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Background/Aims@#We aimed to compare the effectiveness and safety of Janus kinase inhibitors (JAKi) vs. biologic disease- modifying antirheumatic drugs (bDMARD) in Korean patients with rheumatoid arthritis (RA) who had an inadequate response to conventional synthetic DMARDs. @*Methods@#A quasi-experimental, multi-center, prospective, non-randomized study was conducted to compare response rates between JAKi and bDMARDs in patients with RA naïve to targeted therapy. An interim analysis was performed to estimate the proportion of patients achieving low disease activity (LDA) based on disease activity score (DAS)–28– erythroid sedimentation rate (ESR) (DAS28-ESR) at 24 weeks after treatment initiation and to evaluate the development of adverse events (AEs). @*Results@#Among 506 patients enrolled from 17 institutions between April 2020 and August 2022, 346 (196 JAKi group and 150 bDMARD group) were included in the analysis. After 24 weeks of treatment, 49.0% of JAKi users and 48.7% of bDMARD users achieved LDA (p = 0.954). DAS28-ESR remission rates were also comparable between JAKi and bDMARD users (30.1% and 31.3%, respectively; p = 0.806). The frequency of AEs reported in the JAKi group was numerically higher than that in the bDMARDs group, but the frequencies of serious and severe AEs were comparable between the groups. @*Conclusions@#Our interim findings reveal JAKi have comparable effectiveness and safety to bDMARDs at 24 weeks after treatment initiation.
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Background@#To investigate the use of cyclooxygenase-2 (COX-2) inhibitors as an initial drug treatment for knee osteoarthritis (OA) patients. @*Methods@#From 2013 to 2015, patients with knee OA were identified from the Korean nationwide claims database. Among them, we extracted incident cases of knee OA to identify the initial drug treatment. Trends in the use of non-steroid anti-inflammatory drugs (NSAIDs) including COX-2 inhibitors were analyzed during the first year after their diagnosis. Associated factors for COX-2 inhibitor use were examined using a multivariate logistic regression model. @*Results@#We identified 2,857,999 incident knee OA patients (955,259 in 2013, 981,314 in 2014, and 921,426 in 2015). The mean ± standard deviation age of patients was 64.2 ± 9.8 years. The frequency of COX-2 inhibitor use as initial treatment increased from 3.5% in 2013 to 7.2% in 2015 (P < 0.01). In patients taking the medication regularly for one year after diagnosis (medication possession ratio ≥ 50%), COX-2 inhibitor use also rapidly increased from 5.5% in 2013 to 11.1% in 2015 (P < 0.01). However, the frequencies of non-selective NSAID and analgesic use did not decrease remarkably. Factors associated with patients using COX-2 inhibitors on initial drug treatment were older age (odds ratio [OR], 1.08), female (OR, 1.24), and comorbidity (OR, 1.03). Type of institution, physician speciality, and insurance type of patients were also associated. @*Conclusion@#In Korea, COX-2 inhibitors have rapidly increased as an initial treatment for knee OA patients, but it has not appeared to reduce the use of non-selective NSAIDs and analgesics.
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Background/Aims@#This study was performed to undertake cross-cultural adaptation and validation of the Educational Needs Assessment Tool (ENAT) in rheumatoid arthritis (RA) for use in Korea. @*Methods@#The study involved two main phases: cross-cultural adaptation of the ENAT from English into Korean, and validation of the Korean ENAT. The first phase followed the established process of cross-cultural adaptation of self-report measures, and in the second phase, the Korean ENAT data were analyzed using the Rasch measurement model. Fit to the model was determined using the observed data infit and outfit statistics. Additional tests of validity included unidimensionality and internal consistency. @*Results@#Adequate conceptual equivalence was achieved following the adaptation process. A total of 123 patients completed the Korean ENAT. The mean age was 46.7 ± 12.3 years and the majority of patients (81.3%) were female. Thirty-five of the 39 items gave good fit to the model. The four items deviating from the model had infit and outfit > 1.50. The item separation index (5.26) and item reliability index (0.97) provided evidence for good reliability of items. All seven domains of the Korean ENAT fit the Rasch model. The internal consistency of the Korean ENAT was high, and unidimensionality was confirmed (person separation index, 3.41; reliability index, 0.92; item separation index, 16.82; reliability index, 1.00). @*Conclusions@#Using the standard procedure for cross-cultural adaptation, the ENAT has been adapted into Korean, and Rasch analysis has confirmed the construct validity, reliability, and unidimensionality of the Korean ENAT.
