Systemic autoimmune rheumatic diseases including systemic lupus erythematous（SLE）are diseases of unknown cause, in which a diverse population is formed without a gold standard for each disease. Therefore, only classification criteria（for a patient group）have been created and revised, and international diagnostic criteria（for individual patient）cannot be proposed. The treatment strategy is not directly determined by the disease diagnosis, but by the severity of the disease. Severity, in turn, is determined by the prediction of poor prognosis in a relatively short term, namely the current degree of organ damage, the current activity of organ damage, the contribution of the affected organ to life and vital function, and the treatment responsiveness. It is easy to understand if activity is defined as the progression speed（time differential value）of organ damage. Although clinical evaluations currently in widespread use meet certain criteria, it is expected that they will be complemented and improved by the use of new imaging tests, biomarkers, and artificial intelligence in the future.
A 79-year-old women was referred to our hospital because of severe arthritis. She had been having joint pain for more than 1 year and anti-CCP antibody was positive. She was diagnosed as having rheumatoid arthritis and treated with methotrexate and prednisolone. In addition, she was diagnosed as having non-tuberculosis mycobacterium according to sputum test for non-tuberculosis mycobacterium（NTM）and treated with chemotherapy for her NTM.
Her RA activity was very high and Sarilumab was added to her treatment in combination with methotrexate. After adding Sarilumab, her RA activity decreased. On the other hand, her PCR test for NTM was negative.
After 1 year, her RA was in remission. Sarilumab was decreased from 200 to 150 mg. Her RA has been in remission and NTM was also stable.
Our case suggests that it is possible that we may use biologics for patients with high disease activity RA who have pulmonary NTM if NTM remains stable.
Objective: To examine the status of rheumatoid arthritis（RA）patients who received shortening dosing interval of subcutaneous tocilizumab（TCZ-SC）.
Subjects and methods: We retrospectively investigated RA patients treated with shortening TCZ-SC dose interval at Rheumatology & Collagen Disease Center of our hospital as of 2018. Clinical parameters such as MMP-3, CRP, ESR, PtGA-VAS and CDAI were respectively examined before shortening the TCZ-SC dose interval and approximately 8 weeks later.
Result: Shortening of the dosing interval of TCZ-SC was initiated in 11 RA patients. It was extended to every other week in 3 of the patients after achieving the treatment goal, and effectiveness was maintained. In some cases, we confirmed the Prednisolone（PSL）could be tapered or discontinued by shortening the dosing interval. Serum MMP-3 levels were significantly reduced by shortening the TCZ-SC dosing interval. Also, other clinical parameters were improved.
Conclusion: Shortening the dosing interval of TCZ-SC should be considered as a valuable and effective treatment to try before switching to other biologics. It was also suggested that the dosing interval could be extended to every other week after achieving the treatment goal by shortening dosing interval of TCZ-SC.
Background: The development of drug therapies for rheumatoid arthritis（RA）, and control of synovitis has now become easier. However, once patients are relieved of pain, they become physically more active and sometimes overuse their joints. Here we analyzed the clinical characteristics of such patients who had overused their joints.
Methods: In-depth history taking about joint overuse and physical examinations were performed prospectively for 3148 consecutive patients with RA who visited our outpatient department between August 2016 and October 2016. Patients who had joint pain and swelling of the strained joints, were diagnosed as having joint overuse. Their clinical features and laboratory data before they developed joint overuse were collected from their medical records. As comparative controls, we selected 123 age- and sex-matched contemporary patients with RA who had no joint overuse from among 3148 patients.
Results: Forty-one patients（10 men and 31 women）with a median age of 62.0 years were diagnosed as having joint overuse. Logistic regression analysis revealed that treatment with biological disease-modifying antirheumatic drugs（bDMARDs; odds ratio [OR], 3.10; 95% confidence interval [CI], 1.24 - 7.76）, low health assessment questionnaire disability index（HAQ-DI; OR, 0.27 95% CI, 0.09-0.80）, and Steinbrocker stage III or IV（OR, 5.90; 95% CI, 2.28-15.2）were significantly associated with the development of joint overuse.
Conclusion: When patients with advanced RA have low HAQ-DI using bDMARDs, they are at risk of joint overuse. Appropriate education would be important for such patients to prevent such overuse.
The effect of intraarticular injection with triamcinolone（TCN）for rheumatoid arthritis（RA）patient was reviewed retrospectively, and evaluated statistically.
RA patients who were injected intraarticularly with TCN from April 2014 to March 2019 were picked up. Their clinical parameters were compared before and after injection with a paired T-test. Patients were classified according to number of injections. Changes in clinical parameters including bone mineral density（BMD）were compared between pairs of the groups with ANOVA.
Injections were performed 1020 times for 208 patients including 45 males and 163 females with 67.1 as the mean age. All components of the simplified disease activity index and pain score with visual analog scale decreased significantly within within 1%, but there was no significant decrease at any time in the modified Health Assessment Questionnaire, This tendency was also demonstrated at one year after injection. There was no significant difference of clinical parameters between any pair of the groups when classified by frequency of injection, while prevalence of adverse events tended to occur more in groups with more injections compared to groups with fewer injection, but without statistical significance.
