Management Of Rheumatologic Diseases Research Articles

Effectiveness and safety in the management of chronic inflammatory diseases with etanercept and infliximab biosimilars in Colombian patients

ObjectiveTo determine the effectiveness and safety of infliximab and etanercept biosimilar drugs in patients diagnosed with rheumatoid arthritis, ankylosing spondylitis, ulcerative colitis, and psoriasis in a specialized institution in Colombia, between 2015 and 2019. MethodsA retrospective study in patients treated with infliximab and etanercept biosimilar drugs treated in an institution specializing in the management of rheumatological diseases, to verify the clinimetric indicators of effectiveness and reports of adverse drug reactions. Clinical, sociodemographic, and pharmacological variables were identified over 5 years of follow-up. Results207 patients were identified with a mean age of 48.7±15.1 years, 61.4% were women. Of the patients, 58.0% (n=120) used infliximab and 42.0% (n=87) etanercept. It was found that 46 (22.2%) patients had adverse drug reactions. At the end of the observation period, 61.6% (n=72) of the patients with RA had achieved control of the disease (mild activity or remission), and 57.9% (n=117) had problems with access to and persistence with therapy. ConclusionIn a group of patients treated in Colombia, the biosimilars of infliximab and etanercept showed proportions of effectiveness and safety comparable to the reference drugs, but lack of adherence to treatment was quite common.

Efectividad y seguridad en el manejo de enfermedades inflamatorias crónicas con medicamentos biosimilares de etanercept e infliximab en pacientes colombianos

ObjectiveTo determine the effectiveness and safety of infliximab and etanercept biosimilar drugs in patients diagnosed with rheumatoid arthritis, ankylosing spondylitis, ulcerative colitis, and psoriasis in a specialized institution in Colombia, between 2015 and 2019. MethodsA retrospective study in patients treated with infliximab and etanercept biosimilar drugs treated in an institution specializing in the management of rheumatological diseases, to verify the clinimetric indicators of effectiveness and reports of adverse drug reactions. Clinical, sociodemographic, and pharmacological variables were identified over 5 years of follow-up. Results207 patients were identified with a mean age of 48.7 ± 15.1 years, 61.4% were women. Of the patients, 58% (n = 120) used infliximab and 42% (n = 87) etanercept. It was found that 46 (22.2%) patients had adverse drug reactions. At the end of the observation period, 61.6% (n = 72) of the patients with RA had achieved control of the disease (mild activity or remission), and 57.9% (n = 117) had problems with access to and persistence with therapy. ConclusionIn a group of patients treated in Colombia, the biosimilars of infliximab and etanercept showed proportions of effectiveness and safety comparable to the reference drugs, but lack of adherence to treatment was quite common.

S2256 Crohn's Disease Induced by Secukinumab

INTRODUCTION: Secukinumab, an interleukin (IL)-17 antagonist used in the management of rheumatological diseases, has been associated with new onset and exacerbation of pre-existing inflammatory bowel disease (IBD). There are very few reports of cases of new-onset severe IBD after initiating secukinumab therapy, and we describe one such case. CASE DESCRIPTION/METHODS: A 44-year-old male with a history of psoriasis, recently initiated on secukinumab with first dose 1 month prior, presented with bloody diarrhea and abdominal pain. Admission workup was notable for elevated inflammatory markers, negative workup for infectious causes of diarrhea and CT abdomen showing colitis. Colonoscopy revealed severe inflammation and ulcerations in the left colon and inflammation with erosions in terminal ileum. Biopsies revealed findings consistent with Crohn's disease. Secukinumab was discontinued and he was started on budesonide and mesalamine. Diarrhea and abdominal pain significantly improved prior to discharge. On a clinic visit 2 weeks later, he had complete resolution of symptoms, and was then initiated on ustekinumab for control of both his Crohn's disease and psoriasis. DISCUSSION: The pathogenesis of IBD is thought to involve complex interactions between genetic, environmental or microbial factors and dysregulated immune responses. IL-17 was thought to contribute to IBD pathogenesis based on increased expression of IL-17 in the mucosa and serum in IBD patients. However, trials of IL-17 antagonists in patients with IBD were not successful. Exacerbation of IBD or new-onset IBD in patients on secukinumab has been increasingly described in case reports, and has been reported to be around 1%. In one case report of new IBD, the patient had a positive family history. On the other hand, other reviews have reported no increased incidence of IBD in patients treated with secukinumab compared to known rates of IBD in patients with ankylosing spondylitis, psoriasis, and psoriatic arthritis. It appears that the overall incidence of IBD in patients using secukinumab is rare. Prior to initiating this drug, evaluating patients for IBD or the susceptibility to IBD should be considered including any GI symptoms and personal or family history of IBD. In the emergence of new GI symptoms, the possibility of drug-induced IBD should be considered. Biologic drugs targeting other pathways like ustekinumab (IL12/23) or infliximab and adalimumab (TNF-alpha) may be a safer choice in patients with co-existing IBD and rheumatological conditions.

