FRI0064 SAFETY OF LOW DOSE METHOTREXATE (MTX) AND TUBERCULOSIS (TB)

Background:

Increased awareness of the importance of MTX in rheumatic disease is leading to more MTX use in patients from TB-endemic areas. Current management guidelines for rheumatic disease address TB in the context of biologics but not MTX use.

Objectives:

To systematically review the published literature on TB rates with MTX ≤30 mg per week.

Methods:

We searched CINAHL, Embase, Global, MEDLINE and World of Science databases (Jan 1990 to May 2018) for terms including ‘methotrexate’ and ‘tuberculosis’. We also searched citations from review articles. Titles, abstracts or full manuscripts of the 4707 reports identified were screened independently by 2 reviewers to identify studies reporting TB in patients taking MTX. Study quality was assessed using the McGill Mixed Methods Appraisal Tool (MMAT). Data was extracted on TB incidence (new TB diagnosis vs reactivation of latent TB), and outcomes (pulmonary, dissemination, death) and safety of isoniazid, INH. Descriptive summaries are presented on studies providing outcomes in patients taking MTX ≤30 mg per week.

Results:

After removing duplicates and studies not meeting criteria or providing sufficient information, 31 studies were included (8 cohort, 7 case-control, 1 clinical trial, 15 case reports/case series). Only 27% of articles reported data from low to moderate human development index countries. Studies were of moderate quality. Seven case control studies were heterogeneous but most demonstrated a modest increased risk of TB with MTX (Table). Five cohort studies reported TB incidence rates in rheumatic disease (treated with MTX +/- biologics) ranging from 102-367.9/100,000 patient-years. These rates were generally higher than comparator general population rates. Two cohort studies of MTX in RA (without biologic) reported cumulative TB incidence in Maldova (12 TB cases in 44 RA patients, 27%) and in China (9/114, 7.9%). Other cohort studies generated rates of overt infection (143/100,000 patient years in Spain, higher if co-prescribed with corticosteroids and other immunosuppressants in South Africa), and latent TB rates detection (16/922 RA screened, 1.7%, in Canada). When reported, rates of extra-pulmonary TB were higher than comparator general population rates. One clinical trial (China), 2 cohorts (Japan, USA) and 2 case-series (Belgium, USA) evaluated safety of INH and MTX. Isoniazid-related hepatotoxicity and neutropenia were generally more common when taken with MTX, but were usually reversible.

Conclusion:

Despite a paucity of high-quality data, this review confirms that TB screening and clinical surveillance are needed in patients from TB-endemic areas who are prescribed MTX, particularly with co-administration of corticosteroids or other immunosuppressants. Isoniazid, if monitored, appears safe and prevents TB reactivation.

References:

Table .

Case control studies

Region (Year)DiagnosisTB with MTXTB without MTXOdds RatioMexico(1999)Mixed (4 RA)1/65/752.76Japan(2004)RA3/4717/1540.56Canada(2009)RA29/48321/10463.12Brazil(2010)Lupus2/31/57112Taiwan(2012)Psoriasis33/144464/23411.2Taiwan(2015)JIA4/3574/10262.90South Africa (2017)RA0/1340/18NA

JIA=juvenile idiopathic arthritis

Acknowledgments:

Funded by the International League Against Rheumatism and McGill University Global Health Scholar Awards

Disclosure of Interests:

Anna Davidson: None declared, Alize Gunay: None declared, Ines Colmegna: None declared, Diane Lacaille: None declared, Hal Loewen: None declared, Michele Meltzer: None declared, Rosie Scuccimarri: None declared, Yewondwossen Mengistu: None declared, Sasha Bernatsky: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

SAT0078 SAFETY OF LOW DOSE METHOTREXATE (MTX) IN HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION

Background:

Increased awareness of the efficacy of MTX in rheumatic disease is leading to more MTX use in patients from HIV endemic areas. While HIV related immunosuppression may contribute to improvement of some rheumatic diseases, immune reconstitution from highly active antiretroviral therapy (HAART) may lead to exacerbation or presentation of autoimmune disorders for which MTX therapy may be warranted. Most management guidelines for rheumatic disease do not address MTX use in the context of HIV.

Objectives:

To systematically review the published literature on the safety of using MTX ≤30 mg per week in HIV.

Methods:

We searched CINAHL, Embase, Global, MEDLINE and World of Science databases (Jan 1990 to May 2018) for terms including ‘methotrexate’ and ‘human immunodeficiency virus’. We also searched citations from review articles. Titles, abstracts or full manuscripts were screened independently by 2 reviewers to identify studies reporting HIV in patients taking MTX. Study quality was assessed using the McGill Mixed Methods Appraisal Tool (MMAT). Data was extracted on MTX and HIV adverse events (MTX toxicity, HIV viral load, CD4 count). Descriptive summaries are presented for studies providing outcomes in patients taking MTX ≤30 mg per week.

