Treatment adherence in patients with rheumatoid arthritis and systemic lupus erythematosus

This study assessed self-reported adherence in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) from underserved healthcare settings. We conducted a cross-sectional survey of 102 ethnically diverse patients--70 with RA and 32 with SLE--attending rheumatology clinics at publicly funded hospitals in Houston, Texas; 43% were Hispanic, 32% African-American, and 25% White. Treatment adherence was evaluated using the compliance questionnaire rheumatology (CQR; 0, low adherence and 100, high adherence) and the questionnaire of the Adult AIDS Clinical Trials Group (AACTG). The patients were also asked how often they forgot to take their prescribed medications or discontinued them on their own. Mean patient age was 48.5 years; 75% were female, 32% were African-American, 43% Hispanic, and 25% White. Only one third reported never forgetting to take their medications; 40% reported having stopped their medications on their own because of side effects, and 20% because of lack of efficacy. Mean CQR score was 69.1 +/- 10.5, suggesting moderate adherence overall. Differences were also observed across ethnic groups: 23% of ethnic minority patients had problems taking their medications at specified times compared to 11% of Whites (p = 0.03). Lower education and side effects were associated with lower adherence. No differences were observed between RA and SLE patients. Many patients with RA and SLE report problems with treatment adherence. These appear to be more prevalent in African Americans and Hispanics than Whites; the impact of decreased adherence on outcomes could be significant and should be considered when treating patients with RA and SLE.     

The frequency of circulating immune complexes in rheumatoid arthritis and systemic lupus erythematosus

Summary Sera from patients with rheumatoid arthritis and systemic lupus erythematosus have been examined for the presence of complement-fixing immune complexes using three assays, (a) a fluid phase Clq binding assay, (b) a solid phase Clq binding assay and (c) the Raji cell assay.By simultaneously screening all the sera within each disease group we established that circulating immune complexes frequently occur but that there is a discordance between the assays, even between the two assays involving binding to Clq. Distinct clinical profiles emerged with the fluid phase Clq binding assay being most frequently positive in sera from patients with extra-articular rheumatoid arthritis. The solid phase Clq binding assay and the Raji cell assay were more frequently positive in sera from patients with systemic lupus erythematosus. The prevalence of circulating immune complexes and the comparative performance of the three assays in each disease is examined in detail.     

Impact of antiphospholipid syndrome on disease characteristics and outcome in patients with systemic lupus erythematosus

Aim of the workTo assess the impact of antiphospholipid syndrome (APS) on systemic lupus erythematosus (SLE) clinical characteristics and disease outcome.Patients and methods216 SLE patients were classified according to the presence of APS into: SLE group (n = 109) and SLE-APS (n = 107). Evaluation of clinical, laboratory tests, immunological tests, SLE disease activity index 2000 (SLEDAI-2 K) and SLE damage index (SDI) were done.ResultsThe 216 patients mean age was 32.1 ± 8.4 years and the F:M was 8.4:1. There was a significantly higher frequency of abortion, neurological and cardiac manifestations (p < 0.001, p = 0.008, p = 0.016 respectively) in SLE-APS group. The SDI was significantly higher in SLE-APS patients (p < 0.001) with special attention to the presence of cerebrovascular accident (CVA) (p = 0.01), pulmonary hypertension (p = 0.04), cardiomyopathy (p = 0.034) and venous thrombosis (p < 0.0001). The frequency of thrombosis and active SLEDAI-2 K visits were significantly related to higher damage in SLE-APS (p < 0.001 and p < 0.001 respectively). Damage in SLE group was associated with hypocomplementemia (p = 0.015) and thrombosis (p = 0.049). Factors associated with damage in all SLE patients were male gender (p = 0.024), serositis (p = 0.02), neurological involvement (p < 0.001), thrombotic events (p < 0.001), cumulative doses of oral (p = 0.02) and pulse (p = 0.004) steroids and frequency of cyclophosphamide (CYC) use (p = 0.003). Predictors of damage included male gender, APS, neurological manifestations, use of steroids and CYC (p = 0.045, OR = 8.5; p < 0.0001, OR = 4.3; p = 0.001, OR = 6.3; p = 0.047, OR = 1.03; p = 0.005, OR = 2.96, respectively).ConclusionAPS adversely affect SLE disease course with prominent impact on end organ damage especially cerebral, cardiopulmonary and vascular events denoting the need for strict control of disease activity and early diagnosis.     

