Comparative Effectiveness of Tofacitinib and Adalimumab in Axial Spondyloarthritis: A Real-World Clinical Context Multicenter Study.

INTRODUCTION: Tofacitinib, an oral Janus kinase inhibitor, is a putative choice in the treatment of axial spondyloarthritis (AxSpA). The objective of this study was to compare the effectiveness and tolerability of tofacitinib with adalimumab, in AxSpA, in a real-world clinical setting. METHODS: In this multicentric medical records review study, adult patients with active AxSpA treated with either tofacitinib 5 mg twice daily or adalimumab 40 mg subcutaneously fortnightly were recruited. Effectiveness was measured with Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Drug-cost analysis was calculated with Incremental Cost-Effectiveness Ratio (ICER drug ). RESULTS: Among the 266 patients, 135 were treated with tofacitinib and 131 with adalimumab (follow-up: 6.5 ± 1.6 months). Mean improvement of BASDAI (3.39 ± 0.09 vs. 3.14 ± 1.16, respectively) and that of ASDAS (1.78 ± 0.68 vs. 2.07 ± 2.08, respectively) were comparable between the adalimumab and tofacitinib groups. A higher proportion of patients achieved BASDAI50 response in the second (49.5% vs. 31.6%) and fourth month (83.9% vs. 62.8%) and ASDAS low disease activity in the fourth month (71.6% vs. 47.9%) in the adalimumab group. All disease activity measurements were similar by the sixth month in both groups. A higher proportion of patients in the tofacitinib group than in the adalimumab group required change in therapy (14.8% vs. 7.6%, respectively). ICER drug for adalimumab compared with tofacitinib was US $188.8 per patient in the adalimumab group for each person-month with BASDAI <4. CONCLUSIONS: Tofacitinib showed comparable effectiveness with adalimumab in patients with AxSpA at the sixth month, despite lesser response in the initial months, with favorable ICER drug .

Efficacy and safety of intravenous and subcutaneous immunoglobulin therapy in idiopathic inflammatory myopathy: A systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis on the efficacy and safety of intravenous (IVIg) and subcutaneous (SCIg) immunoglobulin (Ig) therapy in the treatment of idiopathic inflammatory myopathy (IIM) and juvenile dermatomyositis (JDM). METHODS: PubMed, Embase and SCOPUS were searched to identify studies on Ig therapy in patients with IIM and/or JDM (2010-2020). Outcome measures were complete response (CR) or partial response (PR) in terms of muscle power and extramuscular disease activity measures on the International Myositis Assessment and Clinical Studies Group (IMACS) core set domains. RESULTS: Twenty-nine studies were included (n = 576, 544 IIM, 32 JDM). Muscle power PR with pooled Ig therapy was 88.5% (95% confidence interval (CI): 80.6-93.5, n = 499) and PR with SCIg treatment was 96.61% (95% CI: 87.43-99.15, n = 59). Pooled PR with first-line use of IVIg was 77.07% (95% CI: 61.25-92.89, n = 80). Overall, mean time to response was 2.9 months (95% CI: 1.9-4.1). Relapse was seen in 22.76% (95% CI: 14.9-33). Studies on cutaneous disease activity and dysphagia showed significant treatment responses. Glucocorticoid and immunosuppressant sparing effect was seen in 40.9% (95% CI: 20-61.7) and 42.2% (95% CI: 20.4-64.1) respectively. Ig therapy was generally safe with low risk of infection (1.37%, 95% CI: 0.1-2.6). CONCLUSIONS: Add-on Ig therapy improves muscle strength in patients with refractory IIM, but evidence on Ig therapy in new-onset disease and extramuscular disease activity is uncertain.

Bilateral Nodular Episcleritis: A Rare Presentation of Relapsing Polychondritis.

Herein, the authors report a case of relapsing polychondritis (RP) presenting as isolated bilateral nodular episcleritis. A 23-year-old male presented to us with bilateral large ocular surface masses for which he had received antitubercular medications. A workup was performed to rule out infective, neoplastic, and immune etiologies, after which the patient was then treated empirically with systemic steroids. No response to steroids was noted, so the lesions were removed surgically. On follow up, he developed redness of both ears sparing the lobules. A biopsy from ear lesions supported the diagnosis of RP. At a follow up of 2 years, the patient is free of any ocular or systemic manifestation. To the best of the authors' knowledge, this is the first reported case of RP presenting with bilateral giant nodular episcleritis and treated successfully with surgery. A multidisciplinary approach is essential for the management of such cases. A long-term close follow up is vital for early detection of associated malignancies like multiple myeloma.

Lean Mass and Disease Activity are the Best Predictors of Bone Mineral Loss in the Premenopausal Women with Rheumatoid Arthritis.

