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Therapeutic Apheresis and Dialysis 2014; 18(5):509–514 doi: 10.1111/1744-9987.12126 © 2013 The Authors Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis
Ultrasound Evaluation of the Effects of Leukocytapheresis on Rheumatoid Arthritis Shuzo Yoshida,1 Tohru Takeuchi,1 Yoichiro Maeda,2 Yuko Kimura,1 Kenichiro Hata,1 Yuri Hiramatsu,1 Takeshi Shoda,3 Shigeki Makino,1 Toshiaki Hanafusa,1 and Nobuhisa Shibahara2 1
Department of Internal Medicine (I), Osaka Medical College, Takatsuki-City, 2Blood Purification Center, and 3 Internal Medicine, Arisawa General Hospital, Hirakata, Osaka, Japan
Abstract: Leukocytapheresis (LCAP) is effective in treating rheumatoid arthritis (RA). Ultrasound (US) examination of joints is useful for evaluating disease activity and therapeutic effects in RA, but the clinical assessment of LCAP therapy with US has been little reported. We investigated the usefulness of US for evaluating the effects of LCAP in patients with RA. US examination was performed in six patients (total of seven cases) who underwent LCAP. Twenty-eight joints (bilateral shoulders, elbows, wrists, 1st to 5th metacarpophalangeal joints, 1st to 5th proximal interphalangeal joints, and knee joints) were evaluated by a systematic multiplanar grey-scale and power Doppler (PD) examination. Disease activity of RA was evaluated using the 28-joint Disease Activity Score with erythrocyte sedimentation rate (DAS28-ESR). Moderate or good responses to
LCAP based on the DAS28-ESR were observed in four of the seven cases although C-reactive protein (CRP) and ESR did not decrease. LCAP significantly reduced the mean total PD score 17.3 ± 11.6 to 13.0 ± 10.5 (P = 0.0469). The total PD score decreased in six of the seven cases, and the number of joints with PD score ≥2 decreased in five of the seven cases. The rate of decrease in the number of joints with PD score ≥2 correlated strongly with the DAS28-ESR and its components, especially swollen joint counts and evaluator’s global assessment, but not with the rate of decrease in CRP and ESR. US imaging of joints may be useful for evaluating the therapeutic effects of LCAP on RA compared to other inflammatory parameters. Key Words: Leukocytapheresis, Musculoskeletal Ultrasound, Power Doppler, Rheumatoid Arthritis, Ultrasonography.
Rheumatoid arthritis (RA) is a chronic inflammatory disease clinically characterized by synovitis and immunological abnormalities (1). The involvement of lymphocytes and macrophages plays a crucial role in the pathogenesis of RA (2). Methotrexate (MTX) is a gold-standard drug for the treatment of RA, and biologics are used in patients who are unresponsive to MTX or have high disease activity. However, these treatments cannot be used in some patients due to complications, adverse effects, and economic reasons. Leukocytapheresis (LCAP) is an apheresis therapy that removes leukocytes from the peripheral blood (3) and has been reported to be useful in RA patients,
particularly those who cannot be treated with or who are unresponsive to MTX or biologics (4,5). Composite disease activity scores such as the Disease Activity Score (DAS), Simplified Disease Activity Index, and Clinical Disease Activity Index are used to evaluate the disease activity of RA. In recent years, ultrasound (US) imaging of joints has been reported to correlate strongly with these composite disease activity scores and has attracted attention as a useful objective tool for the evaluation of disease activity and diagnosis (6), and some studies have reported on the usefulness of US for evaluating therapeutic effects of biologics (7–9). LCAP is reported to reduce the DAS and its components; however, it remains largely unknown whether it improves US findings of the joints. In this study, we performed US in RA patients treated with LCAP and evaluated the changes in US imaging and their relation with clinical and laboratory findings.
