Psoriatic Arthritis

Rheumatologists tend to order the same types of tests to monitor their patients’ responses to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), but they vary widely in how often they order tests and how they respond to abnormal results, responses to a survey suggest.

“The study found that, although guidelines exist, people didn’t follow them consistently. They also responded to abnormal test results in wildly different ways,” senior study author Philip C. Robinson, MBChB, PhD, of the University of Queensland, Herston, Australia, said in an interview.

“The take-home message of this study is that everyone is doing something different, which means that the system likely has a lot of low-value activity and that money is being wasted,” he added. “However, we don’t have the evidence to guide people to make better choices.”

The literature on laboratory monitoring of people taking csDMARDs for rheumatic disease is scant, the authors wrote in BMC Rheumatology, and current guidelines on csDMARD monitoring vary, likely because of the lack of high-quality evidence for specific monitoring regimens.

“An enormous amount of money is spent on DMARD monitoring with little evidence to support current practices,” Dr. Robinson said. So he and his colleagues asked rheumatologists and rheumatology trainees about their attitudes and practices related to laboratory monitoring of csDMARDs in an online questionnaire.

They used the Australian Rheumatology Association newsletter to invite around 530 Australian rheumatologists and trainees, around 4,500 of Dr. Robinson’s Twitter followers, and 25 Australian and overseas email contacts, to respond to questions about csDMARDs they prescribed, frequency and patterns of monitoring, influences of additional factors and combination therapy, responses to abnormal tests, and attitudes toward monitoring frequency.

The researchers based their questions on csDMARD monitoring guidelines published by the American College of Rheumatology (which recommends monitoring every 2-4 weeks from initiation to 3 months, every 8-12 weeks during months 3-6, and every 12 weeks from 6 months onward), and from the British Society for Rheumatology (whose guidance is similar but bases monitoring frequency on how long DMARD doses remain stable).

The 221 valid responses they collected included 53 from Australia and 39 from the United States. Overall, 53% of respondents were in public practice, 56% were women, and 56% had practiced rheumatology for 11 or more years.

Respondents reported more frequent monitoring of patients with multiple comorbidities and those taking csDMARD combinations, including methotrexate and leflunomide. Responses to abnormal monitoring results varied widely, and 40% of respondents reported that monitoring tests are performed too often. Compared with females, males reported greater tolerance of significant test abnormalities before acting. They also were more likely to report that guidelines recommend, and doctors perform, tests too frequently.
 

Testing, monitoring patterns can differ from current guidelines

Rheumatologists who were asked to comment on the survey welcomed its results.

They came as no surprise to Daniel E. Furst, MD, professor emeritus of medicine at the University of California, Los Angeles.

“Most guidelines point out in the introduction that they are recommendations and need to be modified by specific patient and environmental needs,” he noted in an interview.

Stephen Myers, MD, assistant professor of clinical medicine in the division of rheumatology at the University of Southern California, Los Angeles, said: “The findings seem generally consistent with my observed practices and those of my peers, with the exception of sulfasalazine, which we tend to monitor every 3 months, similar to the way we monitor other csDMARDs.”

Caoilfhionn Connolly, MD, MSc, postdoctoral fellow in rheumatology at Johns Hopkins University, Baltimore, called “the variability in monitoring somewhat surprising given that both the American College of Rheumatology and the British Society for Rheumatology provide guidance statements on optimal monitoring.

“As the authors highlight,” she added, “the variability in monitoring and response to lab abnormalities is likely driven by the lack of a high-quality evidence base, which should ideally be derived from clinical trials.”

Medication monitoring is critical to ensuring patient safety in rheumatology and other specialties, said Puja Khanna, MD, MPH, a rheumatologist and clinical associate professor of medicine at the University of Michigan, Ann Arbor.

Dr. Khanna described how in 2018, the Michigan Medicine health care system revisited its processes and protocols for medication monitoring.

Previously, “we were reliant on society guidelines that were not used consistently across the academic and community rheumatology practices,” she said. “Using lean thinking methodology, we found that we lacked familiarity with laboratory monitoring protocols amongst the interdisciplinary teams involved in the process and that we had a clear need for consensus.

“A consistent departmental protocol was created to help streamline the workflow for ancillary support staff, to close identified operational gaps, and to reduce delays in monitoring that impacted safe practice patterns,” Dr. Khanna added.

“We developed standardized medication- and disease-based monitoring protocols for eight medical specialties, where the person who writes a prescription that requires monitoring can utilize standard work flows to enroll the patient in the medication monitoring program and have dedicated ancillary support staff follow the results periodically and alert clinicians in a timely manner,” she explained. “Almost 15,000 patients are currently monitored in this collaborative program involving clinicians, nurses, pharmacists, and IT and administrative teams.”
 

Guidelines may not capture clinical realities of csDMARD monitoring

Dr. Myers and colleagues may monitor testing more intensively if, for example, a patient becomes ill, has side effects, or has taken medication incorrectly. But they’ll less intensively monitor a patient who’s been stable on a csDMARD.

“In my current academic practice, deciding lab monitoring frequency is left up to physicians. In my previous private practice experience, lab monitoring seemed to be more frequent than the current guidelines for many patients, compared to public or academic practice,” he said. “It would be interesting to compare monitoring practices in private, public, and academic settings.

“The clinical reality is that frequent monitoring depends on the regular follow-up, which for some patients is difficult, due to socioeconomic factors including lack of childcare and public transport,” Dr. Myers added.

Dr. Khanna mentioned that “guidelines tend to provide details of extant practice patterns, usually taken from evidence-based data. With monitoring, however, that is tough to achieve, unless substantial data can be found in large national registries of patients on immunosuppressive medications.”

Experience and comfort with using immunosuppressive medications, and medicolegal liability considerations, especially because many immunomodulatory agents confer adverse effects, can contribute to clinicians’ behaviors varying from guidelines, she added.
 

A good scoping review, and further research needed

“This article did what it was supposed to do: Define the various approaches to monitoring,” Dr. Furst said. “It is the next steps that will make a difference in practice.

“Next steps ... may require delving into large observational data sets such as registries to ascertain the consequences of different monitoring strategies for various patient groups and disparate drugs and drug combinations,” added Dr. Furst, who coauthored a 2017 review summarizing guidelines for laboratory monitoring in patients with rheumatoid arthritis.

