Drug Utilization Pattern and Cost Analysis in Rheumatoid Arthritis Patients – A Cross–Sectional Study in Tertiary Care Hospital, Mumbai.

Aims: To study the current prescription pattern and to analyze the cost of the treatment Prescribed to RA patients referred to rheumatology OPD in KEM hospital. Study Design: Cross-sectional study. Place and Duration of Study: Department of Medicine and Department of Pharmacology, Seth GSMC & KEM Hospital, between July 2011 and December 2011. Methodology: The study protocol was approved by the institutional ethics committee. Patients attending Rheumatology OPD for existing RA disease were recruited as per inclusion criteria. Written informed consent was sought. It was a cross-sectional study. Total 100 consecutive rheumatoid arthritis patients (fulfilling the American College of Rheumatology Criteria 1987) were recruited from 1st July to 1st September 2011. Results: Majority of patients (67%) in the study population were on combination of two DMARDs. Most frequently prescribed two DMARDs combination was methotrexate and hydroxychloroquine (64%). Average total cost per prescription was found to be 763.39 (US$ 14), while average hospital and out of pocket expense were 281.12 (US$ 5) and 482.88 (US$ 9) respectively. Conclusion: The drug use pattern in RA was found to be DMARDs based and majority of the cost was borne by the patient. The total cost increased was due to administration of drugs to treat the adverse drug reaction. Prospective studies in a larger number of patients are needed to assess the utility of prescription audit and cost analysis of drugs used in RA.

Assessment of use of complementary alternative medicine and its impact on quality of life in the patients attending rheumatology clinic, in a tertiary care centre in India.

Purpose: Complementary and alternative medicine (CAM) has witnessed an increase in use in recent times in rheumatological conditions and is expected to have impact on the quality of life (QOL). We had planned to conduct this study to investigate the extent of use of CAM and its effect on QOL of patients at a tertiary care center. Materials and Methods: Ethics committee approval was obtained. Sixty patients suffering from osteoarthritis (OA) and rheumatoid arthritis (RA) were enrolled as per the selection criteria, after obtaining their informed consent. Each patient was interviewed for CAM use/non-use, and Western Ontario and McMaster Universities (WOMAC) (modified) index for QOL was recorded by the study personnel. Statistical Analysis: The normality was checked by using Kolmogorov-Smirnov test. Descriptive statistics was performed and Mann-Whitney U-test was used to compare the QOL of CAM users and non-users. Results: Of the 60 patients enrolled with OA (10) and RA (50), 58% (35/60) used CAM. Ayurveda and massage therapy were the commonest [80% (28/35)], followed by yoga asana [34% (12/35)] and homoeopathy [20% (7/35)]. It was observed that combinations of therapies were used too. Nearly half [49% (17/35)] of the CAM users were on self-prescribed medication and 71% (25/35) of them did not inform the physician of CAM use. The QOL of CAM users (WOMAC score: 56.31 ± 6.82) was better than that of CAM non-users (WOMAC score: 60.16 ± 4.02) (P value 0.01). Conclusion:Patients with RA frequently used CAM and QOL improvised with CAM use. We observed that self-administration of CAM was common and this was not informed to the treating physician.

Cardiac amyloidosis.

We present a 54 year old male who presented with congestive cardiac failure and was diagnosed as restrictive cardiomyopathy with mild mitral regurgitation on 2D echocardiography. Cardiac amyloidosis was diagnosed in view of renal biopsy revealing amyloid deposition. Patient did not have any obvious etiology for secondary amyloidosis.

Tumefactive demyelination.

We present a case of 22 year old female who had pulmonary tuberculosis followed by tuberculous meningitis and tuberculomas in past. This time she presented to us with right hemiparesis and altered sensorium. Diagnosis of tumefactive demyelination was made on the basis of typical MRI findings. Patient showed good response to steroids.

Serum uric acid in acute myocardial infarction.

