Wilkie R, Bjork M, Costa-Black KM
… +2 more, Parker M, Pransky G
Best Pract Res Clin Rheumatol
· 2020 Apr · PMID 32321677
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Improving work participation for individuals with rheumatic and musculoskeletal diseases (RMDs), has gained increasing interest over the last 10 years. New approaches are based upon increasing adoption of a biopsychosoci...Improving work participation for individuals with rheumatic and musculoskeletal diseases (RMDs), has gained increasing interest over the last 10 years. New approaches are based upon increasing adoption of a biopsychosocial approach to improving work participation, incorporating evidence that health professionals within multidisciplinary teams have a key and critical role. In particular, interaction between health professionals and employers, and rehabilitation services that are linked to the workplace are key elements for improving work participation for people with RMDs. This review outlines recent research that underpins approaches for health professionals to develop their role in improving work participation for people with RMDs based on recent research; it outlines how to measure work-related outcomes in clinical practice, models of work participation, and approaches for health professionals to improve work participation outcomes. The potential for developing the role of health professionals in future years is also outlined.
Best Pract Res Clin Rheumatol
· 2020 Apr · PMID 32307230
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Within rheumatology, telehealth is essential to modern rehabilitation due to the demographic development with more and more elderly people. At present, telehealth solutions are used as part of the rehabilitation process...Within rheumatology, telehealth is essential to modern rehabilitation due to the demographic development with more and more elderly people. At present, telehealth solutions are used as part of the rehabilitation process in assessment, interventions and evaluation. Telehealth interventions are as effective as conventional follow-ups or self-management assessments, but the evidence on the effect is still sparse. Telehealth interventions seem to support a physically active lifestyle in the short term. In general, telehealth solutions are well received by patients, but the development must be based on user involvement, behaviour theory and the World Health Organisation principles of creating health literate organisations in order to ensure usability, effectiveness and further implementation.
Richter MD, Hughes GC, Chung SH
… +3 more, Ezeanuna M, Singh N, Thompson JA
Best Pract Res Clin Rheumatol
· 2020 Aug · PMID 32299675
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The growth of cancer immunotherapy has led to an urgent need for a multispecialty approach to treating patients with advanced malignancies. Checkpoint inhibitor therapies cause a wide range of toxicities termed immune-re...The growth of cancer immunotherapy has led to an urgent need for a multispecialty approach to treating patients with advanced malignancies. Checkpoint inhibitor therapies cause a wide range of toxicities termed immune-related adverse events (irAEs) that can affect any organ system. Similar to the anti-tumor responses induced by these medications, irAEs represent an interruption of self-tolerance that results in T cell-driven cytotoxicity, the exact mechanisms of which are likely heterogeneous. This review describes the various immunologic pathways that may lead to irAEs along with the diverse clinical manifestations seen in clinical practice. Treatment based on the severity and specific organ involvement will also be discussed, along with an overview of current guidelines and potential challenges that arise with immunosuppressive medications.
BACKGROUND/OBJECTIVE: Corticosteroids have long been used to effectively treat rheumatic disorders, but adverse effects associated with extended-duration regimens generate disagreement among clinicians regarding optimal...BACKGROUND/OBJECTIVE: Corticosteroids have long been used to effectively treat rheumatic disorders, but adverse effects associated with extended-duration regimens generate disagreement among clinicians regarding optimal tapering strategies. The objective of this systematic review was to assess clinical outcomes of differing tapering regimens after corticosteroid monotherapy in adults with rheumatic disorders. METHODS: A systematic review of Medline/PubMed, Embase, Cochrane, International Pharmaceutical Abstracts, Web of Science, Scopus, Global Index Medicus, American College of Rheumatology, gray literature, and reference lists up to June 27, 2018, was conducted by 2 authors. Randomized controlled trials, case-control studies, and prospective observational studies comparing at least 2 tapering strategies of medium- to high-dose (>7.5 mg but ≤100 mg oral prednisone equivalent daily), extended-duration (≥10 days) corticosteroids were included if they reported at least 1 efficacy and 1 adverse effect parameter. RESULTS: Two studies met criteria for the review, which included 62 patients. One study examined a prednisolone versus a modified release prednisone taper for giant cell arteritis and suggested 80% (n = 4) and 85.7% (n = 6) remission rates, respectively, at 26 weeks. The other study examined a methylprednisolone versus a prednisone taper for polymyalgia rheumatica and reported 100% and 89% remission rates, respectively, at 26 weeks. Adverse effects reported between the 2 studies included sleep, hyperglycemia, infection, and fractures. However, the studies were not powered to detect differences in these outcomes. CONCLUSIONS: There is no high-level evidence to guide tapering until discontinuation after extended courses of medium- to high-dose treatment regimens, as current guidelines rely heavily on expert opinion and small case series with a trial-and-error approach. This review supports the need for additional research to shift tapering recommendations to a more evidence-based practice.
