A case with life-threatening interstitial pneumonia associated with bucillamine treatment

Abstract

We report a case of bucillamine-induced interstitial pneumonia accompanied by severe hypoxemia in an 83-year-old woman who had rheumatoid arthritis. Respiratory failure worsened even after withdrawal of bucillamine and administration of high-dose corticosteroids, and mechanical ventilation was required. A review of 15 cases with bucillamine-induced pulmonary injury suggests that advanced age may be associated with the development of severe interstitial pneumonia. Bucillamine can cause corticosteroid-resistant and life-threatening lung injury, especially in the elderly.     

Proposals for leflunomide use to avoid lung injury in patients with rheumatoid arthritis

Abstract

Among the 5,043 consecutive patients registered in the postmarketing surveillance for leflunomide, 61 were reported to have lung injury and 24 died from it. The adjusted multivariate logistic regression analysis of the risk factors showed that preexisting interstitial lung disease posed the greatest risk, as well as loading dose, smoking history, and low body weight of 40 kg or less with odds ratios of 8.17, 3.97, 3.12, and 2.91, respectively. In 12 patients, lung injury developed even 2 months after leflunomide withdrawal. When patients with (n = 9) and without (n = 13) fatal outcome were compared, eight out of the former, and six out of the latter had preexisting interstitial lung disease; the former showed severe hypoxemia, high serum C-reactive protein level, hypoalbuminemia, and continuous lymphocytopenia, and required mechanical ventilation. On the basis of these results and literature review, the committee proposes that leflunomide should only be recommended as a second-line drug, should not be administered to patients with preexisting interstitial lung disease, should also not be administered to patients with smoking history or those with low body weight, and should be administered without loading dose. Careful monitoring is necessary, and when lung injury develops, leflunomide elimination using colestyramine is mandatory.     

Rituximabe para o tratamento da artrite reumatoide: Revisão sistemática

IntroductionRheumatoid arthritis (RA) is a chronic autoimmune disease characterized by systemic joint inflammation that often leads to significant disability. Several effective anti–TNF agents have been used, but some patients have shown an inadequate response. Rituximab is a therapeutic monoclonal antibody indicated in such cases.MethodsWe conducted a systematic review to access efficacy and safety of rituximab in patients with active RA which have or have not been treated with anti–TNF agents before, and to relate outcome with RF and anti–CCP serology. We searched major electronics databases, grey literature and searched for references manually. We used Review Manager®5.1 for meta–analysis.ResultsWe included six RCTs comparing rituximab 1000 mg with placebo. Methotrexate was used by both groups. Treatment with rituximab was more effective in naïve and in anti–TNF treatment failure patients ACR20/50/70 and EULAR response. We observed lower changes in Total Genant–modified Sharp score, erosion score and joint narrowing scores in the rituximab group, and SF–36, FACIT–T and HAQ–DI scores were also better in this group. There were no differences between groups regarding safety outcomes, with exception of acute injection reactions, which were more common on rituximab group. More RF/anti–CCP seropositive patients achieved ACR20 than RF/anti–CP negative patients in rituximab group.ConclusionAvailable data support the use of rituximab for the treatment of RA, as it is an effective and safe option for naïve and anti–TNF treatment failure patients. RF and anti–CCP seam to influence treatment results, but this inference needs further research.     

Does non-surgical periodontal treatment influence on rheumatoid arthritis? A systematic review and meta-analysis

ObjectiveThe objective of this systematic review was to evaluate the efficacy of non-surgical periodontal therapy on rheumatoid arthritis activity.Material and methodsArticles published until April 2019 were electronically searched and screened using PubMed / MEDLINE, Scopus, and Cochrane databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). This study was recorded in the international PROSPERO database (CRD42019132205). The PICO question (population, intervention, comparison, results) was: in adult patients with rheumatoid arthritis and periodontitis (P), does non-surgical periodontal treatment (I), as compared to no treatment (C), provides better outcomes in rheumatoid arthritis activity (O).ResultsAfter searching the databases, seven articles were selected for qualitative and five for quantitative analysis. The total number of participants included was 292, with an average age of 50.5 years. All patients had rheumatoid arthritis and periodontal disease. Non-surgical periodontal treatment significantly reduced Disease Activity Score 28 (P = 0.004; I² = 92%) and erythrocyte sedimentation rate (P = 0.01; I² = 78%), but with no significant effect on C-reactive protein (P = 0.34; I² = 92%).ConclusionsIt can be concluded that non-surgical periodontal treatment can benefit patients with rheumatoid arthritis.     

