The Indian Rheumatology Association

The Professional Organization of Rheumatologists and other Health Professionals in India

Research From India

Summary of Published Articles from India
Edited by:
Dr. Avinash Jain
Dr. Padmanabha Shenoy

In case we have missed highlighting your work please send us the link on indianrheum@gmail.com. We don’t want any relevant work to go unnoticed. And we will be more than happy to have your suggestions as well.

Compiled By
CHANAKYA KODISHALA
Manchester
UK

A lot of research is coming up from India which is incredible and will definitely help in putting Indian Rheumatology on World Map. Explore India!

This section of the website brings out the latest research work published in the last three months. Besides the papers being published in various esteem journals, more than 300 abstracts were submitted to IRACON last year highlighting the amount of work being done. There are multiple multi-center projects transpiring across the country which is remarkable.

The aim of the section is not just to apprise you of the work happening in India, but to shed some light on India specific problem and possible solutions. This section has been divided into various rheumatic diseases for relatively easier reading.

For further reading, you can click on the doi in the reference section.

Inflammatory Arthritides

A.October – January 2019

Research in inflammatory arthritides in the past three months has covered a wide spectrum of areas involving basic pathogenesis, clinical aspects, therapeutic questions and epidemiology. However clinical aspects have been the major focus.

In understanding the pathogenic mechanisms in rheumatoid arthritis, Michael BR et al1 found higher levels of microparticles (MPs), platelet derived MPs and MPs other than those of platelet origin in the synovial fluid as well as peripheral blood hence suggesting their role in the pathogenesis of the disease. Also higher levels of platelet derived MPs may suggest their role in systemic involvement. Furthermore, increased levels of MPs other than those of platelet origin indicate the necessity to study the MPs from other cell lineages.

Kumar P et al2 studied the distribution of various rheumatological diseases in rural and urban areas of Lucknow, India. They used a Community Oriented Program for the Control of Rheumatic Diseases scheme in a cluster of rural (n = 5118) and urban (n = 5053) communities through a door‐to‐door survey. They found that OA knee, fibromyalgia, backache and Non Specific Pain were predominant health problems of both areas. Female preponderance was observed in all rheumatological diseases in both the areas.

Chandrashekara S et al3 studied the prevalence of remission in RA patients and the influence of different factors like literacy, socioeconomic status, presence of comorbidity and treatment strategy in achieving remission. 1990 RA patients who were recruited for the Karnataka Rheumatoid arthritis comorbidity (KRAC) study were evaluated and it was found that the prevalence of remission was around 20%. Early treatment, escalating dose of DMARDs, and patient counseling are important contributing factors for attaining remission.

Sandhu A et al4 prospectively studied 117 patients with rheumatoid arthritis who were treated with methotrexate to see if single nucleotide polymorphisms (SNPs) in folate pharmacokinetic pathway alter levels of intracellular methotrexate polyglutamates and affect response. SNPs were genotyped—rs1045642 (ABCB1 3435C>T), rs1128503 (ABCB1 1236C>T), rs10106 (FPGS 1994A>G), rs1544105 (FPGS G>A), rs11545078 (GGH 452C>T), rs3758149 (GGH -401C>T), and rs1051266 (RFC1 80G>A). They found that GGH 452C>T CC genotypewas significantly associated with response to methotrexate.GGH 452C>T CC genotype and DAS28 at baseline were independent predictors of response.None of the SNPs affected MTX-glu1–5levels.

Dekkers JS et al5 investigated the association between autoantibody status and early remission in newly diagnosed RA patients treated with MTX using real-world data. They reported 1826 patients from the METEOR database (an international observational registry) and stratified into autoantibody-positive (RF- and/or ACPA-positive) or autoantibody negative (RF- and ACPA-negative). They found that the autoantibody status was not associated with early remission in newly diagnosed RA-patients receiving MTX at 3 or 6 months and concluded that MTX is effective as an initial treatment strategy regardless of autoantibody status.

