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Is methotrexate really as hepatotoxic as presumed?
i n d i a n j o u r n a l o f r h e u m a t o l o g y 9 ( 2 0 1 4 ) S 7 eS 6 7
care centre.They underwent clinical evaluation, routine blood investigations, PFT, 6MWT, Chest Xray and HRCT (where indicated). Results: Sixty-one patients (aged 27 68 years) were included. Symptoms pertaining toespiratory illness were noted in 40% and clinical signs in 21%. Onefourth patients had abnormal chest radiogramswhile abnormal HRCT was noted in 5(n7). Pulmonary function abnormalities noted were restrictive defect (54%), small airway disease (2%), obstruction (1.7%) and mixed defect (1.7%). Only half of patients could walk at least 80% of predicted distance on standardized 6 Minute Walk Test while 22.4% experienced significant desaturation (>4% all from baseline) on pulseoximetry. Respiratory diagnosis was established in 64% patients which included isolated restrictive PFT abnormality (39%), ILD (14.7%), small airway disease (4.9%), pleural effusion (1.6%), emphysema (1.6%) & tuberculosis (1.6%). Among 13 patients who had significant desaturation on 6MWT, 11 had respiratory disorders such as ILD (8) restrictive abnormality in PFT (2) and emphysema (1). It is noteworthy that one third of patients with respiratory diagnosis did not have any symptoms pertaining to the respiratory illness. Conclusion: RA patients under report respiratory symptoms for various reasons. The study highlights the importance of active search for respiratory illness irrespective of symptoms. Desaturation on 6MWT appears to be a significant predictor of severe pulmonary disease. It might be advisable to perform this easy non invasive test at frequent intervals to diagnose asymptomatic pulmonary disease.
P57. Granulomatous synovitis of wrist in rheumatoid arthritis- is it tuberculosis of wrist? Gurkirat Kaur Gilla, Chanakyaa, Marjorie Correab, Babu Phillipc, Vineeta Shobaa; aDepartments of Medicine; bPathology and c Radiology, St John's Medical College Hospital, Bangalore, India Introduction: We report a case of seropositive rheumatoid arthritis who presented with multiple discharging sinuses of the wrist. Methods: A 32-year old womanpresented with inflammatory polyarthritis since 9 months. At presentation she had swelling and tenderness of bilateral knee and right elbow along withloss of appetite and intermittent fever. Multiple discharging sinuses were present on left wrist with exuberant synovial thickening. Synovial thickening and sinuses extended far beyondlimits of wrist joint. Discharging sinuses had appeared while on combination DMARDs.Investigations revealed normocytic normochromic anemia, elevated ESR and CRP. Her anti CCP titres were elevated. Montoux test was strongly positive. She underwent synovial biopsyand drainage of left wrist joint which revealed presence of necrotizing granulomatousinflammation. However, this tissue was negative for acid fast bacilli and fungal elements. X-ray of left hand showed severe juxta-articular osteopenia with destruction of carpal bones and metacarpalsof 4thand 5th digit. MRI of the wrist was suggestive of features of chronic osteomyelitis-probably tubercular with erosions of carpals, proximal metacarpals and radius. Currently patient is on treatment with combination DMARDs and therapeutic trial with ATT. Conclusion: Granulomas are extremely rare in rheumatoid arthritis and their presence in a biopsy along with widespread destruction of bones favors tuberculosis. However absence of AFB in an immunosuppressed patient needs careful follow up.
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P58. Is methotrexate really as hepatotoxic as presumed? Kaushik S. Bhojani, Neelu K. Bhojani, Arifa Siddiqui, Shubhada Kalke; Kennisha Rheumatology Care & Diagnostics, Bhandup, Mumbai, India Introduction: Methotrexate (Mtx), the mainstay of treatment in RA has been considered to be potentially hepatotoxic, with a practice of withholding the drug in case of altered liver function and discontinuation in case of such recurrence. We evaluated patients of RA on Mtx for other co-morbidities which could be responsible for the liver abnormalities. Methods: A single centre retrospective analysis of all patients of RA over 3 years was performed. All patients with altered SGPT on Mtx were identified. Mtx was withheld for 2 weeks and restarted if the rechecked SGPT had normalized. Cases where the SGPT did not normalize at 2 weeks or became abnormal again on restarting Mtx, were investigated for metabolic causes such as Diabetes, dyslipidemia, Hypothyroidism. Viral markers and autoantibodies were checked if the earlier set of tests was normal. Most tests were performed in the same laboratory. Results: Total no¼1660. Patients with abnormal SGPT on Mtx¼ 204 (12.29%). Of these 97 had dyslipidemia (47.55%), 20 had increased TSH (9.8%) and 29 had elevated blood sugars (14.22%). 24 patients had more than one metabolic abnormality (11.76%). HbsAg and HCV were positive in 1.47 and 0.98% respectively. 22.06 % of patients had liver abnormalities on USG mainly fatty liver. Correction of the metabolic abnormalities resulted in normal SGPT enabling continuation of Mtx. Conclusions: Only 12.29% of patients developed altered LFT on Mtx. Of these more than 70% of patients had correctable metabolic abnormalities indicating that Mtx may not be as hepatotoxic as presumed earlier.
