Histological evaluation of liver in two rheumatoid arthritis patients with chronic hepatitis B and C treated with TNF-alpha blockade: case reports.

Tumor necrosis factor (TNF)-alpha antagonists successfully modulate the pathogenesis of rheumatoid arthritis (RA). However, little is known about the effect of TNF-alpha blockade on the histology of chronic viral hepatitis. We describe the cases of two patients with RA, one with concurrent chronic hepatitis B virus and the other with hepatitis C virus infection who, as part of their evaluation, underwent liver biopsies while undergoing treatment with a TNF-alpha antagonist.

Effects of methotrexate use in a patient with rheumatoid arthritis and multiple sclerosis.

Rheumatoid arthritis (RA) and multiple sclerosis (MS) share similar pathophysiologic processes but coexistence of both diseases in the same patient has rarely been described. We describe the case of a 32 year old woman with rheumatoid arthritis treated with 12.5 mg of methotrexate once a week and 1 mg folic acid who developed paresthesias of her upper and lower extremities. Three years later, she acutely developed 6th nerve palsy, gait imbalance and urinary urgency and a diagnosis of multiple sclerosis was made. The use of methotrexate, though effective in controlling her rheumatoid arthritis, did not influence the development or progression of her multiple sclerosis. Although RA and MS may coexist in the same patient, treatment of one disease may have no influence on the clinical course of the other. Thus, the mechanism by which methotrexate suppresses disease activity in RA but not in MS despite both being T-cell mediated autoimmune diseases requires further investigative studies.

Outcomes analysis of Internet-based CME initiatives for diagnosis and treatment of fibromyalgia patients: transition from education to physician behavior to patient health.

A well designed outcomes research study was performed in which 20 primary care physicians were selected to participate. Each physician had more than 30 fibromyalgia patients in their practice. The study design consisted of four phases. In phase one, physicians undertook a self-assessment of their practice. Phase two of the study involved diagnosis and treatment of a virtual case vignette. The third phase consisted of analysis of the data from phase two and providing feedback from an expert rheumatologist, and the fourth phase was to complete patient report forms for five patients in their practice. The year-long study was completed by 12 physicians and resulted in data on 60 patients. The results of this study provide an insight into how physicians are diagnosing and treating patients with fibromyalgia. In this study, we transition from continuing medical education to physician behavior to patient outcomes.

Use of tumor necrosis factor-alpha (TNF-alpha) antagonists infliximab, etanercept, and adalimumab in patients with concurrent rheumatoid arthritis and hepatitis B or hepatitis C: a retrospective record review of 11 patients.

An understanding of the cytokine cascade in a rheumatoid joint has led to the development of new therapeutic options, including drugs targeting tumor necrosis factor-alpha (TNF-alpha). The safety profile of these agents in patients with hepatitis-induced liver disease, however, remains a concern because of risks associated with immune suppression. To examine the effect of three different TNF-alpha antagonists, infliximab, etanercept, and adalimumab, on serum transaminases and hepatitis viral load in patients with rheumatoid arthritis (RA) and concurrent hepatitis B (HBV) or hepatitis C (HCV). Medical records of 11 patients with diagnosis of RA and documented seropositivity for hepatitis B or hepatitis C were retrospectively reviewed for worsening of hepatic inflammation and viral proliferation as measured by a rise in aspartate aminotransferase (AST) or alanine aminotransferase (ALT) and viral load while using these agents. Three patients had RA with concurrent chronic HBV and eight patients had RA with concurrent chronic HCV. Seven patients remained on a single anti-TNF-alpha agent and four patients switched to a second anti-TNF-alpha agent due to treatment failure. Two patients showed a transient elevation in AST and/or ALT from normal, but in all 11 patients, AST and ALT levels were within one time the upper range of normal at the conclusion of the study. No significant increase in viral load was seen except one patient who showed a fourfold increase from baseline. Our case series supports results obtained from previous studies examining the safety of anti-TNF-alpha agents in patients with underlying hepatic disease. Use of these agents in patients with HBV or HCV may be associated with a transient transaminitis but appears to be safe overall. In both groups, frequent monitoring of serum transaminase levels and viral load is essential.

Risk of development of lung cancer is increased in patients with rheumatoid arthritis: a large case control study in US veterans.

OBJECTIVE: To investigate the occurrence of lung cancer in patients with rheumatoid arthritis (RA) in the US veteran population. Patients with rheumatic diseases appear to have an increased risk for the development of lymphoproliferative and some solid organ malignancies. METHODS: We conducted a retrospective case control study using prospectively collected data from the Veterans Integrated Service Networks (VISN) 16 Veteran Affairs (VA) database from 1998 to 2004. We studied the association of RA and lung cancer and analyzed data on 483,721 VA patients. Patients were identified by searching for the diagnoses of RA and lung cancer based on the International Classification of Diseases (ICD) codes. We identified 8768 (1.81%) patients with a diagnosis of RA (ICD code 714.0), 7280 (1.5%) patients with lung cancer (ICD code 162.0), 247 patients with lung cancer and RA, and 7033 patients with lung cancer but no RA. Logistic regression analysis was performed to adjust for age, gender, race, and tobacco and asbestos exposure. Statistical tests were conducted at a 5% level of significance. RESULTS: The diagnosis of RA was determined to have a significant association with lung cancer in this veteran population. Patients with RA are 43% (odds ratio 1.43) more likely to develop lung cancer than patients without RA, when adjusted for covariates. CONCLUSION: Our study shows a significant positive association between RA and the development of lung cancer in the veteran population. Veterans with RA have an increased incidence of lung cancer when compared to the non-RA population.

Successful etanercept use in an HIV-positive patient with rheumatoid arthritis.

Limited information exists on treatment of rheumatoid arthritis in a patient with coexisting human immunodeficiency virus (HIV) infection. We report a case of a patient with rheumatoid arthritis who then became HIV positive. His HIV viral load was controlled with antiretroviral therapy, but he continued to have active rheumatoid arthritis despite therapy with hydroxychloroquine, sulfasalazine, and corticosteroids. Because of unremitting rheumatoid disease, we are now treating him with a TNFalpha inhibitor, and his rheumatoid disease activity has decreased from 28 swollen and tender joint count to less than 5.