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Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The suitability of biologic therapy in patients with rheumatoid arthritis (RA) of moderate activity is currently being discussed. The aim of the study was to compare the results of treatment of patients with RA of moderate and high activity with the first anti-TNF agent in routine clinical practice. This was a retrospective cohort study of patients enrolled in the ATTRA national registry. In total, 2416 patients were enrolled in the study, of which 2231 had high activity (DAS 28 > 5.1) and 185 patients had moderate activity (DAS 28 3.2-5.1). Patients were followed for one year, and DAS 28 values were lower in the moderate group than in the high activity group at all intervals evaluated, p < 0.001. Low activity (DAS 28 < 3.2) was achieved by patients with moderate activity in 74% and patients with high activity in 52.2%, p < 0.001. Significant differences in favor of treatment of moderate activity were also found for other secondary endpoints. Furthermore, a comparison of patients with medium and high activity, selected by the method of propensity score matching, who no longer differ in the input characteristics, was performed. Patients with moderate activity are 2.4 times more likely to achieve remission or low activity according to DAS 28 after six months and 1.7 times more likely to achieve remission or low activity after 12 months of treatment compared to patients with high activity at the beginning of treatment. This extensive retrospective analysis of the outcome of anti-TNF therapy treatment showed that the therapy of RA patients with moderate is more effective than that of those with high activity because the desired goal is achieved significantly more often, i.e., reaching a state of low activity or remission. [ABSTRACT FROM AUTHOR]

Baricitinib is a new immunosuppressive drug for the treatment of rheumatoid arthritis (RA). It is a small molecule, specifically a JAK inhibitor, which intracellularly inhibits signal transduction and activation of proinflammatory cytokines. The authors conducted an open, retrospective study in the national ATTRA registry to obtain data from routine clinical practice with this drug in the Czech Republic. The study included 243 patients with a mean age of 44 years and a disease duration of 13 years. The initial activity was high with the mean CRP of 19.1 mg/L, the number of swollen joints of 8, and the DAS 28 of 5.6. After one year of treatment, there was a significant decrease in all indicators of activity. Remission was achieved in about 39.3% of patients and low activity (assessed by DAS 28) in about 68.8% of patients. Retention on treatment was 71.8% after 12 months. All components of quality of life have improved significantly. Furthermore, some predictive factors of achieving a state of low activity or remission were evaluated. Patients receiving baricitinib as the third biological or targeted synthetic DMARD have been shown to have a worse response than patients with earlier use of baricitinib. Specifically, a statistically significant difference was found compared to the first line. There was also worse retention on the drug. Another predictive factor for remission evaluated at the start of treatment was concomitant MTX treatment, which was not predictive of remission or persistence in remission. Another predictive factor for remission and low activity at the beginning of treatment was the initial level of disease activity. Patients with moderate activity had a significantly lower DAS 28 after three months of treatment than patients with high activity at baseline, but after 12 months, this difference was no longer significant. In conclusion, baricitinib is an effective tsDMARD in the treatment of RA in monotherapy and in combination with MTX. There is a better chance of achieving remission after the failure of MTX and two bDMARDs; after the failure of the third and other bDMARDs the chance of achieving remission is lower. [ABSTRACT FROM AUTHOR]

Aim. A number of studies have shown that the ability to work in patients with ankylosing spondylitis (AS) is reduced compared to the general population. Furthermore, it has also been shown that reducing disease activity by biological disease-modifying antirheumatic drugs (bDMARDs) improves the patient's ability to work, both in paid and unpaid work. The Work Productivity and Activity Impairment Questionnaire (WPAI) is a validated indicator of work ability that has also proven itself in AS. Methods. The aim of the study was to compare the effectiveness of biological treatment in patients with radiographic and non-radiographic axial spondyloarthritis (nr-axSpA) and also to evaluate the effect on work ability in both subsets of the disease. The study included 2599 patients with a diagnosis of AS and 333 patients with a diagnosis of nr-axSpA. Results. Biological treatment was significantly effective. Treatment retention was 42% better in patients with ankylosing spondylitis than with non-radiographic axial spondyloarthritis. After six months of treatment, the non-radiographic subset had a lower Health Assessment Questionnaire (HAQ) and a lower Ankylosing Spondylitis Disease Activity Score (ASDAS), which were already balanced at later intervals. Some differences were found in the overall health assessment by the SF-36 (Short Form 36 Health Survey). Furthermore, the effect of disease activity and its possible reduction of the individual components of WPAI was evaluated. The mean percentage of missed working hours decreased from an initial 12.3 ± 0.8 to 3.5 ± 0.5 after 24 months of treatment in AS. Presenteeism improved by 34.5% (p < 0.001), overall reduction of activities by 36.4% (decrease from 61.5% to 25.1%, p < 0.001). A correlation of disease activity assessed by ASDAS prior to initiation of the first biologic therapy with WPAI components was also performed. ASDAS correlated highly with all components of WPAI, i.e. absenteeism, presenteeism, overall limitation of work capacity and limitation of activities. The decrease in ASDAS correlated with the decrease in all WPAI components in all evaluated intervals. Conclusion. Treatment with bDMARDs significantly improves the ability of paid and unpaid work in both forms of axial spondyloarthritis. [ABSTRACT FROM AUTHOR]

Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The recommendations of the Czech Society for Rheumatology (ČRS) for the treatment of ankylosing spondylitis (AS) were published in 2012, and, therefore, the decision of the ČRS committee proceeded to the innovation of these criteria. It was based on the ASAS / EULAR recommendations for the treatment of axial spondyloarthritis, published in 2017, which are based on published records and the consensus of leading experts. Compared to the older criteria, there are several important innovations. The first and fundamental difference is the fact that these recommendations already apply to patients with a wider range of axial spondyloarthritis (SpA), i.e., radiographic and non-radiographic SpA and not just ankylosing spondylitis. There is also some innovation in views on the evaluation of disease activity so that the ASDAS score is now preferred. The intentions of this score also define a threshold for the initiation of biologic therapy (ASDAS ≥ 2.1) and more specifically defined treatment targets. Another new element is the introduction of newer drugs, i.e., IL-17 inhibitors. The current recommendations list IL-17 inhibitors as an alternative to first-line treatment with TNF inhibitors. These recommendations also include instructions on how to proceed in patients with extra-articular symptoms, i.e., acute anterior uveitis, idiopathic inflammatory bowel disease, and osteoporosis. [ABSTRACT FROM AUTHOR]

Secukinumab is a monoclonal antibody that inhibits interleukin 17A, which has been introduced into the treatment of axial spondyloarthritis (axSpA) after successful phase III clinical trials. The open-label extension of MEASURE studies 1, 2 and 3 demonstrated the long-term efficacy and safety of the drug. The aim of the analysis is to evaluate the long-term effectiveness in real clinical practice in the Czech Republic. Methods: A retrospective, open-label, cohort study of patients with axSpA treated with secukinumab in the national ATTRA registry was performed, in which patients with axSpA (radiographic and non-radiographic axSpA), who met the indication criteria of the Czech Society for Rheumatology for the biological treatment of spondyloarthritis, were monitored and treated. The following indicators were evaluated: survival on treatment, BASDAI, ASDAS, HAQ, and SF-36. Results: A total of 243 patients with radiographic axSpA were included in the study. The drug survival of secukinumab was 70.8% after 12 months and 63.5% after 24 months of treatment. Clinically significant improvement in ASDAS (≥ 1.1) was achieved in 71.7% of patients. The HAQ score decreased from a mean of 1.3 ± 0.6 to 0.8 ± 0.6 during the first 2 years of treatment. Furthermore, all quality of life parameters evaluated by SF-36 were improved. The ability to work was another parameter evaluating the quality of life. During the 2-year treatment, 37.7% of patients with disabilities or incapacity for work regained their ability to work. On the contrary, 15.7% of working patients or job-seekers lost their ability to work. The safety of the treatment was good, and no new signs of toxicity appeared. In the non-radiographic axSpA group, only 29 patients with similar results have been monitored and treated to date. Conclusion: Treatment survival, efficacy, and safety of secukinumab in real clinical practice are very good, and secukinumab represents a new therapeutic alternative for active axial SpA. [ABSTRACT FROM AUTHOR]

The national registry of biological therapy of rheumatic diseases ATTRA was established 20 years ago. A total of 5324 patients diagnosed with rheumatoid arthritis were entered into the registry. The median follow-up is 5 years and the total patient exposure is 27,358 patient-years. The number of patients is increasing and in recent years there has been an annual increase of 621 patients. Analysis of patients at the beginning of the study shows that these are patients with long disease duration, already with significant functional impairment and high activity (DAS 28 ESR 6.3 ± 0.9). At baseline, 63% of patients were using glucocorticoids, and 82% conventional synthetic DMARDs (csDMARD). Adherence to treatment with the first biological drug was 77.4% after 12 months and 63.8% after 24 months. The most common reasons for discontinuation were secondary failure 37.3%, primary failure 28.3%, and adverse events 25.8%. The mean DAS 28 decreased from 6.3 ± 0.9 to 3.1 ± 1.4 after 24 months. Fifty-five % of patients were in low activity or remission after 2 years of treatment. When assessing the quality of life, there was a significant improvement in all aspects assessed by the SF-36 questionnaire. The ability to work has improved significantly as the values of presenteeism and absenteeism assessed using the WPAI questionnaires have improved. The incidence of adverse reactions is in line with international experience. Tuberculosis occurred in only 19 patients. Conclusion: The ATTRA registry documents the means of treating rheumatoid arthritis with biological drugs in biological treatment centers. The results are very good but show that the T2T principle could be used more intensively in routine clinical practice. The incidence of adverse reactions is lower than in comparable registries, which may be due to insufficient reporting. [ABSTRACT FROM AUTHOR]

This review focuses on the issue of the effectiveness of biological and targeted treatment in seropositive and seronegative patients with rheumatoid arthritis. Rando-mized trials preferentially enroll strongly active patients, i.e. mostly seropositive, with a minority of patients being seronegative. Therefore, the evidence of efficacy in seronegative patients comes primarily from meta-analyses of open-label extensions and registries. Due to different methodologies, results are sometimes inconsistent. However, a larger body of evidence demonstrates that rituximab and abatacept are more effective in seropositive patients, and a trend for efficacy has also been shown for tocilizumab. In contrast, anti-TNF drugs are as effective in both seropositive and seronegative patients. In randomized controlled trials, tofacitinib was more effective in seropositive than in seronegative patients. In conclusion, although some differences in the efficacy of biological and targeted drugs have been found between seropositive and seronegative patients, the differences are not so large as to be the only selection criterion in the selection of a biological or targeted drug. [ABSTRACT FROM AUTHOR]