In their worldwide study Bergstra SA et al6compared consecutive disease modifying antirheumatic drug (DMARD)-treatment regimes in daily practice in patients with rheumatoid arthritis (RA) who failed on initial methotrexate, by using a multiple propensity score (PS) method to control for the spurious effects of confounding by indication. Patients with newly diagnosed RA who had failed initial treatment with methotrexate were selected from METEOR, an international observational registry. They found that patients with RA who had failed initial treatment with methotrexate monotherapy had a better DAS-response after a subsequent switch to a bDMARD-containing treatment regimen than to a regimen with csDMARD(s) only, with or without glucocorticoids.

In an assessment of hepatic fibrosis in patients with rheumatoid arthritis (n=160) on long-term (>5 years) methotrexate therapy using transient elastography (TE) Kumar A et al7 did not find severe hepatic fibrosis or cirrhosis to be common. The cumulative dose of MTX did not correlate with hepatic fibrosis as assessed by Fibroscan.

Dhaon P et al8 compared the performance of DAS28CRP, Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) composite measures to assess status of patients with RA on methotrexate, versus DAS28 CRP as the gold standard in 135 patients. They found an excellent strong positive correlation between DAS28CRP, CDAI and SDAI at initial evaluation but not at final visit. SDAI and CDAI based remission criteria seem to be better than DAS28CRP based remission criteria.

While in the spondyloarthritides, Meghnathi B et al9 reported an interesting analysis in the DESIR cohort and described the prevalence of extreme patient-reported outcomes (PRO) in an early axial spondyloarthritis setting, and compared the phenotype of patients with/without extreme PRO and also evaluated the impact of extreme PRO on the effectiveness of TNF-α blockers (TNFb). It was noted that although presence of extreme PRO in the early axSpA setting was not very frequent, patients with extreme PRO were more likely to receive a TNFb and less likely to maintain the treatment at 2 years. Further studies evaluating the specific impact of extreme PRO on TNFb treatment in axSpA are warranted

In a retrospective study of 35 Indian patients with axial spondyloarthritis (AxSpA) to analyze the effect of continuous use of Nonsteroidal anti-inflammatory drugs (NSAIDs) on their disease activity status Bhalla S et al10 found that NSAIDs were effective (31/35) in reducing ASDAS-CRP disease activity status. The efficacy of NSAIDs observed in this study was much higher than that reported in European/North American patients (only ~ 1/3rd). The reason for this difference needs further studies.

Nails were sonographically assessed in this case control study, Mondal S et al11 for nail unit structures in patients with psoriatic arthritis and their correlations with disease activity indices in 45 patients and 45 controls. They found that USG evidence of nail plate alterations was frequent among PsA patients, even in clinically normal nails. Increased mean nail bed and matrix (NMT) thickness were noted in PsA patients and mean NMT had a moderately positive correlation with NAPSI score.

Juvenile spondyloarthritis disease activity index was evaluated Zanwar A et al12 prospectively in 127 children with enthesitis-related arthritis and found that JSpADA is a valid score for measuring disease activity in enthesitis-related arthritis. Adult scores also performed well. Excluding back mobility needs to be assessed in future to improve JSpADA performance.

Harikrishnan B et al13 summarized two cases of scurvy in young children who presented with difficulty to walk and both of them were referred with a provisional diagnosis of oligoarticular juvenile idiopathic arthritis highlighting the importance for rheumatologists to have a higher index of suspicion for scurvy in children presenting with pain and difficulty to bear weight. Diagnosis of scurvy is difficult and may be missed if not suspected. Lower-extremity pain, limp, and refusal to walk are common presenting complaints of scurvy. In children with oral aversion, autism spectrum disorder and nutritional neglect with difficulty walking, scurvy should be considered in the differential diagnosis. Vitamin C supplementation with correction of underlying conditions is essential to prevent recurrence.

