NEWS & VIEWS The reasons for the gradual decline in severity of RA in general, but in rheumatoid vasculitis in particular, remain unclear. For RA, extra-articular disease has generally become much less common, and the need for surgery (such as cervical spine stabilization and splenectomy for Felty syndrome), which might be considered to be surrogate markers of disease severity, have declined.7,8 Over the past two decades, the treatment of RA has undergone major changes, with increased focus on tight control of inflammation through the introduction of treatto-target initiatives. To achieve this goal, there has been much wider use of methotrexate and, at least in the UK, this approach seems to be temporally associated with the decrease in rheumatoid vasculitis.3,9 In the UK, hydroxychloroquine use has remained fairly stable. Death of patients with rheumatoid vasculitis remains a serious concern, with mortality of 26% at 5 years,2 lower than the 60% reported in one recent study,3 but still important. The relapse rate was 36% at 5 years, however, the median follow-up in this study was only 16 months.2 Treat ment for rheumatoid vasculitis remains a conundrum and is essentially empirical, the conventional approach is intravenous cyclophosphamide (10–15 mg/kg every 2–3 weeks for 3–6 months) combined with corticosteroids, as pioneered by Scott and Bacon in the 1980s.4 Cyclophosphamide was used in 29% of the present study participants2 and a biologic agent was used in 28% (including TNF inhibitor, rituximab, abatacept and anakinra). This heterogeneity in the use of biologic agents reflects a lack of clear evidence to support one approach over another. In the French Autoimmunity and Rituximab registry, there were 17 patients with rheumatoid vasculitis who were treated with rituximab.10 Remission was achieved in 6 months in 12 patients and four had a partial response; one patient died. Mean prednisolone dosage was reduced from 19.2 mg per day to 9.7 mg per day, and 14 patients (82%) were in sustained remission at 12 months. Rheumatoid vasculitis remains a serious consequence of RA, but its frequency is declining, perhaps due to improved con trol of inflammation in RA. The present study 2 suggests that more widespread use of hydroxychloroquine in combination therapy regimens might result in a further decrease in the occurrence of this complication. Rheumatoid vasculitis is therefore down, but not out. 262 | MAY 2014 | VOLUME 10
Department of Rheumatology, Ipswich Hospital NHS Trust, Heath Road, Ipswich IP4 5PD, UK. [email protected] Acknowledgements R.A.W. was supported by Norfolk and Suffolk Comprehensive Research Network. Competing interests The author declares no competing interests. 1.
2.
3.
4.
Voskuyl, A. E. et al. Factors associated with the development of vasculitis in rheumatoid arthritis: results of a case–control study. Ann. Rheum. Dis. 55, 190–192 (1996). Makol, A. et al. Vasculitis associated with rheumatoid arthritis: a case–control study. Rheumatology (Oxford) http://dx.doi.org/ 10.1093/rheumatology/ket475. Ntatsaki, E., Mooney, J., Scott, D. G. I. & Watts, R. A. Systemic rheumatoid vasculitis in the era of modern immunosuppressive therapy. Rheumatology (Oxford) 53, 145–152 (2014). Scott, D. G. & Bacon, P. A. Intravenous cyclophosphamide plus methylprednisolone in treatment of systemic rheumatoid vasculitis. Am. J. Med. 76, 377–384 (1984).
5.
Sokumbi, O., Wetter, D. A., Makol, A. & Warrington, K. A. Vasculitis associated with tumour necrosis factor‑a inhibitors. Mayo Clin. Proc. 87, 739–745 (2012). 6. Morris, S. J. et al. Hydroxychloroquine use associated with improvement in lipid profiles in rheumatoid arthritis patients. Arthritis Care Res. (Hoboken) 63, 530–534 (2011). 7. Bartels, C. M., Bell, C. L., Shinki, K., Rosenthal, A. & Bridges, A. J. Changing trends in serious extra-articular manifestations of rheumatoid arthritis among United State veterans over 20 years. Rheumatology (Oxford) 49, 1670–1675 (2010). 8. Ward, M. M. Decreases in rates of hospitalizations for manifestations of severe rheumatoid arthritis, 1983–2001. Arthritis Rheum. 50, 1122–1131 (2004). 9. Edwards, C. J., Campbell, J., van Staa, T. & Arden, N. K. Regional and temporal variation in the treatment of rheumatoid arthritis across the UK: a descriptive register-based cohort study. BMJ Open 2, e001603 (2012). 10. Puéchal, X. et al. Rituximab therapy for systemic vasculitis associated with rheumatoid arthritis: Results from the AutoImmunity and Rituximab Registry. Arthritis Care Res. (Hoboken) 64, 331–339 (2012).
