Rheumatoid Arthritis

Key clinical point: Patients with seropositive rheumatoid arthritis (RA) were at a higher risk of developing primary open-angle glaucoma (POAG) compared with matched control participants, with risk being evident within 2 years after RA diagnosis and among patients aged ≥75 years.

Major finding: Compared with matched control participants, patients with incident RA were 1.44 times more likely to develop POAG (hazard ratio [HR] 1.44; 95% CI 1.13-1.84), which was predominantly observed within 2 years of RA diagnosis (HR 1.83; 95% CI 1.28-2.61) and in patients aged ≥75 years (HR 2.12;95% CI 1.34-3.35).

Study details: This was a retrospective, nationwide cohort study including 2049 patients with seropositive RA who were propensity score-matched with 8196 control participants without RA.

Disclosures: This study was partly supported by the publication fee from the Graduate School of Public Health, Yonsei University. No conflicts of interest were declared.

Source: Kim SH et al. Development of open-angle glaucoma in adults with seropositive rheumatoid arthritis in Korea. JAMA Netw Open. 2022;5(3):e223345 (Mar 21). Doi:  10.1001/jamanetworkopen.2022.3345

Key clinical point: Patients with seropositive rheumatoid arthritis (RA) were at a higher risk of developing primary open-angle glaucoma (POAG) compared with matched control participants, with risk being evident within 2 years after RA diagnosis and among patients aged ≥75 years.

Major finding: Compared with matched control participants, patients with incident RA were 1.44 times more likely to develop POAG (hazard ratio [HR] 1.44; 95% CI 1.13-1.84), which was predominantly observed within 2 years of RA diagnosis (HR 1.83; 95% CI 1.28-2.61) and in patients aged ≥75 years (HR 2.12;95% CI 1.34-3.35).

Study details: This was a retrospective, nationwide cohort study including 2049 patients with seropositive RA who were propensity score-matched with 8196 control participants without RA.

Disclosures: This study was partly supported by the publication fee from the Graduate School of Public Health, Yonsei University. No conflicts of interest were declared.

Source: Kim SH et al. Development of open-angle glaucoma in adults with seropositive rheumatoid arthritis in Korea. JAMA Netw Open. 2022;5(3):e223345 (Mar 21). Doi:  10.1001/jamanetworkopen.2022.3345

Key clinical point: Patients with seropositive rheumatoid arthritis (RA) were at a higher risk of developing primary open-angle glaucoma (POAG) compared with matched control participants, with risk being evident within 2 years after RA diagnosis and among patients aged ≥75 years.

Major finding: Compared with matched control participants, patients with incident RA were 1.44 times more likely to develop POAG (hazard ratio [HR] 1.44; 95% CI 1.13-1.84), which was predominantly observed within 2 years of RA diagnosis (HR 1.83; 95% CI 1.28-2.61) and in patients aged ≥75 years (HR 2.12;95% CI 1.34-3.35).

Study details: This was a retrospective, nationwide cohort study including 2049 patients with seropositive RA who were propensity score-matched with 8196 control participants without RA.

Disclosures: This study was partly supported by the publication fee from the Graduate School of Public Health, Yonsei University. No conflicts of interest were declared.

Source: Kim SH et al. Development of open-angle glaucoma in adults with seropositive rheumatoid arthritis in Korea. JAMA Netw Open. 2022;5(3):e223345 (Mar 21). Doi:  10.1001/jamanetworkopen.2022.3345

Key clinical point: Some patients with rheumatoid arthritis (RA) had excess disability despite low inflammation level. This persisted over 8-10 years after onset, with age, pain, and depression being significant predictors of disability, independent of inflammation.

Major finding: Nearly 30%-45% of patients with RA persistently showed excess disability over 8-10 years of follow-up, independent of their inflammation status. Patients who were older (odds ratio [OR] 1.05; 95% CI 1.02-1.09) or had higher pain (OR 1.48; 95% CI 1.23-1.78) or depression (OR 1.40; 95% CI 1.01-1.94) were more likely to have higher vs. lower disability trajectory, irrespective of their inflammation level.

Study details: Findings are from an analysis of three cohort studies including 2500 patients with RA and <24 months symptom duration who were followed-up for 8-10 years.

Disclosures: This study was supported by the UK Medical Research Council, Versus Arthritis, UK National Institute for Health Care and Research (NIHR) Manchester Biomedical Research Centre, and NIHR Nottingham Biomedical Research Centre. The authors declared no competing interests directly relevant to this manuscript.

Source: Gwinnutt JM et al. Exploring the disparity between inflammation and disability in the 10-year outcomes of people with rheumatoid arthritis. Rheumatology (Oxford). 2022 (Mar 11). Doi: 10.1093/rheumatology/keac137

Key clinical point: Some patients with rheumatoid arthritis (RA) had excess disability despite low inflammation level. This persisted over 8-10 years after onset, with age, pain, and depression being significant predictors of disability, independent of inflammation.

Major finding: Nearly 30%-45% of patients with RA persistently showed excess disability over 8-10 years of follow-up, independent of their inflammation status. Patients who were older (odds ratio [OR] 1.05; 95% CI 1.02-1.09) or had higher pain (OR 1.48; 95% CI 1.23-1.78) or depression (OR 1.40; 95% CI 1.01-1.94) were more likely to have higher vs. lower disability trajectory, irrespective of their inflammation level.

Study details: Findings are from an analysis of three cohort studies including 2500 patients with RA and <24 months symptom duration who were followed-up for 8-10 years.

Disclosures: This study was supported by the UK Medical Research Council, Versus Arthritis, UK National Institute for Health Care and Research (NIHR) Manchester Biomedical Research Centre, and NIHR Nottingham Biomedical Research Centre. The authors declared no competing interests directly relevant to this manuscript.

Source: Gwinnutt JM et al. Exploring the disparity between inflammation and disability in the 10-year outcomes of people with rheumatoid arthritis. Rheumatology (Oxford). 2022 (Mar 11). Doi: 10.1093/rheumatology/keac137

Key clinical point: Some patients with rheumatoid arthritis (RA) had excess disability despite low inflammation level. This persisted over 8-10 years after onset, with age, pain, and depression being significant predictors of disability, independent of inflammation.

Major finding: Nearly 30%-45% of patients with RA persistently showed excess disability over 8-10 years of follow-up, independent of their inflammation status. Patients who were older (odds ratio [OR] 1.05; 95% CI 1.02-1.09) or had higher pain (OR 1.48; 95% CI 1.23-1.78) or depression (OR 1.40; 95% CI 1.01-1.94) were more likely to have higher vs. lower disability trajectory, irrespective of their inflammation level.

Study details: Findings are from an analysis of three cohort studies including 2500 patients with RA and <24 months symptom duration who were followed-up for 8-10 years.

Disclosures: This study was supported by the UK Medical Research Council, Versus Arthritis, UK National Institute for Health Care and Research (NIHR) Manchester Biomedical Research Centre, and NIHR Nottingham Biomedical Research Centre. The authors declared no competing interests directly relevant to this manuscript.

Source: Gwinnutt JM et al. Exploring the disparity between inflammation and disability in the 10-year outcomes of people with rheumatoid arthritis. Rheumatology (Oxford). 2022 (Mar 11). Doi: 10.1093/rheumatology/keac137

Key clinical point: A majority of patients with rheumatoid arthritis (RA) stopped their first-time biological or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) because of nonresponse to the treatment. Patients who stopped because of remission vs. nonresponse had worse disease activity at treatment restart.

Major finding: Nonresponse (38%), adverse events (19%), and remission (8%) were the major reasons to stop the first-time b/tsDMARD, with the median time to restart treatment being shortest among patients with nonresponse (30 days) and longest among those with remission (1597 days). Moreover, RA disease activity was worse at b/tsDMARD restart in patients who stopped b/tsDMARD after achieving remission (P < .0001).

Study details: This was an explorative descriptive cohort study including 2526 patients with RA who stopped their first b/tsDMARD treatment.

Disclosures: The study did not declare any source of funding. No conflicts of interest were declared.

Source: Burkard T et al. Interruptions of biological and targeted synthetic disease-modifying antirheumatic drugs in rheumatoid arthritis: a descriptive cohort study assessing trends in patient characteristics in Switzerland. BMJ Open. 2022;12:e056352 (Mar 15). Doi: 10.1136/bmjopen-2021-056352

Key clinical point: A majority of patients with rheumatoid arthritis (RA) stopped their first-time biological or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) because of nonresponse to the treatment. Patients who stopped because of remission vs. nonresponse had worse disease activity at treatment restart.

Major finding: Nonresponse (38%), adverse events (19%), and remission (8%) were the major reasons to stop the first-time b/tsDMARD, with the median time to restart treatment being shortest among patients with nonresponse (30 days) and longest among those with remission (1597 days). Moreover, RA disease activity was worse at b/tsDMARD restart in patients who stopped b/tsDMARD after achieving remission (P < .0001).

Study details: This was an explorative descriptive cohort study including 2526 patients with RA who stopped their first b/tsDMARD treatment.

