BackgroundPsoriatic arthritis (PsA) is an inflammatory spondyloarthritis associated with psoriasis. Over the recent years the treatment of PsA has changed dramatically with the use of synthetic (s) disease modified anti-rheumatic drugs (DMARDs) as well as biologic (b) DMARDs, particularly tumor necrosis factor inhibitors. The goal of all these therapies is to achieve remission or minimal disease activity (MDA) [1]. Once remission is achieved and sustained the question is whether the treatment should be continued at full dosage, at a tapered dosage or should be discontinued. For PsA there are no recommendations for dosage tapering or discontinuation of biologic therapy and literature data regarding maintained clinical remission is conflicting.B-mode (BM) musculoskeletal (MS) ultrasound (US) has been widely shown to be more sensitive than clinical assessment in detecting joint synovitis and enthesitis [2,3] and Doppler technique is able to identify inflammatory activity [3,4].ObjectivesTo describe and compare clinical and MSUS features between PsA patients treated with full and tapered dosage of bDMARDs. The secondary objective was to compare clinical and MSUS features between PsA patients treated with bDMARDs with and without concomitant sDMARDs.MethodsWe evaluated 102 patients with PsA treated with bDMARDs. The bDMARD dosage tapering had been made in patients with a maintained remission or MDA according to their attending rheumatologist and with the patient acceptance. The bDMARDs tapering consisted of the followings: increase the interval between doses for subcutaneous bDMARDs or reduction of the dose for intravenous bDMARDs. The clinical evaluation consisted of a dermatologic and rheumatologic assessment of disease activity. The presence of BM and colour Doppler (CD) synovitis, tenosynovitis, enthesopathy and paratenonitis was investigated by a rheumatologist blinded to drug dosage, clinical assessments and laboratory results.ResultsSeventy four (72.5%) patients received full dosage of bDMARDs and 28 (27.5%) received tapered dosage. The duration with biologic therapy and with current biologic therapy were significantly higher in patients with tapered dosages (p=0.008 and p=0.001, respectively). We found no significant differences between clinical, laboratory and US variables, both for BM and CD between patients with full and tapered dosage and between patients with and without concomitant sDMARD.ConclusionsClinical assessment, MSUS variables, and MDA status are similar in patients receiving full and tapered dosage of bDMARDs.ReferencesGossec L et al. Ann Rheum Dis. 2012 Jan;71(1):4-12Balint PV et al. Ann Rheum Dis 2002;61:905-10D'Agostino MA et al. Arthritis Rheum 2003;48:523-33Naredo E et al. Arthritis Rheum 2008;58:2248-56Disclosure of InterestNone declared
Appropriate isolation and oseltamivir use in flu positive patients: 2018=27% (6/22); 2019=74% (17/23). Conclusion and relevance Increased flu screening in 2019 despite a national fall in hospitalised flu cases compared with 2018 suggests that clinicians were more likely to consider influenza when rapid diagnostics were available on-site. Onsite testing significantly reduced TAT, having a measurable impact on the appropriateness of isolation and oseltamivir use. The absence of isolation facilities in the coronary care unit represented a significant clinical risk of influenza exposure.
underwent surgery twice for wound debridement and samples were taken. After 6 days of empirical treatment, microbiological culture of exudate revealed Streptococcus pyogenes, and directed antibiotic therapy with penicillin and clindamycin was given. Skin lesions improved progressively with the treatment and lymphocyte count was 1.12×10×3/mL. However, he had to undergo plastic surgery for loss of granulated substance in the affected tissue. Clindamycin was suspended after 7 days and penicillin G after 14 days of treatment. One month later, a significant improvement in cutaneous injuries caused by baricitinib was observed, although he continued to need daily cures for sequels. Conclusion and relevance This adverse reaction was reported to the pharmacovigilance centre and caused baricitinib discontinuation. Immunosuppression caused by baricitinib and probable subsequent infections should be taken into account when starting this treatment in susceptible patients.
