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Optimising the treatment for rheumatoid arthritis
112
European Journal of Internal Medicine 24 (2013) e112–e138
Contents lists available at ScienceDirect
European Journal of Internal Medicine j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e j i m
ECIM 2013
12. Rheumatology ID: 105 Optimising the treatment for rheumatoid arthritis D. Predeteanua,b a Internal Medicine and Rheumatology, “Sf. Maria” Clinical Hospital, Bucharest, Romania b Research Center on Rheumatic Diseases, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
Rheumatoid arthritis (RA) is a systemic chronic inflammatory disease characterised by joint inflammations responsible for destructions leading to the physical handicap with all the consequences derived from it. Various nonbiologic (methotrexate, leflunomide, sulphasalasine etc.) and biologic drugs anti-TNF (infliximab, adalimumab, etanercept) and anti-CD20 (Rituximab) are approved in Romania for the treatment of RA, but the treatment in view of reaching the targets in accordance with the Treat-to Target concept (remission, low disease activity) is chosen in accordance with the 2010 EULAR recommendations for the treatment of patients with RA. The patient, 45 year, woman, was admitted last time to hospital for a new evaluation of the disease in view of the 3rd cycle of rituximab. The disease, set on in 1997 with pains and swellings of small joints of fingers and toes, morning stiffness for about 1 h alleviated by movement. The positive diagnosis of the disease was made in the same year in accordance with the 1984 ACR Classification Criteria for RA and the first course of treatment consisted of nonsteroidal antiinflammatory drugs and corticosteroids. The remissive treatment was postponed for about 8 years as the patient insisted on having a child. Since 2009 the patient was periodically monitored in our clinic and the treatment with methotrexate up to 20 mg/week + sulphasalasine 2 g/day + hidroxiclorochin was started. Since the beginning of the treatment, the patient presented predictive factors for erosive course of the disease: female gender, increased levels of RF and anti-CCP antibodies, and X-ray erosions on hands. After 2 years of treatment with associated remissive drugs, the patient still demonstrated active disease (DAS28 = 5.7). The patient fulfilled the criteria for Romanian Guidelines for Biologic treatment in RA and she was then started on biologic therapy with adalimumab 40 mg every other week, in association with methotrexate 20 mg/week and low doses of corticosteroids (10 mg/day). At the end of 2 years of treatment with adalimumab with positive results, the patient presented again signs and symptoms of reactivation of the disease (DAS28 = 7.1) with very high levels of RF (N1400 UI/mL) and anti-CCP antibodies (N200 UI/mL). For these reasons the patient was considered secondary nonresponsive. At this moment it might have been useful to determine the level of anti0953-6205/$ – see front matter
adalimumab antibodies and the blood level of adalimumab, but these tests were not available in clinical practice. My experience made me switch from adalimumab to rituximab, continuing the classical therapy with methotrexate and low doses of corticosteroids. There were more important reasons for this switching: decreased efficacy of the second anti-TNF after nonresponsitivity to the first anti-TNF drug, high level of autoimmunity explained by high synovial expression of CD20 lymphocytes, effect of rituximab on osteoclastogenesis etc. After 3 cycles of rituximab, the patient is now in clinical remission (DAS28 = 1.99), without any side effects with improvement of quality of the life. doi:10.1016/j.ejim.2013.08.285
ID: 252 Prevalence of fragility vertebral fractures in internal medicine, an underestimated issue? The point study from the scientific society FADOI C. Vitalia, A. Valeriob, C.L. Muzzulinic, C. Pintaudid, G. Scanellie, C. Sacchettif, I. Iorig, G. Vescovoh, M. Campaninii, A. Mazzonej a
Internal Medicine, Hospital of Piombino, Livorno, Italy FADOI Foundation, Research Department, Milan, Italy c Internal Medicine, Hospital of Ceva, Cuneo, Italy d Internal Medicine, Hospital Pugliese-Ciaccio, Catanzaro, Italy e Internal Medicine, Azienda Ospedaliera-Universitaria “S. Anna”, Ferrara, Italy f Internal Medicine, Hospital of Sassuolo, Modena, Italy g Internal Medicine, Arcispedale S. Maria Nuova, Reggio Emilia, Italy h Internal Medicine, Hospital “San Bortolo”, Vicenza, Italy i Department of Internal Medicine, Hospital Maggiore della Carità, Novara, Italy j Medical Department, Hospital of Legnano, Milan, Italy b
Objective: It seems likely that osteoporosis and fragility fractures are a not negligible finding among patients hospitalized in Internal Medicine (IM), and they influence quality of life and prognosis. However, few data are available in the literature on the real impact of the problem in the context of IM, as well as on the association between osteoporosis and possible risk factors/predictors in this setting. Aims of our study were to assess the prevalence of osteoporotic vertebral fractures in patients hospitalized in IM for any cause, and to evaluate the relationship between fractures and a number of clinical variables. Methods: POINT (Prevalence of Osteoporosis in INTernal medicine) is an epidemiological, cross-sectional, multicenter study which enrolled patients hospitalized in IM (only excluding patients not able to comply