Hemorheological parameters are related to subclinical atherosclerosis in systemic lupus erythematosus and rheumatoid arthritis patients

Objectives

Rheological characteristics of blood are strongly linked to atherothrombosis in the general population, but its contribution to atherosclerosis in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) is currently unclear. This work examines the relationship between blood rheology, traditional cardiovascular (CV) risk factors, inflammation and subclinical atherosclerosis in SLE and RA.

Methods

Whole blood viscosity (WBV), plasma viscosity (PV), erythrocyte deformability (ED), aggregation (EA) and erythrocyte NO production were measured in 197 patients (96 SLE and 101 RA) and compared to 97 controls, all females without previous CV events. Clinical information was obtained and fasting lipids and acute phase reactants were measured. The relationship between hemorheological parameters, CV risk factors and inflammation was assessed in patients and the impact of these variables on carotid intima-media thickness (cIMT) was evaluated in univariate followed by multivariate regression analyses.

Results

WBV and ED are significantly lower in patients, while EA is elevated as compared with controls. Hemorheological disturbances correlate with CV risk factors and markers of inflammation and are more profound in patients with metabolic syndrome. Multivariable analysis showed that menopause (OR 34.72, 95%CI 4.44–271.77), obesity (OR 4.09, 95%CI 1.00–16.68) and WBV (OR 3.98; 95%CI 1.23–12.83) are positively associated whereas current corticosteroid dose (OR 0.87; 95%CI 0.78–0.98), and erythrocyte NO production (OR 0.16; 95%CI 0.05–0.52) are negatively associated with cIMT.

Conclusion

Disturbed hemorheological parameters in SLE and RA women are related to the presence of CV risk factors and inflammation. WBV and erythrocyte NO are independently associated with the early stages of atherosclerosis.     

Influence of perception of glucocorticoids on compliance of treatment in patients with rheumatoid arthritis and systemic lupus erythematosus

BackgroundGlucocorticoids (GCs) are alleged as hazardous medications among Egyptian patients and their relatives.Aim of the workTo highlight the beliefs held about GCs and the effect of these beliefs on adherence to GCs treatment.Patients and methodsThe study included 70 systemic lupus erythematosus (SLE) patients, 70 rheumatoid arthritis (RA) patients and 140 GC-naïve subjects as the control. The demographic and socioeconomic standards of the patients and control as well as the GCs use experience in patients were recorded. GCs perception was assessed by Beliefs about medication Questionnaire (BMQ). Adherence was assessed by Compliance Questionnaire of Rheumatology (CQR).ResultsGCs were significantly perceived as harmful and of low benefit by the control (p < 0.001, p < 0.001, respectively), a beneficial drug by SLE patients, while RA patients had significantly higher harm scores (p = 0.015 and p = 0.003 respectively). Most of SLE and RA patients were non-adherent (57.1% and 65.7%, respectively). Higher general-BMQ harm scores were significantly associated with a lower odd of adherence (OR: 0.25, 95%CI: 0.1–0.63). Reduced OR of necessity > concern was associated with higher socioeconomic standards and maximum oral GCs dose (OR:0.09 and 0.96, respectively). Increased OR of high necessity was significantly associated with number of currently used disease modifying anti-rheumatic drugs (DMARDs) (OR:5.54, p = 0.025). High OR of harm perception was significantly associated with higher socioeconomic standards (OR: 5.12, p = 0.016).ConclusionGCs are perceived as pillars in management by SLE and RA patients. Concerns about side effects and dependency are still troublesome. Improvement of patients’ GCs perception impacts level of adherence to treatment.     