“A significant oversight is the lack of consideration regarding monitoring for corticosteroids, which are well known to have very consequential adverse events and require careful monitoring,” Dr. Furst observed.

“The difference between men’s and women’s monitoring strategies is of some interest,” he added, “but will only be important if it leads to an understanding of and change in monitoring recommendations.”

Dr. Connolly also noted the differences in strategies between male and female respondents.

“Of interest, male respondents were more likely to feel that monitoring was performed too frequently and were also more tolerant of significant abnormalities,” she said. “This begs the question of whether rheumatologist gender differentially impacts other areas of clinical practice.”

Despite the small sample size that limits generalizability, the results provide preliminary insight into the varied practices among rheumatologists worldwide, Dr. Connolly added.

“Given the frequency of csDMARD prescription, the study highlights the clinical unmet need for a more robust evidence base to guide clinical practice,” she said. “The study also adds to important efforts to provide high-value care to patients with rheumatic diseases and may form the basis for larger studies to facilitate the pragmatic utilization of lab monitoring and ultimately optimize both the quality and value of rheumatological care globally.”

Dr. Robinson and coauthors urged further research. “We need more studies of higher quality to help inform the best strategy for protecting our patients from harm from our commonly used rheumatic medicines,” he said.

Dr. Robinson and two coauthors reported relationships with pharmaceutical companies. The remaining authors and all uninvolved sources, who commented by email, reported no relevant relationships. The study received no funding.

Rheumatologists tend to order the same types of tests to monitor their patients’ responses to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), but they vary widely in how often they order tests and how they respond to abnormal results, responses to a survey suggest.

“The study found that, although guidelines exist, people didn’t follow them consistently. They also responded to abnormal test results in wildly different ways,” senior study author Philip C. Robinson, MBChB, PhD, of the University of Queensland, Herston, Australia, said in an interview.

“The take-home message of this study is that everyone is doing something different, which means that the system likely has a lot of low-value activity and that money is being wasted,” he added. “However, we don’t have the evidence to guide people to make better choices.”

The literature on laboratory monitoring of people taking csDMARDs for rheumatic disease is scant, the authors wrote in BMC Rheumatology, and current guidelines on csDMARD monitoring vary, likely because of the lack of high-quality evidence for specific monitoring regimens.

“An enormous amount of money is spent on DMARD monitoring with little evidence to support current practices,” Dr. Robinson said. So he and his colleagues asked rheumatologists and rheumatology trainees about their attitudes and practices related to laboratory monitoring of csDMARDs in an online questionnaire.

They used the Australian Rheumatology Association newsletter to invite around 530 Australian rheumatologists and trainees, around 4,500 of Dr. Robinson’s Twitter followers, and 25 Australian and overseas email contacts, to respond to questions about csDMARDs they prescribed, frequency and patterns of monitoring, influences of additional factors and combination therapy, responses to abnormal tests, and attitudes toward monitoring frequency.

The researchers based their questions on csDMARD monitoring guidelines published by the American College of Rheumatology (which recommends monitoring every 2-4 weeks from initiation to 3 months, every 8-12 weeks during months 3-6, and every 12 weeks from 6 months onward), and from the British Society for Rheumatology (whose guidance is similar but bases monitoring frequency on how long DMARD doses remain stable).

The 221 valid responses they collected included 53 from Australia and 39 from the United States. Overall, 53% of respondents were in public practice, 56% were women, and 56% had practiced rheumatology for 11 or more years.

Respondents reported more frequent monitoring of patients with multiple comorbidities and those taking csDMARD combinations, including methotrexate and leflunomide. Responses to abnormal monitoring results varied widely, and 40% of respondents reported that monitoring tests are performed too often. Compared with females, males reported greater tolerance of significant test abnormalities before acting. They also were more likely to report that guidelines recommend, and doctors perform, tests too frequently.
 

Testing, monitoring patterns can differ from current guidelines

Rheumatologists who were asked to comment on the survey welcomed its results.

They came as no surprise to Daniel E. Furst, MD, professor emeritus of medicine at the University of California, Los Angeles.

“Most guidelines point out in the introduction that they are recommendations and need to be modified by specific patient and environmental needs,” he noted in an interview.

Stephen Myers, MD, assistant professor of clinical medicine in the division of rheumatology at the University of Southern California, Los Angeles, said: “The findings seem generally consistent with my observed practices and those of my peers, with the exception of sulfasalazine, which we tend to monitor every 3 months, similar to the way we monitor other csDMARDs.”

Caoilfhionn Connolly, MD, MSc, postdoctoral fellow in rheumatology at Johns Hopkins University, Baltimore, called “the variability in monitoring somewhat surprising given that both the American College of Rheumatology and the British Society for Rheumatology provide guidance statements on optimal monitoring.

“As the authors highlight,” she added, “the variability in monitoring and response to lab abnormalities is likely driven by the lack of a high-quality evidence base, which should ideally be derived from clinical trials.”

Medication monitoring is critical to ensuring patient safety in rheumatology and other specialties, said Puja Khanna, MD, MPH, a rheumatologist and clinical associate professor of medicine at the University of Michigan, Ann Arbor.

Dr. Khanna described how in 2018, the Michigan Medicine health care system revisited its processes and protocols for medication monitoring.

Previously, “we were reliant on society guidelines that were not used consistently across the academic and community rheumatology practices,” she said. “Using lean thinking methodology, we found that we lacked familiarity with laboratory monitoring protocols amongst the interdisciplinary teams involved in the process and that we had a clear need for consensus.

“A consistent departmental protocol was created to help streamline the workflow for ancillary support staff, to close identified operational gaps, and to reduce delays in monitoring that impacted safe practice patterns,” Dr. Khanna added.

“We developed standardized medication- and disease-based monitoring protocols for eight medical specialties, where the person who writes a prescription that requires monitoring can utilize standard work flows to enroll the patient in the medication monitoring program and have dedicated ancillary support staff follow the results periodically and alert clinicians in a timely manner,” she explained. “Almost 15,000 patients are currently monitored in this collaborative program involving clinicians, nurses, pharmacists, and IT and administrative teams.”
 