Tc-99m diethylenetriamine pentaacetic acid (DTPA): Is it reliable for assessment of methotrexate-induced cumulative effect on renal filtration in rheumatoid arthritis patients?

Methotrexate[MTX] is commonly employed as the initial DMARD used for treatment of Rheumatoid arthritis[RA]. We aimed to contribute to the safety profile of MTX by assessing its cumulative effect on renal filtration. Fifty two RA adult females with normal base-line serum creatinine and GFR at the initial diagnosis of the disease were included. Group-1[G1] included 30 patients[mean age 40.4 ± 4.4 years] on MTX and NSAIDS, while 22 RA patients[mean age 38.5 ± 8.2 years] who received NSAIDs only served as the control group[G2]. Renal function was assessed by GFR-measurement using Technetium diethylenetriamine-pentaacetic acid[Tc-99 m-DTPA] at the point of the study time corresponding to disease duration. 21/30[70%] in G1 showed reduced GFR compared to 6/22[27.3%] in G2[P0.007] with 3.3 ± 0.5% annual reduction of GFR. Reduced GFR in G1 showed significant negative correlation with age[r = ?0.396, P = 0.005], MTX-cumulative dose[r = ?0.263, P = 0.049], MTX-intake duration[r = ?0.293, P = 0.031] and NSAID-intake duration[r = ?0.344, P = 0.014]. Low dose MTX has a slow cumulative effect on renal filtration manifested by GFR reduction over time that could be monitored by Tc-99 m DTPA.     

CXC ligand 13 in rheumatoid arthritis and its relation to secondary Sjögren’s syndrome

Aim of the workThe aim of the present study was to measure the level of the chemokine CXC ligand 13 protein (CXCL13) in the plasma and unstimulated saliva of rheumatoid arthritis (RA) patients in order to find out its role in the disease activity and its relation to secondary Sjögren’s syndrome (sSS).Patients and methodsThe study was conducted on thirty rheumatoid arthritis patients attending the Outpatient Clinic of Rheumatology and Rehabilitation department of Ain shams University Hospitals. The patients’ group had been classified into group (1) which included fifteen RA patients associated with sSS diagnosed according to the American–European Consensus Group Classification Criteria and group (2) which included fifteen RA patients not associated with sSS. Ten healthy subjects were included as a control group. Patients were subjected to full history taking, clinical examination, and laboratory detection of CXCL13 level in the plasma and saliva of patients as well as the control groups using ELISA technique. Assessment of disease activity in RA patients was done using the disease activity score (DAS28).ResultsPlasma levels of CXCL13 were significantly higher in RA patients than control group (p < 0.001). Plasma levels of CXCL13 were significantly correlated with the RA disease activity (r = 0.677, p < 0.001) and disease duration (r = 0.406, p < 0.05), while the salivary levels were higher in those with sSS and correlated with sSS disease duration (r = 0.536, p < 0.05). A highly significant correlation was found between salivary CXCL13 and severity of sSS (r = 0.816, p < 0.001). Salivary levels of CXCL13 above 110 pg/ml may diagnose sSS with sensitivity 80% and specificity 84%.ConclusionThe results of this preliminary study point out the importance of CXCL13 as a marker for RA disease activity, its role in diagnosing sSS, and estimation of sSS severity.     

小剂量糖皮质激素联合来氟米特及羟氯喹治疗类风湿关节炎的疗效观察

目的观察小剂量激素联合来氟米特及羟氯喹治疗类风湿关节炎(RA)的临床疗效。方法将64例RA患者随机分为两组:治疗组:小剂量泼尼松联合来氟米特及羟氯喹组,予以来氟米特30mg/d,强的松10mg/d,晨起口服,羟氯喹200mg,2次/d口服;对照组:来氟米特联合醋氯芬酸组,予以来氟米特30mg/d,醋氯芬酸0.1/次、2~3次/日,两组均为32例,疗程为12周。比较两组治疗前后的ESR、C反应蛋白指标及关节疼痛改善程度。结果 与对照组相比,治疗组的完全缓解率与部分缓解率较高,临床DAS28评分、ESR、C反应蛋白水平降低,差异有统计学意义(P0.05)。结论 小剂量强的松联合来氟米特及强氯喹治疗类风湿关节炎能有效改善患者关节肿痛症状,明显抑制炎症反应,控制病情进展。