Successful use of rituximab for cutaneous vasculitis.
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Abdomen↗
Biomedical subjects
Eliza F Chakravarty
Publications and source records attributed to Eliza F Chakravarty.
Obstetric hospitalizations in the United States for women with systemic lupus erythematosus and rheumatoid arthritis.
OBJECTIVE: To estimate the national occurrence of pregnancies in women with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) and to compare pregnancy outcomes in these patients with those in women with pregestational diabetes mellitus (DM) and with the general obstetric population. METHODS: We studied the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project to estimate the number of obstetric hospitalizations, deliveries, and cesarean deliveries in women with SLE, RA, pregestational DM, and the general obstetric population. Pregnancy outcomes included length of hospital stay, hypertensive disorders including preeclampsia, premature rupture of membranes, and intrauterine growth restriction. RESULTS: Of an estimated 4.04 million deliveries, 3,264 occurred in women with SLE, 1,425 in women with RA, and 13,574 in women with pregestational DM. Women with SLE, RA, and pregestational DM had significantly increased rates of hypertensive disorders compared with the general obstetric population (23.2%, 11.1%, 27.4%, and 7.8%, respectively), longer hospital stays, and significantly higher risk of cesarean delivery. Although women with SLE, RA, and pregestational DM were significantly older than women in the general obstetric population, disparities in the risk of adverse outcomes of pregnancy remained statistically significant after adjustment for maternal age. CONCLUSION: To our knowledge, this is the first study to examine national data on pregnancy outcomes in women with common rheumatic diseases. As with underlying pregestational DM, women with SLE and RA appear to have a higher age-adjusted risk of adverse outcomes of pregnancy and longer hospital stays than do pregnant women in the general population, and careful antenatal monitoring should be performed.
Arthritis, Rheumatoid↗
Science as experiment; science as observation.
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Antirheumatic Agents↗
Factors that predict prematurity and preeclampsia in pregnancies that are complicated by systemic lupus erythematosus.
OBJECTIVE: The purpose of this study was to describe the outcomes of a 10-year cohort of pregnancies in patients with systemic lupus erythematosus and to evaluate clinical and laboratory markers for adverse outcomes. STUDY DESIGN: We reviewed all pregnancies in patients with systemic lupus erythematosus who were seen at Stanford University from 1991 to 2001. Univariate analyses were performed to identify potential risk factors for adverse outcomes. RESULTS: Sixty-three pregnancies in 48 women were identified. Approximately 35% of the pregnancies occurred in women with previous renal disease and 10% in women with previous central nervous system disease. Flares occurred in 68% of the pregnancies, the majority of which were mild to moderate. Preeclampsia complicated 12 pregnancies. Factors that were associated with premature delivery included prednisone use at conception (relative risk, 1.8), the use of antihypertensive medications (relative risk, 1.8), and a severe flare during pregnancy (relative risk, 2.0). Thrombocytopenia was associated with an increased risk of preeclampsia (relative risk, 3.2). CONCLUSION: Flares, most of which were mild to moderate, occurred most of the pregnancies in our cohort of patients with systemic lupus erythematosus. Thrombocytopenia, hypertension, and prednisone use may be predictive factors for particular adverse outcomes.
Adult↗
Coronary artery disease in patients with systemic lupus erythematosus.
BACKGROUND: A 24-year-old woman with an 11-year history of systemic lupus erythematosus presented with exacerbation of chronic abdominal pain followed by substernal chest pain. She had a history of pericarditis secondary to systemic lupus erythematosus and of varicella-zoster reactivation secondary to immunosuppression. Long-term medications included prednisolone, hydroxychloroquine, aspirin, and mycophenolate mofetil. INVESTIGATIONS: Physical examination, mesenteric angiography, CT of the abdomen, esophagogastroduodenoscopy, colonoscopy, pelvic ultrasound, laboratory testing, serologic testing, cardiac echocardiography, electrocardiography and coronary angiography. DIAGNOSIS: Acute myocardial infarction secondary to severe multivessel atherosclerotic coronary artery disease. MANAGEMENT: Intra-aortic balloon pump followed by emergent four-vessel coronary artery bypass grafting. Aspirin, hydroxychloroquine, and mycophenolate mofetil were continued and a judicious tapering of prednisolone was initiated.
Adult↗
Skin cancer, rheumatoid arthritis, and tumor necrosis factor inhibitors.
OBJECTIVE: To determine the rates of reported non-melanoma skin cancer (NMSC) in a large cohort of patients with rheumatoid arthritis (RA) in comparison to patients with osteoarthritis (OA) and to determine risk factors for the development of NMSC in patients with RA. METHODS: Self-reported information from 15,789 patients with RA and 3,639 patients with OA were collected through semi-annual questionnaires since 1999. Survival analyses were used to determine incidence rates for NMSC among patients with RA and OA. Multivariate Cox proportional hazard models were used to estimate hazard ratios (HR) for the development of NMSC. Separate analyses were performed for patients with RA to explore associations between use of immunosuppressive medication and development of NMSC. RESULTS: The crude (unadjusted) incidence rate for reported NMSC among patients with RA and OA were 18.1 and 20.4 per 1000 patient years, respectively. OA patients were older, more likely to be Caucasian, and had higher past incidence of NMSC. Age, male sex, Caucasian race, and history of NMSC prior to entry into the database were associated with an increased risk of NMSC in multivariate Cox proportional hazard models. After adjustment for covariates, RA was associated with an increased risk of NMSC (HR 1.19, p = 0.042). Among RA patients, the development of NMSC was associated with use of prednisone (HR 1.28, p = 0.014) and tumor necrosis factor (TNF) inhibitors alone or with concomitant methotrexate (HR 1.24, p = 0.89 and HR 1.97, p = 0.001, respectively) in addition to established risk factors including fair skin, age, male sex, and previous history of NMSC. No association was found between use of methotrexate or leflunomide and development of NMSC (HR 1.12, p = 0.471, HR 0.83, p = 0.173, respectively). CONCLUSION: In this large, national cohort, RA was associated with an increased risk for development of NMSC. Among patients with RA, use of TNF inhibitors and prednisone were associated with an increased risk of NMSC.
