ObjectiveTo investigate whether antidrug antibodies and/or drug non‐trough levels predict the long‐term treatment response in a large cohort of patients with rheumatoid arthritis (RA) treated with adalimumab or etanercept and to identify factors influencing antidrug antibody and drug levels to optimize future treatment decisions.MethodsA total of 331 patients from an observational prospective cohort were selected (160 patients treated with adalimumab and 171 treated with etanercept). Antidrug antibody levels were measured by radioimmunoassay, and drug levels were measured by enzyme‐linked immunosorbent assay in 835 serial serum samples obtained 3, 6, and 12 months after initiation of therapy. The association between antidrug antibodies and drug non‐trough levels and the treatment response (change in the Disease Activity Score in 28 joints) was evaluated.ResultsAmong patients who completed 12 months of followup, antidrug antibodies were detected in 24.8% of those receiving adalimumab (31 of 125) and in none of those receiving etanercept. At 3 months, antidrug antibody formation and low adalimumab levels were significant predictors of no response according to the European League Against Rheumatism (EULAR) criteria at 12 months (area under the receiver operating characteristic curve 0.71 [95% confidence interval (95% CI) 0.57, 0.85]). Antidrug antibody–positive patients received lower median dosages of methotrexate compared with antidrug antibody–negative patients (15 mg/week versus 20 mg/week; P = 0.01) and had a longer disease duration (14.0 versus 7.7 years; P = 0.03). The adalimumab level was the best predictor of change in the DAS28 at 12 months, after adjustment for confounders (regression coefficient 0.060 [95% CI 0.015, 0.10], P = 0.009). Etanercept levels were associated with the EULAR response at 12 months (regression coefficient 0.088 [95% CI 0.019, 0.16], P = 0.012); however, this difference was not significant after adjustment. A body mass index of ≥30 kg/m2 and poor adherence were associated with lower drug levels.ConclusionPharmacologic testing in anti–tumor necrosis factor–treated patients is clinically useful even in the absence of trough levels. At 3 months, antidrug antibodies and low adalimumab levels are significant predictors of no response according to the EULAR criteria at 12 months.

Adequately trained PEs can deliver clearly structured undergraduate skills, teaching with equivalent learning outcomes to those of rheumatology consultants. PEs are a valuable development to augment musculoskeletal education in the face of expanding student numbers.

Although widely regarded as a disease of women, osteoporosis does cause considerable morbidity and mortality in men. The lifetime risk of an osteoporortic fracture for a man is 1 in 12 and 30% of all hip fractures occur in men. In women, low-trauma distal forearm fracture is widely regarded as a typical early manifestation of postmenopausal osteoporosis. Traditionally, this has not been thought to be the case for men. We present a case-control study of 147 men with distal forearm fracture compared with 198 age-matched controls. The controls were selected from a pre-existing database of dual-energy X-ray absorptiometry scans of healthy volunteers. Both groups were sent questionnaires regarding basic demographics, fracture history and risk factors for osteoporosis, and the fracture group was asked to attend for bone densitometry. There were 103 responses from the fracture group (70%), of whom 67 (47%) underwent densitometry. There were 165 (83%) responses from the control group. Secondary causes of osteoporosis could be identified in 51% of the fracture group and 37% of the control group. The fracture group had significantly lower bone mineral density at all sites measured compared with the controls (0.75 g/cm(2) vs 0.85 g/cm(2) at the femoral neck, p<0.0001; 0.95 g/cm(2) vs 1.03 g/cm(2) at the total femur, p = 0.001; and 0.99 g/cm(2) vs 1.06 g/cm(2) at the lumbar spine, p = 0.001). These differences remained after adjusting for age and body mass index ( p<0.0005 at all sites). Overall, 41.8% of the fracture group were osteoporotic in at least one site ( T-score <-2.5 SD below the mean for young men) compared with only 10.3% of controls. This study is the first to demonstrate that men with distal forearm fractures have lower bone mineral density than their peers and a higher risk of osteoporosis.

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