arm. Multivariate meta-regression adjusted to these three factors were conducted for the relative risk (RR) for ACR70. Thus, heterogeneity was attenuated (I2 = 24%) and the explanatory power of the model increased (R2 = 85%). In this model, rituximab did not modify the chance of achieving an ACR70 response compared to abatacept (RR = 1.773, 95%CI 0.113-10.21, p = 0.765). In contrast, abatacept was associated with RR = 2.217 (95%CI 1.554-3.161, p < 0.001) for ACR70 compared to tocilizumab. Conclusion We found high heterogeneity among studies comparing rituximab, abatacept, and tocilizumab. On multivariate metaregressions, if the conditions of the RCTs were similar, we estimate that abatacept could increase the chance of reaching an ACR70 response by 2.2-fold compared to tocilizumab. Key messages Abatacept could increase the chance of reaching an ACR70 response by 2.2-fold compared to tocilizumab.

Desarrollo de psoriasis durante el tratamiento con Abatacept en artritis reumatoidea / Development of psoriasis during treatment with Abatacept in rheumatoid arthritis

Abatacept es el primer agente biológico aprobado para el tratamiento de la Artritis Reumatoidea (AR) que actúa inhibiendo la co-estimulación de linfocitos T. Si bien se ha reportado su eficacia en psoriasis y artritis psoriásica, existen casos de psoriasis inducida por el fármaco como así también reactivación de las lesiones en pacientes previamente enfermos. Una mujer con antecedentes de AR en tratamiento con Abatacept endovenoso presentó máculas eritemato-escamosas y pruriginosas en toda la superficie corporal, clínica e histológicamente compatibles con psoriasis. La suspensión del tratamiento con Abatacept, ocasionó la desaparición de las lesiones cutáneas. Mas de 4 años después se encuentra en tratamiento con Rituximab sin haber vuelto a presentar compromiso cutáneo.

Abatacept is the first biological agent approved for the treatment of Rheumatoid Arthritis (RA) that acts blocking interaction of T lymphocytes. Although its efficacy in psoriasis and psoriatic arthritis has been reported, there are reports of drug induced psoriasis as well as reactivation of cutaneous lesions. A woman with a history of RA under treatment with Abatacept IV presented erythematous-scaly and pruritic macules on the entire body surface, clinically and histologically compatible with psoriasis. The suspension of treatment with Abatacept caused the disappearance of the cutaneous lesions. More than 4 years later he is in treatment with Rituximab without presenting cutaneous lesions.

Pancitopenia y aplasia medular asociada a abatacept en una paciente con Artritis Reumatoide / Pancytopenia and medular aplasia associated to abatacept in a patient with rheumatoid arthritis

El tratamiento de pacientes con artritis reumatoide (AR) debe ser temprano y agresivo para prevenir el daño articular y la discapacidad. Los fármacos no biológicos modificadoes de enfermedad, como el metotrexato, han sido utilizados par controlar la actividad de la enfermedad y para prevenir el daño de las articulaciones. Existen pacientes con AR resistentes al tratamiento con fármacos modificadores de la enfermedad y otros que no responden adecuadamente a la terapia con inhibidores de factores de necrosis tumoral. Nosotros describimos el caso de una paciente de sexo femenino de 77 años que se presentó al servicio de emergencias con fiebre, mucositis y mal estado general luego de recibir una dosis de abatacept. A su ingreso el laboratorio demostró: glóbulos blancos 500 cel/mm3, neutrófilos 150 cel/mm3, plaquetas 21000 cel/mm3, hematocrito 29%, VCM 81, LDH 314 UI/L, función renal y hepatograma normales. En el examen clínico se objetivaron ulceras y lesiones ampollares en mucosa yugal. El medulograma evidenció hipocelularidad, con disminución de las tres series. El informe anatomopatológico fue de médula ósea hipoplásica. Recibió tratamiento con factor estimulante de colonias de neutrófilos, ácido fólico y metilprednisona, con resolución del cuadro a los 3 días de instituido el tratamiento. Hasta nuestro conocimiento esta es la primera comunicación de pancitopenia asociada a abatacept es una paciente con artritis AR intolerante a metotrexato

