Advent of biologic agents drastically changed the outcome of rheumatoid arthritis (RA) treatment. However, with its high cost and relatively high incidence of opportunistic infection, application of biologics has to be very cautious. In this sense, selection of RA patients of poor joint prognosis is important. Factors of poor joint prognosis in RA patients have been determined in many reports. American college of rheumatology (ACR) and European league against rheumatism (EULAR) recommendations adopted anti-CCP antibodies and rheumatoid factors as the most important biomarkers to predict poor prognosis. High disease activity such as high ESR and CRP is also the important prognostic factors. The major genetic factor of poor prognosis is HLA-DR. HLA-DR shared epitope in 70-74 amino acid position of DRβ chain (QRRAA, QKRAA, RRRAA) is of poor prognosis and DERAA in the same position of DRβ chain is of good prognosis. DERAA is reported to be more dominant than anti-CCP antibodies, i.e. RA patients with anti-CCP(+) DERAA(+) are less bone-destructive than those with anti-CCP(+) DERAA(-). Other than HLA, polymorphisms in PADI4, DKK1, IL15, CD40, MMP9, IL2RA, GRZB, IL4R, and SPAG16 are the candidate genes to predict poor prognosis, but proving their association is difficult mainly due to the heterogeneity of treatment and RA subsets such as CCP positivity in the cohorts.

View full abstract

[in Japanese]

View full abstract

    In this study, we examined the clinical outcomes of each biological agents for rheumatoid arthritis and searched for the factors contributing to those outcomes. This study included all 114 cases in which biological agents were used for rheumatoid arthritis before September 2013 and studied the retention rate as well as clinical outcomes and each of the parameters at 3 and 6 months after treatment and at the final follow-up exam. We also investigated factors revealing a significant difference between the DAS28-CRP remission and low disease activity compared to moderate disease activity and high disease activity groups at the time of the final follow-up exam. The retention rate was 82.4% at 1 year and 60.9% at 8.9 years; TZC and ETN tended to be high, and ABT and IFX tended to be low. Before the treatment, 61.4% cases showed a high disease activity; however, only 16.7% showed high activity at the final follow-up exam, and 39.5% cases were in remission. According to multivariate analysis using multiple logistic regression analysis, low PSL dosage at baseline and high lymphocyte count 3 months after the initiation of treatment are the associated factors leading to remission or low disease activity in the end. The cut-off PSL dosage at the baseline in those cases was 4 mg/day.

View full abstract

Objectives: Iguratimod (IGU) is newly synthetic DMARDs and under clinical use for patients with rheumatoid arthritis (RA) in Japan. We examined the efficacy of IGU monotherapy for patients with RA.
Methods: Eleven (5 men, 6 women) patients who underwent IGU monotherapies were included in this study. The clinical therapeutic effects at week 24 after the initiation of IGU were analyzed (LOCF).
Results: Before IGU treatment; C-reactive protein (CRP) 1.9±1.8 mg/dl, erythrocyte sedimentation rate (ESR) 61.6±28.7 mm/h, tender Joints Count (TJC) 13.2±10.7, swollen Joints Count (SJC) 14.5±8.7, Pt Visualized Analog Scale (VAS) 50.9±21.5 mm, Dr VAS 58.6±25.5 mm, matrix metalloproteinase-3 (MMP-3) 219.0±168.6 ng/ml, disease activity score (DAS) 28-CRP(4) 5.4±1.8, simplified disease activity index (SDAI) 40.5±23.5. At week 24; CRP 1.6±2.9 mg/dl, ESR 51.5±25.9 mm/h, TJC 2.2±5.9, SJC 6.4±7.2, Pt VAS 29.2±27.6 mm, Dr VAS 28.3±23.4 mm, MMP-3 281.8±407.5 ng/ml, DAS28-CRP(4) 3.1±1.4, SDAI 16.0±15.4. All parameters except for CRP, ESR and MMP-3 were significantly reduced at week 24.
Conclusions: IGU monotherapy represents a practical choice to treat RA patients.

View full abstract

Objective: To determine factors associated with development of pneumonia during RA treatment.
Methods: We retrospectively analyzed 42 patients who developed pneumonia and were hospitalized from 2000-2014 except for aspiration pneumonia and pneumocystis pneumonia, and compared them with 523 patients who did not developed pneumonia, and those who were administered antirheumatic drugs for more than 3 months but did not developed pneumonia.
Results: RA patients without pneumonia had a higher prevalence of concomitant with MTX or Bio. RA with pneumonia had a higher prevalence of pulmonary disease and concomimtance with prednisolone.
Conclusion: We must be alert to the possibility of pneumonia in RA patients especially if they have pulmonary disease regardless of MTX or Bio treatment.

View full abstract

Objectives: Total knee arthroplasty (TKA) is commonly performed to relieve pain and improve function in patients with rheumatoid arthritis (RA). However, treatment with posterior cruciate ligament–retaining (CR-type) TKA is controversial, particularly in patients with RA. In the present study, we aimed to investigate the clinical results of CR-type TKA and evaluate the efficacy of this type of prosthesis in patients with RA.
Methods: In our hospital, 97 CR-type TKA procedures were performed in 78 patients with RA between January 2001 and October 2009. Among them, we assessed 61 CR-type TKA procedures in 44 patients with RA who underwent follow-up for at least 5 years. The assessment was based on the Knee Society clinical score (KSS) and an independent radiographic analysis.
Results: The mean maximum flexion angle of the knees changed to 106.2° at final visit time from 111.6˚ at preoperative time and the maximum extension angle significantly improved to -3.9˚ at final visit time from -12.1˚ at preoperative time. KSS improved significantly after TKA. Radiolucent lines were detected in zone 1 and 4 of the femur and zone 1 and 2 of the tibia, but no patients had obvious loosening detected using X-ray. Serum CRP and MMP-3 were improved after TKA. There were 6 patients who suffered complications such as venous thrombosis of lower extremity, late infection, and supracondylar fracture.
Conclusion: Although additional long-term follow-up studies are required, the results of our medium-term follow-up study indicate that CR-type TKA is not problematic, even in patients with RA.