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Background@#We aimed to examine the uptake of infliximab and etanercept biosimilars in patients with rheumatoid arthritis (RA) and its economic implication for healthcare expenditure. @*Methods@#Using Korean Health Insurance Review and Assessment Service National Patient Samples, we extracted RA patients who used biologic disease modifying anti-rheumatic drugs (bDMARDs) between 2009 and 2018. Descriptive statistics were used to explain the basic features of the data. We calculated the proportion of users of each bDMARD among total patients with bDMARDs half-yearly. We assessed changes in the utilization proportions of bDMARDs including 4 tumor necrosis factor inhibitors (TNFis) and 2 non-TNFis, which have been approved for RA in Korea: etanercept, infliximab, adalimumab, golimumab, tocilizumab, and abatacept, and analyzed the changes in market share of biosimilars among the bDMARDs after their introduction. Overall trends of medical costs for each bDMARD were presented over the 10-year period. @*Results@#Since the introduction of the biosimilar TNFis in 2012, the proportion of their use among bDMARDs steadily increased to 15.8% in 2018. While there has been a gradual increase in the use of biosimilar TNFis, the use of the corresponding originators has been decreasing. The introduction of biosimilar TNFis has resulted in a decrease in the medical costs of patients using either originator or biosimilar TNFis. @*Conclusion@#In Korea, the proportional use of biosimilar TNFis has gradually increased since their introduction. The availability of less expensive biosimilar TNFis seems to have brought about a decrease in the medical costs of users of the originators.
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Background@#Patients with rheumatoid arthritis (RA) undergoing targeted therapy have a higher risk of developing tuberculosis (TB). This requires diagnosis and treatment of latent tuberculosis infection (LTBI). We aimed to evaluate whether diagnosis and treatment of LTBI in RA are effective in Korea, and to estimate the risk of TB development by calculating the incidence rate of active TB among RA patients receiving targeted therapy. @*Methods@#We analyzed data from two prospective cohort studies of RA patients who received biologic disease-modifying antirheumatic drugs (bDMARDs) or Janus kinase (JAK) inhibitor.We selected new starters of targeted therapy and classified them into three groups receiving tumor necrosis factor (TNF) inhibitor, non-TNF inhibitor, and JAK inhibitor, respectively. We then compared LTBI prevalence, treatments, and active TB incidence during first-line therapy in each group. @*Results@#A total of 765 RA patients (574 TNF inhibitor users, 132 non-TNF inhibitor users, and 59 JAK inhibitor users) were included in this study. Observation periods were 1,255.2 personyears (PYs), 264.7 PYs, and 53.3 PYs, respectively. All 765 patients underwent LTBI screening, and the positivity rate was 26.5% (n = 203). Of the 203 LTBI-positive patients, 189 (93.1%) received treatment. Only one patient, who was in the TNF inhibitor group, and was negative for the interferon gamma release assay (IGRA), did not receive LTBI treatment and developed active TB during follow-up. @*Conclusion@#Although the prevalence of LTBI in RA patients who started targeted therapy was slightly elevated, the Korean guidelines specifying LTBI screening and treatment were effective in preventing latent TB from becoming active.
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Background/Aims@#This study was performed to undertake cross-cultural adaptation and validation of the Educational Needs Assessment Tool (ENAT) in rheumatoid arthritis (RA) for use in Korea. @*Methods@#The study involved two main phases: cross-cultural adaptation of the ENAT from English into Korean, and validation of the Korean ENAT. The first phase followed the established process of cross-cultural adaptation of self-report measures, and in the second phase, the Korean ENAT data were analyzed using the Rasch measurement model. Fit to the model was determined using the observed data infit and outfit statistics. Additional tests of validity included unidimensionality and internal consistency. @*Results@#Adequate conceptual equivalence was achieved following the adaptation process. A total of 123 patients completed the Korean ENAT. The mean age was 46.7 ± 12.3 years and the majority of patients (81.3%) were female. Thirty-five of the 39 items gave good fit to the model. The four items deviating from the model had infit and outfit > 1.50. The item separation index (5.26) and item reliability index (0.97) provided evidence for good reliability of items. All seven domains of the Korean ENAT fit the Rasch model. The internal consistency of the Korean ENAT was high, and unidimensionality was confirmed (person separation index, 3.41; reliability index, 0.92; item separation index, 16.82; reliability index, 1.00). @*Conclusions@#Using the standard procedure for cross-cultural adaptation, the ENAT has been adapted into Korean, and Rasch analysis has confirmed the construct validity, reliability, and unidimensionality of the Korean ENAT.