BACKGROUND: There is evidence that high uric acid is a negative prognostic factor in patients with mild to severe heart failure. A study showed a close correlation between serum uric acid concentration and Killip classification in patients of acute myocardial infarction. MATERIAL AND METHODS: We studied 100 patients with acute myocardial infarction and 50 controls. Serum uric acid level was measured on day 0, 3 & 7 of MI. RESULTS: There was a statistically significant higher level of serum uric acid concentration in patients of MI on day of admission as compared to controls. Patients with history of MI in the past had higher serum uric acid levels. On all the days serum uric acid levels were higher in patients who were in higher Killip class. All the five patients who died after 3 days of hospital stay had serum uric acid level more than 7.0 gm/dL and all of them were Killip class IV. CONCLUSIONS: Serum uric acid levels are higher in patients of acute myocardial infarction correlated with Killip class. Combination of Killip class and serum uric acid level after acute myocardial infarction is a good predictor of mortality after AMI.

Evaluation of efficacy and tolerability of dothiepin hydrochloride in the management of major depression in patients suffering from rheumatoid arthritis.

Several studies have shown that 20 to 66.2% of patients with rheumatoid arthritis have associated psychiatric comorbidity especially depression. Dothiepin hydrochloride is a well-established and effective antidepressant in patients with depressive symptoms of varying severity and co-existing anxiety. To document the efficacy and tolerability of dothiepin hydrochloride in the management of major depressive disorder (MDD) in rheumatoid arthritis patients a phase IV, open, single arm, prospective study was initiated with dothiepin hydrochloride in the dose of 75 mg/day, duration of therapy was 6 weeks. Twenty-five rheumatoid arthritis patients suffering from co-morbid MDD completed the 6-week dothiepin hydrochoride treatment and were considered for final analysis. There was significant reduction (p < 0.05) in mean HAM-D scores at week 2 (13.92 +/- 5.45), week 4 (9.28 +/- 4.13) and week 6 (5.72 +/- 3.26) compared to baseline (21.64 +/- 5.93). There was significant reduction (p < 0.05) in mean HAM-A scores at week 2 (6.52 +/- 3.34), week 4 (4.0 +/- 2.25) and week 6 (2.76 +/- 1.59) compared to baseline (10.68 +/- 3.68). The global impression of efficacy at the end of 6 weeks of dothiepin hydrochloride treatment was rated by the clinician (psychiatrist) as marked and moderate improvement in 20 (80%) and 5 patients (20%) respectively. Only 2 patients reported dry mouth as an adverse event in the study. The overall assessment of tolerability at the end of 6 weeks of dothiepin hydrochloride treatment was rated by the clinician (psychiatrist) as good and fair in 19 (76%) and 6 patients (24%) respectively. Dothiepin hydrochloride was found to be an effective and well-tolerated drug in the management of MDD and anxiety in patients suffering from rheumatoid arthritis.

Biphasic demyelination of the nervous system following anti-rabies vaccination.

Acute disseminated encephalomyelitis (ADEM) is an acute or subacute condition characterized by widespread multifocal neurological deficits of variable severity. We report a case of a 45-year-old man with ADEM following anti-rabies vaccine (ARV).

Idiopathic hypereosinophilic syndrome manifesting as pulmonary oedema.

Idiopathic hypereosinophilic syndrome is a progressive and fatal disease if not treated effectively. We report this case since hypereosinophilia is an uncommon cause of pulmonary oedema.

Neuropathy in rheumatoid arthritis.

