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P14 Use of infliximab in ankylosing spondylitis—a practical approach
S10
Indian Journal of Rheumatology 2009 November; Vol. 4, No. 3 (Suppl)
Poster presentations
climbing up and sitting on the floor. Analysis of the third phase is going on. Interim analysis reveals that commonest diagnosis clinically is osteoarthritis knee and non articular rheumatism. Higher prevalence of osteoarthritis and non articular rheumatism is noted among Females.
Material and Method: We reviewed 219 patients who visited our hospital over a 7 years period from 2003–09 and who were positive for RO-52, SS-B, SS-A either alone or in combination by the immunoblot method. The case files were analysed retrospectively to find out how many were worked up for completed diagnosis and were symptomatic at the time of presentation. to labelled as having SS and also developed the symptom related to SS during followup.
P14 Use of infliximab in ankylosing spondylitis—a practical approach
Results: 219 patients were analysed of which 114 were categorised as primary SS, 51 had secondary sjogren’s syndrome and 37 had either UCTD or other CTD. Of the 219 patient 153 were female and 26 were male, with a mean age of 43 (24–78) years. Majority of the patients presented with musculo-skeletal symptoms not fulfilling any criteria for other specific rheumatological disease. Since we had not performed sialography or salivary gland biopsy none of the patients could fulfil criteria for SS completely. Only 50.8% (58 of 114) had symptons of either dry mouth or eye symptoms at presentation, while of the remaining 56 (49%), 6 (10.7%) developed symptoms of dry mouth or eyes (10.7%) over a mean follow-up of 2 years 6 months. Only one patient developed features of other CTD. None of the three autoantibodies had significant association with either development or association of dry mouth, except duration of first symptoms relatable to SS. The findings are tabulated in the table below.
K Narayanan, DS Bhakuni, OP Garg, V Vasdev, R Jain Army Hospital Research and Referral, New Delhi Background: Biologicals have revolutionalised the treatment of Ankylosing spondylitis (AS). However the use of these drugs are restricted in our country due to economic reasons. Even in service hospitals where treatment is free all patients who require biologic agents are not getting the dose as recommended. We share our experience with intermittent on demand use of Infliximab in AS. Methods: This study was conducted in Army Hospital (R&R), New Delhi from July 2006 to June 2009. All cases of AS with treatment failure to NSAIDs, BASDAI > 4 and CRP > 10 mg/l were included in the study after screening for tuberculosis and other infections. 5 mg/kg of infliximab was given initially and followed up monthly. BASDAI, BASFI and CRP were estimated in every visit. Repeat doses were given as and when the patients had recurrence of symptoms with abnormal CRP levels and BASDAI core o > 4. All patients were planned to give at least 3 doses and followed up for one year. Results: 180 patients received infliximab. ASAS 20 response was present in 97% patients of which 57 % had ASAS 40 response. Duration of response varied from 2 weeks to 6 months (Mean 8 weeks). Number of doses ranged from 1 to 11 (mean 3). Best response was after the first dose. Infusion reactions were the commonest adverse effect (8 cases). Tuberculosis was detected in 3 cases. Headache, Herpes zoster and skin infections (Boils) were some of the undesired effects of therapy encountered. On follow up without further biologic therapy patients felt the disease has become milder and the requirement of NSAIDS reduced and had significant improvement in BASFI. Conclusion: Intermittent on demand use of infliximab is safe and effective in AS and can offer reasonable functional improvement although radiologic progression is not halted. The efficacy of the drug gradually decreases on repeated use.
P15 Pattern of DMARD use and associated comorbidities in chronic RA who have received more than 10 years of DMARD therapy K Narayanan, R Jain, DS Bhakuni, Garg, V Vasdev Army Hospital Research and Referral, New Delhi Background: Rheumatoid arthritis (RA) is the commonest inflammatory arthritis one encounters in our routine practice. Treatment of RA have undergone a paradigm shift over last two decades. It is interesting to note that how some of the older patients have received various DMARDS and their response to therapy. Methods: This study was conducted in Army Hospital Research and Referral, New Delhi. Cases of chronic RA attending rheumatology OPD from January 2009 to June 2009 were included in the study. All patients were reevaluated and their old medical documents were perused. Details of drug therapy and associated comorbidities were noted in those who received treatment for more than 10 years. Results: Out of 325 RA patients screened, 55 (20%) patients had received DMARDs for more than 10 years. There were 43 females and 12 males. All patients were on Methotrexate. 34 (60%) patients were receiving Lefunomide and 27 (50%) were on Hydroxychloroquine. Sulfasalazine was prescribed for 4 patients. Only 5 patients were on monotherapy with Methotrexate. Combination of Methotrexate and leflunomide was well tolerated in 21 (38%). Neutropaenia and transaminitis occurred in some patients. DMARDs have been changed many times during the course of illness due to side effects or due to prescription bias of consultants. Eleven patients had received biologics previously.13 patients had undergone either Total knee replacement and 4 had total hip replacement. One patient had tendon release surgery. Sicca symptoms, subcutaneous nodules, Anaemia and Interstitial lung disease were some of the common extra articular features seen. Hypertension, Diabetes and Hypothyroidism were the commonest comorbity encountered. Conclusion: Majority of chronic RA patients are on combination of Methotrexate with leflunomide or Hydroxychloroquine. These drugs are effective and well tolerated even after many years of use.
