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Chandrashekara S. Comment on: Prevalence of LTBI in patients with autoimmune diseases and accuracy of IGRA in predicting TB relapse: Reply. Rheumatology (Oxford) 2024; 63:e148. [PMID: 37647646 DOI: 10.1093/rheumatology/kead442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Affiliation(s)
- S Chandrashekara
- ChanRe Rheumatology and Immunology Center and Research, Bengaluru, India
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Chandrashekara S, Panchagnula R, Chennupati Y. Prevalence of LTBI in patients with autoimmune diseases and accuracy of IGRA in predicting TB relapse. Rheumatology (Oxford) 2023; 62:3952-3956. [PMID: 37348542 DOI: 10.1093/rheumatology/kead315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/05/2023] [Accepted: 06/12/2023] [Indexed: 06/24/2023] Open
Abstract
OBJECTIVES The current study evaluated latent tuberculosis infection (LTBI) positivity in a cohort of Indian subjects and the accuracy of IFN-gamma release assay (IGRA) in predicting tuberculosis (TB) reactivation. METHODS This cross-sectional, retrospective chart-based study considered patients diagnosed with autoimmune rheumatic diseases (AIRDs), especially those who received treatment with biologics or targeted synthetic (ts)DMARDs. The patients had undergone LTBI screening and IGRA test. The study excluded patients with inadequate information and those who had undergone test exclusively for diagnostic purpose. Statistical analyses were carried out for descriptive, demographic and clinical variables. Accuracy and error rate in predicting the absence of TB reactivation were calculated for IGRA test. RESULTS The study selected 943 patients who had undergone IGRA pre-screening prior to the initiation of biologics or tsDMARDs with a mean age of 42.93 ± 14.01 years and male-to-female ratio of 1:2.08. RA was the most common primary diagnosis (43.16%). The proportion of subjects who received single, double and triple or more DMARDs or immune suppressants were 54.35%, 33.33% and 7.69%, respectively. Among the selected subjects, 125 patients were LTBI positive and 816 were negative. All patients, except one who tested positive at baseline, received antitubercular prophylaxis. Accuracy of IGRA in predicting the absence of TB reactivation was 99.6%, with an error rate of 0.46. CONCLUSION LTBI screening is beneficial in AIRDs patients prior to the prescription of biologics or tsDMARDs. IGRA is ideal for identifying patients with increased likelihood of developing TB upon receiving biologics or tsDMARDs with reasonable accuracy.
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Affiliation(s)
- S Chandrashekara
- ChanRe Rheumatology and Immunology Center and Research, Bengaluru, India
| | | | - Yogitha Chennupati
- ChanRe Rheumatology and Immunology Center and Research, Bengaluru, India
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Chandrashekara S. Osteoporosis in Rheumatology. Indian J Orthop 2023; 57:176-180. [PMID: 38107813 PMCID: PMC10721574 DOI: 10.1007/s43465-023-01024-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/09/2023] [Indexed: 12/19/2023]
Abstract
Introduction Osteoporosis is a common diagnosis and comorbidity observed in patients with rheumatic diseases. It is frequently associated with conditions such as rheumatoid arthritis, spondyloarthropathy, systemic lupus erythematosus, and other autoimmune rheumatic diseases. Conclusion The incidence of osteoporosis is influenced by factors such as uncontrolled disease, prolonged and higher doses of steroid use, immobility, advanced age, and postmenopausal status. Achieving good control of the underlying disease, minimizing or avoiding the use of steroids for extended periods, and ensuring adequate supplementation of vitamin D and calcium are crucial in reducing the incidence of osteoporosis. Regular screening and appropriate management of osteoporosis can significantly decrease the associated morbidity and mortality.
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Affiliation(s)
- S. Chandrashekara
- ChanRe Rheumatology and Immunology Center and Research, Bengaluru, India
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Patil A, Chanakya K, Shenoy P, Chandrashekara S, Haridas V, Kumar S, Daware M, Janardana R, Pinto B, Subramanian R, Nagaraj S, Singh YP, Singhai S, Jois R, Jain V, Srinivasa C, Dharmanand BG, Dharmapalaiah C, Sangeetha KN, Rao VK, Shobha V. A prospective longitudinal study evaluating the influence of immunosuppressives and other factors on COVID-19 in autoimmune rheumatic diseases. BMC Rheumatol 2022; 6:32. [PMID: 35698182 PMCID: PMC9192133 DOI: 10.1186/s41927-022-00264-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 03/16/2022] [Indexed: 12/15/2022] Open
Abstract
Background We conducted this study to identify the influence of prolonged use of hydroxychloroquine (HCQ), glucocorticoids and other immunosuppressants (IS) on occurrence and outcome of COVID-19 in patients with autoimmune rheumatic diseases (AIRDs).
Methods This was a prospective, multicenter, non-interventional longitudinal study across 15 specialist rheumatology centers. Consecutive AIRD patients on treatment with immunosuppressants were recruited and followed up longitudinally to assess parameters contributing to development of COVID-19 and its outcome. Results COVID-19 occurred in 314 (3.45%) of 9212 AIRD patients during a median follow up of 177 (IQR 129, 219) days. Long term HCQ use had no major impact on the occurrence or the outcome of COVID-19. Glucocorticoids in moderate dose (7.5–20 mg/day) conferred higher risk (RR = 1.72) of infection. Among the IS, Mycophenolate mofetil (MMF), Cyclophosphamide (CYC) and Rituximab (RTX) use was higher in patients with COVID 19. However, the conventional risk factors such as male sex (RR = 1.51), coexistent diabetes mellitus (RR = 1.64), pre-existing lung disease (RR = 2.01) and smoking (RR = 3.32) were the major contributing risk factors for COVID-19. Thirteen patients (4.14%) died, the strongest risk factor being pre-existing lung disease (RR = 6.36, p = 0.01). Incidence (17.5 vs 5.3 per 1 lakh (Karnataka) and 25.3 vs 7.9 per 1 lakh (Kerala)) and case fatality (4.1% vs 1.3% (Karnataka) and 4.3% vs 0.4% (Kerala)) rate of COVID-19 was significantly higher (p < 0.001) compared to the general population of the corresponding geographic region. Conclusions Immunosuppressants have a differential impact on the risk of COVID-19 occurrence in AIRD patients. Older age, males, smokers, hypertensive, diabetic and underlying lung disease contributed to higher risk. The incidence rate and the case fatality rate in AIRD patients is much higher than that in the general population.
Supplementary Information The online version contains supplementary material available at 10.1186/s41927-022-00264-0.
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Affiliation(s)
| | - K Chanakya
- Department of Clinical Immunology and Rheumatology, St. John's Medical College Hospital, Sarjapur Road, Bengaluru, 560034, India
| | | | | | | | | | | | - Ramya Janardana
- Department of Clinical Immunology and Rheumatology, St. John's Medical College Hospital, Sarjapur Road, Bengaluru, 560034, India
| | - Benzeeta Pinto
- Department of Clinical Immunology and Rheumatology, St. John's Medical College Hospital, Sarjapur Road, Bengaluru, 560034, India
| | | | | | | | | | | | | | | | | | | | | | | | - Vineeta Shobha
- Department of Clinical Immunology and Rheumatology, St. John's Medical College Hospital, Sarjapur Road, Bengaluru, 560034, India.
