{"id":2812,"date":"2015-04-28T06:05:46","date_gmt":"2015-04-28T06:05:46","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=2812"},"modified":"2017-03-23T10:40:43","modified_gmt":"2017-03-23T10:40:43","slug":"a-retrospective-study-on-clinical-characteristics-of-rheumatoid-arthritis-patients","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol6no2\/a-retrospective-study-on-clinical-characteristics-of-rheumatoid-arthritis-patients\/","title":{"rendered":"A Retrospective Study on Clinical Characteristics of Rheumatoid Arthritis Patients"},"content":{"rendered":"

Introduction <\/strong><\/p>\n

Rheumatoid arthritis (RA) affects 0.75-1% of the Indian population and the aetiopathogenesis involves genetic factors, development of autoantibodies and synovial inflammation (Neena et al<\/em>., 2013) Early therapeutic intervention improves the therapeutic outcome dramatically and detection of antibodies and imaging technologies are insisted at these stages. The therapeutic principles involve early initiation of disease modifying antirheumatic drugs (DMARDs) and systematic evaluation of disease activity.<\/p>\n

The first line drugs for RA treatment are disease modifying antirheumatic drugs (DMARDs) and methotrexate was available from 1950 and has a long clinical experience. It is used as monotherapy or combination therapy. Biologics are introduced who are non-responders for DMARDs and they are costlier and have similar adverse effect profile.\u00a0 The usage of non \u2013steroidal anti-inflammatory drugs (NSAIDs) had changed in the last decade and cyclooxygenase-2 inhibitors are preferred for long-term use. Glucocorticoids are used for rapid relief from synovitis and combat RA flares.<\/p>\n

Studies pertaining to clinical characteristics of Indian RA patients are sparse and studies in this area could be useful in improving quality of life in these patients. In this communication, we report our observations on the clinical characteristics of RA patients attending the rheumatology unit.<\/p>\n

Materials and methods<\/strong><\/p>\n

The study was ethically approved and the ethics clearance number is 13\/111. The study was conducted in PSG hospitals, rheumatology unit. The data was collected retrospectively over a period of 1 year from September 2012 and August 2012. The case records were verified retrospectively and the information was recorded on age, gender, associated illnesses (hypertension, diabetes mellitus, and other disorders), articular manifestations (pattern of joints affected), laboratory measurements and study of prescriptions, which included DMARDS, steroids, NSAIDs and the type of combinations.<\/p>\n

Results <\/strong><\/p>\n

Data of 75 RA patients were included in the study. No patient was excluded from the analysis. There were 17 (22.67%) males and 58 (77.33%) females (F: M = 3.4:1) and the mean age of the study population was 48.1 \u00b1 12.9. The calculated BMI for women were 24.2 and for men it was 25.4. The mean systolic blood pressure was found to be 124.45 \u00b1 16.57 and mean diastolic pressure was found to be 75.40 \u00b1 12 and the mean pulse pressure was 92.03 \u00b1 18.11. (Table 1)<\/p>\n

The patients\u2019 initial visit to the rheumatology unit was 3.05 \u00b1 1.83 months. The creatinine levels were 0.71 \u00b1 0.25, the serum glutamic oxaloacetic transferase or aspartate aminotransferase (SGOT or AST) levels were 20.04 \u00b1 11.49 and serum glutamatic pyruvic transaminase or alanine aminotransferase (SGPT or ALT) levels were 19.91 \u00b1 14.62 units \/ liter. The mean duration of the disease was 4.36 \u00b1 3.81years. (Table 1)<\/p>\n

