Etanercept is a monoclonal antibody targeted against Tumour Necrosis Factor-alpha (TNF-a) which is an effective treatment for rheumatoid arthritis and is in cases where conventional disease modifying agents such as methotrexate have failed. Neurological complications of treatment have been documented. We describe a case of transverse myelitis occurring in a 48 year-old lady with RA since 1994 who had been receiving etanercept for four years.
Background/Aims BSR states: “GCA is a medical emergency. Patients should be evaluated by a specialist ideally on the same working day if possible and in all cases within 3 working days.” Currently in this DGH there is no pathway for diagnosis and management of GCA. Patients are referred from their GP and A&E directly to the Ambulatory emergency care unit (AECU), but it is not guaranteed they will be seen by a specialist within 3 days. We were also receiving inappropriate referrals for possible GCA such as patients under the age of 50 or chronic headache. We have 7-day access to acute ultrasonography in this DGH. We aimed to utilise this service in our fast-track GCA pathway. Aims: 1. All patients with suspected GCA to be seen within 3 working days by specialist. 2. Reduce the number of inappropriate referrals. 3. Reduce irreversible sequelae (visual loss, scalp tissue necrosis and stroke) Methods We developed a fast-track pathway containing referral criteria, directions for obtaining urgent ultrasonography and management advice. This was uploaded onto the intranet and was put up as posters in the AECU (see pathway). Baseline measurement: data were collected from ambulatory care referrals over a 5-month period. 29 patients were referred as possible GCA. After introduction of the pathway, data were re-collected over a 3-month period, with nine patients referred as possible GCA. Results Outcomes measured: The percentage of inappropriate referrals decreased by 16% . The percentage of patients reviewed by rheumatology within 3 days increased from 44% to 78%. The percentage of sequelae did not change. Visual loss occurred in both groups at presentation (transient in one patient). Prior to pathway implementation, 31% of patients referred had raised CRP/ESR. ESR/CRP was not tested in 34% of referrals. Following implementation, 100% of patients had CRP and ESR tested; of these 66% had raised CRP/ESR. Conclusion We have shown that having a fast-track pathway in place results in higher likelihood of a specialist evaluation within 3 days, as per BSR guidelines. To improve we suggest implementation of dedicated same-day AECU appointments for Rheumatology Specialists. Disclosure P.M. Lakhani: None. S. Ali: None. E. Sames: None. P. Agarwal: None. R. Lisk: None.
Background Methotrexate (MTX) has been used for many years as treatment for Rheumatoid Arthritis (RA), and remains the first line disease modifying therapy with a well established efficacy and safety profile. Side effects include gastrointestinal (GI) symptoms, deranged liver function, pneumonitis and bone marrow suppression. Subcutaneous (SC) MTX offers improved tolerability and bioavailability when compared to oral MTX1. Patients with GI disturbances from oral MTX are often switched to the SC route. Other reasons for switching include mucositis, malaise and lack of efficacy on the maximum oral dose. Although few randomised controlled trials of parenteral versus oral MTX exist, the majority suggests a benefit to switching from oral to parenteral MTX2. MTX acts as a dihydrofloate reducatase inhibitor and therefore macrocytosis is a well recognised side effect. Although Azathioprine may also lead to macrocytosis3 studies imply no link between this and overt bone marrow toxicity4 and similar conclusion have not been reached with MTX either via the oral or SC route. Objectives To determine whether MCV is affected by SC MTX in a cohort of RA patients in a district general hospital setting. Methods Twenty nine patients with RA on SC MTX were analysed. Inclusion criteria were diagnosis of RA and treatment with SC MTX. All patients were treated with supplemental oral folic acid. Data was collected for the time period spanning September 2009 to December 2013. Macrocytosis is defined as an MCV of 100 or greater on five consecutive readings, or more than 105 on three readings. Results The average duration of disease was 15.3 years. 9 of 29 (31%) patients on SC MTX demonstrated macrocytosis. Of these, 5 (17%) exhibited a higher than normal MCV on oral MTX before conversion to SC administration. Four (14%) became macrocytic on SC MTX, with a prior normal MCV on oral treatment. Of the 14% who showed macrocytosis on SC MTX the average Hb was 12.6g/dl. In the 20 patients who did not develop macrocytosis the average Hb was 12.4g/dl. Data were collected for potentially confounding factors such as vitamin B12 or folate deficiency, thyroid dysfunction and myeloma. Two of the fifteen patients who had raised MCV were found positive for one of these factors (low folate and high TSH). Conclusions Only 14% of patients developed macrocytosis after conversion from oral to SC MTX. There was little difference in Hb between the patients who were macrocytic and those who were not. No overt case of anaemia was identified. None developed severe manifestations of bone marrow failure such as sustained pancytopenia. Our data suggest patients on SC MTX do not have a greater propensity to develop macrocytosis, and even in those who do there was no concurrent anaemia. More research on the implication of macrocytosis and SC MTX therapy is needed. References Hoekstra et al. J Rheumatol. 2004 Apr;31(4):645-8. Moitra RK. Et al. 2005 Feb;44(2):256-7. Bernstein CNet al. DigDis Sci. 1994;39:1638–41 Thomas CW et al. Inflamm Bowel Dis. 2003;9:2...
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.