Dear Editor,
We have read with interest the paper written by Dr. Keisuke Ono et al [1] whose title is “Reactive arthritis after COVID-19 infection” and we would like to share some medical thoughts we have concerning its content.
In this paper, a male patient was admitted with COVID-19 pneumonia. On day 21, he developed an acute bilateral arthritis in his ankles, with mild enthesitis in his right Achilles tendon; given the circumstances and having excluded all the other plausible factors that might be related with this onset, the authors stated that such elements were given by a reactive arthritis whose primer was SARS-CoV-2.
Regarding the definition of reactive arthritis (ReA), we would like to highlight some doubts and we belive that this element is contradicts the nature of ReA itself; first of all, as of today, ReA is to be given by bacterial infections only, should they be STDs-related or gastrointestinal. No viral agent has ever been either directly or indirectly linked to such element due to its pathogenesis. As Dr. Rebanta K. et al. properly stated in their papers, when ReA- associated invasive bacteria reach the systemic circulation, T lymphocytes are induced by bacterial fragments such as lipopolysaccharide and nucleic acids; These elements activate cytotoxic-T cells then attack the synovium and other self-antigens through molecular mimicry. It is believed that anti-bacterial cytokine response is also impaired in ReA, resulting in the decreased e...
Dear Editor,
We have read with interest the paper written by Dr. Keisuke Ono et al [1] whose title is “Reactive arthritis after COVID-19 infection” and we would like to share some medical thoughts we have concerning its content.
In this paper, a male patient was admitted with COVID-19 pneumonia. On day 21, he developed an acute bilateral arthritis in his ankles, with mild enthesitis in his right Achilles tendon; given the circumstances and having excluded all the other plausible factors that might be related with this onset, the authors stated that such elements were given by a reactive arthritis whose primer was SARS-CoV-2.
Regarding the definition of reactive arthritis (ReA), we would like to highlight some doubts and we belive that this element is contradicts the nature of ReA itself; first of all, as of today, ReA is to be given by bacterial infections only, should they be STDs-related or gastrointestinal. No viral agent has ever been either directly or indirectly linked to such element due to its pathogenesis. As Dr. Rebanta K. et al. properly stated in their papers, when ReA- associated invasive bacteria reach the systemic circulation, T lymphocytes are induced by bacterial fragments such as lipopolysaccharide and nucleic acids; These elements activate cytotoxic-T cells then attack the synovium and other self-antigens through molecular mimicry. It is believed that anti-bacterial cytokine response is also impaired in ReA, resulting in the decreased elimination of the bacteria. Therefore, since SARSCoV-2 is not capable of expressing nor producing bacteria-like fragments, it appears to be incompatible with ReA-inducing mechanisms. [2]
The American College of Rheumatology, as well as Dr. Selmi and colleagues, clearly support the need for bacterial agents for the diagnosis of Reactive Arthritis [3]. The clinical description of the patient (acute bilateral arthritis in his ankles, with mild enthesitis in his right Achilles tendon, without rash, conjunctivitis, or preceding diarrhoea or urethritis, HLA B27 negativity and clinical response to NSAIDs) is undoubtedly compatible with a diagnosis of viral arthritis [4] as per its criteria. Moreover It would appear that the references that Dr. Keisuke Ono et al. put at the end of the paper not support their theory; on the other hand, all the quoted papers specify the need for a bacterial infection [5].
Given these elements, in our opinion it would be better to reconsider the statement of COVID-19- induced ReA and to re-classify this case as it is supposed to b: a Viral Arthritis. We have recently published a case report with some considerations to support our thesis on SARS-COV2 viral
arthritis [6].
We believe that the debate on this topic is very important in order to standardize the definitions.
Best Regards
References
1. Ono K, Kishimoto M, Shimasaki T, et al Reactive arthritis after COVID-19 infection RMD Open 2020;6:e001350.
2. Cheeti A, Chakraborty RK, Ramphul K. Reactive Arthritis (Reiter Syndrome) [Updated
2020 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499831/
3. Selmi C, Gershwin ME. Diagnosis and classification of reactive arthritis. Autoimmun Rev.
2014 Apr-May;13(4-5):546-9. doi: 10.1016/j.autrev.2014.01.005. Epub 2014 Jan 10. PMID:
24418301.
