Risk of adverse events including serious infections in rheumatoid arthritis patients treated with tocilizumab: a systematic literature review and meta-analysis of randomized controlled trials.

OBJECTIVE: To assess the risk of adverse events (AEs) in patients with RA treated with tocilizumab, an IL-6 receptor antibody, in published randomized controlled trials (RCTs). METHODS: A systematic literature search was conducted using the Cochrane library, PUBMED and EMBASE for all RCTs (of the use of tocilizumab for RA) until September 2009. Fixed effect meta-analyses were conducted to compare the incidence of AEs after treatment with tocilizumab 8 and 4 mg/kg in combination with MTX, and 8 mg/kg tocilizumab monotherapy, with controls. Pooled summary odds ratios (ORs) were calculated using the Mantel-Haenszel method. RESULTS: Six trials were analysed (four trials included 8 mg/kg tocilizumab and MTX combination therapy, three of which also assessed the 4 mg/kg dose). Three studies assessed tocilizumab monotherapy at 8 mg/kg. Pooled ORs revealed statistical significance for an increased risk of AEs in the 8 mg/kg combination group compared with controls (OR = 1.53; 95% CI 1.26, 1.86). The risk of infection was significantly higher in the 8 mg/kg combination group compared with controls (OR = 1.30; 95% CI 1.07, 1.58). No increased incidence of malignancy, tuberculosis reactivation or hepatitis was seen. CONCLUSION: Tocilizumab in combination with MTX as a treatment for RA is associated with a small but significantly increased risk of AEs, which is comparable with that of other biologics. Vigilance for untoward effects is, therefore, imperative in any patient treated with these immuno-suppressive agents.

Improvement in diagnosis and management of musculoskeletal conditions with one-stop clinic-based ultrasonography.

We evaluated the impact of clinic-based musculoskeletal ultrasonography (MSUS) on diagnosis and management of cases as seen in day-to-day rheumatology practice. Data were retrieved for demography, background condition, clinical findings, indications, regions scanned, and outcomes of MSUS, and categorised as: new-patients and follow-up. New-patient records were analysed as to whether MSUS had helped to confirm or change clinical diagnosis or was of no additional help. In follow-ups, we determined whether MSUS had helped in disease assessment, detection of co-existing problems or revision of diagnosis. Its impact on treatment decisions was noted. A total of 237 patients (146 women; mean age 55.9+/-17.2 years) had 264 regions scanned; hands,50.7%. In 78/237 (32.9%) there was disagreement between clinical and MSUS findings. Amongst new-patients (72), 13/39 (33.3%) referred with inflammatory arthritis had no MSUS evidence of inflammation in or around joints. In 76.3% it helped in confirming or changing diagnosis. Of the follow-ups (165), in 78.7%, 13.9% and 7.2% it helped in assessment, detection of co-existing problems and revision of diagnosis, respectively. MSUS influenced treatment in 45/165 (27.27%) cases. In 60/67 (89.55%) cases of rheumatoid arthritis (RA), it was done for disease assessment; in 31/60 (51.66%) it influenced treatment. MSUS, as a clinic-based service in rheumatology, has significant impact on the diagnosis and treatment of patients. This has potential to reduce diagnostic uncertainty and follow-up visits and ensure better outcomes.

Severe bilateral rachitic genu valgum in patients with nonbullous congenital ichthyosiform erythroderma: a report of two cases and review of literature.

We present two cases of ichthyosiform erythroderma associated with severe bilateral genu valgum. Other musculoskeletal features associated with this condition are described. The details and outcome of operative intervention for the correction of the deformities are discussed. The disturbances of the metabolism of vitamin D and medical management are discussed. A review of literature is presented.