Guidelines may not capture clinical realities of csDMARD monitoring

Dr. Myers and colleagues may monitor testing more intensively if, for example, a patient becomes ill, has side effects, or has taken medication incorrectly. But they’ll less intensively monitor a patient who’s been stable on a csDMARD.

“In my current academic practice, deciding lab monitoring frequency is left up to physicians. In my previous private practice experience, lab monitoring seemed to be more frequent than the current guidelines for many patients, compared to public or academic practice,” he said. “It would be interesting to compare monitoring practices in private, public, and academic settings.

“The clinical reality is that frequent monitoring depends on the regular follow-up, which for some patients is difficult, due to socioeconomic factors including lack of childcare and public transport,” Dr. Myers added.

Dr. Khanna mentioned that “guidelines tend to provide details of extant practice patterns, usually taken from evidence-based data. With monitoring, however, that is tough to achieve, unless substantial data can be found in large national registries of patients on immunosuppressive medications.”

Experience and comfort with using immunosuppressive medications, and medicolegal liability considerations, especially because many immunomodulatory agents confer adverse effects, can contribute to clinicians’ behaviors varying from guidelines, she added.
 

A good scoping review, and further research needed

“This article did what it was supposed to do: Define the various approaches to monitoring,” Dr. Furst said. “It is the next steps that will make a difference in practice.

“Next steps ... may require delving into large observational data sets such as registries to ascertain the consequences of different monitoring strategies for various patient groups and disparate drugs and drug combinations,” added Dr. Furst, who coauthored a 2017 review summarizing guidelines for laboratory monitoring in patients with rheumatoid arthritis.

“A significant oversight is the lack of consideration regarding monitoring for corticosteroids, which are well known to have very consequential adverse events and require careful monitoring,” Dr. Furst observed.

“The difference between men’s and women’s monitoring strategies is of some interest,” he added, “but will only be important if it leads to an understanding of and change in monitoring recommendations.”

Dr. Connolly also noted the differences in strategies between male and female respondents.

“Of interest, male respondents were more likely to feel that monitoring was performed too frequently and were also more tolerant of significant abnormalities,” she said. “This begs the question of whether rheumatologist gender differentially impacts other areas of clinical practice.”

Despite the small sample size that limits generalizability, the results provide preliminary insight into the varied practices among rheumatologists worldwide, Dr. Connolly added.

“Given the frequency of csDMARD prescription, the study highlights the clinical unmet need for a more robust evidence base to guide clinical practice,” she said. “The study also adds to important efforts to provide high-value care to patients with rheumatic diseases and may form the basis for larger studies to facilitate the pragmatic utilization of lab monitoring and ultimately optimize both the quality and value of rheumatological care globally.”

Dr. Robinson and coauthors urged further research. “We need more studies of higher quality to help inform the best strategy for protecting our patients from harm from our commonly used rheumatic medicines,” he said.

Dr. Robinson and two coauthors reported relationships with pharmaceutical companies. The remaining authors and all uninvolved sources, who commented by email, reported no relevant relationships. The study received no funding.

Rheumatologists tend to order the same types of tests to monitor their patients’ responses to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), but they vary widely in how often they order tests and how they respond to abnormal results, responses to a survey suggest.

“The study found that, although guidelines exist, people didn’t follow them consistently. They also responded to abnormal test results in wildly different ways,” senior study author Philip C. Robinson, MBChB, PhD, of the University of Queensland, Herston, Australia, said in an interview.

“The take-home message of this study is that everyone is doing something different, which means that the system likely has a lot of low-value activity and that money is being wasted,” he added. “However, we don’t have the evidence to guide people to make better choices.”

The literature on laboratory monitoring of people taking csDMARDs for rheumatic disease is scant, the authors wrote in BMC Rheumatology, and current guidelines on csDMARD monitoring vary, likely because of the lack of high-quality evidence for specific monitoring regimens.

“An enormous amount of money is spent on DMARD monitoring with little evidence to support current practices,” Dr. Robinson said. So he and his colleagues asked rheumatologists and rheumatology trainees about their attitudes and practices related to laboratory monitoring of csDMARDs in an online questionnaire.

They used the Australian Rheumatology Association newsletter to invite around 530 Australian rheumatologists and trainees, around 4,500 of Dr. Robinson’s Twitter followers, and 25 Australian and overseas email contacts, to respond to questions about csDMARDs they prescribed, frequency and patterns of monitoring, influences of additional factors and combination therapy, responses to abnormal tests, and attitudes toward monitoring frequency.

The researchers based their questions on csDMARD monitoring guidelines published by the American College of Rheumatology (which recommends monitoring every 2-4 weeks from initiation to 3 months, every 8-12 weeks during months 3-6, and every 12 weeks from 6 months onward), and from the British Society for Rheumatology (whose guidance is similar but bases monitoring frequency on how long DMARD doses remain stable).

The 221 valid responses they collected included 53 from Australia and 39 from the United States. Overall, 53% of respondents were in public practice, 56% were women, and 56% had practiced rheumatology for 11 or more years.

Respondents reported more frequent monitoring of patients with multiple comorbidities and those taking csDMARD combinations, including methotrexate and leflunomide. Responses to abnormal monitoring results varied widely, and 40% of respondents reported that monitoring tests are performed too often. Compared with females, males reported greater tolerance of significant test abnormalities before acting. They also were more likely to report that guidelines recommend, and doctors perform, tests too frequently.
 

Testing, monitoring patterns can differ from current guidelines

Rheumatologists who were asked to comment on the survey welcomed its results.

They came as no surprise to Daniel E. Furst, MD, professor emeritus of medicine at the University of California, Los Angeles.

“Most guidelines point out in the introduction that they are recommendations and need to be modified by specific patient and environmental needs,” he noted in an interview.

Stephen Myers, MD, assistant professor of clinical medicine in the division of rheumatology at the University of Southern California, Los Angeles, said: “The findings seem generally consistent with my observed practices and those of my peers, with the exception of sulfasalazine, which we tend to monitor every 3 months, similar to the way we monitor other csDMARDs.”

Caoilfhionn Connolly, MD, MSc, postdoctoral fellow in rheumatology at Johns Hopkins University, Baltimore, called “the variability in monitoring somewhat surprising given that both the American College of Rheumatology and the British Society for Rheumatology provide guidance statements on optimal monitoring.

