Drug survival and the associated predictors in South Korean patients with rheumatoid arthritis receiving tacrolimus

BACKGROUND/AIMS@#To investigate the drug survival rate of tacrolimus (TAC) and analyze the potential predictors of this rate in patients with rheumatoid arthritis (RA) in routine care.@*METHODS@#2018-01-16: In this retrospective longitudinal study, we enrolled 102 RA patients treated with TAC from April 2009 to January 2014 at a tertiary center in South Korea. The causes of TAC discontinuation were classified as lack of efficacy (LOE), adverse events (AEs), and others. The drug survival rate was estimated using the Kaplan-Meier method and the predictors of this rate were identified by Cox-regression analyses.@*RESULTS@#TAC was discontinued in 27 of 102 RA patients (26.5%). The overall 1-, 2-, 3-, and 4-year TAC continuation rates were 81.8%, 78.4%, 74.2%, and 69.1%, respectively and the median follow-up period from the start of TAC was 32.5 months. The number of TAC discontinuations due to LOE, AEs, and others were 15 (55.6%), 11 (40.7 %), and 1 (3.7%), respectively. The baseline high disease activity was a significant risk factor for TAC discontinuation after adjusting for confounding factors (hazard ratio [HR], 2.49; 95% confidence interval [CI], 1.16 to 5.35; p = 0.019). In addition, underlying interstitial lung disease was significantly associated with TAC withdrawal due to AEs (HR, 3.49; 95% CI, 1.06 to 11.46; p = 0.039).@*CONCLUSIONS@#In our study, TAC showed a good overall survival rate in patients with RA in real clinical practice. This suggests that the long-term TAC therapy has a favorable efficacy and safety profile for treating RA.

Effect of Rheumatoid Factor on Vascular Stiffness in General Population without Joint Symptoms / 고신대학교의과대학학술지

OBJECTIVES: The role of rheumatoid factor (RF) in vascular stiffness and cardiovascular risk in subjects without joint symptoms remains unclear. We investigated vascular stiffness in subjects without joint symptoms using pulse wave velocity (PWV), calculated Framingham risk scores (FRS), an estimator of cardiovascular risk, and analyzed whether vascular stiffness and FRS were affected by RF. METHODS: Two hundred forty-two subjects were included in this population-based study. RF was quantified with turbid immunometry using a cut-off of RF > 15 IU/ml to denote RF positivity. Information was then obtained on joint symptoms. Brachial-ankle PWV (baPWV) was measured using an automated device. RESULTS: Of the 242 subjects, 15 were RF-positive. RF-positive subjects without joint symptoms had a higher baPWV and FRS than RF-negative subjects without joint symptoms, but the difference did not reach statistical significance. However, when we stratified the subjects into two groups (group A – high RF: RF ≥ 40 IU/ml; group B – low RF: RF < 40 IU/ml), group A showed significantly higher baPWV (1640.7 ± 179.6 ㎝/s vs. 1405.7 ± 225.7 ㎝/s, P = 0.008) and FRS (25.7 ± 4.87 vs. 11.8 ± 9.6, P < 0.001). Multiple regression analysis was used to examine potential confounders, and RF exhibited significant but modest effects on baPWV (adjusted R-squared = 0.038, P = 0.030). CONCLUSIONS: In a sample of the general population without joint symptoms, higher levels of RF were associated with increased vascular stiffness, suggesting a pathophysiologic link between RF and endothelial dysfunction.

Co-existent Mixed Connective Tissue Disease and Papillary Thyroid Cancer in a Patient with Primary Biliary Cirrhosis / 대한내과학회지

A 40-year-old female previously diagnosed with primary biliary cirrhosis was referred to the hospital complaining of muscle weakness, arthralgia, Raynaud's phenomenon, and thick skin. After work-up, she was diagnosed with both mixed connective tissue disease (MCTD) and papillary thyroid cancer (PTC), based on the Alarcon-Segovia criteria and pathological examination, respectively. High-dose glucocorticoid and azathioprine were introduced to treat active myositis of MCTD, and total thyroidectomy was performed to treat PTC. This report highlights the possible association between MCTD and thyroid cancer, and suggests that MCTD is associated with PTC, similar to other autoimmune diseases including Sjögren's syndrome, systemic sclerosis, and systemic lupus erythematosus.

