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OBJECTIVES: To identify predictive factors of radiological progression in early arthritis patients treated by remission-steered treatment. METHODS: In the IMPROVED study, 610 patients with early rheumatoid arthritis (RA) or undifferentiated arthritis (UA) were treated with methotrexate (MTX) and a tapered high dose of prednisone. Patients in early remission (disease activity score (DAS) <1.6 after 4â months) tapered prednisone to zero. Patients not in early remission were randomised to arm 1: MTX plus hydroxychloroquine, sulfasalazine and prednisone, or to arm 2: MTX plus adalimumab. Predictors of radiological progression (≥0.5 Sharp/van der Heijde score; SHS) after 2â years were assessed using logistic regression analysis. RESULTS: Median (IQR) SHS progression in 488 patients was 0 (0-0) point, without differences between RA or UA patients or between treatment arms. In only 50/488 patients, the SHS progression was ≥0.5: 33 (66%) were in the early DAS remission group, 9 (18%) in arm 1, 5 (10%) in arm 2, 3 (6%) in the outside of protocol group. Age (OR (95% CI): 1.03 (1.00 to 1.06)) and the combined presence of anticarbamylated protein antibodies (anti-CarP) and anticitrullinated protein antibodies (ACPA) (2.54 (1.16 to 5.58)) were independent predictors for SHS progression. Symptom duration <12â weeks showed a trend. CONCLUSIONS: After 2â years of remission steered treatment in early arthritis patients, there was limited SHS progression in only a small group of patients. Numerically, patients who had achieved early DAS remission had more SHS progression than other patients. Positivity for both anti-CarP and ACPA and age were independently associated with SHS progression. TRIAL REGISTRATION NUMBERS: ISRCTN Register number 11916566 and EudraCT number 2006 06186-16.
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OBJECTIVE: The aim of this study was to assess whether baseline characteristics in patients with undifferentiated arthritis or early RA affect the possibility of achieving drug-free remission after 1 year (DFR1 year) of early remission induction therapy. METHODS: We included 375 patients participating in the IMPROVED study who achieved remission (DAS < 1.6) after 4 months (early remission) and were by protocol able to achieve DFR1 year. Having started with MTX plus prednisone, patients tapered prednisone to zero; after 8 months, those still in remission tapered MTX to zero, while those not in remission restarted prednisone. Characteristics of patients achieving and not achieving DFR1 year were compared. Logistic regression was performed to identify predictors of DFR1 year. RESULTS: After 1 year, 119 patients (32%) were in DFR. Presence of RF, fulfilling the 2010 criteria for RA, and a low tender joint count were associated with achieving DFR1 year, whereas presence of ACPA was not. None of the baseline characteristics was independently associated with DFR1 year. DFR1 year was sustained for 4 months in 65% of the patients. ACPA-positive patients less often had sustained DFR than ACPA-negative patients (58% vs 80%, P = 0.013). CONCLUSION: After 1 year of remission-steered treatment, 32% of the patients who had achieved early remission after 4 months were able to taper medication and achieved DFR. Neither the presence of ACPA nor any other baseline characteristics were independently associated with achieving DFR1 year, but in ACPA-positive patients DFR was less often sustained.
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Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Artritis Reumatoide/inmunología , Artritis/tratamiento farmacológico , Artritis/inmunología , Remisión Espontánea , Adulto , Anciano , Anticuerpos Antiidiotipos/sangre , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Estudios Longitudinales , Masculino , Metotrexato/uso terapéutico , Persona de Mediana Edad , Péptidos Cíclicos/inmunología , Prednisona/uso terapéutico , Inducción de Remisión , Resultado del TratamientoRESUMEN
BACKGROUND: Loin pain haematuria syndrome is characterised by episodes of loin pain and microscopic or macroscopic haematuria, without a urological origin. CASE DESCRIPTION: We describe a 39-year-old woman who was referred to us because of microscopic haematuria and proteinuria without an apparent cause, which had been present for 20 years. For 9 months she had also had continuous loin pain, aggravated by exertion. Additional examination showed erythrocytes in the renal tubules and a thin glomerular basement membrane. We made the diagnosis of "loin pain haematuria syndrome based on thin basement membrane nephropathy". CONCLUSION: Loin pain haematuria syndrome is a potentially debilitating disorder that is often poorly recognized due to the unfamiliarity of physicians with this condition. Treatment of patients with loin pain haematuria syndrome consists of patient education, treatment with ACE inhibitors, pain medication and cognitive behavioural therapy. Renal artery denervation can be considered in cases of persistent, disabling pain.