“As the authors highlight,” she added, “the variability in monitoring and response to lab abnormalities is likely driven by the lack of a high-quality evidence base, which should ideally be derived from clinical trials.”

Medication monitoring is critical to ensuring patient safety in rheumatology and other specialties, said Puja Khanna, MD, MPH, a rheumatologist and clinical associate professor of medicine at the University of Michigan, Ann Arbor.

Dr. Khanna described how in 2018, the Michigan Medicine health care system revisited its processes and protocols for medication monitoring.

Previously, “we were reliant on society guidelines that were not used consistently across the academic and community rheumatology practices,” she said. “Using lean thinking methodology, we found that we lacked familiarity with laboratory monitoring protocols amongst the interdisciplinary teams involved in the process and that we had a clear need for consensus.

“A consistent departmental protocol was created to help streamline the workflow for ancillary support staff, to close identified operational gaps, and to reduce delays in monitoring that impacted safe practice patterns,” Dr. Khanna added.

“We developed standardized medication- and disease-based monitoring protocols for eight medical specialties, where the person who writes a prescription that requires monitoring can utilize standard work flows to enroll the patient in the medication monitoring program and have dedicated ancillary support staff follow the results periodically and alert clinicians in a timely manner,” she explained. “Almost 15,000 patients are currently monitored in this collaborative program involving clinicians, nurses, pharmacists, and IT and administrative teams.”
 

Guidelines may not capture clinical realities of csDMARD monitoring

Dr. Myers and colleagues may monitor testing more intensively if, for example, a patient becomes ill, has side effects, or has taken medication incorrectly. But they’ll less intensively monitor a patient who’s been stable on a csDMARD.

“In my current academic practice, deciding lab monitoring frequency is left up to physicians. In my previous private practice experience, lab monitoring seemed to be more frequent than the current guidelines for many patients, compared to public or academic practice,” he said. “It would be interesting to compare monitoring practices in private, public, and academic settings.

“The clinical reality is that frequent monitoring depends on the regular follow-up, which for some patients is difficult, due to socioeconomic factors including lack of childcare and public transport,” Dr. Myers added.

Dr. Khanna mentioned that “guidelines tend to provide details of extant practice patterns, usually taken from evidence-based data. With monitoring, however, that is tough to achieve, unless substantial data can be found in large national registries of patients on immunosuppressive medications.”

Experience and comfort with using immunosuppressive medications, and medicolegal liability considerations, especially because many immunomodulatory agents confer adverse effects, can contribute to clinicians’ behaviors varying from guidelines, she added.
 

A good scoping review, and further research needed

“This article did what it was supposed to do: Define the various approaches to monitoring,” Dr. Furst said. “It is the next steps that will make a difference in practice.

“Next steps ... may require delving into large observational data sets such as registries to ascertain the consequences of different monitoring strategies for various patient groups and disparate drugs and drug combinations,” added Dr. Furst, who coauthored a 2017 review summarizing guidelines for laboratory monitoring in patients with rheumatoid arthritis.

“A significant oversight is the lack of consideration regarding monitoring for corticosteroids, which are well known to have very consequential adverse events and require careful monitoring,” Dr. Furst observed.

“The difference between men’s and women’s monitoring strategies is of some interest,” he added, “but will only be important if it leads to an understanding of and change in monitoring recommendations.”

Dr. Connolly also noted the differences in strategies between male and female respondents.

“Of interest, male respondents were more likely to feel that monitoring was performed too frequently and were also more tolerant of significant abnormalities,” she said. “This begs the question of whether rheumatologist gender differentially impacts other areas of clinical practice.”

Despite the small sample size that limits generalizability, the results provide preliminary insight into the varied practices among rheumatologists worldwide, Dr. Connolly added.

“Given the frequency of csDMARD prescription, the study highlights the clinical unmet need for a more robust evidence base to guide clinical practice,” she said. “The study also adds to important efforts to provide high-value care to patients with rheumatic diseases and may form the basis for larger studies to facilitate the pragmatic utilization of lab monitoring and ultimately optimize both the quality and value of rheumatological care globally.”

Dr. Robinson and coauthors urged further research. “We need more studies of higher quality to help inform the best strategy for protecting our patients from harm from our commonly used rheumatic medicines,” he said.

Dr. Robinson and two coauthors reported relationships with pharmaceutical companies. The remaining authors and all uninvolved sources, who commented by email, reported no relevant relationships. The study received no funding.

Key clinical point: In patients with psoriatic arthritis (PsA), the percentages of some T_reg cell subgroups and the levels of T_reg-related cytokines, such as transforming growth factor-beta (TGFβ), were decreased.

Major finding: Compared with control individuals without PsA, patients with PsA had a similar proportion of T_reg cells (P = .071), with no significant difference in the proportion of OKT8⁺ T_reg cells (P = .679) and significantly decreased CD4⁺ T_reg cells (standardized mean difference [SMD] −1.501; P = .023). TGFβ levels were lower in patients with PsA vs healthy controls (SMD −2.199; P = .003).

Study details: Findings are from a meta-analysis of 12 studies including 525 patients with PsA and 414 control individuals.

Disclosures: This study was supported by the National Natural Science Foundation of China and other sources. The authors declared no conflict of interests.

Source: Su QY et al. Peripheral T_reg levels and transforming growth factor-β (TGFβ) in patients with psoriatic arthritis: A systematic review meta-analysis. Adv Ther. 2022 (Oct 26). Doi: 10.1007/s12325-022-02337-5

Key clinical point: In patients with psoriatic arthritis (PsA), the percentages of some T_reg cell subgroups and the levels of T_reg-related cytokines, such as transforming growth factor-beta (TGFβ), were decreased.

Major finding: Compared with control individuals without PsA, patients with PsA had a similar proportion of T_reg cells (P = .071), with no significant difference in the proportion of OKT8⁺ T_reg cells (P = .679) and significantly decreased CD4⁺ T_reg cells (standardized mean difference [SMD] −1.501; P = .023). TGFβ levels were lower in patients with PsA vs healthy controls (SMD −2.199; P = .003).

Study details: Findings are from a meta-analysis of 12 studies including 525 patients with PsA and 414 control individuals.

Disclosures: This study was supported by the National Natural Science Foundation of China and other sources. The authors declared no conflict of interests.