P16 Are Auto antibodies enough proof for Sjogren syndrome diagnosis? Chandrashekara S, Anupama KR, Renuka P, Apoorva Kare, Dharmanand BG ChanRe Rheumatology and Immunology Centre and Research, Bangalore Introduction: In regular day to day practice it is often difficult to work up a patient of Sjogren’s syndrome completely especially the salivary gland biopsies and other objective evidence of sialadenitis such as sialography and the easier Schirmer’s test due to various reasons. We analysed the data to evaluate how many patient with a clinical diagnosis of Sjogren’s syndrome (SS) were completely worked up and fulfilled the criteria for diagnosis at the time of presentation and followup.
Sjogren’s Syndrome Criteria ANA profile
Ocular symptoms
Oral symptoms
Ocular signs
Autoantibodies/ arthritis/other MSK symptoms
3+ 2+ SSA+ Ro52+ SSB+
10 5 4 3 1
6 1 1 3 0
0 0 0 1 0
36 25 19 31 19
+ indicate number of autoantibody positive in combination, MSK = musculoskeletal symptoms.
Conclusion: Mere presence of autoantibody of anti-RO, SSB and SSA are not sufficient to consider the diagnosis. They do significantly predict a possibility of Sjogren syndrome. Since diagnosis depend more on either partial organ impairment (Salivary or lacrimal gland) while criteria does not emphasis on musculoskeletal symptoms. Many of the patients in our series had MSk symptoms which predated the onset of sicca symptoms, would have limited us to do the work-up completely. The addition of MSK symptoms with few more noninvasive tests for early diagnosis should increase the sensitivity of making diagnosis of Sjogren syndrome.
P17 Altered cognitive response to pain in addition to the altered pain threshold in fibromyalgia patients than normal and rheumatoid arthritis Chandrashekara S, Vijayadas1, Arun Koushik1, Roopakala MS1, Kishore Kumar Reddy 1 Department of Physiology, MS Ramiah Medical College; 2ChanRe Rheumatology and Immunology Center and Research, Bangalore
Background and Objective: Fibromyalgia (FM) and rheumatoid arthritis (RA) are two chronic pain syndrome characterized by pain The pressure pain threshold (PPT) is increased in both theses painful conditions. PPT measure altered sensitivity while Visual analogue scale (VAS) indicates the perception of pain by the patient. Our aim was to assess pain by PPT using algometer and VAS in FM patients and compare them with normal subjects and RA. Methods: PPT was recorded using digital algometer in 20 FM patients, 20 RA patients and 40 age and sex matched normal subjects. Measurement was done on 18 specific tender point sites according to ACR criteria. Simultaneously, VAS was given to the subjects and asked to mark the severity of pain perceived immediately after algometry. Results: The range of PPT in FM patients was 0.73–3.43 kg/cm2 (1.831) and in RA was 0.267– 3.901 (2.62) in normal subjects 2.06–5.65 kg/cm2. VAS score range was 53–67.63 mm in FM patients 30.5- 49 mm and 19.65–44.85 mm in normal subjects. There was a significant reduction (P < 0.001) in PPT and VAS score in all 18 tender points in FM patients, RA patients were compared to normal subjects. by Annova and pearson correlation. Conclusion: There is significant reduction of PPT in both FM as well RA patients compared to normal subjects. The reduction in threshold was seen in RA even in areas which are not inflamed and adjacent to joint. VAS has tendency of overestimating the effect when compared to algometry especially in fibromyalgia. The VAS estimate was significantly higher in FM suggesting that in addition to altered PPT even the cognitive response to pain to be altered in FM.
P18 Clinical laboratory features in SLE JRS Vijaybabu Background: SLE is an autoimmune multisystem disorder with hemolytic anemia as one of the ACR classification criteria. In previous studies, it has been shown that Coomb’s positivity was associated with ACL positivity, thrombocytopenia, thrombosis and renal disease. This study was undertaken to identify the correlation between Coomb’s positivity and D-dimer as well as various clinicolaboratory features in SLE.
