Anti-Inflammatory Drugs May Have Antidepressant Effects

Anti-inflammatory drugs, such as those prescribed for arthritis, could potentially be effective in the treatment of depression, according to a new meta-analysis conducted by researchers at iPSYCH, a Danish research project focused on finding the causes of major mental disorders.  Click here to read further.

NIHR Signal Stopping biological drugs for rheumatoid arthritis can lead to twice the relapse rate

It seems safer to reduce the dose of biological drugs, rather than to stop them if people with rheumatoid arthritis and their doctors want to avoid relapse. Stopping these powerful drugs caused the disease to recur in 58% of people compared with 29% who continued them. Reducing the dose also led to more relapses for people in remission, but did not cause those with low-grade disease activity to worsen.




Rheumatoid arthritis is a chronic disease which causes pain, swelling and stiffness in the small joints of the hands and feet. It can cause more widespread inflammation. The disease has episodes of improvement and deterioration so judging the effects of treatment can be difficult. Drug treatments suppress the immune system, putting people at higher risk of infection.




From the NIHR Dissemination Centre

Golimumab for treating non-radiographic axial spondyloarthritis [TA 297]

New: Technology appraisal guidance


Golimumab is recommended, within its marketing authorisation, as an option for treating severe non-radiographic axial spondyloarthritis in adults whose disease has responded inadequately to, or who cannot tolerate, nonsteroidal anti-inflammatory drugs.


If patients and their clinicians consider golimumab to be one of a range of suitable treatments, including adalimumab, etanercept and certolizumab pegol, the least expensive (taking into account administration costs and patient access schemes) should be chosen.




Assess the response to golimumab 12 weeks after the start of treatment. Continue treatment only if there is clear evidence of response, defined as:

• a reduction in the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score to 50% of the pre-treatment value or by 2 or more units and
• a reduction in the spinal pain visual analogue scale (VAS) score by 2 cm or more.

NICE draft guideline on rheumatoid arthritis - consultation open

NICE draft guidelines on rheumatoid arthritis in adults are open for consultation until 1st March 2018.


The proposals include giving adults with rheumatoid arthritis access to specialist physiotherapy to help manage their condition and improve their fitness, flexibility and strength.


See the draft guidelines and register to contribute to the consultation process at https://www.nice.org.uk/guidance/indevelopment/gid-ng10014/consultation/html-content-2

Tonogenchoncel-L (Invossa) Gene Therapy for Regeneration of Cartilage in Patients with Degenerative Arthritis or Osteoarthritis of the Knee

Tonogenchoncel-L is a type of treatment which involves taking cells which make up the cartilage and altering them genetically to help stimulate the growth of the cartilage. These modified cells are injected directly into the knee joint with the intention of helping the lost cartilage regrow. If tonogenchoncel-L was licenced in the UK it could provide a unique treatment for people with knee osteoarthritis which has the potential to help cartilage regrow and improve symptoms.

From NIHR Innovation Observatory

Upadacitinib for Adults with Moderate to Severe Active Rheumatoid Arthritis After Conventional Synthetic Disease-Modifying Anti-Rheumatic Drugs (DMARDs) or Biologic DMARDs Failure

There is currently no cure for rheumatoid arthritis and treatment aims to improve quality of life and to prevent or reduce joint damage. The most common treatment options are steroids to reduce inflammation, medications to reduce pain and swelling, and medications that slow the progression of joint damage from RA. Upadacitinib is currently being developed to be taken orally as a treatment option for those who have active moderate to severe RA who do not respond to certain treatment options. This drug works by stopping the inflammation caused by a specific type of protein and if licensed, it may be an option that can be used earlier in the treatment pathway.

From NIHR Innovation Observatory

Subcutaneous Tocilizumab (RoACTEMRA) With or Without Methotrexate for the Treatment of Inadequate Responders in Systemic Juvenile Idiopathic Arthritis

Tocilizumab is a drug that targets and blocks the IL-6 pathway and is currently used for the treatment of many diseases, including sJIA, rheumatoid arthritis and Giant Cell Arteritis (GCA). It is now being developed for patients with sJIA that may have been treated with, and have not responded to another drug called methotrexate. It is being developed to be administered as an injection under the skin (subcutaneous) as opposed to the usual intravenous infusion preparation and this has the potential to reduce patient inconvenience and clinical burden.