Best Pract Res Clin Rheumatol
· 2020 Feb · PMID 32067925
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Targeted therapies using biological disease-modifying antirheumatic drugs (bDMARDs) and small molecule synthetic drugs have revolutionized rheumatological practice. Initially developed for the treatment of immune arthrit...Targeted therapies using biological disease-modifying antirheumatic drugs (bDMARDs) and small molecule synthetic drugs have revolutionized rheumatological practice. Initially developed for the treatment of immune arthritis (rheumatoid arthritis, psoriatic arthritis, and spondylarthritis), both bDMARDs and small molecule synthetic drugs are now increasingly entering the space of connective tissue disease (CTD) treatment. Recent clinical trial data in systemic sclerosis (SSc) have been particularly encouraging with positive effects on outcomes having been observed with nintedanib preventing the decline of lung function in patients with SSc-related interstitial lung disease. Randomized trials targeting B-cells by rituximab in primary Sjogren's syndrome have led to mixed results. Novel strategies to target B-cells in primary Sjögren's syndrome including ianalumab and belimumab are underway and will hopefully result in clear treatment effects. Inflammatory idiopathic myositis (polymyositis (PM) and dermatomyositis (DM)) and antiphospholid syndrome are proving to be more difficult to tackle but are nonetheless the subject of ongoing studies. To what extent new compounds can replace more traditional immunosuppressive drugs remains to be determined, but if the experience in immune arthritis has taught us anything it is that combination therapy may be the way to go.
Bugatti S, Bozzalla Cassione E, De Stefano L
… +1 more, Manzo A
Best Pract Res Clin Rheumatol
· 2019 Oct · PMID 32001167
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The development of rheumatoid arthritis (RA), at least in its autoantibody-positive subset, evolves through a series of events starting well before the appearance of synovitis. The distinction between 'early' and 'establ...The development of rheumatoid arthritis (RA), at least in its autoantibody-positive subset, evolves through a series of events starting well before the appearance of synovitis. The distinction between 'early' and 'established' RA is, therefore, an evolving concept. In routine practice, however, the management of RA still starts with the occurrence of clinically detectable synovitis. As such, the synovial membrane remains a major target for the exploitation of possible stage-specific drivers of the disease. The recognition of a 'window of opportunity', in which treatment is more likely to succeed, raises the hypothesis that there might be a period in which the biological processes of RA are less mature and potentially reversible. The present review aims to provide a general picture of the modifications occurring in RA synovium, analysing the contribution of both infiltrating immune cells and stromal cells. When available, differences between early and established RA will be discussed.
Best Pract Res Clin Rheumatol
· 2019 Oct · PMID 32001166
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Structural damage progression in patients with established rheumatoid arthritis (RA) has traditionally been assessed by conventional radiography (CR), which has proven its value in clinical practice and clinical trials o...Structural damage progression in patients with established rheumatoid arthritis (RA) has traditionally been assessed by conventional radiography (CR), which has proven its value in clinical practice and clinical trials over the past decades. The most prominent abnormalities visualized by CR in RA patients are erosions as a consequence of bone destruction and joint space narrowing (JSN) as a consequence of cartilage damage. Several validated scoring systems to quantify the structural joint damage and progression herein are available. Computed tomography and magnetic resonance imaging are newer, more sensitive methods for detection and monitoring of structural joint damage. A validated scoring system for magnetic resonance imaging of the hands and wrists exists, while no consensus has been reached on a scoring system for computed tomography. Structural damage identified by either CR or magnetic resonance imaging predicts a poorer disease course in patients with both early and established rheumatoid arthritis.