A Case of a Central Retinal Artery Occlusion in a Patient with Rheumatoid Arthritis

A 50-year-old woman, who had been treated for rheumatoid arthritis (RA) over a 10-year period, suddenly presented with monocular vision loss while the RA had a stable course over many years. She was diagnosed with central retinal artery occlusion (CRAO) based on ophthalmologic examinations including optical coherence tomography and fluorescein angiography. There was no evidence of atherosclerosis, infection, and malignancy that can cause CRAO. Considering the association between CRAO and other rheumatic diseases, such as systemic vasculitis and systemic lupus erythematous in previous reports, it was presumed that her RA might have contributed to the development of CRAO. Although cases of CRAO in patients with RA are extremely rare, these findings suggest that physicians need to be aware of the possibility of CRAO in patients with RA who experience decreased visual acuity.

Successful Treatment of Newly Developed, Intractable Digital Ulcers and Gangrene with Bosentan in Systemic Sclerosis

In systemic sclerosis, digital ulcers and gangrene are somewhat common clinical characteristics of obliterative vasculopathy. These manifestations increase morbidities, such as pain, infections, and acroosteolysis. However, patient responses to the appropriate treatments are often inadequate. We treated a patient with systemic sclerosis who had a refractory digital ulcer and gangrene with bosentan, an endothelin receptor antagonist, and observed improvement. Here we systematically review this case.

Discovery of Splenic Sarcoidosis Concurrent with the Diagnosis of Ovarian Cancer: A Case Report

Sarcoidosis is a multisystem inflammatory disease of unknown etiology characterized by noncaseating epithelioid granuloma formation. Although the relationship between sarcoidosis and malignancy has been noted in recent decades, there are few case reports describing the concurrent diagnosis of sarcoidosis and malignancy. Herein, we describe a case of biopsy-proven splenic sarcoidosis mimicking metastasis at the time of ovarian adenocarcinoma. Imaging studies including positron-emission tomography-computed tomography were not useful for differentiating sarcoidosis from malignancy. Thus, our case highlights the importance of histopathological examination to rule out nonmalignant conditions before the diagnosis of metastatic disease is made.

A Case of Thyrotropin (TSH)-Secreting Pituitary Adenoma in a Patient with Ankylosing Spondylitis / 대한내과학회지

A thyrotropin (TSH)-secreting pituitary adenoma is a rare cause of hyperthyroidism, with an incidence of one case per million. Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease of the axial skeleton. Extra-articular manifestations, such as anterior uveitis, may also be prominent features in AS but little is known about the association between AS and thyroid diseases including TSH-secreting pituitary adenomas. We present a case study of a 26-year-old male AS patient who was diagnosed with a TSH-secreting pituitary adenoma using a thyrotropin releasing hormone stimulation test, measurement of the TSH alpha-subunit, and magnetic resonance imaging, and subsequently treated with a transsphenoidal tumor resection.

Severe Pulmonary Hypertension in Primary Sjogren's Syndrome

A 65 year-old female with a history of xerostomia and xerophthalmia was presented with dyspnea on exertion (New York Heart Association class III). Echocardiography and cardiac catheterization demonstrated severe pulmonary hypertension (PH). Laboratory examinations showed positive anti-nuclear and anti-Ro/SS-A antibodies. Schirmer's test was positive and salivary gland scintigraphy revealed severely decreased tracer uptakes in both parotid and submandibular glands. By excluding other possible causes of PH during further examinations, she was diagnosed with severe PH associated with primary Sjogren's syndrome. Her dyspnea symptom was much improved with endothelin receptor antagonist and azathioprine.