Trends in hospital visits and healthcare costs of gout and seropositive rheumatoid arthritis in Korea from 2010 to 2017 using National Healthcare Claims

Background/Aims@#We examined temporal trends in the rate of gout and seropositive rheumatoid arthritis (RA) hospital visits and healthcare costs in Korea. @*Methods@#We conducted a serial cross-sectional analysis of Korean national healthcare claims. We calculated the annual increase in hospital visits (emergency department [ED] visits, outpatient visits, and hospitalizations) and total healthcare costs per visit. @*Results@#From 2010 to 2017, the annual rates of ED visits, outpatient visits, and hospitalizations for gout increased from 6.28 to 21, from 638.38 to 1059.55, and from 12.37 to 15.6 per 100,000 persons, respectively. Before 2013, ED visits for gout were most common in patients over 70 years old, but they were most common in those aged between 30 and 49 years after 2013. The number of patients with ED visits, outpatient visits, and hospitalizations for RA from 2010 to 2017 increased from 1.25 to 1.87, from 219.04 to 307.49 and from 8.44 to 12.32 per 100,000 persons, respectively. However, there was no increase in the prevalence of ED visits for RA in any age group except for those older than 70 years. The cost per ED visit for gout significantly decreased from 496.3 to 273.6 US dollar during the study period. There was no significant change in the cost per ED visit for RA between 2010 and 2017. @*Conclusions@#There was a large increase in ED visits for gout during the study period. Further studies are needed to analyze the reason behind increased ED visits for gout and suggest ways on how to improve gout care.

Association of body composition with disease activity and disability in rheumatoid arthritis

Background/Aims@#To explore the associations between body composition and pain, disease activity, and disability in rheumatoid arthritis (RA). @*Methods@#The study enrolled 335 patients with RA and underwent body composition measurement with an InBody analyzer. The associations of body mass index (BMI), body fat mass, and skeletal muscle mass with disease activity score in 28 joints (DAS28), an index derived to measure the subjective component of DAS28 (DAS28-P), a pain visual analogue scale (VAS), and disability measured with the health assessment questionnaire (HAQ) were explored. Obesity was defined as BMI ≥ 25 kg/m2 @*Results@#The median (interquartile range) disease duration was 6 years (3.5 to 9) and the mean DAS28 score was 3.6 ± 1.1. The mean BMI was 23.6 ± 3.6 kg/m2 and 109 patients (32.5%) were obese. Compared with non-obese patients, obese patients had a higher C-reactive protein (1.68 mg/dL vs. < 0.1 mg/dL, p = 0.013), higher pain VAS score (40 vs. 35, p = 0.031), and higher DAS28-erythrocyte sedimentation rate score (3.75 ± 1.18 vs. 3.46 ± 1.11, p = 0.031). In multivariate regression analysis, the DAS28 score in females was positively associated with the current steroid dose, body fat mass, and HAQ score, while the HAQ score in females was associated with older age, DAS28, lower skeletal muscle mass, and higher body fat/skeletal muscle ratio. In the multivariate regression analysis, the DAS28-P score in females was positively associated with body fat/skeletal muscle ratio and HAQ. @*Conclusions@#Body composition, such as the body fat mass and body fat/skeletal muscle ratio, is significantly associated with disease activity and disability in female RA patients.

Comparative efficacy of biological agents in methotrexate-refractory rheumatoid arthritis patients: a Bayesian mixed treatment comparison

BACKGROUND/AIMS: Biological agents (biologics) targeting proinflammatory signaling have emerged as an important treatment option in rheumatoid arthritis (RA). Despite the clinical effectiveness of biologics for patients with RA who do not respond to ‘traditional’ disease-modifying anti-rheumatic drugs (DMARDs), there are concerns regarding their cost and long-term safety. In this study, we aimed to compare the efficacy of various biologics and traditional DMARDs in RA patients refractory to methotrexate (MTX). METHODS: Four DMARDs (hydroxychloroquine, sulfasalazine, MTX, leflunomide) and five anti-tumor necrosis factor drugs (adalimumab, etanercept, golimumab, infliximab, and certolizumab) were selected. A systematic search of published studies was performed from inception through July 2013. Randomized trials of adults with MTX-refractory RA comparing two or more of the selected medications were included. Among 7,938 titles identified, in total, 16 head-to-head trials were selected. Two reviewers independently abstracted the study data and assessed methodological quality using the Cochrane Risk of Bias. Comparative efficacy was analyzed using a Bayesian mixed treatment comparison (MTC). RESULTS: In total, 9, 4, and 11 studies were included for the outcome measures of the Health Assessment Questionnaire (HAQ), Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) < 2.6 (remission), and American College of Rheumatology (ACR) 70 response, respectively. The treatments with the highest efficacy for each outcome measure were certolizumab combined with MTX, golimumab combined with MTX, and certolizumab combined with MTX, respectively. CONCLUSIONS: Based on MTC analysis, using data from published randomized controlled trials, certolizumab and golimumab combined with MTX showed the highest efficacy in the three outcome measures (HAQ, DAS28-ESR < 2.6, and ACR 70 response) in MTX-refractory RA patients.