Functional disability and health-related quality of life in South Africans with rheumatoid arthritis and systemic lupus erythematosus

There is a paucity of data on the impact of chronic rheumatic diseases on functional disability and overall health-related quality of life (HRQOL) in Africans. Materials and methods: We compared Black South Africans (BSA) with rheumatoid arthritis (RA) (n=50) and systemic lupus erythematosus (SLE) (n=50) to geographically and ethnically matched controls cared for at a tertiary care facility. The modified health assessment questionnaire (mHAQ) and Medical Outcome Study short-form 36 (SF-36) scores and indices of disease activity and organ damage were collected from each group. Results: Compared to the controls, both the RA and SLE groups fared significantly worse in respect of all the domains and summary scales of the SF-36. Compared to the SLE group, the RA group scored significantly worse with respect to the mHAQ disability index (mHAQ-DI), physical function and bodily pain (BP) SF-36 subscales, and SF-36 summary physical component score (SF-PCS). In the RA group, both the mHAQ-DI and SF-PCS correlated strongly (p<0.005) with the tender joint count, patient global assessment, 28-joint composite disease activity score, physician global assessment, and pain score. The SF-PCS showed only a weak inverse correlation with the swollen joint count (r=−0.29, p<0.05). In the SLE group, the systemic lupus erythematosus disease activity index correlated inversely best with the SF-36 general health subscale (r=−0.56, p<0.0001) and, to a lesser extent, with the mental health, BP, and vitality subscales, and SF-PCS and SF-mental component summary scores. Conclusion: Both RA and SLE have profound effects on HRQOL in BSA, with BP and physical disability particularly worse in RA patients. Disease activity, rather than organ damage or sociodemographic characteristics, correlates best with certain aspects of functional disability and HRQOL in both RA and SLE. Further longitudinal studies are needed to assess the clinical utility of measures of functional disability and HRQOL in this population.     

NK and NKT cell dynamics after rituximab therapy for systemic lupus erythematosus and rheumatoid arthritis

Biomarkers of clinical response to rituximab (RTX) therapy and early predictors of outcome are still under investigation. We report a flow cytometric immunophenotyping analysis from peripheral blood leukocyte subpopulations of two patients with systemic lupus erythematosus (SLE) associated thrombocytopenia and one patient with rheumatoid arthritis (RA), before and after 6 weeks of treatment with RTX. Our results show a reduced population of CD19(+) expressing cells (B cells) after RTX treatment in all three patients. Increased frequency of peripheral regulatory CD4(+)CD25(high) T cell subset and the CD3(-)CD16(-)CD56(bright) NK cell subset after RTX therapy were also observed in all patients, the latter being more pronounced in the SLE patient with sustained clinical response. In addition, an increased population of NKT cell subsets was observed in the patients with clinical response. This is the first evaluation of NK and NKT cells as biomarkers of clinical response after rituximab therapy in rheumatic diseases.     

Relations between surface expression of the interleukin-2 receptor and release of the soluble form of the receptor in cultured mononuclear cells from patients with rheumatoid arthritis or systemic lupus erythematosus