RHEUMATOID ARTHRITIS
When TNF inhibitors fail in RA —weighing up the options Lucia Silva-Fernandez and Kimme Hyrich
What is the best rheumatoid arthritis therapy after failure of a first anti-TNF drug? No consensus has been reached on whether to switch to rituximab or an alternative TNF inhibitor. New observational studies suggest that either course can be effective. But are more data needed? Silva-Fernandez, L. & Hyrich, K. Nat. Rev. Rheumatol. 10, 262–264 (2014); published online 11 March 2014; doi:10.1038/nrrheum.2014.34
Over the past decade, anti-TNF therapies have formed part of the routine treatment of patients with rheumatoid arthritis (RA) who have failed to respond to traditional synthetic DMARDs. Despite the general suc cess of these drugs, approximately one-third of patients will discontinue treatment with an anti-TNF agent in the first year of ther apy, mostly because of inefficacy or adverse events.1 However, other determinants, inclu ding patient and doctor preferences and expectations, and the availability of different biologic drugs, also affect the ‘survival’ of a drug—in other words, the successful use of a drug without the need to switch treatment strategy.2,3 There is no consensus on the best choice of therapy following failure of an antiTNF agent, and options include treatment with an alternative anti-TNF drug or switch ing to another class of biologic therapy, such as rituximab, abatacept or tocilizumab. Two
prospective observational studies now published, Chatzidionysiou et al.4 and Emery et al.,5 have further addressed this issue. Since 2006, when rituximab was licensed for the management of RA in patients who have failed at least one anti-TNF drug, the question of whether a second anti-TNF drug or rituximab would be more effective has been widely discussed. The rationale for switching between anti-TNF drugs is that variations exist in their chemical structures, pharmacokinetic properties and immuno genicity, whereas introducing biologic agents with a different mechanism of action might overcome an anti-TNF class-effect, particularly in cases of primary failure or recurrence of class-associated adverse events.6 No randomized clinical trial has directly compared rituximab to an alternative anti-TNF drug in patients who have failed to respond to anti-TNF therapy, but a www.nature.com/nrrheum
© 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS number of observational studies have shown that both strategies can achieve substantial clinical effectiveness.1,3,6–9 An analysis of data from the Swedish biologics register, ARTIS,4 showed that after the failure of an anti-TNF drug, up to 40% of patients switching to a second anti-TNF drug achieved low disease-activity (defined by a 28-joint Disease Activity Score [DAS28] ≤3.2) or remission (DAS28≤2.6), suggesting that, for many patients, this approach is a viable treatment option. The best clinical results were achieved with etanercept after failing a monoclonal antibody (mAb) as first anti-TNF therapy because of loss of efficacy. Compared with infliximab as a second anti-TNF therapy, etanercept was also associated with longer drug survival. The SWITCH-RA study 5 showed that, after discontinuation of an initial anti-TNF therapy, switching to rituximab was associated with a greater reduction in three‑ variable DAS28 (DAS28[3]) at 6 months compared with switching to a second antiTNF drug, although, overall, both groups did exp erience a mean improvement in DAS28(3). Although many patients with RA who have an inadequate response to one antiTNF treatment benefit from subsequent therapy with another biologic agent, it remains unclear which subgroup of patients would benefit the most from each therapeu tic strategy.10 A need to identify strong pre dictive factors to help optimize therapy for individual patients exists. Not all patients with an inadequate response to anti-TNF treatment have similar disease characteristics and comorbidities, nor do they fail to respond for the same reasons. Data from the British Society for Rheumatology Bio logics Register for RA1 showed that patients receiving rituximab as their second biologic agent after failure of a single antiTNF drug were more likely to achieve EULAR response criteria, and an improvement in Health Assessment Questionnaire scores at 6 months, than those receiving a second anti-TNF drug. The two cohorts differed, however, in baseline characteristics, because patients who received rituximab had a higher mean DAS28 and more comorbidities than those who received a second anti-TNF. An analysis of pooled data from 10 European registries identified anticyclic citrullinated peptide antibody positivity, a low baseline DAS28 and previous use of only one biologic agent as predictors of a good EULAR response to rituximab.7 Cons istent with previous studies, 3,6 the