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Background@#We aimed to examine the uptake of infliximab and etanercept biosimilars in patients with rheumatoid arthritis (RA) and its economic implication for healthcare expenditure. @*Methods@#Using Korean Health Insurance Review and Assessment Service National Patient Samples, we extracted RA patients who used biologic disease modifying anti-rheumatic drugs (bDMARDs) between 2009 and 2018. Descriptive statistics were used to explain the basic features of the data. We calculated the proportion of users of each bDMARD among total patients with bDMARDs half-yearly. We assessed changes in the utilization proportions of bDMARDs including 4 tumor necrosis factor inhibitors (TNFis) and 2 non-TNFis, which have been approved for RA in Korea: etanercept, infliximab, adalimumab, golimumab, tocilizumab, and abatacept, and analyzed the changes in market share of biosimilars among the bDMARDs after their introduction. Overall trends of medical costs for each bDMARD were presented over the 10-year period. @*Results@#Since the introduction of the biosimilar TNFis in 2012, the proportion of their use among bDMARDs steadily increased to 15.8% in 2018. While there has been a gradual increase in the use of biosimilar TNFis, the use of the corresponding originators has been decreasing. The introduction of biosimilar TNFis has resulted in a decrease in the medical costs of patients using either originator or biosimilar TNFis. @*Conclusion@#In Korea, the proportional use of biosimilar TNFis has gradually increased since their introduction. The availability of less expensive biosimilar TNFis seems to have brought about a decrease in the medical costs of users of the originators.
ABSTRACT
Background@#Patients with rheumatoid arthritis (RA) undergoing targeted therapy have a higher risk of developing tuberculosis (TB). This requires diagnosis and treatment of latent tuberculosis infection (LTBI). We aimed to evaluate whether diagnosis and treatment of LTBI in RA are effective in Korea, and to estimate the risk of TB development by calculating the incidence rate of active TB among RA patients receiving targeted therapy. @*Methods@#We analyzed data from two prospective cohort studies of RA patients who received biologic disease-modifying antirheumatic drugs (bDMARDs) or Janus kinase (JAK) inhibitor.We selected new starters of targeted therapy and classified them into three groups receiving tumor necrosis factor (TNF) inhibitor, non-TNF inhibitor, and JAK inhibitor, respectively. We then compared LTBI prevalence, treatments, and active TB incidence during first-line therapy in each group. @*Results@#A total of 765 RA patients (574 TNF inhibitor users, 132 non-TNF inhibitor users, and 59 JAK inhibitor users) were included in this study. Observation periods were 1,255.2 personyears (PYs), 264.7 PYs, and 53.3 PYs, respectively. All 765 patients underwent LTBI screening, and the positivity rate was 26.5% (n = 203). Of the 203 LTBI-positive patients, 189 (93.1%) received treatment. Only one patient, who was in the TNF inhibitor group, and was negative for the interferon gamma release assay (IGRA), did not receive LTBI treatment and developed active TB during follow-up. @*Conclusion@#Although the prevalence of LTBI in RA patients who started targeted therapy was slightly elevated, the Korean guidelines specifying LTBI screening and treatment were effective in preventing latent TB from becoming active.
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Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterised by symmetrical involvement of the joints, associated extra-articular manifestations and functional disability. In Korea, several epidemiologic studies reporting prevalence and incidence rates of RA have been conducted using large databases such as claims databases, national surveys, prospective cohort databases or electronic health records; according to these data sources, the estimated prevalence ranged from 0.27% to 1.85%. The prevalence of extra-articular manifestations such as interstitial lung disease (ILD) and Sjögren’s syndrome (SS) were also reported, but an issue of external validity of the study results persisted. In this review, we detail the epidemiology of Korean RA patients, focusing on the prevalence of RA and the frequency of systemic extra-articular manifestations including ILD and SS reported in previous studies. In addition, we discuss the current methodological issues which are inherent in Korean epidemiologic studies for patients with RA with understanding of the characteristics of each database.
