Rheumatology

But I Have Promises to Keep…… Vikas Agarwal Indian Journal of Rheumatology 2019 14(1):1-1

Challenges in assessing the disease activity of takayasu arteritis Durga Prasanna Misra, Anupam Wakhlu Indian Journal of Rheumatology 2019 14(1):2-3

Is rituximab "The Wonder Drug" for antineutrophil cytoplasmic antibodies-associated vasculitis? Saket Jha, GSRSNK Naidu, Aman Sharma Indian Journal of Rheumatology 2019 14(1):4-6

Advanced therapies for inflammatory rheumatic diseases in resource-poor settings Vinod Chandran Indian Journal of Rheumatology 2019 14(1):7-8

Utility of CD64 expression on neutrophils as a marker to differentiate infectious versus noninfectious disease flares in autoimmune disorders Ashutosh K Mangalam, Rajwardhan Yadav Indian Journal of Rheumatology 2019 14(1):9-11

Rituximab in relapsed/refractory antineutrophil cytoplasmic antibody associated vasculitis: A single-center prospective observational study Ekbote Gayatri, Tanna Dhaval, Negalur Natasha, Bindroo Muzaffar, Raval Dhiren, Sharma Lucky, Rajiva Gupta Indian Journal of Rheumatology 2019 14(1):12-16 Background: Induction with cyclophosphamide (CYC) and glucocorticoids in antineutrophil cytoplasmic antibody-associated vasculitis (AAV) has a relapse of 30%–50%. Studies show that rituximab (RTX) is superior to CYC in refractory/relapsed AAV. We prospectively analyzed efficacy and safety of RTX in CYC-failed cases of AAV. Methods: Patients with AAV who relapsed or were refractory to CYC therapy were given RTX 1 gm at 0 and 15 days, followed by maintenance with 500 mg every 4–6 months. All patients received oral prednisolone. Disease activity was defined by Birmingham Vasculitis Activity Score/Wegener's granulomatosis (BVAS/WG). Remission was defined by the European League Against Rheumatism criteria. Results: From August 2012 to July 2018, 67 patients with AAV were seen at our center; 21 patients who relapsed after inductions with CYC or were refractory to CYC received RTX; 8 (38%) were refractory and 13 (62%) were relapsed AAV; 20 were anti-proteinase 3 positive and 1 was anti-myeloperoxidase positive. All were granulomatosis with polyangiitis (GPA). Mean time to relapse was 12.04 ± 7.8 months. Most common indication for RTX was lung followed by ophthalmic, renal, ear nose throat, and nervous system involvement. Median follow-up after induction with RTX was 24 months. Mean BVAS/WG was 11.2 at baseline, 0.66 at the end of 3 months, 0.16 at the end of 6 months, and remained stable at that value at 18 months. At 24 months, 16 patients (76.19%) remained in remission. One was refractory to RTX treatment even after 2 years. Two patients died and two were still under follow-up. Conclusion: In our experience, RTX is a good induction and maintenance strategy for relapsed/refractory AAV.

Prescribing patterns and safety of biologics in immune-mediated rheumatic diseases: Karnataka biologics cohort study group experience Vineeta Shobha, Vijay Rao, Anu Mohan Desai, Ramesh Jois, Chandrashekara Srikantiah, BG Dharmanand, Sharath Kumar, Pradeep Kumar, Chethana Dharmapalaiah, KM Mahendranath, Shiva Prasad, Manisha Daware, Yogesh Singh, Uma Karjigi Indian Journal of Rheumatology 2019 14(1):17-20 Introduction: Biologics are widely used in Autoimmune rheumatologic diseases (AIRDs), however the need to capture real life data which monitors indications, adverse reactions cannot be over emphasized. Methods: This is a cross-sectional ambidirectional multi-center study conducted over 8 months from January 2016 to August 2016, across 12 tertiary care rheumatology centers in Karnataka, India conducted by members of the Karnataka Rheumatology Association. Results: The most common biologic prescribed is tumour necrosis factor antagonist etanercept. Commonest indication for biologics being Spondyloarthropathy group of disorders. The most common cause for stopping biologics is clinical improvement. Only 4.8% of patents discontinued biologics due to ADRs. Conclusion: The prescribing patterns, mode of use, prebiologics screening methods, and adverse event profile are similar across centres. Pre-screening for latent tuberculosis (TB) is consistent across centres, and TB prophylaxis appears to be effective in preventing its reactivation.