P59. Assessment of impact of disease activity on the quality of life in patients of rheumatoid arthritis H. Singh, G. Sukhija, V. Tanwar, P. Talapatra, P. Kaur, S. Arora, A. Kalra; Department of Medicine & Rheumatology, Pt. BDS PGIMS, Rohtak, India Introduction: Maintainence of quality of life (QoL) is key to the management of chronic disorders. Limited Indian studies are available on QoL and its relation to disease activity in rheumatoid arthritis.s Methods: Thirty literate patients of RA (as per ACR 1987 criteria) were assessed twice at baseline (MO) and Three months (M3) for quantum of disease activity (using DAS28/CDAI) and QoL (using the SF-36 questionnaire). The results were compiled and statistically analyzed. Descriptive were calculated and Pearson's correlation coefficient was used for inter-variable comparisons. Results: Mean age of study population was 43.83±10.68 years; mean duration of illness was 74.2±65.38 with a male/female ratio of 1:6.5. The mean DAS28 score was 5.54±1.79 and 4.61±1.34; CDAI score was 28.43±16.9 and 18.17±10.42; Physical Component Score (PCS) was 32.58±11.10 and 36.18±9.46; and Mental Component Score (MCS) was 47.39±8.10 and 49.61±6.51 respectively at M0 and M3. PCS and MCS had an inverse correlation with CDAI and DAS28 on both occasions (all p-values 0.001).Physical role functioning (RP), general health (GH) and vitality (VT) were three most affected variabless.
care centre.They underwent clinical evaluation, routine blood investigations, PFT, 6MWT, Chest Xray and HRCT (where indicated). Results: Sixty-one patients (aged 27 68 years) were included. Symptoms pertaining toespiratory illness were noted in 40% and clinical signs in 21%. Onefourth patients had abnormal chest radiogramswhile abnormal HRCT was noted in 5(n7). Pulmonary function abnormalities noted were restrictive defect (54%), small airway disease (2%), obstruction (1.7%) and mixed defect (1.7%). Only half of patients could walk at least 80% of predicted distance on standardized 6 Minute Walk Test while 22.4% experienced significant desaturation (>4% all from baseline) on pulseoximetry. Respiratory diagnosis was established in 64% patients which included isolated restrictive PFT abnormality (39%), ILD (14.7%), small airway disease (4.9%), pleural effusion (1.6%), emphysema (1.6%) & tuberculosis (1.6%). Among 13 patients who had significant desaturation on 6MWT, 11 had respiratory disorders such as ILD (8) restrictive abnormality in PFT (2) and emphysema (1). It is noteworthy that one third of patients with respiratory diagnosis did not have any symptoms pertaining to the respiratory illness. Conclusion: RA patients under report respiratory symptoms for various reasons. The study highlights the importance of active search for respiratory illness irrespective of symptoms. Desaturation on 6MWT appears to be a significant predictor of severe pulmonary disease. It might be advisable to perform this easy non invasive test at frequent intervals to diagnose asymptomatic pulmonary disease.
