FRI0419 LOW DOSE OF GLUCOCORTICOIDS FOR PAIN CONTROL IN THE ESTROGEN-DEPENDENT PRIMARY POLYARTICULAR OSTEOARTHRITIS

Background:

Low doses of glucocorticoids (GCs) can be useful in the management of osteoarthritis when it is related to hypoestrogenic states (estrogen-dependent primary polyarticular osteoarthritis [EDPOA]), that usually can appear after the menopause. Deflazacort is a GC that has similar anti-inflammatory effects than other steroids, but with fewer side effects.

Objectives:

To describe the average dose of GCs that best controlled articular pain, based on tender joint count in patients with EDPOA.

Methods:

The diagnosis of EDPOA was made in postmenopausal patients with polyarticular compromised (six or more joints affected), morning stiffness less than 30 minutes, erythrocyte sedimentation rate less than 45mm/hour and imaging studies with changes related to osteoarthritis (radiography, magnetic resonance imaging or bone scintigraphy). Patients with autoimmune diseases such as rheumatoid arthritis, lupus or Sjögren syndrome were excluded.

The clinical records of patients diagnosed with EDPOA and treated between January 2015 and June 2019 at the Valle del Lili foundation Hospital were reviewed. The patients treated with deflazacort GC were included. Pain was assessed by the treating rheumatologist using the visual analog scale (VAS, possible score 0-10). Tender joints were those with VAS> 5. The count of compromised joints was compared with inflammatory findings on bone scintigraphy (Figure 1).

Figure 1.

Comparison between number of joints with inflammatory findings on bone scintigraphy and number of swollen joints in physical evaluation

The number of tender joints was recorded at the start of treatment, which was a dose of 6 mg/day of deflazacort for two months. Subsequently, the dose was reduced depending on the improvement of pain (items: intensity of pain and number of tender joints) until achieving a stabilization along the time with an improvement of 75% of the items evaluated. The number of painful joints was recorded again two months after the stabilization on pain control was achieved.

Quantitative variables were described with medians and interquartile ranges because the absence of normal distribution of the sample size. To assess the presence of a significant decrease on the number of tender joints the Wilcoxon range test was used, a value of p<0.001 was considered statistically significant. The data were analyzed with Stata v.15.

Results:

Twenty-eight patients with EDPOA were included, with a median of age of 50 years (IQR 44-51), 56 years (IQR 52-66) and 61 years (IQR 54-69) at the time of menopause, onset of symptoms and the diagnosis of EDPOA respectively. A median of 18 tender joints (IQR 10-27) was obtained from the physical examination of the records reviewed. The dose of deflazacort that achieved stabilization on the improvement of the pain along the time was 21mg/week (IQR 12-21); after 8 weeks of treatment the number of tender joints was 2 (IQR 1-4), which implies a reduction of 14 (IQR 8-20; p<0.0001) on the tender joint count (Figure 2).

Figure 2.

Number of tender joints before and after eight weeks of treatment achieving with a stable pain control in patients with EDPOA treated with deflazacort with a media dose of 3mgr/day.

Conclusion:

In this case series a media dose of deflazacort of 21mg per week (3mg/day) was useful to significantly reduce the number of tender joints in patients with EDPOA.

References:

[1]Roman-Blas JA, Castañeda S, Largo R,et al. Osteoarthritis associated with estrogen deficiency. Arthritis Research & Therapy 2009;11:241.

[2]Cvoro A, Yuan C, Paruthiyil S,et al. Crosstalk between glucocorticoid and estrogen receptors occurs at a subset of proinflammatory genes. The Journal of Immunology 2011;186:4354-4360.

[3]Féline K, Marion K, Annelies B,et al. Results of a 6-week treatment with 10 mg prednisolone in patients with hand osteoarthritis (HOPE): a double-blind, randomised, placebo-controlled trial. Lancet 2019;394:1993-2001.

Disclosure of Interests:

None declared

Clinical and virological effects during two years of ongoing adefovir dipivoxil in the treatment of lamivudine-resistant chronic hepatitis B infection

OBJECTIVE

Our aim was to evaluate the efficacy and safety of adding adefovir to lamivudine therapy for hepatitis B virus (HBV)-infected patients resistant to Ramivudine.

PATIENTS AND METHODS

Among 17 studied patients, 7 had chronic active HBV infection and 10 were posttransplant with HBV infection (9 with de novo HBV). They received lamivudine plus adefovir therapy for 2 years. We assessed reductions in serum HBV-DNA and alanine aminotransferase (ALT) levels, loss of HBeAg (in HBeAg+ cases), and HBsAg clearance.

RESULTS

A virological response, as defined by HBV-DNA below the cut off by hybridization, was observed in 12 (70.6%) patients and loss of HBeAg in 4 (44.4%) of the 9 initially HBeAg-positive cases. A biochemical response, defined as a decreased serum ALT to the normal range, occurred in 4 (26.7%) patients. Median serum creatinine increased in 3 of 15 (20%) patients, excluding those on hemodialysis. There were two noteworthy cases of sustained HBsAg seroconversion with adefovir (11.8%): one patient with de novo HBV infection posttransplantation and positive hepatitis C virus-RNA serology, and one patient with decompensated HBV cirrhosis in whom viral replication ceased, making him eligible for transplantation.

