Şebnem Ataman

Injection-site reaction to etanercept: role of skin test in the diagnosis of such reaction and successful desensitization.

1. Patterson R, Greenberger PA, Halwig JM, Liotta JL, Roberts M. Allergic bronchopulmonary aspergillosis. Natural history and classification of early disease by serologic and roentgenographic studies. Arch Intern Med 1986;146:916–918. 2. Tillie-Leblond I, Tonnel AB. Allergic bronchopulmonary aspergillosis. Allergy 2005;60:1004–1013. 3. Brinkmann F, Schwerk N, Hansen G, Ballmann M. Steroid dependency despite omalizumab treatment of ABPA in cystic fibrosis. Allergy 2010;65:134–135. 4. Kanu A, Patel K. Treatment of allergic bronchopulmonary aspergillosis (ABPA) in CF with anti-IgE antibody (omalizumab). Pediatr Pulmonol 2008;43:1249–1251. 5. Van der Ent CK, Hoekstra H, Rijkers GT. Successful treatment of allergic bronchopulmonary aspergillosis with recombinant anti-IgE antibody. Thorax 2007; 62:276–277. 6. Pérez-de-Llano LA, Vennera MC, Parra A, Guallar J, Marin M, Asensio O et al. Effects of omalizumab in Aspergillus-associated airway disease. Thorax 2011;11:epub. Injection-site reaction to etanercept: role of skin test in the diagnosis of such reaction and successful desensitization

Rapid subcutaneous desensitization for the management of local and systemic hypersensitivity reactions to etanercept and adalimumab in 12 patients

Etanercept and adalimumab are first line therapies for the treatment of inflammatory and autoimmune diseases. However, local and systemic hypersensitivity reactions preclude their use in sensitized patients. Immune-mediated adverse reactions to etanercept and adalimumab reported in the literature include injection site reactions (ISRs) and immediate systemic hypersensitivity reactions such as pruritus, urticaria, angioedema, and anaphylaxis. ISRs are thought to be T lymphocyte-mediated delayed type IV hypersensitivity reactions, which may preclude subsequent medication administration. Rapid drug desensitization protocols have been developed for the delivery of a variety of parenteral chemotherapeutic agents, including monoclonal antibodies, to sensitized patients. However, desensitization protocols have not been standardized for the treatment of ISRs and systemic reactions following subcutaneousmedication injections.We have previously reported 2 patients who experienced an ISR to etanercept and adalimumab and were successfully desensitized to allow subsequent medication administration. On the basis of this experience, we standardized the protocols for subcutaneous administration in patients sensitized to etanercept and adalimumab. We report the successful desensitization of 7 patients who experienced adverse reactions to etanercept (6 ISRs and 1 systemic reaction), and of 5 patients with reactions to adalimumab (4 ISR and 1 urticaria).

Correlations among enthesitis, clinical, radiographic and quality of life parameters in patients with ankylosing spondylitis.

Abstract Objectives. To investigate the relationship between enthesitis and disease activity, functional status, fatigue, joint mobility, radiological damage, laboratory parameter and quality of life in patients with ankylosing spondylitis (AS). Methods. A total of 421 patients with AS (323 male and 98 female) who were included in the Turkish League Against Rheumatism Registry were enrolled in the study. The Bath AS Disease Activity Index (BASDAI), fatigue, the Bath AS Functional Index (BASFI), the Bath AS Metrology Index (BASMI), the Maastricht AS Enthesitis Score (MASES), AS quality of life (ASQoL), the Bath AS Radiology Index (BASRI) and erythrocyte sedimentation rate (ESR) were evaluated. Results. Enthesitis was detected in 27.3% of patients. There were positive correlations between MASES and BASDAI, BASFI and fatigue (p < 0.05). MASES was not correlated with BASRI, BASMI, ASQoL and ESR. The mean MASES score was 1.1 ± 2.4. The most frequent regions of enthesopathies were right iliac crest, spinous process of L5 and proximal to the insertion of left achilles tendon, respectively. Conclusions. Enthesitis was found to be associated with higher disease activity, higher fatigue, worse functional status and lower disease duration. As enthesitis was correlated with BASDAI, we conclude that enthesitis can reflect the disease activity in patients with AS.