Pentraxin 3 is better than conventional inflammatory markers for disease activity assessment in takayasu arteritis Phani Kumar Devarasetti, Rajendra Varaprasad Irlapati, Liza Rajasekhar Indian Journal of Rheumatology 2019 14(1):21-27 Objective: The objective of this study is to measure plasma pentraxin 3 (PTX3) levels in Takayasu arteritis (TA) patients and to compare the accuracy of PTX3, high-sensitive C-reactive protein (hsCRP), and erythrocyte sedimentation rate (ESR) in distinguishing active disease from the inactive disease. Methods: In a prospective, cross-sectional study, TA patients fulfilling 1990 American College of Rheumatology criteria and healthy controls were enrolled in this study. The Indian Takayasu Clinical Activity Score (ITAS 2010) and ITAS ESR were recorded. Patients were divided into active, grumbling and inactive disease using physician global assessment. Plasma PTX3, hsCRP, and ESR were measured. Receiver operating curves for PTX3 (pg/ml), hsCRP (mg/L), and ESR (mm at 1 h) were constructed to differentiate active from the inactive disease. Inter-group comparisons were made using Mann–Whitney test. Results: Forty patients and 20 controls with median age of 26 and 24 years, respectively, were enrolled in this study. Median disease duration was 2 years. Fourteen patients had active, 8 grumbling, and 18 inactive disease. ITAS 2010 and ITAS ESR in active disease (5 [3–8.5], 7.5 [5–11.5]) were significantly higher than grumbling (0.6 (0–1.5], 2.5 [1–4.5]) or inactive disease (0.5 [0–1.3], 2 [1.7–3]) (P = 0.001). PTX3 (pg/mL) was higher in cases (505 [261–1358]) as compared to that of controls (317 [135–450]) (P < 0.026), in active disease (1335 [464–2128]) was higher than grumbling (689 [246–2114]), but significantly higher than inactive TA (369 [145–512]) (P < 0.001). ESR (mm/h) and hsCRP (mg/L) of 49 (33–61.2), 12.9 (4–21), respectively, in active disease was similar to grumbling (44 [31–63], 10.7 [3–14.7]), but significantly higher than inactive disease (38 [24–45], 1.8 [1.4–2.2]) (P = 0.03). Sensitivity, specificity, and area under the curve for ESR (>46 mm), hsCRP (17.1 mg/L), PTX3 (>745 pg/ml) was (55, 89, and 0.72), (46, 89, and 0.75), and (64, 95, and 0.82), respectively. Conclusion: Elevated PTX3 in TA demonstrates more accuracy than hsCRP and ESR in differentiating active from the inactive disease. These biomarkers may differentiate grumbling from inactive disease better than ITAS2010 or ITAS-ESR.

Serum sclerostin levels in rheumatoid arthritis and correlation with disease activity and bone mineral density Urmila Dhakad, Rasmi Ranjan Sahoo, Akhil Pawan Goel, Sourav Pradhan, Ragini Srivastava, Siddharth Kumar Das Indian Journal of Rheumatology 2019 14(1):28-31 Background: This study aims to assess serum sclerostin, an inhibitor of the Wnt/β-catenin signaling pathway, in rheumatoid arthritis (RA) and its correlation with disease activity and bone mineral density (BMD). Methods: RA patients (>18 years) fulfilling the ACR/EULAR (2010) criteria for RA were included. Postmenopausal women, those with other autoimmune diseases, secondary causes of osteoporosis, severe vitamin D deficiency, chronic liver disease, chronic kidney disease stage 3 and above, and those patients on anticonvulsants were excluded. Rheumatoid factor, anticitrullinated protein antibody, 25-OH Vitamin D estimation, plain radiographs of hands, and BMD measurement by dual-energy X-ray absorpiometry were done in patients. Disease activity was assessed by clinical disease activity index (CDAI). Serum sclerostin levels in RA patients and controls (age and sex matched) were measured by commercial enzyme-linked immunosorbent assay (ELISA) and the relationship of sclerostin with low BMD, ESR, CDAI, and erosion were explored. Results: The mean age of patients (n = 47) was 32.7 ± 6.8 years and mean disease duration was 4.2 ± 2 years. All patients were women, mean body mass index was 22.38±4.4 and mean vitamin D level was 27.9±16.4 ng/ml. 25.5% of RA patients had low BMD at least one site (Z-score: −2 or less). Serum sclerostin was significantly higher in patients compared to controls (8422 ± 3655 pg/ml vs. 6479 ± 1510 pg/ml, P = 0.002). Serum sclerostin levels did not correlate significantly with ESR (r = −0.31 and P = 0.048), CDAI (r = −0.11 and P = 0.45), BMD at lumbar spine (L1–L4, r = 0.14, and P = 0.35), femur neck (r = 0.06 and P = 0.67), and wrist (r = 0.12 and P = 0.41). Conclusion: Serum sclerostin levels were elevated in RA patients but did not correlate with disease activity and BMD.

Dual antibody status predicts sustained remission in patients with rheumatoid arthritis Praveen Pratap Jadhav, Jaya Dilip Avhad, Mahendra Mahajan, Asmanaz Mehemud Patel, Hemant Ramchandra Gavli, Janhavee Praveen Jadhav, Vaibhav Khandelwal Indian Journal of Rheumatology 2019 14(1):32-36 Background: Rheumatoid factor (RF) and anti-cyclic citrullinated protein (ACCP) estimation have been used to improve the diagnosis of rheumatoid arthritis (RA). However, their role in prognostication of RA, individually and in combination, is not well studied. This is, especially, true for Indian patients. Methods: Consecutive 945 patients who had their RF and ACCP determined were included in the study. They were followed up for 3 months to 24 months. Swollen joint count, erythrocyte sedimentation rate, disease activity score 28 (DAS 28), and Indian version of Health Assessment Questionnaire (HAQ) were checked during each visit. They were treated with conventional disease-modifying agents (DMARDS). Results: At presentation, patients with both antibodies positive had the most severe disease, while those with both antibodies negative had the least severe disease. Among discordant antibody status (one antibody positive and the other negative), patients with ACCP positivity presented with higher disease activity than with RF positivity. Patients with dual antibody positivity were much less likely to be in remission than with both negative antibodies. The percentage of patients in remission were 34.2, 29.5, 32.4, and 24.7, respectively, for RF−/ACCP−, ACCP+/RF−, ACCP−/RF+, and ACCP+/RF+. Both, ACCP (odds ratio [OR]: 0.76; 95% confidence interval [CI]: 0.74–0.78) and RF (OR: 0.68; 95% CI: 0.66–0.70) positivity were associated with lower odds of sustained remission (P < 0.05). Conclusion: Dual antibody-positive status at presentation carries poor prognosis, higher disease activity, higher HAQ score, and lesser chance of remission in RA patients with conventional treatment. Patients with both antibodies negative status had the best prognosis. Although patients with discordant antibody status had an intermediate prognosis, the ones with ACCP had higher disease activity at follow-up.