Indian Journal of Rheumatology 2009 November; Vol. 4, No. 3 (Suppl)
Poster presentations
climbing up and sitting on the floor. Analysis of the third phase is going on. Interim analysis reveals that commonest diagnosis clinically is osteoarthritis knee and non articular rheumatism. Higher prevalence of osteoarthritis and non articular rheumatism is noted among Females.
Material and Method: We reviewed 219 patients who visited our hospital over a 7 years period from 2003–09 and who were positive for RO-52, SS-B, SS-A either alone or in combination by the immunoblot method. The case files were analysed retrospectively to find out how many were worked up for completed diagnosis and were symptomatic at the time of presentation. to labelled as having SS and also developed the symptom related to SS during followup.
P14 Use of infliximab in ankylosing spondylitis—a practical approach
Results: 219 patients were analysed of which 114 were categorised as primary SS, 51 had secondary sjogren’s syndrome and 37 had either UCTD or other CTD. Of the 219 patient 153 were female and 26 were male, with a mean age of 43 (24–78) years. Majority of the patients presented with musculo-skeletal symptoms not fulfilling any criteria for other specific rheumatological disease. Since we had not performed sialography or salivary gland biopsy none of the patients could fulfil criteria for SS completely. Only 50.8% (58 of 114) had symptons of either dry mouth or eye symptoms at presentation, while of the remaining 56 (49%), 6 (10.7%) developed symptoms of dry mouth or eyes (10.7%) over a mean follow-up of 2 years 6 months. Only one patient developed features of other CTD. None of the three autoantibodies had significant association with either development or association of dry mouth, except duration of first symptoms relatable to SS. The findings are tabulated in the table below.
K Narayanan, DS Bhakuni, OP Garg, V Vasdev, R Jain Army Hospital Research and Referral, New Delhi Background: Biologicals have revolutionalised the treatment of Ankylosing spondylitis (AS). However the use of these drugs are restricted in our country due to economic reasons. Even in service hospitals where treatment is free all patients who require biologic agents are not getting the dose as recommended. We share our experience with intermittent on demand use of Infliximab in AS. Methods: This study was conducted in Army Hospital (R&R), New Delhi from July 2006 to June 2009. All cases of AS with treatment failure to NSAIDs, BASDAI > 4 and CRP > 10 mg/l were included in the study after screening for tuberculosis and other infections. 5 mg/kg of infliximab was given initially and followed up monthly. BASDAI, BASFI and CRP were estimated in every visit. Repeat doses were given as and when the patients had recurrence of symptoms with abnormal CRP levels and BASDAI core o > 4. All patients were planned to give at least 3 doses and followed up for one year. Results: 180 patients received infliximab. ASAS 20 response was present in 97% patients of which 57 % had ASAS 40 response. Duration of response varied from 2 weeks to 6 months (Mean 8 weeks). Number of doses ranged from 1 to 11 (mean 3). Best response was after the first dose. Infusion reactions were the commonest adverse effect (8 cases). Tuberculosis was detected in 3 cases. Headache, Herpes zoster and skin infections (Boils) were some of the undesired effects of therapy encountered. On follow up without further biologic therapy patients felt the disease has become milder and the requirement of NSAIDS reduced and had significant improvement in BASFI. Conclusion: Intermittent on demand use of infliximab is safe and effective in AS and can offer reasonable functional improvement although radiologic progression is not halted. The efficacy of the drug gradually decreases on repeated use.
P15 Pattern of DMARD use and associated comorbidities in chronic RA who have received more than 10 years of DMARD therapy K Narayanan, R Jain, DS Bhakuni, Garg, V Vasdev Army Hospital Research and Referral, New Delhi Background: Rheumatoid arthritis (RA) is the commonest inflammatory arthritis one encounters in our routine practice. Treatment of RA have undergone a paradigm shift over last two decades. It is interesting to note that how some of the older patients have received various DMARDS and their response to therapy. Methods: This study was conducted in Army Hospital Research and Referral, New Delhi. Cases of chronic RA attending rheumatology OPD from January 2009 to June 2009 were included in the study. All patients were reevaluated and their old medical documents were perused. Details of drug therapy and associated comorbidities were noted in those who received treatment for more than 10 years. Results: Out of 325 RA patients screened, 55 (20%) patients had received DMARDs for more than 10 years. There were 43 females and 12 males. All patients were on Methotrexate. 34 (60%) patients were receiving Lefunomide and 27 (50%) were on Hydroxychloroquine. Sulfasalazine was prescribed for 4 patients. Only 5 patients were on monotherapy with Methotrexate. Combination of Methotrexate and leflunomide was well tolerated in 21 (38%). Neutropaenia and transaminitis occurred in some patients. DMARDs have been changed many times during the course of illness due to side effects or due to prescription bias of consultants. Eleven patients had received biologics previously.13 patients had undergone either Total knee replacement and 4 had total hip replacement. One patient had tendon release surgery. Sicca symptoms, subcutaneous nodules, Anaemia and Interstitial lung disease were some of the common extra articular features seen. Hypertension, Diabetes and Hypothyroidism were the commonest comorbity encountered. Conclusion: Majority of chronic RA patients are on combination of Methotrexate with leflunomide or Hydroxychloroquine. These drugs are effective and well tolerated even after many years of use.