Source: Su QY et al. Peripheral T_reg levels and transforming growth factor-β (TGFβ) in patients with psoriatic arthritis: A systematic review meta-analysis. Adv Ther. 2022 (Oct 26). Doi: 10.1007/s12325-022-02337-5

Key clinical point: In patients with psoriatic arthritis (PsA), the percentages of some T_reg cell subgroups and the levels of T_reg-related cytokines, such as transforming growth factor-beta (TGFβ), were decreased.

Major finding: Compared with control individuals without PsA, patients with PsA had a similar proportion of T_reg cells (P = .071), with no significant difference in the proportion of OKT8⁺ T_reg cells (P = .679) and significantly decreased CD4⁺ T_reg cells (standardized mean difference [SMD] −1.501; P = .023). TGFβ levels were lower in patients with PsA vs healthy controls (SMD −2.199; P = .003).

Study details: Findings are from a meta-analysis of 12 studies including 525 patients with PsA and 414 control individuals.

Disclosures: This study was supported by the National Natural Science Foundation of China and other sources. The authors declared no conflict of interests.

Source: Su QY et al. Peripheral T_reg levels and transforming growth factor-β (TGFβ) in patients with psoriatic arthritis: A systematic review meta-analysis. Adv Ther. 2022 (Oct 26). Doi: 10.1007/s12325-022-02337-5

Key clinical point: Serum calprotectin (CLP) serves as an important inflammatory biomarker for diagnosing and monitoring disease activity in psoriatic arthritis (PsA).

Major finding: Participants with PsA vs control individuals without psoriasis or PsA had higher median CLP levels (3.816 vs 0.707 μg/mL; P < .001). The concentration of serum CLP decreased significantly along with the disease activity from 3.816 at baseline to 2.052, 1.681, and 1.655 μg/mL at 3, 6, and 12 months, respectively (all P < .001).

Study details: Findings are from a longitudinal study including 71 patients with PsA, 55 patients with psoriasis, and 50 control individuals.

Disclosures: This study was supported by the interdisciplinary clinical research project of Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Li B et al. Serum calprotectin as a promising inflammatory biomarker in psoriatic arthritis: A 1-year longitudinal study. Rheumatol Ther. 2022 (Oct 21). Doi: 10.1007/s40744-022-00501-5

Key clinical point: Serum calprotectin (CLP) serves as an important inflammatory biomarker for diagnosing and monitoring disease activity in psoriatic arthritis (PsA).

Major finding: Participants with PsA vs control individuals without psoriasis or PsA had higher median CLP levels (3.816 vs 0.707 μg/mL; P < .001). The concentration of serum CLP decreased significantly along with the disease activity from 3.816 at baseline to 2.052, 1.681, and 1.655 μg/mL at 3, 6, and 12 months, respectively (all P < .001).

Study details: Findings are from a longitudinal study including 71 patients with PsA, 55 patients with psoriasis, and 50 control individuals.

Disclosures: This study was supported by the interdisciplinary clinical research project of Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Li B et al. Serum calprotectin as a promising inflammatory biomarker in psoriatic arthritis: A 1-year longitudinal study. Rheumatol Ther. 2022 (Oct 21). Doi: 10.1007/s40744-022-00501-5

Key clinical point: Serum calprotectin (CLP) serves as an important inflammatory biomarker for diagnosing and monitoring disease activity in psoriatic arthritis (PsA).

Major finding: Participants with PsA vs control individuals without psoriasis or PsA had higher median CLP levels (3.816 vs 0.707 μg/mL; P < .001). The concentration of serum CLP decreased significantly along with the disease activity from 3.816 at baseline to 2.052, 1.681, and 1.655 μg/mL at 3, 6, and 12 months, respectively (all P < .001).

Study details: Findings are from a longitudinal study including 71 patients with PsA, 55 patients with psoriasis, and 50 control individuals.

Disclosures: This study was supported by the interdisciplinary clinical research project of Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Li B et al. Serum calprotectin as a promising inflammatory biomarker in psoriatic arthritis: A 1-year longitudinal study. Rheumatol Ther. 2022 (Oct 21). Doi: 10.1007/s40744-022-00501-5

Key clinical point: The Disease Activity index for Psoriatic Arthritis (DAPSA) based on a quick quantitative C-reactive protein (qCRP) assay (Q-DAPSA) showed perfect agreement with conventional DAPSA in the majority of patients with PsA.

Major finding: Overall, 98.1% of patients were similarly categorized into disease activity groups (remission and low, moderate, and high disease activity) using Q-DAPSA and DAPSA, with both indices showing identical numerical values in 57.7% of patients.

Study details: Findings are from a multicenter, cross-sectional study including 104 patients with PsA and available CRP values (measured by routine laboratory and quick qCRP assays).

Disclosures: This study was partially supported by Novartis. The authors declared receiving grants, personal fees, or support for attending meetings and travels from Novartis and other sources.

Source: Proft F et al. Evaluation of the Disease Activity index for PSoriatic Arthritis (DAPSA) with a quick quantitative C reactive protein assay (Q-DAPSA) in patients with psoriatic arthritis: A prospective multicentre cross-sectional study. RMD Open. 2022;8:e002626 (Nov 2). Doi: 10.1136/rmdopen-2022-002626

Key clinical point: The Disease Activity index for Psoriatic Arthritis (DAPSA) based on a quick quantitative C-reactive protein (qCRP) assay (Q-DAPSA) showed perfect agreement with conventional DAPSA in the majority of patients with PsA.

Major finding: Overall, 98.1% of patients were similarly categorized into disease activity groups (remission and low, moderate, and high disease activity) using Q-DAPSA and DAPSA, with both indices showing identical numerical values in 57.7% of patients.

Study details: Findings are from a multicenter, cross-sectional study including 104 patients with PsA and available CRP values (measured by routine laboratory and quick qCRP assays).

Disclosures: This study was partially supported by Novartis. The authors declared receiving grants, personal fees, or support for attending meetings and travels from Novartis and other sources.

