Rheumatoid arthritis (RA) is one of the most common chronic inflammatory diseases. It mainly involves joints, as well as extra-articular organs. The extra-articular manifestations (EAM) are more common in patients with severe active disease, and the mortality of RA patients with EAM is 2.5 times of RA patients without EAM. Renal damage is rare in EAM, which mainly includes renal damage associated with RA itself, renal amyloidosis, and drug-induced secondary renal damage. In recent years, researches on RA renal damage have gradually increased, and mainly focused on therapy and prognosis. The recent research progress of RA renal damage are summarized in this review.
Therapeutic drug monitoring (TDM) has been more widely used in small molecule agents, such as immuno-suppressants, antiepileptic drugs and antibiotics, with less attention in the field of therapeutic biological agents. Monoclonal drugs represented by tumor necrosis factor alpha (TNF-α) inhibitors have shown a good relationship between exposure and efficacy in clinical studies. There are corresponding guidelines and consensus for the recommendations of TDM based on current research evidence. Therefore, this paper introduced the current evidence, strategies and considerations for TDM in the optimal treatment of adalimumab from the perspective of adalimumab TDM to provide references for the clinical practice of adalimumab TDM.
Objective To evaluate the surgical treatment and effectiveness of rheumatoid forefoot reconstruction with arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads. Methods Between January 2007 and August 2009, 7 patients with rheumatoid forefoot were treated by reconstruction with arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads. They were all females with an average age of 62 years (range, 56-71 years) and with an average disease duration of 16 years (range, 5-30 years). All patients manifested hallux valgus, hammer toe or mallet toe of 2-5 toes, 5 feet complicated by subluxation of the second metatarsophalangeal joint. The improved American Orthopaedic Foot amp; Ankle Society (AOFAS) score was 36.9 ± 6.4. The hallux valgus angle was (46 ± 5)°, and the intermetarsal angle was (12 ± 2)° by measuring the load bearing X-ray films preoperatively. Results All incisions healed by first intention after operation. The X-ray films showed bone fusion of the first metatarsophalangeal joint at 3-4 months after operation. Seven patients were followed up 2.9 years on average (range, 2-4 years), gait was improved and pain was rel ieved. The hallux valgus angle decreased to (17 ± 4)° and the intermetarsal angle was (11 ± 2)° at 3 months postoperatively, showing significant differences when compared with preoperative values (P lt; 0.05). The improved AOFAS score was 85.3 ± 5.1 at 2 years postoperatively, showing significant difference when compared with preoperative score (t=4.501, P=0.001). One patient had recurrent metatarsalgia at 4 years after operation. Conclusion Arthrodesis of the first metatarsophalangeal joint and arthroplasty of lesser metatarsal heads for rheumatoid forefoot reconstruction can correct hallux valgus, remodel the bearing surface of the forefoot, and rel ieve pain, so it can be considered as a procedure that provides improvement in the cl inical outcome.
【Abstract】 Objective To explore the effectiveness of multiple joint arthroplasty in treating lower limb joint disease. Methods Between January 2000 and December 2007, 5 patients with lower limb joint disease (three or more joints were involved) were treated with total hip and knee arthroplasty. There were 3 males and 2 females, aged from 27 to 59 years (mean, 41.8 years). Two patients had ankylosing spondylitis and 3 had rheumatoid arthritis, whose hip and knee joints were involved. Four patients lost the ability of walking preoperatively, 1 patient could only walk with crutch. The Harris score was 24 ± 24 and the Hospital for Special Surgery (HSS) score was 28 ± 15. All patients underwent multiple joint arthroplasty simultaneously (2 cases) or multiple-stage (3 cases). Results Wounds healed by first intention in all patients. In 1 patient who had dislocation of the hip after operation, manipulative reduction and immobilization with skin traction were given for 3 weeks, and no dislocation occurred; in 2 patients who had early sign of anemia, blood transfusion was given. All patients were followed up 46-140 months with an average of 75 months. The patients could walk normally, and had no difficulty in upstairs and downstairs. The stability of the hip and knee was good, and no joint infection or loosening occurred. The Harris score was 88 ± 6 at last follow-up, showing significant difference when compared with the preoperative score (t=8.16, P=0.00); the HSS score was 86 ± 6, showing significant difference when compared with the preoperative score (t=13.96, P=0.00). Conclusion Multiple joint arthroplasty is an effective treatment method in patients with lower limb joint disease, which can significantly improve life quality of patients.