was 70 (57-83) years. Background: 50% had arterial hypertension, 37.5% heart disease, 25% diabetes, 25% chronic obstructive pulmonary disease and 12.5% active neoplasia. The diagnosis was severe pneumonia in all cases. The average duration of hospitalisation was 29 (4-73) days. 50% of patients were admitted to the ICU and required mechanical ventilation. In 75%, the dose was 600 mg and the rest required 400 mg, all single doses. The average time from symptom onset to drug administration was 15 (10-30) days. Concomitant drug therapy for SARS-CoV-2: 100% hydroxychloroquine with azithromycin, 87.5% lopinavir/ritonavir, 37.5% methylprednisolone boluses, 25% oral methylprednisolone and 12.5% interferon-ß-1b. 87.5% of patients were discharged. No adverse reactions were reported. Conclusion and relevance Treatment with tocilizumab could be considered a safe and effective option in patients with severe SARS-CoV-2 pneumonia. Further studies are necessary to confirm these preliminary results. Adjustment of the treatments to the criteria established by the regulatory agencies and the recording of health outcomes could contribute to more efficient therapies.
was 70 (57-83) years. Background: 50% had arterial hypertension, 37.5% heart disease, 25% diabetes, 25% chronic obstructive pulmonary disease and 12.5% active neoplasia. The diagnosis was severe pneumonia in all cases. The average duration of hospitalisation was 29 (4-73) days. 50% of patients were admitted to the ICU and required mechanical ventilation. In 75%, the dose was 600 mg and the rest required 400 mg, all single doses. The average time from symptom onset to drug administration was 15 (10-30) days. Concomitant drug therapy for SARS-CoV-2: 100% hydroxychloroquine with azithromycin, 87.5% lopinavir/ritonavir, 37.5% methylprednisolone boluses, 25% oral methylprednisolone and 12.5% interferon-ß-1b. 87.5% of patients were discharged. No adverse reactions were reported. Conclusion and relevance Treatment with tocilizumab could be considered a safe and effective option in patients with severe SARS-CoV-2 pneumonia. Further studies are necessary to confirm these preliminary results. Adjustment of the treatments to the criteria established by the regulatory agencies and the recording of health outcomes could contribute to more efficient therapies.
BackgroundTocilizumab (TCZ), a recombinant humanised antibody targeting soluble and membrane IL-6 receptor, is commonly used in rheumatoid arthritis (RA) patients refractory to tumour necrosis factor inhibitors, demonstrating 60–80% effectiveness. Clinical parameters such as years of disease prior to TCZ treatment, naïve for biological therapy (BT naïve), baseline Disease Activity Score 28 (DAS28) and Health Assessment Questionnaire (HAQ), have been associated with response to TCZ, although with conflicting results. Identification of clinical predictors of response may lead to a better selection of BT alternatives in DMARDs refractory RA patients.PurposeTo assess the effectiveness of TCZ in RA patients and the influence of clinical parameters.Material and methodsThis was a retrospective cohort study. Linear or logistic regression models were applied to evaluate the influence of clinical parameters (baseline DAS28, baseline HAQ, BT naïve, years of disease prior to TCZ treatment, age at TCZ start, concomitant DMARDs and corticosteroids, baseline CRP and ESR) on TCZ effectiveness, measured according to relative percentage of variation in DAS28, and EULAR response (responders vs non-responders), after 18 months of therapy in RA patients.Results61 patients (83.6% women; 53.4±12.6 years) were investigated, with mean disease duration of 10 (7–18) years and 8 (3–13.5) years of disease evolution before TCZ therapy. Only 22 patients were naïve for BT (22/61; 36.1%). Baseline DAS28 and HAQ were 5.6±1.15 and 1.66±0.66, respectively. EULAR response was 88.5% (54/61), and relative percentage of DAS28 variation was −58.9% (−68.8, −44.7) at 18 months. The decrease in relative percentage of DAS28 variation (R2=0.229) was higher in patients with higher baseline DAS28 (coef: −7.98; 95% CI −13.1, −2.8; p=0.03), lower baseline HAQ (coef: 14.9; 95% CI 6.02, 23.8; p=0.01) and BT naïve (coef= −11.5, 95% CI −22.3, −8.0; p=0.036). EULAR response was more frequent in patients with higher baseline DAS28 (OR 3; 95% CI 1.2, 8.3; p=0.048), shorter time of disease prior to TCZ treatment (OR 0.8; 95% CI 1.02–1.5, p=0.026) and lower number of BT failures (OR 0.31; 95% CI 0.11–0.99; p=0.016).ConclusionTCZ effectiveness in RA patients after 18 months of therapy was >88% (EULAR), with an approximated 60% of relative reduction in DAS28. High baseline DAS28, low baseline HAQ, BT naïve patients and shorter time of disease prior to TCZ treatment have been identified as predictors of better response to TCZ therapy. Hence TCZ should become the first option of BT in refractory DMARDs RA patients.No conflict of interest
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