Comparative efficacy of biological agents in methotrexate-refractory rheumatoid arthritis patients: a Bayesian mixed treatment comparison

BACKGROUND/AIMS: Biological agents (biologics) targeting proinflammatory signaling have emerged as an important treatment option in rheumatoid arthritis (RA). Despite the clinical effectiveness of biologics for patients with RA who do not respond to ‘traditional’ disease-modifying anti-rheumatic drugs (DMARDs), there are concerns regarding their cost and long-term safety. In this study, we aimed to compare the efficacy of various biologics and traditional DMARDs in RA patients refractory to methotrexate (MTX). METHODS: Four DMARDs (hydroxychloroquine, sulfasalazine, MTX, leflunomide) and five anti-tumor necrosis factor drugs (adalimumab, etanercept, golimumab, infliximab, and certolizumab) were selected. A systematic search of published studies was performed from inception through July 2013. Randomized trials of adults with MTX-refractory RA comparing two or more of the selected medications were included. Among 7,938 titles identified, in total, 16 head-to-head trials were selected. Two reviewers independently abstracted the study data and assessed methodological quality using the Cochrane Risk of Bias. Comparative efficacy was analyzed using a Bayesian mixed treatment comparison (MTC). RESULTS: In total, 9, 4, and 11 studies were included for the outcome measures of the Health Assessment Questionnaire (HAQ), Disease Activity Score 28-erythrocyte sedimentation rate (DAS28-ESR) < 2.6 (remission), and American College of Rheumatology (ACR) 70 response, respectively. The treatments with the highest efficacy for each outcome measure were certolizumab combined with MTX, golimumab combined with MTX, and certolizumab combined with MTX, respectively. CONCLUSIONS: Based on MTC analysis, using data from published randomized controlled trials, certolizumab and golimumab combined with MTX showed the highest efficacy in the three outcome measures (HAQ, DAS28-ESR < 2.6, and ACR 70 response) in MTX-refractory RA patients.

A Case of Polymyositis with Normal Creatine Kinase / 대한내과학회지

Proximal muscle weakness can be induced by many diseases, such as muscular dystrophies, inflammatory muscle diseases, and polymyalgia rheumatica. Differential diagnosis of these diseases is important. The patient had proximal muscle weakness with a normal creatine kinase (CK) level. Our initial diagnosis was polymyalgia rheumatica because the CK level was normal. The patient was treated with low-dose corticosteroid. However, the muscle weakness did not improve. The diagnosis of polymyositis was confirmed by a muscle biopsy. We suggest that if the patient has typical symptoms with normal CK, then evaluations for inflammatory muscle diseases are essential.

A Case of Systemic Lupus Erythematosus Diagnosed by Initial Presentation of Digital Gangrene / 대한내과학회지

Although digital gangrene is an uncommon clinical feature, it may lead to serious complications, such as amputation. Therefore, it requires prompt evaluation and treatment. Digital gangrene is often seen in systemic sclerosis, but is rare in systemic lupus erythematosus (SLE). In SLE, digital gangrene results from vasculitis, vasospasm, and thromboembolism. Here, we report a 15-year-old male SLE patient who initially presented with digital gangrene, and present a review of the relevant literature.

Vasculitis as a Presenting Feature of Multiple Myeloma in a Patient with Rheumatoid Arthritis

Paraneoplastic vasculitis is a part of secondary vasculitis, the hematological neoplasm, such as lymphoma or myelodysplastic syndrome, which is most frequently observed. However, in multiple myeloma, cutaneous vasculitis is a rare complication, particularly as an initial clinical symptom. We report one case where a purplish reticulated patch on the lower extremity and an ear lobe skin necrotic change developed in a rheumatoid arthritis patient. He was diagnosed with multiple myeloma and cutaneous vasculitis.

Vasculitis as a Presenting Feature of Multiple Myeloma in a Patient with Rheumatoid Arthritis

Paraneoplastic vasculitis is a part of secondary vasculitis, the hematological neoplasm, such as lymphoma or myelodysplastic syndrome, which is most frequently observed. However, in multiple myeloma, cutaneous vasculitis is a rare complication, particularly as an initial clinical symptom. We report one case where a purplish reticulated patch on the lower extremity and an ear lobe skin necrotic change developed in a rheumatoid arthritis patient. He was diagnosed with multiple myeloma and cutaneous vasculitis.