From NIHR Innovation Observatory

Subcutaneous Tocilizumab (RoACTEMRA) With or Without Methotrexate for the Treatment of Inadequate Responders in Systemic Juvenile Idiopathic Arthritis

Tocilizumab is a drug that targets and blocks the IL-6 pathway and is currently used for the treatment of many diseases, including sJIA, rheumatoid arthritis and Giant Cell Arteritis (GCA). It is now being developed for patients with sJIA that may have been treated with, and have not responded to another drug called methotrexate. It is being developed to be administered as an injection under the skin (subcutaneous) as opposed to the usual intravenous infusion preparation and this has the potential to reduce patient inconvenience and clinical burden.

From the NIHR Innovation Observatory. 

NIHR Signal Exercise improves symptoms and function for people with ankylosing spondylitis

People with ankylosing spondylitis showed improvement in their symptoms and their ability to perform day-to-day tasks when they did more exercise. Symptom and function scores improved by almost one point on a 10-point scale after 3 to 12 weeks of exercise.
People with ankylosing spondylitis showed improvement in their symptoms and their ability to perform day-to-day tasks when they did more exercise. Symptom and function scores improved by almost one point on a 10-point scale after 3 to 12 weeks of exercise.
Ankylosing spondylitis is a type of arthritis which mainly affects the spine, causing pain, stiffness and progressive fusion of the spine. There have been recent advances in pharmacological treatment, and it was uncertain whether exercise along with modern drug treatment has useful benefits.
This review pooled the results of eight trials comparing different types of exercise with education or no exercise. People’s symptoms and ability to perform daily activities improved regardless of whether they were receiving new drug treatments.
The functional improvements shown in this research and the potential to prolong independence and working life for the most severely affected might also be another important reason to maintain activity.
From the NIHR Dissemination Centre

Tocilizumab (RoACTEMRA) [subcutaneous injection with an auto injector device] for adult patients with moderate to severe active rheumatoid arthritis - after DMARD failure

There is currently no cure for rheumatoid arthritis. The most common treatment options are steroids to reduce inflammation, medications to reduce pain and inflammation and medications that slow the progression of joint damage from RA. Tocilizumab is already licensed for the treatment of RA as both intravenous and subcutaneous (pre-filled syringe) formulations, however its use, via an auto-injector device is being developed. This is expected to improve the ease of patients treating themselves, in those who have active moderate to severe RA who do not respond to some conventional treatments

From the NIHR Innovation Observatory

Total distal radioulnar joint replacement for symptomatic joint instability or arthritis [IPG595]

New: Interventional procedures guidance from NICE:

Evidence-based recommendations on total distal radioulnar joint replacement for symptomatic joint instability or arthritis in adults. This involves removing the wrist end of the ulna (one of the forearm bones) and replacing it with a metal prosthesis that also attaches to the wrist end of the radius (the other forearm bone).

1.1 Current evidence on the safety and efficacy of total distal radioulnar joint replacement for symptomatic joint instability or arthritis is limited in quantity and quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research.

1.2 Clinicians wishing to do total distal radioulnar joint replacement for symptomatic joint instability or arthritis should:

Sarilumab for moderate to severe rheumatoid arthritis [TA485]

New Technology appraisal guidance from NICE:

Evidence-based recommendations on sarilumab (Kevzara) for treating moderate to severe rheumatoid arthritis in adults.

Sarilumab, with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to intensive therapy with a combination of conventional disease-modifying antirheumatic drugs (DMARDs), only if:

• disease is severe (a disease activity score [DAS28] of more than 5.1) and
• the company provides sarilumab with the discount agreed in the patient access scheme.

Promonitor for monitoring response to biologics in rheumatoid arthritis [MB126]

New Medtech innovation Briefing from NICE:

The technology described in this briefing is Promonitor. It is used to monitor response to biologic therapies.

The innovative aspect is that each sample only needs to be run once, potentially allowing for a higher throughput of tests.

The intended place in therapy would be in addition to current methods of monitoring drug response in people with rheumatoid arthritis.

Promonitor (Grifols–Progenika) is a portfolio of assays, run on an enzyme-linked immunosorbent assay (ELISA) technology platform, that measure drug levels (etanercept, infliximab, infliximab biosimilars, adalimumab, rituximab, golimumab) and their correlating anti‑drug antibodies (anti‑etanercept, anti‑infliximab, anti‑adalimumab, anti‑rituximab, anti‑golimumab). The focus of this briefing is the use of Promonitor tests to monitor response to biologic treatments for rheumatoid arthritis. Monitoring drug response can help determine which drug works best for the patient.

Tofacitinib for moderate to severe rheumatoid arthritis [TA480]

New Guidance from NICE:

Evidence-based recommendations on tofacitinib (Xeljanz) for treating moderate to severe rheumatoid arthritis in adults.