SWITCH-RA study 5 showed that the longi tudinal improvement in DAS28 was more favourable in patients receiving rituximab than in those receiving an alternative antiTNF drug. After adjustment for baseline differences, patients who were positive for rheumatoid factor had a significantly greater improvement in DAS28 and erythro cyte sedimentation rate after 6 months of rituximab treatment than those on antiTNF therapy. However, the relative benefit of rituximab varied with the cause of the prior anti-TNF failure, as this difference in the DAS28 improvement remained statistically significant only among the cohort of patients who discontinued the anti-TNF drug because of inefficacy. This enhancement of clinical response to rituximab in seroposi tive patients and in those who discontinued their first anti-TNF because of inefficacy has been observed in other studies.3,6,8,9 Never theless, in most of these studies, patients selected to receive rituximab had higher disease activity levels at baseline than those selected to receive a second anti-TNF drug5,6 and, therefore, had a better chance of achiev ing a significant improvement in the DAS28, given that the capacity of DAS28 reduction is nonlinear and there is likely to be an element of regression to the mean. Also, patients were given rituximab preferentially after anti-TNF drug inefficacy, which would explain both the higher DAS28 at baseline, in comparison to those who stopped due to an adverse event, and the better response.6 Other observational studies found better effectiveness of rituximab only when compared with a mAb, not with etanercept.2,3 When the efficacy of rituximab was compared to the efficacy of a second anti-TNF drug by the type of switch, the smallest improvements in DAS28 were found in the subgroup of patients who switched from one mAb to another.3 These findings are similar to an analysis of effectiveness, stratified by the type of anti-TNF switch, by Chatzidionysiou et al., 4 who found a greater improvement in DAS28 at 6 months in patients switching from any of the mAbs to etanercept than in the reciprocal groups (etanercept switching to a mAb). Together, these observational data suggest that the choice of a mAb as a second anti-TNF ther apy might not be as clinically effective as etanercept or rituximab in patients with RA. We must not forget that treatment- selection bias is present in these observational studies. Many factors, both measured and unmeasured, might influence the choice of a second therapy, including seropositivity,
NATURE REVIEWS | RHEUMATOLOGY
Rituximab
Anti-TNF drug
NP
G
primary versus secondary failure of a first anti-TNF therapy, comorbidities and patient choice, given the marked difference in dosing schedules. Statistical adjustment can only partially account for this channelling bias. Although observational data can suggest an ideal pathway of therapy, there is a clear need for prospective randomized controlled trials to compare different treatments after failure of a first anti-TNF drug as well as for the identification of strong predictive factors to help guide individual patient treatment decisions. Being able to identify patients who are likely to respond to particular drugs would help physicians and patients in their choice of therapy and would probably reduce the financial burden of biologic therapies. Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, the University of Manchester, Manchester Academic Health Science Centre, Room 2.800 Stopford Building, Oxford Road, Manchester M13 9PT, UK (L.S.‑F., K.H.). Correspondence to: K.H. [email protected] Acknowledgements L.S.‑F. was supported in part by a EULAR Scientific Training Bursary. Competing interests The authors declare no competing interests. 1.
2.
3.
Soliman, M. M. et al. Rituximab or a second anti-tumor necrosis factor therapy for rheumatoid arthritis patients who have failed their first anti-tumor necrosis factor therapy? Comparative analysis from the British Society for Rheumatology Biologics Register. Arthritis Care Res. (Hoboken) 64, 1108–1115 (2012). Gomez-Reino J. J. et al. Change in the discontinuation pattern of tumour necrosis factor antagonists in rheumatoid arthritis over 10 years: data from the Spanish registry BIOBADASER 2.0. Ann. Rheum. Dis. 71, 382–385 (2012). Chatzidionysiou, K. & van Vollenhoven, R. F. Rituximab versus anti-TNF in patients who
VOLUME 10 | MAY 2014 | 263 © 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS
4.
5.
6.
7.