Remitting seronegative symmetrical synovitis with pitting edema: an adult case with excellent prognosis

Sir, In 1985, McCarty et al. described a form arthritis in elderly patients and suggested that it was a distinct subset of seronegative rheumatoid arthritis with a predictable course to complete remission [1]. The patient we report here presented with symmetrical and seronegative polyarthritis closely resembling the syndrome originally described by McCarty et al. A 43-year-old manual worker presented to the emergency service in October 1992 with an abrupt onset of fever, malaise, loss of appetite and painful swelling of his knees, ankles and shoulders. He ad no relevant medical history. At examination, body temperature was 38.6 ~ with normal cardiovascular, pulmonary, gastrointestinal and genitourinary system findings. Ankle, knee and shoulder joints were tender and swollen accompanied by pitting edema over the dorsum of the feet, ankle and pretibial regions. The results of the laboratory tests were as follows: Hemoglobin 9.9 g/dl; leukocyte count 10 400/ ram3; hematocrit 27.8%; platelet count 535 000/mm3; differential leukocyte count 84% neutrophils, 4% eosinophilis and 12% lymphocytes. Erythrocytes were normochromic and normocytic. Urinalysis showed 7-8 erythrocytes and 2-3 leukocytes per high-power field. Erythrocyte sedimentation rate (ESR) was 115 mm/h. Serum biochemical analysis of urea, creatinine, fasting blood sugar, ALT, AST, LDH, GGT, creatine, phosphokinase, Na, K, Ca, P, total protein, albumin, total lipid, total cholesterol and triglycerides were all normal. Serum protein electrophoresis showed a descreased albumin level (51.1 g/dl) and increased ~1 and/3 globulin levels (5.4 g/dl and 13.9 g/dl, respectively) Immunoglobulins G, A and M were in normal limits. Complement component 3 (C3) was mildly elevated (1.37 g/l). Tests for serum IgM rheumatoid factor, anti-nuclear antibodies and anti-dsDNA were negative. Serum antistreptolysin-O titer was less than 200 Todd units, and C-reactive protein was positive at 192 mg/1. Serological tests for hepatitis B surface antigen (HBsAg) and antibody (anti-HBs) were all negative. Throat and stool cultures did not reveal any pathogens. Blood and urine cultures were negative. Analysis of synovial fluid taken from the knee joint showed decreased viscosity and a leukocyte count of 4000/ram 3 consisting mainly of lymphocytes. Synovial fluid cultures were negative. Roentgenograms of knees, ankles, shoulders, hands and hips were normal. The patient was admitted to the hospital and put on indomethacin (150 rag/day). Fever disappeared in 24 h with a rapid improvement in arthralgias and edema. ESR fell to 30 mm/h. The patient remained well for almost a week, but then edema recurred on the dorsum of both hands and wrists (Fig. 1). ESR was 80 mm/h. Edema did not respond to higher indomethacin dosage (200 mg/ day). Indomethacin was stopped and glucocorticoid at a dose of 20 rag/day was started. As edema disappeared in 24 h, glucocorticoid was reduced to 15 mg/day after 3 days. The patient was discharged 1 week later while on 10 mg/day glucocorticoids. Glucocorticoid therapy was gradually tapered and discontinued altogether during the following month. Results of HLA histocompatibility typing were as follows: A2, A3, B5 (B35 + B51), BW4, BW6, CW4, DQW1, DRW52. This patient was followed up for 12 months with no recurrence.

Obesity Associated With Active, But Preserved Joints in Rheumatoid Arthritis: Results From our National Registry

Objectives This study aims to investigate the prevalence of obesity in patients with rheumatoid arthritis (RA) and associations with disease outcomes. Patients and methods The study population comprised of 1,038 patients with RA (198 males, 840 females; mean age 56.1±12.6 years; range 19 to 94 years) who had been included in National RA-Registry. RA disease activity measures, physical function, quality of life, joint destruction, laboratory tests, as well as pain, fatigue, general health, and patient and physician global health assessments on a visual analog scale were collected. Results Our patients had established RA with mean disease duration of 10.2±8.8 years and moderate disease activity (disease activity score in 28 joints: mean 3.7±1.6). According to the body mass index (BMI), 70% of the patients were overweight (n=362, 34.9%) or obese (n=364, 35.1%). These patients had higher disease activity scores in 28 joints, visual analog scale-pain and visual analog scale-patient global scores, and higher levels of fasting blood glucose; however, they had lower radiographic scores than normal-BMI patients (p<0.05). Regression analyses showed that the BMI was independently and inversely associated with disease activity scores in 28 joints and Sharp/van der Heijde scores after the adjustments for biologic and treatment-related factors (p<0.05). Conclusion Our findings indicate that obesity is more common in patients with RA than the general population. High disease activity and low radiographic damage were associated with high BMI in this National RA-Registry.

