Osteonecrosis may complicate the course of systemic lupus erythematosus and may contemporaneously affect multiple joints. The major risk factor associated with the development of osteonecrosis is the use of glucocorticoid at high doses. Recent studies using serial MRI, which represents the “gold standard” for the early detection of osteonecrosis, yielded some interesting findings about the natural history of this clinical entity. Osteonecrosis in the majority of the cases is asymptomatic and occurs early in the course of the disease. Its later occurrence is associated with lupus flare that requires the increase of corticosteroid dose. The optimal treatment of osteonecrosis is controversial. In case of silent osteonecrosis involving a small area conservative strategy is usually adequate. When lesions are symptomatic surgical treatment as core decompression or free vascularized fibular grafting is required; extracorporeal shockwave treatment may represent an alternative therapeutic approach. When the lesion has a medium-large dimension or involves a weight-bearing area bone collapse is a common complication requiring total joint replacement. Coadministration of bisphosphonate or warfarin with high doses of corticosteroid might be a promising preventive strategy of osteonecrosis.
BackgroundThe aim of the Rheumatoid Arthritis (RA) treatment is the achievement of remission or low disease activity in the shortest possible time. The EULAR Task Force suggests that in cases of persistent remission, after tapering glucocorticoids, patients and physicians may decide together to titrate the dose of conventional synthetic disease-modifying antirheumatic drugs (DMARDs) or consider tapering biological DMARDs.ObjectivesThe objective of this study is to evaluate in RA patients on remission after a standard tocilizumab (TCZ) dose (8mg/kg/month) the persistence of remission by halving the dose.MethodsThe patients in persistent (>1 year without flare) clinical remission (DAS28 <2.6) and with the absence of US signs of disease activity were included in this study. They were assigned consecutively (1: 1) to continue TCZ at a standard-dose regimen (8 mg/kg) or to 4 mg/kg reduced-dose regimen.Clinical and US evaluations were performed every 2 months in all patients.The clinical assessment included: anthropometric and demographic characteristics (age, sex, height, weight), disease duration, laboratory markers (Erythrocyte Sedimentation Rate [ESR], C –Reactive Protein [CRP], rheumatoid factor, Anti–citrullinated protein antibody [ACPA], complete blood count, liver and renal function tests), disease activity scores (DAS28-CRP).ResultsNineteen of the 26 RA patients treated with tocilizumab in our Unit met the first inclusion criteria for randomization, i.e.: persistent clinical remission (DAS28 <2.6). However, 4 of these patients had US signs of disease activity. The other 15 patients did not show any sign of US disease activity and were therefore assigned consecutively with a 1: 1 ratio to continue TCZ at a standard-dose regimen (8 mg/kg) or to 4 mg/kg reduced-dose regimen. No significant or relevant differences between the 2 groups of patients were observed. Over the 12 months of follow up the mean DAS28 values were very similar in patients who continued the standard 8mg/kg TCZ dose and in those who switched to a reduced dose of 4 mg/kg. In none of them a disease flare in terms of both DAS28 and US assessment was observed.ConclusionsFor the tiny number of subjects and the relatively short follow up, we are not able to draw conclusions, but our results indicate that in patients with severe RA, unresponsive to anti-TNFα agents and achieving a full remission with TCZ treatment a dose tapering to 4 mg/kg may be considered, keeping in mind the positive consequences on the economic burden of therapy and that TCZ safety profile is dose dependent.Disclosure of InterestNone declared
Background Rituximab (RTX), a chimeric monoclonal antibody targeting CD20 B cell antigens, is a safe and effective treatment for rheumatoid arthritis (RA) [1]. It has been approved for RA patients who have inadequately responded to one or more anti-TNF agent and has recently been demonstrated to be significantly more effective after a first anti-TNF than switching to a second [2]. Long-term extensions of randomised controlled trials have demonstrated that prolonged RTX exposure of up to 9.5 years does not affect its safety, but there are no data concerning real-life clinical experience. Objectives The aim of this multicentre clinical study was to evaluate the retention of RTX treatment in patients with RA. Methods The clinical records of 472 RA patients treated with RTX from August 2006 to December 2013 in ten Italian rheumatology centres were reviewed, and treatment survival and the impact of selected variables were evaluated using Kaplan-Meier and Cox survival analyses. Results Four hundred and seventy-two patients with a diagnosis of RA based on the 1987 ACR classification criteria (81.6% female; mean age 56.2±12.8 years; mean disease duration 10.5±8 years; 76.3% RF positive; 75% anti-CCP positive) were treated with RTX for a mean of 40.1±26.37 months (range 0-122). Seventy-six percent were co-treated with MTX, and 24% had previously received two or more anti-TNF agents. Their median DAS28 score at baseline was 5.07±1.3. For patients completing at least 12, 24, 36, 48 and 60 months of follow-up, the retention rates were respectively 87.9%, 78.8%, 72.5%, 67.6% and 63.8% (Fig. I) Treatment discontinuations because of adverse events and inefficacy had a similar temporal trend. Multivariate analysis (Cox regression) showed that none of the considered predictive variables was significantly associated with treatment survival: gender p=0.399; age p=0.486; disease duration p=0.999, baseline DAS28 p=0.412; number of previous anti-TNFα failures p=0.975; the presence of RF p=0.513; MTX treatment p=0.340. Conclusions Our findings show that 63.8% of RA patients continued treatment with RTX for 60 months. References Chi Chiu Mok. Rituximab for the treatment of rheumatoid arthritis: an update. Drug Des Devel Ther. 2013;8:87-100 Emery P, et al. Rituximab versus an alternative TNF inhibitor in patients with rheumatoid arthritis who failed to respond to a single previous TNF inhibitor: SWITCH-RA, a global, observational, comparative effectiveness study. Ann Rheum Dis. 2014. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3994
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