At present, clinical remission becomes the real treatment target of rheumatoid arthritis (RA) due to an appearance of the biologics, and life prognosis as well as a joint function has been improving. Furthermore, biologics for different target molecules in RA is developing for patients showing inadequate response to conventional biologics. On the other hand, development of biologics for other rheumatic diseases except RA is not enough. Because the organ failure with immunoreaction has a complexity that the organ is built by various cells, it is suggested that the control of the disease is difficult only by the inhibition of one target molecule. In systemic lupus erythematosus, B-cell related molecules is popular for development of biologics, but the effect is not so stronger than conventional immunosuppressive drug and steroid therapy even if the decrease of the antibody production and the improvement of the complement are observed. In Sjogren's syndrome, biologics is suggested to be effective for the extraglandular symptom, but to be difficult in improvement of the glandular symptom. In Japan rituximab is approved for ANCA-related vasculitis, molecules target for the surface marker of B lymphocyte for vasculitis have a lot of attention. Various preparations also are during a clinical trial about fibrosis of the scleroderma. The development of the biologics for other rheumatic diseases except RA is slow, but it will be pushed forward in future.

    The increased risk of interstitial lung disease (ILD) and infectious pulmonary complications in rheumatoid arthritis (RA) patients who are receiving antirheumatic disease-modifying drugs (DMARDs) is of significant concern. Rheumatologists are confronted by many difficulties in daily practice of managing patients who have developed such life-threatening complications. Since the current aim of RA therapy is to achieve remission, the use of methotrexate and biological DMARDs is increasing, even for patients with RA-associated ILD (RA-ILD) and those at increased risk for developing tuberculosis, nontuberculous mycobacterial (NTM) disease, or Pneumocystis jirovecii pneumonia (PCP). However, there is no standardized staging or risk-evaluation system for pulmonary conditions of RA-ILD patients prior to and after the commencement of DMARD therapy. Besides RA-ILD, bronchial/bronchiolar abnormalities have been observed in many RA patients. In some cases, such abnormalities may represent a subclinical NTM infection. Screening for subclinical NTM infection is difficult because of a lack of specific diagnostic tests that are similar to the tuberculosis skin test and the interferon-γ release assay. Screening and preventive treatments for latent tuberculosis infection prior to the introduction of DMARDs have been recommended, but the practice of directly observed therapy for tuberculosis is not sufficiently implemented. Outbreaks of PCP can occur among RA outpatients through person-to-person transmission. Unlike HIV-positive individuals, RA patients rapidly develop fulminate pneumonia with severe oxygenation impairment and irreversible respiratory failure. This review discusses the safety and risk of introducing or continuing DMARDs for RA patients with ILD or those at the risk of pulmonary infectious complications.

[Objectives] Comprehensive disease remission (CDR) has gained attention as a new target for rheumatoid arthritis (RA) treatment in recent years. Key factors for long-lasting CDR achievement were investigated statistically.
[Methods] Patient’s average 28-joint disease activity score (DAS28-CRP)， yearly progress of Sharp/van der Heijde Score (dSHS), health assessment questionnaire disability index (HAQ-DI), and CDR were calculated for a 1-year period after the first visit to our clinic by 421 RA patients who have been followed up for more than 3 years. Sensitivity and specificity of indices were statistically evaluated for each year from the 4^th. Probability of CDR after the 4^th year was statistically evaluated for DAS28-CRP and pain score using visual analogue scale (PS-VAS) at the first treatment year .
[Results] All four parameters demonstrated reliable sensitivity and specificity of approximately 90% for remission the following year. These were also demonstrated even from first year to fourth year. While more than 60% sensitivity for CDR at late year was demonstrated when DAS28-CRP at first year is controlled within 1.8. PS-VAS within 10mm demonstrated 80% sensitivity for CDR．
[Conclusion] These results suggested that initial treatment is very important for sustaining CDR． Pain control is also a reliable parameter for predicting CDR.

Objective: Although generic drugs (generics) are considered equivalent in quality, efficacy, and safety to original drugs, there are some cases where switching to a generic resulted in diminished effects or adverse events. In this study, we surveyed patients with rheumatoid arthritis (RA) who had been prescribed an antirheumatic and later switched to a generic.
Methods: Subjects were 200 outpatients with RA (47 men and 153 women; mean age 59.5 years) who had been prescribed an antirheumatic; their data was confirmed from their prescription records.
Results: The drugs that were administered at our hospital are MTX (Rheumatrex®, Metolate®), SASP (Azulfidine®), BUC (Rimatil®), and TAC (Prograf®). The rate of change to the respective generic (number of changes to/number of prescriptions for a generic) was 16.4% (19/116) for MTX, 22.2% (18/81) for SASP, 11.1% (3/27) for BUC, and 7.1% (1/14) for TAC. Of the patients who were switched to a generic, 4 experienced diminished effect and 5 experienced adverse events. A diminished effect was observed in two cases with MTX and in one case each with SASP and BUC. Three cases of itching (adverse event) were observed after the switch. There was also one case each of cholecystitis and alopecia areata.
Conclusion: While in most cases no issues were observed after the switch to a generic, there were some cases where the effect was diminished or an adverse event was observed. It needs to be clearly explained to patients that there may be a diminished effect or that an adverse event could occur when switching to a generic.