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Shobha V, Kodishala C, Chandrashekara S, Kumar S, Haridas V, R Rao V, Jois R, Daware M, Singh Y, Singhai S, Dharmanand BG, Chebbi P, Subramanian R, Kamath A, Karjiigi U, K Jain V, Dharmapalaiah C, Prasad S, Srinivasa C, Janardana R, Pinto B, Nazir B, Harshini AS, Mahendranath KM. Clinical profiling of psoriatic arthritis: an observational cross-sectional study from Karnataka Psoriatic Arthritis Cohort. Indian J Rheumatol 2022. [DOI: 10.4103/injr.injr_213_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chandrashekara S, Paul B. A narrative review of clinical evidence validating the efficacy of topiroxostat in managing hyperuricemia. Indian J Rheumatol 2022. [DOI: 10.4103/injr.injr_59_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Shobha V, Jain A, Chandrashekara S, Shenoy P, Pandya S, Chotalia P, Kumar S, Malviya S, Singh Y, Patil A, Gupta V, Srivastava P, Parimi V, Kodishala C, Janardana R, Pinto B, Bhandari S, Rankawat G, Jadhav P, Potugari D, Sharma V, Parmar A, Kayidhi S, Antony P, Badika A, Sharma A. Impact of COVID-19 on rheumatic diseases in india: Determinants of mortality and adverse outcome: A retrospective, cross-sectional cohort study. Indian J Rheumatol 2022. [DOI: 10.4103/injr.injr_278_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Pareek A, Chandrashekara S, Mehta RT. Hydroxychloroquine retinopathy-less than meets the eye. Eye (Lond) 2021; 35:2897. [PMID: 32989274 PMCID: PMC8452663 DOI: 10.1038/s41433-020-01196-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Anil Pareek
- Medical Affairs & Clinical Research, Ipca Laboratories Limited, Mumbai, India.
| | | | - Ravi T Mehta
- Medical Affairs, Ipca Laboratories Limited, Mumbai, India
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Chandrashekara S, Lingaraju DC, Renuka P, Anupama KR. Potential of neutrophil to lymphocyte ratio in predicting sustained remission in rheumatoid arthritis compared to other immune activation markers. Indian J Med Res 2021; 152:234-243. [PMID: 33107483 PMCID: PMC7881809 DOI: 10.4103/ijmr.ijmr_1676_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background & objectives: Cells and cell proportions may indicate the equilibrium status of the immune system. The present study was conducted to evaluate the role of cytokines and the immunocompetent cells as biomarkers of remission in rheumatoid arthritis (RA) patients intended to withdraw or reduce disease-modifying anti-rheumatic drug (DMARD) treatment. Methods: This prospective observational study involved newly diagnosed and treated RA patients who fulfilled 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria. The patients were classified based on disease activity score (DAS)28-C-reactive protein (CRP)(3) score into remission (≤2.6) and treatment-naïve/active (>2.6) groups. Remission patients were followed up for six months and were reclassified into those in sustained remission (≤2.6) and relapse (>2.6) based on the DAS28-CRP(3) score. Various cytokines and cell surface markers were quantitated using whole blood samples, and the CD3+/CD19+ and FOXP3+/CD4+ ratios were calculated. The clinical, demographic, cytokine and cellular phenotype characteristics were compared between remission and treatment-naïve groups. The factors associated with sustained remission were verified. Results: Of the 72 patients, 52 were in remission and 20 were DMARD naïve and had active disease. Duration of illness, interleukin-6 (IL-6) and IL-10 were significantly different between remission and treatment naïve/active disease patients. Increased likelihood for achieving sustained remission was noted in RA patients with baseline NLR ≤2. Other demographic/clinical variables and cell phenotypes, namely age, gender, duration of illness, CD3+, CD4+, FOXP3+, CD19+, CD3+/CD19+, FOXP3+/CD4+ and cytokines - IL-6 and IL-10 were not associated with sustained remission. Interpretation & conclusions: The present preliminary study highlighted the potential of NLR in predicting sustained remission in RA patients with a cut-off <2. Further study with a large sample size should be done to confirm this finding.
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Affiliation(s)
- S Chandrashekara
- Department of Rheumatology & Clinical Immunology, ChanRe Rheumatology & Immunology Centre & Research, Bengaluru, India
| | - Deepak Chikkulikere Lingaraju
- Department of Rheumatology & Clinical Immunology, ChanRe Rheumatology & Immunology Centre & Research, Bengaluru, India
| | - P Renuka
- Department of Pathology & Immunology, ChanRe Diagnostic Laboratory, Bengaluru, India
| | - K R Anupama
- Department of Basic Research, ChanRe Rheumatology & Immunology Centre & Research, Bengaluru, India
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Shobha V, Chanakya K, Haridas V, Kumar S, Chebbi P, Pinto B, Jain V, Ramaswamy S, Prasad S, Patil A, Rao V, Yathish GC, Dharmanand BG, Jois R, Kamath A, Dharmapalaiah C, Sangeeta KN, Janardana R, Srinivasa C, Harshini AS, Srinivasulu N, Singh Y, Singhai S, Mahendranath KM, Chandrashekara S. Do all patients with rheumatic Diseases have a higher risk of COVID 19? Initial results from the Karnataka Rheumatology Association COVID 19 Cohort Study (KRACC). Indian J Rheumatol 2021. [DOI: 10.4103/injr.injr_261_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chandrashekara S, Jaladhar P, Paramshetti S, Ramachandran V, Nizar SF, Kori D. Post COVID Inflammation Syndrome: Different Manifestations Caused by the Virus. J Assoc Physicians India 2020; 68:33-34. [PMID: 33247640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Incidence of viral pneumonia has been reported in several patients diagnosed with COVID-19. The infection has also been linked to the development of inflammatory syndromes and related clinical manifestations. RESULT The present study discusses four cases of COVID infection showing varying clinical features. The post-COVID inflammation syndrome was associated with non-specific inflammation and post viral arthritis in three cases. One other subject had vasculitis leading to central retinal artery occlusion. CONCLUSION As the number of cases of COVID-19 cases has been increasing globally, it is advisable that physicians consider the possibility of post-COVID manifestations while examining patients with non-specific inflammation. A short course of NSAIDs and hydroxychloroquine regimen has been found to be beneficial for alleviating symptoms, and in rare cases with organ threatening inflammation, steroids may be required.