The relationship between surface expression of the interleukin-2 receptor (IL-2R) and release of the soluble form of the receptor (sIL-2R or sCD25) was investigated with peripheral blood mononuclear cells (PBMCs) from individuals with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). The spontaneous release of sCD25 was significantly increased in PBMCs from RA patients and decreased in cells from SLE patients, compared with normal controls. However, the extent of sCD25 release from phytohaemagglutinin (PHA)-stimulated PBMCs did not differ between RA or SLE patients and normal controls. The serum concentration of sCD25 was significantly increased in SLE or RA patients compared with the normal controls. Whereas the surface expression of CD25 by unstimulated PBMCs did not differ among the three groups of subjects, this parameter was significantly reduced for PHA-stimulated PBMCs from RA patients relative to those from normal controls. The surface expression of CD25 showed a positive correlation with sCD25 release for PBMMCs from SLE patients under either basal or stimulated conditions. No such relation was apparent for cells from RA patients. The surface expression of IL-2R (CD122) under basal or stimulated conditions was significantly reduced in PBMCs from RA or SLE patients, compared with cells from normal controls. Thus, the increased concentration of sCD25 in the serum of individuals with these autoimmune rheumatic diseases may result from two different mechanisms: an increase in the spontaneous release of sCD25 in RA, and reduced clearance of this protein in SLE.     

Evaluation of plasma C3d and immune complex determinations in the assessment of disease activity of patients with rheumatoid arthritis,systemic lupus erythematosus,and spondylitis ancylopoetica

Summary Patients with rheumatoid arthritis, systemic lupus erythematosus, and spondylitis ancylopoetica were examined, along with healthy controls, for C3d plasma levels, circulating immune complexes, C3 serum levels, and CRP. Immune complexes were determined using a C1q binding assay, a 2.75% PEG precipitation technique, including the analysis of IgG and C3, and a new laser nephelometric latex test. C3d plasma levels were significantly (P<1%) elevated in all groups of patients as compared to controls. With regard to the demonstration of circulating immune complexes, the PEG precipitation method discriminated best between patients and the control population. It was not possible to differentiate between the different disease entities with neither C3d serum levels or immune complexes. Concerning the assessment of disease activity, none of the evaluated parameters alone appears to be of clinical relevance. The individual application of more than one immune complex assay in combination with the measurement of C3d serum levels must be recommended if disease activity is to be assessed.     

Thyroid dysfunction in systemic lupus erythematosus and rheumatoid arthritis: Its impact as a cardiovascular risk factor

IntroductionThyroid dysfunction and autoantibodies have been frequently associated with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).Aim of the workTo assess thyroid function and anti-thyroid antibodies in both diseases and elucidate the effects of the thyroid dysfunction on the clinical parameters, disease activity and cardiovascular risk.Patients and methodsForty SLE and forty RA female patients in addition to twenty controls were included. Free thyroxine (FT3), free triiodothyronine (FT4), thyroid stimulating hormone (TSH), anti-thyroid peroxidase antibodies (TPOabs), anti-thyroglobulin antibodies (TGabs), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), triglycerides (TG), total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and intima-media thickness (IMT) were measured. Disease activities were assessed in both diseases. In RA patients, the anti-cyclic citrullinated peptide (anti-CCP) was evaluated.ResultsA significantly higher TSH level was found in SLE patients compared to RA patients and controls. No significant difference was present between the RA patients and controls. Anti-TPOabs and anti-TGabs were more frequently detected in SLE (85% and 55%) compared to RA (50% and 37.5%). Abnormal thyroid function tests were detected in SLE, RA patients and controls in 52.5%, 17.5% and 10%, respectively. Subclinical hypothyroidism was the most common abnormality present followed by clinical hypothyroidism then euthyroid sick syndrome in both SLE and RA patients. A positive anti-CCP and high disease activity score (DAS28) in RA were among the strongest independent determinants of cardiovascular disease.ConclusionThyroid dysfunction is frequent in SLE and RA patients. Those with thyroid dysfunction had increased cardiovascular risk.     

The clearance of heat-damaged erythrocytes by the reticulo-endothelial system in systemic lupus erythematosus and rheumatoid arthritis

Summary Reticulo-endothelial function was assessed in 20 patients with active rheumatoid arthritis and 11 patients with systemic lupus erythematosus with regard to the clearance of heat-damaged erythrocytes (HDE). In contrast to previous reports, no correlations were found between disease activity, levels of circulating immune complexes and splenic function. There was no evidence of an obvious hypofunction in the reticulo-endothelial system of the spleen in patients with rheumatoid arthritis or systemic lupus erythematosus. Moreover, a splenic hyperfunction is suggested to be present in some patients. A method for measuring the specific uptake by the liver, spleen and the clearance rate (T 1/2) of the HDE is also described.     

