In 2012, EULAR recommendations for the role of the nurse in chronic inflammatory arthritis management were published and efforts were made to encourage implementation in each country. The level of agreement on the recommendations was high, but they were reported not to be fully implemented.

  The 2018 revised version of recommendations has been published, which incorporated higher levels of evidence and new insights. The revised version has newly added the overarching principles. It indicates that rheumatology nurses are part of a healthcare team, providing evidence-based care, and that rheumatology nursing is based on shared decision-making with the patient. In addition, eight recommendations have been proposed. The first three recommendations are based on the patient's perspective and the remaining five from the nurse's perspective. Patients are recommended to consult nurses about the support for their needs such as acquisition of knowledge and disease management during the entire course of the illness. Nurses are required to provide patients with support such as psychosocial issues for better improvement of self-assessment skills and self-efficacy, including telehealth. In addition, they also need to receive specialized nursing education to improve and continue their own knowledge and skills for playing wider roles. This updated version is intended to be more applicable and practical and, moreover, is expected to serve as a guide for rheumatic care and to be implemented widely.

Objectives: Remichek Q^® is a test kit that qualitatively examines the blood concentration of infliximab（IFX）. In patients with rheumatoid arthritis（RA）who received IFX, Remicheck Q^® was used to evaluate the blood concentration of IFX, and the relationship between IFX blood concentration and disease activity in clinical practice was examined.

Methods: This study included 57 patients at the Niigata Rheumatic Center diagnosed with RA and administered IFX. The study period was from October 2017 to April 2018. We retrospectively analyzed the patients’ background characteristics, disease activity, and IFX dose when the Remicheck Q^® was conducted.

Results: Forty-four patients showed positive results（77%）. The DAS28-ESR tended to be lower in negative patients than in positive ones（2.67 ± 1.13 vs. 2.48 ± 0.44, p=0.775）. The CDAI（6.6 ± 6.5 vs. 3.1 ± 2.7, p=0.049）and SDAI（6.9 ± 6.8 vs. 3.2 ± 2.7, p=0.048）were significantly lower in negative patients than in positive ones. Doses of IFX were significantly lower negative patients than in positive ones（6.8 ± 2.6 mg/kg vs. 5.1 ± 2.4 mg/kg, p=0.032）, but prednisolone and methotrexate were not significantly different. All 13 negative patients achieved remission according to DAS28-CRP, and 5 achieved Boolean remission.

Conclusion: There are cases of good disease activity even when Remicheck Q^® is negative. This is one of the reasons that there may be many cases in the Remicheck Q^® negative group that are highly responsive to TNF inhibitor. It will be necessary to measure Remicheck Q^® in patients with inadequate therapeutic effects early after the start of IFX to examine its usefulness.

［Object］The Leeds satisfaction questionnaire（LSQ）was developed by J. Hill et al. in 1992 as a satisfaction rating scale of patients with rheumatoid arthritis（RA）. But there have been no studies that use the LSQ in Japan. This study was designed to examine the satisfaction in Japanese RA patients using the LSQ, which was translated into Japanese, and to examine the factors related to that satisfaction. ［Methods］A questionnaire was mailed to the home of 401 RA outpatients of Toyama University hospital. The questionnaire was composed of three parts: personal data, the Japanese LSQ itself, and disease activity（using the MDHAQ-RAPID3 index）. ［Results］Of the 401 questionnaires sent out, 190 patients returned a valid survey. In all six LSQ categories—general satisfaction, giving of information, empathy with the patient, technical quality and competence, attitude toward the patient, and access and continuity—the patient responses averaged over three points out of a possible five. The highest score was for technical quality and competence, while the lowest scores were for empathy and then attitude. Using a multiple regression analysis, it showed that the Patient’s Global Assessment of Disease Activity（PtGA）had the greatest influence on satisfaction in four out of the six categories. ［Conclusions］1）The satisfaction of RA outpatients is high at our hospital, but we need to improve empathy and attitude toward the patient. 2）The lower the PtGA, the more satisfied the patient was.