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Affiliation(s)
- S Chandrashekara
- Managing Director, ChanRe Rheumatology and Immunology Center and Research, Bengaluru, Karnataka
| | - Prakruthi Jaladhar
- Fellow in Rheumatology and Immunology, ChanRe Rheumatology and Immunology Center and Research, Bengaluru, Karnataka
| | - Shruti Paramshetti
- Fellow in Rheumatology and Immunology, ChanRe Rheumatology and Immunology Center and Research, Bengaluru, Karnataka
| | - Veena Ramachandran
- Fellow in Rheumatology and Immunology, ChanRe Rheumatology and Immunology Center and Research, Bengaluru, Karnataka
| | - Sayid Fahad Nizar
- Fellow in Rheumatology and Immunology, ChanRe Rheumatology and Immunology Center and Research, Bengaluru, Karnataka
| | - Devaraj Kori
- Resident, ChanRe Rheumatology and Immunology Center and Research, Bengaluru, Karnataka
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Karjigi U, Kodishala C, Chandrashekara S, Kumar S, Haridas V, R S, Jois R, Daware M, Rao VKR, Dharmanand BG, Jain VRK, Singh YP, Singhai S, Chebbi P, Dharmapalaiah C, Kamath A, Prasad S, C S, Aithala R, Pinto B, Nazir B, Alur Shivakumar H, K M M, Shobha V. AB0785 REAL LIFE EXPERIENCE OF METHOTREXATE BASED DUAL COMBINATION DMARDS IN PSORIATIC ARTHRITIS- RESULTS FROM KARNATAKA PSORIATIC ARTHRITIS COHORT (KPsAC). Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Biologics have been the focus of recent treatment guidelines and ‘Treat to Target’ strategies for both psoriasis (PsO) & psoriatic Arthritis (PsA). However, in day-today practice, combination DMARDs anchored around methotrexate are mainstay in majority of patients.Objectives:To describe experience and effectiveness of Methotrexate in combination with conventional DMARDs in Karnataka Psoriatic Arthritis Cohort.Methods:Treatment information was extracted from KPsAC (n=549) which is a cross sectional, non-interventional study conducted across 17 rheumatology practicing centres in Karnataka, India using a structured proforma. This study was approved by respective Ethical committee. Information on efficacy was extracted for various csDMARDs in combination with methotrexate. Standard disease activity outcome measures were used for assessing the response to therapy (DAPSA, PASI, HAQ, MDA5). All participating rheumatologists underwent training to calculate PASI and other outcome scores.Results:Nearly half of the patients in our cohort were on methotrexate (44%) monotherapy. Proportion of patients who received combination csDMARD anchored on methotrexate were 29%. The choice of add on csDMARD was as per clinician discretion or subject preference. Patients were divided in to three groups based on treatments they were receiving at the time of study: Methotrexate (Mtx)+Leflunomide (Lef), Mtx+Sulfasalazine (SSz) and Mtx+Apremilast(Apr). Their characteristics along with outcome measures are depicted in table 1. In Mtx+Apr group: remission or low disease activity was present in 42%, HAQ score of <0.5 was seen in 82%, and only one patient had a PASI of > 10. PASI was significantly lower in the Mtx+Apr group compared to Mtx+Lef group (p<0.009) and Mtx +Ssz group (p < 0.020)Conclusion:Apremilast is an orally administered, small molecule inhibitor of phosphodiesterase 4 (PDE4)**. In this observational study, 3 groups of methotrexate plus csDMARD- leflunomide, sulphasalazine and apremilast fared similarly for articular domain of PsA. However, in cutaneous domain, PASI was significantly lower in apremilast + methotrexate group. To our knowledge, this is the first real life report of the use of combination DMARDs in unselected PsA patients demonstrating effectiveness of apremilast in cutaneous domain. Methotrexate remains anchor DMARD for treatment of PsA in 2/3rdof PsA patients. Addition of apremilast to methotrexate inadequate responders appears to be beneficial in PsA with persistent cutaneous disease. However, being an observational study, this needs to be confirmed in controlled clinical trials.References:**Apremilast: A Review in Psoriasis and Psoriatic Arthritis, Drugs March 2017, Volume 77, Issue 4.Table.Characteristics and comparison of combination csDMARDsMTX+SSZ(N=39)MTX+LEF (n=77)MTX+APR(N=45)Median Age (years)373935Median disease duration (months)96101112Enthesitis (Ever)6(15%)21(27%)4(8%)Dactylitis (Ever)9((23%)28(36%)12 (26%)DAPSA < 46(15%)9(11%)10(22%) 4-1414(36%)25(32%)13(29%) 14-287(18%)24(31%)11(24%)PASI >107(18%) #14(18%) *1(2%) *#HAQ < 0.530(77%)60(78%)37(82%)MDA 5 achieved16(41%)25(32%)19(42%)*P value < 0.009 #P value <0.02Disclosure of Interests:None declared
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Kodishala C, Chandrashekara S, Kumar S, Haridas V, R S, Jois R, Daware M, Rao VKR, B G D, Jain VRK, Singh YP, Singhai S, Chebbi P, Dharmapalaiah C, Kamath A, Karjigi U, Prasad S, C S, Aithala R, Pinto B, Nazir B, Alur Shivakumar H, K M M, Shobha V. AB0790 CLINICAL PROFILING OF PSORIATIC ARTHRITIS (PsA): AN OBSERVATIONAL STUDY FROM A SOUTH INDIAN PSORIATIC ARTHRITIS COHORT. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.2527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Clinical patterns and disease burden of PsA varies in different parts of the world. Demographic studies from Indian subcontinent are sparseObjectives:To study the cutaneous, articular profile of PsA and describe their disease activity, disability and co-morbidities (CMs)Methods:This is a multicenter, cross-sectional, non-interventional study from Karnataka, India. All consecutive PsA patients defined by CASPAR or expert diagnosis were evaluated over 8 months from 17 Rheumatology centers across Karnataka using standard parameters such as PASI, DAPSA, Indian version of HAQ-DI1, psoriatic co-morbidity index2(Cidx) and MDA 5. Patient consent and EC obtainedResults:549 PsA patients were evaluated and their disease characteristics are shown in Table 1 & 2. PsA preceded psoriasis in in 81 (14.7%).Table 1.Patient characteristics (n=549)DEMOGRAPHICSPsACommonest age group of PsA (yrs)31-40PsA SubclassificationM:F6:5Symmetric polyarthritis216(40.7%)Type 1 PsoriasisType 2 Psoriasis279(55.8%)221(44.2%)Mean duration (yrs)Asymmetric oligoarthritis202(38.1%)Psoriasis8.8(±7.8)DIP predominant88(16.6%)PsA5.2(±6.3)Arthritis mutilans16(4.2%)PsA preceded psoriasis81(14.7%)Dactylitis182(33.9%)Family h/oPsoriasis107(19.7%)Enthesitis109(20.3%)PsA33(6%)Mean TJC686.3(±8.9)AS11(2%)Mean SJC683.5(±5.2)Uveitis5(0.9%)Type of PsoriasisPlaque253(59.9%)IBD3(0.5%)Erythrodermic 31(7.3%)Type I & II psoriasis did not differ in PASI, DAPSA, HAQ-DI or having a family h/o psoriasis. Type II psoriasis had higher Cidx than type I (p=0.0001). Pt pain VAS, DAPSA, PhyGA, PtGA & SJC significantly correlated with higher HAQ-DI (p<0.0001). TJC, ESR, CRP & PASI had minor correlation with HAQ-DI. Females had higher HAQ-DI compared to males (p=0.02). Knee joint involvement caused disability most frequently. Cidx was higher in males (p=0.008). Minor correlation was found between Cidx with age, HAQ-DI & DAPSA. Mean BMI of our cohort was 26.8(±14.8) kg/m2. 56.5% were overweight. Higher BMI was not associated with age, duration of arthritis, DAPSA, PASI, HAQ-DI & Cidx.Infections (any time) were recorded in 10.8%, of which skin was the commonest site in 38.9%; 30.5% of these needed hospitalizations.Conclusion:Despite mild skin disease in majority, more than half of the patients have moderate to severe joint activity. Mild to moderate functional disability in nearly half of our cohort indicate high burden of damage. High incidence of co-morbidities in PsA compared with general population is in line with published literature. In addition to aggressive control of articular activity, detection and control of co-morbidities must be an integral part of PsA management.References:[1]https://doi.org/10.1093/rheumatology/41.12.1457[2]http://dx.doi.org/10.1136/annrheumdis-2016-eular.4598Table 2.Disease characteristicsDISEASE ACTIVITYDISABILITYCO-MORBIDITIESMean PASI: 3.8(7.4)Mean HAQ-DI: 0.3(0.45)Mean Cidx: 0.98(1.6)Mild (PASI 0-5)480(80%)Mild-mod disability260(48.2%)N with 1 or more CMs232(42.3%)Severe (>10)57(10.6%)ADL with most frequent disabilityClimbing a flight of stairs 189(35%)HTNT2DMSmokingPsA severity19.8%16.6%5.4%3.2%Mean DAPSA: 18.8(16.6)ADL with highest disability scoreSitting cross-legged/squattingAnxietyIHDDyslipidemiaOthers3.1%2.3%2%<2% eachRemission100(19.9%)Low DA145(28.8%)Moderate DA137(27.2%)High DA123(24.5%)Family h/o CV dis/stroke72(15.2%)Disclosure of Interests:None declared