Malaviya A et al14 reported that the strategy of clinical screening for active Tuberculosis infection with “4S complex,” standard chest radiograph, and an augmented Mantoux testing (10 TU purified protein derivative, [PPD]) simultaneously with QuantiFERON®-TB Gold (QFTG) test for the screening of latent tuberculosis infection (LTBI) in patients with systemic inflammatory rheumatic diseases (SIRDs) treated with biological disease-modifying antirheumatic drugs (bDMARDs) was effective in identifying active TBI in patients treated with bDMARDs.

In their comment on the article by the Chang et al on characteristics of chronic chikunguniya virus related arthritis Sharma SK et al15 presented Indian data from 2016-2017 years and compared it with the Columbian cohort reported by Chang et al. Interestingly, among Indian patients with chikungunya virus, 4.2% satisfied clinical and radiologic criteria for RA, which was not reported in the Columbian cohort. Various treatment patterns have been noted in different cohorts around the world like NSAIDs, Corticosteroids, DMARDs, Anti-TNF agents with varying success rates. In the Indian patients, different treatment patterns and effectiveness were outlined and MTX was found to be most promising. They concluded that Chikungunya is an emerging global pandemic, and the high rates of chronicity postinfection are worrisome. The infection has been shown to unmask RA and even spondyloarthropathy. In absence of guidelines for treatment, further investigations into effective therapies are needed.

References

B.February 2019

Chattopadhyay A et al1 in their correspondence with the authors of ‘Low incidence of vertebral fractures in early spondyloarthritis: 5-year prospective data of the DESIR cohort’, expressed concerns that the external validity of the data remains questionable in view of high female to male ratio, lower proportion of HLA B27 positive patients, diagnostic utility of low back pain criteria used. Also, they noted the median delay in the diagnosis to be less than the previously reported studies and speculated if the described cohort was different from the usual axial spondyloarthritis patients in having higher peripheral arthritis making them recognizable sooner.

In his correspondence with the authors of ‘How to treat patients with rheumatoid arthritis when methotrexate has failed? The use of a multiple propensity score to adjust for confounding by indication in observational studies, Ahmed S2 expressed concerns regarding not utilizing ACR 20,50,70 measures to measure the outcome in the analyses and brought his views on using the propensity score (PS) in the study whether PS is a guiding star or a falling star.

Appani SK et al 3 reported an open label prospective study to evaluate the efficacy of methotrexate (MTX) in psoriatic arthritis. In a total of 73 patients, MTX initiated at ⩾15 mg/week with targeted escalation resulted in significant improvement in the skin, joint, dactylitis, enthesitis and functional domains of PsA

Dhakad U et al4 in their study measured serum sclerostin levels in rheumatoid arthritis (RA) patients and found that serum sclerostin was significantly elevated in RA patients but did not correlate with the disease activity and bone mineral density.

In an audit of the electronic records of 945 rheumatoid arthritis patients, Jadhav et al 5 found that dual antibody-positive status (RF+/ACCP+) at presentation carries poor prognosis, higher disease activity, higher HAQ score, and lesser chance of remission with conventional treatment. Patients with dual antibody negative status had the best prognosis. Although patients with discordant antibody status had an intermediate prognosis, the ones with ACCP had higher disease activity at follow-up.

References

  • Chattopadhyay A, Dhir V, Jain S. “Everything we see is a perspective, not the truth”. Ann Rheum Dis. February 2019:annrheumdis-2019-215109. doi:10.1136/annrheumdis-2019-215109.
  • Ahmed S. Metering the METEOR in methotrexate failure: is propensity score a falling star? Ann Rheum Dis. November 2018:annrheumdis-2018-214612. doi:10.1136/annrheumdis-2018-214612.
  • Appani SK, Devarasetti PK, Irlapati RVP, Rajasekhar L. Methotrexate achieves major cDAPSA response, and improvement in dactylitis and functional status in psoriatic arthritis. Rheumatology. December 2018. doi:10.1093/rheumatology/key369.
  • Dhakad U, Sahoo R, Goel A, Pradhan S, Srivastava R, Das S. Serum sclerostin levels in rheumatoid arthritis and correlation with disease activity and bone mineral density. Indian J Rheumatol. 2019;14(1):28. doi:10.4103/injr.injr_113_18.
  • Jadhav P, Avhad J, Mahajan M, et al. Dual antibody status predicts sustained remission in patients with rheumatoid arthritis. Indian J Rheumatol. 2019;14(1):32. doi:10.4103/injr.injr_107_18.

