Search

Objective To identify predictors of early response to tocilizumab (TCZ) in patients with active rheumatoid arthritis (RA) seen in daily routine clinical practice. Methods A multicenter ambispective observational study of 126 RA patients treated with TCZ as a first- or second-line biological therapy. The variables associated to achieve the therapeutic goal (remission defined as a DAS28-ESR < 2.6) at 3 and 6 months were identified using regression analysis. Results TCZ was administered as the first biologic in 26% of patients. Overall, 34% of patients received TCZ as monotherapy. EULAR response and remission were obtained in 82% and 31% of patients at 3 months and in 86% and 40% at 6 months. In the multivariate analysis, the predictive factors increasing the likelihood of clinical remission at 3 months were baseline ESR > 30 mm/h (OR = 19.07, 95% CI: 2.720–133.716), baseline CRP > 10 mg/L (OR = 4.95; 95% CI: 1.464–13.826), and the presence of extra-articular manifestations of the disease (OR = 15.45, 95% CI: 2.334–102.319). The factors that decreased it were higher concentrations of hemoglobin (OR = 0.53, 95% CI: 0.319–0.910), higher baseline DAS28-ESR (OR = 0.30, 95% CI: 0.145–0.635) and the number of previous DMARDs (OR = 0.41, 95% CI: 0.221–0.779), and biological therapies used (OR = 0.33, 95% CI: 0.155–0.734). The only factor that remained statistically significant at 6 months was higher baseline DAS28-ESR (OR = 0.55, 95% CI: 0.347–0.877). No relationship was found with the neutrophil count or with the RF or ACPA positivity. Conclusion In routine clinical practice, strong acute phase response, the presence of extra-articular manifestations, and the number of previous DMARDs and biological therapies used may help to identify patients who will have a rapid response to TCZ. However, it is likely that no parameter will predict response if taken separately. [ABSTRACT FROM AUTHOR]

Objective To investigate the frequency and type of giant cell arteritis (GCA)-related ischemic complications in a series of patients with GCA who, for a substantial period of time (i.e., at least 3 mo), lacked vascular symptoms and presented with apparently isolated polymyalgia rheumatica (PMR). Methods Retrospective follow-up study of an unselected population of 167 patients with GCA diagnosed from 1985 to 2014. Results In all, 18 patients (11%) developed GCA on a background of a prior history of PMR. They were diagnosed as having isolated PMR because they did not have clinical evidence of GCA at diagnosis and exhibited a prompt and complete response to low-dose steroid therapy. However, during the course of treatment, 17 patients later experienced an arteritic relapse with the development of typical craniofacial symptoms, and one patient developed signs of upper extremity vascular insufficiency, resulting in the diagnosis of large-vessel GCA. The median time to GCA diagnosis from the initiation of low-dose steroid therapy was 9 ± 14.4 mo (range: 3−39). At the time of GCA diagnosis, severe ischemic complications were observed in 50% (9/18) of the patients. Of these patients 22% (4/18) were considered to have “true” occlusive disease (i.e., permanent visual loss, stroke, and/or limb claudication). Late inflammation of the aorta and its branches occurred in 4 (22%) of the patients during long-term follow-up. Conclusion Patients with GCA presenting with apparently isolated PMR have a significant risk of developing transient or permanent disease-related ischemic complications; these complications occurred in 50% of the cases. [ABSTRACT FROM AUTHOR]