Intraarticular injection is useful for disease activity and pain control, and improvement of activity in daily living. There remains some debate about effect determined by frequency of injection.
Background: Patients with rheumatoid arthritis（RA）are often hospitalized for treatment of cancer, trauma, and cardiovascular event into departments other than rheumatology. Some patients might need medication adjustments for disease-modifying anti-rheumatic drugs. In addition, patients with disabilities in their daily activities may find it inconvenient or difficult to spend time in a hospital environment. In such settings, rheumatology certified staff should provide appropriate care to these patients. However, information about these issues is sparse.
Objectives: To investigate the background of RA patients admitted to departments other than rheumatology, and to clarify whether these patients need management by rheumatology certified staff to adjust medications or the hospital environment.
Patients and methods: Between October 1, 2018 and May 31, 2019, RA patients referred to the rehabilitation department from departments other than rheumatology were enrolled. Patients’ background, medications for RA, and ability to perform daily life activities were obtained from medical records.
Results: Of 2,687 patients referred to the rehabilitation department, 51 RA patients（1.9%）were identified. The average age was 75.8 years old and there were 39 women（76%）. The average Functional Independence Measure（FIM）was 70.7 points. Thirty patients（59%）had received RA treatment at other facilities. Thirty（59%）patients were hospitalized urgently for acute illness or trauma. Usage rates for prednisolone, methotrexate, and biologics were 76%, 31%, and 20%, respectively. Rheumatology-certified staff intervened in 13 cases（25%）; 3 involved rehabilitation and 15 were related to medication adjustment.
Conclusions: Some RA patients admitted to departments other than rheumatology needed adjustment of medications or their daily environment. A multidisciplinary approach is needed to provide care led by certified staff during hospital stays for treating diseases other than rheumatic conditions.
Objective: A post-marketing all-patient surveillance of canakinumab is underway to assess its safety and effectiveness in Japanese patients with colchicine-resistant Familial Mediterranean fever（crFMF）. We report an interim analysis 2.5 years post-launch of all crFMF patients who received canakinumab in daily medical practice. Methods: Thirty-nine patients were included in a data lock as of 30 June 2019, and all patients were included in the safety set and effectiveness set. Results: The mean age of the patients at treatment initiation was 40 years. The majority of patients were atypical cases with MEFV gene mutation（non-Exon10）（n=22）, followed by typical cases with gene mutation（Exon10）（n=10）, atypical cases without gene mutation（n=5）, and typical cases with unknown gene mutation（n=2）. Adverse drug reactions（ADRs）were reported in 25.64%（n=10）, and serious ADRs were reported in 10.26%（n=4）（two events of osteoarthritis and one event each of diverticulitis, haemosiderosis, enterovesical fistula, bursitis, bursal fluid accumulation, oedema, and pain）. Although the proportion of responders as defined in this survey was 20.51%（n=8/39）, the proportion of clinical remission was 65.71%（n=23/35）and that of serological remission was 85.29%（n=29/34）. Conclusion: This interim analysis showed no new safety concern. We will continue to assess the safety and effectiveness of canakinumab through this surveillance.
We report a case of severe consumption thrombocytopenia after tocilizumab（TCZ）administration. The patient was a 66-year-old Japanese woman with rheumatoid arthritis diagnosed at 20 years of age. Owing to exacerbation of her condition, intravenous TCZ was administered in July 2018. However, 12 days later, she visited our department because of petechiae on both legs. Her blood platelet count markedly decreased from 340,000/µl（before administration）to 6,000/µl（after administration）, and she was hospitalized on the same day. On the day of hospitalization, intravenous immunoglobulin infusion and prednisolone（50 mg/day）administration were initiated together with platelet transfusion. The thrombocyte corrected count increment at approximately 24 h after the initial platelet transfusion was 2511/µl, suggesting increased platelet destruction. The platelet count gradually improved and recovered to 340,000/µl on day 8 of hospitalization. The laboratory findings revealed elevated platelet-associated Immunoglobulin G and immature platelet levels. Bone marrow puncture revealed that both erythroid and granulocytic series were normal in terms of number and morphology, and her megakaryocyte levels were mildly increased. Based on the clinical course and these findings, drug-induced immune thrombocytopenia caused by TCZ was suspected. Consumption thrombocytopenia can occur after TCZ administration.
Recently, biosimilars（BS）have been used for the treatment of rheumatoid arthritis. Many clinical studies have demonstrated that switching from reference product biologics to BSs present no problems with efficacy or safety. However, no clinical study has switched from one BS to another. Therefore, 102 patients who had been treated with etanercept BS（ETN-BS, LBEC0101）for more than 12 weeks and had a remission of DAS28-CRP were analyzed after switching to another ETN-BS（YLB113）for 12 weeks or longer. Remission was maintained after the ETN-BS was changed to another ETN-BS. However, 9 cases returned to the previous BS. The reasons were subcutaneous injection pain in 6 cases, itchy skin in 2 cases, and redness at the injection site in 1 case. There was no difference in efficacy between the BSs but adverse events were different. Therefore, switching between BSs is possible but should be done carefully.