Systemic Lupus Erythematosus

A.October – January 2019

Goswami RP et al1 performed a historical head-to-head comparative efficacy study in lupus nephritis (LN) remission induction between high dose cyclophosphamide (HDCyC), low dose cyclophosphamide (LDCyC), mycophenolate mofetil (MMF) and rituximab. They found that high dose cyclophosphamide and rituximab were the most effective therapeutic strategies in patients with LN, especially in the Indian context. Rituximab was highly effective in relapsing disease.

Pilania RK et al2 reported two interesting cases of lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) associated with systemic lupus erythematosus in children and they also performed systematic review of the literature and identified 32 reported cases in the literature so far and opined that LAHPS is an uncommonly identified cause of bleeding in patients with SLE and must be suspected while evaluating these children.

Gunashekar S et al3 in their cross-sectional study compared the articular manifestations of mixed connective tissue disease (MCTD) and systemic lupus erythematosus (SLE) by clinical examination and musculoskeletal ultrasound. They found that a higher proportion of patients with MCTD had at least one swollen and tender joint as compared with patients with SLE, as well as higher use of methotrexate and NSAIDs. However, there was no difference in ultrasound detected synovitis or tenosynovitis.

In their elaborate review on oral manifestations of autoimmune connective tissue diseases Pandey A et al4 described the oral manifestations and dental considerations associated with these diseases which will allow the practitioner in holistic management of these patients. For clinicians and dentists, it is important to aware of these manifestations. When health-care professionals work together as a team, they can improve patient outcomes and quality of life.

References

B.February 2019

Reddy S et al1 reported a case of childhood lupus presenting as Guillain–Barre syndrome that partially responded to corticosteroids and IV immunoglobulins and thereafter responded to rituximab treatment with dramatic response.

Pilania R K et al2, reported a rare and interesting presentation of pediatric lupus as chylous ascites and podocytopathy.

References

  • Reddy R, Punnen A, Bella A, Kumar S. Guillain–barre syndrome as a presenting feature of systemic lupus erythematosus in a child and it’s complete resolution with rituximab treatment. Indian J Rheumatol. 2019;14(1):74. doi:10.4103/injr.injr_118_18.
  • Pilania RK, Jindal AK, Sandesh G, et al. Chylous ascites and podocytopathy as the presentation of childhood lupus—an unusual occurrence. Lupus. 2019;28(2):244-248. doi:10.1177/0961203318817831.

Idiopathic Inflammatory Myositis

A.October – January 2019

In his correspondence to the authors of the 2017 EULAR/ACR classification criteria for adult and juvenile idiopathic inflammatory myopathies and their major subgroups, Malaviya AN1 raised concern for not putting more emphasis on myositis-specific antibodies (MSAs). He reviewed the data available in the literature on these MSAs and points out that we now are able to recognize a bunch of new MSAs and each of them having a different clinical course and response to treatment. So classifying these disorders without the involvement of these MSAs could muddle the results of any drug trial. These indeed are an important concern for the ‘general rheumatologist’ to better understand this field.

References

Vasculitis

A.October – January 2019

The studies on vasculitis focused on Kawasaki disease, commentary on the cardiovascular risk in ANCA vasculitis and few interesting case reports

Gopalan K et al1 followed up 27 children of Kawasaki disease and measured their carotid intimal medial thickness (cIMT) and lipid profile at 1 and 5 years after the acute episode and found that cIMT was higher in children with KD as compared with control subjects and the lipid abnormalities were long standing and hence concluded that children with KD need careful long-term follow-up even when they do not have overt and persistent coronary artery abnormalities. It is possible that consequences of KD in childhood may impact health status of young adults several years later.