previously failed one TNF inhibitor in an observational cohort. Scand. J. Rheumatol. 42, 190–195 (2013). Chatzidionysiou, K. et al. Effectiveness of TNF inhibitor switch in RA: results from the national Swedish register. Ann. Rheum. Dis. http://dx.doi.org/10.1136/annrheumdis2013-204714. Emery, P. et al. Rituximab versus an alternative TNF inhibitor in patients with rheumatoid arthritis who failed to respond to a single previous TNF inhibitor: SWITCH-RA, a global, observational, comparative effectiveness study. Ann. Rheum. Dis. http://dx.doi.org/ 10.1136/annrheumdis-2013-203993. Finckh, A. et al. Which subgroup of patients with rheumatoid arthritis benefits from switching to rituximab versus alternative anti-tumour necrosis factor (TNF) agents after previous failure of an anti-TNF agent? Ann. Rheum. Dis. 69, 387–393 (2010). Chatzidionysiou, K. et al. Highest clinical effectiveness of rituximab in autoantibody-positive patients with
rheumatoid arthritis and in those for whom no more than one previous TNF antagonist has failed: pooled data from 10 European registries. Ann. Rheum. Dis. 70, 1575–1580 (2011). 8. Gomez-Reino, J. J. et al. Comparative effectiveness of switching to alternative tumour necrosis factor (TNF) antagonists versus switching to rituximab in patients with rheumatoid arthritis who failed previous TNF antagonists: the MIRAR Study. Ann. Rheum. Dis. 71, 1861–1864 (2012). 9. Soliman, M. M. et al. Effectiveness of rituximab in patients with rheumatoid arthritis: observational study from the British Society for Rheumatology Biologics Register. J. Rheumatol. 39, 240–246 (2012). 10. Salliot, C. et al. Indirect comparisons of the efficacy of biological antirheumatic agents in rheumatoid arthritis in patients with an inadequate response to conventional diseasemodifying antirheumatic drugs or to an antitumour necrosis factor agent: a meta-analysis. Ann. Rheum. Dis. 70, 266–271 (2011).
VASCULITIS SYNDROMES
Dealing with increased vascular risk and mortality in GCA Sarah L. Mackie and Bhaskar Dasgupta
New data suggest that the first 2 years of treatment for giant-cell arteritis carry substantial risks, including myocardial infarction and death. Will these findings have implications for clinical practice? Mackie, S. L. & Dasgupta, B. Nat. Rev. Rheumatol. 10, 264–265 (2014); published online 18 March 2014; doi:10.1038/nrrheum.2014.38
Giant-cell arteritis (GCA) has well-known early ischaemic complications such as sight loss, but the risk of cardiovascular events is less well-understood. Population-based studies now reveal an association of GCA with cardiovascular disease (CVD) 1 and with increased mortality 2 early in the dis ease course, but questions remain about the causes of these associations and the potential implications for the care of patients with GCA, including assessment and monitoring for CVD. GCA is an age-associated vasculitis, with an incidence of 2.2 cases per 10,000 personyears.3 In GCA, inflammation within the walls of medium and large blood vessels results in intimal hyperplasia that can occlude blood vessels, producing ischa emic manifestations such as jaw or limb claudication, blindness or stroke. Vascular imaging in GCA commonly demonstrates large-vessel vasculitis (LVV) with aortitis; LVV can sometimes manifest as a systemic inflammatory syndrome without cranial GCA symptoms.4 264 | MAY 2014 | VOLUME 10
The mainstay of treatment for GCA is immediate high-dose glucocorticoid therapy to prevent ischaemic visual loss or stroke. Glucocorticoids control the initial inflammatory symptoms, but relapses frequently occur upon reducing the dose, and several years of treatment can be required. Evidence is emerging, however, that glucocorticoids only partially control the disease.5,6 Addi tionally, long-term use of high-dose glucocorticoids is proatherogenic and related to obesity, dyslipidaemia, hypertension and diabetes mellitus in a dose-related manner. Other risks of glucocorticoid use, such as osteoporosis and skin atrophy, relate to cumulative exposure to these agents. A key question thus arises for clinical practice: what is the cardiovascular prognosis for patients newly diagnosed with GCA? Using data from The Health Improvement Network (THIN) UK primary care database, Tomasson et al.1 conducted a retrospective, matched cohort study, identifying 3,408 incident cases of GCA. For every patient with a new diagnosis of GCA, five