Neutrophil-lymphocyte and platelet-lymphocyte ratios in rheumatoid arthritis patients: Relation to disease activity

Aim of the work: To assess the neutrophil–lymphocyte ratio (NLR) and platelet–lymphocyte ratio (PLR) in rheumatoid arthritis (RA) patients and compare between active cases and those in remission. Patients and methods: The study included 50 RA patients and 20 matched control. Patients were enrolled into 2 equally divided groups; group A (active) with a disease activity score (DAS-28) ≥2.6 and group B (remission) <2.6. Laboratory investigations included the calculation of the NLR and PLR for all subjects. Results: The mean age of patients was 40.7?±?10.1?years and the mean of disease duration was 5.9?±?3.4?years. The DAS-28 was 3.9?±?0.9 in active patients and 2.1?±?0.3 in those in remission (p?=?.001). NLR was 2.8?±?2.1 in the patients and 2.1?±?0.59 in the control (p?=?.15). PLR was 1.7?±?0.9 in the patients and 1.27?±?0.46 in the control (p?=?.09). Active patients had an NLR of 3.27?±?2.81 and PLR of 1.8?±?1.2 while they were 2.3?±?0.84 and PLR 1.5?±?0.59 in patients in remission (p?=?.05 and p?=?.18 respectively). There was a significant difference regarding NLR and PLR between active patients and control (2.1?±?0.59 and 1.27?±?0.46; p?=?.03 and p?=?.04 respectively). In active patients, the NLR and PLR significantly correlated with the patients age (p?=?.02 and p?=?.006) and with the DAS-28 (p?=?.001 and p?=?.03 respectively). Conclusion: NLR and PLR are 2 emerging inflammatory biomarkers which could be used to evaluate disease activity in active RA patients. A larger scale longitudinal study is recommended to confirm the present results and further demonstrate the relation to medications received and disease outcome.     

Evaluation of visfatin in patients with systemic lupus erythematosus: Correlation with disease activity and lupus nephritis

IntroductionRenal involvement affects about 50% of SLE patients accounting for significant morbidity and mortality in these patients. The adipokine “visfatin” acting as a growth factor for B-lymphocyte-precursors, exerts several proinflammatory functions. It was demonstrated as a marker of endothelial dysfunction (ED) in chronic kidney disease (CKD) thus could be a factor linking inflammation in SLE and kidney disease.Aim of the workTo assess serum visfatin level in SLE patients and its correlation to disease activity and lupus nephritis (LN) in these patients.Patients and methodsSerum level of visfatin using enzyme-linked immunosorbent assay (ELISA), chemical and immunological markers of SLE and LN were measured in 40 SLE patients and 40 age and sex matched healthy controls. Disease activity and renal involvement were assessed using SLE Disease Activity Index (SLEDAI) and Renal SLEDAI respectively further dividing patients into active versus inactive and LN versus non-LN respectively. Renal biopsies were taken from LN subgroup and were classified according to the modified WHO classification.ResultsA significantly higher serum visfatin level was found on comparing SLE patients (mean 109 ± 180 ng/ml, median18) with controls (mean 9.4 ± 11 ng/ml, median2.5) with statistically highly significant difference (z = 5.2, P < 0.001). Also there was a statistically significant difference as regards serum visfatin level between active SLE patients (mean 173 ± 111 ng/ml, median 14) and inactive patients (mean 139 ± 88 ng/ml, median 5) (z = 2.1, P < 0.05) as well as between patients with LN (mean 226 ± 180 ng/ml, median18) and patients with no LN (mean 101 ± 140 ng/ml, median 8(2-229)) (z = 2.1, P < 0.05). Visfatin had a highly significant positive correlation with disease duration (r = 0.48, P < 0.001), SLEDAI (r = 0.62, P < 0.001) as well as ESR, CRP and, renal score (r = 0.45, 0.35, and 0.65, respectively) while inverse correlation with estimated GFR (r = ?0.614) and C3 and C4 titre (r = ?0.26, r = ?0.35, respectively) was recorded. Visfatin showed high sensitivity in detecting active SLE and LN 83% and 85%, respectively.ConclusionSerum visfatin is strongly associated with LN in SLE patients and is a promising biomarker for prediction of renal involvement in these patients. It reflects SLE activity specially LN activity namely renal score and GFR decline. Further prospective studies are required to confirm visfatin as a destructive mediator of predictive and prognostic value in active lupus nephritis.     