Elmamoun M, Eraso M, Anderson M
… +24 more, Maharaj A, Coates L, Chandran V, ILAR-PsA recommendations group, Abogamal A, Adebajo AO, Ajibade A, Ayanlowo O, Azevedo V, Bautista-Molano W, Carneiro S, Goldenstein-Schainberg C, Hernandez-Velasco F, Ima-Edomwonyi U, Lima A, Medina-Rosas J, Mody GM, Narang T, Ortega-Loayza AG, Ranza R, Sharma A, Toloza S, Vega-Espinoza L, Vega-Hinojosa O
Clin Rheumatol
· 2020 Jun · PMID 31950441
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BACKGROUND: Psoriatic arthritis (PsA) is a challenging heterogeneous disease. The European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) last published their re...BACKGROUND: Psoriatic arthritis (PsA) is a challenging heterogeneous disease. The European League Against Rheumatism (EULAR) and the Group for Research and Assessment of Psoriasis and PsA (GRAPPA) last published their respective recommendations for the management of PsA in 2015. However, these guidelines are primarily based on studies conducted in resource replete countries and may not be applicable in countries in the Americas (except Canada and USA) and Africa. We sought to adapt the existing recommendations for these regions under the auspices of the International League of Associations for Rheumatology (ILAR). PROCESS: The ADAPTE Collaboration (2009) process for guideline adaptation was followed to adapt the EULAR and GRAPPA PsA treatment recommendations for the Americas and Africa. The process was conducted in three recommended phases: set-up phase; adaptation phase (defining health questions, assessing source recommendations, drafting report), and finalization phase (external review, aftercare planning, and final production). RESULT: ILAR recommendations have been derived principally by adapting the GRAPPA recommendations, additionally, EULAR recommendations where appropriate and supplemented by expert opinion and literature from these regions. A paucity of data relevant to resource-poor settings was found in PsA management literature. CONCLUSION: The ILAR Treatment Recommendations for PsA intends to serve as reference for the management of PsA in the Americas and Africa. This paper illustrates the experience of an international working group in adapting existing recommendations to a resource-poor setting. It highlights the need to conduct research on the management of PsA in these regions as data are currently lacking.Key Points• The paper presents adapted recommendations for the management of psoriatic arthritis in resource-poor settings.• The ADAPTE process was used to adapt existing GRAPPA and EULAR recommendations by collaboration with practicing clinicians from the Americas and Africa.• The evidence from resource-poor settings to answer clinically relevant questions was scant or non-existent; hence, a research agenda is proposed.
Altabás-González I, Pérez-Gómez N, Pego-Reigosa JM
Best Pract Res Clin Rheumatol
· 2019 Aug · PMID 31810549
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Muscular symptoms, which may be due to multiple causes, are one of the most common early complaints in a rheumatology practice. Musculoskeletal symptoms in rheumatic conditions are very varied, ranging from mechanical pr...Muscular symptoms, which may be due to multiple causes, are one of the most common early complaints in a rheumatology practice. Musculoskeletal symptoms in rheumatic conditions are very varied, ranging from mechanical problems to muscular symptoms derived from inflammatory and systemic autoimmune diseases. Several drugs commonly used by different specialists and certain drugs used in rheumatology can also cause a wide variety of muscle symptoms. A description of different systemic autoimmune diseases follows to describe the different forms of involvement of the musculoskeletal system that they cause, as well as the main causes with which a differential diagnosis should be made. In this chapter, we will try to give some clues to reach an early diagnosis using clinical criteria, particularly based on a directed anamnesis and physical examination, discussing possible guidelines for the complimentary tests that may be required in patients with muscle complaints.