Disclosures: The study did not declare any source of funding. No conflicts of interest were declared.

Source: Burkard T et al. Interruptions of biological and targeted synthetic disease-modifying antirheumatic drugs in rheumatoid arthritis: a descriptive cohort study assessing trends in patient characteristics in Switzerland. BMJ Open. 2022;12:e056352 (Mar 15). Doi: 10.1136/bmjopen-2021-056352

Key clinical point: A majority of patients with rheumatoid arthritis (RA) stopped their first-time biological or targeted synthetic disease-modifying antirheumatic drug (b/tsDMARD) because of nonresponse to the treatment. Patients who stopped because of remission vs. nonresponse had worse disease activity at treatment restart.

Major finding: Nonresponse (38%), adverse events (19%), and remission (8%) were the major reasons to stop the first-time b/tsDMARD, with the median time to restart treatment being shortest among patients with nonresponse (30 days) and longest among those with remission (1597 days). Moreover, RA disease activity was worse at b/tsDMARD restart in patients who stopped b/tsDMARD after achieving remission (P < .0001).

Study details: This was an explorative descriptive cohort study including 2526 patients with RA who stopped their first b/tsDMARD treatment.

Disclosures: The study did not declare any source of funding. No conflicts of interest were declared.

Source: Burkard T et al. Interruptions of biological and targeted synthetic disease-modifying antirheumatic drugs in rheumatoid arthritis: a descriptive cohort study assessing trends in patient characteristics in Switzerland. BMJ Open. 2022;12:e056352 (Mar 15). Doi: 10.1136/bmjopen-2021-056352

Key clinical point: Higher levels of circulating adiponectin and leptin were associated with an increased risk for all-cause and cardiovascular mortality in patients with rheumatoid arthritis (RA).

Major finding: Patients in the highest vs. lowest quartile of adiponectin were at a 46% higher risk for all-cause mortality (hazard ratio [HR] 1.46; P = .009) and an 85% higher risk for cardiovascular mortality (HR 1.85; P = .003). Patients in the highest vs. lowest quartile of both adiponectin and leptin were at a 73% higher risk for all-cause mortality (HR 1.73; P = .002).

Study details: This was a longitudinal study including 2583 patients with RA.

Disclosures: This study did not declare any source of funding. JF Baker and TR MIkuls reported receiving consulting fees and research support from various sources.

Source: Baker JF et al. Elevations in adipocytokines and mortality in rheumatoid arthritis. Rheumatology (Oxford). 2022 Mar 23. Doi: 10.1093/rheumatology/keac191

Key clinical point: Higher levels of circulating adiponectin and leptin were associated with an increased risk for all-cause and cardiovascular mortality in patients with rheumatoid arthritis (RA).

Major finding: Patients in the highest vs. lowest quartile of adiponectin were at a 46% higher risk for all-cause mortality (hazard ratio [HR] 1.46; P = .009) and an 85% higher risk for cardiovascular mortality (HR 1.85; P = .003). Patients in the highest vs. lowest quartile of both adiponectin and leptin were at a 73% higher risk for all-cause mortality (HR 1.73; P = .002).

Study details: This was a longitudinal study including 2583 patients with RA.

Disclosures: This study did not declare any source of funding. JF Baker and TR MIkuls reported receiving consulting fees and research support from various sources.

Source: Baker JF et al. Elevations in adipocytokines and mortality in rheumatoid arthritis. Rheumatology (Oxford). 2022 Mar 23. Doi: 10.1093/rheumatology/keac191

Key clinical point: Higher levels of circulating adiponectin and leptin were associated with an increased risk for all-cause and cardiovascular mortality in patients with rheumatoid arthritis (RA).

Major finding: Patients in the highest vs. lowest quartile of adiponectin were at a 46% higher risk for all-cause mortality (hazard ratio [HR] 1.46; P = .009) and an 85% higher risk for cardiovascular mortality (HR 1.85; P = .003). Patients in the highest vs. lowest quartile of both adiponectin and leptin were at a 73% higher risk for all-cause mortality (HR 1.73; P = .002).

Study details: This was a longitudinal study including 2583 patients with RA.

Disclosures: This study did not declare any source of funding. JF Baker and TR MIkuls reported receiving consulting fees and research support from various sources.

Source: Baker JF et al. Elevations in adipocytokines and mortality in rheumatoid arthritis. Rheumatology (Oxford). 2022 Mar 23. Doi: 10.1093/rheumatology/keac191

Key clinical point: Frailty may be partially reversible with treatment in early rheumatoid arthritis (RA) and is associated with a greater risk for hospitalization and all-cause mortality in early and established RA.

Major finding: Patients with early RA improved from moderate/severe frailty to mild (33%) and robust (13%) states in the first 6 months of treatment with disease-modifying antirheumatic drugs. In early and established RA, the moderate/severe vs. robust frailty level was associated with unscheduled hospitalization (incidence rate ratio [IRR] 2.88; 95% CI 1.97-4.20, and IRR 2.74; 95% CI 2.29-3.29, respectively) and all-cause mortality (hazard ratio [HR] 4.41; 95% CI 1.85-10.49 and HR 1.68; 95% CI 1.26-2.13, respectively).

Study details: This was a longitudinal analysis of two cohorts including 899 and 3605 patients with early and established RA, respectively.

Disclosures: No information on funding was reported. No conflicts of interest were declared.

Source: Hanlon P et al. Frailty in rheumatoid arthritis and its relationship with disease activity, hospitalisation and mortality: a longitudinal analysis of the Scottish Early Rheumatoid Arthritis cohort and UK Biobank. RMD Open. 2022;8:e002111 (Mar 15). Doi: 10.1136/rmdopen-2021-002111

Key clinical point: Frailty may be partially reversible with treatment in early rheumatoid arthritis (RA) and is associated with a greater risk for hospitalization and all-cause mortality in early and established RA.

Major finding: Patients with early RA improved from moderate/severe frailty to mild (33%) and robust (13%) states in the first 6 months of treatment with disease-modifying antirheumatic drugs. In early and established RA, the moderate/severe vs. robust frailty level was associated with unscheduled hospitalization (incidence rate ratio [IRR] 2.88; 95% CI 1.97-4.20, and IRR 2.74; 95% CI 2.29-3.29, respectively) and all-cause mortality (hazard ratio [HR] 4.41; 95% CI 1.85-10.49 and HR 1.68; 95% CI 1.26-2.13, respectively).

Study details: This was a longitudinal analysis of two cohorts including 899 and 3605 patients with early and established RA, respectively.

Disclosures: No information on funding was reported. No conflicts of interest were declared.

Source: Hanlon P et al. Frailty in rheumatoid arthritis and its relationship with disease activity, hospitalisation and mortality: a longitudinal analysis of the Scottish Early Rheumatoid Arthritis cohort and UK Biobank. RMD Open. 2022;8:e002111 (Mar 15). Doi: 10.1136/rmdopen-2021-002111

Key clinical point: Frailty may be partially reversible with treatment in early rheumatoid arthritis (RA) and is associated with a greater risk for hospitalization and all-cause mortality in early and established RA.

Major finding: Patients with early RA improved from moderate/severe frailty to mild (33%) and robust (13%) states in the first 6 months of treatment with disease-modifying antirheumatic drugs. In early and established RA, the moderate/severe vs. robust frailty level was associated with unscheduled hospitalization (incidence rate ratio [IRR] 2.88; 95% CI 1.97-4.20, and IRR 2.74; 95% CI 2.29-3.29, respectively) and all-cause mortality (hazard ratio [HR] 4.41; 95% CI 1.85-10.49 and HR 1.68; 95% CI 1.26-2.13, respectively).

Study details: This was a longitudinal analysis of two cohorts including 899 and 3605 patients with early and established RA, respectively.

Disclosures: No information on funding was reported. No conflicts of interest were declared.

Source: Hanlon P et al. Frailty in rheumatoid arthritis and its relationship with disease activity, hospitalisation and mortality: a longitudinal analysis of the Scottish Early Rheumatoid Arthritis cohort and UK Biobank. RMD Open. 2022;8:e002111 (Mar 15). Doi: 10.1136/rmdopen-2021-002111

Key clinical point: An ultralow dose (200 mg) of rituximab infusion and an increased time interval between COVID-19 vaccination and rituximab infusion significantly improved humoral response to COVID-19 vaccine in patients with rheumatoid arthritis (RA).

Major finding: Positive vaccination response was more frequently observed in the 200 mg vs. 1000 mg rituximab infusion group (odds ratio [OR] 3.07; P = .03) and improved with greater time interval between rituximab infusion and COVID-19 vaccination (per month OR 1.67; P < .0001).

Study details: This was a prospective cohort study, RTX-COVAC, including 196 patients with RA who received at least one dose of rituximab (200, 500, or 1000 mg) in the year prior to their first dose of COVID-19 vaccination.

Disclosures: This study did not receive any specific funding. AA den Broeder reported receiving personal fees, congress invitations, and grants outside the submitted work from various sources. Other authors declared no conflicts of interest.

