[in Japanese]

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    The goal of this study was to determine the efficacy and safety of low-dose mizoribine -pulse therapy in combination with methotrexate in rheumatoid arthritis patients with an insufficient response to methotrexate.
    Methods: Our study was retrospectively conducted. A total of 37 patients with rheumatoid arthritis, who showed an inadequate response to methotrexate, were given mizoribine in combination with methotrexate. Patients first received 100mg and later 150mg of mizoribine together with methotrexate. We evaluated clinical improvements in the disease activity score (DAS28CRP) using the European League against Rheumatism (EULAR) criteria. In addition to the good response and moderate response rates, the LUNDEX were calculated.
    Results: thirty-five patients (95%) were given a dosage 150mg of mizoribine every time. Outcomes were continuation of treatment in 10 patients (27.0%), termination of treatment due to inefficacy in 25 patients (67.6%), termination of treatment for toxicity in no patients, and 2 other patients (5.4%). The good response and moderate response rates and the LUNDEX corrected responses were 28% and 24% at one month, 36% and 35% at 2 months, 36% and 25% at 3 months, 35% and 22% at 4 months, 43% and 20% at 5 months, and 43% and 21% at 6 months, respectively.
    Conclusion: Low-dose mizoribine pulse therapy in combination with methotrexate in patients with rheumatoid arthritis is well tolerated. That therapy should be investigated for those who are poorly controlled by methotrexate and for whom the use of biologic treatment was impossible.

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Purpose: The efficacy and safety of treatment with tocilizumab (TCZ) were evaluated in our institution.
Methods: A total of 28 patients who started TCZ therapy for at least 24 weeks were evaluated.
Results: Nineteen patients had received at least one biological agent before TCZ therapy. Five patients received monotherapy. Mean DAS28 (ESR) scores were 5.9 at baseline and 2.54 at 24 weeks. Rates of good EULAR response and remission (DAS28 (ESR) of ＜2.6) were 75％, and 60.7％ at weeks 24, respectively. The treatment continuation rate was 100％. A total of 33 adverse events occurred in 21 patients. Analysis of patients by factors possibly affecting remission revealed no significant differences by patient characteristics.
Discussion: We conclude that TCZ is a beneficial drug in daily clinical practice.

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    “Community cooperation clinical pathway for rheumatoid arthritis treatment with biological agents”was constructed in the north Kawauchi district of Osaka. We are cooperating with 23 medical institutions as a key facility in this cooperation clinical pathway. A retrospective analysis for the selection and persistence rate of biological agents was performed. The mean age of the 306 patients with rheumatoid arthritis who were started on biological agents from 2006 to 2010 was 57.0 years. In the selection of biological products of IFX, ETN, TCZ, and ADA, late-started TCZ and ADA often became the second selections. There was no difference in the persistence rate in these four biological agents in the patient groups of the first selections. 25.1% of the patient group administered IFX had an increased dosage of IFX, and the persistence rate in these patients was higher than in the patients with the usual dosage. The administering period was extended in patients being administered ADA and ETN by 73.1% and 25.0%, respectively, and the persistence rate in these patients was higher than patients with “the usual administering period”. Aged patients tended to select the biological agents of subcutaneous injection formulation (ETN and ADA). Few cases reached remission in the coordinated patient group.
    However, the persistence rate of biological agents in this group was high. There is a possibility that biological agents can be selected for aged patients by this cooperation clinical pathway.

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    A 67-year-old Japanese woman was admitted to our Center complaining of general fatigue with a leukopenia value of 1600/μl. Chest high-resonance computed tomography revealed an initial involvement of interstitial pneumonia and she showed no dyspnea with the value of SaO₂ 96% in room air. We speculated Pneumocystis jiroveci pneumonia (PCP) and started combination therapy with methylprednisolone and antipneumocystis agent. In a few days, we noticed an elevated value of serum β-D-glucan＞300 pg/ml. It was strongly suggested that advocated corticosteroids as adjunctive therapy for PCP for patients with rheumatoid arthritis would give rise to significant effects on PCP in light of its poor prognosis. Further, the prophylaxis with antipneumocystis agents would be recommended to block person-to-person transmission of Pneumocystis jiroveci as the predominant route of acquisition.

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    The pleurisy of SLE or RA is often reported, however that of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is rare. We report an elderly case of RS3 PE syndrome with bilateral pleural effusions, impeding differential diagnosis of infection.
    An 83-year-old woman was diagnosed “rheumatoid arthritis” in another clinic and treated by a 5mg daily dose of oral prednisolone for four years. She was admitted to our hospital because of acute onset of polyarthralgia, edema of the both hands and feet, and high fever. CRP was markedly elevated. Rheumatoid factor was weakly positive, although anti-CCP was negative. Ga-scintigraphy showed uptake in shoulders and wrists, however bone erosion was not found by plain radiography. The pleural effusion was in large quantities without invasion of lung. Effusion containing many neutrophils was exudative and negative for rheumatoid factor, bacteria, and malignant cells.
    It was difficult to discriminate from infection. With a 20mg daily dose of oral prednisolone, remission of polyarthritis and pitting edema occurred, with a coincidental decrease of pleural effusions, leading to the diagnosis of RS3PE syndrome. Her symptoms and laboratory signs of inflammation improved and she was discharged.
    RS3PE syndrome is considered to be one of the elderly disorders which present promptly as polyarthritis and edema with pleurisy.

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    Bronchiectasis is one of the respiratory diseases which are complicated with rheumatoid Arthritis (RA). Pulmonary infection related with bronchiectasis influences the choice of treatment for RA. Rhuematologists hesitate to administer immunosuppressive agents and/or biological drugs to RA patients with bronchiectasis because they are at a higher risk for pulmonary infection than those without bronchiectasis. When RA patients with bronchiectasis have pulmonarysurgery done, they will have a lower risk for pulmonary infection and a probability of treating RA with immunosuppressive agents and/or biological drugs. Therefore we should consider surgery for bronchiectasis as a treatment unless a series of antibiotics have therapeutic effects on RA patients with bronchiectasis.
    A 66-year-old woman with RA and bronchiectasis suffered repeated pulmonary infection. Although her RA control was not sufficient, it was difficult to treat her with immunosuppressive agents such as MTX and/or biological drugs. Consequently we operated on her for bronchiectasis by pulmonary lobectomy to reduce the risk of pulmonary infection. After the surgery was done, pulmonary infection seldom occurred and we have successfully introduced MTX to her treatment.However her RA activity is still high and her subjective complaints have not remarkably improved.
    Therefore we will introduce biological drugs and move her treatment to the next stage.

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