Received May 2013; revised August 2013. Address correspondence and reprint requests to Dr Shuzo Yoshida, Department of Internal Medicine (I), Osaka Medical College, Takatsuki-City, Japan. Email: [email protected]. ac.jp
509
510
S Yoshida et al. PATIENTS AND METHODS
Patients The subjects of this study were six patients with RA (a total of seven cases) who underwent LCAP in Arisawa General Hospital between April 2011 and August 2012. All patients fulfilled the 1987 American College of Rheumatology criteria for RA (10). All patients fulfilled the following inclusion criteria of this study: (i) resistance to at least two types of disease-modifying antirheumatic drugs including MTX or biologics or unable to take the previous drugs because of adverse effects; (ii) more than four tender joints and more than four swollen joints, and (iii) a 28-joint DAS with erythrocyte sedimentation rate (DAS28-ESR) of >5.1. Patients with leukopenia (WBC count
Therapeutic Apheresis and Dialysis 2014; 18(5):509–514 doi: 10.1111/1744-9987.12126 © 2013 The Authors Therapeutic Apheresis and Dialysis © 2013 International Society for Apheresis
Ultrasound Evaluation of the Effects of Leukocytapheresis on Rheumatoid Arthritis Shuzo Yoshida,1 Tohru Takeuchi,1 Yoichiro Maeda,2 Yuko Kimura,1 Kenichiro Hata,1 Yuri Hiramatsu,1 Takeshi Shoda,3 Shigeki Makino,1 Toshiaki Hanafusa,1 and Nobuhisa Shibahara2 1
Department of Internal Medicine (I), Osaka Medical College, Takatsuki-City, 2Blood Purification Center, and 3 Internal Medicine, Arisawa General Hospital, Hirakata, Osaka, Japan
Abstract: Leukocytapheresis (LCAP) is effective in treating rheumatoid arthritis (RA). Ultrasound (US) examination of joints is useful for evaluating disease activity and therapeutic effects in RA, but the clinical assessment of LCAP therapy with US has been little reported. We investigated the usefulness of US for evaluating the effects of LCAP in patients with RA. US examination was performed in six patients (total of seven cases) who underwent LCAP. Twenty-eight joints (bilateral shoulders, elbows, wrists, 1st to 5th metacarpophalangeal joints, 1st to 5th proximal interphalangeal joints, and knee joints) were evaluated by a systematic multiplanar grey-scale and power Doppler (PD) examination. Disease activity of RA was evaluated using the 28-joint Disease Activity Score with erythrocyte sedimentation rate (DAS28-ESR). Moderate or good responses to
LCAP based on the DAS28-ESR were observed in four of the seven cases although C-reactive protein (CRP) and ESR did not decrease. LCAP significantly reduced the mean total PD score 17.3 ± 11.6 to 13.0 ± 10.5 (P = 0.0469). The total PD score decreased in six of the seven cases, and the number of joints with PD score ≥2 decreased in five of the seven cases. The rate of decrease in the number of joints with PD score ≥2 correlated strongly with the DAS28-ESR and its components, especially swollen joint counts and evaluator’s global assessment, but not with the rate of decrease in CRP and ESR. US imaging of joints may be useful for evaluating the therapeutic effects of LCAP on RA compared to other inflammatory parameters. Key Words: Leukocytapheresis, Musculoskeletal Ultrasound, Power Doppler, Rheumatoid Arthritis, Ultrasonography.
Rheumatoid arthritis (RA) is a chronic inflammatory disease clinically characterized by synovitis and immunological abnormalities (1). The involvement of lymphocytes and macrophages plays a crucial role in the pathogenesis of RA (2). Methotrexate (MTX) is a gold-standard drug for the treatment of RA, and biologics are used in patients who are unresponsive to MTX or have high disease activity. However, these treatments cannot be used in some patients due to complications, adverse effects, and economic reasons. Leukocytapheresis (LCAP) is an apheresis therapy that removes leukocytes from the peripheral blood (3) and has been reported to be useful in RA patients,
particularly those who cannot be treated with or who are unresponsive to MTX or biologics (4,5). Composite disease activity scores such as the Disease Activity Score (DAS), Simplified Disease Activity Index, and Clinical Disease Activity Index are used to evaluate the disease activity of RA. In recent years, ultrasound (US) imaging of joints has been reported to correlate strongly with these composite disease activity scores and has attracted attention as a useful objective tool for the evaluation of disease activity and diagnosis (6), and some studies have reported on the usefulness of US for evaluating therapeutic effects of biologics (7–9). LCAP is reported to reduce the DAS and its components; however, it remains largely unknown whether it improves US findings of the joints. In this study, we performed US in RA patients treated with LCAP and evaluated the changes in US imaging and their relation with clinical and laboratory findings.
Received May 2013; revised August 2013. Address correspondence and reprint requests to Dr Shuzo Yoshida, Department of Internal Medicine (I), Osaka Medical College, Takatsuki-City, Japan. Email: [email protected]. ac.jp
509
510
S Yoshida et al. PATIENTS AND METHODS
Patients The subjects of this study were six patients with RA (a total of seven cases) who underwent LCAP in Arisawa General Hospital between April 2011 and August 2012. All patients fulfilled the 1987 American College of Rheumatology criteria for RA (10). All patients fulfilled the following inclusion criteria of this study: (i) resistance to at least two types of disease-modifying antirheumatic drugs including MTX or biologics or unable to take the previous drugs because of adverse effects; (ii) more than four tender joints and more than four swollen joints, and (iii) a 28-joint DAS with erythrocyte sedimentation rate (DAS28-ESR) of >5.1. Patients with leukopenia (WBC count