Best Pract Res Clin Rheumatol
· 2019 Apr · PMID 31547980
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Approximately 20% of men and women aged 50 years or older will present with a vertebral fragility fracture - a prevalence that steadily increases with age. The condition may be associated with severe pain and disability,...Approximately 20% of men and women aged 50 years or older will present with a vertebral fragility fracture - a prevalence that steadily increases with age. The condition may be associated with severe pain and disability, significant reductions in overall quality of life, mobility, social participation, sleep quality and increased fear for the future. There is, however, no current consensus on what constitutes the best management of symptomatic vertebral fractures. Moreover, evidence supporting common treatment approaches is scarce and often of poor quality. The lack of adequate management of VFF and associated osteoporosis and the burden of this condition to patient and society are estimated to increase substantially in coming years as recurrent, disabling episodes are set to occur. This chapter will address these issues, including a discussion on existing care pathways for vertebral fragility fractures, and an overview of the evidence supporting recommendations of the main international clinical practice guidelines.
Ranhoff AH, Saltvedt I, Frihagen F
… +3 more, Raeder J, Maini S, Sletvold O
Best Pract Res Clin Rheumatol
· 2019 Apr · PMID 31547979
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Hip fractures are common among older people, and the prognosis is serious in terms of mobility, independence in daily life activities, and cognition, with 42% of patients never achieving the same function as before the f...Hip fractures are common among older people, and the prognosis is serious in terms of mobility, independence in daily life activities, and cognition, with 42% of patients never achieving the same function as before the fracture. Norway has the highest incidence of hip fractures, and the important tasks are to improve patient care and prevent new fractures. The aim was to develop Norwegian Guidelines for Interdisciplinary Care for Hip Fractures, which included models of care, organization, and clinical issues. These guidelines were based on review of the literature, including existing guidelines such as the NICE guidelines, as well as clinical experience of the members of the group, where consensus was reached after discussions. The guidelines focus on interdisciplinary patient management through a clinical pathway from admission to discharge. Here, we will present a shortened and internationally adapted version of these guidelines, which has newly been released.
Crossley KM, van Middelkoop M, Barton CJ
… +1 more, Culvenor AG
Best Pract Res Clin Rheumatol
· 2019 Feb · PMID 31431275
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Patellofemoral pain is one of the most common knee complaints, particularly among physically active young individuals. Although once thought to be self-limiting, prospective studies have demonstrated the propensity towar...Patellofemoral pain is one of the most common knee complaints, particularly among physically active young individuals. Although once thought to be self-limiting, prospective studies have demonstrated the propensity towards the chronicity of patellofemoral pain (PFP). The pathogenesis of PFP is complex, with multiple interactive pathways suggested to contribute to its onset and persistence. Quadriceps weakness is one of the few risk factors of PFP, with at least moderate evidence from prospective studies, although limited clinical trials of lower limb strengthening have generally not been successful in preventing PFP. The challenge of managing PFP is reflected by a lack of evidence-based clinical guidelines. International consensus and current evidence recommends exercise therapy, focussed on hip and knee strengthening, as a cornerstone of management to reduce PFP. Rethinking management approaches beyond exercise therapy to incorporate movement retraining, education and psychosocial aspects provides potential avenues to enhance outcomes for patients with PFP.