Turkish League Against Rheumatism Consensus Report: Recommendations For Management of Axial Spondyloarthritis

Objectives This study aims to update 2011 Turkish League Against Rheumatism SpondyloArthritis Recommendations, and to compose a national expert opinion on management of axial spondyloArthritis under guidance of current guidelines, and implantation and dissemination of these international guidelines into our clinical practice. Patients and methods A scientific committee of 28 experts consisting of 14 rheumatologists and 14 physical medicine and rehabilitation specialists (one of them also has an immunology PhD) was formed. The recommendations, systematic reviews, and meta-analyses including pharmacologic and non-pharmacologic treatment were scrutinized paying special attention with convenient key words. The draft of Turkish League Against Rheumatism opinion whose roof consisted of international treatment recommendations, particularly the Assessment of SpondyloArthritis International Society/European League Against Rheumatism recommendations was composed. Assessment of level of agreement with opinions by task force members was established through the Delphi technique. Voting using a numerical rating scale assessed the strength of each recommendation. Results Panel compromised on five basic principles and 13 recommendations including pharmacological and nonpharmacological methods. All of the recommendations had adequate strength. Conclusion Turkish League Against Rheumatism expert opinion for the management of axial spondyloArthritis was developed based on scientific evidence. These recommendations will be updated regularly in accordance with current developments.

Turkish League Against Rheumatism (TLAR) Recommendations for the Pharmacological Management of Rheumatoid Arthritis: 2018 Update Under Guidance of Current Recommendations

Objectives This study aims to report the assessment of the Turkish League Against Rheumatism (TLAR) expert panel on the compliance and adaptation of the European League Against Rheumatism (EULAR) 2016 recommendations for the management of rheumatoid arthritis (RA) in Turkey. Patients and methods The EULAR 2016 recommendations for the treatment of RA were voted by 27 specialists experienced in this field with regard to participation rate for each recommendation and significance of items. Afterwards, each recommendation was brought forward for discussion and any alteration gaining ≥70% approval was accepted. Also, Turkish version of each item was rearranged. Last version of the recommendations was then revoted to determine the level of agreement. Levels of agreement of the two voting rounds were compared with Wilcoxon signed-rank test. In case of significant difference, the item with higher level of agreement was accepted. In case of no difference, the changed item was selected. Results Four overarching principles and 12 recommendations were assessed among which three overarching principles and one recommendation were changed. The changed overarching principles emphasized the importance of physical medicine and rehabilitation specialists as well as rheumatologists for the care of RA patients in Turkey. An alteration was made in the eighth recommendation on treatment of active RA patients with unfavorable prognostic indicators after failure of three conventional disease modifying anti-rheumatic drugs. Remaining principles were accepted as the same although some alterations were suggested but could not find adequate support to reach significance. Conclusion Expert opinion of the TLAR for the treatment of RA was composed for practices in Turkish rheumatology and/or physical medicine and rehabilitation clinics.

Management of Psoriatic Arthritis: Turkish League Against Rheumatism (TLAR) Expert Opinions

Objectives This study aims to establish the first national treatment recommendations by the Turkish League Against Rheumatism (TLAR) for psoriatic arthritis (PsA) based on the current evidence. Patients and methods A systematic literature review was performed regarding the management of PsA. The TLAR expert committee consisted of 13 rheumatologists and 12 physical medicine and rehabilitation specialists experienced in the treatment and care of patients with PsA from 22 centers. The TLAR recommendations were built on those of European League Against Rheumatism (EULAR) 2015. Levels of evidence and agreement were determined. Results Recommendations included five overarching principles and 13 recommendations covering therapies for PsA, particularly focusing on musculoskeletal involvement. Level of agreement was greater than eight for each item. Conclusion This is the first paper that summarizes the recommendations of TLAR as regards the treatment of PsA. We believe that this paper provides Turkish physicians dealing with PsA patients a practical guide in their routine clinical practice.