European Journal of Internal Medicine 24 (2013) e112–e138
Contents lists available at ScienceDirect
European Journal of Internal Medicine j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e j i m
ECIM 2013
12. Rheumatology ID: 105 Optimising the treatment for rheumatoid arthritis D. Predeteanua,b a Internal Medicine and Rheumatology, “Sf. Maria” Clinical Hospital, Bucharest, Romania b Research Center on Rheumatic Diseases, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
Rheumatoid arthritis (RA) is a systemic chronic inflammatory disease characterised by joint inflammations responsible for destructions leading to the physical handicap with all the consequences derived from it. Various nonbiologic (methotrexate, leflunomide, sulphasalasine etc.) and biologic drugs anti-TNF (infliximab, adalimumab, etanercept) and anti-CD20 (Rituximab) are approved in Romania for the treatment of RA, but the treatment in view of reaching the targets in accordance with the Treat-to Target concept (remission, low disease activity) is chosen in accordance with the 2010 EULAR recommendations for the treatment of patients with RA. The patient, 45 year, woman, was admitted last time to hospital for a new evaluation of the disease in view of the 3rd cycle of rituximab. The disease, set on in 1997 with pains and swellings of small joints of fingers and toes, morning stiffness for about 1 h alleviated by movement. The positive diagnosis of the disease was made in the same year in accordance with the 1984 ACR Classification Criteria for RA and the first course of treatment consisted of nonsteroidal antiinflammatory drugs and corticosteroids. The remissive treatment was postponed for about 8 years as the patient insisted on having a child. Since 2009 the patient was periodically monitored in our clinic and the treatment with methotrexate up to 20 mg/week + sulphasalasine 2 g/day + hidroxiclorochin was started. Since the beginning of the treatment, the patient presented predictive factors for erosive course of the disease: female gender, increased levels of RF and anti-CCP antibodies, and X-ray erosions on hands. After 2 years of treatment with associated remissive drugs, the patient still demonstrated active disease (DAS28 = 5.7). The patient fulfilled the criteria for Romanian Guidelines for Biologic treatment in RA and she was then started on biologic therapy with adalimumab 40 mg every other week, in association with methotrexate 20 mg/week and low doses of corticosteroids (10 mg/day). At the end of 2 years of treatment with adalimumab with positive results, the patient presented again signs and symptoms of reactivation of the disease (DAS28 = 7.1) with very high levels of RF (N1400 UI/mL) and anti-CCP antibodies (N200 UI/mL). For these reasons the patient was considered secondary nonresponsive. At this moment it might have been useful to determine the level of anti0953-6205/$ – see front matter
adalimumab antibodies and the blood level of adalimumab, but these tests were not available in clinical practice. My experience made me switch from adalimumab to rituximab, continuing the classical therapy with methotrexate and low doses of corticosteroids. There were more important reasons for this switching: decreased efficacy of the second anti-TNF after nonresponsitivity to the first anti-TNF drug, high level of autoimmunity explained by high synovial expression of CD20 lymphocytes, effect of rituximab on osteoclastogenesis etc. After 3 cycles of rituximab, the patient is now in clinical remission (DAS28 = 1.99), without any side effects with improvement of quality of the life. doi:10.1016/j.ejim.2013.08.285
ID: 252 Prevalence of fragility vertebral fractures in internal medicine, an underestimated issue? The point study from the scientific society FADOI C. Vitalia, A. Valeriob, C.L. Muzzulinic, C. Pintaudid, G. Scanellie, C. Sacchettif, I. Iorig, G. Vescovoh, M. Campaninii, A. Mazzonej a
Internal Medicine, Hospital of Piombino, Livorno, Italy FADOI Foundation, Research Department, Milan, Italy c Internal Medicine, Hospital of Ceva, Cuneo, Italy d Internal Medicine, Hospital Pugliese-Ciaccio, Catanzaro, Italy e Internal Medicine, Azienda Ospedaliera-Universitaria “S. Anna”, Ferrara, Italy f Internal Medicine, Hospital of Sassuolo, Modena, Italy g Internal Medicine, Arcispedale S. Maria Nuova, Reggio Emilia, Italy h Internal Medicine, Hospital “San Bortolo”, Vicenza, Italy i Department of Internal Medicine, Hospital Maggiore della Carità, Novara, Italy j Medical Department, Hospital of Legnano, Milan, Italy b
Objective: It seems likely that osteoporosis and fragility fractures are a not negligible finding among patients hospitalized in Internal Medicine (IM), and they influence quality of life and prognosis. However, few data are available in the literature on the real impact of the problem in the context of IM, as well as on the association between osteoporosis and possible risk factors/predictors in this setting. Aims of our study were to assess the prevalence of osteoporotic vertebral fractures in patients hospitalized in IM for any cause, and to evaluate the relationship between fractures and a number of clinical variables. Methods: POINT (Prevalence of Osteoporosis in INTernal medicine) is an epidemiological, cross-sectional, multicenter study which enrolled patients hospitalized in IM (only excluding patients not able to comply