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Chandrashekara S, Shobha V, Dharmanand BG, Jois R, Kumar S, Mahendranath KM, Haridas V, Prasad S, Singh Y, Daware MA, Swamy A, Subramanian R, Somashekar SA, Shanthappa AM, Anupama KR. Influence of disease duration and socioeconomic factors on the prevalence of infection and hospitalization in rheumatoid arthritis: KRAC study. Int J Rheum Dis 2019; 22:1216-1225. [PMID: 30977300 DOI: 10.1111/1756-185x.13562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 02/06/2019] [Accepted: 02/28/2019] [Indexed: 01/25/2023]
Abstract
AIM The use of healthcare resources by rheumatoid arthritis (RA) patients can be related to the presence of disease, comorbid conditions, use of steroids, and the combined use of immunosuppressants. This study evaluated the risk factors associated with infection and hospitalization in RA. METHODS This multicenter, cross-sectional study enrolled 3247 RA subjects fulfilling the 2010 American College of Rheumatology/European League Against Rheumatism criteria to examine the prevalence of hospitalization and episodes of documentable non-tubercular infections as a part of the "Karnataka rheumatoid arthritis comorbidity" study (KRAC). The study included 2081 subjects and 1166 were excluded due to incomplete data. Demographic, clinical and treatment variables were collected, and the events related to infections and hospitalization were extracted from the medical records. Comparative analysis and multivariate logistic regression were performed. RESULTS Around 22% of the subjects had hospitalizations and 2.9% had infections. Infections were pertaining to dental (1.3%), urinary tract (1.6%) and candidiasis (0.2%). Skin- and soft tissue-related infections were found in 1.8% and 0.3% of patients, respectively. Increased need of hospitalization in RA patients was associated with advanced age (≥60 years), lower education, family income, and longer duration of RA. Presence of comorbidity, usage of three or more disease-modifying anti-rheumatic drugs (DMARDs) and family income influenced the likelihood of infection. Dental infections were less likely in working subjects and more likely in patients with increased disease duration, higher family income, comorbidities and those between the age group 40-59 years. Urinary tract infection was associated with DMARD usage. CONCLUSION Patient-specific risk factors should be considered to improve treatment strategies and to reduce the risk of infection and hospitalization in RA patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - K R Anupama
- ChanRe Rheumatology and Immunology Centre, Bangalore, India
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Chandrashekara S, Dhote SV, Anupama KR. The Differential Influence of Immunological Process of Autoimmune Disease on Lipid Metabolism: A Study on RA and SLE. Indian J Clin Biochem 2019; 34:52-59. [PMID: 30728673 DOI: 10.1007/s12291-017-0715-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 11/06/2017] [Indexed: 12/29/2022]
Abstract
Metabolic parameters like uric acid, lipids and homocysteine are influenced by immunopathological mechanisms underlying the autoimmune disease processes. The current study examined the differences in these parameters and the correlation between inflammatory and metabolic variables in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) patients. The cross-sectional prospective study included 24 treatment-naïve patients with moderate to severe diseases-15 subjects had RA and 9 had SLE. Atherogenic index of plasma (AIP) was used to assess the cardiovascular risk of the patients. Spearman's correlation was performed to verify the relationship between inflammatory and metabolic parameters. A two-tailed P < 0.05 was considered statistically significant for all the analysis. SLE patients had higher uric acid levels, very low density lipoprotein-cholesterol, total cholesterol/high density lipoprotein-cholesterol ratio (TC/HDL-C) and logarithmic ratio of triglycerides to HDL-cholesterol (log[TG/HDL-C]) than RA. Whereas, reduced total lymphocyte count, lipoprotein(a), and low density lipoprotein cholesterol were noted in the former than latter group. Majority of the SLE patients had increased risk of cardiovascular diseases (> 0.24 AIP score) and RA patients in comparison had lower risk. Correlation among serum uric acid, lipid profile constituents and AIP was noted. The immunological process of SLE has greater impact on the metabolic parameters. Higher uric acid levels are suggestive of dysfunctional lipid profile. Understanding the implications of risk factors and its inflammatory role in autoimmune processes may assist in disease management.
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Affiliation(s)
- S Chandrashekara
- ChanRe Rheumatology and Immunology Center and Research, 414/65, 20th Main, West of Chord Road, 1st Block, Rajajinagara, Bangalore, 560010 India
| | - Sachin Vithalrao Dhote
- ChanRe Rheumatology and Immunology Center and Research, 414/65, 20th Main, West of Chord Road, 1st Block, Rajajinagara, Bangalore, 560010 India
| | - K R Anupama
- ChanRe Rheumatology and Immunology Center and Research, 414/65, 20th Main, West of Chord Road, 1st Block, Rajajinagara, Bangalore, 560010 India
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Shobha V, Chandrashekara S, Rao V, Desai A, Jois R, Dharmanand BG, Kumar S, Kumar P, Dharmapalaiah C, Mahendranath KM, Prasad S, Daware MA, Singh Y, Karjigi U, Nagaraj S, Anupama KR. Biologics and risk of tuberculosis in autoimmune rheumatic diseases: A real-world clinical experience from India. Int J Rheum Dis 2018; 22:280-287. [DOI: 10.1111/1756-185x.13376] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 08/01/2018] [Accepted: 08/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - S. Chandrashekara
- ChanRe Rheumatology and Immunology Center and Research; Bangalore India
| | | | - Anu Desai
- St. John's Medical College Hospital; Bangalore India
| | | | | | | | | | | | | | | | | | | | | | | | - K. R. Anupama
- ChanRe Rheumatology and Immunology Center and Research; Bangalore India
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Sosale B, Chandrashekara S, Aravind SR, Renuka P, Anupama K. Influence of cytokine status on insulin resistance and circulating endothelial progenitor cells in type 2 diabetes mellitus. Cytokine 2017; 99:179-185. [DOI: 10.1016/j.cyto.2017.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/30/2017] [Accepted: 09/10/2017] [Indexed: 12/27/2022]
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Sosale B, Sosale AR, Chandrashekara S, Panchagnula R, Dey S, Prasannakumar KM. Effect of vitamin D supplementation on reduction of cardiometabolic risk in patients with type 2 diabetes mellitus and dyslipidemia. Int J Diabetes Dev Ctries 2017. [DOI: 10.1007/s13410-017-0584-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Chandrashekara S, Mukhtar Ahmad M, Renuka P, Anupama KR, Renuka K. Characterization of neutrophil-to-lymphocyte ratio as a measure of inflammation in rheumatoid arthritis. Int J Rheum Dis 2017; 20:1457-1467. [PMID: 28952205 DOI: 10.1111/1756-185x.13157] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The neutrophil to lymphocyte ratio (NLR) is one of the well-recognized sensitive measures of inflammation. This cross-sectional observational study was aimed at characterizing the relationship of NLR with the inflammatory markers erythrocyte sedimentation rate (ESR), C-reative protein (CRP), Disease Activity Score of 28 joints (DAS28)-CRP(3), joint counts and quality measures of rheumatoid arthritis (RA). MATERIALS AND METHODS Patients with RA were recruited in two phases. The following were assessed for all patients: joint count, pain by visual analogue scale (VAS), complete blood count, ESR, CRP and quality index assessment using the Short Form health survey (SF-36) questionnaire. A subgroup analysis was also performed to evaluate the association between NLR and cytokines. RESULTS Four hundred and eighty-nine subjects were recruited. Distribution of NLR values corresponded with DAS28-CRP(3) rather than CRP and ESR. A significant difference in VAS, swollen joint counts (SJC-28), inflammatory parameters and general health outcome measures was observed among the NLR groups. A weak correlation was observed between NLR and RA disease measures. It had least bias at lower ranges with DAS28-CRP(3) than CRP and ESR. The NLR cut-off value of 1.4 classified the patients in deep remission with 90% specificity, 24% sensitivity, likelihood ratio positive (LR+) 2.46 and likelihood ratio negative (LR-) 0.84. CRP was a significant baseline predictor of NLR. A significant influence of interleukin-6 on CRP was noted. CONCLUSION In contrast to the traditional markers, NLR may serve as a less expensive and effective measure of inflammation in RA. Its efficacy is comparable to that of CRP and it is not impacted by the cytokines influencing CRP and ESR.
