Efficacy and Toxicity Profile of Methotrexate Chloroquine Combination in Treatment of Active Rheumatoid Arthritis

Background

The present study was conducted to study the efficacy and toxicity profile of methotrexate chloroquine combination in treatment of active rheumatoid arthritis.

Methods

24 patients of rheumatoid arthritis confirming to revised American Rheumatism Association (ARA) criteria were studied prospectively for twenty months. Clinical evaluation was made every 3 months. Clinical disease variables measured at each visit were number of joints with swelling, number of joints with tenderness and pain, duration of morning stiffness and physician and patient assessment of disease activity. Blood counts, liver function tests and other adverse effects due to drugs were monitored every 2 months.

Results

10 patients demonstrated more than 50% improvement. 4 patients withdrew from study, 2 because of excessive nausea and vomiting and 2 because of noncompliance. Other side effects noted were hyperpigmentation, photosensitivity, skin rashes, raised transaminases and stomatitis.

Conclusion

Methotrexate chloroquine combination has good efficacy and toxicity profile. Gastrointestinal side effects are most common and usually responsible for the discontinuation of the drugs.Key Words: Rheumatoid arthritis, Methotrexate, Chloroquine, Efficacy, Toxicity     

Routine Cyclosporine concentration - C2 level Monitoring. Is it helpful during the early post Transplant Period?

Background

Pre dose or trough blood cyclosporine (CSA) concentration is routinely monitored and the result is used to alter patient''s drug dosing. Patients with identical pre dose blood CSA may have very different systemic exposure to the drug. Recently CSA 2 hour post dose level [C2] has been reported to correlate better with drug exposure. We undertook this study to evaluate the influence of trough and C2, CSA concentration monitoring on short-term renal allograft outcomes.

Methods

25 patients of renal transplant receiving a triple drug regimen of CSA micro emulsion (Panacea Biotec) 8mg/kg, azathioprine 1mg/kg and prednisolone 0.5mg/kg were analyzed prospectively for graft outcomes. CSA levels were monitored in whole blood by radioimmunoassay using monoclonal antibodies, at 72 hours after the transplant.

Results

The mean age of patients was 37.08 + 9.1 years. There were 20 males and 5 females. The mean age of donors was 40.2 + 8.2 years. There were 11 related donors with at least a haplomatch, 4 spousal and 10 unrelated donors with a nil antigen match. The mean pre dose CSA concentration was 289.22 + 171.9ng/ml; range (98.8 + 783.41ng/ml). The CSA concentration at 2 hours after the CSA administration was 838 + 310.87ng/ml (range, 169 + 1268ng/ml). 3 (12%) patients had acute rejection. In these patients the mean pre dose CSA concentration was 328.67ng/ml and the mean C2, CSA concentration was 1006.26ng/ml. CSA induced hemolytic uraemic syndrome was diagnosed in one patient. The trough and C2, CSA concentration levels were 174 and 870.83ng/ml respectively in this patient.

Conclusion

In our study CSA levels, trough and peak showed significant inter patient variability. The trough and C2 concentration levels did not correlate with the episodes of acute rejection. We conclude that in a triple drug regimen with fixed dosing schedules routine trough CSA level monitoring is not helpful in the acute post renal transplant period.Key Words: Cyclosporine levels, Cyclosporine trough levels, C2 levels     

Vitamin E administration and reversal of neurological deficits in protein-energy malnutrition

Neurological signs including posterior column, spinocerebellar, retinal, and peripheral nerve deficits are being increasingly recognized in vitamin E deficiency states. Children suffering from protein-energy malnutrition (PEM) revealed significantly reduced serum alpha-tocopherol levels compared to age-matched normal children, the deficient subjects also exhibited the widely recognized signs of tocopherol deficiency. In this prospective therapeutic intervention study moderate PEM subjects were administered aqueous oral vitamin E supplementation for 6 weeks and compared with control PEM subjects. The parameters studied included pre- and post-therapy serum alpha-tocopherol levels, alpha-tocopherol lipid ratio, lipid profile, creatine phosphokinase levels, and electroneurophysiological studies. Vitamin E supplementation normalized serum alpha-tocopherol levels (p < 0.001), alpha-tocopherol lipid ratio (p < 0.001), reduced creatine phosphokinase levels (p < 0.01), and reduced neurological signs in PEM subjects (p < 0.001). The observed improvement in neurological dysfunction among PEM subjects is of great interest, especially in developing countries. While larger studies are recommended, the importance of vitamin E administration in PEM is being reported.     

A single-centre experience of retroperitoneoscopy using the balloon technique

OBJECTIVE: To report the experience in one centre of the efficacy and safety of retroperitoneal laparoscopic procedures (RLPs). PATIENTS AND METHODS: During 1991-2000, 351 RLPs using the balloon technique were undertaken in 340 patients (mean age 34.9 years, range 4-74); the details and outcome were reviewed. Initial access was by the mini-open digital dissection technique in 152 and by the closed percutaneous technique in the remaining 199 procedures. Patients had not undergone previous retroperitoneal procedures, except for nine who had a percutaneous nephrostomy and eight ipsilateral abdominal surgery. There were 172 renal, seven adrenal, 97 ureteric, 50 gonadal, 13 lymphatic system, three vesical, two autonomic nervous system and seven vertebral RLPs. Nitrous oxide was used for pneumo-insufflation in 103 procedures, instead of CO2. RESULTS: The RLP was successful in 318 of the 351 procedures (90.6%). The operative duration was 0.5-5.5 h, depending on the difficulty of the procedure and the presence or absence of adhesions. The overall incidence of complications was 12.9%, but decreased to 9% for the last 100 procedures. There were only five major complications, e.g. avulsion of the ureter, torn renal pelvis, colonic injury and severe hypotension, but none were related to balloon dissection. The mean blood loss was 37.7 mL and the reason for transfusion in three patients was not operative blood loss but displacement of the ligature in two and severe hypotension after removing a phaeochromocytoma in one. The mean duration of analgesic use was 2.5 days, the hospital stay 3 days and return to work 14 days. CONCLUSION: Retroperitoneal laparoscopy using the balloon technique is a reasonably safe, efficient and reliable minimally invasive procedure. The efficiency, efficacy and safety of RLPs depend more on experience than on the type of access technique, type of balloon or medium used to inflate the balloon. Balloon rupture causes no tissue damage, and expansion to approximately 800 mL in adults is safe if the retroperitoneal space has not previously been invaded. The use of nitrous oxide for pneumo-insufflation in the retroperitoneal space is safe if proper precautions are taken.     

Cardiac MR spectroscopy in the new millennium

Spectroscopy is close to becoming an integral part of the clinical MR examination to achieve a complete morphological, functional, and metabolic evaluation of the human heart. 31P-NMR spectroscopy is used to noninvasively assess human myocardial energy metabolism. Abnormalities in the phosphocreatine (PCr) to ATP ratio are observed in ischemic heart disease, heart failure, transplanted hearts, and hypertrophic cardiomyopathy. NMR spectroscopy 31P spectra obtained at rest, during exercise or pharmacological stress allow the observation of the earliest metabolic responses of myocardial ischemia. 1 spectroscopy can evaluate the concentration of intracellular creatine and myocardial lipids as a means of evaluating myocardial viability. The increase in total 23Na in ischemic tissue provides information about the extent and location of viable tissue. Higher magnetic fields, gradient strength, and technological advances in pulse sequence and localization will result in better spatial and temporal resolution improving the clinical utility of the technique.