The associated symptoms were morning stiffness, fatigue, joint swelling, joint deformity and difficulty in daily activities like walking, standing, sitting, and polyarthralgia. The duration of morning stiffness was 51.42 \u00b1 33.98 minutes. The number of tender and small joints affected was 13.87 \u00b1 8.94. Most of the patients were at the active stage of the disease, functional class 2-4. The articular manifestations recorded as pattern of joint involvement were mostly knee and wrist.\u00a0 The type of joints affected were metacarpophalangeal (MCP), interphalangeal (IPJ) in case of wrist and in case of elbow it was ulnar joint (UL) followed by ankle and shoulder. Radiographic examination for wrist, knee, elbow, spine and shoulder were done for some of the patients. (Table 1)<\/p>\n

Half of the study population had done rheumatoid factor (RF) test and most of them were RF positive. The hematological parameters revealed slight anemic condition. The most prominent comorbidities were hypertension and diabetes mellitus, followed by thyroid disorders, asthma, cerebral disease and renal failure. (Table 1)<\/p>\n

Most of the patients had previous treatments with DMARDs stopped due to symptomatic relief and some were on Ayurvedic therapy. The first line DMARD was found to be methotrexate and was administered as monotherapy or combination therapy with other DMARDs like leflunomide, hydroxychloroquine and sulfasalazine. The widely used steroid was prednisolone, followed by deflazocort and NSAID was etoricoxib. The very common prescription pattern was DMARD with a steroid and NSAID. The only biologic therapy found was rituximab and only one patient had been prescribed. In most of the prescriptions H2 blockers such as famotidine or proton pump inhibitors such as rabeprazole were prescribed. All the methotrexate prescriptions had folic acid as adjunct and most of the patients had calcitriol in the prescription. The prescription pattern revealed polypharmacy with DMARDs, steroids, NSAIDs, calcium salts, calcitriol, antihypertensives, antidepressants and antidiabetics. The adverse reactions reported were sleep disturbance and some of the patients skipped medication. (Table 1)<\/p>\n

