The Effect of Chronic Disease Management on the Treat-to-Target of Gout: A Cross-Sectional Study

Background: The treat-to-target (T2T) strategy is essential for patients with gout. However, the rate of T2T is low. This study aimed to explore doctor-led chronic disease management on the T2T of gout, survey the rate of T2T and assess the predictors associated with poor control of serum urate levels (SUA) in a large population of patients with gout receiving urate-lowering treatment (ULT). Methods: A multi-center, cross-sectional study was conducted. We surveyed the relevant information of outpatients who received ULT for more than six months using electronic questionnaires, including demographics, disease-related conditions, comorbid conditions, and management. The patients with gout were divided into the SUA > 360 µmol/L and ≤ 360 µmol/L, and the patient characteristics between the two groups were compared. We analyzed the predictors of SUA > 360 µmol/L and poor disease control.Results: We collected 425 (90.8% of the patients) valid questionnaires. There were significant differences in the gender, education level, regular visits, medication adherence, diabetes, economic burden and community doctor's help between the SUA > 360 µmol/L (n=311, 73.18%) and ≤ 360 µmol/L (n=114, 26.82%) groups. The predictors of SUA >360 µmol/L were general medication adherence (OR=2.35; 95% CI 1.17–4.77; p=0.016), poor medication adherence (OR=4.63; 95% CI 2.28–9.51; p<0.001) and community doctor’s help (OR=0.60; 95% CI 0.37–0.97; p=0.036 for full model, OR=0.58; 95% CI 0.36–0.93; p=0.023 for simplified model). There were significant differences in the gender, regular visits, medication adherence, gout popular science, established health files, and community doctor’s help between the not well controlled (n=361, 84.94%) and well controlled (n=61, 14.35%) groups. The predictors of not well controlled were Tophi (OR=2.48; 95% CI 1.17–5.61; p=0.023), general medication adherence (OR=2.78; 95% CI 1.28–6.05; p=0.009), poor medication adherence (OR=6.23; 95% CI 2.68–14.77; p<0.001) and no gout popular science (OR=4.07; 95% CI 1.41–13.91; p=0.015).Conclusion: The T2T and well controlled rates were very low. The medication adherence, the community doctor’s help and gout popular science which was the doctor-led chronic gout management should be further improved to increase the T2T and well controlled rate.Trial registration: ChiCTR, ChiCTR2000034700, Registered 15 July 2020. http://www.chictr.org.cn/showproj.aspx?proj=55778

Do NSAIDs Take Us Away From Treatment Goals in Axial Spondyloarthritis: A Story About Dysbiosis or Just a Matter of Bias?

Non-steroidal anti-inflammatory drugs (NSAIDs) remain the mainstay of treatment for spondyloarthritides (SpA), a group of entities with common clinical and pathophysiological aspects, but also with differential features. Although NSAIDs provide significant symptomatic relief, especially for joint pain and morning stiffness, their role in achieving and maintaining the treatment goals advocated by the treat to target strategy in SpA is not entirely clear. These agents can induce changes in the composition of the intestinal microbiota, also favoring an alteration of the barrier function in the gut epithelium. All of this, favored by a pre-disposing genetic background, could activate a specific type of aberrant immune response in the gut lamina propria, also known as type-3 immunity. This article offers a perspective on how NSAIDs, despite their undeniable value in the short-term SpA treatment, could hinder the achievement of medium and long-term treatment goals by compromising the barrier function of the gut mucosa and potentially altering the composition of the gut microbiota.

New Horizons A New Paradigm for Treating to Target with Second-Generation Obesity Medications

In treating obesity as a chronic disease, the essential goal of weight loss therapy is not the quantity of weight loss as an end unto itself, but rather the prevention and treatment of complications to enhance health and mitigate morbidity and mortality. This perspective on obesity care is consistent with the complications-centric AACE obesity guidelines and the diagnostic term of Adiposity-Based Chronic Disease (ABCD). Many complications require 10-20% weight loss to achieve therapeutic goals; however, existing obesity medications fail to produce ≥10% weight loss in the majority of patients. In June, 2021, semaglutide 2.4 mg/week was approved for chronic weight management. Phase 3 clinical trials demonstrated that this medication produced &gt;10% placebo-subtracted weight loss, more than half of patents lost ≥15%, and over one third lost ≥20% of baseline weight. This essentially doubles effectiveness over existing obesity medications, provides sufficient weight loss to ameliorate a broad range of complications, and qualifies as the first member of a second-generation class of obesity medications. The advent of second-generation medications fully enables a treat-to-target approach for management of ABCD as a chronic disease. Specifically, with this degree of efficacy, second-generation medications permit active management of body weight as a biomarker to targets associated with effective treatment and prevention of specific complications. ABCD can now be managed similar to other chronic diseases such as type 2 diabetes, hypertension, and atherosclerosis which are treated to biomarker targets that can be modified based on the clinical status of individual patients (i.e., HbA1c, blood pressure, and LDL-c) to prevent the respective complications of these diseases.

