Faculty Bibliography

One of the major developments in the treatment of rheumatoid arthritis over the last decade and a half has been the realization that early and aggressive treatment leads to better outcomes for most patients. Early use of methotrexate and switching to a combination treatment regimen within the first 3-6 months if there is inadequate response to methotrexate is the currently accepted paradigm for rheumatoid arthritis treatment. To achieve better outcomes it is not enough to just use combination treatments; disease activity also needs to be measured and monitored with a 'treat-to-target' approach, where remission or low disease activity is the target and available medications are used either alone or in combination to get there. 2013 Future Medicine Ltd

OBJECTIVE: To compare Behcet's syndrome (BS) cohorts from the US and Japan in terms of rates of concordance with the International Study Group (ISG) criteria and Japanese criteria, disease manifestations, and treatment. METHODS: All BS patients seen at the NYU Hospital for Joint Diseases in the US and the Kameda Medical Center and St. Luke's International Hospital in Japan between 2003 and 2010 were included. Diagnosis of BS was made on the basis of clinical manifestations and the clinical decisions of experienced specialists familiar with BS. We classified the patients into complete and incomplete types based on their symptoms; both complete or incomplete types were assumed to fulfil the Japanese criteria. RESULTS: A total of 769 patients (US n = 634, Japan n = 135) were reviewed. 61.5 % in the US and 63.7 % in Japan fulfilled the ISG criteria. Similarly, there was no difference in the proportions of US and Japanese patients who fulfilled the Japanese criteria. Japanese patients were less likely to be female and to have genital ulcers, but were more likely to have epididymitis and pulmonary disease. Significantly more patients were treated with colchicine, sulfasalazine/mesalazine, and NSAIDs in Japan, while significantly more patients in the US received first-line immunosuppressants. CONCLUSIONS: The concordance rates for ISG and Japanese criteria fulfillment in the US and Japan were not significantly different. These findings could help to clarify regional differences in the diagnostic and clinical features of BS.

Behcet's syndrome (BS) shows a peculiar distribution, with a much higher prevalence in countries along the ancient Silk Road compared with rest of the world. BS also seems to follow a more severe course in ethnic groups with higher prevalence. Diagnosis depends on clinical findings. Criteria sets may not help in patients with less frequent types of involvement. Management strategies should be modified according to the age and sex of the patient and the organs involved. Being a serious health problem in endemic areas, BS also attracts global attention as a model to study inflammatory diseases of unknown cause.

OBJECTIVES: Tocilizumab has demonstrated efficacy in managing rheumatoid arthritis (RA) from week 2 onward. This sub-study assessed effects of tocilizumab plus disease-modifying anti-rheumatic drugs (DMARDs) during the first week of therapy. METHODS: Rapid Onset and Systemic Efficacy was a 24-week, randomised, double-blind, placebo-controlled, parallel-group trial. Adults with moderate to severe active RA taking DMARDs received tocilizumab 8 mg/kg (or placebo) plus DMARDs every 4 weeks. Data were analysed from the first 62 patients at designated study sites who agreed to clinical evaluation and blood sampling at days 3 and 7 and had C-reactive protein levels >/=1 mg/dl. Outcomes included American College of Rheumatology core data set measures, disease activity score using 28 joints (DAS28) and routine assessment of patient index data 3 (RAPID3) scores. RESULTS: Baseline evaluations were similar between groups (tocilizumab, n=40; placebo, n=22). Patient global assessments of disease activity and pain improved significantly in favour of tocilizumab (mean change from baseline to day 7: -16.2 [tocilizumab], 0.8 [placebo] [p=0.005] and -12.2 [tocilizumab], 1.4 [placebo] [p=0.01], respectively). Physician global assessment of disease activity also improved more with tocilizumab (-15.4 [tocilizumab], -5.6 [placebo] [p=0.05]). Changes from baseline in tender/swollen joint counts, physical function and RAPID3 scores were not significantly different between groups. DAS28 significantly improved with tocilizumab versus placebo at day 7 (-1.16 [tocilizumab], -0.27 [placebo] [p=0.007]). CONCLUSIONS: Tocilizumab showed significant improvement in patient-reported disease activity, pain and DAS28 score as early as day 7 after first infusion, earlier than physician-reported measures, which may take longer to manifest.

OBJECTIVE: To analyze a patient self-report joint count from the Rheumatoid Arthritis Disease Activity Index (RADAI) on a Multidimensional Health Assessment Questionnaire (MDHAQ) in a cohort of consecutive patients seen in usual rheumatology care with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), osteoarthritis (OA), psoriatic arthritis (PsA), and gout. METHODS: Each patient completed an MDHAQ, which included a RADAI, at each visit in one usual care setting. In order to include a physician measure, a random visit at which there was a recorded physician global estimate was selected for each of 465 patients (174 patients with RA, 75 with SLE, 113 with OA, 53 with PsA, and 50 patients with gout). The RADAI was analyzed for total scores (range 0-48), number of involved joint groups (range 0-16), and each specific joint group, and then compared in the 5 diagnostic groups to one another and to other MDHAQ measures and the Routine Assessment of Patient Index Data 3 (RAPID3). RESULTS: In patients with RA, SLE, OA, PsA, and gout, mean RADAI scores (range 0-48) were 12.4, 6.5, 10.1, 6.7, and 2.7, respectively. The mean numbers of involved joint groups (range 0-16) were 6.9, 3.8, 4.8, 4.5, and 1.7, respectively, and the median numbers were 6, 2, 4, 4, and 1, respectively. RADAI scores were correlated significantly with the physician global estimate, except in SLE, and at higher levels with the MDHAQ and RAPID3 scores in all diagnostic groups. CONCLUSION: The RADAI self-report joint counts can be used to record self-report involvement of specific joints and joint groups in patients with SLE, OA, PsA, and gout, with minimal effort on the part of the rheumatologist.

OBJECTIVES: To determine the preferred treatment for patients with Behcet's syndrome. METHODS: A questionnaire was given to all participants of the 2010 meeting of the International Society for Behcet's Disease. RESULTS: Forty-one respondents from 6 different subspecialties. In the case of a patient with (severe) posterior uveitis or parenchymal central nervous system (CNS) disease no consensus was seen. A diffuse spectrum of different schedules were given. In both uveitis and CNS disease the majority of respondents preferred treatment options consisting of combination systemic therapy and systemic corticosteroids. TNF was preferred as first line drug in uveitis in 7.5% and in severe uveitis in 32.5% of respondents. In parenchymal CNS disease TNF blockage was given by 17% of the respondents. EULAR guidelines regarding uveitis were followed by 12/40 physicians. In patients with a new deep vein thrombosis, 90% of respondents would intensify immunosuppression. More than half would also anticoagulate. CONCLUSIONS: Although consensus about how to treat patients with Behcet syndrome in different clinical situations is far from present, treatment has become more intensive when compared to 10-20 years ago. More uniformity should be sought for in the decision process in individual patients with Behcet's syndrome, regarding their treatment, as well as adhering to evidence, as presented in the EULAR guidelines, when present.