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God Forgives Always Our Bodies Forgive Only Sometimes

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. September 2005:. NS, a 32 year-old Bengali female,. 3 years’ history.

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God Forgives Always Our Bodies Forgive Only Sometimes

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  1. 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

  6. Jan 2006: The patient showed up again

  7. 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

  10. 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

  11. 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

  12. Decision: Adalimumab 40mg SC fortnightly MTX 3tab/week Isoniazid1x1

  13. March 2006 Coming for 3rd shot Reporting improvement by 30% that started right after the second Ada shot

  14. 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

  16. September 2006 The patient showed up again

  17. 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

  20. Decision: Restart MTX 12.5mg IM weekly P15 INH 1x1

  21. The patient was then again lost to follow up Third time

  22. December 2006 The patient showed up again

  23. 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

  25. 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.

  26. 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

  27. Discussion Lots of Lost to follow up

  28. Efficacy of Second Courses of Anti-Rheumatoid Treatments

  29. In general, second courses are More likely unsuccessful Or at best less successful Not to mention a new increased likelihood for ADR

  30. 425 patients with RA who had stopped treatment Nagashima et al., 2005 Methorexate Injectable gold Sulfasalazine 12 months’ second course

  31. Wichita Arthritis Center (Hurst et al., 2002) Data collected from 1160 patient with RA over 20 years

  32. MTX HCQ Gold Wichita Arthritis Center (Hurst et al., 2002) A second trial of the same drug, was far less effective than the first course

  33. 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:

  34. 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

  35. 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.

  36. 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

  37. 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.

  38. 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?

  39. 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!!!!!

  40. Used Dose in RA: 400mg per day Effective Dose in RA: 800mg per day Pulse Dose in RA: 1200mg per day

  41. The Golden Remission Of Gold Treatment Personal experience with Gold Treatment

  42. Best remission u can ever see If Gold chooses to: Save you the trouble of its side effects Be genuinely effective with your rheumatoidy joints

  43. But if you choose to stop it,

  44. Your gold and/or your body will hardly forgive you

  45. (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

  46. Back to our patient Our patient was lost to follow up and, more importantly, stopped all her medicines several times

  47. 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

  48. 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 patient’s luck

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