Table 1 Demographic and clinical characteristics of Rheumatoid arthritis patients.<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Number of patients studied (N)<\/strong><\/td>\n75<\/td>\n<\/tr>\n
Mean age<\/td>\n48.1 \u00b1 12.9<\/td>\n<\/tr>\n
Female<\/td>\n58 (77.33%)<\/td>\n<\/tr>\n
Male<\/td>\n17 (22.67%)<\/td>\n<\/tr>\n
Female: Male ratio<\/td>\n3.41:1<\/td>\n<\/tr>\n
Mean duration of disease (years)<\/td>\n4.36 \u00b1 3.81<\/td>\n<\/tr>\n
Patients initial visit to rheumatology unit (months)<\/td>\n3.05 \u00b1 1.83<\/td>\n<\/tr>\n
Mean hemoglobin (g%)<\/td>\n12.06 \u00b1 2.20<\/td>\n<\/tr>\n
RBC count (million cells \/ cu.mm)<\/td>\n4.58 \u00b1 0.37<\/td>\n<\/tr>\n
ESR (mm\/hr)<\/td>\n52.57 \u00b1 15.57<\/td>\n<\/tr>\n
RF positive cases<\/td>\n20<\/td>\n<\/tr>\n
RF negative cases<\/td>\n9<\/td>\n<\/tr>\n
<\/td>\n<\/td>\n<\/tr>\n
Clinical characteristics <\/em><\/strong><\/td>\n<\/td>\n<\/tr>\n
Mean BMI (Female)<\/td>\n24.2<\/td>\n<\/tr>\n
Mean BMI (Male)<\/td>\n25.4<\/td>\n<\/tr>\n
Mean Systolic blood pressure<\/td>\n124.45 \u00b1 16.57<\/td>\n<\/tr>\n
Mean Diastolic blood pressure<\/td>\n75.40 \u00b1 12<\/td>\n<\/tr>\n
Mean Pulse pressure<\/td>\n92.03 \u00b1 18.11<\/td>\n<\/tr>\n
Serum Creatinine (mg\/dl)<\/td>\n0.71 \u00b1 0.25<\/td>\n<\/tr>\n
SGOT (U\/L)<\/td>\n20.04 \u00b1 11.49<\/td>\n<\/tr>\n
SGPT (U\/L)<\/td>\n19.91 \u00b1 14.62<\/td>\n<\/tr>\n
\u00a0<\/em><\/strong><\/td>\n<\/td>\n<\/tr>\n
Duration of morning stiffness (minutes)<\/em><\/strong><\/td>\n51.42 \u00b1 33.98<\/td>\n<\/tr>\n
<\/td>\n<\/td>\n<\/tr>\n
Articular manifestations (Pattern of Joint involvement)<\/em><\/strong><\/td>\n<\/td>\n<\/tr>\n
Knee<\/td>\n57.35%<\/td>\n<\/tr>\n
Wrist<\/td>\n51.87%<\/td>\n<\/tr>\n
Ankle<\/td>\n35.99%<\/td>\n<\/tr>\n
Shoulder<\/td>\n15.96%<\/td>\n<\/tr>\n
Elbow<\/td>\n14.63<\/td>\n<\/tr>\n
<\/td>\n<\/td>\n<\/tr>\n
Prescription pattern<\/em><\/strong><\/td>\n<\/td>\n<\/tr>\n
1DMARD ONLY (Methotrexate, Leflunomide, Hydroxychloroquine and Sulfasalazine)<\/td>\n24.16<\/td>\n<\/tr>\n
2 DMARDS<\/td>\n6.65<\/td>\n<\/tr>\n
ONLY 1STEROID (Prednisolone)<\/td>\n6.65<\/td>\n<\/tr>\n
ONLY 1NSAID (Etoricoxib)<\/td>\n1.33<\/td>\n<\/tr>\n
1 STEROIDS+ 1NSAID<\/td>\n1.33<\/td>\n<\/tr>\n
ONLY BIOLOGICS (Rituxinab)<\/td>\n1.33<\/td>\n<\/tr>\n
BIOLOGICS+1STEROID<\/td>\n1.33<\/td>\n<\/tr>\n
1 DMARD +1 NSAID<\/td>\n1.33<\/td>\n<\/tr>\n
2 DMARDS + 1NSAID<\/td>\n1.33<\/td>\n<\/tr>\n
1 DMARD+1STEROID+1NSAID<\/td>\n41.23<\/td>\n<\/tr>\n
2 DMARDS+ 1STEROID + 1NSAID<\/td>\n13.33<\/td>\n<\/tr>\n
<\/td>\n<\/td>\n<\/tr>\n
Comorbidity<\/em><\/strong><\/td>\n<\/td>\n<\/tr>\n
Hypertension<\/td>\n8 (11%)<\/td>\n<\/tr>\n
Diabetes mellitus<\/td>\n8 (11%)<\/td>\n<\/tr>\n
Hypothyroidism<\/td>\n2 (2.66%)<\/td>\n<\/tr>\n
Bronchial asthma<\/td>\n1 (1.33%)<\/td>\n<\/tr>\n
Cerebrovascular accident<\/td>\n1(1.33%)<\/td>\n<\/tr>\n
Renal failure<\/td>\n1(1.33%)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Discussion<\/strong><\/p>\n

This study is designed to obtain information about the clinical characteristics and prescription trends of RA patients attending the rheumatology unit. The study was retrospective and suffers the limitation of this type of investigation. Nevertheless, the results highlight the trends of clinical and prescription patterns. This is a tertiary care based hospital study.<\/p>\n

The demographic profile revealed female preponderance similar to previous studies and the case reports does not reveal information about the socio-economic status of the patients. In western countries smoking and alcohol consumption is highlighted as important trigger of RA and previous studies had shown low prevalence of such triggers in Indian female RA patients. The lag time in reaching the rheumatology care is not recorded. Some of the reports revealed the trial for alternative therapies and the present study we found stopping of allopathic drugs and trying Ayurvedic<\/em> therapy, which may be due to adverse effects or unsatisfactory with the current treatment profile. The body mass index shows the marginal weight increase in these patients (Tembe et al<\/em>., 2008). The articular manifestations of the present study highlights the presence of multiple joint involvement and synovitis in wrist, knee, ankle and shoulder were found to be common. The frequent complaints of the RA patients were morning stiffness, fatigue, disability in joint movements and fever.<\/p>\n

