meet the professors - prof lars klareskog
TRANSCRIPT
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Drugs is not everything; Take environment and socioeconomy into
account
Lars KlareskogRheumatology Unit and Rheumatlogy Clinic
Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
Meet the professor session Kochi Nov 2016
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Accidents in childrenRagnar BerfenstamProfessor in Public Health
• In the 1950.ties accidents were the most common cause of severe handicap and death in children
• Ragnar Berfenstam (pediatrician and professor of public health in Uppsala) investigated the environment involved in the accidents.
• He not only collected and published these data. He contributed t to changing these environments
•Accidents leading to handicap and death dimininished drastically in Sweden
An Early Example of Research, Medicine and Prevention
Uppsala University
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EIRA (Epidemiological Investigation of risk factors for RA); A population-based case control study based on a national incident
RA registry in Sweden
from 1996
Register for early RAn=19.000 Anti-Rheumatic
Therapy In Sweden
”ARTIS”n=26.000
EIRA(Epidemiologic
Investigation of risk factors for RA
n=4.000
Healthy contolsn=5.600
Case control study
from1999
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• Patient research partners contribute in defining problems; → Which modifiable risk factors for disease ? → What is important ?• Collection of information:
→Questionnaire: information on environment/life style among cases and controls→ DNA/plasma/sera genetic immunological and “biomarker” information
EIRA Epidemiologic Investigation of risk factors for RA
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Genes Environment/life style
Life time riskfor disease
Genetic end environmental risk factors for subsets of RA
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Prevention and treatment of RA in a longitudinal perspective
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Tor Olofsson et al. Ann Rheum Dis 2014;73:845-853
Results of treatment – not so good as we wish – here measured by sick leaveAnd very different for different groups of our patients
Early RA registry
Sick leave registry
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1 | 63 | 73 | 48 | 184 | 9.47 | 10.98 | 7.22 | 27.67 | 34.24 | 39.67 | 26.09 | | 21.58 | 28.97 | 39.67 | ---------+--------+--------+--------+ 2 | 94 | 68 | 28 | 190 | 14.14 | 10.23 | 4.21 | 28.57 | 49.47 | 35.79 | 14.74 | | 32.19 | 26.98 | 23.14 | ---------+--------+--------+--------+ 3 | 12 | 15 | 4 | 31 | 1.80 | 2.26 | 0.60 | 4.66 | 38.71 | 48.39 | 12.90 | | 4.11 | 5.95 | 3.31 | ---------+--------+--------+--------+ 4 | 21 | 23 | 9 | 53 | 3.16 | 3.46 | 1.35 | 7.97 | 39.62 | 43.40 | 16.98 | | 7.19 | 9.13 | 7.44 | ---------+--------+--------+--------+
36
43
3739
2729
0
5
10
15
20
25
30
35
40
45
methotrexate n=626 TNF inhibitors n=301
% g
ood
resp
onde
rs
Never Past CurrentSmoking status
p=0.52
p=0.03
p=0.95
p=0.05
Current smoking determines influecnes response to therapy Extensive ongoing efforts in ”omics” research but with meager results
Saevarsdottir S et al, Arthritis & Rheumatism, 2011
Register for early RAn=19.000 Biologics
Registry(ARTIS)
n=23.000
Use of registries and associatedbiobanks to analyse:• Clinical characteristics• Pharmacogenomics• Biomarkers• Environment/life style factors
Main Results (also when including ”omics): Current smoking is the most important
determinant for bad response
smokerssmokers
Percent good responders
metotrexate TNF-blockade
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S W EF O T
Saevarsdottir S et al, ARD 2014
Smoking is the dominant predictors of joint destruction
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Sedentary< 2 hours PA/week
Moderate exercise≥ 2 hours PA/week
Regular moderate exerciseExercise 1-2 times/week, at least 30 minutes
Regular work-outExercise 3 times/week,
at least 30 minutes
ExerciseQuestionnaire: Which of the following alternatives fits best to your physical activity (PA) 5 years ago?
8%
46%
26%
20%
Sandberg M et al, ARD 2014
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Saedis Saevarsdottir
Disease activity (DAS28)
Physician assessment(4 categories)
Pain (VAS)
Functional impairment (HAQ)
Physical activity at leisure time OR* 95% CI OR* 95% CI OR* 95% CI OR* 95% CI
Sedentary 1.00 Ref. 1.00 Ref. 1.00 Ref. 1.00
Ref.
Moderate 0.84 0.30 - 1.59 0.92 0.49 – 1.74 0.90 0.48 - 1.68 1.04 0.55 -1.98
Regular moderate 0.58 0.30 – 1.12 0.66 0.33 – 1.30 0.60 0.31 -1.16 0.98 0.50 - 1.92
Regular / work-out 0.41 0.20 - 0.82 0.58 0.28 – 1.19 0.52 0.26 -1.04 0.49 0.24 - 0.99
P-value for trend <0.01 0.02 <0.01 <0.01
The higher the level of physical activity, the lower the likelihood of having disease activity measures above median
Logistic regression was used to calculate odds ratios (OR) with 95% confidence interval (95%CI) of having outcome measures above median level, adjusted for potential confounders (sex, age, year, smoking, body mass index, alcohol consumption, socioeconomic status, vegetable intake and physically demanding work 5years before diagnosis).
Sandberg et al Ann Rheum Dis. 2014 Aug;73(8):1541
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Obese have only half the chance to accomplish a good clinical response (to anything) as compared to normal weight people
Saedis SaevarsdottirSandberg M et al Ann Rheum Dis. 2014 May 12.
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Some more conclusions• Optimisation of treatment (treat to target etc) requires
knowledge on effects of environment/life style in addition to knowledge of drugs, timing and measurement of outcome
• Any type of biomarker development risks to provide a new biomarker for smoking (or BMI, or diet etc) if you do not have information on environment/life style
• Great opportunities for better use of today´s therapies !!
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Traditional outcome measures do not cover everythingA case of mine
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• 18 years: Swollen ancle and finger joints, positive RF/CCP. Diagnosis RA. Treatment with low dose cortisone, NSAID:s, sulphasalazine, methotrexate
• 20 years: Worsening of disease, pain and destruction (X-ray) left wrist. Treatment with methotrexate, choroquine, prednisolone (did not tolerate sulfasalazine)
• 25 years: Clinical improvement, only 3 swollen joints but continued destruction, worst in left wrist
A young woman
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Hö
Vä
Briefly after diagnosis(at 20 years of age)
Hö
After 5 years of treatmentwith methotrexate, suphasalazine, cyclosporin,cortisone)
Hö
Vä
X-rays of wrists
Hö
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What to do ?
• Be satisfied with the improvement (only three joints are now affected; left wrist, PIP II and left ancle joint; no increase in CRP) ?
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What to do ?
• Be satisfied with the improvement (only three joints are now affected; left wrist, PIP II and left ancle joint) ?
• BUT – The young woman is training to become a concert violonist !
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So – what happened ?
• 24 years of age. Gets TNF-blockade (etanercept)
• 25 years: No continued destruction, no morning stiffness. Begins musical conservatorium
• Now: Part-time musician. No more destruction
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Hö
Vä
Shortly after disease onset
HöVä After 5 years of treatment
with conventional DMARD:s
Hö
Vä After 6 years additionaltreatment with TNF-blockade
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Thoughts
• Which outcome meaasures to use in the single individual patient ?• Impact of guidelines for the individual patient ?