Basha A et al2 studied the profile of autoantibodies on long term follow-up of children with Kawasaki disease (KD). They found that about 22% of children tested positive for autoantibodies which being Anti nuclear antibodies (ANA), anti-thyroid microsomal antibody (TMA) or Anti neutrophil cytoplasmic antibodies (ANCA). They opined that these autoantibodies likely develop in children with KD during the acute stage and may persist for many years. There is no concrete evidence to suggest that these children are at increased risk of developing an autoimmune disease in the future. However, there is some justification for prolonged surveillance for development of autoimmune manifestations.

Guleria S et al3 reported two cases of dengue-triggered kawasaki disease.
Misra DP et al4 in their correspondence with the authors of the article Cardiovascular disease in ANCA-associated vasculitis (AAV): the danger lurking beneath the surface!, acknowledged the findings that along with traditional risk factors, higher disease activity at baseline also independently predicted cardiovascular events (CVE) and cardiovascular mortality in a large cohort of AAV and discussed these findings in the light of recent literature. They pointed out various studies to highlight the risk of CVE in AAV being no less than other rheumatologic diseases and opined that cardiovascular risk scoring systems should recognize AAV as a coronary artery disease equivalent, and consequently advocate lower targets for modifiable risk factors such as low-density lipoprotein cholesterol in such individuals.

Sharma A et al5 reported a case of novel CECR1 gene mutations causing deficiency of adenosine deaminase 2, mimicking antiphospholipid syndrome.

Bhattacharjee R et al6 reported a young male with necrotic erythema nodosum leprosum masquerading as cutaneous vasculitis.

References

B.February 2019

Gayatri E et al1 prospectively analysed the efficacy of rituximab (induction and maintenance) in patients with refractory/relapsing ANCA associated vasculitis from a tertiary care north Indian institute. In 21 patients of refractory/relapsing AAV, they found rituximab achieved sustained remission in more than three quarters of the patients making it a good agent for treatment of refractory/relapsing AAV.

In a prospective, cross-sectional study of forty Takayasu Arteritis from a south Indian tertiary care center, Devarasetti PK et a2l found that elevated Pentraxin 3 was more accurate than hsCRP and ESR in differentiating active from the inactive disease. These biomarkers may differentiate grumbling from inactive disease better than ITAS2010 or ITAS-ESR.

Santhanam S et al3 reported an interesting case of a childhood Polyarteritis nodosa (c-PAN) in 14-year-old girl presenting with extensive CNS vasculitis with severe neurological deficits and systemic symptoms like myalgia, leg ulcers, weight loss, axonal neuropathy, and proteinuria. With immunosuppressive therapy her proteinuria reduced but no major improvement in the neurological symptoms highlighting the importance of considering c-PAN in the differential diagnosis of childhood CNS vasculitis.

A rare vasculitis mimic was reported by Jain VK et al 4 in a middle aged female presenting as recurrent ulcers over the bilateral lower limbs with mononeuritis multiplex. On evaluation she was found to have Livedoid vasculopathy (skin biopsy) associated with protein S deficiency (investigations) which mimicked systemic vasculitis.

Siddharth Jain et al 5 in their correspondence with the authors of the recent article- A novel glucocorticoid-free maintenance regimen for anti-neutrophil cytoplasm antibody-associated vasculitis by Pepper et al, commented on the slight overestimation of remission rates without glucocorticoid use. They also expressed their concern regarding the occurrence of serious adverse effects comparing with the RITUXVAS study.

Vikas Sharma et al6 reported an interesting association of Kikuchi-Fujimoto disease with relapsing polychondritis in a young boy.

Chattopadhyay A et al7 in their correspondence with the authors of ‘comparison of individually tailored versus fixed-schedule rituximab regimen to maintain ANCA-associated vasculitis remission: results of a multicentre, randomised controlled, phase III trial (MAINRITSAN2)’ expressed their doubts and concerns over the relapse rates and cost-effective analyses.