reference participants matched for age and sex were identified. Cardiovascular outcomes were myocardial infarction (MI), stroke (cerebrovascular accident; CVA), and peripheral vascular disease (PVD). Par ticipants were only included if they had no prior CVD (defined as MI, CVA or PVD). Comp aring patients with GCA with the reference participants, incidence rate ratios after adjustment for cardiovascular risk factors were 2.03 (1.70–2.43, 95% CI) for MI, 1.27 (1.05–1.53, 95% CI) for CVA, and 2.12 (1.60–2.79) for PVD. Most of the excess risk for CVD was early in the disease course, within the first month or two of GCA diagnosis. This time course is similar to that of the ischaemic sight loss in early GCA, and makes one wonder whe ther the increased risk of CVD was due to vascular occlusion produced by active GCA. There was also a sustained, approximately two-fold, increase in incidence rate of both MI and PVD. In analyses adjusted for age, sex and pre-existing cardiov ascular risk factors, the estimated risk of MI, like CVA, seemed to be greatest during the first month, and declined over time until stabilizing around 2 years from diagnosis, whereas the estimated risk of PVD seemed not to vary over time. We might speculate that this early risk of MI might partly be attributable to active aortitis leading to undiagnosed aortic dissection. We should be cautious, however, about over-interpreting the 1‑month and 3‑month estimates in this study, because these estimates relied on imputation of miss ing cardiovascular risk data (data on cardiovascular risk factor covariates was complete for only 38% of participants). Detection bias, due to increased cardiovascular surveillance after GCA diagnosis, is also likely to be greatest during this period. Associations with CVD have also been observed in other chronic inflammatory diseases, including rheumatoid arthritis, ankylosing spondylitis and systemic lupus erythematosus. Interestingly, polymyalgia rheumatica (PMR), the disease most closely linked to GCA, also is associated with vascular disease.7 So, is the GCA association with CVD due to the inflammatory disease, to glucocorticoid treatment, or both? It is tempting from these data to propose that: in the first month, some of the increased risk of CVD could be directly attributable to effects of the GCA itself; over the next 2 years CVD risk could be related to glucocorticoid doserelated cardiovascular or metabolic effects, interacting with partially-controlled local or www.nature.com/nrrheum
© 2014 Macmillan Publishers Limited. All rights reserved
Department of Rheumatology, Ipswich Hospital NHS Trust, Heath Road, Ipswich IP4 5PD, UK. [email protected] Acknowledgements R.A.W. was supported by Norfolk and Suffolk Comprehensive Research Network. Competing interests The author declares no competing interests. 1.
2.
3.
4.
Voskuyl, A. E. et al. Factors associated with the development of vasculitis in rheumatoid arthritis: results of a case–control study. Ann. Rheum. Dis. 55, 190–192 (1996). Makol, A. et al. Vasculitis associated with rheumatoid arthritis: a case–control study. Rheumatology (Oxford) http://dx.doi.org/ 10.1093/rheumatology/ket475. Ntatsaki, E., Mooney, J., Scott, D. G. I. & Watts, R. A. Systemic rheumatoid vasculitis in the era of modern immunosuppressive therapy. Rheumatology (Oxford) 53, 145–152 (2014). Scott, D. G. & Bacon, P. A. Intravenous cyclophosphamide plus methylprednisolone in treatment of systemic rheumatoid vasculitis. Am. J. Med. 76, 377–384 (1984).
5.
Sokumbi, O., Wetter, D. A., Makol, A. & Warrington, K. A. Vasculitis associated with tumour necrosis factor‑a inhibitors. Mayo Clin. Proc. 87, 739–745 (2012). 6. Morris, S. J. et al. Hydroxychloroquine use associated with improvement in lipid profiles in rheumatoid arthritis patients. Arthritis Care Res. (Hoboken) 63, 530–534 (2011). 7. Bartels, C. M., Bell, C. L., Shinki, K., Rosenthal, A. & Bridges, A. J. Changing trends in serious extra-articular manifestations of rheumatoid arthritis among United State veterans over 20 years. Rheumatology (Oxford) 49, 1670–1675 (2010). 8. Ward, M. M. Decreases in rates of hospitalizations for manifestations of severe rheumatoid arthritis, 1983–2001. Arthritis Rheum. 50, 1122–1131 (2004). 9. Edwards, C. J., Campbell, J., van Staa, T. & Arden, N. K. Regional and temporal variation in the treatment of rheumatoid arthritis across the UK: a descriptive register-based cohort study. BMJ Open 2, e001603 (2012). 10. Puéchal, X. et al. Rituximab therapy for systemic vasculitis associated with rheumatoid arthritis: Results from the AutoImmunity and Rituximab Registry. Arthritis Care Res. (Hoboken) 64, 331–339 (2012).