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Background@#In this study, we aimed to evaluate and compare the treatment indication for patients with glucocorticoid-induced osteoporosis (GIOP) in various clinical practice guidelines. @*Methods@#We searched for potentially relevant studies conducted from January 2000 to March 2020 using online databases, including PubMed, Ovid-EMBASE, Guidelines International Network, National Institute for Health and Clinical Excellence, KoreaMed, KMbase, and KoMGI. We reviewed and analyzed the guidelines that included recommendations on GIOP and fulfilled the inclusion criteria. @*Results@#A total of 94 articles were selected based on review of the title and abstract; 14 guidelines were assessed upon reviewing the full text. The bone mineral density score for therapeutic intervention of GIOP in postmenopausal women was presented in 7 guidelines, among which 3 guidelines set a T-score of −2.5 or lower and the other 4 guidelines proposed a less stringent cut-off point of −1.5 or lower. Among the 10 guidelines published since 2012 after the emergence of the fracture risk assessment tool (FRAX), 6 guidelines included FRAX in their criteria for defining intervention thresholds. However, they were further divided into fixed-probability (n=3) and age-dependent (n=3) thresholds based on the country. @*Conclusions@#Recently developed guidelines use FRAX as the criterion for establishing the treatment of patients with GIOP. However, these intervention thresholds need to be adapted for each country.
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Background@#To estimate the prevalence of Sjögren's syndrome (SS) in patients with rheumatoid arthritis (RA) and to compare the clinical features of RA patients with and without SS. @*Methods@#We conducted a retrospective study of RA patients who visited a rheumatology clinic in a tertiary referral hospital in Korea between May 20 and July 22, 2016. All patients fulfilled the classification criteria for RA, and the diagnosis of SS was made clinically by rheumatologists and according to the 2002 American-European Consensus Group (AECG), 2012 American College of Rheumatology (ACR), and 2016 ACR/European League Against Rheumatism (EULAR) classification criteria. The prevalence was estimated as the number of SS patients within the total number of RA patients. The disease activity and treatment pattern of RA were compared between patients with and without SS. @*Results@#Among 827 RA patients, 72 patients (8.7%) were diagnosed with SS by a rheumatologist, though only 60 patients (7.3%) satisfied the 2002 AECG classification criteria for SS. Fifty-two patients (6.3%) and 56 patients (6.8%) fulfilled the 2012 ACR and 2016 ACR/EULAR classification criteria, respectively. The prevalence of SS in RA patients was 10.5%, 17.0%, and 67.6% in rheumatoid factor, antinuclear antibody (≥ 1:80), and anti-Ro antibody positive patients, respectively. @*Conclusion@#The prevalence of SS among RA patients was 8.7% according to rheumatologists' diagnosis. The presence of SS did not affect the treatment patterns of RA patients. However, the autoantibody profiles and demographics of RA patients with SS differed from those of patients without SS.
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Background@#In this study, we aimed to evaluate and compare the treatment indication for patients with glucocorticoid-induced osteoporosis (GIOP) in various clinical practice guidelines. @*Methods@#We searched for potentially relevant studies conducted from January 2000 to March 2020 using online databases, including PubMed, Ovid-EMBASE, Guidelines International Network, National Institute for Health and Clinical Excellence, KoreaMed, KMbase, and KoMGI. We reviewed and analyzed the guidelines that included recommendations on GIOP and fulfilled the inclusion criteria. @*Results@#A total of 94 articles were selected based on review of the title and abstract; 14 guidelines were assessed upon reviewing the full text. The bone mineral density score for therapeutic intervention of GIOP in postmenopausal women was presented in 7 guidelines, among which 3 guidelines set a T-score of −2.5 or lower and the other 4 guidelines proposed a less stringent cut-off point of −1.5 or lower. Among the 10 guidelines published since 2012 after the emergence of the fracture risk assessment tool (FRAX), 6 guidelines included FRAX in their criteria for defining intervention thresholds. However, they were further divided into fixed-probability (n=3) and age-dependent (n=3) thresholds based on the country. @*Conclusions@#Recently developed guidelines use FRAX as the criterion for establishing the treatment of patients with GIOP. However, these intervention thresholds need to be adapted for each country.