Source: Proft F et al. Evaluation of the Disease Activity index for PSoriatic Arthritis (DAPSA) with a quick quantitative C reactive protein assay (Q-DAPSA) in patients with psoriatic arthritis: A prospective multicentre cross-sectional study. RMD Open. 2022;8:e002626 (Nov 2). Doi: 10.1136/rmdopen-2022-002626

Key clinical point: The Disease Activity index for Psoriatic Arthritis (DAPSA) based on a quick quantitative C-reactive protein (qCRP) assay (Q-DAPSA) showed perfect agreement with conventional DAPSA in the majority of patients with PsA.

Major finding: Overall, 98.1% of patients were similarly categorized into disease activity groups (remission and low, moderate, and high disease activity) using Q-DAPSA and DAPSA, with both indices showing identical numerical values in 57.7% of patients.

Study details: Findings are from a multicenter, cross-sectional study including 104 patients with PsA and available CRP values (measured by routine laboratory and quick qCRP assays).

Disclosures: This study was partially supported by Novartis. The authors declared receiving grants, personal fees, or support for attending meetings and travels from Novartis and other sources.

Source: Proft F et al. Evaluation of the Disease Activity index for PSoriatic Arthritis (DAPSA) with a quick quantitative C reactive protein assay (Q-DAPSA) in patients with psoriatic arthritis: A prospective multicentre cross-sectional study. RMD Open. 2022;8:e002626 (Nov 2). Doi: 10.1136/rmdopen-2022-002626

Key clinical point: The addition of ultrasound-detected features, such as tenosynovitis and enthesitis, to the CASPAR (ClASsification criteria for Psoriatic Arthritis) scoring system improved its diagnostic utility.

Major finding: Specificity improved (84.0% to 91.4%) and sensitivity was similar (94.5% to 95.7%) after ultrasound features, such as tenosynovitis and enthesitis, were integrated in the original CASPAR criteria which had been based on physical examination.

Study details: Findings are from a cross-sectional study including 326 participants, of which 164 were diagnosed with PsA.

Disclosures: This study was supported by the Interdisciplinary Clinical Research Project of the Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Geng Y et al. Improved diagnostic performance of CASPAR criteria with integration of ultrasound. Front Immunol. 2022;13:935132 (Oct 10). Doi: 10.3389/fimmu.2022.935132

Key clinical point: The addition of ultrasound-detected features, such as tenosynovitis and enthesitis, to the CASPAR (ClASsification criteria for Psoriatic Arthritis) scoring system improved its diagnostic utility.

Major finding: Specificity improved (84.0% to 91.4%) and sensitivity was similar (94.5% to 95.7%) after ultrasound features, such as tenosynovitis and enthesitis, were integrated in the original CASPAR criteria which had been based on physical examination.

Study details: Findings are from a cross-sectional study including 326 participants, of which 164 were diagnosed with PsA.

Disclosures: This study was supported by the Interdisciplinary Clinical Research Project of the Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Geng Y et al. Improved diagnostic performance of CASPAR criteria with integration of ultrasound. Front Immunol. 2022;13:935132 (Oct 10). Doi: 10.3389/fimmu.2022.935132

Key clinical point: The addition of ultrasound-detected features, such as tenosynovitis and enthesitis, to the CASPAR (ClASsification criteria for Psoriatic Arthritis) scoring system improved its diagnostic utility.

Major finding: Specificity improved (84.0% to 91.4%) and sensitivity was similar (94.5% to 95.7%) after ultrasound features, such as tenosynovitis and enthesitis, were integrated in the original CASPAR criteria which had been based on physical examination.

Study details: Findings are from a cross-sectional study including 326 participants, of which 164 were diagnosed with PsA.

Disclosures: This study was supported by the Interdisciplinary Clinical Research Project of the Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Geng Y et al. Improved diagnostic performance of CASPAR criteria with integration of ultrasound. Front Immunol. 2022;13:935132 (Oct 10). Doi: 10.3389/fimmu.2022.935132

Key clinical point: Patients with psoriatic arthritis (PsA) were more likely to have cardiovascular diseases (CVD) and metabolic syndrome (MS) than patients with rheumatoid arthritis (RA).

Major finding: MS (odds ratio [OR] 1.54; P = .002) and CVD (OR 6.13; P = .001) were more frequently observed in patients with PsA vs RA.

Study details: Findings are from a cross-sectional study including 197 patients with PsA and 279 patients with RA.

Disclosures: This study was supported by Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Li B et al. Discrepancy in metabolic syndrome between psoriatic arthritis and rheumatoid arthritis: A direct comparison of two cohorts in one center. Rheumatol Ther. 2022 (Oct 20). Doi: 10.1007/s40744-022-00502-4

Key clinical point: Patients with psoriatic arthritis (PsA) were more likely to have cardiovascular diseases (CVD) and metabolic syndrome (MS) than patients with rheumatoid arthritis (RA).

Major finding: MS (odds ratio [OR] 1.54; P = .002) and CVD (OR 6.13; P = .001) were more frequently observed in patients with PsA vs RA.

Study details: Findings are from a cross-sectional study including 197 patients with PsA and 279 patients with RA.

Disclosures: This study was supported by Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Li B et al. Discrepancy in metabolic syndrome between psoriatic arthritis and rheumatoid arthritis: A direct comparison of two cohorts in one center. Rheumatol Ther. 2022 (Oct 20). Doi: 10.1007/s40744-022-00502-4

Key clinical point: Patients with psoriatic arthritis (PsA) were more likely to have cardiovascular diseases (CVD) and metabolic syndrome (MS) than patients with rheumatoid arthritis (RA).

Major finding: MS (odds ratio [OR] 1.54; P = .002) and CVD (OR 6.13; P = .001) were more frequently observed in patients with PsA vs RA.

Study details: Findings are from a cross-sectional study including 197 patients with PsA and 279 patients with RA.

Disclosures: This study was supported by Peking University First Hospital, China, and other sources. The authors declared no conflict of interests.

Source: Li B et al. Discrepancy in metabolic syndrome between psoriatic arthritis and rheumatoid arthritis: A direct comparison of two cohorts in one center. Rheumatol Ther. 2022 (Oct 20). Doi: 10.1007/s40744-022-00502-4

Key clinical point: Among patients with psoriatic arthritis (PsA), sonographic enthesitis was more prevalent in men than women.

Major finding: Compared with women, men had higher total ultrasound and gray scale enthesitis scores (both P = .01) and sonographic active inflammatory score (P = .005), as reflected by higher hypoechogenicity, thickening, and enthesophytes (P < .05), with the male sex being associated with a significantly higher ultrasound inflammatory enthesitis score (P = .02).