Best Pract Res Clin Rheumatol
· 2019 Feb · PMID 31431274
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Anterior cruciate ligament (ACL) rupture occurs most commonly in young and active individuals and can have negative long-term physical and psychological impacts. The diagnosis is made with a combination of patient's hist...Anterior cruciate ligament (ACL) rupture occurs most commonly in young and active individuals and can have negative long-term physical and psychological impacts. The diagnosis is made with a combination of patient's history, clinical examination, and, if appropriate, magnetic resonance imaging. The objectives of management are to restore knee function, address psychological barriers to activity participation, prevent further injury and osteoarthritis, and optimize long-term quality of life. The three main treatment options for ACL rupture are (1) rehabilitation as first-line treatment (followed by ACL reconstruction (ACLR) in patients, who develop functional instability), (2) ACLR and post-operative rehabilitation as the first-line treatment, and (3) pre-operative rehabilitation followed by ACLR and post-operative rehabilitation. We provide practical recommendations for informing and discussing management options with patients, and describe patient-related factors associated with a worse ACL-rupture outcome. Finally, we define evidence-based rehabilitation and present phase-specific rehabilitation recommendations and criteria to inform return to sport decisions.
Best Pract Res Clin Rheumatol
· 2019 Feb · PMID 31431273
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Participation in sport and recreation has important positive implications for public health across the lifespan; however, the burden of sport-related musculoskeletal injury is significant, with the greatest risk being in...Participation in sport and recreation has important positive implications for public health across the lifespan; however, the burden of sport-related musculoskeletal injury is significant, with the greatest risk being in youth and young adults. Moving upstream to primary prevention of injury is a public health priority that will have significant implications for reducing the long-term consequences of musculoskeletal injury including early post-traumatic osteoarthritis. The primary targets for the prevention of musculoskeletal injury in sport include neuromuscular training (NMT), rule modification, and equipment recommendations. Currently, there is significant high-quality evidence to support the widespread use of NMT warm up programs in team and youth sport, with an expected significant impact of reducing the risk of musculoskeletal injury by over 35%. Policy disallowing body checking in youth ice hockey has led to a >50% reduction in injuries, and rules limiting contact practice in youth American football has significant potential for injury prevention. There is evidence to support the use of bracing and taping in elite sport to reduce the risk of recurrent ankle sprain injury but not for use to prevent the primary injury, and wrist guards are protective of sprain injuries in snowboarding. Future research examining the maintenance of NMT programs across real-world sport and school settings, optimization of adherence, additional benefit of workload modification, and evaluation of rule changes in other sports is needed.
Best Pract Res Clin Rheumatol
· 2019 Feb · PMID 31431272
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Although safety in sports and physical activity is an important prerequisite for continuing participation and maintenance of a healthy, physically active lifestyle, to date little effort has been placed upon moving evide...Although safety in sports and physical activity is an important prerequisite for continuing participation and maintenance of a healthy, physically active lifestyle, to date little effort has been placed upon moving evidence into preventive practice. Amongst researchers it is still often assumed that a program will disseminate itself after proven to be effective. Recently, however, there has been an increased recognition of the importance of theory-driven approaches to enhance implementation research. This manuscript aims to provide guidance for sports and physical activity injury researchers and practitioners to perform implementation research and practice. First, we will discuss the differences between research questions across the research spectrum and explain the 'drop' in effect when moving controlled evidence to a practical context. We will discuss two ways of increasing real-world effectiveness of preventive programs, i.e. through targeting the users' behaviour or through revising the intervention. Finally, we will present various implementation frameworks and tools that can guide the reader in their own efforts towards implementation practice and research.
O'Sullivan K, O'Keeffe M, Forster BB
… +3 more, Qamar SR, van der Westhuizen A, O'Sullivan PB
Best Pract Res Clin Rheumatol
· 2019 Feb · PMID 31431266
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Adolescent low back pain has received limited research attention despite its potentially considerable impact on quality of life. The role of diagnostic triage to identify serious or specific pathology and/or order releva...Adolescent low back pain has received limited research attention despite its potentially considerable impact on quality of life. The role of diagnostic triage to identify serious or specific pathology and/or order relevant investigations is considered. An overview of contemporary pain mechanisms is provided, with specific reference to the wide range of risk factors for persistent low back pain. Education and exercise framed within a biopsychosocial framework are the cornerstones of treatment. There is a lack of data on more comprehensive personalized treatment approaches among adolescents. One such approach - Cognitive Functional Therapy - which has shown promise in adults and active adolescents with low back pain, is described and illustrated using a case study. The most promising avenues, in practice and research, may be those that view adolescent low back pain as less of a local structural spinal issue and more of an indication of the general health of the adolescent.