4. Marks M, Marks JL. Viral arthritis. Clin Med (Lond). 2016;16(2):129-134.
doi:10.7861/clinmedicine.16-2-129
5. T. E. W. Feltkamp (1995) Factors Involved in the Pathogenesis of HLA-B27 Associated
Arthritis, Scandinavian Journal of Rheumatology, 24:sup101, 213-217, DOI:
10.3109/03009749509100931
6. Parisi S, Borrelli R, Bianchi S, Fusaro E. Viral arthritis and COVID-19. Lancet Rheumatol.
2020 Oct 5. doi: 10.1016/S2665-9913(20)30348-9. Epub ahead of print. PMID: 33043303;
PMCID: PMC7535796.
I read with interest the results of the C-View study (1). In the study it is reported that 17 patients (19%) were on systemic glucocorticoids in the 48-week pre-baseline period, and 6 patients (7%) used systemic glucocorticoid in the certolizumab (CZP) treatment period. The report does not elaborate on the median dose used by each of these groups of people. Adverse events are increase with increasing doses of systemic glucocorticoid and reporting these doses would be of value to help assess the results of the trial.
High doses in the pre-baseline period and low doses in the treatment period could have the effect of reducing the estimated treatment effect of CZP on acute anterior uveitis (AAU). Low doses in the pre-baseline period and high doses in the treatment period could have the opposite effect.
In addition, it was reported that five patients (6%) entered the CZP treatment period with an AAU flare. It was not reported how these patients were assessed for the outcome. Were these flares on entry assumed to be a flare in the CZP treatment period or were only new onset flares in the CZP treatment period counted towards flares in the CZP treatment period?
Philip C. Robinson
University of Queensland, Brisbane, Australia
1. van der Horst-Bruinsma I, van Bentum R, Verbraak FD, Rath T, Rosenbaum JT, Misterska-Skora M, et al. The impact of certolizumab pegol treatment on the incidence of anterior uveitis flares in patients w...
I read with interest the results of the C-View study (1). In the study it is reported that 17 patients (19%) were on systemic glucocorticoids in the 48-week pre-baseline period, and 6 patients (7%) used systemic glucocorticoid in the certolizumab (CZP) treatment period. The report does not elaborate on the median dose used by each of these groups of people. Adverse events are increase with increasing doses of systemic glucocorticoid and reporting these doses would be of value to help assess the results of the trial.
High doses in the pre-baseline period and low doses in the treatment period could have the effect of reducing the estimated treatment effect of CZP on acute anterior uveitis (AAU). Low doses in the pre-baseline period and high doses in the treatment period could have the opposite effect.
In addition, it was reported that five patients (6%) entered the CZP treatment period with an AAU flare. It was not reported how these patients were assessed for the outcome. Were these flares on entry assumed to be a flare in the CZP treatment period or were only new onset flares in the CZP treatment period counted towards flares in the CZP treatment period?
Philip C. Robinson
University of Queensland, Brisbane, Australia
1. van der Horst-Bruinsma I, van Bentum R, Verbraak FD, Rath T, Rosenbaum JT, Misterska-Skora M, et al. The impact of certolizumab pegol treatment on the incidence of anterior uveitis flares in patients with axial spondyloarthritis: 48-week interim results from C-VIEW. RMD Open. 2020;6(1).
Dear Editor,
Jean W. Liew and collaborators recently reported a systematic literature review and meta-analysis comprising the association of body mass index (BMI) on disease activity in axial spondyloarthritis (axSpA) [1]. We consider these data very interesting, as BMI is a modifiable factor. The inclusion criteria defined by the authors were based on the following issues: 1) ankylosing spondylitis, non-radiographic axSpA or all spondyloarthropathies; 2) BMI as primary exposure; 3) a validated measure of disease activity or treatment response, measured by BASDAI or ASDAS as the primary outcome. The search date was 15th December 2019. The authors selected 20 articles for full-text review but then excluded 7 articles, three for not having the primary exposure or outcome of interest, three for not reporting disease activity stratified by BMI at baseline and one for incomplete reporting results (no references provided). Finally, the authors included 13 observational studies in the qualitative analysis and 12 studies in the quantitative meta-analysis. In spite of the broad literature search strategy employed by the authors, at least one article is missed in the included studies, which may reduce the strength of the final conclusions.
Our research group published a manuscript, last February 2019 in the journal Arthritis Research and Therapy, attending this issue [2]. This reported the results of a prospective observational study including a total of 180 patients wit...
Dear Editor,
Jean W. Liew and collaborators recently reported a systematic literature review and meta-analysis comprising the association of body mass index (BMI) on disease activity in axial spondyloarthritis (axSpA) [1]. We consider these data very interesting, as BMI is a modifiable factor. The inclusion criteria defined by the authors were based on the following issues: 1) ankylosing spondylitis, non-radiographic axSpA or all spondyloarthropathies; 2) BMI as primary exposure; 3) a validated measure of disease activity or treatment response, measured by BASDAI or ASDAS as the primary outcome. The search date was 15th December 2019. The authors selected 20 articles for full-text review but then excluded 7 articles, three for not having the primary exposure or outcome of interest, three for not reporting disease activity stratified by BMI at baseline and one for incomplete reporting results (no references provided). Finally, the authors included 13 observational studies in the qualitative analysis and 12 studies in the quantitative meta-analysis. In spite of the broad literature search strategy employed by the authors, at least one article is missed in the included studies, which may reduce the strength of the final conclusions.
Our research group published a manuscript, last February 2019 in the journal Arthritis Research and Therapy, attending this issue [2]. This reported the results of a prospective observational study including a total of 180 patients with axSpA treated with TNF inhibitors (TNFi) (infliximab or adalimumab) that investigated the influence of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and BMI on clinical response to TNF inhibitors, measured by BASDAI and ASDAS. For this purpose, descriptive analysis and regression logistics models were employed considering the presence of possible interactions and confounding covariates. The presence of interactions can have important implications for the interpretation of statistical models. Therefore, when a possible interaction terms is to be considered in the regression model, this needs always to be assessed before confounding. Using an overall adjusted summary estimate is advised only if no significant interaction is present [3]. Interestingly, we found a significant interaction between BMI and DMARDs. The use of concomitant csDMARDs with TNFi increased the probability of achieving clinical response in overweight/obese axSpA patients (OR: 7.86, 95%CI: 2.39–25.78) but no association was found for normal-weight patients (OR: 1.10, 95%CI: 0.33-3.58). According to these results, we wonder whether BMI is just an independent factor of poor treatment response or if this in fact acts as an effect modifier for other factors influencing on this. In addition, disease activity at baseline stratified by BMI groups is also reported in our manuscript. Therefore, after reviewing the inclusion criteria proposed by Liew et al., we consider our work fulfilled all of them and its inclusion in the present review could contribute to reward it.
References
[1] Liew JW, Huang IJ, Louden DN, et al. Association of body mass index on disease activity in axial spondyloarthritis: systematic review and meta-analysis. RMD Open 2020;6:e001225.
[2]Hernández-Breijo B, Plasencia-Rodríguez C, Navarro-Compán V, et al. Association between concomitant csDMARDs and clinical response to TNF inhibitors in overweight patients with axial spondyloarthritis. Arthritis Res Ther. 2019;21:66.
[3] Pearce N., Greenland S. Confounding and Interaction. In: Ahrens W, Pigeot I, eds. Handbook of Epidemiology. New York, NY: Springer 2014: 659-84.
I read the article by Hua et al.1 that was published in this journal with great interest. The authors provided an excellent review of the literature regarding the clinical efficacy and toxicity of glucocorticoids (GCs) in rheumatoid arthritis (RA). The review included comprehensive discussion about the efficacy of GCs as a bridging therapy in addition to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) based on the rapid onset of action of these drugs.1 The authors advocate that because even low-doses of GCs might have adverse effects, administration of these drugs should be restricted to the lowest dose for the shortest time.1 The first part about the effectiveness of GCs was well documented and convincing; however, the second part about the safety of these drugs seemed a little less convincing. This might be attributed to the fact that a small number of studies on the safety of GCs have been published. In particular, little evidence regarding bone-related adverse effects has been presented. We have obtained very preliminary data in our hospital about the effects of GCs on bone health, including fractures and osteoporosis, and would like to contribute these as a comment.