Source: van der Togt CJT et al. Humoral response to Coronavirus Disease-19 vaccines is dependent on dosage and timing of rituximab in patients with rheumatoid arthritis. Rheumatology (Oxford). 2022 (Apr 4). Doi: 10.1093/rheumatology/keac206

Key clinical point: An ultralow dose (200 mg) of rituximab infusion and an increased time interval between COVID-19 vaccination and rituximab infusion significantly improved humoral response to COVID-19 vaccine in patients with rheumatoid arthritis (RA).

Major finding: Positive vaccination response was more frequently observed in the 200 mg vs. 1000 mg rituximab infusion group (odds ratio [OR] 3.07; P = .03) and improved with greater time interval between rituximab infusion and COVID-19 vaccination (per month OR 1.67; P < .0001).

Study details: This was a prospective cohort study, RTX-COVAC, including 196 patients with RA who received at least one dose of rituximab (200, 500, or 1000 mg) in the year prior to their first dose of COVID-19 vaccination.

Disclosures: This study did not receive any specific funding. AA den Broeder reported receiving personal fees, congress invitations, and grants outside the submitted work from various sources. Other authors declared no conflicts of interest.

Source: van der Togt CJT et al. Humoral response to Coronavirus Disease-19 vaccines is dependent on dosage and timing of rituximab in patients with rheumatoid arthritis. Rheumatology (Oxford). 2022 (Apr 4). Doi: 10.1093/rheumatology/keac206

Key clinical point: An ultralow dose (200 mg) of rituximab infusion and an increased time interval between COVID-19 vaccination and rituximab infusion significantly improved humoral response to COVID-19 vaccine in patients with rheumatoid arthritis (RA).

Major finding: Positive vaccination response was more frequently observed in the 200 mg vs. 1000 mg rituximab infusion group (odds ratio [OR] 3.07; P = .03) and improved with greater time interval between rituximab infusion and COVID-19 vaccination (per month OR 1.67; P < .0001).

Study details: This was a prospective cohort study, RTX-COVAC, including 196 patients with RA who received at least one dose of rituximab (200, 500, or 1000 mg) in the year prior to their first dose of COVID-19 vaccination.

Disclosures: This study did not receive any specific funding. AA den Broeder reported receiving personal fees, congress invitations, and grants outside the submitted work from various sources. Other authors declared no conflicts of interest.

Source: van der Togt CJT et al. Humoral response to Coronavirus Disease-19 vaccines is dependent on dosage and timing of rituximab in patients with rheumatoid arthritis. Rheumatology (Oxford). 2022 (Apr 4). Doi: 10.1093/rheumatology/keac206

A small new study of women suggests that adopting a low-fat vegan diet and then eliminating remaining trigger foods may dramatically reduce symptoms of rheumatoid arthritis (RA) within months. After 16 weeks, the mean Disease Activity Score in 28 joints (DAS28) decreased from 4.5 to 2.5 (P < .001), and the mean number of swollen joints dipped from 7.0 to 3.3 (P = .03).

The study was published in the American Journal of Lifestyle Medicine. It’s not clear whether the vegan diet or the restriction of trigger foods – or both or neither – was helpful. Significant weight loss in the diet group could have played a role in reducing symptoms.

galitskaya / iStock / Getty Images

Still, the dietary strategy is “a life-changing experience for people,” lead author Neal D. Barnard, MD, an internal medicine specialist and adjunct professor of medicine at George Washington University, Washington, D.C, and president of the Physicians Committee for Responsible Medicine, said in an interview. “Doctors should know about it, and they should try it themselves.”

The researchers launched the study to determine the feasibility of a “practical and easy-to-prescribe diet” without caloric limits, Dr. Barnard said. “People have done a variety of studies where they’ve looked at diet changes, often with fasting, and the quality has been variable.”

There’s no consensus in the medical literature on which dietary approach is best for patients with RA. A 2021 systematic review by Philippa and colleagues found positive results for the Mediterranean diet, high doses of omega-3 fatty acids, vitamin D supplementation, and sodium restriction. Fasting had significant but temporary effects, and the reviewers noted “outcomes from vegetarian, elimination, peptide, or elemental diets suggested that responses are very individualized.”

For the new randomized, crossover study, researchers assigned 44 women to one of two diet phases. After 16 weeks, they had a 4-week washout period, then began the other 16-week phase. A total of 32 patients completed the study, and they had a mean age of 57 years. Overall, 66% were White, 16% were Black, and 79% held a college degree or graduate degree.

In the 16-week intervention phase, participants went on a low-fat vegan diet. After 4 weeks, they eliminated common RA trigger foods such as grains with gluten, nuts, citrus fruits, and chocolate. After week 7, the subjects added back the trigger foods one by one, keeping them in their diet if they didn’t seem to cause pain.

In the 16-week placebo phase, the women took a supplement that they were told contained omega-3 oils and vitamin E. However, the amounts of omega-3 and vitamin E were very low and had no apparent effect.

Participants in the diet phase attended weekly 1-hour dietary support-group sessions. Thirty-two women completed the full study.

Average DAS28 scores fell in the diet phase, compared with the supplement phase (treatment effect, 1.8 [95% confidence interval [CI], 3.2 to 0.4]; P = .01), as did swollen joints (treatment effect, –4.2 [95% CI, –8.3 to –0.1], P = .047).

While the researchers reported dips in the DAS28 score and swollen joints, “the reductions in the number of painful and tender joints did not reach statistical significance (treatment effects, –4.1 [95% CI, –8.7 to +0.5]; P = .08; and –1.8 [95% CI, –5.5 to +1.9]; P = .41, respectively).”

Mean body weight fell by 6.5 kg among those in the diet group, while those in the placebo group gained 0.8 kg (treatment effect, –7.3 kg [95% CI, –9.4 to –5.1]; P < .001).

The researchers noted “the presumed mechanisms by which diets such [as this intervention strategy] reduce joint symptoms relate to the removal of inflammatory elements of an omnivorous diet, the presence of anti-inflammatory constituents in a plant-based diet, and diet-induced reductions in gut permeability that may, in turn, reduce the passage of antigens into circulation.”

Patients tolerate the diet well, Dr. Barnard said. “It’s practical for day-to-day life, and you don’t have to check into a fasting hospital.”

Elliott O’Donovan Photography

The message for physicians, he said, is to encourage patients to try changing their eating patterns before turning to medication. “It’s a good idea for anyone to have a chance to try a diet change,” he said. “You’ll know within a matter of weeks whether it will work.”

Vegan diets are also cheaper than diets with meat and dairy, he added.

The study has various limitations. It began with 44 participants, but 12 failed to complete it for various reasons. Four participants who were assigned to the diet phase first refused to resume their regular diets during the next phase. It’s not clear if the lost weight is most responsible for the diet’s benefits, Harvard Medical School rheumatologist Daniel H. Solomon, MD, MPH, said in an interview. In his review of the study findings, Dr. Solomon said that another possibility is that certain aspects of the diet – and not the full diet – were responsible.

A small new study of women suggests that adopting a low-fat vegan diet and then eliminating remaining trigger foods may dramatically reduce symptoms of rheumatoid arthritis (RA) within months. After 16 weeks, the mean Disease Activity Score in 28 joints (DAS28) decreased from 4.5 to 2.5 (P < .001), and the mean number of swollen joints dipped from 7.0 to 3.3 (P = .03).

The study was published in the American Journal of Lifestyle Medicine. It’s not clear whether the vegan diet or the restriction of trigger foods – or both or neither – was helpful. Significant weight loss in the diet group could have played a role in reducing symptoms.

galitskaya / iStock / Getty Images

Still, the dietary strategy is “a life-changing experience for people,” lead author Neal D. Barnard, MD, an internal medicine specialist and adjunct professor of medicine at George Washington University, Washington, D.C, and president of the Physicians Committee for Responsible Medicine, said in an interview. “Doctors should know about it, and they should try it themselves.”

The researchers launched the study to determine the feasibility of a “practical and easy-to-prescribe diet” without caloric limits, Dr. Barnard said. “People have done a variety of studies where they’ve looked at diet changes, often with fasting, and the quality has been variable.”

There’s no consensus in the medical literature on which dietary approach is best for patients with RA. A 2021 systematic review by Philippa and colleagues found positive results for the Mediterranean diet, high doses of omega-3 fatty acids, vitamin D supplementation, and sodium restriction. Fasting had significant but temporary effects, and the reviewers noted “outcomes from vegetarian, elimination, peptide, or elemental diets suggested that responses are very individualized.”

For the new randomized, crossover study, researchers assigned 44 women to one of two diet phases. After 16 weeks, they had a 4-week washout period, then began the other 16-week phase. A total of 32 patients completed the study, and they had a mean age of 57 years. Overall, 66% were White, 16% were Black, and 79% held a college degree or graduate degree.

In the 16-week intervention phase, participants went on a low-fat vegan diet. After 4 weeks, they eliminated common RA trigger foods such as grains with gluten, nuts, citrus fruits, and chocolate. After week 7, the subjects added back the trigger foods one by one, keeping them in their diet if they didn’t seem to cause pain.

