The novel coronavirus pandemic that originated from Wuhan, China in December 2019 is rapidly spreading around the world, causing many victims and having a significant impact on our lives. In this review, I would like to provide an overview of the general situation of novel coronavirus infections and the current state of development of therapeutic agents, and address the rheumatology practice in the Corona Era.
In children, COVID-19-related diseases are less frequent and less aggressive. However, precise analysis has revealed that children in paediatric ICUs included many infants and young children with such severe symptoms as respiratory distress and multiple organ failure. In the United States, 74 children admitted to paediatric ICUs were estimated to be a reflection of the 176, 190 children globally infected with SARS-CoV-2.
For us paediatricians, there is a strong concern whether SARS-CoV-2 has a potential for intrauterine vertical transmission. After caesarean delivery, newborns were free from SARS-CoV-2 infections because samples taken from neonates proved to be sterile. However, neonates with confirmed SARS-CoV-2 infections were then infected after birth via exposure to coughs or microdroplets from their mothers. Thus, neonates born from COVID-19-positive mothers should be separated as soon as possible after delivery, and then fed formula exclusively.
Children with chronic rheumatic diseases under treatment with anti-rheumatic therapy―especially biologics ― are supposedly sensitive to SARS-CoV-2. On the other hand, hydroxychloroquine and tocilizumab were quite effective for patients progressing to ARDS/multiple organ dysfunction due to a cytokine storm. It will be beneficial to maintain undergoing therapy for chronic rheumatic diseases in the setting of the COVID-19 pandemic because stopping the therapy could cause inflammatory relapses to occur and there might not then be a way to suppress the inflammation.
In the course of COVID-19 infections, some cases were diagnosed with Kawasaki disease. However, in East Asia, Japan, and Korea ― the most prevalent areas of incidences of Kawasaki disease ― there still seem to be no reports suggesting a relationship between COVID-19 and Kawasaki disease. Thus, we must remain vigilant and keep on the lookout for the time being as more information is gathered about COVID-19’s characteristics.
Recently patients with rheumatoid arthritis are being treated with biologic agents, and biologic agents are often used in combination with methotrexate. However, there are some cases where biological agents cannot be used together for some reason. Therefore, we review the efficacy and safety of biologic monotherapy.
Background: Elderly onset rheumatoid arthritis（EORA）often develops with high disease activity. Comorbidities are associated with intolerance to the treatment. Certolizumab pegol（CZP）for early RA patients was shown to be effective in C-OPERA study, but the evidence in elderly patients is limited. We aimed to investigate the effectiveness of early induction of CZP in EORA.
Methods: We retrospectively analyzed the data obtained from consecutive 14 EORA patients who started treatment with CZP within 3 months after the induction of conventional synthetic disease modifying anti-rheumatic drugs.
Results: Disease duration of RA at the time of induction of CZP was 3（2-4）months. The duration from introduction of csDMARDs was 17.5（13.3-23.0）days. Interstitial pneumonia was accompanied in 2 patient, chronic kidney disease in 5 patients and diabetes mellitus in 6 patients. After 4 weeks of treatment with CZP, DAS28-ESR（5.5（4.9-6.3）vs. 3.4（2.5-4.1）, p=0.001）and HAQ-DI（1.3（0.7-2.0）vs. 0.1（0-0.7）, p=0.001）were significantly improved. No infection occurred during the observational period. Within 24 weeks, 2 patients stopped using CZP because of secondary failure.
Conclusion: Early introduction of CZP was effective in ameliorating disease activity and activity of daily life among elderly patients.
［Objectives］Correlation between pain decrease and increase and clinical parameters in patients with rheumatoid arthritis（RA）were statistically investigated.
［Methods］From August 2010, RA patients were treated for more than five years under treat to target treatment protocol with monitoring disease activity score, Health Assessment Questionnaire（HAQ）, EuroQOL score with five dimensions（EQ5D）, and pain score with visual analog scale（PS-VAS）every three months.
Subjects were identified based on weather PS-VAS was less than 10mm.（G-PR）, and they were classified based on whether PS-VAS increased to more than 10mm（G-PRf and G-PRr）. These two groups were also compared for the same parameters from the baseline to later than the second year.