P57. Granulomatous synovitis of wrist in rheumatoid arthritis- is it tuberculosis of wrist? Gurkirat Kaur Gilla, Chanakyaa, Marjorie Correab, Babu Phillipc, Vineeta Shobaa; aDepartments of Medicine; bPathology and c Radiology, St John's Medical College Hospital, Bangalore, India Introduction: We report a case of seropositive rheumatoid arthritis who presented with multiple discharging sinuses of the wrist. Methods: A 32-year old womanpresented with inflammatory polyarthritis since 9 months. At presentation she had swelling and tenderness of bilateral knee and right elbow along withloss of appetite and intermittent fever. Multiple discharging sinuses were present on left wrist with exuberant synovial thickening. Synovial thickening and sinuses extended far beyondlimits of wrist joint. Discharging sinuses had appeared while on combination DMARDs.Investigations revealed normocytic normochromic anemia, elevated ESR and CRP. Her anti CCP titres were elevated. Montoux test was strongly positive. She underwent synovial biopsyand drainage of left wrist joint which revealed presence of necrotizing granulomatousinflammation. However, this tissue was negative for acid fast bacilli and fungal elements. X-ray of left hand showed severe juxta-articular osteopenia with destruction of carpal bones and metacarpalsof 4thand 5th digit. MRI of the wrist was suggestive of features of chronic osteomyelitis-probably tubercular with erosions of carpals, proximal metacarpals and radius. Currently patient is on treatment with combination DMARDs and therapeutic trial with ATT. Conclusion: Granulomas are extremely rare in rheumatoid arthritis and their presence in a biopsy along with widespread destruction of bones favors tuberculosis. However absence of AFB in an immunosuppressed patient needs careful follow up.
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P58. Is methotrexate really as hepatotoxic as presumed? Kaushik S. Bhojani, Neelu K. Bhojani, Arifa Siddiqui, Shubhada Kalke; Kennisha Rheumatology Care & Diagnostics, Bhandup, Mumbai, India Introduction: Methotrexate (Mtx), the mainstay of treatment in RA has been considered to be potentially hepatotoxic, with a practice of withholding the drug in case of altered liver function and discontinuation in case of such recurrence. We evaluated patients of RA on Mtx for other co-morbidities which could be responsible for the liver abnormalities. Methods: A single centre retrospective analysis of all patients of RA over 3 years was performed. All patients with altered SGPT on Mtx were identified. Mtx was withheld for 2 weeks and restarted if the rechecked SGPT had normalized. Cases where the SGPT did not normalize at 2 weeks or became abnormal again on restarting Mtx, were investigated for metabolic causes such as Diabetes, dyslipidemia, Hypothyroidism. Viral markers and autoantibodies were checked if the earlier set of tests was normal. Most tests were performed in the same laboratory. Results: Total no¼1660. Patients with abnormal SGPT on Mtx¼ 204 (12.29%). Of these 97 had dyslipidemia (47.55%), 20 had increased TSH (9.8%) and 29 had elevated blood sugars (14.22%). 24 patients had more than one metabolic abnormality (11.76%). HbsAg and HCV were positive in 1.47 and 0.98% respectively. 22.06 % of patients had liver abnormalities on USG mainly fatty liver. Correction of the metabolic abnormalities resulted in normal SGPT enabling continuation of Mtx. Conclusions: Only 12.29% of patients developed altered LFT on Mtx. Of these more than 70% of patients had correctable metabolic abnormalities indicating that Mtx may not be as hepatotoxic as presumed earlier.
P59. Assessment of impact of disease activity on the quality of life in patients of rheumatoid arthritis H. Singh, G. Sukhija, V. Tanwar, P. Talapatra, P. Kaur, S. Arora, A. Kalra; Department of Medicine & Rheumatology, Pt. BDS PGIMS, Rohtak, India Introduction: Maintainence of quality of life (QoL) is key to the management of chronic disorders. Limited Indian studies are available on QoL and its relation to disease activity in rheumatoid arthritis.s Methods: Thirty literate patients of RA (as per ACR 1987 criteria) were assessed twice at baseline (MO) and Three months (M3) for quantum of disease activity (using DAS28/CDAI) and QoL (using the SF-36 questionnaire). The results were compiled and statistically analyzed. Descriptive were calculated and Pearson's correlation coefficient was used for inter-variable comparisons. Results: Mean age of study population was 43.83±10.68 years; mean duration of illness was 74.2±65.38 with a male/female ratio of 1:6.5. The mean DAS28 score was 5.54±1.79 and 4.61±1.34; CDAI score was 28.43±16.9 and 18.17±10.42; Physical Component Score (PCS) was 32.58±11.10 and 36.18±9.46; and Mental Component Score (MCS) was 47.39±8.10 and 49.61±6.51 respectively at M0 and M3. PCS and MCS had an inverse correlation with CDAI and DAS28 on both occasions (all p-values 0.001).Physical role functioning (RP), general health (GH) and vitality (VT) were three most affected variabless.