In the 16-week placebo phase, the women took a supplement that they were told contained omega-3 oils and vitamin E. However, the amounts of omega-3 and vitamin E were very low and had no apparent effect.

Participants in the diet phase attended weekly 1-hour dietary support-group sessions. Thirty-two women completed the full study.

Average DAS28 scores fell in the diet phase, compared with the supplement phase (treatment effect, 1.8 [95% confidence interval [CI], 3.2 to 0.4]; P = .01), as did swollen joints (treatment effect, –4.2 [95% CI, –8.3 to –0.1], P = .047).

While the researchers reported dips in the DAS28 score and swollen joints, “the reductions in the number of painful and tender joints did not reach statistical significance (treatment effects, –4.1 [95% CI, –8.7 to +0.5]; P = .08; and –1.8 [95% CI, –5.5 to +1.9]; P = .41, respectively).”

Mean body weight fell by 6.5 kg among those in the diet group, while those in the placebo group gained 0.8 kg (treatment effect, –7.3 kg [95% CI, –9.4 to –5.1]; P < .001).

The researchers noted “the presumed mechanisms by which diets such [as this intervention strategy] reduce joint symptoms relate to the removal of inflammatory elements of an omnivorous diet, the presence of anti-inflammatory constituents in a plant-based diet, and diet-induced reductions in gut permeability that may, in turn, reduce the passage of antigens into circulation.”

Patients tolerate the diet well, Dr. Barnard said. “It’s practical for day-to-day life, and you don’t have to check into a fasting hospital.”

Elliott O’Donovan Photography

The message for physicians, he said, is to encourage patients to try changing their eating patterns before turning to medication. “It’s a good idea for anyone to have a chance to try a diet change,” he said. “You’ll know within a matter of weeks whether it will work.”

Vegan diets are also cheaper than diets with meat and dairy, he added.

The study has various limitations. It began with 44 participants, but 12 failed to complete it for various reasons. Four participants who were assigned to the diet phase first refused to resume their regular diets during the next phase. It’s not clear if the lost weight is most responsible for the diet’s benefits, Harvard Medical School rheumatologist Daniel H. Solomon, MD, MPH, said in an interview. In his review of the study findings, Dr. Solomon said that another possibility is that certain aspects of the diet – and not the full diet – were responsible.

A small new study of women suggests that adopting a low-fat vegan diet and then eliminating remaining trigger foods may dramatically reduce symptoms of rheumatoid arthritis (RA) within months. After 16 weeks, the mean Disease Activity Score in 28 joints (DAS28) decreased from 4.5 to 2.5 (P < .001), and the mean number of swollen joints dipped from 7.0 to 3.3 (P = .03).

The study was published in the American Journal of Lifestyle Medicine. It’s not clear whether the vegan diet or the restriction of trigger foods – or both or neither – was helpful. Significant weight loss in the diet group could have played a role in reducing symptoms.

galitskaya / iStock / Getty Images

Still, the dietary strategy is “a life-changing experience for people,” lead author Neal D. Barnard, MD, an internal medicine specialist and adjunct professor of medicine at George Washington University, Washington, D.C, and president of the Physicians Committee for Responsible Medicine, said in an interview. “Doctors should know about it, and they should try it themselves.”

The researchers launched the study to determine the feasibility of a “practical and easy-to-prescribe diet” without caloric limits, Dr. Barnard said. “People have done a variety of studies where they’ve looked at diet changes, often with fasting, and the quality has been variable.”

There’s no consensus in the medical literature on which dietary approach is best for patients with RA. A 2021 systematic review by Philippa and colleagues found positive results for the Mediterranean diet, high doses of omega-3 fatty acids, vitamin D supplementation, and sodium restriction. Fasting had significant but temporary effects, and the reviewers noted “outcomes from vegetarian, elimination, peptide, or elemental diets suggested that responses are very individualized.”

For the new randomized, crossover study, researchers assigned 44 women to one of two diet phases. After 16 weeks, they had a 4-week washout period, then began the other 16-week phase. A total of 32 patients completed the study, and they had a mean age of 57 years. Overall, 66% were White, 16% were Black, and 79% held a college degree or graduate degree.

In the 16-week intervention phase, participants went on a low-fat vegan diet. After 4 weeks, they eliminated common RA trigger foods such as grains with gluten, nuts, citrus fruits, and chocolate. After week 7, the subjects added back the trigger foods one by one, keeping them in their diet if they didn’t seem to cause pain.

In the 16-week placebo phase, the women took a supplement that they were told contained omega-3 oils and vitamin E. However, the amounts of omega-3 and vitamin E were very low and had no apparent effect.

Participants in the diet phase attended weekly 1-hour dietary support-group sessions. Thirty-two women completed the full study.

Average DAS28 scores fell in the diet phase, compared with the supplement phase (treatment effect, 1.8 [95% confidence interval [CI], 3.2 to 0.4]; P = .01), as did swollen joints (treatment effect, –4.2 [95% CI, –8.3 to –0.1], P = .047).

While the researchers reported dips in the DAS28 score and swollen joints, “the reductions in the number of painful and tender joints did not reach statistical significance (treatment effects, –4.1 [95% CI, –8.7 to +0.5]; P = .08; and –1.8 [95% CI, –5.5 to +1.9]; P = .41, respectively).”

Mean body weight fell by 6.5 kg among those in the diet group, while those in the placebo group gained 0.8 kg (treatment effect, –7.3 kg [95% CI, –9.4 to –5.1]; P < .001).

The researchers noted “the presumed mechanisms by which diets such [as this intervention strategy] reduce joint symptoms relate to the removal of inflammatory elements of an omnivorous diet, the presence of anti-inflammatory constituents in a plant-based diet, and diet-induced reductions in gut permeability that may, in turn, reduce the passage of antigens into circulation.”

Patients tolerate the diet well, Dr. Barnard said. “It’s practical for day-to-day life, and you don’t have to check into a fasting hospital.”

Elliott O’Donovan Photography

The message for physicians, he said, is to encourage patients to try changing their eating patterns before turning to medication. “It’s a good idea for anyone to have a chance to try a diet change,” he said. “You’ll know within a matter of weeks whether it will work.”

Vegan diets are also cheaper than diets with meat and dairy, he added.

The study has various limitations. It began with 44 participants, but 12 failed to complete it for various reasons. Four participants who were assigned to the diet phase first refused to resume their regular diets during the next phase. It’s not clear if the lost weight is most responsible for the diet’s benefits, Harvard Medical School rheumatologist Daniel H. Solomon, MD, MPH, said in an interview. In his review of the study findings, Dr. Solomon said that another possibility is that certain aspects of the diet – and not the full diet – were responsible.

The vast majority of children and young people with rheumatic and musculoskeletal diseases (RMDs) and COVID-19 are not hospitalized, according to the most significant global investigation of short-term COVID-19 outcomes in this patient group to date.

In the study, only 1 in 15 (7%) children and young people (younger than 19 years) with RMDs and COVID-19 were hospitalized, and even then, they experienced only mild symptoms; 4 of 5 of those hospitalized did not require supplemental oxygen or ventilatory support.

The study also found that those with severe systemic RMDs and obesity were more likely to be hospitalized than children with juvenile idiopathic arthritis (JIA).

Treatment with biologics, such as tumor necrosis factor inhibitors, did not appear to be associated with more severe COVID-19; however, the study found that children and young people with obesity (body mass index ≥ 30) were more likely to be hospitalized, although only 6% of patients in this study had a BMI in this category. Three patients died – two from areas of lower resources who were diagnosed with systemic lupus erythematosus (SLE) at approximately the same time they were diagnosed with COVID-19, and one with a preexisting autoinflammatory syndrome who was being treated with low-dose glucocorticoids and methotrexate.

Published in Annals of the Rheumatic Diseases, the study was led by Kimme L. Hyrich, MD, PhD, and Lianne Kearsley-Fleet, PhD, both from the University of Manchester (England). Dr. Hyrich is also a consultant rheumatologist at Manchester University Hospitals NHS Foundation Trust.

In an interview, Dr. Hyrich explained that overall these data are reassuring and show that the majority of children and young people with RMDs are not at high risk of severe COVID-19.

“Many parents and families with children who have RMDs have lived with great fear over the pandemic about whether or not their children are at an increased risk of severe COVID-19,” said Dr. Hyrich. “Many are immunosuppressed or take other immunomodulatory medications. This has also had a great impact on schooling and children’s well-being.”

In the study, children with SLE, mixed connective tissue disease (MCTD), or vasculitis were more likely to have severe COVID-19. “[This] is not surprising given the typically greater systemic involvement and need for more aggressive immunosuppressive therapy than the majority of individuals with JIA,” the researchers wrote.

Dr. Hyrich added: “There may be times when children are on particularly high doses of immunosuppression or their disease is particularly active, when they may need more protection, and rheumatology teams can advise parents and young people about this.”