Treatment of patient with rheumatoid arthritis (RA) should be early and aggressive to prevent joint injury and disability. Disease-modifying antirheumatic drugs (DMARDs) like methotrexate has been used as initial treatment toward the disease activity and to prevento joint damage. Some patients with RA are resistant to initial therapy with nonbiiologic DMARDs or TNF inhibitiors. We described a 77 years old women who presented to the emergency room with fever andoral lesions after been treated with abatacept. On examination patient appeared ill. She had oral ulcers. laboratory testing showed white cells count 500 cells per mm3, hematocrit 29 %, platelets count 21000 cells per mm3, LDH 314 U/l. Renal and liver functions were normal. Bone marrow showed decreased in the three cells lineages. Patient was treated with granulocyte colony-stimulating factor, folic acid, and prednisone. Patient improved her physical and laboratory features three days after admission. This case showed the rare association between pancytopenia and abatacept in a patient with RA

Eficacia de medicamentos biológicos aprobados por ley 20850, para pacientes con artritis reumatoide refractaria a tratamiento / Efficacy of biological drugs approved by law N°20. 850, for patients with rheumatoid arthritis refractory to treatment

INTRODUCCIÓN: La artritis reumatoide es una enfermedad crónica, sistémica, de origen autoinmune, caracterizada por compromiso articular simétrico. Dentro de su tratamiento destacan fármacos antirreumáticos, modificadores de la enfermedad, glucocorticoides y agentes biológicos. Estos últimos, han llegado a revolucionar la progresión de la enfermedad, otorgando una mejor calidad de vida a los pacientes. CUERPO DE LA REVISIÓN: En Chile, los fármacos biológicos están asegurados para personas con artritis reumatoide refractaria a tratamiento por la ley 20.850 "Ley Ricarte Soto", que incluye los fármacos adalimumab, etanercept, abatacept y rituximab. Por lo tanto, el objetivo de esta investigación fue resumir los principales estudios que aseguran la eficacia de estos medicamentos. CONCLUSIÓN: Se ha demostrado la eficacia de los medicamentos biológicos, con clara superioridad en relación con la progresión radiológica, síntomas, alteración funcional y nivel de actividad de la enfermedad comparativamente con los placebos.

INTRODUCTION: Rheumatoid arthritis is a chronic, systemic disease of autoimmune origin, characterized by symmetrical joint involvement. Its treatment includes antirheumatic drugs, disease modifiers, glucocorticoids and biological agents. The latter have come to revolutionize the progression of the disease, giving a better quality of life to patients. REVIEW BODY: In Chile, biological drugs are insured for people with rheumatoid arthritis refractory to treatment by the 20.850 "Ricarte Soto Law", which includes the drugs adalimumab, etanercept, abatacept and rituximab. Therefore, the objective of this research was to summarize the main studies that ensure the efficacy of these medications. CONCLUSION: The efficacy of biological drugs has been demonstrated, with clear superiority in relation to radiological progression, symptoms, functional alteration and level of disease activity compared to placebos.

The role of abatacept in the treatment of type 2 diabetic nephropathy in rats / 中华内分泌代谢杂志