ObjectiveTo evaluate the efficacy and safety of tocilizumab for treating active rheumatoid arthritis (RA).MethodsSeventy-seven patients with active RA who treated from November 2013 to April 2015 in the Outpatient Department of Rheumatology in West China Hospital of Sichuan Universiy with follow-up data were involved. Their clinical data were retrospectively analyzed. Tocilizumab was infused every 4 weeks at a dose of 8 mg/kg and concomitant use of other disease-modifying anti-rheumatic drugs (DMARDs) was allowed. Activity and efficacy were evaluated by Disease Activity Score-28 (DAS28) and European League Against Rheumatism (EULAR) response.ResultAfter the treatment, the DAS28 devreased from the baseline 6.88±1.09 to 4.99±1.53 (4th week), 4.31±1.37 (8th week), 3.74±1.15 (12th week) and 2.66±0.68 (24th week) (P<0.05). The disease activity level assessed by DAS28 was 11.1%, and the low activity was 9.5%, and the values were 10.5%, 32.2% and 66.6%, 16.7% (P<0.05) respectively at the 12th and 24th week. EULAR good/moderate response rates were 17.5%/76.2%, 39.0%/57.4% and 66.7%/33.3% at 8, 12 and 24 weeks. The differences in the decline over time in tender joint count, swollen joint count visual analogue score, Health Assessment Questionnaire score, erythrocyte sedimentation rate and C-reactive protein before and after the treatment were statistically significant (P<0.05). Adverse event was found in 21 cases who were alleviated after the treatment (1 anaphylactic reaction, and the other were mild).ConclusionTocilizumab is safe and effective in treatment of active RA patients.
ObjectiveTo evaluate the effectiveness of total hip arthroplasty (THA) with impacted autologous bone grafting and a cementless cup in the treatment of rheumatoid arthritis (RA) with protrusio acetabuli. MethodsBetween January 2001 and April 2009, 18 cases (20 hips) of RA with protrusio acetabuli were treated, including 6 males and 12 females with an average age of 46 years (range, 36-62 years). The disease duration was 3-10 years (mean, 6 years). Preoperative Harris score was 40.25±6.68. The protrusio acetabuli was (5.70±4.26) mm. According to Sotelo-Garza and Charnley classification criterion, there were 12 hips of type 1 (protrusio acetabuli 1-5 mm), 5 hips of type 2 (6-15 mm), and 3 hips of type 3 (>15 mm). All patients received THA with impacting bone graft and cementless prosthesis for recovery of acetabular center of rotation. ResultsThe average operation time was 74 minutes (range, 48-126 minutes); the average blood loss was 350 mL (range, 150-650 mL). Deep venous thrombosis of lower extremity and poor healing of incision occurred in 3 and 2 cases respectively. Other patients achieved primary healing of incisions. The mean time of follow-up was 108 months (range, 60-156 months). According to X-ray films, bone grafting fusion was observed within 6 months after operation. At last follow-up, the Harris score was 87.20±4.21, showing significant difference when compared with preoperative score (t=-27.68, P=0.00); the protrusio acetabuli was (-1.11±0.45) mm, showing significant difference when compared with preoperative value (t=5.66, P=0.00). No loosening of acetabular components was found. ConclusionFor RA patients with protrusio acetabuli, THA with impacted autologous bone grafting and a cementless cup has satisfactory medium term effectiveness.
Objective To evaluate the efficacy and safety of Leflunomide (LEF) in the treatment of Rheumatoid Arthritis (RA), so as to provide scientific proof for applying LEF in China. Methods Randomized controlled trials (RCTs) about the effect of LEF on patients with RA from January 1989 to January 2011 were searched from the following databases, CNKI, WanFang Data, MEDLINE, EMbase and CBM. After two reviewers independently screened the studies according to the inclusion and exclusion criteria, extracted the data and assessed the quality, the data were analyzed by RevMan 5.0 software. Results Among 3247 patients in 16 included RCTs, 1711 patients were in the LEF group, while the other 1536 patients were in the Methotrexate (MXT) group. The results of meta-analyses showed there was no significant difference in the efficacy between LEF and MXT (RR=1.03, 95%CI 0.94 to 1.11, Pgt;0.05), but a significant difference was found in the side reaction (RR=0.67, 95%CI 0.49 to 0.94, Plt;0.05). Conclusion Based on the current studies, Leflunomide is as effective as the commonly-used Methotrexate in the treatment of rheumatiod arthritis at present, much safer than Methotrexate, and thought as a safe and effective SAARD. For the quality restrictions of the included studies, more double blind RCTs with high quality are required to further assess the effects.
ObjectiveTo study the short-term efficacy and safety of tocilizumab in treating patients with active and resistant rheumatoid arthritis (RRA). MethodForty patients with RRA treated with tocilizumab between October 2013 and October 2014 were included in our study. The combined drug treatment was continued with the addition of tocilizumab 8 mg/kg per four weeks. The clinical responses and laboratory parameters were evaluated at the baseline, week 1, 4, 12, 16 and 24, and week 4 and 8 of tocilizumab withdrawal. ResultsTocilizumab was effective for several clinical lesions and laboratorial parameters at all time points. With the extension of treatment, the effect was better. At week 1, the visual analogue scale score of pain by patients, erythrocyte sedimentation rate, C-reactive protein (CRP), disease activity score 28 (DAS28) and health assessment questionnaire (HAQ) results decreased significantly (P<0.05). At week 12, the inflammatory biomarkers of all patients were normal, and 62.9% (22/35) of the patients achieved American College of Rheumatology (ACR)20, and 28.6% (10/35) of the patients achieved ACR50. At week 24, twelve patients achieved ACR50 and low activity (DAS28 score≤3.2), and the score of HAQ was minimum (3.1±1.6). The score of HAQ was significantly different between week 24 and the baseline (20.2±6.7) (P<0.01). All parameters were not significantly changed at week 4 of tocilizumab withdrawal compared with those before the withdrawal. Most parameters increased significantly at week 8 of tocilizumab withdrawal compared with week 4 of withdrawal (P<0.01) except for swollen joints, CRP, DAS28 and HAQ. The main adverse reactions were abnormal hepatic function and dyslipidemia followed by leukopenia. Only one patient stopped treatment because of adverse reaction. ConclusionsTocilizumab has rapid efficacy onset and good safety. After tocilizumab withdrawal, the efficacy can be maintained for 4 to 8 weeks.