Studies such as those by Zimmerman and Curtis and Viner and colleagues have found that generally, children with no underlying disease are less susceptible to symptomatic COVID-19 and that reports of death are rare. Findings show that the younger the child, the less likely they will be symptomatic.

Adult data suggest a higher risk of COVID-related death among patients with arthritis, lupus, or psoriasis. A recent systematic review of the literature suggested that increased risk of COVID-related death only applies to subgroups of people with RMDs.

However, whether children and young people with RMDs are likely to have more severe COVID-19 and whether there is additional risk attributable to either their underlying disease or its therapy remain unknown. The goal of the study by Dr. Hyrich and colleagues was to address these questions.

The global analysis aimed to describe characteristics of those children and young people (younger than 19 years) with preexisting RMDs who also had COVID-19; to describe outcomes following COVID-19; and to identify characteristics associated with more severe COVID-19 outcomes.

Data were drawn from the European Alliance of Associations for Rheumatology COVID-19 Registry, the Childhood Arthritis and Rheumatology Research Alliance Registry, and the CARRA-sponsored COVID-19 Global Paediatric Rheumatology Database.

Demographic information included primary RMD diagnosis; RMD disease activity (remission, low, moderate, high, or unknown); RMD treatments, including glucocorticoid use and which disease-modifying antirheumatic drug (DMARD) the patient was taking at the time of COVID-19; and comorbidities (none, ocular inflammation, interstitial lung disease, asthma, diabetes, obesity, hypertension, cerebrovascular accident, renal disease, inflammatory bowel disease, and heart disease).

With respect to COVID-19, information collected included diagnosis date, whether the case was presumptive or confirmed, clinical symptoms, hospitalization and/or death because of COVID-19, and whether the patient stopped receiving rheumatic therapies.

Rheumatology diagnoses were categorized into four groups: JIA; SLE, MCTD, vasculitis, or other RMD; autoinflammatory syndromes; and “other,” including chronic recurrent multifocal osteomyelitis, sarcoidosis, or ocular inflammation.

Of the 607 children and young people with reported SARS-CoV-2 infection from 25 different countries (464 from the EULAR COVID-19 Registry), 499 (82%) cases were polymerase chain reaction confirmed, and 399 (66%) patients were female (median age, 14 years). Most (62%) had JIA: 37%, polyarticular JIA; 30%, oligoarticular JIA; 12%, enthesitis-related JIA; 9%, systemic JIA; 4%, psoriatic JIA; and 9%, JIA of unknown subcategory. Furthermore, 13% of patients had autoinflammatory syndromes, 8% with SLE or MCTD, 3% with vasculitis, and 2% with inflammatory myopathy.

No associations were seen between DMARD treatment (conventional-synthetic, biologic/targeted-synthetic, or combination therapy), compared with no DMARD treatment, glucocorticoid use, and hospitalization.

Owing to substantial differences in reporting of race and ethnicity between data sources, the researchers were unable to analyze whether Black, Asian, and minority ethnic groups with pediatric RMDs are at higher risk of COVID-19–related death, compared with those of White ethnicity, as has been reported for the general population.

The study also did not account for variants of SARS-CoV-2 other than to note that data were collected prior to the spread of the Omicron variant. Also, the registries did not capture vaccination status (though very few children had received vaccines at the time of data collection) or information on long COVID or multisystem inflammatory syndrome in children.

Dr. Hyrich and Dr. Kearsley-Fleet have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The vast majority of children and young people with rheumatic and musculoskeletal diseases (RMDs) and COVID-19 are not hospitalized, according to the most significant global investigation of short-term COVID-19 outcomes in this patient group to date.

In the study, only 1 in 15 (7%) children and young people (younger than 19 years) with RMDs and COVID-19 were hospitalized, and even then, they experienced only mild symptoms; 4 of 5 of those hospitalized did not require supplemental oxygen or ventilatory support.

The study also found that those with severe systemic RMDs and obesity were more likely to be hospitalized than children with juvenile idiopathic arthritis (JIA).

Treatment with biologics, such as tumor necrosis factor inhibitors, did not appear to be associated with more severe COVID-19; however, the study found that children and young people with obesity (body mass index ≥ 30) were more likely to be hospitalized, although only 6% of patients in this study had a BMI in this category. Three patients died – two from areas of lower resources who were diagnosed with systemic lupus erythematosus (SLE) at approximately the same time they were diagnosed with COVID-19, and one with a preexisting autoinflammatory syndrome who was being treated with low-dose glucocorticoids and methotrexate.

Published in Annals of the Rheumatic Diseases, the study was led by Kimme L. Hyrich, MD, PhD, and Lianne Kearsley-Fleet, PhD, both from the University of Manchester (England). Dr. Hyrich is also a consultant rheumatologist at Manchester University Hospitals NHS Foundation Trust.

In an interview, Dr. Hyrich explained that overall these data are reassuring and show that the majority of children and young people with RMDs are not at high risk of severe COVID-19.

“Many parents and families with children who have RMDs have lived with great fear over the pandemic about whether or not their children are at an increased risk of severe COVID-19,” said Dr. Hyrich. “Many are immunosuppressed or take other immunomodulatory medications. This has also had a great impact on schooling and children’s well-being.”

In the study, children with SLE, mixed connective tissue disease (MCTD), or vasculitis were more likely to have severe COVID-19. “[This] is not surprising given the typically greater systemic involvement and need for more aggressive immunosuppressive therapy than the majority of individuals with JIA,” the researchers wrote.

Dr. Hyrich added: “There may be times when children are on particularly high doses of immunosuppression or their disease is particularly active, when they may need more protection, and rheumatology teams can advise parents and young people about this.”

Studies such as those by Zimmerman and Curtis and Viner and colleagues have found that generally, children with no underlying disease are less susceptible to symptomatic COVID-19 and that reports of death are rare. Findings show that the younger the child, the less likely they will be symptomatic.

Adult data suggest a higher risk of COVID-related death among patients with arthritis, lupus, or psoriasis. A recent systematic review of the literature suggested that increased risk of COVID-related death only applies to subgroups of people with RMDs.

However, whether children and young people with RMDs are likely to have more severe COVID-19 and whether there is additional risk attributable to either their underlying disease or its therapy remain unknown. The goal of the study by Dr. Hyrich and colleagues was to address these questions.

The global analysis aimed to describe characteristics of those children and young people (younger than 19 years) with preexisting RMDs who also had COVID-19; to describe outcomes following COVID-19; and to identify characteristics associated with more severe COVID-19 outcomes.

Data were drawn from the European Alliance of Associations for Rheumatology COVID-19 Registry, the Childhood Arthritis and Rheumatology Research Alliance Registry, and the CARRA-sponsored COVID-19 Global Paediatric Rheumatology Database.

Demographic information included primary RMD diagnosis; RMD disease activity (remission, low, moderate, high, or unknown); RMD treatments, including glucocorticoid use and which disease-modifying antirheumatic drug (DMARD) the patient was taking at the time of COVID-19; and comorbidities (none, ocular inflammation, interstitial lung disease, asthma, diabetes, obesity, hypertension, cerebrovascular accident, renal disease, inflammatory bowel disease, and heart disease).

With respect to COVID-19, information collected included diagnosis date, whether the case was presumptive or confirmed, clinical symptoms, hospitalization and/or death because of COVID-19, and whether the patient stopped receiving rheumatic therapies.

Rheumatology diagnoses were categorized into four groups: JIA; SLE, MCTD, vasculitis, or other RMD; autoinflammatory syndromes; and “other,” including chronic recurrent multifocal osteomyelitis, sarcoidosis, or ocular inflammation.

Of the 607 children and young people with reported SARS-CoV-2 infection from 25 different countries (464 from the EULAR COVID-19 Registry), 499 (82%) cases were polymerase chain reaction confirmed, and 399 (66%) patients were female (median age, 14 years). Most (62%) had JIA: 37%, polyarticular JIA; 30%, oligoarticular JIA; 12%, enthesitis-related JIA; 9%, systemic JIA; 4%, psoriatic JIA; and 9%, JIA of unknown subcategory. Furthermore, 13% of patients had autoinflammatory syndromes, 8% with SLE or MCTD, 3% with vasculitis, and 2% with inflammatory myopathy.

No associations were seen between DMARD treatment (conventional-synthetic, biologic/targeted-synthetic, or combination therapy), compared with no DMARD treatment, glucocorticoid use, and hospitalization.

Owing to substantial differences in reporting of race and ethnicity between data sources, the researchers were unable to analyze whether Black, Asian, and minority ethnic groups with pediatric RMDs are at higher risk of COVID-19–related death, compared with those of White ethnicity, as has been reported for the general population.

The study also did not account for variants of SARS-CoV-2 other than to note that data were collected prior to the spread of the Omicron variant. Also, the registries did not capture vaccination status (though very few children had received vaccines at the time of data collection) or information on long COVID or multisystem inflammatory syndrome in children.

Dr. Hyrich and Dr. Kearsley-Fleet have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The vast majority of children and young people with rheumatic and musculoskeletal diseases (RMDs) and COVID-19 are not hospitalized, according to the most significant global investigation of short-term COVID-19 outcomes in this patient group to date.