  This case was a 37-year-old woman, who was a non-working mother. She was diagnosed with rheumatoid arthritis（RA）and had difficulty doing her hobbies due to painful symptoms. To give the patient the ability to self-manage her symptoms, we suggested the self-evaluation of her daily activities using a notebook. The RA was diagnosed in 2007, and symptoms worsened in 2015. In 2016, abatacept was started, and occupational therapy was started at our outpatient rehabilitation center. In addition to the range-of-motion exercises and the life-style guidance reducing the stress of wrist joints, we had the patient use the self-management method of recording her daily activities in her notebook. Following this method, she wrote down the severity of the symptoms and consulted us about the way in which she increased or decreased the intensity of her daily activities, based on the results recorded in the notebook. One year after the intervention, the wrist pain both at rest and in motion disappeared. Although malaise accompanied by menstrual period only remained, she could cope with the symptoms and restarted her hobbies. Thus, we suggest that the use of a notebook enables patients to gain the ability to self-manage RA symptoms.

Objective:

  The purpose of this study was to examine the efficacy and safety of alogliptin in subjects with glucocorticoid-induced hyperglycemia and autoimmune diseases.

Methods:

  The subjects were 101 patients who started alogliptin for glucocorticoid-induced hyperglycemia at Niigata Rheumatic Center from January 2011 to October 2017. The clinical parameters and adverse events after the initiation of alogliptin were analyzed retrospectively. We conducted subgroup analyses to determine the effect of alogliptin alone for the treatment of hyperglycemia as well as its effect on rheumatoid arthritis（RA）. Wilcoxon signed-rank test was used to analyze clinical outcomes.

Results:

  Seventy-four patients were enrolled（Group 1）. After treatment with alogliptin, hemoglobin A1c（HbA1c）was significantly reduced at 24 weeks（7.10 to 6.50, p=0.00000818）. In Group 2（n=57）, which consisted of patients who used a fixed dose of a glucocorticoid and antidiabetic agents, HbA1c was significantly reduced at 24 weeks（7.10 to 6.50, p=0.000467）. In Group 3（n=22）, which consisted of patients who used a fixed dose of a glucocorticoid and anti-rheumatic drugs, there were no significant differences in any clinical parameter for arthritis. No patients dropped out due to exacerbation of arthralgia. Two of 22（9%）patients had worsened RA activity, but continued alogliptin.

Conclusion:

  These results suggest that alogliptin was effective in the treatment of glucocorticoid-induced hyperglycemia, and was associated with few adverse effects. Although there were no significant differences in any clinical parameter for arthritis during the study, we should monitor RA activity after administration of dipeptidyl peptidase-4 inhibitors in patients with RA.

  Objective: This study evaluated the differences of clinical performance between 50 mg and 100 mg of golimumab in patients with rheumatoid arthritis

  Methods: The clinical background and the changes of disease activity score（DAS28-ESR）were analyzed for 72 patients（36 cases in the 50 mg group, 36 cases in the 100 mg group）who were treated with golimumab for at least three months.

  Results: The rates of concomitant use of methotrexate（MTX）were 83.3% in the 50 mg group and 47.2% in the 100 mg group. The mean doses of MTX were 8.3 and 7.2 mg/week respectively. Also, the rates of concomitant use of prednisolone（PSL）were 58.3% in the 50 mg group and 52.7% in the 100 mg group. The mean doses of PSL were 4.4 and 4.2 mg/week respectively. The DAS 28-ESR at baseline were 3.80 in 50 mg group and 4.12 in 100 mg group（n.s.）. The rates of remission at 12 and 24 weeks were 54.9%, 42.3% in the 50 mg group and 64.6%, 73.9% in the 100 mg group. The average differences of DAS 28-ESR from baseline at 12 weeks were -0.75 in the 50 mg group and -1.48 in the 100 mg group, which showed significant difference（p<0.05）.