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Affiliation(s)
| | | | | | - K R Anupama
- ChanRe Rheumatology and Immunology Centre, Bangalore, India
| | - K Renuka
- ChanRe Rheumatology and Immunology Centre, Bangalore, India
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Chandrashekara S, Shobha V, Dharmanand BG, Jois R, Kumar S, Mahendranath KM, Haridas V, Prasad S, Singh Y, Daware MA, Swamy A, Subramanian R, Somashekar SA, Shanthappa AM, Anupama KR. Comorbidities and related factors in rheumatoid arthritis patients of south India- Karnataka Rheumatoid Arthritis Comorbidity (KRAC) study. Reumatismo 2017; 69:47-58. [PMID: 28776358 DOI: 10.4081/reumatismo.2017.898] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 01/17/2017] [Accepted: 04/27/2017] [Indexed: 11/23/2022] Open
Abstract
The aim was to study the prevalence of comorbidities in rheumatoid arthritis (RA) patients in everyday clinical practice and their association with disease-specific and demographic factors. The multi-center study recruited 3,247 (at 14 centers, and 265) were excluded due to incomplete data. The number of subjects considered for the analysis was 2982. The mean (±standard deviation) age was 48.98±12.64 years and the male-to-female ratio was 1:5. The data was collected based on a pre-structured pro forma by trained clinical research associates through interview and verification of charts and reports available in the patient records. The following comorbidities were studied: cardiovascular disease, hypertension, diabetes mellitus, hypercholesterolemia, thyroid disease, psychiatric diseases like depression, and pulmonary disease. Hypertension (20.7%), diabetes mellitus (14.4%) and thyroid disease (18.3%) were the most prevalent comorbidities. Hypercholesterolemia (5.3%), pulmonary diseases (2.1%), cardiovascular diseases (0.2%) and depression (0.03%) were prevalent in ≤5% of the study population. The overall presence of comorbidity increased with age and reduced with the duration of illness prior (DOIP). The age, gender, and DOIP differed significantly between groups with and without hypercholesterolemia. Females had a statistically increased prevalence of thyroid disease. The prevalence of comorbidities in RA patients from south India is around 40% and the incidence of comorbidity increased with age. As per the literature evidence, the prevalence in the current study subjects was higher when compared to prevalence of similar diseases occurring in the general south Indian population.
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Chandrashekara S, Shobha V, Dharmanand BG, Jois R, Kumar S, Mahendranath KM, Haridas V, Prasad S, Singh Y, Daware MA, Swamy A, Subramanian R, Somashekar SA, Shanthappa AM, Anupama KR. Reduced incidence of extra-articular manifestations of RA through effective disease control: Karnataka Rheumatoid Arthritis Comorbidity (KRAC) study. Int J Rheum Dis 2016; 20:1694-1703. [DOI: 10.1111/1756-185x.12957] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S. Chandrashekara
- ChanRe Rheumatology and Immunology Center; Bangalore Karnataka India
| | - Vineeta Shobha
- St. John's Medical College Hospital; Bangalore Karnataka India
| | | | - Ramesh Jois
- Kanva Diagnostics Center; Bangalore Karnataka India
| | | | | | | | - Shiva Prasad
- Vikram Hospital Pty. Ltd.; Mysore Karnataka India
| | | | | | | | | | | | | | - K. R. Anupama
- ChanRe Rheumatology and Immunology Center; Bangalore Karnataka India
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Chandrashekara S, Shobha V, Dharmanand BG, Jois R, Kumar S, Mahendranath KM, Haridas V, Prasad S, Singh Y, Daware MA, Swamy A, Subramanian R, Somashekar SA, Shanthappa AM, Anupama KR. Factors influencing remission in rheumatoid arthritis patients: results from Karnataka rheumatoid arthritis comorbidity (
KRAC
) study. Int J Rheum Dis 2016; 21:1977-1985. [DOI: 10.1111/1756-185x.12908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - K. R. Anupama
- ChanRe Rheumatology and Immunology Center Basaweswaranagar Bangalore India
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Chandrashekara S, Rajendran A, Bai Jaganath A, Krishnamurthy R. Neutrophil-lymphocyte ratio, pain perception, and disease activity score may serve as important predictive markers for sustained remission in rheumatoid arthritis. Reumatismo 2015; 67:109-15. [PMID: 26876190 DOI: 10.4081/reumatismo.2015.838] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 12/21/2015] [Accepted: 12/27/2015] [Indexed: 11/22/2022] Open
Abstract
The implementation of new treatment strategies based on current recommendations has enabled a greater number of patients with rheumatoid arthritis (RA) to achieve remission. However, there are no definite predictors of sustained remission. Moreover, the absence of clear consensus on the time of withdrawal or reduction of treatment further adds to the treatment burden. This pilot study was intended to evaluate the prognostic potential of various RA-related parameters. All the enrolled subjects (n=124) were clinically evaluated on the basis of various parameters including age, gender, duration of illness before the initiation of disease-modifying anti-rheumatic drugs, tender and swollen joints (28 joints), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), hemoglobin percentage, lymphocyte count, total white-blood cell counts, and neutrophil to lymphocyte ratio (NLR). Student's t-test and discriminant function analysis were performed. The specificity of all parameters and their best possible cut-off to predict relapse were calculated using the receiver operating characteristic (ROC) analysis. A significant difference in terms of pain perception, NLR, tendency to have a significant tender joint count and absolute lymphocyte counts was identified between the patients in sustained remission and those in relapse. The ROC analysis indicated that NLR was consistent in predicting remission. CRP, ESR, and/or disease activity score may not be very effective in differentiating patients with sustainable remission/low disease activity. NLR along with patient's perception of pain may assist in predicting sustained remission.
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Affiliation(s)
- S Chandrashekara
- ChanRe Rheumatology and Immunology Center, Basaweswaranagar, Bangalore.
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Chandrashekara S, Patted A. Role of vitamin D supplementation in improving disease activity in rheumatoid arthritis: An exploratory study. Int J Rheum Dis 2015; 20:825-831. [PMID: 26481198 DOI: 10.1111/1756-185x.12770] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM The aim of this exploratory study is to estimate the relationship between vitamin D (vit D) deficiency and active rheumatoid arthritis (RA), and the role of supplementation in improving disease activity. METHOD A randomized recruitment, consent screening, open-label interventional study was conducted in patients who fulfilled American College of Rheumatology/European League Against Rheumatism 2010 criteria for diagnosing RA and on stable disease-modifying anti-rheumatic drugs (DMARDs) for 3 months. Serum vit D levels and Disease Activity Score of 28 joints/C-reactive protein (DAS28-CRP) disease activity status were estimated at the first visit. Subjects with low vit D levels and DAS28-CRP > 2.6 were supplemented with vit D for 12 weeks, and were assessed for improvement in disease activity and serum vit D levels. RESULTS One hundred and fifty RA patients of mean age 49 ± 12.1 years, mean duration of illness 78 ± 63 months, and on treatment with DMARDs for 44 ± 39 months were recruited for the study. Of these, 73 (49%) subjects were found to have DAS28-CRP > 2.6 and serum vit D below 20 ng/mL. The patients received vit D supplement of 60 000 IU/week for 6 weeks, followed by 60 000 IU/month for a total duration of 3 months. Disease activity and vit D status were assessed for 59 (80.8%) patients who reported at the end of 12 weeks of treatment. Mean DAS28-CRP of these patients showed a statistically significant improvement from 3.68 ± 0.93 at baseline to 3.08 ± 1.11 after supplementation (P = 0.002). Serum vit D levels improved from 10.05 ± 5.18 to 57.21 ± 24.77 ng/mL (P < 0.001) during the period. CONCLUSION Supplementation of vit D in RA patients with persisting disease activity and vit D deficiency contributed to significant improvement in disease activity within a short duration.