Serum interleukin-23 level in rheumatoid arthritis patients: Relation to disease activity and severity

Aim of the work

The aim of this study was to evaluate interleukin-23 (IL-23) level in the sera of rheumatoid arthritis (RA) patients and to determine its relation with disease activity and severity.

Risk factors for sexual dysfunction in Egyptian patients with rheumatoid arthritis and its relation to disease activity

Aim of the work

To assess risk factors for sexual dysfunction in married rheumatoid arthritis (RA) patients.

Antinuclear antibodies measured by enzyme immunoassay in patients with systemic lupus erythematosus: relation to disease activity

To evaluate the correlation between measurements of antinuclear antibodies serum levels by enzyme immunoassay (ANA-EIA), and the degree of systemic lupus erythematosus disease activity. To retest the performance of the test compared to measurement of antinuclear antibodies by immunofluorescence (ANA-IIF). Eighty-five sera from 71 patients with SLE were tested. Demographic, clinical, laboratory, and SLEDAI status were collected. The sera were tested for ANA-EIA and by ANA-IIF at 1:40 and 1:160 dilutions. Serum levels of ANA-EIA were compared to the overall SLEDAI score and to each of its components. A SLEDAI score of ≥6 was considered clinically significant. The sera of fifty-one healthy volunteers served as controls. Serum levels of ANA-EIA were significantly higher in patients with a SLEDAI score of ≥6 compared to the group of patients with a SLEDAI score of <6 (P = 0.004). High serum levels of ANA-EIA correlated significantly with elevated anti DS-DNA antibodies (P < 0.001), low C₃ or C₄ levels (P < 0.001), pyuria (P < 0.011), arthritis (P = 0.019), and new rash (P = 0.019). Levels of ANA-EIA were significantly higher in patients tested positive by IIF compared to those who tested negative. Higher serum levels of ANA-EIA correlated with clinically significant disease activity in patients with SLE. Higher serum levels of ANA-EIA also correlated with some single items of the SLEDAI. The results also reiterated the validity of ANA-EIA testing in patients with SLE. Further longitudinal studies are needed in order to test the hypothesis that serum ANA-EIA levels might reflect fluctuations in disease activity.     

The effect of person-centered counseling on the psychological status of persons with systemic lupus erythematosus or rheumatoid arthritis. A randomized,controlled trial

Objective . We tested the effectiveness of a 6-month person-centered (PC), nondirective, telephone-based counseling intervention for improving the psychological status of persons with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA). Methods . The design was a parallel-group, randomized, controlled study comparing a PC counseling intervention (8 SLE, 28 RA patients) with usual care (7 SLE, 30 RA patients). The Arthritis Impact Measurement Scales was used to measure psychological dysfunction, physical dysfunction, and pain at baseline and at followup. Results . The main finding was that the PC counseling intervention significantly improved the psychological status of the SLE patients (P < 0.05, effect size = 1.13, responsiveness = 0.77) in comparison to usual care. There was no evidence of a benefit for persons with RA or of improvements in physical function or pain for persons with either disease. Conclusions . PC counseling may be an effective intervention for improving the psychological status of persons with SLE, but may not be for those with RA.