Study details: Findings are from a prospective study including 158 patients with PsA, of which 70 patients were men and 88 were women.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Furer V et al. Sex-based differences in sonographic and clinical findings among patients with psoriatic arthritis. J Rheumatol. 2022 (Oct 15). Doi: 10.3899/jrheum.220547

Key clinical point: Among patients with psoriatic arthritis (PsA), sonographic enthesitis was more prevalent in men than women.

Major finding: Compared with women, men had higher total ultrasound and gray scale enthesitis scores (both P = .01) and sonographic active inflammatory score (P = .005), as reflected by higher hypoechogenicity, thickening, and enthesophytes (P < .05), with the male sex being associated with a significantly higher ultrasound inflammatory enthesitis score (P = .02).

Study details: Findings are from a prospective study including 158 patients with PsA, of which 70 patients were men and 88 were women.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Furer V et al. Sex-based differences in sonographic and clinical findings among patients with psoriatic arthritis. J Rheumatol. 2022 (Oct 15). Doi: 10.3899/jrheum.220547

Key clinical point: Among patients with psoriatic arthritis (PsA), sonographic enthesitis was more prevalent in men than women.

Major finding: Compared with women, men had higher total ultrasound and gray scale enthesitis scores (both P = .01) and sonographic active inflammatory score (P = .005), as reflected by higher hypoechogenicity, thickening, and enthesophytes (P < .05), with the male sex being associated with a significantly higher ultrasound inflammatory enthesitis score (P = .02).

Study details: Findings are from a prospective study including 158 patients with PsA, of which 70 patients were men and 88 were women.

Disclosures: This study did not receive any funding. The authors declared no conflict of interests.

Source: Furer V et al. Sex-based differences in sonographic and clinical findings among patients with psoriatic arthritis. J Rheumatol. 2022 (Oct 15). Doi: 10.3899/jrheum.220547

Key clinical point: Patients with psoriatic arthritis (PsA) experienced a slowing of radiographic progression during treatment with etanercept.

Major finding: In patients with available pre-etanercept radiographic data, the annualized radiographic progression was significantly lower with etanercept during the first 18 months than during the pre-etanercept treatment period (P < .005), and a higher proportion of patients showed no progression during etanercept treatment (61.7%) than during the pre-etanercept period (55.3%).

Study details: Findings are from a real-world, noninterventional study including 1821 participants who started treatment with etanercept, of which 1378 patients had rheumatoid arthritis and 440 patients had PsA.

Disclosures: This study was funded by Pfizer. Five authors declared being current or former employees of Pfizer, and the other authors reported ties with several sources, including Pfizer.

Source: Wassenberg S et al. Etanercept is effective and halts radiographic progression in rheumatoid arthritis and psoriatic arthritis: Final results from a German non-interventional study (PRERA). Rheumatol Ther. 2022 (Oct 17). Doi: 10.1007/s40744-022-00491-4

Key clinical point: Patients with psoriatic arthritis (PsA) experienced a slowing of radiographic progression during treatment with etanercept.

Major finding: In patients with available pre-etanercept radiographic data, the annualized radiographic progression was significantly lower with etanercept during the first 18 months than during the pre-etanercept treatment period (P < .005), and a higher proportion of patients showed no progression during etanercept treatment (61.7%) than during the pre-etanercept period (55.3%).

Study details: Findings are from a real-world, noninterventional study including 1821 participants who started treatment with etanercept, of which 1378 patients had rheumatoid arthritis and 440 patients had PsA.

Disclosures: This study was funded by Pfizer. Five authors declared being current or former employees of Pfizer, and the other authors reported ties with several sources, including Pfizer.

Source: Wassenberg S et al. Etanercept is effective and halts radiographic progression in rheumatoid arthritis and psoriatic arthritis: Final results from a German non-interventional study (PRERA). Rheumatol Ther. 2022 (Oct 17). Doi: 10.1007/s40744-022-00491-4

Key clinical point: Patients with psoriatic arthritis (PsA) experienced a slowing of radiographic progression during treatment with etanercept.

Major finding: In patients with available pre-etanercept radiographic data, the annualized radiographic progression was significantly lower with etanercept during the first 18 months than during the pre-etanercept treatment period (P < .005), and a higher proportion of patients showed no progression during etanercept treatment (61.7%) than during the pre-etanercept period (55.3%).

Study details: Findings are from a real-world, noninterventional study including 1821 participants who started treatment with etanercept, of which 1378 patients had rheumatoid arthritis and 440 patients had PsA.

Disclosures: This study was funded by Pfizer. Five authors declared being current or former employees of Pfizer, and the other authors reported ties with several sources, including Pfizer.

Source: Wassenberg S et al. Etanercept is effective and halts radiographic progression in rheumatoid arthritis and psoriatic arthritis: Final results from a German non-interventional study (PRERA). Rheumatol Ther. 2022 (Oct 17). Doi: 10.1007/s40744-022-00491-4

Key clinical point: Compared with adalimumab, both 15 mg and 30 mg upadacitinib showed similar or better efficacy through 2 years and a similar safety profile in patients with psoriatic arthritis (PsA).

Major finding: At week 104, a similar proportion of patients receiving 15/30 mg upadacitinib vs adalimumab achieved ≥20% improvement in the American College of Rheumatology criteria (69.0%/69.5% vs 63.4%), whereas significantly more patients receiving 30 mg upadacitinib vs adalimumab achieved minimal disease activity (45.9% vs 37.8%; P < .05). The safety profiles of upadacitinib and adalimumab were comparable.

Study details: Findings are from an exploratory analysis of the SELECT-PsA 1 study including 1704 patients with active PsA and inadequate response/intolerance to ≥1 non-biologic disease-modifying antirheumatic drug who were randomly assigned to receive upadacitinib (15 or 30 mg) or adalimumab.

Disclosures: This study was funded by AbbVie. Six authors declared being current or former employees or stockholders of AbbVie. The other authors reported ties with several sources, including AbbVie.