The aim of this review is to assess the position of methotrexate (MTX) in a modern strategy for the treatment of active rheumatoid arthritis. It has been noted that MTX is not used adequately in routine clinical practice, neither in frequency, dose and possible forms of administration. As recommended by EULAR (European League Against Rheumatism), MTX should always be part of the first treatment strategy. It can also be an anchor drug when other synthetic or biological drugs are added to MTX in case of inadequate response. More recently, the combination of MTX with glucocorticoids has been shown to be beneficial in initiating treatment for early rheumatoid arthritis. The dose of 10 mg MTX per week with rapid titration to 25–30 mg per week is recommended as an initial dose. With rapid dose escalation, up to 40% of patients can achieve low disease activity status. MTX is always given in combination with folic acid. The problem of oral MTX is non-constant absorption, especially at doses higher than 15 mg per week. It is, therefore, preferable to switch to subcutaneous administration of MTX. A meta-analysis of 7 studies showed greater efficacy of subcutaneous MTX than oral. Subcutaneous administration also results in a faster onset of action. It has also been shown that switching to subcutaneous MTX can reduce the need for biological treatment by up to 20%, making it a pharmacologically advantageous procedure. Subcutaneous MTX is currently available, with autoinjectors in the form of pre-filled pens being particularly preferred. [ABSTRACT FROM AUTHOR]

According to the recommendations of EULAR/ACR and the Czech Society for Rheumatology, the goal of treatment for each patient with rheumatoid arthritis (RA) is to achieve remission. Alternatively, in patients with long-standing disease to achieve low disease activity. The subject of the first part of this review is to analyze the most commonly used remission definitions, including DAS 28 CRP or DAS 28 ESR, SDAI and CDAI. It is also emphasized that the temporal parameters for assessing remission whether it is a one-time, cumulative achievement or so-called sustained remission (defined as DAS 28 < 2.6 for at least 6 months) must always be reported. The next section discusses the occurrence of remission in routine clinical practice, with evidence being obtained primarily from registries and long-term cohort studies. Therapeutic strategies can also influence the achievement of remission, while the application of the T2T principle clearly increases remission frequency. Factors influencing the achievement of remission have been studied. The most important positive predictors of remission include the use of biological drugs, lower baseline activity, shorter disease duration, biologically naïve patients and some others. In the end, the issue of why to strive for remission at all is discussed. The reasons are: improving the quality of life, improving physical function, reducing cardiovascular risk, reducing the need for major orthopedic interventions, and increasing labor productivity. Finally, some new data is presented suggesting remission for some Janus kinase inhibitors may be more frequent than for TNF inhibitors. [ABSTRACT FROM AUTHOR]

Epidemiological studies show a steady increase in the incidence of hyperuricemia and gout in the population. Gout therapy can be divided into the treatment of an acute gout attack and the issue of lowering uric acid levels. Any acute gout attack should be treated pharmacologically and treatment initiated immediately. As an alternative, colchicine, non-steroidal anti-inflammatory drugs and corticosteroids may be used. Combinations such as colchicine plus non-steroidal anti-inflammatory drugs or intra-articular corticosteroids with NSAIDs or colchicine can also be used in severe polyarticular, refractory attacks. In patients with severe refractory and frequent attacks, the interleukin-1 inhibitor canakinumab may be used. Patients indicated for hypouricemic treatment are those with a high frequency of attacks, tofi, and joint destruction. The treatment of hyperuricemia should be comprehensive and consist of non-pharmacological and pharmacological therapy. Medicaments that are available include uric-acid lowering drugs (allopurinol, febuxostat) and uricosuric agents (benzbromarone). Allopurinol is the drug of first choice, whereas febuxostat is recommended in the second line in patients who do not have shown sufficient response to or who are into-lerant of allopurinol. Febuxostat is suitable in patients with moderate renal insufficiency where a renal sparing effect has been demonstrated. Lesinurad, an inhibitor of the kidney URAT-1 transporter, is used in combination with allopurinol or febuxostat. [ABSTRACT FROM AUTHOR]