Objective To observe the role of abatacept in the treatment of diabetic nephropathy in rats. Methods Type 2 diabetic nephropathy rat model was established, and was randomly divided into abatacept group and non-intervention group, 15 each. 15 normal rats were served as control group ( NC) . The abatacept group was given abatacept for 8 weeks. The control group was set at the same time period. Then the blood biochemical indexes, blood flow parameters of renal main artery, elasticity of renal parenchymal, HE staining of renal parenchymal and ultrastructure of podocytes were all evaluated. The expression of CD31, CD34, podocin, nephrin, and B7-1 in renal parenchyma were detected. Results Compared to the NC group, the fasting blood glucose, creatinine clearance rate, urine albumin excretion rate, and kidney hypertrophy index in the non-intervention and abatacept groups were significantly increased (P<0. 05);creatinine clearance rate, urine albumin excretion rate, and kidney hypertrophy index in the abatacept group were significantly lower compared to the non-intervention group (P<0. 05). There were significant differences in peak systolic velocity, end diastolic velocity, and mean velocity among these 3 groups, and these differences were ranked as non-intervention group<abatacept group<control group ( P<0. 05 ); there were significant differences in systolic acceleration, pulsatility index, and resistance index among these three groups, with the differences ranked as non-intervention>abatacept>control groups (P<0. 05). There were significant differences in the stiffness of kidneys among these three groups, with the differences ranked as non-intervention>abatacept>control groups (P<0. 05). HE staining and transmission electron microscope observation showed that there were obvious changes in the renal parenchyma of rats in the non-intervention group and the abatacept group, and the changes of kidney in the non-intervention group were worse than those in the abatacept group. CD31 and CD34 expression in kidney parenchyma of rats in the abatacept group and non-intervention group were higher than those in the control group, the abatacept group and non-intervention group>the control group (P<0. 05), while no significant differences between the abatacept group and non-intervention group in CD31 and CD34 expression (P>0. 05). There were significant differences in podocin and nephrin expression in kidney parenchyma of rats among these three groups, and these differences were ranked as the control>abatacept>non-intervention groups (P<0. 05). There were significant differences in B7-1 expression in kidney parenchyma of rats among these three groups, and these differences were ranked as the control<abatacept<non-intervention groups (P<0. 05). Conclusion Abatacept may significantly alleviate the renal injury in type 2 diabetic nephropathy rats.

Long-term Safety and Efficacy of Abatacept in Koreans with Rheumatoid Arthritis

OBJECTIVE: The safety and efficacy of intravenous (IV) abatacept in patients with active RA unresponsive to methotrexate have been demonstrated in short-term (ST) studies in global populations and a ST, Phase III study in a Korean patient population. Abatacept's long-term safety and efficacy profile has been established in open-label global studies with treatment up to 5 years. The objective of this study was to determine the long-term safety and efficacy of abatacept in patients with RA from the ST Korean study. METHODS: This was an open-label long-term extension (LTE) of a Phase III, multicenter, randomized, double-blind, placebo-controlled study in which Korean patients who had received IV abatacept or placebo in the ST trial (169 days) were given the option to receive open-label abatacept to Day 1485 with 84 days' follow-up (total 1,569 days, ~4 years). RESULTS: A total of 105 patients were enrolled in the LTE (86.7% female, median age 49.0 years). Abatacept was generally well tolerated. Adverse events were mostly mild or moderate and no new safety signals were identified. Improvement in disease activity (assessed by ACR response and DAS28 [CRP]), physical function (assessed by KHAQ-DI), and quality of life (assessed by SF-36 score) were maintained in patients initially treated with abatacept or observed in patients who had switched to abatacept after placebo in the ST study. CONCLUSION: Long-term treatment with IV abatacept over 1485 days was generally well tolerated in Korean patients with RA. Additionally, the efficacy profile from the ST study was maintained over the LTE.

Long-term Safety and Efficacy of Abatacept in Koreans with Rheumatoid Arthritis

OBJECTIVE: The safety and efficacy of intravenous (IV) abatacept in patients with active RA unresponsive to methotrexate have been demonstrated in short-term (ST) studies in global populations and a ST, Phase III study in a Korean patient population. Abatacept's long-term safety and efficacy profile has been established in open-label global studies with treatment up to 5 years. The objective of this study was to determine the long-term safety and efficacy of abatacept in patients with RA from the ST Korean study. METHODS: This was an open-label long-term extension (LTE) of a Phase III, multicenter, randomized, double-blind, placebo-controlled study in which Korean patients who had received IV abatacept or placebo in the ST trial (169 days) were given the option to receive open-label abatacept to Day 1485 with 84 days' follow-up (total 1,569 days, ~4 years). RESULTS: A total of 105 patients were enrolled in the LTE (86.7% female, median age 49.0 years). Abatacept was generally well tolerated. Adverse events were mostly mild or moderate and no new safety signals were identified. Improvement in disease activity (assessed by ACR response and DAS28 [CRP]), physical function (assessed by KHAQ-DI), and quality of life (assessed by SF-36 score) were maintained in patients initially treated with abatacept or observed in patients who had switched to abatacept after placebo in the ST study. CONCLUSION: Long-term treatment with IV abatacept over 1485 days was generally well tolerated in Korean patients with RA. Additionally, the efficacy profile from the ST study was maintained over the LTE.

