This thesis describes the outcomes an possibilities of drug-tapering in rheumatoid arthritis (RA) patients treated to target. Data from the BeSt cohort were used, in which early RA patients were... Show moreThis thesis describes the outcomes an possibilities of drug-tapering in rheumatoid arthritis (RA) patients treated to target. Data from the BeSt cohort were used, in which early RA patients were randomized to 4 treatment arms: initial monotherapy, sequential or step-up, or initial combination therapy, with prednisone or TNF-blocker infliximab. The disease activity score (DAS) was measured every three months and treatment was changed or added to in case of insufficient response (DAS >2.4). This thesis shows that continued low disease activity steered treatment is possible and leads to maintenance of good functional ability in the majority of patients during 8 years of follow-up. Initial combination therapy is beneficial in the first months of treatment but is not associated with better longer-term results, except in anti-citrullinated protein antibodies positive patients. Initial combination therapy with TNF-blo cker infliximab can be successfully discontinued in over 50% of early RA patients, and in around 20% of all patients, all medication can be stopped when prolonged remission is achieved. Show less
Rheumatoid arthritis (RA) is a chronic disease requiring immediate pharmacological treatment. Chronically-ill patients may also benefit from self-management support and multidisciplinary care. This... Show moreRheumatoid arthritis (RA) is a chronic disease requiring immediate pharmacological treatment. Chronically-ill patients may also benefit from self-management support and multidisciplinary care. This thesis focused on 1) self-management support, and 2) productive interactions between the informed patient and the multidisciplinary care team as applied to the management of RA, with a focus on the patient perspective. With respect to self-management support, this thesis showed that there is a considerable information need among RA patients. An instrument to systematically assess information need (the Dutch ENAT) was translated and tested among RA patients. A website to inform patients about practical aspects of regional health care services had a positive effect on the information need of RA patients. Concerning multidisciplinary team care, this thesis suggests that despite advances in (non-)pharmacological care, subgroups of RA patients remain in need of multidisciplinary team care. The WHODAS II was found to be a valid and responsive instrument to evaluate the effectiveness of team care. However, the ICF Core Sets for RA appeared to be the most useful instrument to make a comprehensive assessment of the RA patient and to optimize goal setting and goal evaluation, as they best covered the aspects considered important by patients. Show less
Regular participation in moderate-intensity physical activity (PA) is beneficial for patients with rheumatoid arthritis (RA); however, a large proportion of patients with RA are not physically... Show moreRegular participation in moderate-intensity physical activity (PA) is beneficial for patients with rheumatoid arthritis (RA); however, a large proportion of patients with RA are not physically active. In this dissertation, we describe the pilot-testing of an intervention to promote PA among patients with RA, as well as several preliminary studies which informed the development of the intervention. These preliminary investigations identified autonomous motivation, self-efficacy, PA goal achievement and use of self-regulation techniques as important predictors of PA behavior change. As such, and based on existing literature, motivational interviewing (MI) and self-regulation coaching (SR) were selected as intervention techniques which could impact upon these variables. In a randomized controlled trial, the combined MI+SR intervention led to increased autonomous motivation, self-efficacy and physical activity comp ared to a patient education control group over 32 weeks. Process analyses revealed that autonomous motivation and use of self-regulation skills explained the sustained increases in PA behavior, and that certain characteristics of MI sessions explained changes in autonomous motivation and PA. Despite increasing their PA, patients who received the intervention did not improve on any disease related variables. Practical implications of the findings are discussed. Show less
Rheumatoid Arthritis (RA) is a chronic inflammatory disorder that typically affects cartilage and bone of small and middle-sized joints. Infiltration of the synovium by inflammatory cells causes... Show moreRheumatoid Arthritis (RA) is a chronic inflammatory disorder that typically affects cartilage and bone of small and middle-sized joints. Infiltration of the synovium by inflammatory cells causes destruction of cartilage, erosion of the adjacent bone and ultimately loss of function of the affected joint. Systemic inflammation, often going in parallel, can affect several organs and has long-term impact on organ function. This thesis presents work that investigates several aspects of basic immunological disease mechanisms with relevance to the inflammatory immune response in RA. Specifically, three main research questions triggered the experiments presented and form the outline of this thesis: 1. Do regulatory T cells feature anti-inflammatory properties besides the inhibition of effector T cells, which could help explain their therapeutic effectiveness in a murine model of established arthritis? 2. Are there specific features of the immune response to citrullinated antigens that could contribute to inflammation in RA, and can analysis of these features help in understanding the characteristics of anti citrullinated protein antibody producing B cells and their development? 3. Do certain genetic variants that associate with RA susceptibility contribute also to disease progression, as evidenced by the rate of joint destruction in RA? Show less
With the implementation of new treatment options, including biologicals and the early, agressive start of target-steered treatment the outlook for rheumatoid arthritis patients improved... Show moreWith the implementation of new treatment options, including biologicals and the early, agressive start of target-steered treatment the outlook for rheumatoid arthritis patients improved considerably the past decades. This thesis describes several aspects of modern rheumatoid arthritis treatment from the perspective of the BeSt study, a randomised controlled trial comparing four treatment strategies. The main findings from BeSt were that initial combination therapy, including high dose prednisone or the tumour necrosis factor inhibitor infliximab led to an earlier improvement in functional limitations and quality of life, earlier clinical remission and less joint damage after 5 years of follow-up than initial monotherapy. From one year onwards clinical outcomes were comparable across the groups. Drug free remission was possible in up to 20% of patients. Besides the primary outcomes of the BeSt study, this thesis de scribes the association between disease activity and functional capacity, the association between clinical signs of synovitis and joint damage progression at joint level, a comparison between disease activity measures and remission criteria, a comparison between radiological scoring methods, an evaluation of the effect of discontinuation of medication in case of low disease activity and remission and the association between disease activity, treatment and blood pressure. Show less