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Affiliation(s)
| | - Anand Patted
- ChanRe Rheumatology and Immunology Center, Bangalore, India
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Chopra A, Chandrashekara S, Iyer R, Rajasekhar L, Shetty N, Veeravalli SM, Ghosh A, Merchant M, Oak J, Londhey V, Barve A, Ramakrishnan MS, Montero E. Itolizumab in combination with methotrexate modulates active rheumatoid arthritis: safety and efficacy from a phase 2, randomized, open-label, parallel-group, dose-ranging study. Clin Rheumatol 2015; 35:1059-64. [PMID: 26050104 DOI: 10.1007/s10067-015-2988-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 05/14/2015] [Accepted: 05/30/2015] [Indexed: 11/28/2022]
Abstract
The objective of this study was to assess the safety and efficacy of itolizumab with methotrexate in active rheumatoid arthritis (RA) patients who had inadequate response to methotrexate. In this open-label, phase 2 study, 70 patients fulfilling American College of Rheumatology (ACR) criteria and negative for latent tuberculosis were randomized to four arms: 0.2, 0.4, or 0.8 mg/kg itolizumab weekly combined with oral methotrexate, and methotrexate alone (2:2:2:1). Patients were treated for 12 weeks, followed by 12 weeks of methotrexate alone during follow-up. Twelve weeks of itolizumab therapy was well tolerated. Forty-four patients reported adverse events (AEs); except for six severe AEs, all others were mild or moderate. Infusion-related reactions mainly occurred after the first infusion, and none were reported after the 11th infusion. No serum anti-itolizumab antibodies were detected. In the full analysis set, all itolizumab doses showed evidence of efficacy. At 12 weeks, 50 % of the patients achieved ACR20, and 58.3 % moderate or good 28-joint count Disease Activity Score (DAS-28) response; at week 24, these responses were seen in 22 and 31 patients. Significant improvements were seen in Short Form-36 Health Survey and Health Assessment Questionnaire Disability Index scores. Overall, itolizumab in combination with methotrexate was well tolerated and efficacious in RA for 12 weeks, with efficacy persisting for the entire 24-week evaluation period. (Clinical Trial Registry of India, http://ctri.nic.in/Clinicaltrials/login.php , CTRI/2008/091/000295).
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Affiliation(s)
- Arvind Chopra
- Department of Rheumatology, Center for Rheumatic Disease, Pune, India
| | - S Chandrashekara
- ChanRe Rheumatology and Immunology Centre and Research, Bangalore, India
| | - Rajgopalan Iyer
- Department of Orthopedics, St. John's Medical College Hospital, Bangalore, India
| | - Liza Rajasekhar
- Department of Rheumatology, Nizams institute of Medical sciences, Hyderabad, India
| | - Naresh Shetty
- Department of Orthopedics, M.S. Ramaiah Memorial Hospital, Bangalore, India
| | | | - Alakendu Ghosh
- Department of Rheumatology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Mrugank Merchant
- Department of Orthopedics, Shubhechha Multispecialty Hospital, Vadodara, India
| | - Jyotsna Oak
- Department of Rheumatology, LTM Medical College & LTMG Hospital, Mumbai, India
| | - Vikram Londhey
- Medicine Department and Rheumatology Clinic, TNMC & BYL Nair Charitable Hospital, Mumbai, India
| | - Abhijit Barve
- Research & Development, Biocon Research Limited, Bommasandra Industrial Estate - phase IV, Bangalore, 560099, India.
| | - M S Ramakrishnan
- Research & Development, Biocon Research Limited, Bommasandra Industrial Estate - phase IV, Bangalore, 560099, India
| | - Enrique Montero
- Research & Development, Biocon Research Limited, Bommasandra Industrial Estate - phase IV, Bangalore, 560099, India.,Center of Molecular Immunology, Havana, Cuba
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Kay J, Chopra A, Chandrashekara S, Olakkengil D, Bhojani K, Bhatia G, Rathi G, Thomas M, Maroli S, Thomson E, Lassen C, Shneyer L, Wyand M. AB0420 Secondary Efficacy Outcomes from a Phase 3 Study Support Clinical Equivalence Between BOW015 and Infliximab in Patients with Active Rheumatoid Arthritis on Stable Methotrexate Doses. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.4286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chandrashekara S, Anitha R, Anitha J, Renuka K. Neutrophil-lymphocyte ratio may serve as an important predictive marker for sustained rheumatoid arthritis remission. Indian Journal of Rheumatology 2014. [DOI: 10.1016/j.injr.2014.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Narone U, Chandrashekara S. The quantum on inflammation is the critical predictors of achieving remission or low disease activity in treatment naïve rheumatoid arthritis. Indian Journal of Rheumatology 2014. [DOI: 10.1016/j.injr.2014.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kay J, Chopra A, Chandrashekara S, Olakkengil D, Bhojani K, Bhatia G, Rathi G, Thomas M, Maroli S, Thomson E, Shneyer L, Wyand M. OP0012 A Phase 3, Randomized, Double-Blind, Active Comparator Study of the Efficacy and Safety of Bow015, A Biosimilar Infliximab, in Patients with Active Rheumatoid Arthritis on Stable Methotrexate Doses. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.1595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
OBJECTIVE Remission is an ideal target in the management of rheumatoid arthritis (RA). We compared American College of Rheumatology (ACR) 1981 preliminary definition of remission, European League Against Rheumatism (EULAR) disease activity score of 28 joints - C-reactive protein (DAS28 (3)-CRP) and DAS28 (3)-ESR (erythrocyte sedimentation rate) and newer ACR/EULAR remission criteria from 2011. We assessed the agreement between these definitions using kappa statistics in a real-time clinical scenario. MATERIALS AND METHODS This is a cross sectional study in which 460 patients' charts were reviewed. Their data on tender and swollen joint counts, visual analogue scale of patient global assessment (Pt GA), ESR and CRP were retrieved. One hundred patients who fulfilled one of the remission criteria and had all the required five variables were selected and they were categorized into remission using all the four definitions. RESULTS Only one case out of 100 fulfilled all four remission criteria. Among 100 cases: ACR 1981 classified six in remission; ACR/EULAR 2011, eight; DAS28 (3)-ESR, 24; and DAS28 (3)-CRP classified 100 patients in remission. A substantial number of patients continued to have features suggesting persisting active inflammation, despite being categorized into remission. A major portion of disagreement was in ESR and CRP. The value spread of all clinical parameters such as swollen joint count, tender joint count and Pt GA had no significant difference in the patients classified as being in remission. CONCLUSION The DAS28 (3)-CRP overestimated remission compared to all other criteria. Disagreement was more in laboratory inflammatory parameters. A uniform definition of remission is needed.
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Affiliation(s)
- S Chandrashekara
- ChanRe Rheumatology and Immunology Center and Research, Basaweswarnagar, Bangalore, India.
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Chandrashekara S. The treatment strategies of autoimmune disease may need a different approach from conventional protocol: a review. Indian J Pharmacol 2013; 44:665-71. [PMID: 23248391 PMCID: PMC3523489 DOI: 10.4103/0253-7613.103235] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 06/25/2012] [Accepted: 09/01/2012] [Indexed: 12/19/2022] Open
Abstract
Autoimmune disease (AD) is one of the emerging noncommunicable diseases. Remission is a possibility in AD, but current treatment strategies are not able to achieve this. We have well-established protocols for infections, oncology, metabolic diseases, and transplantation which are often used as models for the management of AD. Studies and observations suggest that in contrast to diseases used as a role model, AD has wide variability, different causative and pathogenic process, which is highly dynamic, making the current treatment strategies to fall short of expected complete remission. In this brief review, it is attempted to highlight the current understanding of AD and the probable gaps in the treatment strategies. Few hypothetical suggestions to modify the treatment protocols are presented.