Methotrexate exposure and risk of strongyloidiasis.

Rheumatologic disease patients receiving immunomodulating drugs such as methotrexate (MTX) have increased infection rates. Strongyloides, a global endemic intestinal parasite, can cause significant or fatal disease in immunocompromised patients. The risk of serious Strongyloides infection with MTX dosed for rheumatologic disease is unknown. We performed a systematic literature review searching EMBASE, Medline and Web of Science databases. All studies reporting humans exposed to MTX and tested for Strongyloides were reviewed. Exclusion criteria were bone marrow transplantation, intrathecal route and MTX exposure completed >1year prior to clinically apparent Strongyloides disease. After excluding duplicates, 294 articles were reviewed. Of these, 29 cases were described in 27 papers. Twenty cases (69%) had an underlying rheumatologic or dermatologic disease, the rest had a haematologic disease. Hyperinfection or dissemination was found in 59% of cases (52% low-dose MTX; 75% high-dose MTX). Death occurred in 34% of cases (19% low-dose MTX; 75% high-dose MTX, P<0.01). All eight patients on high-dose MTX received other immunosuppressants. Corticosteroids were taken in 18/21 patients on low-dose MTX. One of the three patients on MTX monotherapy had hyperinfection syndrome. None had disseminated Strongyloides. Serious Strongyloides infection can occur with low-dose MTX particularly when given with other immunosuppression. Global travel and greater awareness of rheumatologic conditions in low- to middle-income countries will increase the exposure of individuals prescribed MTX (with or without corticosteroids) to Strongyloides. Strongyloides screening and treatment should be considered for individuals receiving low-dose MTX therapy, particularly if combined with additional immunosuppression.

Ultrasound applications for the practicing rheumatologist

Musculoskeletal ultrasound is an increasingly used tool for the evaluation and management of rheumatologic diseases. Its utilisation by rheumatologists is varied around the world and is dependent upon training and local expertise. Its applications can be broadly categorised into three main areas; for the education of patients, to aid the rheumatologist in the diagnosis and monitoring of disease, and therapeutically for joint aspiration and injection. Ultrasound is a safe, portable, easily repeatable, dynamic images in multiple planes and cheap form of imaging. Ultrasound however, is operator dependent and has a number of artefacts that can result in misinterpretation. Musculoskeletal Ultrasound uses a number of modes to characterise joint pathology, including grey scale, colour and power Doppler, spectral Doppler, 3D imaging, elastography. Musculoskeletal ultrasound can detect and monitor multiple joint pathologies including synovitis, tenosynovitis, and tendon pathologies, entheseal processes, bone erosions and osteophytes, cartilage changes and bursal pathologies.

Management of rheumatologic diseases in pregnancy

Rheumatic diseases include a variety of chronic multisystem disorders with a high percentage of autoimmune conditions. Many of these diseases affect women of child-bearing age, and so pregnancy poses an important challenge for doctors looking after these women. Knowledge about medication safety, the effect of pregnancy on such diseases, and vice versa, together with preconception counseling and multidisciplinary team care, are basic pillars needed to provide the best obstetric and medical care to these women. In this review, the management of the most common autoimmune rheumatic diseases prior, during and after pregnancy will be discussed, along with the most relevant issues regarding medications.

Tai Chi and yoga as complementary therapies in rheumatologic conditions

Tai Chi and yoga are complementary therapies which have, during the last few decades, emerged as popular treatments for rheumatologic and musculoskeletal diseases. This review covers the evidence of Tai Chi and yoga in the management of rheumatologic diseases, especially osteoarthritis of the knee, hip and hand, and rheumatoid arthritis. There is evidence that Tai Chi and yoga are safe, and some evidence that they have benefit, leading to reduction of pain and improvement of physical function and quality of life in patients. Recommendations for Tai Chi in knee osteoarthritis have recently been issued by the American College of Rheumatology. To allow broader recommendations for the use of Tai Chi and yoga in rheumatic diseases, there is a need to collect more evidence researched with larger randomised controlled trials.

