Interstitial Lung Disease in Rheumatoid Arthritis: A Practical Review

Rheumatoid arthritis (RA) is a systemic inflammatory disease, which primarily causes symmetric polyarthritis. An extrarticolar involvement is common, and the commonly involved organ is lungs. Although cardiac disease is responsible for most RA-related deaths, pulmonary disease is also a major contributor, accounting for ~10-20% of all mortality. Pulmonary disease is a common (60-80% of patients with RA) extra-articular complication of RA. Optimal screening, diagnostic, and treatment strategies of pulmonary disease remain uncertain, which have been the focus of an ongoing investigation. Clinicians should regularly assess patients with RA for the signs and symptoms of pulmonary disease and, reciprocally, consider RA and other connective tissue diseases when evaluating a patient with pulmonary disease of an unknown etiology. RA directly affects all anatomic compartments of the thorax, including the lung parenchyma, large and small airways, pleura, and less commonly vessels. In addition, pulmonary infection and drug-induced lung disease associated with immunosuppressive agents used for the treatment of RA may occur.

Improvement of HbA1c in Patients with Type 2 Diabetes Mellitus and Rheumatoid Arthritis Treated with bDMARDs

Objective

The aim of our study was to evaluate the possible role of biological treatments for rheumatoid arthritis (RA) in improving the glycemic profile in patients affected not only by RA but also by type 2 diabetes mellitus (2TDM).

Methods

An observational retrospective study was conducted using data from patients referred to our Rheumatology Unit. Patients with active RA despite standard DMARDs therapy and concomitant 2TDM were selected into one of five exposure groups to first-line bDMARDs (adalimumab, golimumab, etanercept, tocilizumab, sarilumab) and observed for the outcome of CRP, ESR, DAS28CRP and glycated hemoglobin (HbA1c) variations.

Results

After the start of treatment, there was a significant reduction in the values of acute phase reactants ESR and CRP (p<0.01), DAS28-CRP (p<0.01) and HbA1C (p<0.05), in the absence of any confounding factors such as a reduction in BMI or a change in steroid doses. There was no statistically significant difference between the various treatments. Anti-IL6 drugs appear to be associated with a slightly greater reduction in HbA1c values, bordering on statistical significance (p=0.047).

Conclusion

Initiation of a bDMARD appears to be associated with an improvement in concomitant 2TDM in patients with active RA, which, in the first hypothesis, is linked with a reduction of the inflammatory milieu.

The macrophages in rheumatic diseases

Macrophages belong to the innate immune system giving us protection against pathogens. However it is known that they are also involved in rheumatic diseases. Activated macrophages have two different phenotypes related to different stimuli: M1 (classically activated) and M2 (alternatively activated). M1 macrophages release high levels of pro-inflammatory cytokines, reactive nitrogen and oxygen intermediates killing microorganisms and tumor cells; while M2 macrophages are involved in resolution of inflammation through phagocytosis of apoptotic neutrophils, reduced production of pro-inflammatory cytokines, and increased synthesis of mediators important in tissue remodeling, angiogenesis, and wound repair. The role of macrophages in the different rheumatic diseases is different according to their M1/M2 macrophages phenotype.

User preference for a portable syringe pump for iloprost infusion

Purpose

Administration of intravenous iloprost – a first-line European League Against Rheumatism (EULAR)-recommended choice for the treatment of scleroderma (SSc)-related digital vasculopathy – requires repeated treatment cycles of 6 hours per day in a hospital setting. During the infusion, patient mobility is considerably restricted due to the size and fixity of traditional syringe pumps. The aim of this study was to evaluate the satisfaction level of patients and nurses, after the introduction of a new portable syringe pump (Infonde^®, Italfarmaco S.p.A., Milan, Italy) at the Department of Rheumatology, Magenta Hospital, Milan, Italy.

Patients and methods

Thirty-four consecutive SSc patients receiving stable therapy with iloprost, previously administered with a fixed pump, were treated using the portable Infonde^® pump. Patients (n=34) and nurses (n=4) were asked to answer a nine- and six-item questionnaire, respectively, to assess the satisfaction of the administration comparing the new device versus the previous one. The health care staff of the ward developed the questionnaire, and the response scores ranged from 0 (fixed device better) to 10 (portable device better); thus a score >5 indicates a preference for Infonde^®.

Results

Patients’ answers indicated a preference towards the new portable syringe pump, versus the previous fixed pump. Questionnaires administered to patients generated a total of 306 responses, with over 95% of the responses in the range 8–10, of which 89% had a score equal to 10. The responses of nurses showed a score equal to 10 in 100% cases. No significant adverse events were recorded, indicating no change in the tolerability profile of the drug.

Conclusion

Iloprost administration with Infonde^® pump was preferred by both patients and health care professionals, and was well tolerated. The possibility to perform daily activities and the freedom of movement suggest a positive impact of Infonde^® on the treatment, with a potential favorable effect on the quality of life of patients during the many hours spent receiving the infusion.

NK cell count as predictor of clinical response in patients with rheumatoid arthritis treated with rituximab

Purpose

The relationship between antiCD20 therapy with rituximab and the lymphocytes phenotype in patients with rheumatoid arthritis was investigated, with an attempt to establish a relationship between commonly used clinical activity indices and variations in leukocyte count, in particular natural killer (NK) lymphocytes.

Methods

Patients with seropositive (cyclic citrullinated peptides and rheumatoid factor positive) rheumatoid arthritis (according to the American College of Rheumatology 1987 criteria) refractory to conventional and antitumor necrosis factor-alpha agents who were subsequently treated with rituximab, a chimeric monoclonal antibody directed against CD20, were enrolled between January 2009 and September 2009. All subjects were treated with rituximab standard rheumatologic dose of 1.0 g on days 1 and 15 every 6 months for at least 2 years. A clinical evaluation was performed at baseline and subsequently every 3 months thereafter. At each assessment activated NK (CD56+/CD16+/CD54bright) cell count was collected and disease activity was assessed using Disease Activity Score in 28 Joints and the Simplified Disease Activity Index (SDAI).

Results

Thirty-four patients were enrolled (mean age ± standard deviation: 54.8 ± 12.8 years). Basal SDAI was 21.75 ± 5.4 and NK cell count mean value was 157.6 ± 90. After 24 months, SDAI was 14 ± 1.2 and NK cell count mean value was 301.7 ± 21 (P < 0.05). An inverted correlation between SDAI and NK count was observed at 3 months (r = −0.36, P < 0.05), 6 months (r = −0.48, P < 0.45), 9 months (r = −0.47, P < 0.05), 12 months (r = −0.41, P < 0.01), 15 months (r = −0.58, P < 0.05), 18 months (r = −0.53, P < 0.05), 21 months (r = −0.68, P < 0.05), and 24 months (r = −0.61, P < 0.05). A linear regression model between all variables collected and SDAI/Disease Activity Score in 28 Joints at 6 months and 12 months confirmed a significant relationship between SDAI/Disease Activity Score in 28 Joints and NK cell count.

Conclusion

The data confirm the clinical efficacy of rituximab and suggests the use of NK cells as a predictor of clinical response in patients with rheumatoid arthritis.

Validation of an Italian version of the arthritis impact measurement scales 2 (ITALIAN-AIMS2) for patients with osteoarthritis of the knee. Gonarthrosis and Quality of Life Assessment (GOQOLA) Study Group

OBJECTIVE

To validate a translated version of the revised and expanded Arthritis Impact Measurement Scales (AIMS2) to be used by Italian patients with osteoarthritis (OA) of the knee.

METHODS

The AIMS2 was translated into Italian and administered to a cohort of 178 outpatients with symptomatic OA of the knee who attended 12 participating rheumatological institutes in northern, central and southern Italy. A random sample of 71 patients were readministered the AIMS2, 7 days after the first visit, to evaluate the instrument's test-retest reliability. After 6 months, the subjects were asked to return to the institutes for a second administration of the questionnaire.

RESULTS

The internal consistency reliability of each scale score, as estimated by Cronbach's alpha coefficient, was high and indicated that the components of the scale measured the same construct. The items all correlated with each other, but there was no redundancy; this indicates that each domain addressed a somewhat different aspect of functional disability. The test-retest reliability equalled or exceeded 0.80 for eight of the 12 scales. Factor analysis provided a three-factor health status model explaining 63.5% of the variance. Arthritis pain and psychological scale were loaded on the first factor, together with physical scales for mobility level and walking and bending. The upper limb function scales formed the second factor. The third factor was determined by the social dimension. These results demonstrate that the physical health status scales of the AIMS2 are valid, as shown by the significant, moderate to high correlations between the AIMS2 subscales and the majority of the clinical measures.

CONCLUSION

Our data suggest that, like the original questionnaire, the translated version of AIMS2 is a reliable, consistent and valid instrument for measuring health status and physical functioning in patients with OA of the knee.