Results:

After removing duplicates and studies not meeting criteria or not providing sufficient information, 42 of the 2714 identified reports were included (1 clinical trial, 2 cohort, 1 cross-sectional study, 38 case reports/case series). Most reports (81%) originated from USA or Europe. Study quality was generally good with most studies fulfilling 50-100% of MMAT criteria. The randomized controlled trial (USA) assessing MTX on atherosclerotic disease in HIV showed that adverse events were more common in MTX versus placebo (12.8% vs 5.6%, p non-inferiority <0.05) and included infection, transient CD4 and CD8 drop, pulmonary toxicity, and death (1 attributed to MTX/HIV, 1 unrelated). One cohort study (South Africa) reported 43 RA patients on MTX who acquired HIV. In this cohort, RA generally improved despite only 5 individuals continuing MTX. No data on MTX adverse event rates was reported. One cohort study (USA) reported 13 HIV patients with myositis. One received MTX (with other immunosuppression) without MTX adverse effects but died due to AIDS. A cross-sectional study (France) of 43 HIV pts with autoimmune disease reported one patient on MTX (and other immunosuppression) developed an adverse event (cytopenia) compared to 5/33 patients not on MTX (cytopenia). The 38 case reports/series described 54 individuals with HIV receiving MTX. Of these studies, 27 (describing 42 subjects) reported on MTX adverse events and 35 (describing 46 subjects) reported on HIV adverse events. MTX adverse events developed in 29 subjects (hematologic 13, renal/hepatic 1, opportunistic infections 10, other events 2). HIV adverse events were noted in 23 subjects (Kaposi’s sarcoma 4, CD4 decrease 16, HIV viral titer increase 4). Five deaths were reported (2 infection, 1 infection and wasting, 2 HIV related deaths). Most subjects also received corticosteroids or other immunosuppressants including biologics.

Conclusion:

There remains limited data on the safety of low dose MTX in HIV. Surveillance for HIV is warranted for individuals on MTX who are at risk for acquiring HIV. Caution and careful monitoring for MTX toxicity, opportunistic infections and HIV state is suggested if MTX is used in the setting of HIV particularly if combined with other immunosuppression.

References:

[1] Clin Infectious Disease 2019:68

[2] J Rheumatology 2014:41

[3] Arthritis and Rheumatism 2003:49

[4] Medicine 2017:96

Acknowledgments :

Funding from International League Against Rheumatism

McGill University Global Health Scholar Awards

Disclosure of Interests:

Alize Gunay: None declared, Anna Davidson: None declared, Ines Colmegna: None declared, Diane Lacaille: None declared, Hal Loewen: None declared, Michele Meltzer: None declared, Yewondwossen Mengistu: None declared, Rosie Scuccimarri: None declared, Zenebe Yirsaw: None declared, Sasha Bernatsky: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

A case of Beckwith-Wiedemann syndrome with peculiar dental findings

BACKGROUND

Beckwith-Wiedemann syndrome (BWS, OMIM 130650) is a rare genetic disorder characterised by overgrowth, tumor predisposition and congenital malformations. Few systemic manifestations and oral features have been reported so far.

CASE REPORT

We report on a case of BWS, describing all features expanding the knowledge on oro-dento-facial phenotypes, along with a review of the literature.

Non-directed, carbonate-mediated C–H activation and aerobic C–H oxygenation with Cp*Ir catalysts

Carbonate additives enhance the activity of [Cp*Ir(H₂O)₃](OTf)₂ for non-directed C–H activations and the aerobic C–H oxygenation of alkyl arenes.

Influence of caffeic acid phenethyl ester on bone healing in a rat model

OBJECTIVE

To examine the effects of caffeic acid phenethyl ester (CAPE; a component of honey bee-hive propolis with antioxidant, anti-inflammatory, antiviral and anticancer properties) on bone regeneration and fibrotic healing in a rat model.

METHODS

Male Sprague-Dawley rats (n = 63; mean age 7 weeks; weight 280-490 g) were randomly divided into three groups: A, cranial defect with no bone healing treatment (n = 21); B, cranial defect treated with CAPE (n = 21); C, cranial defect treated with CAPE and β-tricalcium phosphate/hydroxyl apatite (n = 21). Rats were anaesthetized with ketamine (8 mg/100 g) by intraperitoneal injection and a cranial critical size bone defect was created. Following surgery, CAPE (10 µmol/kg) was administered by daily intraperitoneal injection. Seven rats in each group were killed at days 7, 15 and 30 following surgery. Bone regeneration, fibrotic healing and osteoblast activity were evaluated by histopathology.