Efficacy, safety and tolerability of using abatacept for the treatment of rheumatoid arthritis

The objective is to provide an update on the clinical efficacy, safety and tolerability of the use of abatacept for treating rheumatoid arthritis. A systematic review (up to June 2011) followed by meta-analyses was performed. Randomized controlled clinical trials comparing abatacept at a dose of 10 mg/kg with a placebo, both with concomitant methotrexate, were used. Only high- or moderate-quality studies were included. The efficacy was evaluated based on changes in the ACR, DAS and HAQ; safety was assessed based on serious adverse events, serious infections, malignancies and deaths; tolerability was evaluated based on the withdrawals due to adverse events, serious adverse events and lack of efficacy. All these parameters were evaluated within one year of treatment. Nine studies met the inclusion criteria, comprising 4,219 patients. For all of the efficacy parameters, the abatacept group had better results than the placebo group, except in the case of HAQ improvement >0.3, which presented no statistically significant difference. None of the safety parameters presented a significant difference between the groups. The tolerability parameters were also similar between groups, with the exception of withdrawals due to lack of efficacy. For this criterion, the abatacept group presented favorably compared to the control group. Abatacept showed a higher efficacy compared to placebo without significant differences between the abatacept and control group in terms of safety.

O objetivo foi fornecer dados atualizados sobre eficácia clínica, segurança e tolerabilidade do uso de abatacepte para o tratamento da artrite reumatoide. Realizaram-se uma revisão sistemática (com dados até junho/2011) e metanálises. Somente estudos clínicos controlados randomizados comparando o abatacepte (10 mg/kg) com placebo, ambos com uso concomitante de metotrexato, foram incluídos; todos possuíam qualidade alta ou moderada. A eficácia foi avaliada baseando-se em mudanças no ACR, DAS e HAQ; a segurança foi avaliada pelos eventos adversos e infecções graves, malignidades e mortes e a tolerabilidade pelo abandono do tratamento devido a eventos adversos (graves ou não) e falta de eficácia. Todos esses parâmetros foram avaliados ao final de um ano de tratamento. Nove estudos se adequaram aos critérios de inclusão, envolvendo 4219 pacientes. Em todos os parâmetros avaliados, o grupo tratado com abatacepte obteve melhores resultados, exceto para a melhora (>0,3) no HAQ (sem diferença estatisticamente significativa). Nenhum critério de segurança ou tolerabilidade apresentou diferença significativa entre os grupos, com exceção dos abandonos devido à falta de eficácia (grupo abatacepte apresentou resultados favoráveis em relação ao controle). O abatacepte possui maior eficácia quando comparado com o placebo, sem diferença significativa entre os grupos em termos de segurança.

Seguridad de abatacept en pacientes con artritis reumatoidea / Safety of abatacept in patients with rheumatoid arthritis

Abatacept (ABA) es una proteína de fusión que inhibe la señal coestimulatoria del linfocito T y está indicado en pacientes con artritis reumatoidea (AR) y artritis crónica juvenil moderada a severa sin respuesta a metotrexato (MTX). ABA ha demostrado su eficacia y seguridad en numerosos estudios controlados, doble ciego, randomizados en poblaciones seleccionadas. La incidencia de eventos adversos en estos estudios oscila entre 80 y 400 por 100 pacientes año. El objetivo del presente estudio fue evaluar la seguridad de ABA en pacientes con AR no seleccionados de la vida real. Material y métodos: Se incluyeron en forma consecutiva todos los pacientes con AR (criterios ACR'87) de 4 centros de reumatología que hubieran recibido al menos 1 dosis de ABA. Se consignaron datos socio-demográficos, características clínicas de la enfermedad, número de infusiones, dosis, y medicación concomitante. Se evaluaron todos los eventos adversos y se determinó la severidad y causalidad. Se consideraron las causas de suspensión del tratamiento. Análisis estadístico: Se evaluó la incidencia de eventos adversos/100 pacientes año de tratamiento, las variables categóricas fueron comparadas por Chi cuadrado y las continuas por test de Student o ANOVA...