We retrospectively reviewed the medical records of 883 patients with RA who visited our hospital in 2018. Of these, 364 patients (41.2%, Figure 1A) were prescribed GCs. At the last visits in 2018, appro...
I read the article by Hua et al.1 that was published in this journal with great interest. The authors provided an excellent review of the literature regarding the clinical efficacy and toxicity of glucocorticoids (GCs) in rheumatoid arthritis (RA). The review included comprehensive discussion about the efficacy of GCs as a bridging therapy in addition to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) based on the rapid onset of action of these drugs.1 The authors advocate that because even low-doses of GCs might have adverse effects, administration of these drugs should be restricted to the lowest dose for the shortest time.1 The first part about the effectiveness of GCs was well documented and convincing; however, the second part about the safety of these drugs seemed a little less convincing. This might be attributed to the fact that a small number of studies on the safety of GCs have been published. In particular, little evidence regarding bone-related adverse effects has been presented. We have obtained very preliminary data in our hospital about the effects of GCs on bone health, including fractures and osteoporosis, and would like to contribute these as a comment.
We retrospectively reviewed the medical records of 883 patients with RA who visited our hospital in 2018. Of these, 364 patients (41.2%, Figure 1A) were prescribed GCs. At the last visits in 2018, approximately 80% of the patients who were receiving GCs used 5 mg/day or less of GCs; the mean dosage was 4.1 mg/day (Figure 1B). Vertebral fractures were more frequently observed in patients who were receiving GCs than in those not receiving them (p = 0.028, Figure 1C). The incidence of non-vertebral fractures was the same regardless of GC use (Figure 1D). Osteoporosis, defined as <80% of the young-adult mean bone mineral density of the lumber spine or left femoral neck, was diagnosed in 195 patients (22.1%). The incidence of osteoporosis was twice as high among patients who were receiving GCs compared with those who were not receiving them (Figure 1E). The effect of GCs on osteoporosis was observed in both male and female patients (Figure 1F).
Figure is available upon request.
Patients with RA are at a high risk of fracture, and the use of GCs for more than 3 months is associated with an increased risk of vertebral fracture regardless of the dosage.2,3 Our data were very preliminary, and thus, it had several limitations. For example, we did not consider differences in patient backgrounds. However, this simplified retrospective study supports, at least in part, the concept that GCs should be used at minimal dosage and for the shortest duration possible.1
References
Hua C, Buttgereit F, Cobe B. Glucocorticoids in rheumatoid arthritis: current status and future studies. RMD Open 2020;6(1):e000536.
Xue AL, Wu SY, Jiang L, Feng AM, Guo HF, Zhao P. Bone fracture risk in patients with rheumatoid arthritis: A meta-analysis. Medicine (Baltimore) 2017;96:e6983.
Ozen G, Pedro S, Wolfe F, Michaud K. Medications associated with fracture risk in patients with rheumatoid arthritis. Ann Rheum Dis 2019;78:1041–1047.
Acknowledgments
The study protocol was approved by the Ethics Committee of the Osaki Citizen Hospital (No. 20190822-25) and performed in accordance with the Declaration of Helsinki.
Dear Editor,
Show MoreWe have read with interest the paper written by Dr. Keisuke Ono et al [1] whose title is “Reactive arthritis after COVID-19 infection” and we would like to share some medical thoughts we have concerning its content.
In this paper, a male patient was admitted with COVID-19 pneumonia. On day 21, he developed an acute bilateral arthritis in his ankles, with mild enthesitis in his right Achilles tendon; given the circumstances and having excluded all the other plausible factors that might be related with this onset, the authors stated that such elements were given by a reactive arthritis whose primer was SARS-CoV-2.