Comorbidity profiles play a vital role in deciding the therapy and effectiveness of the treatment. The most common comorbid conditions were hypertension and diabetes mellitus. This is similar to previous studies. The systolic pressure was found to be higher than normal and diastolic pressure was increased to a moderate extent and the creatinine levels were normal (Al-Bishri et al<\/em>., 2013)<\/p>\n

In the current study most of the prescriptions had DMARDs and their combinations, which prevents joint damage and suitable for patients with active inflammation. The frequently used DMARD was methotrexate and other drugs of this category were leflunomide, hydroxychloroquine and sulfasalazine. This selection may be due to cost effectiveness and folic acid supplementation could alleviate the hepatotoxicity and gastrointestinal disturbances of methotrexate. Methotrexate has several mechanisms in treating RA and is preferred due to its anti-inflammatory effect through adenosine pathway. Apart from this, other drugs of this class are also having the similar adverse effect profile. Liver functions tests in the current study shows normal levels of hepatic transaminases and this assessment decides the treatment (Georg et al<\/em>., 2008). The usage of steroids at night time may be to provide relief from morning stiffness, which is the characteristic feature of RA (Cornelia et al<\/em>., 2010). NSAID found in the present study is etoricoxib is gastrofriendly and provides prompt relief from joint pain (Clarke, 2007). Prescription pattern reveals the trend of polypharmacy and this may be due to existing comorbidies, and expectation of immediate relief by the patients. Careful monitoring of disease remission status and adverse events could improve the quality of life and therapeutic outcome of the disease.<\/p>\n

To conclude the present study shows the most common complaints, frequently used drug combinations in RA patients. The higher use of DMARDs and their combinations reveal intensive therapy and use of NSAIDs and steroids for symptomatic relief. Chronic use of these drugs warrants the need for assessment of disease remission and frequent adverse effect monitoring.<\/p>\n

Acknowledgements <\/strong><\/p>\n

Authors would like to thank Dr.V.N.Nagaprabu, the consultant rheumatologist for the clinical support.\u00a0 In addition, we are grateful to Mr.Sasibhushan reddy, Mr.B.Balaji, Mr.Ranjithkumar and Mr.Samuel Thavamani for their help in successful completion of the study.<\/p>\n

References <\/strong><\/p>\n

    \n
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  3. Cornelia M Spies, Johannes WJ Bijlsma, Gerd-Ru\u00a8 diger Burmester andFrank Buttgereit. Pharmacology of glucocorticoids in rheumatoid arthritis. Current Opinion in Pharmacology<\/em> 2010: 10:302\u2013307<\/li>\n
  4. Georg Schett, Christian Stach, Jochen Zwerina, Reinhard Voll, and Bernhard Manger. How Antirheumatic Drugs Protect Joints From Damage in Rheumatoid Arthritis. Arthritis and Rheumatism <\/em>2008: 58 (10); 2936-2948.<\/li>\n
  5. Neena Chitnis, Preeti Nagnur-Metha, Rohini Samant, Kaushik S. Bhojani, and Vinay R. Joshi.\u00a0 Lag time between disease onset and first visit to a tertiary rheumatology centre of patients with rheumatoid arthritis. Indian Journal of Rheumatology<\/em> 2013:30; 1-4.<\/li>\n
  6. Tembe AG, Kharbanda1 P, Bhojani K, and Joshi VR. Profile of rheumatoid arthritis patients attending a private tertiary hospital rheumatology clinic. Indian Journal of Rheumatology<\/em>\u00a0 2008: 3 (4); 144-147.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

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