Abatacept (ABA) is a fusion protein that inhibits the T cell costimulatorysignal and is indicated in patients with moderate to severe RheumatoidArthritis (RA) and Juvenil Idiopathic Arthritis, not responding to methotrexate. ABA has demonstrated eficacy and security in severalcontrolled, double-blind, randomized studies in selected populations.The objective of the present study was to evaluate security of ABA in patients with RA in the real life. Material and Methods: Consecutive patients with RA (ACR´87 classification) from 4 rheumatology centers that received at least one infusion of ABA were included. Socio-demographic data, disease characteristics, number of infusions, dosis, and concomitant medicationswere registered. All Adverse Events (AE) were evaluated and severityand causality were determined. Causes of treatment discontinuationwas also considered.Statistical analysis: Incidence of AE per 100 patient-years was evaluated, categorical variables were compared by Chi2 and continuous variables by Student T-test or ANOVA. Results: 184 patients were included, 155 (84.2%) were female, median age was 56 years (IQR 48-64) and median duration of disease was 13 years (IQR 8-18). 94.7% of the patients were rheumatoidfactor-positive and 82% had erosive disease. 90% were treatedwith concomitant DMARDs, methotrexate being the most frequent(76.5%). In 67% of the patients ABA was the first biologic agent used, and 23% had previously received at least one anti-TNF. Median duration of treatment with ABA was 24 months (IQR 11-34) and median number of infusions was 23 (IQR 10-34). Incidence of all AE was 46.18 per 100 patient-years, being the more frequents: Infections (27.3 per 100 patient-years), and infusion reactions (8.6 per100 patient-years)...

Uso do abatacepte em uma paciente com artrite psoriásica / Use of the abatacept in a patient with psoriatic arthritis

Artrite psoriásica (AP) é uma artrite inflamatória soronegativa de causa desconhecida. Classicamente, a AP apresenta cinco formas clínicas, sendo a oligoartrite assimétrica a mais comum. Descrevemos o caso de uma paciente com AP refratária às drogas modificadoras da doença, que evoluiu com hepatite medicamentosa após quimioprofilaxia com isoniazida, administrada previamente ao tratamento com anti-TNFα. Em virtude do risco de ativação de tuberculose (TB) latente pela administração de anti-TNFα, da hepatotoxicidade decorrente do tratamento da TB, e baseado no fato de o tratamento da AP se assemelhar ao da artrite reumatoide, optou-se pelo tratamento empírico com abatacepte. Aproximadamente vinte dias após a segunda dose do biológico, a paciente evoluiu com importante melhora clínica, resolução da artrite, regressão das lesões de pele e melhora da anemia e das provas de atividade inflamatória.

Psoriatic arthritis (PA) is an inflammatory seronegative arthritis of unknown origin. Classically, PA has five clinical forms, and asymmetric oligoarthritis is the most common type. We describe the case of a patient with PA refractory to disease-modifying drugs, who developed drug-induced hepatitis after chemoprophylaxis with isoniazid, administered prior to the treatment with an anti-TNFα agent. Due to the risk of activating latent tuberculosis with the administration of anti-TNFα and hepatotoxicity onset caused by the TB treatment and based on the fact that the treatment of PA is similar to the treatment of rheumatoid arthritis, a decision was made to use the empirical treatment with abatacept. Approximately twenty days after the second infusion of the drug, the patient showed clinical improvement, resolution of the arthritis, almost complete disappearance of the skin lesions and improvement of anemia and inflammatory tests.