Best Pract Res Clin Rheumatol
· 2018 Dec · PMID 31427057
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Increasing therapeutic options are available for gout management. Anti-inflammatory agents are used in the acute management of gout flares, and interleukin-1 inhibitors are effective for those unable to take conventional...Increasing therapeutic options are available for gout management. Anti-inflammatory agents are used in the acute management of gout flares, and interleukin-1 inhibitors are effective for those unable to take conventional anti-inflammatory treatments. Lowering of serum urate remains the cornerstone of effective long-term management. Allopurinol is the first-line urate-lowering therapy, and a gradual dose-escalation strategy to serum urate target is recommended. Febuxostat and lesinurad have been approved more recently. In a large cardiovascular outcomes trial, higher all-cause and cardiovascular mortality was observed with febuxostat than with allopurinol. Lesinurad should be co-prescribed with a xanthine oxidase inhibitor, and close monitoring of kidney function is required. Evidence for non-pharmacological management is limited, but personalised lifestyle modification may reduce associated cardiovascular risk. In this review, we discuss current principles in the gout management paradigm, consider strategies for managing complex, clinical scenarios, and review emerging therapies.
Best Pract Res Clin Rheumatol
· 2018 Dec · PMID 31427056
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Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) represent a family of systemic inflammatory diseases occurring in adults aged 50 years and above. Clinical presentation of PMR/GCA can be variable, making diagn...Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) represent a family of systemic inflammatory diseases occurring in adults aged 50 years and above. Clinical presentation of PMR/GCA can be variable, making diagnosis at times challenging. There has been an increased appreciation of the role of various large-vessel imaging modalities to help confirm a diagnosis of GCA. Systemic corticosteroids (CS) remain the mainstay of treatment for both PMR and GCA, yet both relapses and CS-related side effects are common. Recent research has demonstrated efficacy of certain biologic agents in these diseases, with particular emphasis on the role of interleukin-6 (IL-6) blockade in GCA. This chapter discusses the latest updates on the diagnosis and treatment of PMR/GCA, with an emphasis on clinical care.
Sharif K, Gendelman O, Langevitz P
… +7 more, Reitblat T, Watad A, Shoenfeld Y, Azuri J, Amital H, Bragazzi NL, Shovman O
Best Pract Res Clin Rheumatol
· 2018 Oct · PMID 31203927
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Golimumab is a recombinant human monoclonal antibody targeted against tumour necrosis factor-alpha (TNF-α). Golimumab is effective in the management of patients with active psoriatic arthritis (PsA). The aim of this stud...Golimumab is a recombinant human monoclonal antibody targeted against tumour necrosis factor-alpha (TNF-α). Golimumab is effective in the management of patients with active psoriatic arthritis (PsA). The aim of this study is to evaluate the clinical efficacy and survival of golimumab monotherapy versus co-administration with methotrexate (MTX) in patients with PsA in the clinical practice. This retrospective observational trial included patients with PsA. Efficacy was assessed by disease activity scores - DAS28, BASDAI, physician global assessment of disease (PGA) and CRP. Golimumab survival rate was estimated using the Kaplan-Meier analysis and univariate and multivariate Cox regression models. Forty-one patients with PsA were recruited; 26 patients were treated with golimumab, whereas 15 patients received combination therapy with MTX. The treatment resulted in significantly improved clinical measures of disease activity in comparison with baseline, including DAS28 CRP (4.1 vs 2.6, p ≤ 0.0001) and BASDAI (5.6 vs 3.8, p ≤ 0.001). Overall, 29 (71%) patients continued golimumab treatment (18 patients on monotherapy and 11 on combination therapy). The difference in the duration of golimumab survival between the combination therapy and monotherapy groups was not statistically significant (12.5 vs 12 months, p = 0.2). Similar efficacy profiles and survival rates were documented in patients with PsA regardless of the co-administration of methotrexate.