References

  • Gayatri E, Dhaval T, Natasha N, et al. Rituximab in relapsed/refractory antineutrophil cytoplasmic antibody associated vasculitis: A single-center prospective observational study. Indian J Rheumatol. 2019;14(1):12. doi:10.4103/injr.injr_138_18.
  • Devarasetti P, Irlapati R, Rajasekhar L. Pentraxin 3 is better than conventional inflammatory markers for disease activity assessment in takayasu arteritis. Indian J Rheumatol. 2019;14(1):21. doi:10.4103/injr.injr_95_18.
  • Santhanam S, Thambithurai R, Palaniappan N, Vij M, Kalyanasundaram S. Childhood polyarteritis nodosa presenting as central nervous system vasculitis. Indian J Rheumatol. 2019;14(1):65. doi:10.4103/injr.injr_129_18.
  • Jain V, Hegde K, Panchagnula R. Livedoid vasculopathy with mononeuritis multiplex associated with protein S deficiency mimicking systemic vasculitis. Indian J Rheumatol. 2019;14(1):69. doi:10.4103/injr.injr_97_18.
  • Jain S, Naidu G, Dhir V, Jain S, Sharma A. Comment on: A novel glucocorticoid-free maintenance regimen for anti-neutrophil cytoplasm antibody-associated vasculitis. Rheumatology. 2018. doi:10.1093/rheumatology/key403.
  • Sharma V, Kumar M, Rastogi P, Kumar R, Sharma A, Dhir V. Kikuchi–Fujimoto disease with relapsing polychondritis. Rheumatology. January 2019. doi:10.1093/rheumatology/key449.
  • Chattopadhyay A, Acharya N, Mishra D, Sharma V, Naidu G, Sharma A. “MAINRITSAN2-the future”, with some doubts! Ann Rheum Dis. October 2018:annrheumdis-2018-214486. doi:10.1136/annrheumdis-2018-214486.

Systemic Sclerosis

A.October – January 2019

Sircar G et al1 conducted an open label, randomized, controlled trial comparing intravenous cyclophosphamide vs rituximab for the treatment of early diffuse scleroderma lung disease. Sixty patients were randomly assigned to cyclophosphamide or rituximab groups. Primary outcomes were forced vital capacity percent predicted at 6 months. Secondary outcomes were: absolute change in litres at 6 months; modified Rodnan skin scores at 6 months, 6-min walk test, Medsgers score and new onset or worsening of existing pulmonary hypertension by echocardiographic criteria. They found that found that RTX treatment at-least similar efficacy and had significantly fewer major adverse events than CYC over the study period of 6 months. And hence they concluded that RTX is a safe and effective alternative to CYC in the primary therapy of skin and lung manifestations of scleroderma.

Fingertip abnormalities in the form of digital ulcers and gangrene is well known in systemic sclerosis (SSc), but little has been described about the frequency and systemic associations of finger print (FP) abnormalities in these patients. Chanakya K et al2 in a pilot study, found that FP abnormalities occur frequently in SSc patients leading to non-recognition at various places where biometric authentication is needed. Poor FP quality was noted in SSc patients and no association was noted with digital vasculopathy. Documentation of this abnormality should allow the use of other biometric tools for personal identification.

References

Miscellaneous

A.October – January 2019

Kataria S et al1 in their review “Digital health: a new dimension in rheumatology patient care” brought out the recent advances in the field of digital health and highlighted unique features of these technologies which would help in routine care. The components could be smartphone apps, sensors, video, social media platforms or messenger platforms, wearables or a combination of these enabling healthcare delivery and overcoming the constraints of distance, location and time.Specialty specific apps, personalized patient education as per disease status, remote specialist consultations or virtual health coach to guide on lifestyle modifications are some of the developments which have been facilitated by increased digitization in all walks of life. They concluded that however, more data, efficacy and objective results are needed which would be fulfilled by ongoing observational studies, clinical trials, systematic review and meta-analysis to further establish the role of digital health in the realms of patient care.

