Rheumatoid Arthritis: Luc M

Ruyssen-Witrand A, Gossec L, Salliot C, Luc M, Duclos M, Guignard S, Dougados M. · Paris René Descartes University, Medicine Faculty, AP-HP, Cochin Hospital, Rheumatology B Department, Paris, France. · Clin Exp Rheumatol. · Pubmed #17631740 No free full text.

Abstract: OBJECTIVE: Tumor necrosis factor (TNF) blockers have been reported to increase the risk of infections, thrombosis, and delayed healing. However, there is little data on the risk of complications after surgery in rheumatic patients receiving TNF blockers. The aim of this study was to assess the complication rate after surgery in such patients, to assess the effect of interrupting TNF blocker therapy, and to identify other potential predictors of complications. METHODS: This was a systematic, retrospective monocenter study of all patients treated with TNF blockers and who underwent surgery. Complications were recorded and complication rates were compared based on the type of surgery and the timing of the discontinuation of TNF blockers before surgery (above 2 or 5 half-lives). The complication rates were compared with those reported in the literature (orthopaedic procedures in RA patients: 7%, abdominal surgery: 13%). RESULTS: Between 1997 and 2004, 770 patients were treated with TNF blockers of whom 92 underwent surgery (127 surgical procedures). The most frequent underlying disease was rheumatoid arthritis (77%). Most of the surgical procedures were orthopaedic (85%). The complication rates for orthopaedic procedures and for abdominal procedures were 13% and 43%, respectively. The infection rate after orthopaedic procedures was 6.5%. Interrupting therapy before surgery did not significantly decrease the postoperative complication risk. There were no independent factors predicting complications. CONCLUSION: In daily practice the complication rate after surgery is high in patients treated with TNF blockers. Discontinuing TNF therapy before surgery should be considered, although this study did not clearly demonstrate its role.

Duclos M, Gossec L, Ruyssen-Witrand A, Salliot C, Luc M, Guignard S, Dougados M. · Rene Descartes University, Faculty of Medicine, Paris, France. · J Rheumatol. · Pubmed #17014004 No free full text.

Abstract: OBJECTIVE: Tumor necrosis factor (TNF) blockers are efficacious in clinical trials in rheumatic diseases. However, their efficacy in daily practice, depending on the specific diagnosis or the use of concomitant therapy, remains to be confirmed. Our objective was to evaluate TNF blocker retention rates and their predisposing factors in daily practice. METHODS: Retrospective evaluation of all TNF blocker therapies in one center. Retention rate was evaluated using a Kaplan-Meier survival data analysis technique in which the event was discontinuation of the drug due to inefficacy or toxicity with log-rank tests and a Cox proportional-hazards regression model. RESULTS: From 1997 to 2004, 770 patients with inflammatory rheumatism received at least one TNF blocker; 142 received more than one agent (975 treatment courses: 493 etanercept, 335 infliximab, 147 adalimumab). The underlying disease was mainly rheumatoid arthritis (RA), found in 57.1% of patients, and spondyloarthropathies (SpA) in 37.7%. The percentage of patients receiving the same treatment at Month 12, 24, and 36 was 64.0%, 50.3%, and 39.4%, respectively. No difference between the 3 TNF blockers was found (p = 0.48). The retention rate was longer for the first treatment course [hazard ratio (HR) 2.17, 95% confidence interval (95% CI) 1.82-2.58, p < 0.0001]; longer for patients with SpA (HR 1.60, 95% CI 1.20-2.13, p = 0.001); and longer without concomitant DMARD (HR 0.70, 95% CI 0.51-0.97, p = 0.03). CONCLUSION: Our results indicate a lower retention rate of TNF blockers in daily practice compared with clinical trials, with no difference between the 3 currently available agents. Moreover, results suggest greater benefit in SpA. The role of concomitant DMARD remains to be confirmed.

Salliot C, Gossec L, Ruyssen-Witrand A, Luc M, Duclos M, Guignard S, Dougados M. · René-Descartes University, Medicine Faculty, AP-HP, Cochin Hospital, Rheumatology B Department, Paris, France. · Rheumatology (Oxford). · Pubmed #16880188 links to  free full text

Abstract: OBJECTIVE: To evaluate the rate of infections in rheumatic patients treated with tumour necrosis factor (TNF)-alpha blockers in daily practice and to determine potential risk factors of infections. METHODS: Systematic retrospective study was conducted in a tertiary-referral centre of all patients receiving at least one TNF-alpha blocker, between 1997 and December 2004. Serious infections were defined as life-threatening, requiring hospitalization or sequelae. The incidence of infections during the first TNF-alpha blocker course was compared with the incidence during the period just before such therapy, in the same patients and a number needed to harm was calculated. Univariate and multivariate analysis between patients who suffered from at least one infection during treatment or not, was conducted in order to determine potential associated risk factors. RESULTS: Among the 709 patients treated with at least one TNF-alpha blocker, 57.7% had rheumatoid arthritis; a total of 275 infectious events in 245 patients (34.5%) were reported during all treatment courses. Among these infections, 47 infections in 44 patients (6.2%) fulfilled the definition of serious infections. The incidence rate of serious infections was 3.4 +/- 38.7 per 100 patient-yrs before TNF-alpha blocker therapy vs 10.5 +/- 86.9 during the first TNF-alpha blocker course (P = 0.03, number needed to harm = 14). The single risk factor picked up by multivariate analysis to explain infections was previous joint surgery [odds ratio (OR) = 2.07, 95% confidence interval (CI) = (1.43-2.98), P < 0.0001] and, if surgery was taken out of the model, the cumulative dose of steroids [OR = 1.28 (1.04-1.59), P = 0.02]. CONCLUSION: The rate of serious infections during TNF-alpha blocker treatment observed in daily practice conditions was much higher than in phase III trials evaluating TNF-alpha blockers. Serious infections are frequent in daily practice and close monitoring is required.

Leydet-Quilici H, Luc M, Armingeat T, Pham T, Lafforgue P. · No affiliation provided · Joint Bone Spine. · Pubmed #17379563 No free full text.

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