Call for action: incorporating wellness practices into a holistic management plan for rheumatoid arthritis—going beyond treat to target

This expert opinion article explores the strategy of adopting a holistic approach to the management of rheumatoid arthritis (RA) by incorporating the wellness practices of exercise, optimised sleep, optimised nutrition, mindfulness, social connectedness and positive emotions into the management plan. The aim is to attain optimal health for each patient beyond that achievable by limiting disease management to pharmacological treatment to attain the lowest achievable composite scores of disease activity, as recommended with the current treat-to-target approach, and addressing the recent recognition of pain control as a key patient-reported outcome. Incorporating wellness practices into a busy clinical setting requires creativity and customisation based on the individual practice setting and the individual needs of each patient. Such practices can help people living with RA to achieve optimum wellness through the introduction of measures—according to individual need—designed to improve the aspects of life most impacted for that person, thereby complementing treat-to-target and pain control strategies with pharmacological agents. Clinicians must consider wellness practices in addition to treat-to-target pharmacological agents for the holistic management of people with RA.

LLDAS is an attainable treat-to-target goal in childhood-onset SLE

ObjectivesTo study whether clinical remission (CR) and Low Lupus Disease Activity State (LLDAS) are achievable goals in childhood-onset SLE.MethodsData on medication use and disease activity were prospectively collected. LLDAS was defined as Safety of Estrogen in Lupus Erythematosus National Assesment-SLE disease Activity Index (SELENA-SLEDAI) ≤4 with zero scores for renal, Central Nervous System (CNS), serositis, vasculitis and constitutional components, no increase in any SLEDAI component since the previous visit, PGA ≤1, and prednisone dose ≤7.5 mg/day. CR on treatment (Tx) was defined as a Physician Global Assessment <0.5, SELENA-SLEDAI=0, with prednisone ≤5 mg/day and maintenance treatment with immunosuppressives. CR off Tx was the same but without prednisone or other immunosuppressive usage.Results51 patients (700 visits) were included. Within 3 months after diagnosis, 94.1% of children were treated with hydroxychloroquine and 60.8% with prednisone. Prednisone dosage decreased from a median of 0.74 mg/kg/day at diagnosis to 0.44 mg/kg/day at 3 months and 0.16 mg/kg/day at 6 months after diagnosis. Use of mycophenolate mofetil increased from 25.5% to 56.9% within 6 months after diagnosis. All children achieved LLDAS (median 186 days) and 72.5% remained in LLDAS >50% of time. 52.9% children achieved CR on Tx, and only 21.6% children achieved CR off Tx.ConclusionsLLDAS is an attainable treat-to-target goal in contrast to CR on and off Tx. Even more, LLDAS can be reached with limited use of corticosteroids with early introduction of immunosuppressives.

Capsule Endoscopy in Inflammatory Bowel Disease: When? To Whom?

Capsule endoscopy (CE) has proven to be a valuable diagnostic modality for small bowel diseases over the past 20 years, particularly Crohn’s disease (CD), which can affect the entire gastrointestinal tract from the mouth to the anus. CE is not only used for the diagnosis of patients with suspected small bowel CD, but can also be used to assess disease activity, treat-to-target, and postoperative recurrence in patients with established small bowel CD. As CE can detect even mildly non-specific small bowel lesions, a high diagnostic yield is not necessarily indicative of high diagnostic accuracy. Moreover, the cost effectiveness of CE as a third diagnostic test employed usually after ileocolonoscopy and MR or CT enterography is an important consideration. Recently, new developments in colon capsule endoscopy (CCE) have increased the utility of CE in patients with ulcerative colitis (UC) and pan-enteric CD. Although deflation of the colon during the examination and the inability to evaluate dysplasia-associated lesion or mass results in an inherent risk of overestimation or underestimation, the convenience of CCE examination and the risk of flare-up after colonoscopy suggest that CCE could be used more actively in patients with UC.

Implementation of the Treat-to-Target Concept in Evaluation of Psoriatic Arthritis Patients

Background: The treat-to-target approach was recently adopted for psoriatic arthritis (PsA) management. Objective: To assess the implementation of the “treat-to-target” (T2T) concept in daily management of PsA by use of composite scores of disease activity versus clinical judgement alone. Methods: A total of 117 PsA patients from a longitudinal PsA cohort were enrolled consecutively in the study during each patient’s first clinic visit during 2016–2017. Clinic notes from the treating rheumatologist were reviewed by an independent rheumatologist, noting clinical impression of disease activity, treatment changes based on clinical judgement, and rationale. Treatment changes were then compared to the use of formal disease activity parameters in Minimal Disease Activity (MDA) and Disease Activity Index for Psoriatic Arthritis (DAPSA) composite measures. All associations were assessed using the chi-square test or the Mann–Whitney test, as appropriate. Results: The 117 PsA patient cohort consisted of 65.5% women, mean age 58.4 ± 13.6 years. Clinical judgement of treating rheumatologist concorded with MDA and DAPSA in 76 (65.5%) and 74 (64.9%) patients, respectively. Agreement between clinical judgement and composite measure criteria did not correlate with patient age, sex, alcohol/tobacco use, or treatment regimens chosen. Disagreement between physician assessment and MDA occurred in 40 (34.5%) cases: in 30 cases, the MDA status was overestimated due to disregard of patient reported outcomes (PRO), while underestimation of MDA status occurred in 25% of cases with treatment changes made in patients with a single active joint or enthesis. Underestimation of disease activity using DAPSA occurred in 22 cases and could be attributed to disregarding tender joint count, patient pain visual analogue scale and C-reactive protein level. Conclusion: In our cohort, agreement between clinical impression and formal composite measure utilization for implementation of T2T strategy occurred in 65% of patients. Discordance resulted from physicians’ overlooking PRO and emphasizing objective findings when using clinical judgement alone.