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What's new in rheumatology

What's new in rheumatology
Authors:
Paul L Romain, MD
Monica Ramirez Curtis, MD, MPH
Literature review current through: Feb 2022. | This topic last updated: Feb 22, 2022.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

DRUG THERAPY

New naming convention for therapeutic monoclonal antibodies (January 2022)

The number of therapeutic monoclonal antibodies (mAbs) continues to increase. In order to reduce sound-alikes and specify structural components of the immunoglobulins, the World Health Organization International Nonproprietary Names (INN) Programme has developed four new suffixes to be used instead of "mab" for antibodies developed from 2022 onward [1]. Unmodified immunoglobulins will end in "tug"; mAbs with an engineered constant region will end in "bart"; bifunctional mAbs will end in "mig"; and variable region fragments will end in "ment." (See "Overview of therapeutic monoclonal antibodies", section on 'Naming convention for therapeutic mAbs'.)

Cardiovascular and malignancy risk with Janus kinase inhibitors (September 2021)

The level of risk for cardiovascular (CV) events and malignancy with Janus kinase (JAK) inhibitors is uncertain. Unpublished data from a phase 4 open-label trial comparing tofacitinib with a tumor necrosis factor (TNF) inhibitor in over 4300 patients ≥50 years old on methotrexate for rheumatoid arthritis (RA) and with elevated CV risk showed a small, largely dose-dependent increased risk of nonfatal myocardial infarction, thrombosis, lymphoma, and lung cancer with tofacitinib [2,3]. These findings prompted the US Food and Drug Administration to advise screening for relevant risk factors in patients with serious inflammatory diseases, including RA and ulcerative colitis, and to limit use of tofacitinib, baricitinib, and upadacitinib to patients with an inadequate response or intolerance to TNF inhibitors [2]. European regulators issued a narrower advisory to limit use of tofacitinib in older patients (≥65 years), current or past smokers, and those with other CV and malignancy risk factors [3]. (See "Janus kinase inhibitors for rheumatologic and other inflammatory disorders: Biology, principles of use, and adverse effects", section on 'Overview of adverse effects'.)

ORTHOPEDICS, SPINE, AND SOFT TISSUE RHEUMATIC DISORDERS

Extended dosing of tranexamic acid for total knee arthroplasty (November 2021)

For patients undergoing total knee arthroplasty, prophylactic tranexamic acid (TXA) at the time of surgery is recommended to minimize blood loss. The TRAC-24 trial found that extending TXA dosing for 24 hours postoperatively reduced the indirect calculated blood loss at 48 hours compared with intraoperative dosing alone (mean difference 126 mL), but mortality and thromboembolic events were similar for both groups [4]. We administer postoperative TXA to patients with excessive bleeding. Additional study is required before routine postoperative TXA can be recommended. (See "Total knee arthroplasty", section on 'Tranexamic acid'.)

OSTEOARTHRITIS

Lack of benefit for platelet-rich plasma injections for knee osteoarthritis (January 2022)

Although intra-articular platelet-rich plasma (PRP) injections are increasingly used for the management of knee osteoarthritis (OA), evidence to support use has been limited. A randomized trial including 288 patients with symptomatic mild to moderate knee OA found that, compared with placebo, intra-articular injections of PRP had similar effects on pain and medial tibial cartilage volume on magnetic resonance imaging at 12 months [5]. These findings do not support the use of intra-articular PRP injections for the management of knee OA. (See "Management of knee osteoarthritis", section on 'Platelet-rich plasma'.)

Rapidly destructive hip disease after intraarticular glucocorticoid injection (January 2022)

Intraarticular glucocorticoid injections are sometimes used for symptom management for hip osteoarthritis (OA), but there is a concern that intraarticular glucocorticoids can also accelerate joint degeneration. In a case-control study comparing 40 patients with rapidly destructive hip disease (RDHD) and 717 controls who underwent total hip arthroplasty for OA, at least one intraarticular glucocorticoid injection was associated with a higher risk of RDHD (odds ratio 8.6) [6]. A dose-response effect was also observed, in which the risk of RDHD was higher with increasing doses of glucocorticoids as well as with the number of injections received. These findings support our approach of avoiding routine use of intraarticular glucocorticoid injections for patients with hip OA. (See "Management of hip osteoarthritis", section on 'Limited role of intraarticular glucocorticoids'.)

Lack of benefit for platelet-rich plasma injections for ankle osteoarthritis (November 2021)

Injection of intra-articular platelet-rich plasma (PRP) has been a therapeutic agent of interest for the management of osteoarthritis (OA), although most studies have evaluated knee OA symptoms. The first randomized trial to evaluate its use in ankle OA included 100 patients and found that intra-articular PRP injections, compared with placebo injections, did not improve a composite score of pain and function during the 26-week follow-up period [7]. These findings do not support the use of PRP injections for patients with ankle OA. (See "Investigational approaches to the management of osteoarthritis", section on 'Platelet-rich plasma'.)

VASCULITIS

New antineutrophil cytoplasmic antibody-associated vasculitis guideline (September 2021)

The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides are a group of diseases that involve inflammation of small and medium-sized vessels and include granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). The American College of Rheumatology (ACR)/Vasculitis Foundation has recently published guidelines for the management of the ANCA-associated vasculitides [8]. These guidelines provide recommendations for induction and maintenance therapy for GPA, MPA, and EGPA, which are largely consistent with our approach. (See "Granulomatosis with polyangiitis and microscopic polyangiitis: Induction and maintenance therapy", section on 'Initial treatment approach'.)

