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      Comparison of the Effect of Disease: Modifying Antirheumatic Drugs Alone or in Combination with Biologic Drugs in the Outcome of Patients with Rheumatoid Arthritis

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          Abstract

          Background:

          Rheumatoid arthritis (RA) is a rheumatic disease that could be disabling if not treated. The aim of RA therapy is to resolve tenderness and swelling in the joints. The present study was conducted to compare two methods of RA treatment with disease-modifying anti-rheumatic drugs (DMARDs) and DMARDs with biologic drugs in two groups of patients.

          Materials and Methods:

          The present study was a nonrandomized clinical trial which was conducted from July to September 2017 on 110 patients who were selected based on the American College of Rheumatology (2010) criteria for RA. Patients were divided into two groups of 55: Groups A and B. For the treatment of Group A, prednisolone along with one or two drugs from the DMARDs combinations was used. Group B received one biologic drug besides with the drugs of the group A. T-test and covariance analysis was used to compare the outcomes of both groups.

          Results:

          Disease activity score (DAS-28) at the beginning of the study was 4.23 (0.81) in Group A and 4.51 (0.7) in Group B ( P = 0.05). At the end of the study, DAS-28 was 3.52 (0.79) in Group A and 3.75 (0.85) in Group B ( P = 0.1). DAS-28 activity index had a significant difference between both two groups at the beginning of the study ( P = 0.05), but at the end of the study, the difference was not statistically significant ( P = 0.1).

          Conclusions:

          Simultaneous use of DMARDs and biologic drugs in RA patients could lead to improvement the disease symptoms and decrease the severity and activity of the disease.

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          Most cited references7

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          Impact of concomitant use of DMARDs on the persistence with anti-TNF therapies in patients with rheumatoid arthritis: results from the British Society for Rheumatology Biologics Register

          Objective To evaluate the effect of different concomitant disease modifying antirheumatic drugs (DMARDs) on the persistence with antitumour necrosis factor (anti-TNF) therapies in patients with rheumatoid arthritis (RA). Method This analysis included 10 396 patients with RA registered with the British Society for Rheumatology Biologics Register, a prospective observational cohort study, who were starting their first anti-TNF therapy and were receiving one of the following DMARD treatments at baseline: no DMARD (n=3339), methotrexate (MTX) (n=4418), leflunomide (LEF) (n=610), sulfasalazine (SSZ) (n=308), MTX+SSZ (n=902), MTX+ hydroxychloroquine (HCQ) (n=401) or MTX+SSZ+HCQ (n=418). Kaplan–Meier survival analysis was used to study the persistence with anti-TNF therapy in each DMARD subgroup up to 5 years. Multivariate Cox proportional hazard models, stratified by anti-TNF used and start year and adjusted for a number of potential confounders, were used to compare treatment persistence overall and according to the reason for discontinuation between each of the DMARD subgroups, using MTX as reference. Results One-year drug survival (95% CI) for the first anti-TNF therapy was 71% (71% to 72%) but this dropped to 42% (41% to 43%) at 5 years. Compared with MTX, patients receiving no DMARD, LEF or SSZ were more likely to discontinue their first anti-TNF therapy while patients receiving MTX in combination with other DMARDs showed better treatment persistence. Conclusions These results support the continued use of background DMARD combinations which include MTX. Consideration should be given to the discontinuation of LEF and SSZ monotherapy at the time anti-TNF therapies are started, with the possible exception of the SSZ+ETN combination.
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            Effect of Conjugated Linoleic Acid, Vitamin E, Alone or Combined on Immunity and Inflammatory Parameters in Adults with Active Rheumatoid Arthritis: A Randomized Controlled Trial