  Conclusion: From our findings, the administration 100 mg of GLM tended to show better clinical efficacy in the early period of treatment.

  The concept of treat to target（T2T）, in which the risks of the disease are comprehensively evaluated and taken to a very low level within an acceptable period, is becoming waidespread in the treatment of rheumatoid arthritis, subsequently in the treatment of spondyloarthritis and systemic lupus erythematosus. However, any uniform measurement of disease activity may not be suitable for a variety of patients with the same disease, and thus a gap is observed in the popularization between the concept and clinical practice of T2T. Emerging challenges include clinical evaluation of the patients in a super-aged society and the measurement of the blood trough level of biological agents. Therefore, the need for a multidisciplinary patient care is increasing more than ever.

Treatment to target supported by rehabilitation and equipments for patients with rheumatoid arthritis

Basic therapy, pharmacotherapy, surgery and rehabilitation have been provided as the main remedies for patients with rheumatoid arthritis（RA）. Nowadays, after the introduction of the Biologics（Bio）, the position of pharmacotherapy among these remedies seems more important and well-situated. On the other hand, in the RA treatment guideline 2014, rehabilitation with exercise and occupational therapy is recommended, and these therapies are necessary to increase activities of daily living of RA patients. In this report, we describe the effectiveness of some devices and the home exercise instruction that is based on the community-based integrated-care system of the Ministry of Health, Labour and Welfare.

  The purpose of using biomarkers is to help diagnosis, assessing disease activity, predicting prognosis, classifying into disease subset and so on. There are various kinds of biomarkers including autoantibodies, cytokines, cell surface markers, genomic data, gene expression, micro RNA, metabolome etc. Anti-CCP antibody is a specific diagnosis biomarker of rheumatoid arthritis （RA）, but one has to be careful it can be positive in various collagen vascular diseases. Combining anti-CCP antibody with rheumatoid factor（RF）predicts prognosis of joint damage more precisely, especially in anti-CCP（-）subset. MMP-3 is not a good marker for diagnosis of RA, but is useful for predicting erosive disease. Anti-CCP antibody is also a good marker for predicting erosive disease, but there is a report that HLA-DR13 predicts less joint damage in anti-CCP（+）RA. So, we surveyed the charts of anti-CCP（+）RA patients with HLA-DR13 allele, and found that there is a fraction of patients who did not develop bone erosions even after 10 years of RA history. In contrast, most patients with very long RA history develop severe bone erosions even possessing HLA-DR13. HLA-DR13 may become a good biomarker for predicting less erosive disease, but more sophisticated biomarkers are required.

  Inflammatory biomarkers are useful as objective and quantitative indicators of disease activity in rheumatic diseases. The most representative biomarker is CRP, which is an acute phase protein produced in liver during inflammation, and its upregulation is absolutely dependent on stimulation by the cytokine IL-6. Recently, biological agents that target IL-6 signaling have been developed, and CRP often fails to detect disease activity and/or concomitant infection, given that CRP elevation requires intact IL-6 signaling. Thus, a search for new inflammatory biomarkers is warranted. Previously, we performed a proteomics analysis and identified the elevation of leucine-rich α2 glycoprotein（LRG）in sera from patients with rheumatoid arthritis. Similar to CRP, LRG has properties of acute phase proteins upregulated in the liver in response to inflammatory cytokine stimulation. Nevertheless, LRG is induced not only by IL-6 but also by others such as IL-1β, TNF-α and IL-22, and its expression is detectable not only in the liver but also at inflammatory lesions, indicating that LRG has characteristics different from CRP. We have found that LRG is more useful than CRP in evaluating disease activity of rheumatoid arthritis during tocilizumab therapy and ulcerative colitis. As a result of the collaboration with a company, an LRG measurement system for clinical use has already been developed. LRG may be applicable in the near future to an objective and quantitative indicator of disease activity in rheumatic diseases.