BACKGROUND: Paucity of Indian literature on rheumatoid neuropathy creates a lacuna in the critical evaluation and discussion of the subject. We did this study to find out the incidence and pattern of neuropathy and to correlate it with disease parameters and other extra-articular involvement. MATERIAL AND METHODS: We studied 31 patients of rheumatoid arthritis (RA) classified by ACR criteria. Electromyography and nerve conduction studies (EMG/NCV) were done in all the patients apart from routine laboratory and radiological investigations. Electrocardiograph (ECG), pulmonary function tests (PFT) and ophthalmological examination were also carried out to ascertain extra-articular involvement. RESULTS: Ten out of 31 RA patients had neuropathy of which five each were overt and subclinical respectively. Only one patient had entrapment neuropathy. Four of the ten patients had pure motor neuropathy whereas the other six were sensori-motor neuropathies. Four patients had mononeuritis multiplex and five had symmetrical peripheral neuropathy. Nine of the ten neuropathic patients had RA for more than 2 years. Seven patients had other extra-articular features along with neuropathy. CONCLUSIONS: One-third of patients with RA have evidence of neuropathy. Disease parameters such as activity, rheumatoid factor and functional and radiological grade do not correlate with neuropathy. Non-entrapment sensori-motor type of neuropathy is the most common type.

Relationship between osteoarthritis of knee and menopause.

AIM: To study the difference in the onset of osteoarthritis (OA) between males and females with respect to age and to note the relationship between OA of the knees and menopause and hysterectomy in females. MATERIAL AND METHODS: One hundred consecutive patients (50 males and 50 females) were studied for the onset of OA and compared for the statistical difference. In females the relationship between onset of OA and menopause and hysterectomy, if done, was noted. RESULTS: Fifty eight percent of females had onset of symptoms of OA of knees before 50 years of age as compared to only 20% in males (p < 0.05). Sixty four percent of females with OA of knees had the onset of symptoms either perimenopausally or within five years of natural menopause or hysterectomy. CONCLUSION: There is a definite early peaking of the incidence of OA of knees in women in the fifth decade of life as compared to males. There is an association between OA of knees and menopause and we suggest correlating it with the levels of sex hormones.

Leprosy: a close mimic in a rheumatology clinic.

Cutaneous and neurological manifestations of leprosy are readily diagnosed. However, physicians sometimes fail to recognize that leprosy may present with a rheumatic symptoms. A plethora of rheumatic manifestations are associated with leprosy, particularly with lepra reactions. A diligent examination for skin lesions/nerve involvement may uncover the diagnosis of leprosy in a patient referred for a rheumatological disorder. To highlight the fact that leprosy can mimic several rheumatological disorders, we have discussed a few representative cases seen over the past two years at our rheumatology clinic in a teaching hospital. In all these cases, a diagnosis of leprosy was made when the patient was referred for a rheumatic complaint.

Systemic lupus erythematosus in males.

Systemic Lupus Erythematosus is a disease commonly seen in women. A few male kindreds have however been described. In this study, twelve male patients of a series of 175 patients with SLE have been analysed. Arthritis was the most frequent manifestation observed. Renal involvement was seen in as many as 41.65% of patients.

Effect of inhaled terbutaline on platelet activity in bronchial asthma.

Thirty five young subjects with long standing bronchial asthma were studied for the effects of terbutaline misthaler (500 micrograms) during acute asthma. Bronchodilators were omitted for a day before the test. Ten matched controls were also studied. In all subjects, basal IgE level (ELISA), pulmonary parameters (FVC, FEV, PEFR, FEF 25-75 and FEF 75-85) and platelet activity, (platelet clumping/150 WBC on smear, platelet adhesiveness, blood recalcification time and kaolin clotting time for platelet factor3) were compared. During acute asthma, the subjects displayed IgE levels > or = 500 IU/ml (n = 33), activation of clotting (n = 30) and eosinophilia > or = 450/cmm (n = 28). These changes were not seen in normal controls. Terbutaline resulted in a reversal of airway obstruction, mainly of small airways, while the platelet hyperactivity and blood hypercoagulability were rectified (P < 0.001). It is concluded that platelet activity increases in acute asthma and is corrected by inhaled terbutaline concomittant with the relief of bronchospasm.