RHEUMATOID ARTHRITIS
When TNF inhibitors fail in RA —weighing up the options Lucia Silva-Fernandez and Kimme Hyrich
What is the best rheumatoid arthritis therapy after failure of a first anti-TNF drug? No consensus has been reached on whether to switch to rituximab or an alternative TNF inhibitor. New observational studies suggest that either course can be effective. But are more data needed? Silva-Fernandez, L. & Hyrich, K. Nat. Rev. Rheumatol. 10, 262–264 (2014); published online 11 March 2014; doi:10.1038/nrrheum.2014.34
Over the past decade, anti-TNF therapies have formed part of the routine treatment of patients with rheumatoid arthritis (RA) who have failed to respond to traditional synthetic DMARDs. Despite the general suc cess of these drugs, approximately one-third of patients will discontinue treatment with an anti-TNF agent in the first year of ther apy, mostly because of inefficacy or adverse events.1 However, other determinants, inclu ding patient and doctor preferences and expectations, and the availability of different biologic drugs, also affect the ‘survival’ of a drug—in other words, the successful use of a drug without the need to switch treatment strategy.2,3 There is no consensus on the best choice of therapy following failure of an antiTNF agent, and options include treatment with an alternative anti-TNF drug or switch ing to another class of biologic therapy, such as rituximab, abatacept or tocilizumab. Two
prospective observational studies now published, Chatzidionysiou et al.4 and Emery et al.,5 have further addressed this issue. Since 2006, when rituximab was licensed for the management of RA in patients who have failed at least one anti-TNF drug, the question of whether a second anti-TNF drug or rituximab would be more effective has been widely discussed. The rationale for switching between anti-TNF drugs is that variations exist in their chemical structures, pharmacokinetic properties and immuno genicity, whereas introducing biologic agents with a different mechanism of action might overcome an anti-TNF class-effect, particularly in cases of primary failure or recurrence of class-associated adverse events.6 No randomized clinical trial has directly compared rituximab to an alternative anti-TNF drug in patients who have failed to respond to anti-TNF therapy, but a www.nature.com/nrrheum
© 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS number of observational studies have shown that both strategies can achieve substantial clinical effectiveness.1,3,6–9 An analysis of data from the Swedish biologics register, ARTIS,4 showed that after the failure of an anti-TNF drug, up to 40% of patients switching to a second anti-TNF drug achieved low disease-activity (defined by a 28-joint Disease Activity Score [DAS28] ≤3.2) or remission (DAS28≤2.6), suggesting that, for many patients, this approach is a viable treatment option. The best clinical results were achieved with etanercept after failing a monoclonal antibody (mAb) as first anti-TNF therapy because of loss of efficacy. Compared with infliximab as a second anti-TNF therapy, etanercept was also associated with longer drug survival. The SWITCH-RA study 5 showed that, after discontinuation of an initial anti-TNF therapy, switching to rituximab was associated with a greater reduction in three‑ variable DAS28 (DAS28[3]) at 6 months compared with switching to a second antiTNF drug, although, overall, both groups did exp erience a mean improvement in DAS28(3). Although many patients with RA who have an inadequate response to one antiTNF treatment benefit from subsequent therapy with another biologic agent, it remains unclear which subgroup of patients would benefit the most from each therapeu tic strategy.10 A need to identify strong pre dictive factors to help optimize therapy for individual patients exists. Not all patients with an inadequate response to anti-TNF treatment have similar disease characteristics and comorbidities, nor do they fail to respond for the same reasons. Data from the British Society for Rheumatology Bio logics Register for RA1 showed that patients receiving rituximab as their second biologic agent after failure of a single antiTNF drug were more likely to achieve EULAR response criteria, and an improvement in Health Assessment Questionnaire scores at 6 months, than those receiving a second anti-TNF drug. The two cohorts differed, however, in baseline characteristics, because patients who received rituximab had a higher mean DAS28 and more comorbidities than those who received a second anti-TNF. An analysis of pooled data from 10 European registries identified anticyclic citrullinated peptide antibody positivity, a low baseline DAS28 and previous use of only one biologic agent as predictors of a good EULAR response to rituximab.7 Cons istent with previous studies, 3,6 the
