OBJECTIVES:This study aims to provide an update of the European Alliance of Associations for Rheumatology (EULAR) rheumatoid arthritis (RA) management recommendations addressing the most recent insights. METHODS:An International Task Force was formed with a wide expertise and solicited 2 systemic literature research activities on the safety and efficacy of disease-modifying antirheumatic drugs (DMARDs). New evidence was discussed, considering the update from 2022. A voting process was applied to each item. Levels of evidence and strengths of recommendation were assigned, and participants voted on the levels of agreement. RESULTS:The task force agreed on 5 overarching principles and reduced the number of recommendations to 9 concerning use of conventional synthetic DMARDs (methotrexate [MTX], leflunomide, sulfasalazine); glucocorticoids (GCs); biological (b)DMARDs (tumour necrosis factor inhibitors [adalimumab, certolizumab pegol, etanercept, golimumab, infliximab], abatacept, rituximab, tocilizumab, sarilumab, including biosimilars) and targeted synthetic [ts]DMARDs (namely the Janus kinase inhibitors [JAKi] tofacitinib, baricitinib, filgotinib, upadacitinib). Guidance on monotherapy, combination therapy, treatment strategies (treat-to-target), and tapering following clinical remission is provided. Safety aspects, including risk of major cardiovascular events (MACEs) and malignancies, costs and sequencing of b/tsDMARDs were considered. Initially, MTX ideally in combination with short-term GCs is recommended; upon insufficient response after 3 to 6 months, a bDMARD should be added; after careful consideration of risks, including MACEs, malignancies and/or thrombo-embolic events, JAKi may also be considered. If the first bDMARD (or JAKi) fails, any other bDMARD (from another or the same class) or JAKi (considering risks) is recommended. With sustained remission, DMARDs may be tapered, but caution is required as stopping often leads to a flare. Levels of evidence and levels of agreement were high for most recommendations. CONCLUSIONS:These updated EULAR recommendations provide consensus on RA management based on currently available evidence regarding efficacy, safety, and cost.
Background: Methotrexate (MTX) is the anchor and most prescribed disease-modifying anti-rheumatic drug (DMARD) for inflammatory rheumatic diseases (IRDs). MTX can be very efficacious but can also have serious, life-threatening side effects. Adequate education and follow-up of patients/carers are therefore essential, and dedicated rheumatology nurse consultations are an important part of this. However, many patients across European countries lack access to nurse consultations, and there are no agreed-upon, defined standards of care for this topic. Objectives: To develop points to consider (PtC), based on the best available evidence and experts’ opinion, on the nursing education of patients (or carers) with IRDs taking MTX. Methods: A task force of adult and pediatric nurses (n=19) from 16 European countries, one rheumatologist, one pharmacist, and three patient-representatives, was established by the Portuguese Association of Health Professionals in Rheumatology. The group convened virtually to discuss the protocol for developing the PtC, including the research questions for a scoping review and for a European survey to collect patients’/careers’, nurses’ and rheumatologists’ experiences and perceptions about MTX education. The results from these studies informed the development of the PtC statements, which were discussed and voted on in two virtual meetings and one online questionnaire. EULAR Standard Operating Procedures for the development of recommendations/PtC were followed. Results: The consensus resulted in three overarching principles and six PtC. All PtC were based on available scientific evidence, and all obtained high levels of agreement (>8/10). These PtC emphasize the need for continuous, tailored education by trained nurses, the availability of diverse educational methods, and the support for self-management and adherence strategies. Conclusion: A set of PtC has been developed to improve the quality of care provided to patients with IRDs and their carers regarding the education and support nurses should provide on MTX use. The ultimate goal is to optimize MTX intake, improve efficacy, reduce side effects and ensure adherence to treatment. A plan is underway for the European implementation of these PtC, recognizing the crucial relevance of multi-professional rheumatology teamwork.
Objectives:The aims of this study were to (1) explore the health literacy strengths and challenges of migrant patients with inflammatory rheumatic diseases and limited Norwegian language proficiency, and (2) generate and describe typologies of health literacy strengths and challenges within this patient group. Methods:The study was inspired by the Ophelia process for co-designing health literacy interventions. Semi-structured individual interviews were conducted with 19 migrant patients who used interpreters during consultations with health professionals. Participants had various language backgrounds and were recruited from two rheumatology specialist departments. Interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. Results:Participants described a diversity of health literacy strengths and challenges. Four health literacy typologies were generated, illustrating varying patterns of strengths and challenges. Some challenges were exacerbated by participants' situation as a migrant with limited Norwegian proficiency. Navigating the healthcare system and actively engaging with health professionals were common challenges. The intersection of the different challenges could further hinder migrant patients' ability to navigate and utilize healthcare information and services. However, strengths such as supportive social networks could mitigate some issues. Conclusion:The findings from this study highlight a nuanced understanding of health literacy strengths and challenges among migrant patients with inflammatory rheumatic diseases and limited Norwegian language proficiency. The study contributes to the growing body of work inspired by the Ophelia principles. Knowledge from this study will be used to develop vignettes to facilitate idea-generating workshops as part of a larger study co-designing health literacy-informed interventions.
Research on hip fracture prevention in men is limited. In men, physical activity and body mass index were independently and jointly associated with hip fracture risk, with the highest risk among inactive and thin men. Promoting exercise and healthy weight in midlife may reduce fracture burden and support healthy ageing. Hip fractures predominantly affect older people with frailty. The incidence increases with age, and the number is expected to increase substantially due to population aging. Physical inactivity and low body mass index (BMI) are key modifiable risk factors for hip fractures. This study aimed to explore the associations of physical activity and BMI with long-term hip fracture risk in men. This prospective cohort study included 12,900 men aged 40–49 years from the Oslo study 1972–1973. A questionnaire assessed physical activity, whereas height and weight were measured. Hip fractures were identified through linkage to a national database. Cox regression calculated adjusted hazard ratios (HR) with 95
Juvenile idiopathic arthritis (JIA) used to be a joint-destroying disease, but thanks to modern treatment strategies and medications, many patients with JIA today reach inactive disease. However, once disease remission is achieved, there is a lack of knowledge and recommendations regarding maintenance therapy. Drug-free remission is the ultimate goal in JIA, but withdrawal of medications increases the risk of disease flare. Clinical approaches vary widely, underscoring a need for knowledge about maintenance treatment strategies that allow for safe tapering and withdrawal of medications in JIA patients in sustained remission. The MOVE-JIA study is a randomized, controlled trial with the primary objective to compare the effect of two different treatment withdrawal strategies, to a stable dose of methotrexate (MTX) and tumor necrosis factor inhibitors (TNFi), based on the risk of flares in children and adolescents with JIA with sustained inactive disease. A key secondary objective is the proportion of children with disease flare compared between the two withdrawal groups. In this investigator-initiated multicenter, randomized, 3-grouped, parallel, open-label, noninferiority trial, treating physicians at seven Norwegian pediatric rheumatology hospital centers will include 150 patients with JIA. Key eligibility criteria are as follows: Fulfilment of the International League of Associations for Rheumatology (ILAR) classification criteria for non-systemic JIA, inactive disease for ≥ 12 months documented at a minimum of 2 consecutive visits, and no active uveitis for ≥ 24 months under treatment with stable doses of MTX and TNFi. They will be randomized in a 1:1:1 ratio to (A) stable treatment, (B) methotrexate withdrawal, or (C) TNFi withdrawal. Randomization will be stratified for JIA subtype and study center. For patients in group B and C who are still in remission after 12 months, a new randomization will be performed for complete medication withdrawal for the next 12 months. After 24 months, medication adjustments will be done with shared decision-making. The primary endpoint is the rate of disease flare compared between the drug withdrawal groups and the stable treatment group between baseline and 12 months follow-up. The key secondary endpoint is the proportion with disease flare compared between the two withdrawal groups. Incidence and severity of adverse events will be monitored. The results from the MOVE-JIA trial will present an evidence-based treatment strategy for JIA patients with inactive disease. The trial will also give us knowledge about regaining disease remission after flares and possibilities of drug-free remission. All outcomes from the trial will provide a scientific basis for optimized JIA care and result in new treatment recommendations. EU CT 2024–512017–12–00. Registered on October 24th, 2024; ClinicalTrials.gov NCT06653634. Registered on October 24th, 2024. URL: Study Details | NCT06653634 | Optimizing Treatment for Patients With Juvenile Idiopathic Arthritis in Sustained Remission: The MOVE–JIA Trial | ClinicalTrials.gov. Date of first recruitment: October 24th, 2024.