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OBJECTIVE: To evaluate the nonsteroidal anti-inflammatory drugs (NSAID)-sparing effect of symptomatic slow-acting drugs for osteoarthritis (SYSADOA) in knee osteoarthritis (OA) patients. METHODS: A retrospective study was conducted on a cohort of knee OA patients who visited a single academic referral hospital from 2013 to 2014. Among all patients, NSAID users in their first visit were extracted and divided into SYSADOA users and SYSADOA non-users. All patients were observed from their first visit with knee OA to their last visit, NSAID discontinuation, or the date of data collection, July 2017 (mean observational periods: 369.1 days). To evaluate the NSAID-sparing effect of SYSADOA, Cox regression analysis was performed after adjusting for confounding factors. RESULTS: Patients for this study (n=212) were divided into SYSADOA users (n=57) and SYSADOA non-users (n=155). The mean age (68.8 vs. 66.6 years old, p=0.31) and the number of comorbidities (p=0.73) were comparable between the two groups. The SYSADOA users showed higher Kellgren–Lawrence (KL) grade (66.7% of patients with more than KL grade 3) than SYSADOA non-users (42.6% of patients with more than KL grade 3) (p=0.02). In treatment, the frequency of intra-articular injection was higher in the SYSADOA user group than the SYSADOA non-user group (33.3% vs. 9.0%, p<0.01). In Cox regression analysis, SYSADOA use contributed to NSAID discontinuation in knee OA patients (hazard ratio 2.97, 95% confidential interval 1.42∼6.22). CONCLUSION: This real-world analysis demonstrated that SYSADOA use combined with NSAIDs had a significant effect on NSAID discontinuation in patients with knee OA.
Subject(s)
Humans , Anti-Inflammatory Agents, Non-Steroidal , Cohort Studies , Comorbidity , Data Collection , Injections, Intra-Articular , Knee , Osteoarthritis , Osteoarthritis, Knee , Referral and Consultation , Retrospective StudiesABSTRACT
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease affecting various organs. Among its manifestations, inflammatory pseudotumor (IPT) is an extremely rare disease about which no case has been reported of it occurring in the liver. We present a case of a SLE patient with hepatic IPT (hIPT) successfully treated with immunosuppressants. A 16-year-old male with elevated liver enzymes visited our clinic and was diagnosed as SLE. Although no lesion was observed in the initial abdomen ultrasonography, the abdominal CT on hospital day 7 revealed a new hepatic mass resembling an abscess. Despite 5 weeks of antibiotics treatment, the hepatic mass remained, and was re-diagnosed as hIPT secondary to SLE with an abdominal MRI. After high dose prednisolone and mycophenolate mofetil treatment, lupus activity subsided and hIPT disappeared in the follow-up CT. This case suggests that hIPT should be considered as a differential diagnosis among hepatic mass in SLE patients.
Subject(s)
Adolescent , Humans , Male , Abdomen , Abscess , Anti-Bacterial Agents , Autoimmune Diseases , Diagnosis, Differential , Follow-Up Studies , Granuloma , Granuloma, Plasma Cell , Immunosuppressive Agents , Liver , Liver Neoplasms , Lupus Erythematosus, Systemic , Lupus Nephritis , Magnetic Resonance Imaging , Plasma Cells , Prednisolone , Rare Diseases , Tomography, X-Ray Computed , UltrasonographyABSTRACT
BACKGROUND: This study aimed to estimate the incidence and prevalence of idiopathic inflammatory myopathies (IIM) and associated comorbidities in Korea from 2006 to 2015. METHODS: IIM between 2004 to 2015 were identified using the Korean National Health Insurance Service medical claim database. The case definition required more than one visit based on diagnostic codes including juvenile dermatomyositis (JDM), dermatomyositis (DM), or polymyositis (PM) and registration in the Individual Copayment Beneficiaries Program (ICBP) for rare and intractable diseases. IIM patients with a disease-free period of 24 months before the index date were defined as incident cases. The Elixhauser comorbidity score was calculated. RESULTS: Using the base case definition, 1,150 prevalent patients with IIM (117 JDM, 521 DM, 512 PM) were recorded in 2006 and 2,210 (130 JDM, 1,101 DM, 869 PM) in 2015. The prevalence was estimated at 2.3–4.0 (0.9–1.2 for JDM, 1.2–2.7 for DM, 1.4–2.1 for PM)/100,000 person-year (PY). We identified 218 incident cases of IIM in 2006 (18 JDM, 98 DM, 102 PM) and 191 cases (7 JDM, 83 DM, 101 PM) in 2015. The incidence was estimated at 2.9–5.2 (0.7–1.9 for JDM, 1.8–4.0 for DM, 1.6–3.0 for PM)/1,000,000 PY. The mean age (± standard deviation) of prevalent patients with IIM was 51.2 (± 16.9) years, and the percentage of women was 72.1%. More than two-thirds of patients (70.7%) had more than two comorbidities. Twenty percent of patients had interstitial lung diseases. CONCLUSION: In Korea, the incidence and prevalence of IIM were 2.9–5.2/1,000,000 PY and 2.3–4.0/100,000 PY, respectively.