［Results］Of 238 cases, 145 were in G-PRf and 93 were in G-PRr. G-PRf significantly demonstrated a higher ratio of treatment for dementia, longer disease duration, a greater number of comorbidities, higher titers of anti-CCP antibodies and rheumatoid factor, more considerable joint deformity, lower daily activity function, higher PS-VAS at baseline. Attaining PS-VAS remission in the first treatment year significantly correlated with the number of comorbidities at baseline and the Simplified Disease Activity Index at the first year. Change of PS-VAS from first to later than second treatment year significantly correlated with the patientʼs global assessment（PGA）. Quality of life value of G-PRf demonstrated a significant decrease from the first year to later than the second year.
［Conclusion］An increase in PS-VAS correlated with patientʼs comorbidity, disease activity management, and PGA, and affects the patientʼs quality of life.
Rheumatoid arthritis（RA）is a chronic disease with periods of flare-ups and remissions, affecting daily life. Therefore, this disease requires lifelong management. For better management, both patients and health professionals including nurses should understand patients’ disease process and associated life changes. Based on this information, health professionals are needed to provide the optimal necessary support and resolve problems when necessary.
We report a woman with RA interviewed about her life and medical history using the Corbin and Strauss Chronic Illness Trajectory Framework approach. In this model, the reaction of a person with chronic “illness” is regarded as a course that changes over a long period of time, and the “trajectory” is considered as a course that can be understood when looking back at a disease or chronic condition. This approach has been proven to provide useful information for both the patient and the health professionals, allowing both sides to better understand the disease course and associated changes in daily life and psychological condition.
This preliminary study focuses on understanding the value of different phases of the trajectory of illness and sheds more light on the relationship between the patient and the health professionals and how the disease process and patients’ perspectives can facilitate mutual trust and smooth future disease management. Implementing this approach is considered to pave the road for a smooth shared decision making and facilitates effective “treat-to-target（T2T）”.
A 38 year-old man who was previously diagnosed as having bronchial asthma was treated with corticosteroid over a prolonged period of time. Five years ago, he developed osteonecrosis of bilateral femoral heads. One year ago, he was referred to our hospital, because of polyarthralgia. Initially, he was diagnosed with rheumatoid arthritis and treated with anti-rheumatic drugs. His symptoms showed improvement temporarily; however, because polyarthralgia recurred subsequently, MR imaging of multiple joints was performed. The results of this study confirmed a diagnosis of multiple osteonecrosis caused by corticosteroid.
Utility of the patient support program “Believe” on rheumatoid arthritis treatment course.
Objective: Patients with rheumatoid arthritis（RA）treated with tocilizumab（TCZ）are provided to a proprietary patient support program “Believe”. It consists of several educational materials such as patient booklet about the disease and infection, and pulse oximeter（PO）, which had been provided according to the judgment of the doctor since April 2016. The main objective of this study is to examine the utility of “Believe” including PO on RA treatment.
Subjects and Methods: A questionnaire survey had been conducted for 66 RA patients who participated in “Believe” since April 2016 at Katayama Orthopedic Rheumatology Clinic.
Results: Patientsʼanswers for a questionnaire survey for “Believe” were increased knowledge of RA（87.5%）, decreased anxiety（71.2%）, increased awareness for infection（74.2%）and ncreased reassurance for infection by measuring oxygen saturation（Sp02）（57.1%）. For general assessment for “Believe”, 77.0% of patients evaluated “good” or “very good”. 3 cases（5%）showed the abnormal status of SpO2.
Evaluations of “Believe” by 5-point rating were 4.17 for-increased knowledge, 4.10 for increased awareness of infectious diseases and 3.98 for-comprehensive evaluation.
Conclusions: Provided information regarding RA and infection control by the “Believe” system had developed patientʼs knowledge and health management awareness of RA.
“Believe” was considered to be a useful support program for patients who treated with TCZ.
A 49-year-old woman was diagnosed with Systemic lupus erthymatosus（SLE）at 27 years old. She was diagnosed with type V lupus nephritis by kidney biopsy at 39 years old, and received 7.5mg of prednisolone（PSL）and 50mg of cyclosporine as treatment. She was hospitalized due to effort dyspnea in May, 2016. Her mean pulmonary arterial pressure was 51.3mmHg, NYHA/WHO pulmonary hypertension functional classification was class Ⅲ. It was found to be highly unlikely that she had chronic thromboembolic pulmonary hypertension by testing of lung perfusion scintigraphy, so we diagnosed her clinical condition was pulmonary artery hypertension caused by SLE. First, we prescribed her a steroid pulse, a cyclophosphamide pulse, prednisolone 1mg/kg, and 50mg of cyclosporine, then started to use pulmonary vasodilator together. Her mean pulmonary arterial pressure significantly was improved after this treatment. It was reported that collagenosis PAH had good steroid and immunosuppressant reactiveness, but this case wasn’t responsive to the treatment, and was responsive to use with pulmonary vasodilator. By case report, most of the SLE-PAH cases were responsive to precociously use pulmonary vasodilator together have low SLEDAI. I thought that using pulmonary vasodilator together is necessary for SLE-PAH cases which have low SLEDAI.
We conducted hand function training for RA patients and examined the effects on hand function and synovitis.
This study was performed on 17 RA patients admitted to hospital for rehabilitation purposes between January 1, 2018 and May 31, 2019. Hand function training was performed for 17 RA patients daily for 4 weeks by using strengthening and stretching for rheumatoid arthritis of hand（SARAH）developed by Lamb et al in 2015. Functional evaluation included grip and pinch strength, hand pain VAS, and Quick DASH. RA disease activity and dysfunction were evaluated using joint ultrasound, DAS28, and HAQ.
The median age was 71（54-83）years, and the median disease duration was 10（1-60）years. Of 17 RA patients, 8 had positive synovial blood flow. The functional evaluation showed a statistically significant improvement in grip and pinch strength, and VAS after 4 weeks in this positive group, but no improvement was seen in the negative group in any of the items. Joint synovial blood flow of RA showed a statistically significant improvement after week intervention. The blood flow negative group did not show any new synovitis after the intervention. In all groups, DAS28 and HAQ did not show statistically significant improvement after 4 weeks, and there was no significant change in RA symptoms during the intervention period.
It was suggested that SARAH is an effective treatment for improving the hand function without worsening RA synovitis in the short term intervention.
Background: The accurate assessment of renal function is essential for implementing safe therapy among patients with autoimmune diseases. Serum cystatin C（Cys）is less affected by muscle mass. However, factors that affect the serum level of Cys were not fully known. There were various opinions about the effect of glucocorticoid（GC）therapy to serum cystatin C concentration. In this study, we investigated the influence of GC to Cys based eGFR（eGFRcys）and compared chronic kidney disease status using eGFRcreat and eGFRcys.
Methods: This was an observational study in an outpatient rheumatology clinic of a single hospital. The consecutive patients had their serum Cr and Cys measured. The eGFRs were calculated using Cr and Cys（eGFRcreat and eGFRcys）. Patients were divided according to with or without oral GC therapy.
Results: In all, 189 patients（75.1% female）with various autoimmune diseases were included in the study. Their mean（SD）age was 68.3 years old（13.03）. The number of patients taking GC was 124（65.6%）. The mean dosage of GC of 124 patients was 4.6（SD3.18）mg/day of prednisolone. Mean eGFRcys was significantly lower than the mean eGFRcreat. The correlation coefficient between eGFRcreat and eGFRcys was 0.681 in 189 patients. There was no significant difference between the correlation coefficient of patients taking GC and that of patients not taking GC（0.73 vs. 0.62）. 38.6% of patients’ CKD status was discordant. Reclassification by eGFRcys was more likely in elderly patients and those with hypoalbuminemia.
Conclusions: We have observed the influence of small dosage of oral GC on eGFRcys. There are discrepancies in CKD status between eGFRcreat and eGFRcys. eGFRcys might be a good marker of renal function to predict the dose of renally excreted drugs.