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Affiliation(s)
- S Chandrashekara
- Department of Immunology and Rheumatology, NHCL, Watertank Road, Basaweswarnagar, Bangalore, Karnataka, India
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Chandrashekara S. Pharmacokinetic consideration of synthetic DMARDs in rheumatoid arthritis. Expert Opin Drug Metab Toxicol 2013; 9:969-81. [PMID: 23574578 DOI: 10.1517/17425255.2013.789499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Current treatment strategy for rheumatoid arthritis (RA) focuses on tight disease control and remission. The present understanding of the immune-pathological process of RA, mechanism of synthetic DMARDs and the clinical experience of the drugs have raised certain concerns over their clinical use. AREAS COVERED The review summarizes latest concepts in the pathogenesis of RA, and the mechanism of action and pharmacokinetics of commonly used synthetic DMARDs. It also covers the principle of enzyme and receptor kinetics, and limitation of current knowledge on RA disease measures. EXPERT OPINION There is a need to rationalize the use of synthetic DMARDs to help improve RA treatment. One recommendation to assist the rationalization of this treatment is by the construction of suitable models of the disease process, thereby augmenting treatment options. Currently, the dosage and duration of this type of treatment is based on its overall effect and clinical outcome. Each DMARD will confer its effect on a specific component of the multilevel, multicellular, pathological process of RA. Furthermore, developing definitive biomarkers could help to better assess the disease at its various stages instead of using conventional RA measures for drug titration and to help in the rationalization of drug regimen. Integrating pharmacokinetic and pharmacodynamic properties into this model will also help in improving treatment outcomes.
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Affiliation(s)
- S Chandrashekara
- ChanRe Rheumatology and Immunology Center, Department of Immunology and Rheumatology, Bangalore 560079, India.
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Chandrashekara S, Priyanka B. Remission occurs still only in minority of rheumatoid arthritis while a tight control is achievable in a routine clinical practice – A cross section study. Indian Journal of Rheumatology 2013. [DOI: 10.1016/j.injr.2012.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
The disease activity measures in rheumatoid arthritis (RA) have a lot of unmet need for current clinical demand. With available biological and aggressive disease modifying anti-rheumatic drug therapy, the goal of RA treatment has moved toward remission or at least tighter control. The current measures lose their ability to discriminate further once the patient gets into minimal disease or tight control. There are more numbers of parameters, measured to assess disease activity, like joint counts, perception scales and laboratory parameters. There are different composite scores like Disease Activity Score, American College of Rheumatology criteria and clinical disease activity index. In this review we have reviewed the evolution of and changing need for these measures. The relevance of some measures and their use and limitations with reference to various characteristics are presented. Inflammation measures to quantify the RA process is the best way to monitor RA disease activity. C-reactive protein alone or with other biomarkers to specify RA, appear to be good prospective measures.
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Affiliation(s)
- S Chandrashekara
- ChanRe Rheumatology and Immunology Center and Research, Basaweswaranagar, Bangalore, Karnataka, India.
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Suresh K, Chandrashekara S. Sample size estimation and power analysis for clinical research studies. J Hum Reprod Sci 2012; 5:7-13. [PMID: 22870008 PMCID: PMC3409926 DOI: 10.4103/0974-1208.97779] [Citation(s) in RCA: 375] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 02/16/2012] [Accepted: 03/07/2012] [Indexed: 11/04/2022] Open
Abstract
Determining the optimal sample size for a study assures an adequate power to detect statistical significance. Hence, it is a critical step in the design of a planned research protocol. Using too many participants in a study is expensive and exposes more number of subjects to procedure. Similarly, if study is underpowered, it will be statistically inconclusive and may make the whole protocol a failure. This paper covers the essentials in calculating power and sample size for a variety of applied study designs. Sample size computation for single group mean, survey type of studies, 2 group studies based on means and proportions or rates, correlation studies and for case-control for assessing the categorical outcome are presented in detail.
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Affiliation(s)
- Kp Suresh
- Department of Biostatistics, National Institute of Animal Nutrition and Physiology, Bangalore, India
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Chandrashekara S, Renuka P, Suresh K. ESR or CRP, which inflammatory measure can accurately replace clinical measures in rheumatoid arthritis? Indian Journal of Rheumatology 2012. [DOI: 10.1016/j.injr.2012.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Ambarish V, Chandrashekara S, Suresh KP. Moderate regular exercises reduce inflammatory response for physical stress. Indian J Physiol Pharmacol 2012; 56:7-14. [PMID: 23029958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Exercises induce pro-inflammatory cytokines. We assessed the effect of different grades of exercises on inflammatory cytokine response. Twenty healthy volunteers performed a single bout of moderate exercise, a single bout of strenuous exercise and one month regular moderate exercise using standardized 10m Shuttle Walk Test. Interleukin-6 (IL-6) and Tumour Necrosis Factor Alpha (TNF-alpha) were estimated by Sandwich ELISA method after each exercise regime. Statistics were run using SPSS software version 11.0, Systat software. Repeated measures ANOVA has been used for analysis of IL-6 values and Friedman test has been used for analyzing TNF-alpha and IL-6 values. Twenty healthy volunteers (18 to 30 years) were chosen for this study. The mean and SEM of plasma levels (pg/ml) of IL-6 before exercise was 10.70 +/- 1.11 pg/ml, whereas, after acute moderate exercise and acute strenuous exercise it was 12.00 +/- 1.09 pg/ml and 13.35 +/- 0.89 pg/ml respectively. interestingly, after one month of moderate exercise the values decreased to; 8.80 +/- 0.65 pg/ml. Mean and SEM of TNF-alpha before exercise was 121.78 +/- 29.06 pg/ml. With acute moderate exercise and after acute strenuous exercise the values were 132.90 +/- 35.75 pg/ml and 112.05 +/- 29.89 pg/ml respectively. After one month moderate exercise the levels decreased to 94.95 +/- 27.29 pg/ml. The observed changes in both IL-6 and TNF-alpha levels before and after both moderate and strenuous exercise were statistically significant. Although there was a slight decrease in the value of both the cytokines after one month of regular moderate exercise compared to baseline value, the difference in the values was not statistically significant. However, both IL-6 and TNF-alpha levels showed overall statistically significant difference among the different grades of exercise. Plasma IL-6 and TNF-alpha increase with acute moderate exercise and IL-6 increases further with acute strenuous exercise. Their levels tend to fall below baseline with one month of regular moderate exercise indicating that regular moderate exercise has beneficial effects.
