God Forgives Always

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God Forgives Always Our Bodies Forgive Only
Sometimes
Hatem H. El-Eishi, MD Consultant Rheumatologist,
Dr. Soliman Fakeeh Hospital Assistant Professor
of Rheumatology, Cairo University, Egypt
2
September 2005
NS, a 32 year-old Bengali female,
3 years history
Pain in the wrists, hands, elbows, knees and feet
joints.
MS 60 min
Co-morbidities DM
Previous medicines corticosteroids
3
Examination, laboratory testing and plain
radiography revealed
Active Destructive Deforming Rheumatoid
arthritis
Uncontrolled diabetes mellitus
4
Decision
Methorexate 6 tab per week HCQ 400mg per
day P5-10 (was already on that dose)
Management of diabetes
5
The patient was then lost to follow up
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Jan 2006
The patient showed up again
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Shortly after methotrexate treatment had started,
she started to cough
1
2
Chest physician
3
Pulmonary TB diagnosed
Methotrexate stopped four anti-TB drugs for 4
months INH to be maintained for 7 months
thereafter
4
8
At that time, she had a severe flare of her
arthritis with a MS till noon. She was no longer
ambulant and was wheelchair bound.
9
Decision
Restart MTX 3 tab/week HCQ 400 Isoniazid
1x1 Supportive treatment
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Feb 2006
She was still not ambulant and suffering of
severe nocturnal pain and morning stiffness for
most of the day. Patient assessment of pain was
10/10 Patient assessment of disease activity was
9/10 HAQ score was 18/8
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Labs ESR 91 Hb 10.4 ANA negative Crea 0.7,
Urea 17 ALT 27 (up to 65) s. Alb 2.7 24 hr
albumin in urine 240mg/1100ml Blood sugar
controlled
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Decision
Adalimumab 40mg SC fortnightly MTX
3tab/week Isoniazid1x1
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March 2006
Coming for 3rd shot
Reporting improvement by 30 that started right
after the second Ada shot
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At 2.5 weeks
At 0 weeks
Wheelchair bound
Ambulant
MS 2-3 hrs
MS all day long
PAP 6/10 PADA 8/10 HAQ score 14/8
PAP 10/10 PADA 9/10 HAQ score 18/8
ESR 91
Requested labs were not done
15
The patient was then lost to follow up again
Second time
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September 2006
The patient showed up again
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Review of the period from Mar-Sept 2006
Had continued 3 more shots of ada (to a total of
6 shots)
Felt so much better
Stopped all treatment
Except for Diclophenac 75mg daily
18
She complained of pain in the knees and left hip
region and had a morning stiffness of 30 minutes.
She reported that though she felt worse, yet, not
as worse as she felt before she received the
adalimumab shots months ago.
19
Examination Limping, effusion knees grade
II-III (more in right knee), painful limitation
ROM subtalars in addition to the same deformities
Labs ESR 94 CRP 12 Hb 10.3 MCV 89 alb 2.7
crea 0.9 ALT 30
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Decision
Restart MTX 12.5mg IM weekly P15 INH 1x1
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The patient was then again lost to follow up
Third time
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December 2006
The patient showed up again
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Off methotrexate for 1 month and on P5
only Patient assessment of pain was 9/10 Patient
assessment of disease activity was 8/10 HAQ score
was 15/8
24
Decision
Adalimumab 40mg SC fortnightly MTX 10mg IM per
week P5 INH 1x1
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Jan 23, 2007
She appeared for the 3rd shot of Humira. She was
better. She was still compliant with treatment.
She reported that she started to feel better
again right after the second shot.