Aged↗
A randomized, blinded, parallel group, placebo controlled pilot study evaluating the effect of PVAC treatment in patients with diffuse systemic sclerosis.
OBJECTIVE: Systemic sclerosis (SSc) is a disorder characterized by progressive thickening of the skin; there is no effective therapy. PVAC, a potential therapeutic agent derived from delipidated, deglycolipidated Mycobacterium vaccae, has shown effects on cutaneous disease in animal models of SSc. We evaluated the safety and possible biologic effect of intradermal injections of PVAC in patients with diffuse SSc. METHODS: Eighteen patients enrolled in this double blind, placebo controlled, randomized, 24 week pilot study. All patients met criteria for diffuse SSc without evidence of significant renal dysfunction, pulmonary fibrosis, pulmonary hypertension, or congestive heart failure. Patients received 8 intradermal injections of 15 microg PVAC, 50 microg PVAC, or placebo at 3 week intervals. The primary efficacy endpoint was the change in Modified Rodnan Skin Score (MRSS) at Week 24. Each of the active drug arms was compared to placebo. RESULTS: Baseline demographic and disease characteristics were similar across the 3 treatment groups. The median age was 48 years and 14 of 18 (78%) patients were female. The regimens were well tolerated with no reported serious adverse events; however, grade 1 or 2 injection site reactions occurred in the majority of patients receiving PVAC. The MRSS improved by 20.6% in the 15 microg PVAC arm, while it worsened by 29.8% in the placebo arm and by 16.7% in the 50 microg arm. Change in physician and patient global assessments followed similar trends. CONCLUSION: In this pilot study, use of PVAC in patients with SSc appeared safe and was associated with a trend toward improved skin scores in the 15 microg treatment group. Additional evaluation of this therapeutic approach is warranted.
Adult↗
Associations between rheumatoid arthritis and malignancy.
There are many complex associations between rheumatoid arthritis(RA) and malignancy. Patients with rheumatic diseases on the whole appear to be at increased risk for the development of certain malignancies. The data from several studies are persuasive that the presence of RA conveys an increased risk for the development of lymphoproliferative disorders and may convey a decreased risk for the development of malignancies of the digestive tract. Understanding the complex interrelationships between RA and malignancy will lead to more accurate diagnosis of underlying pathology, more effective treatment of symptoms and underlying disease, and appropriate surveillance for the development of later complications.
Antirheumatic Agents↗
A randomized, controlled trial of interferon-beta-1a (Avonex(R)) in patients with rheumatoid arthritis: a pilot study [ISRCTN03626626].
The objective of this study was to evaluate the safety and possible efficacy of IFN-beta-1a for the treatment of patients with rheumatoid arthritis (RA). Twenty-two patients with active RA were enrolled in a phase II randomized, double-blind, placebo-controlled trial of 30 microg IFN-beta-1a by weekly self-injection for 24 weeks. The primary outcome of the study was safety. Secondary outcomes included the proportion of patients achieving an American College of Rheumatology (ACR) 20 response at 24 weeks. There were no significant differences in adverse events reported in the two groups. Fewer than 20% of patients in each arm of the study achieved an ACR 20 response at 24 weeks (P = 0.71). Sixty-nine percent of patients receiving IFN-beta and 67% receiving placebo terminated the study early, most of them secondary to a perceived lack of efficacy. Overall, IFN-beta-1a had a safety profile similar to that of placebo. There were no significant differences in the proportion of patients achieving an ACR 20 response between the two groups.
Journal Article↗
The use of disease modifying antirheumatic drugs in women with rheumatoid arthritis of childbearing age: a survey of practice patterns and pregnancy outcomes.
OBJECTIVE: To describe the practices of rheumatologists when prescribing the disease modifying antirheumatic drugs (DMARD) methotrexate (MTX), leflunomide (LF), etanercept (ET), and infliximab (IN) to women of childbearing age with rheumatoid arthritis (RA) and the pregnancy outcomes of patients who become pregnant while taking these medications. METHODS: A questionnaire was mailed to 600 members of the American College of Rheumatology inquiring about their perception of fetal risk, their recommendations regarding the use of birth control in women of childbearing age taking DMARD, and the pregnancy outcomes of women with DMARD exposure. RESULTS: One hundred seventy-five rheumatologists (29%) returned completed surveys. Respondents were more likely to agree that pregnancy is contraindicated in women taking MTX (95%) or LF (92.7%) than for women taking ET (38.6%) or IN (46.5%). Accordingly, most required birth control for women taking MTX (95.7%) and LF (97.3%), and fewer for women taking ET (75.4%) or IN (73.4%). A total of 65 pregnancies exposed to these DMARD were reported (MTX 38, LF 10, ET 14, IN 2, MTX and ET 1). Only 3 congenital malformations, all in the MTX group, were reported among the 52 pregnancies with known outcomes. CONCLUSION: Rheumatologists agree that there is a risk of teratogenicity with MTX and LF and usually require the use of reliable methods of birth control in women taking these medications. There is no consensus about ET and IN; however, physicians still tend to discuss reliable birth control methods with their female patients. We have confirmed there is a risk of congenital malformations with in utero exposure to MTX. No malformations were reported in infants exposed to LF, ET, or IN, but the number of reported pregnancy outcomes was small.
Adult↗