OTHER RHEUMATOLOGY

Additional COVID-19 vaccine primary series dose for immunocompromised individuals (August 2021, Modified February 2022)

COVID-19 vaccines are less effective among patients with certain immunocompromising conditions than in the general population; additional vaccine doses have been associated with improved effectiveness in this population. We agree with recommendations from the Advisory Committee on Immunization Practices (ACIP) in the United States that individuals with such conditions (table 1) receive an additional mRNA vaccine dose as part of their primary COVID-19 vaccine series (eg, following two doses of an mRNA vaccine or one dose of Ad26.COV2.S vaccine) [9,10]. This additional primary series dose is distinct from the booster dose, which such patients should additionally receive, although at a shorter interval than recommended for the general population. (See "COVID-19: Vaccines", section on 'Immunocompromised individuals'.)

Updated guidance for COVID-19 vaccine use in patients with rheumatic disease (September 2021)

The American College of Rheumatology (ACR) COVID-19 Vaccine Clinical Guidance Task Force has updated their recommendations regarding use of COVID-19 vaccines in patients with rheumatic disease [11]. These now emphasize that a third dose of either of the mRNA vaccines is appropriate for most patients with systemic rheumatic diseases. The ACR also noted a preference for a mRNA vaccine for patients not yet vaccinated, based on the potential benefits and regulatory approval of a three-dose series. The guidance addresses the timing of the vaccination, administration of immunosuppressive agents, and the use of postexposure prophylaxis with monoclonal antibodies in certain patients. (See "COVID-19: Care of adult patients with systemic rheumatic disease", section on 'Timing of vaccine'.)

REFERENCES

  1. Balocco R, De Sousa Guimaraes Koch S, Thorpe R, et al. New INN nomenclature for monoclonal antibodies. Lancet 2022; 399:24.
  2. FDA Drug Safety Communication. FDA requires warnings about increased risk of serious heart-related events, cancer, blood clots, and death for JAK inhibitors that treat certain chronic inflammatory conditions. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requires-warnings-about-increased-risk-serious-heart-related-events-cancer-blood-clots-and-death (Accessed on September 06, 2021).
  3. EMA/PRAC Recommendations for update of the product information for tofacitinib. July 5, 2021. https://www.ema.europa.eu/en/documents/prac-recommendation/prac-recommendations-signals-adopted-7-10-june-2021-prac-meeting_en.pdf (Accessed on September 06, 2021).
  4. Magill P, Hill JC, Bryce L, et al. Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total knee arthroplasty: results of a randomized controlled trial (TRAC-24). Bone Joint J 2021; 103-B:1595.
  5. Bennell KL, Paterson KL, Metcalf BR, et al. Effect of Intra-articular Platelet-Rich Plasma vs Placebo Injection on Pain and Medial Tibial Cartilage Volume in Patients With Knee Osteoarthritis: The RESTORE Randomized Clinical Trial. JAMA 2021; 326:2021.
  6. Okike K, King RK, Merchant JC, et al. Rapidly Destructive Hip Disease Following Intra-Articular Corticosteroid Injection of the Hip. J Bone Joint Surg Am 2021; 103:2070.
  7. Paget LDA, Reurink G, de Vos RJ, et al. Effect of Platelet-Rich Plasma Injections vs Placebo on Ankle Symptoms and Function in Patients With Ankle Osteoarthritis: A Randomized Clinical Trial. JAMA 2021; 326:1595.
  8. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Arthritis Care Res (Hoboken) 2021; 73:1088.
  9. CDC - An Additional Dose of mRNA COVID-19 Vaccine Following a Primary Series in Immunocompromised People. Available at: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-08-13/02-COVID-Dooling-508.pdf (Accessed on August 14, 2021).
  10. Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html (Accessed on February 24, 2022).
  11. American College of Rheumatology COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases (August 19,2021 update). https://www.rheumatology.org/Portals/0/Files/COVID-19-Vaccine-Clinical-Guidance-Rheumatic-Diseases-Summary.pdf (Accessed on August 21, 2021).
Topic 8356 Version 10977.0

References

1 : New INN nomenclature for monoclonal antibodies.

2 : New INN nomenclature for monoclonal antibodies.

3 : New INN nomenclature for monoclonal antibodies.

4 : Oral tranexamic acid for an additional 24 hours postoperatively versus a single preoperative intravenous dose for reducing blood loss in total knee arthroplasty: results of a randomized controlled trial (TRAC-24).

5 : Effect of Intra-articular Platelet-Rich Plasma vs Placebo Injection on Pain and Medial Tibial Cartilage Volume in Patients With Knee Osteoarthritis: The RESTORE Randomized Clinical Trial.

6 : Rapidly Destructive Hip Disease Following Intra-Articular Corticosteroid Injection of the Hip.

7 : Effect of Platelet-Rich Plasma Injections vs Placebo on Ankle Symptoms and Function in Patients With Ankle Osteoarthritis: A Randomized Clinical Trial.

8 : 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis.