A national, multicenter, retrospective study evaluating retention rate and efficacy of tocilizumab treatment in patients with active rheumatoid arthritis who had an inadequate response to csDMARDs and/or TNF inhibitors

BACKGROUND

To describe the disease activity and retention rate in rheumatoid arthritis (RA) patients with inadequate response (IR) to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and/or tumor necrosis factor inhibitors (TNFis) who were prescribed tocilizumab (TCZ) as first-line or second-line biologic treatment in real-world setting.

METHODS

Data gathered from patients' files was used in a multicenter and retrospective context. Retention rates and the Disease Activity Score in 28 joints with CRP (DAS28-CRP) were evaluated at time points. The relationship of drug efficacy with factors such as smoking, obesity, and previous use of TNFis was also examined.

RESULTS

One hundred and twenty-four patients with a median (IQR) RA duration of 3.7 (7.4) years were included. Mean (SD) age was52.9 (12.9) and 75% of the patients were female. TCZ retention rates in the 6th and 12th months were 94.1% and 86.6%, respectively. In all patients, DAS28-CRP level decreased significantly from baseline to Months 3 and 6. There was an increase in patients with remission and/or low disease activity and a decrease in patients with high disease activity at Month 3 and Month 6 (p < 0.001 for both). Disease activity was similar between subgroups based on body mass index, smoking status, and previous use of TNFis at any time point. Regression analysis showed that absence of concomitant corticosteroid treatment independently was associated with remission/LDA achievement at Month 6 [OR = 0.31, 95% CI (0.14- 0.72), p = 0.006], and Month 12 [OR = 0.35, 95% CI (0.13-0.94), p = 0.037]. Overall, 25 mild adverse events were reported.

DISCUSSION

TCZ was found to be effective and safe in RA patients with IR to csDMARDs and/or TNFis. The drug retention rate was considered satisfactory with more than half of the patients continuing TCZ treatment at Month 12.

Pneumomediastinum, pneumatosis intestinalis and pneumoperitoneum in a patient with polymyositis: case-based review

Pneumomediastinum (PnM), pneumatosis intestinalis (PI), and pneumoperitoneum (PP) are rare complications of inflammatory myositis. We present a 59-year-old polymyositis (PM) patient who experienced all three complications simultaneously. The patient who presented with proximal muscle weakness, dysphagia, and weight loss was diagnosed with PM due to elevated muscle enzymes and consistent electromyography and muscle biopsy with inflammatory myopathy. On the 45th day of her immunosuppressive treatment, PnM, PI, and PP were detected incidentally in ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) scan performed for severe weight loss and treatment-resistant severe disease. Since the patient had no symptoms or signs of PnM and PP, no additional intervention was applied to the current treatment, and spontaneous regression was observed in the follow-up. In addition to this case, we reviewed patients with PM who developed PBM, PP, and PI in the literature.

Characterization of Some Microorganisms from Human Stool Samples and Determination of Their Effects on CT26 Colorectal Carcinoma Cell Line

The present study aimed to isolate and identify the potential probiotic, pathobiont, and pathogenic microorganisms in the stool samples of 12 healthy individuals and evaluate their in vitro effects on cancer formation. A total of 83 strains were isolated from the stool samples and identified using MALDI-Biotyper. Fourteen of the isolates were identified as Candida spp., three isolates were identified as Cryptococcus neoformans, 55 isolates were identified as lactic acid bacteria, and the remaining isolates belonged to different 11 bacterial genera. Important microbial properties for cancer prevention and some probiotic properties were examined. All strains maintained their viability under acidic conditions and in media containing bile salts. Of the bacterial strains, 62.5% were resistant to ampicillin, chloramphenicol, gentamicin, erythromycin, kanamycin, penicillin, streptomycin, tetracycline, and vancomycin. All yeast strains were resistant to ketoconazole and susceptible to nystatin. The susceptibility of the strains to fluconazole, voriconazole, amphotericin B, and itraconazole varied. Fifty-nine percent of the strains produced EPS and 21.7% showed proteolytic activity (PA). Of the strains, 15.7% both produced exopolysaccharides (EPS) and had PA. The antioxidant activity (AOA) varied depending on the strains. The pathobiont and pathogenic microorganisms promoted tumor formation, while potential probiotic microorganisms had a suppressive effect on tumor formation (P > 0.01). One yeast (Candida kefyr MK17) and three lactic acid bacteria strains (Lacticaseibacillus paracasei MK73, Lactiplantibacillus plantarum MK55, Limosilactobacillus mucosae MK45) have superior potential thanks to their anticarcinogenic properties as well as tolerance to gastrointestinal tract conditions. Stool samples of each individual contain various potential probiotic, pathobiont, and pathogenic microorganisms.