SWITCH-RA study 5 showed that the longi tudinal improvement in DAS28 was more favourable in patients receiving rituximab than in those receiving an alternative antiTNF drug. After adjustment for baseline differences, patients who were positive for rheumatoid factor had a significantly greater improvement in DAS28 and erythro cyte sedimentation rate after 6 months of rituximab treatment than those on antiTNF therapy. However, the relative benefit of rituximab varied with the cause of the prior anti-TNF failure, as this difference in the DAS28 improvement remained statistically significant only among the cohort of patients who discontinued the anti-TNF drug because of inefficacy. This enhancement of clinical response to rituximab in seroposi tive patients and in those who discontinued their first anti-TNF because of inefficacy has been observed in other studies.3,6,8,9 Never theless, in most of these studies, patients selected to receive rituximab had higher disease activity levels at baseline than those selected to receive a second anti-TNF drug5,6 and, therefore, had a better chance of achiev ing a significant improvement in the DAS28, given that the capacity of DAS28 reduction is nonlinear and there is likely to be an element of regression to the mean. Also, patients were given rituximab preferentially after anti-TNF drug inefficacy, which would explain both the higher DAS28 at baseline, in comparison to those who stopped due to an adverse event, and the better response.6 Other observational studies found better effectiveness of rituximab only when compared with a mAb, not with etanercept.2,3 When the efficacy of rituximab was compared to the efficacy of a second anti-TNF drug by the type of switch, the smallest improvements in DAS28 were found in the subgroup of patients who switched from one mAb to another.3 These findings are similar to an analysis of effectiveness, stratified by the type of anti-TNF switch, by Chatzidionysiou et al., 4 who found a greater improvement in DAS28 at 6 months in patients switching from any of the mAbs to etanercept than in the reciprocal groups (etanercept switching to a mAb). Together, these observational data suggest that the choice of a mAb as a second anti-TNF ther apy might not be as clinically effective as etanercept or rituximab in patients with RA. We must not forget that treatment- selection bias is present in these observational studies. Many factors, both measured and unmeasured, might influence the choice of a second therapy, including seropositivity,
NATURE REVIEWS | RHEUMATOLOGY
Rituximab
Anti-TNF drug
NP
G
primary versus secondary failure of a first anti-TNF therapy, comorbidities and patient choice, given the marked difference in dosing schedules. Statistical adjustment can only partially account for this channelling bias. Although observational data can suggest an ideal pathway of therapy, there is a clear need for prospective randomized controlled trials to compare different treatments after failure of a first anti-TNF drug as well as for the identification of strong predictive factors to help guide individual patient treatment decisions. Being able to identify patients who are likely to respond to particular drugs would help physicians and patients in their choice of therapy and would probably reduce the financial burden of biologic therapies. Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, the University of Manchester, Manchester Academic Health Science Centre, Room 2.800 Stopford Building, Oxford Road, Manchester M13 9PT, UK (L.S.‑F., K.H.). Correspondence to: K.H. [email protected] Acknowledgements L.S.‑F. was supported in part by a EULAR Scientific Training Bursary. Competing interests The authors declare no competing interests. 1.
2.
3.
Soliman, M. M. et al. Rituximab or a second anti-tumor necrosis factor therapy for rheumatoid arthritis patients who have failed their first anti-tumor necrosis factor therapy? Comparative analysis from the British Society for Rheumatology Biologics Register. Arthritis Care Res. (Hoboken) 64, 1108–1115 (2012). Gomez-Reino J. J. et al. Change in the discontinuation pattern of tumour necrosis factor antagonists in rheumatoid arthritis over 10 years: data from the Spanish registry BIOBADASER 2.0. Ann. Rheum. Dis. 71, 382–385 (2012). Chatzidionysiou, K. & van Vollenhoven, R. F. Rituximab versus anti-TNF in patients who
VOLUME 10 | MAY 2014 | 263 © 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS
4.
5.
6.
7.
previously failed one TNF inhibitor in an observational cohort. Scand. J. Rheumatol. 42, 190–195 (2013). Chatzidionysiou, K. et al. Effectiveness of TNF inhibitor switch in RA: results from the national Swedish register. Ann. Rheum. Dis. http://dx.doi.org/10.1136/annrheumdis2013-204714. Emery, P. et al. Rituximab versus an alternative TNF inhibitor in patients with rheumatoid arthritis who failed to respond to a single previous TNF inhibitor: SWITCH-RA, a global, observational, comparative effectiveness study. Ann. Rheum. Dis. http://dx.doi.org/ 10.1136/annrheumdis-2013-203993. Finckh, A. et al. Which subgroup of patients with rheumatoid arthritis benefits from switching to rituximab versus alternative anti-tumour necrosis factor (TNF) agents after previous failure of an anti-TNF agent? Ann. Rheum. Dis. 69, 387–393 (2010). Chatzidionysiou, K. et al. Highest clinical effectiveness of rituximab in autoantibody-positive patients with
rheumatoid arthritis and in those for whom no more than one previous TNF antagonist has failed: pooled data from 10 European registries. Ann. Rheum. Dis. 70, 1575–1580 (2011). 8. Gomez-Reino, J. J. et al. Comparative effectiveness of switching to alternative tumour necrosis factor (TNF) antagonists versus switching to rituximab in patients with rheumatoid arthritis who failed previous TNF antagonists: the MIRAR Study. Ann. Rheum. Dis. 71, 1861–1864 (2012). 9. Soliman, M. M. et al. Effectiveness of rituximab in patients with rheumatoid arthritis: observational study from the British Society for Rheumatology Biologics Register. J. Rheumatol. 39, 240–246 (2012). 10. Salliot, C. et al. Indirect comparisons of the efficacy of biological antirheumatic agents in rheumatoid arthritis in patients with an inadequate response to conventional diseasemodifying antirheumatic drugs or to an antitumour necrosis factor agent: a meta-analysis. Ann. Rheum. Dis. 70, 266–271 (2011).