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Affiliation(s)
- V Ambarish
- Department of Physiology, M.S. Ramaiah Medical College, Bangalore, India
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Rao RM, Nagendra HR, Raghuram N, Vinay C, Chandrashekara S, Gopinath KS, Srinath BS. Influence of yoga on mood states, distress, quality of life and immune outcomes in early stage breast cancer patients undergoing surgery. Int J Yoga 2011; 1:11-20. [PMID: 21829279 PMCID: PMC3144603 DOI: 10.4103/0973-6131.36789] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Context: Breast cancer patients awaiting surgery experience heightened distress that could affect postoperative outcomes. Aims: The aim of our study was to evaluate the effects of yoga intervention on mood states, treatment-related symptoms, quality of life and immune outcomes in breast cancer patients undergoing surgery. Settings and Design: Ninety-eight recently diagnosed stage II and III breast cancer patients were recruited for a randomized controlled trial comparing the effects of a yoga program with supportive therapy plus exercise rehabilitation on postoperative outcomes following surgery. Materials and Methods: Subjects were assessed prior to surgery and four weeks thereafter. Psychometric instruments were used to assess self-reported anxiety, depression, treatment-related distress and quality of life. Blood samples were collected for enumeration of T lymphocyte subsets (CD4 %, CD8 % and natural killer (NK) cell % counts) and serum immunoglobulins (IgG, IgA and IgM). Statistical Analysis Used: We used analysis of covariance to compare interventions postoperatively. Results: Sixty-nine patients contributed data to the current analysis (yoga n = 33, control n = 36). The results suggest a significant decrease in the state (P = 0.04) and trait (P = 0.004) of anxiety, depression (P = 0.01), symptom severity (P = 0.01), distress (P < 0.01) and improvement in quality of life (P = 0.01) in the yoga group as compared to the controls. There was also a significantly lesser decrease in CD 56% (P = 0.02) and lower levels of serum IgA (P = 0.001) in the yoga group as compared to controls following surgery. Conclusions: The results suggest possible benefits for yoga in reducing postoperative distress and preventing immune suppression following surgery.
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Rao RM, Nagendra HR, Raghuram N, Vinay C, Chandrashekara S, Gopinath KS, Srinath BS. Influence of yoga on postoperative outcomes and wound healing in early operable breast cancer patients undergoing surgery. Int J Yoga 2011; 1:33-41. [PMID: 21829282 PMCID: PMC3144607 DOI: 10.4103/0973-6131.36795] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Pre- and postoperative distress in breast cancer patients can cause complications and delay recovery from surgery. OBJECTIVE The aim of our study was to evaluate the effects of yoga intervention on postoperative outcomes and wound healing in early operable breast cancer patients undergoing surgery. METHODS Ninety-eight recently diagnosed stage II and III breast cancer patients were recruited in a randomized controlled trial comparing the effects of a yoga program with supportive therapy and exercise rehabilitation on postoperative outcomes and wound healing following surgery. Subjects were assessed at the baseline prior to surgery and four weeks later. Sociodemographic, clinical and investigative notes were ascertained in the beginning of the study. Blood samples were collected for estimation of plasma cytokines-soluble Interleukin (IL)-2 receptor (IL-2R), tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma. Postoperative outcomes such as the duration of hospital stay and drain retention, time of suture removal and postoperative complications were ascertained. We used independent samples t test and nonparametric Mann Whitney U tests to compare groups for postoperative outcomes and plasma cytokines. Regression analysis was done to determine predictors for postoperative outcomes. RESULTS Sixty-nine patients contributed data to the current analysis (yoga: n = 33, control: n = 36). The results suggest a significant decrease in the duration of hospital stay (P = 0.003), days of drain retention (P = 0.001) and days for suture removal (P = 0.03) in the yoga group as compared to the controls. There was also a significant decrease in plasma TNF alpha levels following surgery in the yoga group (P < 0.001), as compared to the controls. Regression analysis on postoperative outcomes showed that the yoga intervention affected the duration of drain retention and hospital stay as well as TNF alpha levels. CONCLUSION The results suggest possible benefits of yoga in reducing postoperative complications in breast cancer patients.
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Arun MS, Chandrashekara S, Suresh KP. O8 Change in pain pressure threshold reflects disease activity but does not correlate to inflammatory parameter in rheumatoid arthritis. Indian Journal of Rheumatology 2011. [DOI: 10.1016/s0973-3698(11)60097-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Chandrashekara S, Daniel N, Rani DP, Sahoo JK, Suresh KP. P72 C-reactive protein normal level—a systematic meta-analysis. Indian Journal of Rheumatology 2011. [DOI: 10.1016/s0973-3698(11)60182-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Chandrashekara S, Priyanka BU. P9 Remission occurs still only in minority while a tight control is achievable. Indian Journal of Rheumatology 2011. [DOI: 10.1016/s0973-3698(11)60119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Shashikumar NS, Shivamurthy MC, Chandrashekara S. Evaluation of efficacy of combination of methotrexate and hydroxychloroquine with leflunomide in active rheumatoid arthritis. Indian J Pharmacol 2011; 42:358-61. [PMID: 21189905 PMCID: PMC2991692 DOI: 10.4103/0253-7613.71916] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 07/15/2010] [Accepted: 08/05/2010] [Indexed: 11/04/2022] Open
Abstract
Background: Several new drugs for rheumatoid arthritis are available including leflunomide. Comparative studies of treatment with leflunomide (against methotrexate) report a better quality of life. Aim: This study was designed to evaluate the efficacy of combination of methotrexate and hydroxychloroquine with leflunomide, a new disease modifying antirheumatoid drug. Analysis was of intent to treat group. Materials and Methods: This was an open labeled, randomized, comparative clinical trial in the department of rheumatology and immunology, at a tertiary care center in Bangalore. Patients who have diagnosed with rheumatoid arthritis as per American College of Rheumatology aged between 18 and 60 years were recruited and randomized to receive leflunomide (10 mg/day p.o.) or a combination of methotrexate and hydroxychloroquine (7.5 mg/week p.o. and 200 mg/day p.o., respectively) along with folate supplementation for 12 weeks. The European League Against Rheumatism criteria of improvement according to disease activity score 28 was considered as the primary efficacy variable. Baseline and end of study values were evaluated. The duration of the study period was 1 year. Analysis of variance (ANOVA) and Wilcoxon Signed rank test were used for statistical analysis. Results: After 12 weeks, improvement noted in patients treated with leflunomide was similar to those treated with a combination of methotrexate and hydroxychloroquine. There was no statistical significance in improvement in disease activity between the two groups (P = 0.377). Conclusion: Combination of methotrexate and hydroxychloroquine is equivalent to leflunomide in terms of efficacy in reducing disease activity in the initial treatment of severe rheumatoid arthritis.
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Affiliation(s)
- N S Shashikumar
- Department of Pharmacology, Mandya Institute of Medical Sciences, Mandya, India
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Chandrashekara S, Keerthi, Renuka P, Suresh KP. P28 ESR or corrected ESR—factors influencing in a routine measures. Indian Journal of Rheumatology 2010. [DOI: 10.1016/s0973-3698(10)60643-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Chandrashekara S, Suresh KP, Renuka. P21 ESR or CRP, which inflammatory measure is accurate in rheumatoid arthritis? Indian Journal of Rheumatology 2010. [DOI: 10.1016/s0973-3698(10)60636-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Haridas V, Chandrashekara S, Dharmanand BG, Gore S, Gore V, Hubli. P80 Spondyloepiphyseal dysplasia mimiking juvenile rheumatoid arthritis. Indian Journal of Rheumatology 2009. [DOI: 10.1016/s0973-3698(09)60098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Gopinath KS, Raghavendra RM, Acree M, Nalini R, Srinath SB, Ajaikumar BS, Chandrashekara S. Impact of T status and its concerns on NK cell counts in operable breast cancer patients before primary treatment: A cross sectional study. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.22218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Kumar V, Chandrashekara S. P37 Unusual presentation of 2 cases of homocystinaemia in musculoskeletal diseases clinic. Indian Journal of Rheumatology 2007. [DOI: 10.1016/s0973-3698(10)60364-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Chandrashekara S, Vikram H, Sachin S, Suhas S, Kumar KV, Nandakumar BS. O1 Rheumatoid factor and Anti-CCP in rheumatoid arthritis. Indian Journal of Rheumatology 2007. [DOI: 10.1016/s0973-3698(10)60316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Vijayadas, Roopakala MS, Reddy KK, Chandrashekara S. P31 Visual analogue scale over represent pain in comparison to pressure pain threshold in both fibromyalgia and in normal subjects. Indian Journal of Rheumatology 2007. [DOI: 10.1016/s0973-3698(10)60358-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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