In the study, only 1 in 15 (7%) children and young people (younger than 19 years) with RMDs and COVID-19 were hospitalized, and even then, they experienced only mild symptoms; 4 of 5 of those hospitalized did not require supplemental oxygen or ventilatory support.

The study also found that those with severe systemic RMDs and obesity were more likely to be hospitalized than children with juvenile idiopathic arthritis (JIA).

Treatment with biologics, such as tumor necrosis factor inhibitors, did not appear to be associated with more severe COVID-19; however, the study found that children and young people with obesity (body mass index ≥ 30) were more likely to be hospitalized, although only 6% of patients in this study had a BMI in this category. Three patients died – two from areas of lower resources who were diagnosed with systemic lupus erythematosus (SLE) at approximately the same time they were diagnosed with COVID-19, and one with a preexisting autoinflammatory syndrome who was being treated with low-dose glucocorticoids and methotrexate.

Published in Annals of the Rheumatic Diseases, the study was led by Kimme L. Hyrich, MD, PhD, and Lianne Kearsley-Fleet, PhD, both from the University of Manchester (England). Dr. Hyrich is also a consultant rheumatologist at Manchester University Hospitals NHS Foundation Trust.

In an interview, Dr. Hyrich explained that overall these data are reassuring and show that the majority of children and young people with RMDs are not at high risk of severe COVID-19.

“Many parents and families with children who have RMDs have lived with great fear over the pandemic about whether or not their children are at an increased risk of severe COVID-19,” said Dr. Hyrich. “Many are immunosuppressed or take other immunomodulatory medications. This has also had a great impact on schooling and children’s well-being.”

In the study, children with SLE, mixed connective tissue disease (MCTD), or vasculitis were more likely to have severe COVID-19. “[This] is not surprising given the typically greater systemic involvement and need for more aggressive immunosuppressive therapy than the majority of individuals with JIA,” the researchers wrote.

Dr. Hyrich added: “There may be times when children are on particularly high doses of immunosuppression or their disease is particularly active, when they may need more protection, and rheumatology teams can advise parents and young people about this.”

Studies such as those by Zimmerman and Curtis and Viner and colleagues have found that generally, children with no underlying disease are less susceptible to symptomatic COVID-19 and that reports of death are rare. Findings show that the younger the child, the less likely they will be symptomatic.

Adult data suggest a higher risk of COVID-related death among patients with arthritis, lupus, or psoriasis. A recent systematic review of the literature suggested that increased risk of COVID-related death only applies to subgroups of people with RMDs.

However, whether children and young people with RMDs are likely to have more severe COVID-19 and whether there is additional risk attributable to either their underlying disease or its therapy remain unknown. The goal of the study by Dr. Hyrich and colleagues was to address these questions.

The global analysis aimed to describe characteristics of those children and young people (younger than 19 years) with preexisting RMDs who also had COVID-19; to describe outcomes following COVID-19; and to identify characteristics associated with more severe COVID-19 outcomes.

Data were drawn from the European Alliance of Associations for Rheumatology COVID-19 Registry, the Childhood Arthritis and Rheumatology Research Alliance Registry, and the CARRA-sponsored COVID-19 Global Paediatric Rheumatology Database.

Demographic information included primary RMD diagnosis; RMD disease activity (remission, low, moderate, high, or unknown); RMD treatments, including glucocorticoid use and which disease-modifying antirheumatic drug (DMARD) the patient was taking at the time of COVID-19; and comorbidities (none, ocular inflammation, interstitial lung disease, asthma, diabetes, obesity, hypertension, cerebrovascular accident, renal disease, inflammatory bowel disease, and heart disease).

With respect to COVID-19, information collected included diagnosis date, whether the case was presumptive or confirmed, clinical symptoms, hospitalization and/or death because of COVID-19, and whether the patient stopped receiving rheumatic therapies.

Rheumatology diagnoses were categorized into four groups: JIA; SLE, MCTD, vasculitis, or other RMD; autoinflammatory syndromes; and “other,” including chronic recurrent multifocal osteomyelitis, sarcoidosis, or ocular inflammation.

Of the 607 children and young people with reported SARS-CoV-2 infection from 25 different countries (464 from the EULAR COVID-19 Registry), 499 (82%) cases were polymerase chain reaction confirmed, and 399 (66%) patients were female (median age, 14 years). Most (62%) had JIA: 37%, polyarticular JIA; 30%, oligoarticular JIA; 12%, enthesitis-related JIA; 9%, systemic JIA; 4%, psoriatic JIA; and 9%, JIA of unknown subcategory. Furthermore, 13% of patients had autoinflammatory syndromes, 8% with SLE or MCTD, 3% with vasculitis, and 2% with inflammatory myopathy.

No associations were seen between DMARD treatment (conventional-synthetic, biologic/targeted-synthetic, or combination therapy), compared with no DMARD treatment, glucocorticoid use, and hospitalization.

Owing to substantial differences in reporting of race and ethnicity between data sources, the researchers were unable to analyze whether Black, Asian, and minority ethnic groups with pediatric RMDs are at higher risk of COVID-19–related death, compared with those of White ethnicity, as has been reported for the general population.

The study also did not account for variants of SARS-CoV-2 other than to note that data were collected prior to the spread of the Omicron variant. Also, the registries did not capture vaccination status (though very few children had received vaccines at the time of data collection) or information on long COVID or multisystem inflammatory syndrome in children.

Dr. Hyrich and Dr. Kearsley-Fleet have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Vaccination strategies for people with rheumatic diseases have received significant scrutiny in regard to COVID-19 vaccines. People with rheumatoid arthritis (RA) are at higher risk for adverse outcomes related to COVID-19 but also may have reduced immunogenicity to COVID-19 vaccines; thus, temporary withdrawal of medications has been suggested. Renner Araujo and colleagues report the results of a single-center randomized study from Brazil looking at the immune response to two doses of the Sinovac-CoronaVac vaccine in 129 patients with RA. They found that those who stopped methotrexate for 2 weeks after both doses had a higher rate of seroconversion, based on immunoglobulin (Ig) G positivity (78% vs. 54%), than those who remained on methotrexate. Antibody titers were also higher in the "methotrexate-hold" group. Flare rates were higher, based on the Clinical Disease Activity Index (CDAI) — though not on the Disease Activity Scale-28 (DAS-28) — in patients who withdrew from methotrexate. This information is interesting with respect to the use of future inactivated virus vaccines, though its applicability to mRNA vaccines, other than predicting the possibility of flare, is less clear. However, the results could be useful in informed discussions and decision-making regarding withdrawing immunosuppressive drugs.

Some people with rheumatic diseases have been concerned about flares of disease activity related to COVID-19 vaccination. Tedeschi and colleagues conducted a prospective observational study of 71 patients with RA who were previously inoculated against COVID-19 with two mRNA vaccine doses or one adenovirus vector vaccine dose. Using the patient-reported Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5), they measured disease activity weekly from study enrollment through 4 weeks after an additional dose. They did not find any change in mean RADAI-5 score between pre- and post additional dose, nor was disease activity different in patients who stopped disease-modifying antirheumatic drugs (DMARD) compared with those who did not. The study also examined flow cytometry of lymphocyte populations among a subset of these patients (n = 27) and found no significant differences in T peripheral helper cells, T follicular helper cells, age-associated B cells, and plasmablasts among patients before and after the additional vaccine dose. Though the flow cytometry data are difficult to generalize, given the presumed heterogeneity and small number of patients, the lack of change in RA disease activity after the additional vaccine dose is reassuring.

Achievement of remission in patients with RA is also an area of continued interest, especially because of the difficulty of reaching this target under real-world conditions. Larid and colleagues report the prognostic factors of remission and characteristics of 215 patients with RA over 7 years of follow-up at an academic hospital in France. Notably, 33% of patients were in remission at 1 year, of whom 76% remained in remission at 7 years. However, 48% of patients who were not in remission at 1 year achieved remission at 7 years; 58% of study participants were in remission in total at 7 years of follow-up. Those in remission were more frequently being prescribed both conventional synthetic DMARD (csDMARD) and biologic DMARD (bDMARD), while those not in remission at 7 years were receiving corticosteroids at higher doses. Owing to the lack of more precise treatment information, as well as the large number of patients who did not complete the 7-year follow-up visit, drawing conclusions is difficult. While we cannot say, based on these results, that use of certain medication regimens or strategies is more likely to lead to remission, the data at least lend support to the possibility of achieving remission in the long term.

Finally, Ahmad and colleagues performed a post-hoc analysis of the phase 3b AVERT trial of abatacept vs. methotrexate; 172 patients in remission were evaluated at 6 and 12 months after withdrawal of abatacept + methotrexate, abatacept monotherapy, or methotrexate monotherapy. Similar proportions of patients in all three treatment groups experienced a flare (about 58% at 6 months and 66% at 12 months). Patients with higher Health Assessment Questionnaire Disability Index (HAQ-DI) scores and evidence of erosions on MRI at withdrawal were more likely to experience a flare, consistent with prior studies. This highlights potential predictors of withdrawal from therapy. Given the lack of significant difference between the treatment groups, however, it does raise the question of why combination therapy with abatacept and methotrexate is more likely to lead to patients achieving remission in studies without as big an effect on drug-free remission after withdrawal. A more stringent definition of remission rather than DAS-28 C-reactive protein may be desirable.