VASCULITIS SYNDROMES
Dealing with increased vascular risk and mortality in GCA Sarah L. Mackie and Bhaskar Dasgupta
New data suggest that the first 2 years of treatment for giant-cell arteritis carry substantial risks, including myocardial infarction and death. Will these findings have implications for clinical practice? Mackie, S. L. & Dasgupta, B. Nat. Rev. Rheumatol. 10, 264–265 (2014); published online 18 March 2014; doi:10.1038/nrrheum.2014.38
Giant-cell arteritis (GCA) has well-known early ischaemic complications such as sight loss, but the risk of cardiovascular events is less well-understood. Population-based studies now reveal an association of GCA with cardiovascular disease (CVD) 1 and with increased mortality 2 early in the dis ease course, but questions remain about the causes of these associations and the potential implications for the care of patients with GCA, including assessment and monitoring for CVD. GCA is an age-associated vasculitis, with an incidence of 2.2 cases per 10,000 personyears.3 In GCA, inflammation within the walls of medium and large blood vessels results in intimal hyperplasia that can occlude blood vessels, producing ischa emic manifestations such as jaw or limb claudication, blindness or stroke. Vascular imaging in GCA commonly demonstrates large-vessel vasculitis (LVV) with aortitis; LVV can sometimes manifest as a systemic inflammatory syndrome without cranial GCA symptoms.4 264 | MAY 2014 | VOLUME 10
The mainstay of treatment for GCA is immediate high-dose glucocorticoid therapy to prevent ischaemic visual loss or stroke. Glucocorticoids control the initial inflammatory symptoms, but relapses frequently occur upon reducing the dose, and several years of treatment can be required. Evidence is emerging, however, that glucocorticoids only partially control the disease.5,6 Addi tionally, long-term use of high-dose glucocorticoids is proatherogenic and related to obesity, dyslipidaemia, hypertension and diabetes mellitus in a dose-related manner. Other risks of glucocorticoid use, such as osteoporosis and skin atrophy, relate to cumulative exposure to these agents. A key question thus arises for clinical practice: what is the cardiovascular prognosis for patients newly diagnosed with GCA? Using data from The Health Improvement Network (THIN) UK primary care database, Tomasson et al.1 conducted a retrospective, matched cohort study, identifying 3,408 incident cases of GCA. For every patient with a new diagnosis of GCA, five
reference participants matched for age and sex were identified. Cardiovascular outcomes were myocardial infarction (MI), stroke (cerebrovascular accident; CVA), and peripheral vascular disease (PVD). Par ticipants were only included if they had no prior CVD (defined as MI, CVA or PVD). Comp aring patients with GCA with the reference participants, incidence rate ratios after adjustment for cardiovascular risk factors were 2.03 (1.70–2.43, 95% CI) for MI, 1.27 (1.05–1.53, 95% CI) for CVA, and 2.12 (1.60–2.79) for PVD. Most of the excess risk for CVD was early in the disease course, within the first month or two of GCA diagnosis. This time course is similar to that of the ischaemic sight loss in early GCA, and makes one wonder whe ther the increased risk of CVD was due to vascular occlusion produced by active GCA. There was also a sustained, approximately two-fold, increase in incidence rate of both MI and PVD. In analyses adjusted for age, sex and pre-existing cardiov ascular risk factors, the estimated risk of MI, like CVA, seemed to be greatest during the first month, and declined over time until stabilizing around 2 years from diagnosis, whereas the estimated risk of PVD seemed not to vary over time. We might speculate that this early risk of MI might partly be attributable to active aortitis leading to undiagnosed aortic dissection. We should be cautious, however, about over-interpreting the 1‑month and 3‑month estimates in this study, because these estimates relied on imputation of miss ing cardiovascular risk data (data on cardiovascular risk factor covariates was complete for only 38% of participants). Detection bias, due to increased cardiovascular surveillance after GCA diagnosis, is also likely to be greatest during this period. Associations with CVD have also been observed in other chronic inflammatory diseases, including rheumatoid arthritis, ankylosing spondylitis and systemic lupus erythematosus. Interestingly, polymyalgia rheumatica (PMR), the disease most closely linked to GCA, also is associated with vascular disease.7 So, is the GCA association with CVD due to the inflammatory disease, to glucocorticoid treatment, or both? It is tempting from these data to propose that: in the first month, some of the increased risk of CVD could be directly attributable to effects of the GCA itself; over the next 2 years CVD risk could be related to glucocorticoid doserelated cardiovascular or metabolic effects, interacting with partially-controlled local or www.nature.com/nrrheum
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