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Biomedical & Pharmacology Journal Vol. 6(2), 471-475 (2013)
A Retrospective Study on Clinical Characteristics of
Rheumatoid Arthritis Patients
B. PRemkumAR*1, m. SRinivASAmuRthy2 and k. RAjAgoPAl3
1JNTUH-Research Scholar (External) - PSG College of Pharmacy, Coimbatore, Tamilnadu, India.
2Vignan Institute of Pharmaceutical Sciences, Hyderabad, Andrapradesh, India.
3Zydus Cadila Healthcare Ltd, Ahmedabad, Gujarat, India.
(Received: September 30, 2013; Accepted: November 09, 2013) ABStRACt
To study the clinical characteristics of rheumatoid arthritis (RA) patients attending the rheumatology unit in a private hospital. The demographic characteristics, laboratory parameters, comorbidities, articular manifestations and pattern of prescriptions were studied from the case records . A total of 75 RA patients were studied. Female preponderance was observed and the ratio was found to be 3:1. The frequent laboratory measurements were found to be erythrocyte sedimentation rate (ESR), hemoglobin (Hb), and other hematological parameters. The articular manifestations were found to be knee, wrist, ankle, shoulder and elbow joints. The most common comorbidity was found to be hypertension and diabetes mellitus. The prescription pattern revealed the disease modifying antirheumatic drugs (DMARDs) as the first line drugs followed by steroids and non –steroidal anti-inflammatory drugs (NSAIDs). The first line DMARD was found to be methotrexate. The tendency of polypharmacy was more and the most combination was DMARD with a steroid and NSAID. The trend reveals aggressive therapy among rheumatologists. Frequent monitoring of adverse drug reactions like hepatic abnormalities for DMARDs and bone densitometry for oral glucocorticoids and drug interactions could further improve the quality of life of RA patients.
key words: Rheumatoid, CArthritis, DMARD, NSAID, Glucocorticoids, Pharmacy
intRoduCtion
usage of non –steroidal anti-inflammatory drugs (NSAIDs) had changed in the last decade and Rheumatoid arthritis (RA) affects 0.75-1% cyclooxygenase-2 inhibitors are preferred for long- of the Indian population and the aetiopathogenesis term use. Glucocorticoids are used for rapid relief involves genetic factors, development of autoantibodies and synovial inflammation (Neena et al., 2013) Early therapeutic intervention improves Studies pertaining to clinical characteristics the therapeutic outcome dramatically and detection of Indian RA patients are sparse and studies in this of antibodies and imaging technologies are insisted area could be useful in improving quality of life in at these stages. The therapeutic principles involve these patients. In this communication, we report our early initiation of disease modifying antirheumatic observations on the clinical characteristics of RA drugs (DMARDs) and systematic evaluation of patients attending the rheumatology unit. mAteRiAlS And methodS
The first line drugs for RA treatment are disease modifying antirheumatic drugs (DMARDs) The study was ethically approved and the and methotrexate was available from 1950 and has ethics clearance number is 13/111. The study was a long clinical experience. It is used as monotherapy conducted in PSG hospitals, rheumatology unit. The or combination therapy. Biologics are introduced data was collected retrospectively over a period of who are non-responders for DMARDs and they are 1 year from September 2012 and August 2012. The costlier and have similar adverse effect profile. The case records were verified retrospectively and the PREMkUMAR et al., Biomed. & Pharmacol. J., Vol. 6(2), 471-475 (2013)
information was recorded on age, gender, associated comorbidities were hypertension and diabetes il nesses (hypertension, diabetes mel itus, and other mellitus, followed by thyroid disorders, asthma, disorders), articular manifestations (pattern of joints cerebral disease and renal failure. (Table 1) affected), laboratory measurements and study of prescriptions, which included DMARDS, steroids, 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 Data of 75 RA patients were included in the study. No therapy with other DMARDs like leflunomide, patient was excluded from the analysis. There were hydroxychloroquine and sulfasalazine. The widely 17 (22.67%) males and 58 (77.33%) females (F: M used steroid was prednisolone, followed by = 3.4:1) and the mean age of the study population deflazocort and NSAID was etoricoxib. The very was 48.1 ± 12.9. The calculated BMI for women were common prescription pattern was DMARD with 24.2 and for men it was 25.4. The mean systolic blood a steroid and NSAID. The only biologic therapy pressure was found to be 124.45 ± 16.57 and mean found was rituximab and only one patient had been diastolic pressure was found to be 75.40 ± 12 and the prescribed. In most of the prescriptions H2 blockers mean pulse pressure was 92.03 ± 18.11. (Table 1) such as famotidine or proton pump inhibitors such as rabeprazole were prescribed. All the methotrexate The patients’ initial visit to the rheumatology prescriptions had folic acid as adjunct and most unit was 3.05 ± 1.83 months. The creatinine levels of the patients had calcitriol in the prescription. were 0.71 ± 0.25, the serum glutamic oxaloacetic The prescription pattern revealed polypharmacy transferase or aspartate aminotransferase (SGOT or with DMARDs, steroids, NSAIDs, calcium salts, AST) levels were 20.04 ± 11.49 and serum glutamatic calcitriol, antihypertensives, antidepressants and pyruvic transaminase or alanine aminotransferase antidiabetics. The adverse reactions reported were (SGPT or ALT) levels were 19.91 ± 14.62 units / sleep disturbance and some of the patients skipped liter. The mean duration of the disease was 4.36 ± diSCuSSion