BACKGROUND AND OBJECTIVES: Factors determining bone mineral (BM) loss in rheumatoid arthritis (RA) are not well known. This study aimed to determine the occurrence and predictors of BM loss in the young premenopausal women with RA. METHODS: Ninety-six females with RA and 90 matched controls underwent clinical, biochemical, BM density (BMD), and body composition assessments. RA disease activity was assessed using disease activity score-28 (DAS-28) and hand X-ray. RESULTS: In the young premenopausal females with RA having median symptom and treatment duration of 30 (18-60) and 4 (2-12) months, respectively, with moderate disease activity (DAS-28, 4.88 ± 1.17), occurrence of osteoporosis and osteopenia was 7.29% and 25% at spine, 6.25% and 32.29% at hip, and 17.7% and 56.25% at wrist, respectively (significantly higher than controls). RA patients had lower BMD at total femur, lumbar spine (LS), radius total, and radius ultra-distal. Total lean mass (LM) and BM content were significantly lower in RA (P = 0.022 and <0.001, respectively). In RA, BMD at majority of sites (LS, neck of femur, greater trochanter, radius total, and radius 33%) had the strongest positive correlation with LM followed by body fat percent. RA patients with most severe disease had lowest BMD at different sites and lowest LM. Stepwise linear regression revealed LM followed by DAS-28 to be best predictors of BMD. RA patients receiving glucocorticoids did not have significantly different BMDs from patients not taking glucocorticoids. INTERPRETATION AND CONCLUSION: BM loss is a significant problem in the young premenopausal women with recent-onset RA. LM and disease severity were the best predictors of BMD.

Articular cartilage of knee and first MTP joint are the preferred sites to find double contour sign as an evidence of urate crystal deposition in asymptomatic hyperuricemic individuals.

BACKGROUND/OBJECTIVE: A cross-sectional study to determine the preferred sites of urate crystal deposition in asymptomatic hyperuricemic individuals by ultrasound. METHODS: In two years period twenty four asymptomatic hyperuricemic individuals (serum uric acid ≥7mg/dl) and fifty controls (serum uric acid <7mg/dl) with age more than 18 years were included in this study. Double contour sign was looked for at three articular cartilage sites (first metatarsophalangeal, tibiotalar and femoral condyle) whereas hyperechoic aggregates were looked for at one joint site (radiocarpal joint) and two tendon sites (patellar tendon and triceps tendon). The Chi-square test was used to compare the categorical variables and discrete variables were compared by one way analysis of variance. The p-value<0.05 was considered significant. RESULTS: Eight out of 24 asymptomatic hyperuricemic individuals had ultrasound evidence of urate crystal deposition in first metatarsophalangeal joint area followed by knee joint area which was detected in 6 patients. The detection rate of ultrasound abnormalities in asymptomatic hyperuricemic individuals was 45.8% with two joint area (knee and first metatarsophalangeal) and 50% with six sites assessment. Amongst controls, 16% were found to have these abnormal ultrasound findings. CONCLUSION: The highest predilection of urate crystal deposition in asymptomatic hyperuricemic individuals is the articular cartilage of Knee and first metatarsophalangeal joints. This explain the frequent clinical presentation of arthritis in these joint areas.

Ultrasonographic detection of double contour sign and hyperechoic aggregates for diagnosis of gout: two sites examination is as good as six sites examination.

OBJECTIVE: To compare ultrasound-detected abnormalities, namely double contour sign (DCS) and hyperechoic aggregates (HAGs), at two sites (knee and first metatarsophalangeal [1st MTP] joints) versus six sites (knee joint, 1st MTP joint, radiocarpal joint, talar joint, patellar tendon and triceps tendon) in gout patients. METHODS: Forty-seven clinically diagnosed gout patients and 50 subjects (serum uric acid < 7 mg/dL) as controls were included. DCS was looked for at three articular cartilage sites (first metatarsal, tibiotalar and femoral condyle), whereas HAGs were looked for at one joint site (radiocarpal joint) and two tendon sites (patellar tendon and triceps tendon). Ultrasound findings of both the groups were compared. RESULTS: Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive likelihood ratio (LR) of two sites ultrasound findings for gout were 87.2%, 84%, 83.7%, 85.6% and 5.5 respectively. Similar sensitivity, specificity, PPV, NPV and positive LR were observed with six sites ultrasound findings. Among controls, 16% were found to have these abnormal ultrasound findings by both two sites and six sites examinations. CONCLUSION: Screening of two sites (knee and 1st MTP) has similar sensitivity, specificity, PPV, NPV and positive LR as compared to six sites in diagnosing gout.

Central nervous system vasculitis in pediatric microscopic polyangiitis.

Microscopic polyangiitis is a small vessel vasculitis, associated with myeloperoxidaseantineutrophil cytoplasmic antibody. It rarely occurs in children. Central nervous system involvement in pediatric microscopic polyangiitis is not a well known entity with perhaps only five cases till date. We hereby present a 14-year-old girl with arthralgia, seizure, leukocytoclastic vasculitis, interstitial lung disease secondary to recurrent pulmonary hemorrhage, pauci-immune glomerulonephritis and high titers of MPO-ANCA, hence diagnostic of microscopic polyangiitis. Magnetic resonance imaging of brain showed diffuse parenchymal involvement which resolved at six months with development of new foci of microhemorrhages in different stages of evolution, reminiscent of vasculitis.