Clinical Characteristics of Korean Rheumatoid Arthritis Patients with Indications for TNF-alpha Blocker

OBJECTIVE: The aim of this study was to examine clinical characteristics of Korean rheumatoid arthritis (RA) patients with clinically indications for TNF-alpha blocker, and to compare their clinical parameters with the Korean National Health Insurance reimbursement criteria. METHODS: Data were obtained from a registry of RA patients who visited rheumatology clinics of Hallym University affiliated hospitals. Among patients who were previously prescribed DMARDs for more than three months, rheumatologists selected patients clinically indicated for TNF-alpha blocker. The clinical characteristics at the time TNF-alpha blocker use was deemed indicated were examined. Radiographic damage was quantified by Modified Sharp van der Heijde score in hand and foot simple AP radiograph. RESULTS: From August 2010 to January 2013, five rheumatologists in four hospitals selected 109 patients clinically indicated for TNF-alpha blocker. When TNF-alpha blocker was considered, mean DAS28 was 5.2 (range 2.1~8.05), mean swollen joint count was 6 (range 0~22), mean tender joint count was 10.6 (range 0~28), mean ESR was 43.2 mm/hr (range 1~140) and mean CRP was 2.5 mg/dL (range 0.1~18.3). The mean total modified Sharp van der Heijde score was 32.72 (range 0~240). Eighty one percent of subjects did not have enough active joints to satisfy the Korean National Health Insurance reimbursement standard. CONCLUSION: Our results show that patients with clinically indications for TNF-alpha blocker had a broad range of disease activity and clinical parameters, and the majority did not meet the Korean National Health Insurance reimbursement criteria.

Prevalence and Risk Factor of Neck Pain in Elderly Korean Community Residents

Neck pain is a common musculoskeletal condition, which causes substantial medical cost. In Korea, prevalence of neck pain in community based population, especially in elderly subjects, has scarcely been reported. We evaluated the prevalence, the severity and the risk factors of neck pain in elderly Korean community residents. Data for neck pain were collected for 1,655 subjects from a rural farming community. The point, 6-months and cumulative lifetime prevalence of neck pain was obtained in addition to the measurement of the severity of neck pain. The mean age of the study subjects was 61 yr and 57% were females. The lifetime prevalence of neck pain was 20.8% with women having a higher prevalence. The prevalence did not increase with age, and the majority of individuals had low-intensity/low-disability pain. Subjects with neck pain had a significantly worse SF-12 score in all domains except for mental health. The prevalence of neck pain was significantly associated with female gender, obesity and smoking. This is the first large-scale Korean study estimating the prevalence of neck pain in elderly population. Although the majority of individuals had low-intensity/low-disability pain, subjects with neck pain had a significantly worse SF-12 score indicating that neck pain has significant health impact.

Comparison Korean National Health Insurance Reimbursement and Other Guidelines for TNF-alpha Blocker in Rheumatoid Arthritis

OBJECTIVE: The aim of this study was to examine how many Korean rheumatoid arthritis (RA) patients fulfilling the 2008 American College of Rheumatology (ACR) recommendation, 2007 British Society for Rheumatology (BSR) guideline and 2010 Japan College of Rheumatology (JCR) guideline for TNF-alpha blocker, meet the Korean National Health Insurance reimbursement criteria and to evaluate the reasons for failing the Korean National Health Insurance reimbursement criteria. METHODS: Data were obtained from a registry of RA patients who visited rheumatology clinics of Hallym university affiliated hospitals. Patients who were previously prescribed with methotrexate or leflunomide for more than 3 months and had at least one DAS28 examination were included in the present study. RESULTS: Of 642 patients included, 118 episodes meeting ACR guideline for using TNF-alpha blocker were identified in 88 patients (13.7%). In addition, 19 episodes meeting BSR guideline in 17 patients (2.6%) and 21 episodes meeting JCR guideline in 21 patients (6.2%) were identified. Four episodes (4.8%) meeting ACR recommendation, 0 episodes meeting BSR criteria and 5 episodes (12%) meeting JCR criteria, respectively, were eligible for TNF-alpha blocker according to the Korean National Health Insurance reimbursement guideline. The most common reason for failing the Korean National Health Insurance reimbursement criteria was the number of active joint counts (92.6%). CONCLUSION: Our results show that the majority of RA patients satisfying the ACR guideline, BSR and JCR guideline for use of the TNF-alpha blocker did not meet the Korean National Health Insurance reimbursement criteria. Patients most often failed due to active joint count criteria.