The Diagnostic Value of Fluoro-18 Fluorodeoxyglucose (F-18 FDG) PET/CT in Fever or Inflammation of Unknown Origin: A Retrospective Study at a Rheumatology Clinic

Introduction Further diagnostic procedures are necessary for patients with fever of unknown origin (FUO) and unknown cause of inflammation (inflammation of unknown origin - IUO) for the identification of the definitive diagnosis. The aim of this study was to evaluate the contribution and roles of F-18 FDG PET/CT (fluoro-18 fluorodeoxyglucose-positron emission tomography/computed tomography) in the diagnostic process of patients with FUO/IUO. Methods The data of 58 patients who had F-18 FDG PET/CT scans for FUO/IUO were re-evaluated retrospectively. The relationships between definitive diagnosis and fluorodeoxyglucose uptake and SUVmax (maximum standardized uptake value) were examined. Results  Rheumatic disease was diagnosed in 26 patients (44.5%), malignancy in 20 patients (34.5%), and infectious diseases in six patients (10.3%). The most prevalent rheumatic disease in patients with FUO/IUO was systemic vasculitis (n:10, 17.2%), especially large vessel vasculitis. There were 37 patients (63.7%) with clinically significant true positive fluorodeoxyglucose uptake. True positive fluorodeoxyglucose uptake was significantly higher in patients diagnosed with malignancy (85%, 17/20 patients) compared to other diagnoses. Fluorodeoxyglucose uptake above physiological levels was determined in 15 of the 26 patients (57.6%) diagnosed with rheumatic diseases. Conclusion The results of this study showed that F-18 FDG PET/CT is a useful imaging modality in FUO/IUO patients, who present a challenging diagnostic process for clinicians. In addition to malignancies, the presence of chronic inflammatory diseases, especially early period systemic vasculitis, were diagnosed in these patients.

The use of anti-interleukin-1 agents and tumor necrosis factor-alpha inhibitors in renal transplant recipients

Objectives

The aim of this study was to investigate the efficacy and safety of anti-interleukin-1 (anti-IL-1) agents and tumor necrosis factor-alpha (TNF-α) inhibitors in renal transplant patients.

Patients and methods

Between February 2014 and February 2020, data of 12 renal transplant recipients (9 males, 3 females; median age: 51 years; range, 19 to 70 years) who received anti-IL-1 agents or TNF-α inhibitors for inflammatory diseases in the post-transplant time period and were followed in a single transplant center (n=12) were retrospectively analyzed. A total of 46 cases were reported in the literature, before the data were collected. The overall outcomes of all cases were analyzed in this study.

Results

Thirty-seven patients received anti-IL-1 agents in the post-transplant period. The main indications for anti-IL-1 agents were familial Mediterranean fever (FMF) and amyloidosis (75.7%). The continuation rate of colchicine treatment in patients with FMF was 85.7%. Anti-IL-1 agents prevented attacks completely in 89.3% of FMF patients. The number of cases used TNF-α inhibitors among renal transplant patients was lower (n=21). The TNF-α inhibitors were used mainly for inflammatory bowel diseases (57.1%) and ankylosing spondylitis (33.3%) and suppressed the disease activity in most of the patients with inflammatory diseases (72.7%). Death (n=3) and malignancies (n=3) were reported in patients who received TNF-α inhibitors, but not in patients who received anti-IL-1. The renal outcomes and graft survival rates were satisfactory in patients who received both anti-IL-1 agents and TNF-α inhibitors.

Conclusion

Our results support that anti-IL-1 agents can be used effectively and safely in renal transplant patients.

The risk of cancer in patients with primary Sjögren syndrome; A single-center study from Turkey

BACKGROUND

The aim of this study is to determine the risk of cancer in the patients with primary Sjögren syndrome (pSS) from a single-center in Turkey.