stiffness, fatigue, joint swelling, joint deformity and This study is designed to obtain information difficulty in daily activities like walking, standing, about the clinical characteristics and prescription sitting, and polyarthralgia. The duration of morning trends of RA patients attending the rheumatology stiffness was 51.42 ± 33.98 minutes. The number unit. The study was retrospective and suffers the of tender and small joints affected was 13.87 limitation of this type of investigation. Nevertheless, ± 8.94. Most of the patients were at the active the results highlight the trends of clinical and stage of the disease, functional class 2-4. The prescription patterns. This is a tertiary care based articular manifestations recorded as pattern of joint involvement were mostly knee and wrist. The type of joints affected were metacarpophalangeal (MCP), interphalangeal (IPJ) in case of wrist and in case of preponderance similar to previous studies and the elbow it was ulnar joint (UL) followed by ankle and case reports does not reveal information about the shoulder. Radiographic examination for wrist, knee, socio-economic status of the patients. In western elbow, spine and shoulder were done for some of 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 rheumatoid factor (RF) test and most of them were the rheumatology care is not recorded. Some of the RF positive. The hematological parameters revealed reports revealed the trial for alternative therapies and slight anemic condition. The most prominent the present study we found stopping of allopathic PREMkUMAR et al., Biomed. & Pharmacol. J., Vol. 6(2), 471-475 (2013)
table 1: demographic and clinical characteristics of Rheumatoid arthritis patients
number of patients studied (n)
Patients initial visit to rheumatology unit (months) Clinical characteristics Mean BMI (Female) duration of morning stiffness (minutes)
Articular manifestations
(Pattern of joint involvement)
knee
Prescription pattern
1DMARD ONLY (Methotrexate, Leflunomide,
Hydroxychloroquine and Sulfasalazine)2 DMARDS PREMkUMAR et al., Biomed. & Pharmacol. J., Vol. 6(2), 471-475 (2013)
drugs and trying Ayurvedic therapy, which may be are also having the similar adverse effect profile. due to adverse effects or unsatisfactory with the Liver functions tests in the current study shows current treatment profile. The body mass index normal levels of hepatic transaminases and this shows the marginal weight increase in these patients assessment decides the treatment (Georg et al., (Tembe et al., 2008). The articular manifestations 2008). The usage of steroids at night time may be of the present study highlights the presence of to provide relief from morning stiffness, which is the multiple joint involvement and synovitis in wrist, knee, characteristic feature of RA (Cornelia et al., 2010). ankle and shoulder were found to be common. The NSAID found in the present study is etoricoxib is frequent complaints of the RA patients were morning gastrofriendly and provides prompt relief from joint stiffness, fatigue, disability in joint movements and 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 in deciding the therapy and effectiveness of the remission status and adverse events could improve treatment. The most common comorbid conditions the quality of life and therapeutic outcome of the were hypertension and diabetes mel itus. 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 most common complaints, frequently used the creatinine levels were normal (Al-Bishri et al., drug combinations in RA patients. The higher use of DMARDs and their combinations reveal intensive therapy and use of NSAIDs and steroids In the current study most of the prescriptions for symptomatic relief. Chronic use of these drugs had DMARDs and their combinations, which warrants the need for assessment of disease prevents joint damage and suitable for patients remission and frequent adverse effect monitoring. with active inflammation. The frequently used DMARD was methotrexate and other drugs of this ACknowledgementS
category were leflunomide, hydroxychloroquine and sulfasalazine. This selection may be due to cost Authors would like to thank Dr.V.N.Nagaprabu, effectiveness and folic acid supplementation could the consultant rheumatologist for the clinical support. alleviate the hepatotoxicity and gastrointestinal In addition, we are grateful to Mr.Sasibhushan disturbances of methotrexate. Methotrexate has reddy, Mr.B.Balaji, Mr.Ranjithkumar and Mr.Samuel several mechanisms in treating RA and is preferred Thavamani for their help in successful completion of due to its anti-inflammatory effect through adenosine pathway. Apart from this, other drugs of this class RefeRenCeS
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