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Hematuria/diagnóstico , Proteinuria/diagnóstico , Adulto , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Desnervación , Femenino , Hematuria/complicaciones , Hematuria/terapia , Humanos , Dolor/diagnóstico , Dolor/etiología , Proteinuria/etiologíaRESUMEN
INTRODUCTION: The aim of this study was to investigate patient reported outcomes (PROs) of functional ability and health related quality of life (HRQoL) in patients with early (rheumatoid) arthritis during one year of remission steered treatment. METHODS: In this study, 610 patients with early rheumatoid arthritis (RA) or undifferentiated arthritis (UA) were treated with methotrexate (MTX) and tapered high dose of prednisone. Patients in early remission (Disease Activity Score (DAS) <1.6 after 4 months) tapered prednisone to zero and when in persistent remission, also tapered MTX. Patients not in early remission were randomized to either MTX + hydroxychloroquine + sulphasalazine + prednisone (arm 1) or to MTX + adalimumab (arm 2). Every 4 months, patients filled out the Health Assessment Questionnaire (HAQ) and the McMaster Toronto Arthritis Patient Preference Questionnaire (MACTAR), the Short Form 36 (SF-36) and visual analogue scales (VAS). Change scores were compared between treatment groups. The association with achieving remission was analyzed using linear mixed models. RESULTS: During year 1, patients who achieved early remission had the most improvement in PROs with scores comparable to the general population. Patients in the randomization arms showed less improvement. Scores were comparable between the arms. There was a significant association between achieving remission and scores of HAQ, MACTAR and physical HRQoL. CONCLUSIONS: In early arthritis, PROs of functional ability and HRQoL after one year of remission steered treatment reach normal values in patients who achieved early remission. In patients not in early remission, who were randomized to two strategy arms, PROs improved less, with similar scores in both treatment arms. TRIAL REGISTRATIONS: ISRCTN11916566 and EudraCT2006-006186-16.
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Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Dimensión del Dolor , Calidad de Vida , Rango del Movimiento Articular/efectos de los fármacos , Adulto , Anciano , Artritis Reumatoide/diagnóstico , Artritis Reumatoide/psicología , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Quimioterapia Combinada , Diagnóstico Precoz , Femenino , Estudios de Seguimiento , Humanos , Hidroxicloroquina/uso terapéutico , Masculino , Metotrexato/uso terapéutico , Persona de Mediana Edad , Satisfacción del Paciente , Prednisona/uso terapéutico , Rango del Movimiento Articular/fisiología , Recuperación de la Función , Inducción de Remisión , Índice de Severidad de la Enfermedad , Método Simple Ciego , Sulfasalazina/uso terapéutico , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIM: Classifying more patients as rheumatoid arthritis (RA) (2010 American College of Rheumatology/European League Against Rheumatism criteria for RA) may improve treatment outcomes but may cause overtreatment in daily practice. The authors determined the efficacy of initial methotrexate (MTX) plus prednisone treatment in patients with 1987 or 2010 classified RA and undifferentiated arthritis (UA). METHOD: 610 recent onset RA or UA patients started with MTX 25 mg/week and prednisone 60 mg/day tapered to 7.5 mg/day in 7 weeks. Percentage remissions after 4 months were compared between RA (1987 or 2010 criteria) and UA. Predictors for remission were identified. RESULTS: With the 2010 criteria, 19% more patients were classified as RA than with the 1987 criteria, but similar remission rates were achieved: 291/479 (61%) 2010 classified RA and 211/264 (58%) 1987 classified RA patients (p=0.52), and 79/122 (65%) UA patients (p=0.46). Anticitrullinated protein antibodies (ACPA) positive RA patients achieved more remission (66%) than ACPA negative RA patients (51%, p=0.001), but also had a lower mean baseline Disease Activity Score (DAS) (3.2 vs 3.6, p<0.001). Independent predictors for remission were male sex, low joint counts, DAS and Health Assessment Questionnaire, low body mass index and ACPA positivity. CONCLUSION: Initial treatment with MTX and a tapered high dose of prednisone results in similarly high remission percentages after 4 months (about 60%) in RA patients, regardless of fulfilling the 1987 or 2010 criteria, and in UA patients. Independent predictors indicate that initiating treatment while disease activity is relatively low results in more remission.
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Antirreumáticos/uso terapéutico , Artritis/tratamiento farmacológico , Metotrexato/uso terapéutico , Prednisona/uso terapéutico , Antirreumáticos/administración & dosificación , Artritis/patología , Combinación de Medicamentos , Femenino , Humanos , Masculino , Metotrexato/administración & dosificación , Persona de Mediana Edad , Prednisona/administración & dosificación , Inducción de RemisiónRESUMEN
T cell responses to ESAT-6 and culture filtrate protein 10 (CFP-10), antigens expressed by Mycobacterium tuberculosis but not by M. bovis bacille Calmette-Guérin (BCG), were found to discriminate reliably between infection with M. tuberculosis and BCG vaccination. Because the esat-6 and cfp-10 genes occur in M. kansasii and M. marinum, T cell responses to ESAT-6 and CFP-10 were investigated in patients infected with M. kansasii or M. marinum, persons intensively exposed to environmental mycobacteria, and unexposed control subjects. Tuberculin skin tests were performed, and peripheral blood mononuclear cells were cocultured with ESAT-6, CFP-10, peptide mixtures of ESAT-6 and CFP-10, and control antigens. When enzyme-linked immunosorbent assay (ELISA) and enzyme-linked immunospot assay (ELISPOT) were used to measure interferon-gamma production, most M. kansasii- or M. marinum-infected patients and several persons exposed to environmental mycobacteria were found to respond to ESAT-6 and/or CFP-10. ELISA and ELISPOT yielded comparable results, as did whole antigen and peptides (P<.0001). These results may be relevant for the development of novel assays for diagnosis of tuberculosis.