Objective: Bird’s criteria for Polymyalgia rheumatica (PMR) were primarily published in 1979.The aim of this study was to investigate the clinical features in Japanese PMR patients treated at our hospital using Bird’s criteria.
Patients and Methods: Seventy-nine patients with PMR diagnosed according to Bird’s criteria were studied. We examined the items of Bird’s criteria, laboratory findings (CRP, ESR, CH50, MMP-3 and autoantibodies) and primary dosage of prednisolone (PSL).
Results: The average number of items in Bird’s criteria was 3.9 in the PMR patients. Only one patient and five patients complicated with Giant cell (temporal) arteritis and malignancy, respectively. The mean primary dosage of PSL was 14.3±5.7mg/day. In eight patients (10.1%), PSL therapy could be completely withdrawn. The primary dosage of PSL was not related with laboratory findings (CRP, ESR, CH50, MMP-3) or the number of items in Bird’s criteria. The dosage of PSL was higher in PMR patients with “depression and/or loss of weight” and “male” than in PMR patients without these items (p<0.01).
Conclusion: The primary dosage of PSL in the treatment of PMR tended to be decided by physique and physical status compared to the results of laboratory findings. Additional studies of 2012 EULAR/ACR new classification criteria for PMR with or without ultrasound findings in Japanese patients will be required.

    We encountered a case of rheumatoid arthritis with hip destruction due to a communication between the hip joint and trochanteric bursa, even if this case preserved low disease activity. A 43-year-old woman with rheumatoid arthritis had a mass in the right buttock. Although she had no pain initially, she noticed a gradually growing mass, and developed pain and instability while walking within 3 years. Magnetic resonance imaging showed trochanteric bursitis in the buttock. The bursitis persisted despite aspiration for a few times, and hip destruction was subsequently detected. After total hip arthroplasty, she felt no pain in the right hip while walking.　
    Intraoperative findings of excessive synovial fluid that was discharged immediately after incision of the hip joint capsule demonstrated a communication between the trochanteric bursa and hip joint. Although some reports have described iliopectineal bursitis associated with rapid hip joint destruction, to our knowledge, no report has described a similar association between trochanteric bursitis and hip joint destruction. We speculated that the communication caused giant trochanteric bursitis, and it remained a few years because of a “valve-like mechanism” similar to that in a popliteal cyst.

    Anti-synthetase syndrome (ASS) is often accompanied by myositis, exanthema, and non-erosive arthritis. Especially, myositis with anti-PL-12 antibody often accompanied fever, Raynaud’s phenomenon, non-erosive arthritis and interstitial pneumonia. We present a 53-year-old male polyarthritis patient with fever, seborrheic area erythema and slight Gottron’s signs, without interstitial pneumonia. CK level was within the normal range, but aldolase level was elevated. DWIBS (diffusion weighted whole body imaging with background body signal suppression) showed several high regions. In addition, anti-PL-12 antibody was positive. We diagnosed him with dermatomyositis and treated him with prednisolone 50 mg/day (1mg/kg/day). On day 59 of the hospitalization, he was discharged to return home and has had favorable course since then. DWIBS provides noninvasively useful information for diagnosing myositis. This case suggests the applicability of DWIBS in the diagnosis of systemic disease.

    A 72-year old man was referred to our hospital because of shortness of breath for 1.5 years and 7 kg weight loss for 2 months. High-resolution computed tomography (HRCT) revealed interstitial pneumonia and myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) was serologically positive (47.2 U / mL). At the same time, stage I sigmoid colon cancer was revealed by colonoscopy. Therefore, sigmoid colectomy was performed. Vasculitis were histologically detected in submucosa and subserosa of the resected specimen together with well-differentiated adenocarcinoma. Microscopic polyangiitis (MPA) was diagnosed and treated with prednisolone (30 mg / day) and azathioprine (50 mg / day). After immunosuppression therapy, MPO-ANCA became negative and interstitial pneumonia improved gradually on HRCT. In this report, we discuss the relationship between malignancy and vasculitis. In addition, we added a retrospective review of 82 patients diagnosed with ANCA-associated vasculitis (AAV), who had attended our hospital from 2010 to 2015. Among them, 17 patients suffered from malignancy, and all were solid tumor. In 6 cases, AAV and malignancy were detected concurrently, and their malignancy was all in early stage. Three of the 6 patients had gastric cancer, 1 with colon cancer, and 2 with breast cancer. It is suggested that we should be careful about complication with AAV and malignancy.

    Idiopathic retroperitoneal fibrosis (RPF) is a rare disorder characterized by chronic nonspecific inflammation of the retroperitoneum, and results of several pathological studies have suggested that idiopathic RPF could be included under the umbrella term chronic periaortitis, along with inflammatory abdominal aortic aneurysms (AAA). A number of previous reports have already suggested that Chlamydophila pneumoniae infection might contribute to the pathogenesis of inflammatory AAA. So Chlamydophila pneumoniae infection might be also the cause of idiopathic RPF. We report here a 37-year-old woman who was diagnosed with idiopathic RPF with anti Chlamydophila pneumoniae IgM antibody positive.　
    She was admitted our hospital because of high fever and polyarthralgia. Neither antinuclear and anti-CCP antibodies were not detected in serum, and her serum anti- Chlamydophila pneumoniae IgM and IgA antibody were positive. She was diagnosed as reactive arthritis and given 200 mg azithromycin, which was effective for fever and arthritis. We also performed CT scanning and found the homogeneous mass surrounding the lower abdominal aorta and iliac arteries and mild hydronephrosis of right kidney. She was diagnosed as idiopathic RPF and treated with 40 mg prednisolone daily, which was proved to be effective. Her serum IgM antibodies to Chlamydophila pneumoniae had been positive for more than 3 years after diagnosis.