RESULTS

Statistically significant differences in healing were found between all groups. There were no statistically significant within-group differences between day 7 and 15. At day 30, bone healing scores were significantly higher in groups B and C compared with group A.

CONCLUSION

CAPE significantly improved bone-defect healing in a rat model, suggesting that CAPE has beneficial effects on bone healing.

The reliability of microleakage studies using dog and bovine primary teeth instead of human primary teeth

AIM

This was to investigate if dental restorations on human, dog and bovine primary teeth are equitable for microleakage analysis, and the respective marginal adaptation deficiency in in vitro conditions.

MATERIALS AND METHODS

In order to determine the level of microleakage in Class V poly acid-modified composite restorations of human, dog and bovine primary teeth, samples were evaluated by dye-leakage method in sections of the inner area of the restorations.

RESULTS

We found no leakage in 6 out of 10 (60%) human restorations, in 7 out of 10 (70%) of dog and in 7 out of 10 (70%) of bovine teeth. The levels of dye-microleakage were tested with Kruskal-Wallis one-way variant analysis method. The relative leakage differences were not statistically significant among all species (p>0.05).

CONCLUSION

We concluded that dog and bovine primary teeth might be suitable for in vitro studies instead of human ones.

Calculation of measurement uncertainty for plastic (ABS) material in flexural testing

In order to determine mechanical properties of materials various kind of tests can be applied by means of using their tensile strength, lower yield stress, proof stress, impact strength, Brinell, Rockwell and surface hardness, elongation after fracture properties. Among these tests, three point flexural testing method has some advantages such as easy preparation (production) of samples and no gripping problems comparing to tension test. Flexural tests results should be obtained accurately to provide expected testing performance. The measurement uncertainty of flexural tests should be calculated by conducting all effective uncertainty parameters during the test procedure. In this study, the measurement uncertainty of the flexural test of ABS (Acrylonitrile Butadiene Styrene) material was investigated, which is widely used as industrial plastic material in many applications.

Can exposure to manganese and extremely low frequency magnetic fields affect some important elements in the rat teeth?

BACKGROUND

Length and level of exposure to electromagnetic fields (EMFs) is increasing in association with the widespread use of electrical and electronic devices and technological progress. The undesirable effects of extremely low frequency magnetic fields (ELF-MFs) on health have attracted considerable interest.

MATERIALS AND METHODS

Sixty-four four-month-old male Wistar rats divided into eight groups of eight rats each were used. Seven groups were exposed to varying dosages of manganese (Mn) and a 50 Hz magnetic field (MF) of approximately 1 mT, while the last group was set aside as the cage control group and not subjected to any procedure. This study was intended to investigate the interactions between the application of MF and Mn and the elements Ca, Zn, Mg, and P thought to be involved in caries, in rat teeth.

RESULTS

Levels of Ca, Mg, Zn, and P in the experimental group rats were different to those in the control group.

CONCLUSIONS

The results demonstrate that ELF-MF and Mn can have significant effects on levels of elements in rat teeth. Further experimental and epidemiological studies of ELF-MF and Mn are needed in order to evaluate their dental effects.

Bruxism: is it a new sign of the cardiovascular diseases?

AIM

To determine the relationship between bruxism and cardiovascular diseases.

MATERIALS AND METHODS

120 patients who referred to the Dentistry Faculty with the complaint of bruxism were selected. All patients gave informed consent for participation in the study. All of the patients were examined and bruxism was classified. And also these were examined by B-mode ultrasound to measure the Intima Media Thickness (IMT) at the far wall of the common carotid artery. A wide range of vascular risk factors including age, gender, body mass index, and previous history were surveyed. Spearman correlation analysis was performed to ascertain quantitative comparison, Mann-Whitney U and Kruskal-Wallis test were used for comparison of means

RESULTS

There were 66 (55%) male and 54 (45%) female patients, with a female to male ratio of 1/1.2. The mean age was 35.6 +/- 1,25 years (range 18-65 years). In the analysis of bruxism classification and IMT there was a statistical significance between bruxism classification subgroup 1, 2, 3 and IMT. There was no statistical significance between bruxism classification Subgroup 4 and IMT due to the small number of the patients (n = 12).

CONCLUSIONS

Stressful situations can cause both bruxism and cardiovascular disease such as coronary artery diseases, hypertension, arrhythmias, cardiomyopathy. The statistical analysis supported this hypothesis. However, we need to new studies with large number of samples to confirm this hypothesis. Clearly, future studies in this field will need to take into consideration the influence of the following variables: age, use of medication or drugs, smoking habits, and other sleep disorders.