METHODS

Clinical data of the subjects with pSS were retrospectively analyzed. The incidence of cancer for general population was obtained from GLOBOCAN 2018. Age- and sex-specific Standardized Incidence Ratios (SIR) of solid and hematological cancers were calculated compared with the general population.

RESULTS

Four hundred thirty patients with pSS were included in the study. The majority of the patients were female (n=396, 92.1%), and the mean age was 58.6 ±12.0 years. Thirty-four patients (7.9 %) were diagnosed with cancer (26 solid and 8 hematological) during follow-up. The SIR for all cancers was 2.45 (95% CI, 1.625- 3.275). The SIR was 2.42 (95% CI, 1.542-3.298) for solid cancers and 8.42 (95% CI, 2.394 - 14.446) for hematological cancers. The most diagnosed malignancies were breast cancer (n=6), ovarian cancer (n=6), and non-Hodgkin lymphoma (NHL) (n=4). There was an increased risk for ovarian cancer (SIR 12.76; 95% CI, 2.545-22.975). The SIR values were 2.08 (95% CI, 0.419-3.741) and 10.81 (95% CI, 0.216-21.404) for breast cancer and NHL, respectively.

CONCLUSION

The risk of hematological and solid cancers was higher in the patients with pSS when compared to general population. In our pSS cohort, the risk for ovarian cancer was found to be increased, which has not been previously reported in the literature.

Survival analysis of patients with Sjögren's syndrome in Turkey: a tertiary hospital-based study

OBJECTIVES

This study was conducted to determine long-term survival rates and the factors associated with mortality in Turkish primary Sjögren syndrome (pSS) patients.

METHODS

All patients diagnosed with pSS between 2004 and 2014 were included in this study. By January 2019, all subjects still living by the end of the study, as well as any death, were identified. Survival rates and standard mortality rates (SMRs) using general population mortality data were calculated. Mortality-related factors were determined by univariate and multivariate analysis.

RESULTS

During follow-up, 33 cases of 372 pSS patients resulted in death (8.9%). Of those patients, they were typically older at disease onset, at recruitment, and had shorter follow-up times (p < 0.001 for all). The overall SMR of all pSS patients compared with the general population was 2.11 (95% confidence interval (CI) 1.39-2.83). Male pSS patients had a higher SMR than that of general male patients. Overall survival rates were 97.8% at five years, 90.2% at 10 years, and 87.1% at 15 years in patients with pSS. The survival rate of pSS patients was significantly lower than the general Turkish population (p = 0.011). Multivariate Cox regression analysis showed that older age at disease onset and the presence of interstitial lung disease (ILD) were independent risk factors for mortality.

CONCLUSIONS

Based on these data, mortality rates of Turkish pSS patients are higher compared with the general population. Survival significantly decreased in the pSS patients with ILD, especially in older male patients at disease onset. Male gender and malignancy may also be associated with a worse prognosis in pSS patients.Key Point• Mortality in Sjögren's syndrome.

Primary Sjögren's syndrome in patients with celiac disease

BACKGROUND/AIM

Many autoimmune diseases occur concomitantly with celiac disease (CD). We aimed to determine the frequency of Sjögren's syndrome (SS) in CD patients based on SS-specific serology verified by minor labial salivary biopsy.

MATERIALS AND METHODS

Eight-two patients with CD were included in the study. After examination for objective evidence of sicca complex, all patients were tested for serological presence of rheumatoid factor (RF) and antinuclear antibodies (ANAs) and for ANA profile. Minor labial salivary biopsy was performed for patients with positive serology and/or clinical signs of SS.

RESULTS

Of the patients included, 24 (29.3%) had dry eye symptoms while 20 (24.4%) had dry mouth symptoms. Dry eye was detected by Schirmer test in 10 patients (12.2%) and by ocular staining score in only 2 patients (2.4%). All samples were negative for RF while 12 (14.6%) samples were positive for ANAs. Of 82 patients with CD, the diagnosis of SS was established in only one patient (1.2%), while one patient (1.2%) was diagnosed with morphea and 4 patients (4.9%) were classified as having undifferentiated connective tissue disease.

CONCLUSION

The prevalence of SS in CD is low, so there is no need for serologic screening of all patients with CD for SS.