1 Recommendations

1.1 Tofacitinib, with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to intensive therapy with a combination of conventional disease-modifying anti-rheumatic drugs (DMARDs), only if:

• disease is severe (a disease activity score [DAS28] of more than 5.1) and
• the company provides tofacitinib with the discount agreed in the patient access scheme.

Assessing, managing and monitoring biologic therapies for inflammatory arthritis

RCN's updated fourth edition of the RCN’s guidance on assessing, managing and monitoring biologic therapies for inflammatory arthritis which provides a best practice framework for rheumatology specialist practitioners and the wider health care team involved in supporting the administration, monitoring and delivery of care to patients in a variety of settings.

Arthritis: the hidden impact on mental health

Journalist Juliette Wills has lived with inflammatory spinal arthritis for 18 years. In part two of a six-part series, she meets 28-year-old Anoushka, who has had to resign from two jobs and is awaiting her ninth operation.

Arthritis is an unforgiving condition that doesn’t just cause physical pain; for many people it impacts so dramatically on their quality of life that it also causes emotional pain. A study conducted by Revealing Reality for the charity Arthritis Research UK found that a quarter of people with arthritis say they often or frequently feel “low or depressed” on account of their condition. This comes as no surprise to Dr Tom Margham, who works closely with the charity.

Baricitinib for moderate to severe rheumatoid arthritis [TA466]

Baricitinib, with methotrexate, is recommended as an option for treating active rheumatoid arthritis Baricitinib for moderate to severe rheumatoid arthritis in adults whose disease has responded inadequately to intensive therapy with a combination of conventional disease-modifying antirheumatic drugs (DMARDs), only if:

• disease is severe (a disease activity score [DAS28] of more than 5.1) and
• the company provides baricitinib with the discount agreed in the patient access scheme.

Baricitinib, with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to or who cannot have other DMARDs, including at least 1 biological DMARD, only if:

• disease is severe (a DAS28 of more than 5.1) and
• they cannot have rituximab and
• the company provides baricitinib with the discount agreed in the patient access scheme.

Baricitinib can be used as monotherapy for people who cannot take methotrexate because it is contraindicated or because of intolerance, when the criteria in sections 1.1 and 1.2 are met.

• Continue treatment only if there is a moderate response measured using European League Against Rheumatism (EULAR) criteria at 6 months after starting therapy. After an initial response within 6 months, withdraw treatment if at least a moderate EULAR response is not maintained.
• These recommendations are not intended to affect treatment with baricitinib that was started in the NHS before this guidance was published. People having treatment outside these recommendations may continue without change to the funding arrangements in place for them before this guidance was published, until they and their NHS clinician consider it appropriate to stop.

Baricitinib for moderate to severe rheumatoid arthritis - guidance (TA466)

New technology appraisal guidance from NICE on baricitinib (Olumiant) for moderate to severe rheumatoid arthritis in adults.

Baricitinib, with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to intensive therapy with a combination of conventional disease-modifying antirheumatic drugs (DMARDs), only if:

• disease is severe (a disease activity score [DAS28] of more than 5.1) and
• the company provides baricitinib with the discount agreed in the patient access scheme.

Musculoskeletal ultrasound for diagnosis to confirm or rule out a diagnosis of rheumatoid arthritis

In patients with suspected rheumatoid arthritis, does the use ofmusculoskeletal ultrasound increase the ability ofrheumatologists to confirm or rule out a diagnosis ofrheumatoid arthritis at an earlier stage compared to routinediagnostic assessment? 

Evidence note from Healthcare Improvement Scotland:
There is evidence from two overlapping systematic reviews to support the clinical effectiveness of adding musculoskeletal ultrasound to clinical assessment and laboratory testing to diagnose rheumatoid arthritis at an earlier stage of the disease. Results from three primary studies with methodological weaknesses suggest that musculoskeletal ultrasound can increase rheumatologists’ diagnostic certainty, predict progression to inflammatory arthritis and decrease the time to diagnosis or initiation of DMARD therapy in patients with suspected rheumatoid arthritis.

Spondyloarthritis in over 16s: diagnosis and management

This new guideline from NICE covers diagnosing and managing spondyloarthritis that is suspected or confirmed in adults who are 16 years or older. It aims to raise awareness of the features of spondyloarthritis and provide clear advice on what action to take when people with signs and symptoms first present in healthcare settings. It also provides advice on the range of treatments available.

In June 2017, we updated recommendation 1.2.7 to clarify the advice on what imaging should be done.