Rheumatoid arthritis (RA) is a chronic disease, and therefore it is very important that you can administer the biological therapy for a long time. Therefore, so-called survival on biological treatment is observed, especially in the biological treatment registries. The aim of the work: To analyze the 10-year survival on adalimumab treatment and evaluate the reasons for its termination. Another objective was to evaluate predictive factors at the start of treatment for possible cessation of treatment. Methodology: All patients, who were enrolled in the ATTRA National Registry who met the criteria of the Czech Society fo Rheumatology for biological treatment, were included. Demographic characteristics as well as the main indicators of disease activity, such as DAS28, HAQ and EuroQuol, were assessed. Reasons for discontinuation of treatment were evaluated as primary treatment failure, secondary treatment failure and discontinuation for adverse reactions. Only patients, who were treated with adalimumab as the first biological drug and who were treated during 2003-2017, were analyzed. Results: In total 1598 patients with an average disease duration of 10 years and an average DAS28 at baseline of 5.7 ± 0.9 were enrolled. After 10 years of treatment, 27.7% of patients were still treated with adalimumab, the median survival was 43.9 months. The reason for treatment discontinuation was most often the loss of effect at 30.5 %, primary failure at 24.9 % and adverse events at 19.8 %. The predictive factors for longer survival were <50 years versus> 50 years (p = 0.027), maximum failure of 1 csDMARD versus 2 or more in the past (p <0.001), and combination of adalimumab with csDMARD versus monotherapy (p <0.001). Median drug survival was the longest in ankylosing spondylitis, followed by psoriatic arthritis and the shortest in rheumatoid arthritis. Conclusion: Adherence to treatment with adalimumab is very good and is 27.7 % after 10 years of treatment. Of the patients still on treatment, 78 % have low activity or remission. Treatment was well tolerated and no new signs of toxicity occurred. [ABSTRACT FROM AUTHOR]

Biosimilar infliximab CT-P13, developed by Korean company Celltrion, is the first EMA approved biosimilar agent. In double-blind studies in rheumatoid arthritis and ankylosing spondylitis biosimilar infliximab was equally effective and had the same safety profile as the original infliximab.CT-P13 was introduced into clinical practice in the Czech Republic at the end of 2013. All the patients have been treated according to the indications of the Czech Society for Rheumatology at the centers of biological treatment and enrolled in the ATTRA registry. The aim of this study was to evaluate the first year of experience with the CT-P13 agent in the ATTRA national registry. Results: A total of 100 patients with rheumatoid arthritis (RA) were enrolled in the registry. Analysis was then performed on 93 adult patients. The mean age of these patients was 54 years and the disease duration was 10 years. Disease activity was high, the average baseline DAS 28 was 5.7 ± 0.8, number of swollen joints was 8.8 ± 4.3 and CRP levels were 28.1 ± 22.5 mg / l. After nine months of treatment there was a significant decrease in all monitored parameters. At the start of treatment 73.3% of patients had high disease activity according to EULAR and 26.7% of patients had moderate activity. After nine months of treatment 87.5% of patients were in remission, 93.7% had low activity, 6.3% had moderate activity, and none of the patients had high disease activity. The treatment survival after nine months was 78.0%. Seventy-two patients were enrolled in the registry of ankylosing spondylitis (AS) and 68 adult patients thereof were further analyzed. Their average age was 44 years and disease duration of 9 years. Disease activity at the start of treatment was high, and the average BASDAI was 6.2 ± 1.7 and CRP levels were 31.1 ± 26.7 mg / l. After nine months of treatment BASDAI decreased to 0.9 ± 1.4, and quality of life improved (HAQ decreased from 1.1 ± 0.6 to 0.4 ± 0.5). There were improvements in all dimensions of quality of life according to SF-36. In the group of RA patients 21 adverse events and 7 serious adverse events were reported. In patients with AS there were 7 adverse events and no serious adverse event. No new signals of toxicity were reported. Conclusion: First experience with biosimilar CT-P13 in the ATTRA national registry is positive. No new signals of toxicity were reported. [ABSTRACT FROM AUTHOR]

Axial spondyloarthritis (axSpA) lacks reliable indicators that would have predictive value in assessing risk of development of the disease, disease activity or progression or response to treatment, and that could also be measured easily and inexpensively. There are many studies focusing on the detection of such markers. An increased risk of disease onset is usually associated with HLA-B27 antigen; furthermore, promising associations have been demonstrated with some variants of the endoplasmic reticulum aminopeptidase -1 (ERAP1) gene. Biomarkers used for the assessment of disease activity and progression or response to anti-TNF therapy are usually classified into two main groups: biomarkers that are related to the inflammatory process or to metabolism of the joint tissues. C-reactive protein (CRP) along with erythrocyte sedimentation rate (ESR) are the basic pillars of the group of markers reflecting inflammatory activity. However, they have low sensitivity and specificity. Other indicators of inflammatory activity include serum amyloid A (SAA) or interleukin-6 (IL-6), metalloproteinase-3 (MMP-3) and other markers as calprotectin (S100A8 / A9), dickkopf-1 (DKK-1) or cytotoxic T lymphocyte-associated protein-4 (sCTLA-4) or the type III collagen degradation peptide (C3M). Potential predictors of radiographic progression include MMP-3, sclerostin, DKK-1 and certain types of bone morphogenic proteins (BMP-2 and 4). Good response to treatment can be expected especially in patients with higher levels of acute phase reactants and pre-existing structura damage to the spine. A lot of available biomarkers associated with axSpA are based on a large number of studies. Thanks to them we are able to at least partially elucidate the pathogenesis of this disease and to identify other possible approaches to treatment. Most studies, however, have its limitations, such as insufficient number of patients in the studied cohorts, different standards and techniques for the determination of biomarkers in serum, and finally absence of multivariate analysis. The aim of this work was to develop an overview of available serum laboratory markers associated with axSpA. [ABSTRACT FROM AUTHOR]

Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Osteoarthritis (OA) is the most common joint disease. The existing treatment consists of a combination of lifestyle changes, physical therapy, pharmacotherapy, and surgical joint replacement in case of advanced disease. All pharmacological treatment was purely symptomatic. The aim of the pharmaceutical industry is to develop drugs that modify the structural breakdown of cartilage. These drugs are called DMOAD (Disease Modifying OsteoArthritis Drugs). There is no DMOAD available to date, however many of them are in the process of clinical testing. This article aims to provide an overview of these methods. Each agent is described with an expected mechanism of action, the experimental data on animal cartilage, and clinical data when available. The author assesses the following approachess: growth factors, blockage of nitrous oxide, stem cell therapy, platelet-rich plasma (PRP) therapy focusing on the subchondral bone (bisphosphonates, strontium ranelate, zoledronate), anti-inflammatory treatment: anti-cytokine therapy, intra-articular injection of autologous conditioned serum and gene therapy. Innovative surgical techniques are listed briefly as well. [ABSTRACT FROM AUTHOR]

Aim: This study characterized response to the first trial of antitumor necrosis factor (TNF) drugs among rheumatoid arthritis (RA) patients in the Czech registry of biological therapy (ATTRA). Materials & methods: The study included all patients with disease activity scores (DAS28) >5.1, and a few with scores <5.1. Monoclonal antibodies were pooled and compared to etanercept for 1 year. Results: 1945 patients were enrolled (518 etanercept, 1427 antibodies). From week 10-54, mean DAS28 was significantly lower with etanercept; and remission and low disease activity (LDA) rates were significantly higher. Etanercept was a significant predictor of remission. Conclusions: Remission and LDA were more frequent with etanercept than with monoclonal antibodies.. [ABSTRACT FROM AUTHOR]

The concept of classification and diagnosis of axial spondyloarthritis (ax SpA) has been developed in the last 10 years. Axial SpA is basically divided into ankylosing spondylitis (satisfying the so called New York criteria with radiographic sacroiliitis) and so called non-radiographic axial spondyloarthritis, which meets the ASAS criteria. These criteria focus mainly on the new and later again modified criteria for inflammatory back pain (IBP). The first part of the paper presents significant epidemiological studies that evaluate the utilization of individual criteria for inflammatory back pain. The second part of the article discusses different strategies of referring the patients with suspected axial SpA from general practitioners and orthopedic surgeons to specialists (rheumatologists). A simple scheme working with three parameters (inflammatory back pain, HLA B27 antigen positivity, and suspected sacroiliitis on imaging techniques) is equally efficient as more complicated strategies. Positivity of two criteria enables a correct diagnosis of axial SpA in 30-50% of patients. Recently, a so called two-step strategy has been proposed that reduces the number of patients, in whom the determination of HLA-B27 needs to be performed, in half. Novel screening questionnaires, which are filled out by patients, are discussed herein as well. [ABSTRACT FROM AUTHOR]

European League against Rheumatism (EULAR) has appointed a committee of experts (the so called Task Force), which published a new version of the EULAR recommendations for the treatment of rheumatoid arthritis (RA). Methodology: The recommended methodology for the creation of all official EULAR recommendations was applied. After the appointment of the committee a EULAR general methodology, used in production of official EULAR recommendations, was applied. A literature review of all English-language publications from the years 2009--2012 was performed, which supplemented the original evidence from 2010. Every quality randomized, controlled clinical trial published as a full-text article or an abstract from EULAR congresses 2012--2013 was included. Based on evidence, the individual recommendations were proposed and subsequently underwent a total of 5 rounds of the so-called Delphi method. Finally, three overarching principles and a total of 14 recommendations were defined. Results: The major differences between the new and the old recommendations include: achieving a low activity or remission at 6 months, however, achieving at least response to treatment with csDMARDs after 3 months; initiation of MTX therapy either as a monotherapy or in combination with more csDMARDs (MTX + SAS + HCQ); more emphasis on the application of glucocorticoids in early RA in combination with MTX (csDMARDs), however, limited to six months of application; anti-TNF inhibitors, abatacept, tocilizumab, and rituximab in certain circumstances are recommended after failure of MTX as the first biological drug; biosimilars are listed as an alternative -- to date, biosimilar infliximab has already been approved; tofacitinib is mentioned, which may be applied only after failure of at least one anti-TNF drug. Recently, EMA has refused its registration. [ABSTRACT FROM AUTHOR]

Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Tocilizumab is a monoclonal antibody against IL-6R, which is registered for the treatment of moderately and highly active rheumatoid arthritis in the first and second line of biological treatment. Tocilizumab has been registered on the basis of a series of randomized phase III clinical trials. Other valuable data have been obtained from registries of biological treatment. In the present paper the issue of predictive factors of efficacy of tocilizumab is discussed as well. methods: An observational study of the effectiveness of tocilizumab (TCZ) in routine clinical practice has been performed. Patients enrolled in the study met the criteria of the Czech Society for Rheumatology for the application of biological treatment and were filed into the national registry ATTRA. The study monitored the following parameters: demographic characteristics of a patient, previous and current treatment, the presence of RF and anti-CCP antibodies (ACPA), DAS 28, serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), therapeutic response according to EULAR, achieving low disease activity (LDA) after 6 and 12 months (DAS 28 < 3.2) and achieving remission (DAS 28 < 2.6). Pre-treatment predictors of achievement of low disease activity at 6 and 12 months were evaluated. statistical analysis: Univariate logistic regression evaluating the effect of all factors to achieve LDA was performed as the first step. The main factors were assessed by ROC analysis to identify the threshold value that divides the factor preferably in the sense of prediction of achieving LDA. Results: A total of 151 patients, whose test results were evaluated for safety, were enrolled into the registry. Data of 113 patients, who were newly started on TCZ at baseline, were used to assess the treatment efficacy. In the remaining 38 patients the efficacy was not evaluated because these were patients who continued therapy in the registry after the termination of clinical trials. Patients with advanced disease with a mean duration of 11 years and high disease activity (DAS 28 5.9, mean CRP 24.1 mg / l) were included in the analysis. The entire six-month monitoring was completed by 88% of patients treated concomitantly with disease-modifying antirheumatic drugs (DMARDs) and 85% of patients on monotherapy with TCZ. Therapeutic response according to EULAR at 6 months was reached by 88-89% of patients. After 12 months of treatment low disease activity was achieved by 67% of patients and 48% of patients were in remission. There were no differences found between the group treated with monotherapy or the group treated with combination of TCZ + DMARDs in achievement of LDA and remission. The only significant predictive indicator of achievement of low disease activity (LDA) after 12 months of treatment was the number of swollen joints. The incidence of adverse events was comparable between patients treated with monotherapy and combination of TCZ + DMARDs. conclusion: The results of our study show good efficacy of TCZ in patients with rheumatoid arthritis in routine clinical practice. No significant difference was found between patients treated with monotherapy or with combination of TCZ+DMARDs in the efficacy or safety. The only predictive indicator of response to treatment with TCZ was the number of swollen joints. [ABSTRACT FROM AUTHOR]

Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The author presents the recommendations of the Czech Society for Rheumatology for the treatment of osteoarthritis of the knee, hip and hand joints based on the available evidence on efficacy and consensus of the committee of the Czech Society for Rheumatology. In the introductory part of the report the problems that must be resolved before determining a treatment plan for each patient are analyzed: the correct diagnosis of osteoarthritis, osteoarthritis classification (primary, secondary, monoarticular, polyarticular or generalized), the type, intensity and frequency of pain, functional limitations, structural joint damage, rate of progression of degenerative changes, another diseases of the patient, the use of medication and their possible interactions. The basic goals in the treatment of osteoarthritis include: reduction of pain and stiffness of the joint, improvement or at least maintenance of joint mobility, improvement of physical function, alleviation of disability, improvement of health-dependent quality of life, retardation of the progression of joint destruction and education of the patient about the nature of his illness and its treatment. The treatment plan should be designed individually for each patient. Optimal care is provided by several experts, in addition to a rheumatologist, a patient with osteoarthritis should be also treated by a physical therapist, orthopedic surgeon, internist and obesitologist if needed. Each patient should be treated comprehensively. Complex treatment of osteoarthritis consists of non-pharmacological treatment, pharmacological therapy and surgery if needed. Evidence-based non-pharmacological methods of treatment include patient education, lifestyle modification (weight reduction, modification of biomechanical ratios), regular exercise, some means of physical therapy and the use of prosthetic and support devices. Pharmacological treatment with evidence-based effectiveness comprise paracetamol, systemically and locally administered NSAIDs, strong and weak opioids, intra-articular glucocorticoids and some symptomatic slow-acting drugs in osteoarthritis (SYSADOA - glucosamine sulfate, diacerein, an avocado and soy extract, chondroitin sulfate and hyaluronic acid). The surgical procedures with evidence-based effectiveness include replacement of hip and knee joints, both total and unicompartmental. There is no clear evidence on the effectiveness of arthroscopic procedures such as joint lavage and debridement. Osteotomy is recommended for osteoarthritis of the hip, especially in patients with dysplasia. Osteotomy in osteoarthritis of knee joints is not included in the new EULAR recommendations. In OA of the hand joints, there is a direct evidence of effectiveness for education and exercise, NSAIDs, COX-2 inhibitors, local NSAIDs and capsaicin, and chondroitin sulfate. Acetaminophen, glucosamine and local glucocorticoids were recommended upon extrapolation from other sites. [ABSTRACT FROM AUTHOR]