Surendran S et al2 described the clinical, radiological features and treatment patterns in an Indian cohort of 20 children with chronic recurrent multifocal osteomyelitis (CRMO). They identified that delays in referral and diagnosis may lead to prolonged courses of antibiotics, unnecessary radiation exposure from scans and unwarranted surgical procedures including repeated bone biopsies. MRI helps in early diagnosis and can avoid both unnecessary X-rays and bone biopsies.

References

B.February 2019

The biologic prescribing patterns for various autoimmune rheumatic diseases were presented by Shobha V et al1 on behalf of the Karnataka Rheumatology Association from multiple centres across Karnataka, India. They noted that most common biologic prescribed was tumour necrosis factor antagonist etanercept, Spondyloarthropathy group of disorders were the commonest indications for prescribing biologics and clinical response being the most common reason to discontinue them. The prescribing patterns, mode of use, prebiologics screening methods, and adverse event profile were similar across centres. Pre-screening for latent tuberculosis (TB) was consistent across centres, and TB prophylaxis appeared to be effective in preventing its reactivation.

In a cross-sectional study of different rheumatic diseases and their respective co-morbidities at a tertiary care hospital in south India, Yadav BS2 et al found that 45% of patients with rheumatic diseases had some co-morbidities which tended to increase with age and body mass index. The most common amongst them were hypertension, hypothyroidism and diabetes mellitus in descending order of frequency. They emphasized that co-morbidities being common associations with rheumatic diseases, early detection of such is helpful should be an integral part of rheumatology patient care.

In their detailed review on pain management in rheumatic diseases, Goyal N et al3 elaborated the utility of other modalities apart from those controlling the inflammation like use of neuromodulators, percutaneous interventions, interventional spine procedures, platelet rich plasma therapy, ozone therapy and radiofrequency ablation for pain control.

Nallasivan S4 in his review outlined the current practices and recent advances in the management of osteoporosis. He summarized that the current evidence suggests the emergence of new anabolic drugs and biologics with the sequential approach of drug treatment to prevent fractures and improve long-term health. The development of drugs such as abaloparatide and romosozumab will add further to the therapeutic armamentarium.

Mishra D et al5 reported an interesting case of a young lady who was treated with azathioprine and developed alopecia totalis followed by myelosuppression and was detected to have a homozygous mutation in NUDT15 (C415T) but was negative for mutation in TPMT. They also reviewed various other cases reporting alopecia as a marker of azathioprine-induced myelosuppression and their genetic mutations.

Jahnavi A et al6 reported Clinical, Immunological and molecular findings in 57 patients with Severe Combined Immunodeficiency from various parts of India.

References

  • Shobha V, Rao V, Desai A, et al. Prescribing patterns and safety of biologics in immune-mediated rheumatic diseases: Karnataka biologics cohort study group experience. Indian J Rheumatol. 2019;14(1):17. doi:10.4103/injr.injr_79_18.
  • Yadav B, Roy A, Fatima S. A cross-sectional study of different rheumatic diseases and their respective comorbidities at a tertiary care hospital in India. Indian J Rheumatol. 2019;14(1):42. doi:10.4103/injr.injr_112_18.
  • Goyal N, Goyal M, Ravindran V. Management of pain in rheumatic diseases. Indian J Rheumatol. 2019;14(1):49. doi:10.4103/injr.injr_88_18.
  • Nallasivan S. Current treatment of osteoporosis. Indian J Rheumatol. 2019;14(1):57. doi:10.4103/injr.injr_74_18.
  • Mishra D, Sharma S, Sharma A, Jain S, Dhir V. Alopecia as the first manifestation of azathioprine myelosuppression in a genetically predisposed patient. Indian J Rheumatol. 2019;14(1):61. doi:10.4103/injr.injr_127_18.
  • Aluri J, Desai M, Gupta M, et al. Clinical, Immunological, and Molecular Findings in 57 Patients With Severe Combined Immunodeficiency (SCID) From India. Front Immunol. 2019;10:23. doi:10.3389/fimmu.2019.00023.