Source: McInnes IB et al. Efficacy and safety of upadacitinib in patients with psoriatic arthritis: 2-year results from the phase 3 SELECT-PsA 1 study. Rheumatol Ther. 2022 (Oct 15). Doi: 10.1007/s40744-022-00499-w

Key clinical point: Compared with adalimumab, both 15 mg and 30 mg upadacitinib showed similar or better efficacy through 2 years and a similar safety profile in patients with psoriatic arthritis (PsA).

Major finding: At week 104, a similar proportion of patients receiving 15/30 mg upadacitinib vs adalimumab achieved ≥20% improvement in the American College of Rheumatology criteria (69.0%/69.5% vs 63.4%), whereas significantly more patients receiving 30 mg upadacitinib vs adalimumab achieved minimal disease activity (45.9% vs 37.8%; P < .05). The safety profiles of upadacitinib and adalimumab were comparable.

Study details: Findings are from an exploratory analysis of the SELECT-PsA 1 study including 1704 patients with active PsA and inadequate response/intolerance to ≥1 non-biologic disease-modifying antirheumatic drug who were randomly assigned to receive upadacitinib (15 or 30 mg) or adalimumab.

Disclosures: This study was funded by AbbVie. Six authors declared being current or former employees or stockholders of AbbVie. The other authors reported ties with several sources, including AbbVie.

Source: McInnes IB et al. Efficacy and safety of upadacitinib in patients with psoriatic arthritis: 2-year results from the phase 3 SELECT-PsA 1 study. Rheumatol Ther. 2022 (Oct 15). Doi: 10.1007/s40744-022-00499-w

Key clinical point: Compared with adalimumab, both 15 mg and 30 mg upadacitinib showed similar or better efficacy through 2 years and a similar safety profile in patients with psoriatic arthritis (PsA).

Major finding: At week 104, a similar proportion of patients receiving 15/30 mg upadacitinib vs adalimumab achieved ≥20% improvement in the American College of Rheumatology criteria (69.0%/69.5% vs 63.4%), whereas significantly more patients receiving 30 mg upadacitinib vs adalimumab achieved minimal disease activity (45.9% vs 37.8%; P < .05). The safety profiles of upadacitinib and adalimumab were comparable.

Study details: Findings are from an exploratory analysis of the SELECT-PsA 1 study including 1704 patients with active PsA and inadequate response/intolerance to ≥1 non-biologic disease-modifying antirheumatic drug who were randomly assigned to receive upadacitinib (15 or 30 mg) or adalimumab.

Disclosures: This study was funded by AbbVie. Six authors declared being current or former employees or stockholders of AbbVie. The other authors reported ties with several sources, including AbbVie.

Source: McInnes IB et al. Efficacy and safety of upadacitinib in patients with psoriatic arthritis: 2-year results from the phase 3 SELECT-PsA 1 study. Rheumatol Ther. 2022 (Oct 15). Doi: 10.1007/s40744-022-00499-w

Key clinical point: Singleton pregnant women with psoriatic arthritis (PsA) had a significantly higher risk for preeclampsia than matched control pregnant women without PsA.

Major finding: Compared with control women, the risk for preeclampsia was much higher in women with PsA (adjusted odds ratio [aOR] 1.85; 95% CI 1.10-3.12), with the risk being primarily driven by the receipt of monotherapy for PsA before pregnancy (aOR 2.72; 95% CI 1.44-5.13).

Study details: Findings are from an analysis of a register-based cohort study including singleton pregnant women with rheumatoid arthritis (n = 1739), axial spondyloarthritis (n = 819), and PsA (n = 489) who were matched with 17,390, 8190, and 4890 control pregnant women, respectively.

Disclosures: This study was supported by NordForsk and other sources. Some authors declared serving on speakers’ bureaus, receiving research grants, or receiving  consulting fees from several sources.

Source: Secher AEP et al. Risk of pre-eclampsia and impact of disease activity and antirheumatic treatment in women with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis: A collaborative matched cohort study from Sweden and Denmark. RMD Open. 2022;8:e002445 (Nov 3). Doi: 10.1136/rmdopen-2022-002445

Key clinical point: Singleton pregnant women with psoriatic arthritis (PsA) had a significantly higher risk for preeclampsia than matched control pregnant women without PsA.

Major finding: Compared with control women, the risk for preeclampsia was much higher in women with PsA (adjusted odds ratio [aOR] 1.85; 95% CI 1.10-3.12), with the risk being primarily driven by the receipt of monotherapy for PsA before pregnancy (aOR 2.72; 95% CI 1.44-5.13).

Study details: Findings are from an analysis of a register-based cohort study including singleton pregnant women with rheumatoid arthritis (n = 1739), axial spondyloarthritis (n = 819), and PsA (n = 489) who were matched with 17,390, 8190, and 4890 control pregnant women, respectively.

Disclosures: This study was supported by NordForsk and other sources. Some authors declared serving on speakers’ bureaus, receiving research grants, or receiving  consulting fees from several sources.

Source: Secher AEP et al. Risk of pre-eclampsia and impact of disease activity and antirheumatic treatment in women with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis: A collaborative matched cohort study from Sweden and Denmark. RMD Open. 2022;8:e002445 (Nov 3). Doi: 10.1136/rmdopen-2022-002445

Key clinical point: Singleton pregnant women with psoriatic arthritis (PsA) had a significantly higher risk for preeclampsia than matched control pregnant women without PsA.

Major finding: Compared with control women, the risk for preeclampsia was much higher in women with PsA (adjusted odds ratio [aOR] 1.85; 95% CI 1.10-3.12), with the risk being primarily driven by the receipt of monotherapy for PsA before pregnancy (aOR 2.72; 95% CI 1.44-5.13).

Study details: Findings are from an analysis of a register-based cohort study including singleton pregnant women with rheumatoid arthritis (n = 1739), axial spondyloarthritis (n = 819), and PsA (n = 489) who were matched with 17,390, 8190, and 4890 control pregnant women, respectively.

Disclosures: This study was supported by NordForsk and other sources. Some authors declared serving on speakers’ bureaus, receiving research grants, or receiving  consulting fees from several sources.

Source: Secher AEP et al. Risk of pre-eclampsia and impact of disease activity and antirheumatic treatment in women with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis: A collaborative matched cohort study from Sweden and Denmark. RMD Open. 2022;8:e002445 (Nov 3). Doi: 10.1136/rmdopen-2022-002445