In the introduction, the author stresses the need for accurate diagnosis of gout. You can use ACR criteria or newly published EULAR diagnostic criteria. In both criteria, there is an absolute diagnosis based on the proof of sodium urate crystals. The need for a crystallographic analysis of all effusions of unknown etiology is emphasized as well. Cessation of a gout attack as soon as possible, normalization of serum levels of uric acid and removal of urate deposits in the body are the principal objectives in the treatment of gout. Furthermore, the associated diseases need to be addressed and the complications of gout prevented. Early anti-inflammatory treatment is of high importance in the treatment of acute inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drug of choice in uncomplicated gout. Colchicine is used in patients with unclear diagnosis or contraindication to NSAIDs. Even lower dosages of colchicine (0.5 mg 3 times daily) are momentarily recommended, because conventional dosage often leads to adverse effects. A third alternative in the treatment of acute inflammation is the administration of corticosteroids. In cases with mono- or oligoarthritis, intra-articular administration of long-acting corticosteroids is highly recommended. Exclusion of septic arthritis is required. Systemic administration of corticosteroids at an initial dose of 20-50 mg with tapering within two to three weeks is a possible alternative, and is sometimes used especially in forms with polyarticular gout or in cases, where NSAIDs and colchicine cannot be used. However, new attacks occur more frequently after tapering of the dose. Thus, corticosteroids are considered a second-line treatment of gout. During acute inflammation we do not affect hyperuricemia. We initiate the reduction of uricaemia after resolution of acute attacks. Chronic tophaceous gout and radiographically progressive gout are another indication of the correction of hyperuricemia. Non-pharmacological and pharmacological treatment can be used in reducing uricaemia. Non-pharmacological methods should be applied for each patient and should include weight reduction, low-purine diet and alcohol abstinence. Uricosuric and uricostatic agents can be used for pharmacological reduction of uricaemia. Uricosuric agents are indicated only in patients without renal disease (lithiasis). Currently, there is no uricosuric agent available on the Czech market. The most used drug for the treatment of hyperuricaemia is the xanthine oxidase inhibitor allopurinol. It is administered at doses of 100-900 mg per day and an individual dose for each patient must be titered. In case of intolerance or lack of efficacy of allopurinol, a non-purine selective inhibitor of xanthine oxidase, febuxostat, is now available as a secondline treatment of hyperuricaemia. The recommended dose of febuxostat is 80 mg daily. Initiation of an effective hypouricaemic treatment can trigger new attacks, therefore a colchicine prophylaxis for 3-6 months is recommended. For patients with gout often have gout-associated diseases (hypertension, dyslipidemia, diabetes, metabolic syndrome), these should be monitored and treated in collaboration with a relevant specialist. Pegylated uricase (pegloticase) and monoclonal antibody against IL-1 (canakinumab) are promising new drugs for refractory gout that are currently in the final phase of testing and approval. [ABSTRACT FROM AUTHOR]

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Czech Rheumatological Society has issued the Recommendations for the treatment of ankylosing spondylitis (AS), which update the Recommendations from 2004. Successful treatment is based on an accurate and early diagnosis, which can be established using either the modified New York criteria or the recently published criteria of ASAS / EULAR for axial spondyloarthropathies. At baseline examination of each patient with AS the extent of the disease is determined (axial, peripheral, combined or extra-articular symptoms). In addition, the activity of the disease is numerically evaluated with BASDAI score being the universally recommended methodology. Therapy of AS should be complex and consists of non-pharmacological and pharmacological treatment or surgery. Non-pharmacological treatment is based on education of patients and their motivation for a lifelong active rehabilitation program. A combination of individual home exercise and group exercises under the supervision of a physiotherapist is of particular advantage. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the basic pharmacological means with positive effects in 70-80% of patients. NSAIDs with long half-life are recommended. A long-term, daily administration of NSAIDs was demonstrated to slow down the radiological progression of AS. There is no evidence that any DMARD was effective for the axial form of AS. Therefore there is no requirement of DMARD treatment prior to biological therapy. Most studies show some effect of sulfasalazine on peripheral forms of AS. Neither methotrexate nor systemic glucocorticoids were shown to be effective. On the contrary, administration of topical glucocorticoid injections to the sites of peripheral arthritis or enthesitis is recommended. Anti-TNF antagonists are the most effective treatment. The efficacy of anti-TNF therapy in AS is fast, strong and long-term. Although efficacy was demonstrated even in advanced forms of AS a better effect was observed in patients with shorter disease duration. For the treatment of AS etanercept, infliximab, adalimumab and golimumab are indicated. For the treatment with anti- TNF agents the patient should meet the following criteria: Diagnosis of AS according to the modified New York or ASAS criteria; Disease activity BASDAI ≥ 4 at two consecutive check-ups in the period of at least 4 weeks; A positive expert opinion; CRP > 10 mg / l; Absence of contraindication to treatment; Response to therapy should be observed at week 12 and is evaluated as the decrease in BASDAI by 50% or two and more (on a scale of 0-10). In patients with hip involvement who have refractory pain, substantial disability and radiographic destruction of the hip joint a total hip replacement regardless of age is recommended. Corrective osteotomy in patients with significant hyperkyphosis is another recommended surgical method. In case of a suspected vertebral compression fracture a neurosurgeon should be consulted. Conclusion: The new recommendations allow early diagnosis of AS and its intensive treatment, which should lead to reduced disability and improved quality of life of patients with AS. [ABSTRACT FROM AUTHOR]