P16 Are Auto antibodies enough proof for Sjogren syndrome diagnosis? Chandrashekara S, Anupama KR, Renuka P, Apoorva Kare, Dharmanand BG ChanRe Rheumatology and Immunology Centre and Research, Bangalore Introduction: In regular day to day practice it is often difficult to work up a patient of Sjogren’s syndrome completely especially the salivary gland biopsies and other objective evidence of sialadenitis such as sialography and the easier Schirmer’s test due to various reasons. We analysed the data to evaluate how many patient with a clinical diagnosis of Sjogren’s syndrome (SS) were completely worked up and fulfilled the criteria for diagnosis at the time of presentation and followup.
Sjogren’s Syndrome Criteria ANA profile
Ocular symptoms
Oral symptoms
Ocular signs
Autoantibodies/ arthritis/other MSK symptoms
3+ 2+ SSA+ Ro52+ SSB+
10 5 4 3 1
6 1 1 3 0
0 0 0 1 0
36 25 19 31 19
+ indicate number of autoantibody positive in combination, MSK = musculoskeletal symptoms.
Conclusion: Mere presence of autoantibody of anti-RO, SSB and SSA are not sufficient to consider the diagnosis. They do significantly predict a possibility of Sjogren syndrome. Since diagnosis depend more on either partial organ impairment (Salivary or lacrimal gland) while criteria does not emphasis on musculoskeletal symptoms. Many of the patients in our series had MSk symptoms which predated the onset of sicca symptoms, would have limited us to do the work-up completely. The addition of MSK symptoms with few more noninvasive tests for early diagnosis should increase the sensitivity of making diagnosis of Sjogren syndrome.
P17 Altered cognitive response to pain in addition to the altered pain threshold in fibromyalgia patients than normal and rheumatoid arthritis Chandrashekara S, Vijayadas1, Arun Koushik1, Roopakala MS1, Kishore Kumar Reddy 1 Department of Physiology, MS Ramiah Medical College; 2ChanRe Rheumatology and Immunology Center and Research, Bangalore
Background and Objective: Fibromyalgia (FM) and rheumatoid arthritis (RA) are two chronic pain syndrome characterized by pain The pressure pain threshold (PPT) is increased in both theses painful conditions. PPT measure altered sensitivity while Visual analogue scale (VAS) indicates the perception of pain by the patient. Our aim was to assess pain by PPT using algometer and VAS in FM patients and compare them with normal subjects and RA. Methods: PPT was recorded using digital algometer in 20 FM patients, 20 RA patients and 40 age and sex matched normal subjects. Measurement was done on 18 specific tender point sites according to ACR criteria. Simultaneously, VAS was given to the subjects and asked to mark the severity of pain perceived immediately after algometry. Results: The range of PPT in FM patients was 0.73–3.43 kg/cm2 (1.831) and in RA was 0.267– 3.901 (2.62) in normal subjects 2.06–5.65 kg/cm2. VAS score range was 53–67.63 mm in FM patients 30.5- 49 mm and 19.65–44.85 mm in normal subjects. There was a significant reduction (P < 0.001) in PPT and VAS score in all 18 tender points in FM patients, RA patients were compared to normal subjects. by Annova and pearson correlation. Conclusion: There is significant reduction of PPT in both FM as well RA patients compared to normal subjects. The reduction in threshold was seen in RA even in areas which are not inflamed and adjacent to joint. VAS has tendency of overestimating the effect when compared to algometry especially in fibromyalgia. The VAS estimate was significantly higher in FM suggesting that in addition to altered PPT even the cognitive response to pain to be altered in FM.
P18 Clinical laboratory features in SLE JRS Vijaybabu Background: SLE is an autoimmune multisystem disorder with hemolytic anemia as one of the ACR classification criteria. In previous studies, it has been shown that Coomb’s positivity was associated with ACL positivity, thrombocytopenia, thrombosis and renal disease. This study was undertaken to identify the correlation between Coomb’s positivity and D-dimer as well as various clinicolaboratory features in SLE.