Regarding the definition of reactive arthritis (ReA), we would like to highlight some doubts and we belive that this element is contradicts the nature of ReA itself; first of all, as of today, ReA is to be given by bacterial infections only, should they be STDs-related or gastrointestinal. No viral agent has ever been either directly or indirectly linked to such element due to its pathogenesis. As Dr. Rebanta K. et al. properly stated in their papers, when ReA- associated invasive bacteria reach the systemic circulation, T lymphocytes are induced by bacterial fragments such as lipopolysaccharide and nucleic acids; These elements activate cytotoxic-T cells then attack the synovium and other self-antigens through molecular mimicry. It is believed that anti-bacterial cytokine response is also impaired in ReA, resulting in the decreased e...
Dear Editor,
I read with interest the results of the C-View study (1). In the study it is reported that 17 patients (19%) were on systemic glucocorticoids in the 48-week pre-baseline period, and 6 patients (7%) used systemic glucocorticoid in the certolizumab (CZP) treatment period. The report does not elaborate on the median dose used by each of these groups of people. Adverse events are increase with increasing doses of systemic glucocorticoid and reporting these doses would be of value to help assess the results of the trial.
High doses in the pre-baseline period and low doses in the treatment period could have the effect of reducing the estimated treatment effect of CZP on acute anterior uveitis (AAU). Low doses in the pre-baseline period and high doses in the treatment period could have the opposite effect.
In addition, it was reported that five patients (6%) entered the CZP treatment period with an AAU flare. It was not reported how these patients were assessed for the outcome. Were these flares on entry assumed to be a flare in the CZP treatment period or were only new onset flares in the CZP treatment period counted towards flares in the CZP treatment period?
Philip C. Robinson
University of Queensland, Brisbane, Australia
1. van der Horst-Bruinsma I, van Bentum R, Verbraak FD, Rath T, Rosenbaum JT, Misterska-Skora M, et al. The impact of certolizumab pegol treatment on the incidence of anterior uveitis flares in patients w...
Show MoreDear Editor,
Show MoreJean W. Liew and collaborators recently reported a systematic literature review and meta-analysis comprising the association of body mass index (BMI) on disease activity in axial spondyloarthritis (axSpA) [1]. We consider these data very interesting, as BMI is a modifiable factor. The inclusion criteria defined by the authors were based on the following issues: 1) ankylosing spondylitis, non-radiographic axSpA or all spondyloarthropathies; 2) BMI as primary exposure; 3) a validated measure of disease activity or treatment response, measured by BASDAI or ASDAS as the primary outcome. The search date was 15th December 2019. The authors selected 20 articles for full-text review but then excluded 7 articles, three for not having the primary exposure or outcome of interest, three for not reporting disease activity stratified by BMI at baseline and one for incomplete reporting results (no references provided). Finally, the authors included 13 observational studies in the qualitative analysis and 12 studies in the quantitative meta-analysis. In spite of the broad literature search strategy employed by the authors, at least one article is missed in the included studies, which may reduce the strength of the final conclusions.
Our research group published a manuscript, last February 2019 in the journal Arthritis Research and Therapy, attending this issue [2]. This reported the results of a prospective observational study including a total of 180 patients wit...
To the Editor,
I read the article by Hua et al.1 that was published in this journal with great interest. The authors provided an excellent review of the literature regarding the clinical efficacy and toxicity of glucocorticoids (GCs) in rheumatoid arthritis (RA). The review included comprehensive discussion about the efficacy of GCs as a bridging therapy in addition to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) based on the rapid onset of action of these drugs.1 The authors advocate that because even low-doses of GCs might have adverse effects, administration of these drugs should be restricted to the lowest dose for the shortest time.1 The first part about the effectiveness of GCs was well documented and convincing; however, the second part about the safety of these drugs seemed a little less convincing. This might be attributed to the fact that a small number of studies on the safety of GCs have been published. In particular, little evidence regarding bone-related adverse effects has been presented. We have obtained very preliminary data in our hospital about the effects of GCs on bone health, including fractures and osteoporosis, and would like to contribute these as a comment.
We retrospectively reviewed the medical records of 883 patients with RA who visited our hospital in 2018. Of these, 364 patients (41.2%, Figure 1A) were prescribed GCs. At the last visits in 2018, appro...
Show More