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At 2.5 weeks
At 0 weeks
MS none
MS 30 min
Fatigue absent
Fatigue present
PAP 5/10 PADA 7/10 HAQ score was 6/8
PAP 9/10 PADA 8/10 HAQ score was 15/8
TJC 4
TJC 1
SJC 2
SJC 1
Labs ESR 95 CRP 12
Requested baseline labs were not done
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Discussion
Lots of Lost to follow up
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Efficacy of Second Courses of Anti-Rheumatoid
Treatments
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In general,
second courses are
More likely
unsuccessful
Or at best
less successful
Not to mention
a new increased likelihood for ADR
30
Nagashima et al., 2005
Methorexate Injectable gold Sulfasalazine
12 months second course
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Efficacy of first course Efficacy of second course
Methotrexate 52 37
Injectable Gold 40 16
Salazopyrine 25 10
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(Hurst et al., 2002)
Data collected from 1160 patient with RA over 20
years
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(Hurst et al., 2002)
A second trial of the same drug,
was far less effective than the first course
34
ten Worlde et al (1997)
Assessed the effect of resumption of second line
drugs in 51 patients with RA who were in
remission but flared after treatment
discontinuation
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25 were on antimalarial drugs 10 were on
parenteral gold 4 were on d-penicillamine 8 were
on sulphasalazine 2 were on azathioprine 2 were
on methotrexate
36
Within 3 months of treatment resumption,
Disease activity parameters showed improvement
But
remained significantly worse when compared with
that measured before treatment discontinuation.
Only 47 of the patients fulfilled 20 response
criteria.
37
Within 12 months of treatment resumption,
Only 35 of patients were back in remission and
43 were in mild activity while the remainder
were suffering of active disease or were not
responders anymore
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Peculiar Facts About Hydroxychloroquine
Onset of effects in rheumatoid arthritis As
early as three weeks after the start of
therapy An effect after two to three months is
more typical But it may take as long as six
months in some patients.
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Peculiar Facts About Hydroxychloroquine
Efficacy following discontinuation Usually
maintained for the same period of time that it
took to see improvement
What about efficacy of second courses?
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The Good News
Probably more or less as effective as the first
course when compared to other DMARDs
The Bad News
It is not used in the treatment of rheumatoid
arthritis!!!!!
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Used Dose in RA
400mg per day
Effective Dose in RA
800mg per day
Pulse Dose in RA
1200mg per day
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Personal experience with Gold Treatment
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Optimal dosing schedules Antimalarials are
effective in rheumatoid arthritis, but the dose
is usually limited by side effects. As an
example, hydroxychloroquine is more effective in
rheumatoid arthritis at a dose of 800 mg/day than
400 mg/day. However, potential ophthalmologic
toxicity limits the daily dose to 400 mg/day.
Quinacrine is generally used in doses of up to
100 mg/day, sometimes in combination with either
of the two other antimalarials. Although
potential ophthalmologic toxicity limits the
long-term daily dose to 400 mg/day, clinicians
have administered higher initial short-term doses
(1200 mg/day for four weeks) to obtain faster
clinical improvement without inducing significant
toxicity Furst et al., 1999.
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If Gold chooses to
Save you the trouble of its side effects
Be genuinely effective with your rheumatoidy
joints
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Your gold and/or your body will hardly forgive you
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(Evers and Sundstrom, 1983)
Of 23 RA patients who had previously received
gold therapy,
only 4 out of the 11 (36) who had developed a
complete remission with the first course
sustained complete remission with second course
gold
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Back to our patient
Our patient was lost to follow up and, more
importantly, stopped all her medicines several
times
50
But she was lucky enough to twice have the same
favorable response with adalimumab and after the
same latent period of 2-3 weeks and without any
side effects with treatment
51
So far, GOK
If this will always be the case with adalimumab
or other biological agents available or whether
it will be the mere occasional patients luck
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In conclusion
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It is a fact that
Rheumatoid arthritis is a chronic disease where
doctors might think they have a multitude of
winning cards to induce remission of the disease
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Indeed,
They do have a multitude of cards and measures at
hand
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But,
Not all of them are necessarily of the winning
type
With practice, the disease might prove to be
rather stubborn and to remit with only one
particular drug or measure and not with the rest
or the patient might suffer ADR with many of the
available options
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Thus, it is advisable to
Stick to the card that wins for as long as
possible in a chronic disease like RA because
winning cards might, with discontinuation and
resumption of treatment, change their minds
And also to always remember that
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Our God might forgive us for the sins that we do
but our bodies and our anti-rheumatoid drugs
medicines might not
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Thank you