Description of the Efficacy and Safety of Three New Biologics in the Treatment of Rheumatoid Arthritis

English articles on abatacept, golimumab, and tocilizumab in rheumatoid arthritis published between 2002 and 2009 were reviewed systematically. All randomized clinical trials, open-label extensions, meta-analyses, and reviews were examined. There were thirteen articles on abatacept, four on golimumab, and seven on tocilizumab. All three drugs were effective in methotrexate-naive, methotrexate-incomplete responders, and tumor-necrosis-factor-failure rheumatoid arthritis patients. Of the three, only abatacept has been tested in a head-to-head trial with infliximab, in which it was found to be equivalent to infliximab. Golimumab resulted in a more modest improvement than the others in methotrexate-naive patients, although no direct comparisons among the three drugs were possible or appropriate. Descriptive analysis of adverse events showed that patients receiving abatacept, golimumab, and tocilizumab were subject to more adverse events than controls overall, as expected. In the abatacept studies, a few cases of tuberculosis, more cardiovascular events and gastrointestinal bleedings and more basal cell carcinoma were seen. Golimumab was associated with more skin rashes and pneumonia, while tocilizumab was associated with increased lipids, more liver-function abnormalities, and neutropenia. These new medications are useful additions to the rheumatologic armamentarium and represent greater convenience (golimumab) or different mechanisms of action (abatacept and tocilizumab) than tumor-necrosis-factor inhibitors for treating rheumatoid arthritis. As expected, some adverse events occur when using these drugs and patients need to be watched carefully.

IL-2 Pathway Blocking in Combination with Anti-CD154 Synergistically Establishes Mixed Macrochimerism with Limited Dose of Bone Marrow Cells and Prolongs Skin Graft Survival in Mice

To facilitate the establishment of mixed chimerism with limited dose of bone marrow (BM) cells, and to achieve tolerance in skin graft model, combined blocking of costimulatory pathway and IL-2 pathway was used in minimally myeloablative model using busulfan. BM cells (2.5 x 10(7)) of BALB/c were injected into C57BL/6 mice at day 0 with full thickness skin graft after single dose injection of busulfan (25 mg/kg) on day-1. Recipients were grouped and injected the anti-CD154, CTLA4-Ig, anti-IL-2R at days 0, 2, 4, and 6 according to protocol. Mixed macrochimerism were induced in groups treated with anti-CD154+anti-CTLA4-Ig, anti-CD154+anti-IL-2R, and anti-CD154+anti-CTLA4 Ig+anti-IL-2R. Three groups having chimerism enjoyed prolonged graft survival more than 6 months. Superantigen deletion study revealed deletion of alloreactive T cells in combined blockade treated groups. In graft versus host disease model using CFSE staining, CD4+ T cell and CD8+ T cell proliferation were reduced in groups treated with CTLA4-Ig or anti-IL-2R or both in combination with anti-CD154. However, anti-IL-2R was not so strong as CTLA4-Ig in terms of inhibition of T cell proliferation. In conclusion, IL-2 pathway blocking combined with anti-CD154 can establish macrochimerism with limited dose of BM transplantation and induce specific tolerance to allograft.

IL-2 Pathway Blocking in Combination with Anti-CD154 Synergistically Establishes Mixed Macrochimerism with Limited Dose of Bone Marrow Cells and Prolongs Skin Graft Survival in Mice

To facilitate the establishment of mixed chimerism with limited dose of bone marrow (BM) cells, and to achieve tolerance in skin graft model, combined blocking of costimulatory pathway and IL-2 pathway was used in minimally myeloablative model using busulfan. BM cells (2.5 x 10(7)) of BALB/c were injected into C57BL/6 mice at day 0 with full thickness skin graft after single dose injection of busulfan (25 mg/kg) on day-1. Recipients were grouped and injected the anti-CD154, CTLA4-Ig, anti-IL-2R at days 0, 2, 4, and 6 according to protocol. Mixed macrochimerism were induced in groups treated with anti-CD154+anti-CTLA4-Ig, anti-CD154+anti-IL-2R, and anti-CD154+anti-CTLA4 Ig+anti-IL-2R. Three groups having chimerism enjoyed prolonged graft survival more than 6 months. Superantigen deletion study revealed deletion of alloreactive T cells in combined blockade treated groups. In graft versus host disease model using CFSE staining, CD4+ T cell and CD8+ T cell proliferation were reduced in groups treated with CTLA4-Ig or anti-IL-2R or both in combination with anti-CD154. However, anti-IL-2R was not so strong as CTLA4-Ig in terms of inhibition of T cell proliferation. In conclusion, IL-2 pathway blocking combined with anti-CD154 can establish macrochimerism with limited dose of BM transplantation and induce specific tolerance to allograft.