Survey of Current Trends for Diagnosis and Treatment in Korean Gout Patients

OBJECTIVE: The prevalence of gout has increased so accurate diagnosis and constant treatment is important in its management. The purpose this study was to examine the current trends in the diagnosis and treatment of gout patients in Korea. METHODS: We enrolled patients who were diagnosed as having gout and received treatment in university hospital between 2005 and 2008. From the survey, we assessed and analyzed the patient's baseline characteristics, clinical aspects of gout attack, medical institution and specialized department in the first gouty attack, medical institution and specialized department where the gout was initially diagnosed, methods of diagnosis, treatment during gout attack, and knowledge about gout in patients. RESULTS: A total of 136 patients were included in this study, out of which 123 (90.4%) were male and the mean age was 55.2 (range 25~85) years. When patients experienced the first gout attack, the most common medical institution that they attended was a private clinic and the most common specialized department was orthopedics. Medication by oral route was the major method (80.9%) used for the treatment of gout, and the most common medication was a non-steroidal anti-inflammatory drug (NSAID) in 55.9%, allopurinol in 38.2% and colchicine in 20.6% of patients. Many gout patients inappropriately received allopurinol following signs of gout arthritis attack, with little information specifically about gout. CONCLUSION: In our survey, many gout patients received inadequate medications for the treatment of gout and had little knowledge about the disease. For the adequate treatment of gout, patients and doctors need to be educated sufficiently.

Adherence to Uric Acid Lowering Agent of Gouty Patients / 대한류마티스학회지

OBJECTIVE: Gout is crystal-induced arthritis with hyperuricemia. Uric acid lowering agent (UALA) is the maintenance drug of its treatment. Drug adherence is an important factor that influences treatment outcome. The purpose this study was to examine the drug adherence to UALA of 303 gouty patients and to analyze the factors associated with compliance. METHODS: We retrospectively assessed adherence to UALA in 303 patients who visited three hospitals affiliated with Hallym University. Patients were diagnosed as gout and used UALA with at least 6 month follow-up. Two adherence measures were calculated, the percentage of days covered (PDC) and the time until an extended break (at least 60 days) in treatment. A PDC <70% was considered poor adherence and factors associated with poor adherence were examined. RESULTS: Among the 303 patients, 283 (93.4%) were male. Mean age was 55.4+/-13.7 years. Comorbidities included hypertension in 117 (38.6%), diabetic mellitus in 108 (35.6%), angina in 107 (35.3%), myocardial infarction in 108 (35.6%), and heart failure in 113 (37.3%). The mean PDC was 65.8% with 63.4% of patients considered poorly compliant over the study period. Mean treatment duration before an extended break occurred was 203.5 days. Factors associated with good adherence included hypertension and prescription from rheumatologist. CONCLUSION: In our study, adherence to UALA in gouty patient was poor. Understanding the factors associated with adherence to UALA and proper education of gouty patients to improve drug adherence are needed.

Removal of a Common Bile Duct Stone Using ERCP without Fluoroscopic Guidance in a Pregnant Woman / 대한소화기내시경학회지

Pregnancy causes alterations in bile compositions and, an increased incidence of cholelithiasis and the complications related to it. This often requires endoscopic interventions such as endoscopic retrograde cholangiopancreatography (ERCP), but the radiation exposure during the ERCP may be harmful to the fetus. We report here on a case of successful ERCP and therapeutic endoscopic intervention without fluoroscopic guidance for a pregnant woman with common bile duct stone that was complicating her biliary pancreatitis.

Role of Methacholine PC20 in FEF(25-75%) for the Diagnosis of Bronchial Asthma / 결핵및호흡기질환

BACKGROUND: The methacholine bronchial provocation test is a useful tool for evaluating asthma in patients with normal or near normal baseline lung function. However, the sensitivity of this test is 82~92% at most. The purpose of this study is to evaluate the clinical usefulness of FEF(25-75%) in identification of airway hyperresponsiveness in patients with suspected asthmatic symptoms. METHODS: One hundred twenty-five patients who experienced cough and wheezing within one week prior to their visiting the clinic were enrolled. RESULTS: Sixty-four subjects showed no significant reduction of FEV1 or FEF(25-75%) on the methacholine bronchial provocation test (Group I). In 24 patients, FEF(25-75%) fell more than 20% from baseline without a 20% fall of FEV1 during methacholine challenge (Group II). All patients who had more than 20% fall of FEV1 (n=37) also showed more than 20% of reduction in FEF(25-75%) (Group III). Baseline FEV1/FVC (%) and FEF(25-75%) (L) were higher in group II than group III (81.51+/-1.56% vs. 75.02+/-1.60%, p<0.001, 3.25+/-0.21 L vs. 2.45+/-0.21 L, p=0.013, respectively). Group II had greater reductions of both FEV1 and FEF(25-75%) than group I at 25 mg/mL of methacholine (p<0.001). The provocative concentration of methacholine causing a 20% fall in FEF(25-75%) in group II was about three-fold higher than that in group III. CONCLUSION: A 20% fall of FEF(25-75%) by methacholine provocation can be more sensitive indicator for detecting a milder form of airway hyperresponsiveness than FEV1 criteria.