CONCLUSIONS

Currently, adefovir is an effective rescue therapy that broadens the existing range of options for patients with lamivudine-resistant chronic hepatitis B infection, particularly those with decompensated cirrhosis awaiting a liver graft, and those with recurrent posttransplantation HBV. The relatively small biochemical response seen in these patients may be attributable to the high prevalence of concomitant hepatitis C virus infection (41%).

Light and electron microscopic analysis of liver biopsy samples from rheumatoid arthritis patients receiving long-term methotrexate therapy

OBJECTIVE

We study liver damage in forty-two patients with rheumatoid arthritis (RA) using light (LM) and electron microscopy (EM) and assess histological changes after four years of treatment with methotrexate (MTX).

PATIENTS AND METHODS

liver biopsies (LB) were taken before and after four years of treatment. Patients received weekly doses of between 7.5-15 mg of MTX.

RESULTS

Fourteen per cent of the baseline LB presented mild perisinusoidal fibrosis (Roenigk IIIA) and the rest a lower Roenigk grade; EM identified an increase in collagen fibers in the Disse spaces in 50% of baseline LB. Neither microscopy technique revealed histological progression in any of the sequential LB. Variables that correlated with histological abnormalities were patient's age, length of evolution of the disease, alcohol consumption and biochemical data (gammaglutamate transferase and albumin); the cumulative dose of MTX was not correlated with worse histological findings. Correlation between the two microscopy techniques was good, though EM was more sensitive than LM for the detection of fibrosis.

CONCLUSIONS

RA patients present with liver damage before treatment with MTX. The alterations are mild. At low doses MTX treatment is safe. In addition to the recommendations of the American College of Rheumatology, other factors associated with liver impairment are patient's age and length of evolution of the RA.

Current understanding and management of chronic hepatosplenic suppurative brucellosis

To outline the characteristics and define appropriate management of chronic hepatosplenic suppurative brucellosis (CHSB), 905 patients with brucellosis were analyzed. Sixteen episodes of CHSB (14 in the liver and 2 in the spleen) were found in 15 patients. Six patients had had previous remote brucellosis. Twelve patients presented with systemic symptoms, and 12 with local symptoms. Cultures of blood samples yielded negative results in all cases except 1, and the results of cultures of pus specimens were positive for Brucella melitensis in only 2 cases. All patients showed calcium deposits surrounded by a hypodense area on computed tomography. Patients often had low titers of agglutinating antibody. In patients who were receiving conservative management, early response was successful in 50% and late response was successful in 33.3%. In the patients who underwent surgery and concomitant antibiotic therapy, early and late response was successful in 100%. Thus, CHSB mainly represents a local reactivation of previous brucellosis. Its diagnosis may be difficult to establish and surgery may be required to cure many patients.

Early protocol renal allograft biopsies and graft outcome

To evaluate whether biopsies performed early after transplantation in stable grafts can predict graft failure due to chronic transplant nephropathy, a protocol biopsy was performed at three months in 98 patients treated with antilymphocytic antibodies, cyclosporine and prednisone. Patients were followed for 58 +/- 16 months. Histological diagnosis according to the Banff schema were: normal (N = 41), borderline changes (N = 12), chronic transplant nephropathy (CTN; N = 30), CTN associated to borderline changes (N = 11) and acute rejection (N = 4). Biopsies displaying acute rejection were not considered for statistical analysis. Since clinical characteristics of patients displaying CTN either with or without tubulitis were not different, biopsies were grouped as presence or absence of CTN. Patients displaying CTN had an increased incidence of acute rejection before performing biopsy (24.3 vs. 3.9%, P = 0.003), a higher mean cyclosporine level until biopsy (242 +/- 74 vs. 214 +/- 59 ng/ml, P = 0.049) and a lower actuarial graft survival (80.5% vs. 94.4%, P = 0.024). We conclude that early protocol biopsies are useful to detect patients at risk of losing their graft due to chronic transplant nephropathy.

Post-transplant lymphoma in a liver allograft

We describe the development of a lymphoma in a liver allograft shortly after orthotopic liver transplantation. Aspiration and core biopsies of the nodule were persistently negative so that a diagnosis could not be made until the patient underwent retransplantation, when examination of the liver resection specimen revealed a B-cell lymphoma. Using a rapid technique based on the polymerase chain reaction, we were able to demonstrate that the tumor was of donor origin.

Hepatosplenic AIDS-related Kaposi's sarcoma

Abdominal ultrasonography (US) and computed tomography (CT) were performed in one patient with acquired immunodeficiency syndrome (AIDS) and biopsy-proven hepatosplenic Kaposi's sarcoma. Small hyperechoic nodules were seen in the liver and spleen at US. CT revealed hepatosplenomegaly and low-attenuation focal lesions in the liver. These findings, although nonspecific, are suggestive of hepatosplenic involvement in Kaposi's sarcoma.