Subject(s)
Female , Humans , Comorbidity , Dermatomyositis , Incidence , Korea , Lung Diseases, Interstitial , Myositis , National Health Programs , Polymyositis , PrevalenceABSTRACT
Osteoarthritis (OA) is a common chronic degenerative disease, and its prevalence increases with age. For patients with symptomatic OA, pharmacological treatment is suggested if symptoms and function do not improve with nonpharmacological modalities, including exercise, devices, manual therapy, or self-management programs. Attempts have been made to develop medications that prevent the structural progression of OA; however, the pharmacological treatment of OA has focused on the management of pain to improve the functional ability of joints. Clinicians try to prescribe adequate classes and doses of medications for pain relief, considering the affected parts of joints, each patient's comorbidities, and the clinical response to medical treatment, including tolerability and side effects. It is important to titrate the dose of medications as patients' symptoms change over time, maintaining the lowest effective dose for each individual.
Subject(s)
Humans , Comorbidity , Drug Therapy , Joints , Musculoskeletal Manipulations , Osteoarthritis , Prevalence , Self CareABSTRACT
BACKGROUND: Osteoarthritis (OA) is a disease of old age whose prevalence is increasing. This study explored the impact of OA on household catastrophic health expenditure (CHE) in Korea. METHODS: We used data on 5,200 households from the Korea Health Panel Survey in 2013 and estimated annual living expenses and out-of-pocket (OOP) payments. Household CHE was defined when a household's total OOP health payments exceeded 10%, 20%, 30%, or 40% of the household's capacity to pay. To compare the OOP payments of households with OA individuals and those without OA, OA households were matched 1:1 with households containing a member with other chronic disease such as neoplasm, hypertension, heart disease, cerebrovascular disease, diabetes, or osteoporosis. The impact of OA on CHE was determined by multivariable logistic analysis. RESULTS: A total of 1,289 households were included, and households with and without OA patients paid mean annual OOP payments of $2,789 and $2,607, respectively. The prevalence of household CHE at thresholds of 10%, 20%, 30%, and 40% were higher in households with OA patients than in those without OA patients (P < 0.001). The presence of OA patients in each household contributed significantly to CHE at thresholds of 10% (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.16–1.87), 20% (OR, 1.29; 95% CI, 1.01–1.66), and 30% (OR, 1.37; 95% CI, 1.05–1.78), but not of 40% (OR, 1.17; 95% CI, 0.87–1.57). CONCLUSION: The presence of OA patients in Korean households is significantly related to CHE. Policy makers should try to reduce OOP payments in households with OA patients.
Subject(s)
Humans , Administrative Personnel , Cerebrovascular Disorders , Chronic Disease , Family Characteristics , Health Expenditures , Heart Diseases , Hypertension , Korea , Osteoarthritis , Osteoporosis , PrevalenceABSTRACT
Osteoarthritis (OA) is a common chronic degenerative disease, and its prevalence increases with age. For patients with symptomatic OA, pharmacological treatment is suggested if symptoms and function do not improve with nonpharmacological modalities, including exercise, devices, manual therapy, or self-management programs. Attempts have been made to develop medications that prevent the structural progression of OA; however, the pharmacological treatment of OA has focused on the management of pain to improve the functional ability of joints. Clinicians try to prescribe adequate classes and doses of medications for pain relief, considering the affected parts of joints, each patient's comorbidities, and the clinical response to medical treatment, including tolerability and side effects. It is important to titrate the dose of medications as patients' symptoms change over time, maintaining the lowest effective dose for each individual.
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Lithium is a widely used drug for treatment of bipolar disorder. Because of its narrow therapeutic range and renal toxicity, most clinical guidelines recommend regular monitoring of serum lithium level and kidney function for patients taking lithium. We report on a case of a 20 year-old man with occurrence of lithium toxicity after more than one year of lithium maintenance therapy with daily lithium intake of 900 mg. His serum creatinine level was within normal range at admission and elevated compared to his baseline, but still within normal range when lithium toxicity occurred. Acute kidney injury associated with dehydration, analgesics, and nephrotoxic effect of lithium might be a risk factor of lithium toxicity. This case showed the importance of thorough monitoring of serum creatinine level change even if its elevated result is within normal range in observing renal function of patients treated with lithium.