Complications Associated With the Use of Corticosteroids in the Treatment of Athletic Injuries

The potent anti-inflammatory pharmacologic effects of the corticosteroids (cortisone and synthetic derivatives) has led to their extensive usage in the management of rheumatologic diseases and athletic musculoskeletal injuries. The efficacy and risks of locally injected or systemically administered corticosteroids in the treatment of athletic injuries are unclear. To review critically the medical literature and determine complications and risks associated with corticosteroid treatment of athletic injuries. A search of 3 databases-MEDLINE, CINAHL, and Cochrane Clinical Trial Register-was performed using the OVID interface for all years between 1966 and 2003. The search first combined all references under the medical subject headings adrenal cortex hormones, glucocorticoids, and glucocorticoids, synthetic. A second search combined all references under the medical subject headings athletic injuries, sprains and strains, tendon injuries, shoulder injuries, rotator cuff disease, tennis elbow, and lateral epicondylitis. The references identified by these 2 searches were intersected and limited to human only to produce 130 articles. Relevant review articles were scanned, references reviewed, and additional articles retrieved for consideration of inclusion. For inclusion in this critical review, articles must meet the following criteria: (1) subjects were human, (2) subjects had athletic-related injuries, and (3) subjects received corticosteroid treatment. Ultimately, 43 studies met inclusion criteria. Selected articles were then categorized as to whether the primary focus was usage/efficacy of corticosteroid injection therapy, occurrence of complications of corticosteroid injection therapy, or usage or complications of systemic corticosteroid therapy. Twenty-five selected studies primarily examined the usage/efficacy of corticosteroid injections in the treatment of various athletic injuries. Of the 983 total subjects who received corticosteroid injections among these studies, only minor complications of treatment were reported. Eighteen selected studies primarily described complications of corticosteroid injections in the treatment of athletic injuries. Of these, tendon and fascial ruptures were the predominant complications reported. The search identified no articles that addressed the usage of or complications of systemic corticosteroids in the treatment of athletic injuries, although tibial stress fracture and multifocal osteonecrosis occurred in individuals being treated for nonathletic injury conditions. This critical review reveals that the existing medical literature does not provide precise estimates for complication rates following the therapeutic use of injected or systemic corticosteroids in the treatment of athletic injuries. Tendon and fascial ruptures are often reported complications of injected corticosteroids, whereas tibial stress fractures and multifocal osteonecrosis were described with systemic corticosteroids.

Relevance of thiopurine methyltransferase status in rheumatology patients receiving azathioprine

Azathioprine (AZA) is widely used in the management of rheumatological diseases. Despite its efficacy, AZA can often cause bone marrow suppression, notably leucopenia, which has been recorded in up to 17% of patients taking AZA for rheumatoid arthritis, though this can be considered clinically significant in about 3% overall. Severe myelosuppression, associated with abnormal AZA metabolism, is linked to the thiopurine methyltransferase (TPMT) genetic polymorphism. TPMT status can be assessed prior to AZA treatment by measuring enzyme activity or genotyping techniques. Analysis of recent data suggests that by optimizing the AZA dose on the basis of TPMT status testing (with a substantial reduction in dose for patients homozygous for mutant TPMT alleles), a reduction in drug-induced morbidity and cost savings can be made by avoiding hospitalization and rescue therapy for leucopenic events. In this article we review the pharmacogenetic and clinical implications of the TPMT polymorphism, emphasizing its relevance to rheumatologists managing diseases with AZA.

Common Rheumatologic Diseases in Elderly Patients

To review common rheumatologic disorders that affect elderly patients and emphasize the unique diagnostic and therapeutic challenges inherent in the management of rheumatologic diseases in this age-group. We summarize our approach to treatment and management of specific rheumatologic problems in geriatric patients and discuss pertinent studies from the literature. Among the spectrum of rheumatologic disorders frequently encountered in the elderly population are polymyalgia rheumatica, fibromyalgia, giant cell arteritis, crystalline arthropathies (gout and pseudogout), and degenerative joint disease. The initial manifestations of these rheumatologic diseases in elderly patients may differ from the typical findings in younger patients. Geriatric patients may have nonspecific complaints, a decline in physical function, or even confusion. Because of physiologic changes associated with aging and a decrease in functional reserves, elderly patients are susceptible to adverse effects of pharmacologic therapy (including nonsteroidal anti-inflammatory medications, corticosteroids, narcotic analgesics, allopurinol, and colchicine). Clinicians should be alert for such problems as hepatotoxicity and occult gastrointestinal blood loss. Comorbid conditions such as cardiovascular disease and cognitive impairment may complicate management strategies and may limit the goals of both surgical intervention and rehabilitation programs in elderly patients. Rheumatologic disorders in geriatric patients pose special challenges to primary-care physicians. In the selection of optimal pharmacologic and nonpharmacologic therapeutic modalities, clinicians should focus on maintaining or improving the patient's quality of life and level of independent function.