Objective To investigate the frequency, location, characteristics, and clinical significance of subaxial involvement (below C1–C2) in a series of patients with rheumatoid arthritis (RA) and symptomatic involvement of the cervical spine. Methods A total of 41 patients with RA were examined via cervical spine magnetic resonance imaging (MRI). A comparative analysis of the incidence of the different types of subaxial lesions was performed between these patients and 41 age- and sex-matched patients with symptomatic cervical spondylosis. Results Stenosis of the spinal canal was found at the subaxial level in 85% of RA patients, and at the atlantoaxial level in 44%. Comparative analysis between these patients and the cervical spondylosis patients revealed significant differences in the types and frequencies of subaxial lesions. For both conditions, signs of discopathy and end-plate osteophytosis were the most common abnormalities observed on magnetic resonance imaging (MRI). However, in the RA patients these abnormalities coincided with subchondral bone and ligamentous acute inflammatory changes and with secondary destruction (vertebral instability) or repair (vertebral ankyloses). Only evidence of subaxial myelopathy was significantly associated with an increased risk of neurological dysfunction among the RA patients [Ranawat class II or III; P = 0.01; odds ratio (OR) = 11.43], although subaxial cord compression tended toward a significant association with the risk of neurological dysfunction ( P = 0.06; OR = 3.95). Conclusion Subaxial stenosis seems to be the consequence of both the inflammatory process and mechanical-degenerative changes. Despite its frequency, it was not usually related to the occurrence of myelopathy symptoms, not even in cases with MRI evidence of spinal cord compression. [ABSTRACT FROM AUTHOR]

Objective To analyze the clinical features, microbiological spectrum, diagnostic procedures and outcomes in native joint pyogenic arthritis among non-intravenous drug users. Methods We collected all microbiologically proved cases of infectious arthritis at our hospital between 1992 and 2013. Patients with prosthetic joint infection were excluded, as were patients with non-pyogenic arthritis and intravenous drug users. Results We identified 268 patients; the mean age was 61 ± 14.7 years and 62% were men. The incidence increased over the period of study. In 188 patients (70%), one or more underlying medical illnesses were found. The mean symptom duration was 8.9 ± 9.5 days. Globally, 311 affected joints were found, 232 (75%) involving peripheral joints and 79 (25%) axial joints. Staphylococci (55%) and Streptococci (29%) were the predominant microorganisms. Blood cultures were positive in 78% (173/223) of the cases. In 81 patients (30%), one or more concomitant infectious processes were found. Antimicrobial therapy was prescribed 4–8 weeks in most cases, and surgical drainage was performed in 65% of patients. Four patients relapsed and 23 (8%) died. Conclusions The prevalence of pyogenic native joint arthritis in non-intravenous drug users is increasing, frequently affecting old patients with underlying medical conditions. Although large joints are the most frequently compromised, the involvement of axial joints is a relevant feature that has not been recognized in other series. Staphylococci and Streptococci are the main causative agents. Bacteremia and concomitant infectious processes are frequent complications. Diagnostic delay and mortality continue to be important concerns. [ABSTRACT FROM AUTHOR]

Objective To assess the efficacy of tocilizumab (TCZ) in giant cell arteritis (GCA) patients with refractory disease and/or with unacceptable side effects due to corticosteroids. Methods A retrospective multicenter open-label study on 22 GCA patients treated with TCZ at standard dose of 8 mg/kg/month. The main outcomes were achievement of disease remission and reduction of corticosteroid dose. Results The mean age ± standard deviation of patients was 69 ± 8 years. The main clinical features at TCZ onset were polymyalgia rheumatica ( n = 16), asthenia ( n = 7), headache ( n =5), constitutional symptoms ( n = 4), jaw claudication ( n = 2), and visual loss ( n = 2). Besides corticosteroids and before TCZ onset, 19 of 22 patients had also received several conventional immunosuppressive and/or biologic drugs. Of 22 patients, 19 achieved rapid and maintained clinical improvement following TCZ therapy. Also, after a median follow-up of 9 (interquartile range: 6–19) months, the C-reactive protein level had fallen from 1.9 (1.2–5.4) to 0.2 (0.1–0.9) mg/dL ( p < 0.0001) and the erythrocyte sedimentation rate decreased from 44 (20–81) to 12 (2–20) mm/1st hour ( p = 0.001). The median dose of prednisone was also tapered from 18.75 (10–45) to 5 (2.5–10) mg/day ( p < 0.0001). However, TCZ had to be discontinued in 3 patients due to severe neutropenia, recurrent pneumonia, and cytomegalovirus infection. Moreover, 1 patient died after the second infusion of TCZ due to a stroke in the setting of an infectious endocarditis. Conclusion TCZ therapy leads to rapid and maintained improvement in patients with refractory GCA and/or with unacceptable side effects related to corticosteroids. However, the risk of infection should be kept in mind when using this drug in patients with GCA. [ABSTRACT FROM AUTHOR]