            Background: Little information about the effects of conjugated linoleic acids (CLAs) on inflammation and immune function in humans is available. This study investigated the effects of CLAs, with and without Vitamin E on immunity and inflammatory parameters in adults with active rheumatoid arthritis (RA). Methods: In a double-blind clinical trial, 78 patients were randomly divided into four groups, each group receiving one of the following daily supplement for 3 months; group C: 2.5 g CLAs, group E: 400 mg Vitamin E, group CE: CLAs plus Vitamin E, group P: Placebo. Cytokines, matrix metalloproteinase 3 (MMP-3) and citrullinated antibody (CCP-A) were measured by ELISA method and Vitamin E by high-performance liquid chromatography. Results: Consider statistical methods there were no significant differences between groups in cytokines interleukin-2 (IL-2), IL-4, tumor necrosis factor-α (TNF-α), IL-1β, IL-2/IL-4, CCP-A white blood cells and neutrophils, lymphocyte, monocytes, and eosinophils numbers. TNF-α decreased in all groups, but its reduction was significant in group CE. IL-1β increased in groups P (P = 0.004) and E (P = 0.041) but the difference between group P and CE was significant. IL-4 decreased in groups C, CE and E (P = 0.03, P = 0.03, P = 0.07 respectively). IL2 did not change significantly within groups. CCP-A increased in groups P (P = 0.035) and E (P = 0.05), while it decreased in groups CE (P = 0.034). CCP-A and MMP-3 decrease were significant between groups P and CE. MMP-3 reduction was significant in group CE. Conclusions: Co-supplementation CLAs and Vitamin E may be effective in the level of inflammatory markers in RA patients.
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              Combination therapy with biologic agents in rheumatic diseases: current and future prospects.

              Strategies in rheumatoid arthritis (RA) based on 'treat to target' aim to control disease activity, minimize structural damage, and promote longer life. Several disease-modifying antirheumatic drugs (DMARDs) have been shown to be effective including biological DMARDs (bDMARDs). Treatment guidelines and recommendations for RA have also been published. According to those guidelines, conventional synthetic DMARDs (csDMARDs), as monotherapy or combination therapy, should be used in DMARD-naïve patients, irrespective of the addition of glucocorticoids (GCs). Combination therapies with bDMARDs are also essential for conducting treatment strategies for RA, because in every recommendation or guideline for the management of RA, combination therapies of csDMARDs with bDMARDs are recommended for RA patients with moderate or high disease activity after failure of csDMARD treatment. bDMARDs are more efficacious if used concomitantly with methotrexate (MTX) than with MTX monotherapy or bDMARD monotherapy. Thus, retention has been reported to be longer when combined with MTX. The superior efficacy of combination therapy compared with MTX monotherapy or bDMARD monotherapy could be because: (1) it could help to minimize MTX toxicity by reducing the dose of MTX, thus retention rate of the same therapeutic regimen would become high; (2) anti-bDMARD antibodies are observed at lower concentrations when using MTX concomitantly, so less clearance of bDMARDs via less formation of bDMARD and an anti-bDMARD immune complex; (3) of the additive effects of MTX to bDMARD, especially the combination of tumor necrosis factor inhibitors (TNFis) with MTX. Hence, evidence suggests that combination therapy with bDMARDs is more efficacious than monotherapy using a csDMARD or bDMARD, and that MTX is the best drug for this purpose (if MTX is not contraindicated). Finding the most effective drug regimen at the lowest cost will be the aim of RA treatment in the future.
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                Author and article information

                Journal
                Adv Biomed Res
                Adv Biomed Res
                ABR
                Advanced Biomedical Research
                Wolters Kluwer - Medknow (India )
                2277-9175
                2019
                30 April 2019
                : 8
                : 32
                Affiliations
                [1] From the Isfahan Metabolic Bone Disorders Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
                Author notes
                Address for correspondence: Dr. Farzaneh Mirrokni, Isfahan Metabolic Bone Disorders Research Center, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: f.mirrokni2016@ 123456gmail.com
                Article
                ABR-8-32
                10.4103/abr.abr_247_18
                6521615
                d2b26fa9-a714-4987-95b1-eff195365eea
                Copyright: © 2019 Advanced Biomedical Research

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : December 2018
                : February 2019
                Categories
                Original Article

                Molecular medicine
                biologic,disease activity score-28,disease modifying anti-rheumatic drugs,rheumatoid arthritis

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