Vaccination strategies for people with rheumatic diseases have received significant scrutiny in regard to COVID-19 vaccines. People with rheumatoid arthritis (RA) are at higher risk for adverse outcomes related to COVID-19 but also may have reduced immunogenicity to COVID-19 vaccines; thus, temporary withdrawal of medications has been suggested. Renner Araujo and colleagues report the results of a single-center randomized study from Brazil looking at the immune response to two doses of the Sinovac-CoronaVac vaccine in 129 patients with RA. They found that those who stopped methotrexate for 2 weeks after both doses had a higher rate of seroconversion, based on immunoglobulin (Ig) G positivity (78% vs. 54%), than those who remained on methotrexate. Antibody titers were also higher in the "methotrexate-hold" group. Flare rates were higher, based on the Clinical Disease Activity Index (CDAI) — though not on the Disease Activity Scale-28 (DAS-28) — in patients who withdrew from methotrexate. This information is interesting with respect to the use of future inactivated virus vaccines, though its applicability to mRNA vaccines, other than predicting the possibility of flare, is less clear. However, the results could be useful in informed discussions and decision-making regarding withdrawing immunosuppressive drugs.

Some people with rheumatic diseases have been concerned about flares of disease activity related to COVID-19 vaccination. Tedeschi and colleagues conducted a prospective observational study of 71 patients with RA who were previously inoculated against COVID-19 with two mRNA vaccine doses or one adenovirus vector vaccine dose. Using the patient-reported Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5), they measured disease activity weekly from study enrollment through 4 weeks after an additional dose. They did not find any change in mean RADAI-5 score between pre- and post additional dose, nor was disease activity different in patients who stopped disease-modifying antirheumatic drugs (DMARD) compared with those who did not. The study also examined flow cytometry of lymphocyte populations among a subset of these patients (n = 27) and found no significant differences in T peripheral helper cells, T follicular helper cells, age-associated B cells, and plasmablasts among patients before and after the additional vaccine dose. Though the flow cytometry data are difficult to generalize, given the presumed heterogeneity and small number of patients, the lack of change in RA disease activity after the additional vaccine dose is reassuring.

Achievement of remission in patients with RA is also an area of continued interest, especially because of the difficulty of reaching this target under real-world conditions. Larid and colleagues report the prognostic factors of remission and characteristics of 215 patients with RA over 7 years of follow-up at an academic hospital in France. Notably, 33% of patients were in remission at 1 year, of whom 76% remained in remission at 7 years. However, 48% of patients who were not in remission at 1 year achieved remission at 7 years; 58% of study participants were in remission in total at 7 years of follow-up. Those in remission were more frequently being prescribed both conventional synthetic DMARD (csDMARD) and biologic DMARD (bDMARD), while those not in remission at 7 years were receiving corticosteroids at higher doses. Owing to the lack of more precise treatment information, as well as the large number of patients who did not complete the 7-year follow-up visit, drawing conclusions is difficult. While we cannot say, based on these results, that use of certain medication regimens or strategies is more likely to lead to remission, the data at least lend support to the possibility of achieving remission in the long term.

Finally, Ahmad and colleagues performed a post-hoc analysis of the phase 3b AVERT trial of abatacept vs. methotrexate; 172 patients in remission were evaluated at 6 and 12 months after withdrawal of abatacept + methotrexate, abatacept monotherapy, or methotrexate monotherapy. Similar proportions of patients in all three treatment groups experienced a flare (about 58% at 6 months and 66% at 12 months). Patients with higher Health Assessment Questionnaire Disability Index (HAQ-DI) scores and evidence of erosions on MRI at withdrawal were more likely to experience a flare, consistent with prior studies. This highlights potential predictors of withdrawal from therapy. Given the lack of significant difference between the treatment groups, however, it does raise the question of why combination therapy with abatacept and methotrexate is more likely to lead to patients achieving remission in studies without as big an effect on drug-free remission after withdrawal. A more stringent definition of remission rather than DAS-28 C-reactive protein may be desirable.

Vaccination strategies for people with rheumatic diseases have received significant scrutiny in regard to COVID-19 vaccines. People with rheumatoid arthritis (RA) are at higher risk for adverse outcomes related to COVID-19 but also may have reduced immunogenicity to COVID-19 vaccines; thus, temporary withdrawal of medications has been suggested. Renner Araujo and colleagues report the results of a single-center randomized study from Brazil looking at the immune response to two doses of the Sinovac-CoronaVac vaccine in 129 patients with RA. They found that those who stopped methotrexate for 2 weeks after both doses had a higher rate of seroconversion, based on immunoglobulin (Ig) G positivity (78% vs. 54%), than those who remained on methotrexate. Antibody titers were also higher in the "methotrexate-hold" group. Flare rates were higher, based on the Clinical Disease Activity Index (CDAI) — though not on the Disease Activity Scale-28 (DAS-28) — in patients who withdrew from methotrexate. This information is interesting with respect to the use of future inactivated virus vaccines, though its applicability to mRNA vaccines, other than predicting the possibility of flare, is less clear. However, the results could be useful in informed discussions and decision-making regarding withdrawing immunosuppressive drugs.

Some people with rheumatic diseases have been concerned about flares of disease activity related to COVID-19 vaccination. Tedeschi and colleagues conducted a prospective observational study of 71 patients with RA who were previously inoculated against COVID-19 with two mRNA vaccine doses or one adenovirus vector vaccine dose. Using the patient-reported Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5), they measured disease activity weekly from study enrollment through 4 weeks after an additional dose. They did not find any change in mean RADAI-5 score between pre- and post additional dose, nor was disease activity different in patients who stopped disease-modifying antirheumatic drugs (DMARD) compared with those who did not. The study also examined flow cytometry of lymphocyte populations among a subset of these patients (n = 27) and found no significant differences in T peripheral helper cells, T follicular helper cells, age-associated B cells, and plasmablasts among patients before and after the additional vaccine dose. Though the flow cytometry data are difficult to generalize, given the presumed heterogeneity and small number of patients, the lack of change in RA disease activity after the additional vaccine dose is reassuring.

Achievement of remission in patients with RA is also an area of continued interest, especially because of the difficulty of reaching this target under real-world conditions. Larid and colleagues report the prognostic factors of remission and characteristics of 215 patients with RA over 7 years of follow-up at an academic hospital in France. Notably, 33% of patients were in remission at 1 year, of whom 76% remained in remission at 7 years. However, 48% of patients who were not in remission at 1 year achieved remission at 7 years; 58% of study participants were in remission in total at 7 years of follow-up. Those in remission were more frequently being prescribed both conventional synthetic DMARD (csDMARD) and biologic DMARD (bDMARD), while those not in remission at 7 years were receiving corticosteroids at higher doses. Owing to the lack of more precise treatment information, as well as the large number of patients who did not complete the 7-year follow-up visit, drawing conclusions is difficult. While we cannot say, based on these results, that use of certain medication regimens or strategies is more likely to lead to remission, the data at least lend support to the possibility of achieving remission in the long term.

Finally, Ahmad and colleagues performed a post-hoc analysis of the phase 3b AVERT trial of abatacept vs. methotrexate; 172 patients in remission were evaluated at 6 and 12 months after withdrawal of abatacept + methotrexate, abatacept monotherapy, or methotrexate monotherapy. Similar proportions of patients in all three treatment groups experienced a flare (about 58% at 6 months and 66% at 12 months). Patients with higher Health Assessment Questionnaire Disability Index (HAQ-DI) scores and evidence of erosions on MRI at withdrawal were more likely to experience a flare, consistent with prior studies. This highlights potential predictors of withdrawal from therapy. Given the lack of significant difference between the treatment groups, however, it does raise the question of why combination therapy with abatacept and methotrexate is more likely to lead to patients achieving remission in studies without as big an effect on drug-free remission after withdrawal. A more stringent definition of remission rather than DAS-28 C-reactive protein may be desirable.

There does not appear to be superiority of any type of biologic medication for patients with rheumatoid arthritis across different body mass index (BMI) groupings, with obesity and underweight both reducing the effects of the treatments after 6 months of use, according to findings from registry data on nearly 6,000 individuals.

Although interest in the precision use of biologics for RA is on the rise, few patient characteristics have been identified to inform therapeutic decisions, Joshua F. Baker, MD, of the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia, and colleagues wrote.

Previous studies on the effect of obesity on RA treatments have been inconclusive, and a comparison of RA treatments across BMI categories would provide more definitive guidance, they said.

In a study published in Arthritis Care & Research, the researchers used the CorEvitas U.S. observational registry (formerly known as Corrona) to identify adults who initiated second- or third-line treatment for RA with tumor necrosis factor inhibitors (n = 2,891) or non-TNFi biologics (n = 3,010) between 2001 and April 30, 2021.