View full abstract

    The Japan Rheumatism Foundation instituted the rheumatism care nurse system in 2010. Rheumatism care nurses are playing critical roles in the treatment and monitoring of rheumatoid arthritis (RA) patients. In order to obtain the title of rheumatism care nurse and maintain their licenses, nurses who wish to develop this specialty are required to take a course and earn credits. It is easy to get credits in a large city; however, nurses who work in small towns cannot easily obtain these credits because of geographic and time constraints.
    In order to address this issue, we established the Gifu RA Care Meeting, a group development program intended to help nurses working in rural area a get credits to obtain and maintain their rheumatism care nurse licenses. We have convened the meeting nine times in the past two years and two months, since establishing the program in October 2012. We hold the meetings in a town quite far from Gifu city, the capital of Gifu prefecture. In the Gifu RA Care Meeting, we have granted 18 unit credits. In the meetings, many themes are discussed during lectures, such as drug therapy using biologics and antirheumatic drugs, adverse effects of drug therapies, care for daily living, activities of daily living, and so on. Participant numbers at the sessions vary, ranging from 20 to 50 participants, with an average of 30. Cumulative numbers of rheumatism care nurses in Gifu prefecture are increasing gradually: there were 6 in 2010, 14 in 2011, 28 in 2012, and 37 in 2013. Therefore, we have a sense of contributing to the professional development of nurses who work in rural towns far from large cities, but who still want to learn about RA treatment and care.

View full abstract

    An 87-year-old woman admitted to our hospital. She suffered from fever, arthralgia, and sore throat. Markedly elevated serum ferritin, lactate dehydrogenase, and C-reactive protein levels were shown. After exclusion of the other diseases especially infectious diseases, malignant tumors and other connective tissue diseases, we diagnosed her illness as adult-onset Still’s disease. Although we could not detect a sign of significant hemophagocytosis in the bone marrow aspirate specimen, it was supposed to be macrophage activation syndrome with adult-onset Still’s disease. Therefore, we started to treat her as macrophage activation syndrome using high dose glucocorticosteroid (methylprednisolone pulse therapy and high dose dexamethasone), cyclosporine, and plasma exchange. Then, her condition improved and we started to taper steroid. She discharged from our hospital. When the dose of dexamethasone was equivalent to 12.5mg/day of prednisolone, she had fever and rush. Elevated serum C-reactive protein and ferritin levels were shown. She admitted to our hospital again because of a relapse of adult-onset Still’s disease. Although we increased the dose of dexamethasone, the activity of the disease was not controlled. At that time, switching from cyclosporine to tacrolimus resulted in improvement. When we tapered dexamethasone to the dose equivalent to 12.5mg/day of prednisolone again, she did not have a relapse.

View full abstract

Objective: We report a case of skull base neoplasm which should be differentiated from giant cell arteritis.
Case: The patient is a 79-year-old female. She developed diplopia, right temporal headache and facial numbness in right forehead and cheek, tiredness in jaw while eating or talking, 2 kg of body weight loss. She had abnormality of more than one cranial nerve. However, she had no polymyalgia rheumatica like symptoms, or no inflammatory signs. Brain MRI revealed a skull base neoplasm.
Conclusion：It is important to make the assessment carefully for a diagnosis of giant cell arteritis with atypical manifestations.

View full abstract

Background: In July 2010, the Akita Orthopedic Group on Rheumatoid Arthritis (AORA) was founded by unifying hospital-employed and private practice orthopedists involved in treating rheumatoid arthritis in Akita Prefecture, Japan. Akita Prefecture has a land area of about 11.6 thousand square kilometers. As of February 2015, the estimate of the population is around 1.03 million. The combined service area of members covers almost the entire prefecture. The data obtained from the AORA registry reflect actual clinical practice. The data represent long-term follow-up because very few local residents leave or enter the prefecture, and patients without means of long-distance travel are also included.
Objective: We report the results of collection and analysis of AORA patient data.
Subjects and methods: The subjects were patients examined since 2010 by 32 doctors at 28 AORA-affiliated institutions.
Results: As of 2014, 1987 patients (mean age, 66.4 years) have been registered, 80% of whom were female. The mean disease duration was 12 years. Methotrexate had been administered to 56% of the patients, and prednisolone to 44%. The cumulative number of administered biopharmaceuticals was 619. The number of registered patients increased annually by approximately 10%. In 2012, a survey of disease activity was also started. The 28-joint Disease Activity Score using the erythrocyte sedimentation rate (DAS28ESR) decreased from 3.20±1.27 (in 2012) to 3.04±1.22 (in 2014). Low disease activity was observed in 51% of the patients.
Conclusion: The AORA registry included 1987 patients in 2014. Because AORA-affiliated institutions are located near patient residences, treatment retention rates are high. To further advance rheumatoid arthritis treatment in the future, long-term follow-up of data obtained from actual clinical practice in community healthcare appears to be important.

View full abstract