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Authors present report on application of rituximab (RTX) in indication rheumatoid arthritis (RA) in patients treated in Czech Republic in National registry ATTRA. Indications for therapy with RTX according Guidelines of Czech Rheumatologic Society was RA (DAS 28 > 5,1) and failure of at least one disease modifying drug of RA (DMARD) and one anti TNF. Altogether 242 patients were included in the study, 81 % women, mean age was 52 years and duration of disease 12 years. Patients have been treated in the past by average 3 DMARDs and one anti TNF. RTX was given as first biological to 24 % of patients. The activity of RA was high at baseline, but there was significant decrease of activity at week 16 and this effect was sustained after 2 years of follow up in all measured parameters. Status of low disease activity (LDA) DAS 28 < 3,2 was reached in 15,5 % of patients at week 16 and 41,4 % at week 56. All patients, who achieved LDA at week 16 had LDA at week 56. EULAR good and moderate response was achieved in > 80 % patients. Serious adverse events were present in 11,6 %. The most frequents adverse events were serious infections at frequency 13,3/1000 pts. yrs. Serious infusion allergic reactions, leading to interruption of therapy were present in 13,3 / 100 pts. yrs. of patients. Conclusions: Open, cohort study of patients in registry, reflects routine clinical practice. In has shown good ratio efficacy / safety of RTX in patients with active RA. Despite the fact that was cohort of patients with longstanding, refractory RA, it was possible to reach low disease activity in more than 40 % patients after 12 months of therapy. [ABSTRACT FROM AUTHOR]

The aim of our study was to survey the forms of gastroprotective therapy used in the Czech Republic during the treatment with nonsteroidal anti-rheumatic drugs (NSAIDs) in patients with chronic rheumatic diseases with different risk factors for NSAID-induced gastropathy. Methods: We conducted a multicentric study with data collected directly by rheumatologists. Administration of NSAIDs for at least 4 days a week in the last 3 months was considered as chronic use. The study had two parts: the first part was a cross-sectional study with a one-time record of use of gastroprotective therapy at the time of questionnaire completion; the second part was a retrospective observation of adverse effects in the last 3 months. Results: 90 rheumatologists participated in our survey. Records were collected for a total of 869 patients: 275 men (31.65%) and 594 women (68.35%). A total of 789 patients (90.79%) were at risk of NSAID-induced gastropathy; with 397 (45.68%) at high-risk and 392 patients (45.10%) at low risk. At least one gastroprotective drug was used in 648 (74.57%) individuals (coxibs, H2-blockers or proton pump inhibitors), with omeprazole being the most commonly used gastroprotective agent (94.41%). The relationship between risk of NSAID-induced gastropathy and gastroprotective agent used reached statistical significance (p<0.01, r = 0.349); ie gastroprotective drugs were used in 83.88% patients at high risk of gastropathy, in 73.72% patients with low risk, and in 32.50% patients with no risk. No gastroprotective drugs were used in 16.18% high-risk patients and in 26.27% patients with low risk of gastropathy. 672 (77.33%) out of all monitored individuals experienced no difficulties during the NSAIDs treatment, whereas 197 (22.66%) individuals had some ailments under the treatment with NSAIDs. Conclusion: We have found a significant correlation between the GI risk and use of gastroprotective drug. The most commonly used agent was omeprazole (94.41%). However 19.22% of all monitored individuals with at least one risk factor for NSAID-induced gastropathy were not treated with any gastroprotective drug. [ABSTRACT FROM AUTHOR]

Copyright of Czech Rheumatology / Česká Revmatologie is the property of Czech Medical Association of JE Purkyne and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Biological therapy of chronic inflammatory, rheumatic, gastroenterological and dermatological diseases has revolutionized the treatment of these conditions. The number of patients treated with biologicals as well as the range of indications for this therapy is still growing. Although this treatment is relatively safe, adverse events may occur including development of autoimmune disorders. These autoimmune diseases may be divided into autoimmune systemic diseases and organ specific autoimmune diseases. Systemic lupus erythematosus (SLE) and vasculitides are among the most frequently induced systemic autoimmune diseases, whereas demyelinating diseases of the central nervous system (CNS) and peripheral neuropathy, interstitial lung disease and autoimmune hepatitis represent the organ specific group. Autoimmune diseases are most frequently induced by anti-TNF agents. Drug induced lupus usually manifests with constitutional symptoms, skin and joint involvement, haematological abnormalities and serositis. Nephritis and CNS involvement are less common. Anti-TNF induced SLE patients are ANA positive in 100% and anti dsDNA positive in 90%, whereas in classical drug induced SLE and idiopathic SLE, anti dsDNA positivity occurs less frequently. Antinuclear antibodies (ANA) are typical for classical drug induced SLE (occurs in 95%), less frequent in TNF induced SLE (57%) and least frequent in idiopathic SLE (25-40%). The treatment of drug induced SLE consists of discontinuation of TNF therapy in mild cases and mandatory use of corticosteroids and immunosuppressive therapy in more severe cases. The prognosis is good; the portion of patients with persistent disease is approximately 13%. In this review article, the author included two case reports describing patients with drug induced lupus from the Institute of Rheumatology in Prague including their treatment. Patients with skin vasculitis dominated the group of vasculitis patients with 88%, whereas renal involvement and peripheral neuropathy were rare. Conclusion: It is necessary to consider the possibility of drug induced autoimmune disease following a biological therapy when forming a differential diagnosis, and to take adequate therapeutic actions. In most cases, discontinuation of anti-TNF therapy is sufficient, whereas in more severe cases, introduction of immunosuppressive treatment is mandatory. [ABSTRACT FROM AUTHOR]