The study population included adults diagnosed with RA; those with low disease activity or without a 6-month follow-up visit were excluded. BMI was categorized as underweight (less than 18.5 kg/m²), normal weight (18.5-25 kg/m²), overweight (25-30 kg/m²), obese (30-35 kg/m²), and severely obese (35 kg/m² or higher). The three measures of response were the achievement of low disease activity (LDA), a change at least as large as the minimum clinically important difference (MCID), and the absolute change on the Clinical Disease Activity Index (CDAI) from baseline.

A total of 2,712 patients were obese or severely obese at the time of treatment initiation.

Overall, patients with severe obesity had significantly lower odds of achieving either LDA or a change at least as large as the MCID, as well as less improvement in CDAI score, compared with other BMI categories. However, in adjusted models, the differences in these outcomes for patients with severe obesity were no longer statistically significant, whereas underweight was associated with lower odds of achieving LDA (odds ratio, 0.32; P = .005) or a change at least as large as the MCID (OR, 0.40; P = .005). The adjusted model also showed lesser improvement on CDAI in underweight patients, compared with patients of normal weight (P = .006).

Stratification by TNFi and non-TNFi therapies showed no differences in clinical response rates across BMI categories.

The study represents the first evidence of a similar reduction in therapeutic response with both TNFi and non-TNFi in severely obese patients, with estimates for non-TNFi biologics that fit within the 95% confidence interval for TNFi biologics, the researchers wrote. “Our current study suggests that a lack of response among obese patients is not specific to TNFi therapies, suggesting that this phenomenon is not biologically specific to the TNF pathway.”

The study findings were limited by several factors, including the focus on patients who were not naive to biologic treatments and by the relatively small number of underweight patients (n = 57), the researchers noted. Other limitations include unaddressed mediators of the relationship between obesity and disease activity and lack of data on off-label dosing strategies.

However, the results were strengthened by the large sample size, control for a range of confounding factors, and the direct comparison of RA therapies.

The researchers concluded that BMI should not influence the choice of TNF versus non-TNF therapy in terms of clinical efficacy.

The study was supported by the Corrona Research Foundation. Dr. Baker disclosed receiving support from a Veterans Affairs Clinical Science Research and Development Merit Award and a Rehabilitation Research and Development Merit Award, and consulting fees from Bristol-Myers Squibb, Pfizer, CorEvitas, and Burns-White. Two coauthors reported financial ties to CorEvitas.

There does not appear to be superiority of any type of biologic medication for patients with rheumatoid arthritis across different body mass index (BMI) groupings, with obesity and underweight both reducing the effects of the treatments after 6 months of use, according to findings from registry data on nearly 6,000 individuals.

Although interest in the precision use of biologics for RA is on the rise, few patient characteristics have been identified to inform therapeutic decisions, Joshua F. Baker, MD, of the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia, and colleagues wrote.

Previous studies on the effect of obesity on RA treatments have been inconclusive, and a comparison of RA treatments across BMI categories would provide more definitive guidance, they said.

In a study published in Arthritis Care & Research, the researchers used the CorEvitas U.S. observational registry (formerly known as Corrona) to identify adults who initiated second- or third-line treatment for RA with tumor necrosis factor inhibitors (n = 2,891) or non-TNFi biologics (n = 3,010) between 2001 and April 30, 2021.

The study population included adults diagnosed with RA; those with low disease activity or without a 6-month follow-up visit were excluded. BMI was categorized as underweight (less than 18.5 kg/m²), normal weight (18.5-25 kg/m²), overweight (25-30 kg/m²), obese (30-35 kg/m²), and severely obese (35 kg/m² or higher). The three measures of response were the achievement of low disease activity (LDA), a change at least as large as the minimum clinically important difference (MCID), and the absolute change on the Clinical Disease Activity Index (CDAI) from baseline.

A total of 2,712 patients were obese or severely obese at the time of treatment initiation.

Overall, patients with severe obesity had significantly lower odds of achieving either LDA or a change at least as large as the MCID, as well as less improvement in CDAI score, compared with other BMI categories. However, in adjusted models, the differences in these outcomes for patients with severe obesity were no longer statistically significant, whereas underweight was associated with lower odds of achieving LDA (odds ratio, 0.32; P = .005) or a change at least as large as the MCID (OR, 0.40; P = .005). The adjusted model also showed lesser improvement on CDAI in underweight patients, compared with patients of normal weight (P = .006).

Stratification by TNFi and non-TNFi therapies showed no differences in clinical response rates across BMI categories.

The study represents the first evidence of a similar reduction in therapeutic response with both TNFi and non-TNFi in severely obese patients, with estimates for non-TNFi biologics that fit within the 95% confidence interval for TNFi biologics, the researchers wrote. “Our current study suggests that a lack of response among obese patients is not specific to TNFi therapies, suggesting that this phenomenon is not biologically specific to the TNF pathway.”

The study findings were limited by several factors, including the focus on patients who were not naive to biologic treatments and by the relatively small number of underweight patients (n = 57), the researchers noted. Other limitations include unaddressed mediators of the relationship between obesity and disease activity and lack of data on off-label dosing strategies.

However, the results were strengthened by the large sample size, control for a range of confounding factors, and the direct comparison of RA therapies.

The researchers concluded that BMI should not influence the choice of TNF versus non-TNF therapy in terms of clinical efficacy.

The study was supported by the Corrona Research Foundation. Dr. Baker disclosed receiving support from a Veterans Affairs Clinical Science Research and Development Merit Award and a Rehabilitation Research and Development Merit Award, and consulting fees from Bristol-Myers Squibb, Pfizer, CorEvitas, and Burns-White. Two coauthors reported financial ties to CorEvitas.

There does not appear to be superiority of any type of biologic medication for patients with rheumatoid arthritis across different body mass index (BMI) groupings, with obesity and underweight both reducing the effects of the treatments after 6 months of use, according to findings from registry data on nearly 6,000 individuals.

Although interest in the precision use of biologics for RA is on the rise, few patient characteristics have been identified to inform therapeutic decisions, Joshua F. Baker, MD, of the Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia, and colleagues wrote.

Previous studies on the effect of obesity on RA treatments have been inconclusive, and a comparison of RA treatments across BMI categories would provide more definitive guidance, they said.

In a study published in Arthritis Care & Research, the researchers used the CorEvitas U.S. observational registry (formerly known as Corrona) to identify adults who initiated second- or third-line treatment for RA with tumor necrosis factor inhibitors (n = 2,891) or non-TNFi biologics (n = 3,010) between 2001 and April 30, 2021.

The study population included adults diagnosed with RA; those with low disease activity or without a 6-month follow-up visit were excluded. BMI was categorized as underweight (less than 18.5 kg/m²), normal weight (18.5-25 kg/m²), overweight (25-30 kg/m²), obese (30-35 kg/m²), and severely obese (35 kg/m² or higher). The three measures of response were the achievement of low disease activity (LDA), a change at least as large as the minimum clinically important difference (MCID), and the absolute change on the Clinical Disease Activity Index (CDAI) from baseline.

A total of 2,712 patients were obese or severely obese at the time of treatment initiation.

Overall, patients with severe obesity had significantly lower odds of achieving either LDA or a change at least as large as the MCID, as well as less improvement in CDAI score, compared with other BMI categories. However, in adjusted models, the differences in these outcomes for patients with severe obesity were no longer statistically significant, whereas underweight was associated with lower odds of achieving LDA (odds ratio, 0.32; P = .005) or a change at least as large as the MCID (OR, 0.40; P = .005). The adjusted model also showed lesser improvement on CDAI in underweight patients, compared with patients of normal weight (P = .006).

Stratification by TNFi and non-TNFi therapies showed no differences in clinical response rates across BMI categories.

The study represents the first evidence of a similar reduction in therapeutic response with both TNFi and non-TNFi in severely obese patients, with estimates for non-TNFi biologics that fit within the 95% confidence interval for TNFi biologics, the researchers wrote. “Our current study suggests that a lack of response among obese patients is not specific to TNFi therapies, suggesting that this phenomenon is not biologically specific to the TNF pathway.”

The study findings were limited by several factors, including the focus on patients who were not naive to biologic treatments and by the relatively small number of underweight patients (n = 57), the researchers noted. Other limitations include unaddressed mediators of the relationship between obesity and disease activity and lack of data on off-label dosing strategies.

However, the results were strengthened by the large sample size, control for a range of confounding factors, and the direct comparison of RA therapies.

The researchers concluded that BMI should not influence the choice of TNF versus non-TNF therapy in terms of clinical efficacy.

The study was supported by the Corrona Research Foundation. Dr. Baker disclosed receiving support from a Veterans Affairs Clinical Science Research and Development Merit Award and a Rehabilitation Research and Development Merit Award, and consulting fees from Bristol-Myers Squibb, Pfizer, CorEvitas, and Burns-White. Two coauthors reported financial ties to CorEvitas.