ObjectiveTo evaluate the application and effectiveness of bilateral total hip arthroplasty and total knee arthroplasty in the treatment of severe inflammatory arthropathies. MethodsBetween September 2008 and September 2015, 31 patients with severe inflammatory arthropathies were treated with bilateral total hip arthroplasty and total knee arthroplasty. Of 31 cases, 22 were male and 9 were female with an average age of 30 years (range, 20 to 41 years); there were 15 cases of rheumatoid arthritis and 16 cases of ankylosing spondylitis with an average onset age of 14 years (range, 5-28 years); all 4 ankylosed joints were observed in 11 cases, 3 ankylosed joints in 2 cases, 2 ankylosed joints in 6 cases, 1 ankylosed joint in 1 case, and no ankylosed joint in 11 cases. Before operation, the hip range of motion (ROM) value was (17.82±28.18)°, and the knee ROM value score was (26.45±30.18)°; the hip Harris score was 29.64±11.58, and the hospital for special surgery (HSS) score was 27.07±11.04. The patients were grouped and compared in accordance with etiology and ankylosed joint. ResultsOne-stage arthroplasty was performed in 1 case, two-stage arthroplasty in 22 cases, three-stage arthroplasty in 7 cases, and four-stage arthroplasty in 1 case. The total operation time was 325-776 minutes; the total blood loss was 900-3 900 mL; the total transfusion volume was 2 220-8 070 mL; and the total hospitalization time was 21-65 days. The patients were followed up 12-94 months (mean, 51 months). The hip and knee ROM values, Harris score and HSS score at last follow-up were significantly improved when compared with preoperative ones (P < 0.05). The subjective satisfaction degree was good in 16 cases, moderate in 10 cases, and poor in 5 cases. Periprosthetic infection occurred in 2 cases (3 knees), joint stiffness in 3 cases (6 knees), joint instability in 1 case (1 knee), leg length discrepancy of > 2 cm in 2 cases, and flexion deformity of 10° in 1 case (1 knee). The hip and knee ROM values, Harris score and HSS score showed no significant difference between patients with ankylosing spondylitis and patients rheumatoid arthritis at last follow-up (P > 0.05). The hip and knee ROM values of the patients with ankylosed joint were significantly lower than those of patients with no ankylosed joint (P < 0.05); the Harris score and HSS score of the patients with ankylosed joint were lower than those of patients with no ankylosed joint, but no significant difference was found (P > 0.05). ConclusionA combination of bilateral hip and knee arthroplasty is an efficient treatment for severe lower extremities deformity, arthralgia and poor quality of life caused by inflammatory arthropathies. However, the postoperative periprosthetic infection and stiffness of knee are important complications influencing the effectiveness of operation.
ObjectiveTo observe and study the clinical effect of glucosamine in the treatment of patients with knee articular cartilage injury caused by rheumatoid arthritis. MethodsForty-six patients with knee articular cartilage injury caused by rheumatoid arthritis treated from January 2013 to June 2015 were selected as the research subjects, and they were randomly divided into control group (conventional treatment group, n=23) and observation group (conventional and glucosamine treatment group, n=23) . Then the Noyes classification and serum articular cartilage injury related indexes [cartilage oligomeric matrix protein (COMP), matrix metalloproteinase (MMP)-1, MMP-3 and mouse tissue inhibitors of metalloproteinase (TIMP)-1], inflammatory indexes [tumor necrosis factor (TNF)-α, interleukin (IL)- 17 and IL-33] of the two groups before and after treatment were compared. ResultsIn the observation group, after treatment for 4, 8 and 12 weeks, Noyes grade was better than that in the control group, but with no statistical significance (P ＞ 0.05) . In the observation group, after treatment for 4, 8 and 12 weeks, serum inflammatory markers serum COMP, MMP-1, MMP-3 and TIMP-1 and other related indicators of cartilage damage and serum TNF-α, IL-17 and IL-33 were all significantly lower than those in the control group (P ＜ 0.05) . ConclusionIn the treatment of patients with knee articular cartilage injury caused by rheumatoid arthritis, glucosamine has active role for the improvement of articular cartilage injury and inflammatory stress state of patients.