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Penicillamine in ankylosing spondylitis.

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122
LETTERS
tensive Patients with Idiopathic Systemic Lupus Erythematosus,” by Michael J. Reza and coworkers (1).
Penicillamine in Ankylosing Spondylitis
1. Two of the 7 patients were black and it should be
To the Editor:
Penicillamine is a useful drug in the treatment of
rheumatoid arthritis. Recently it was used in ankylosing
spondylitis (AS) with promising results ( I ) . We report
here a patient with long-standing AS and severe peripheral arthritis who was successfully treated with penicillamine.
The 29-year-old patient was admitted to our unit
because of severe peripheral arthritis. At the age of 15
AS was diagnosed. At the age of 23 a left hip replacement was performed. Nine months before his admission,
he developed severe arthritis on the right knee and both
ankles. Treatment with several antiinflammatory drugs
was unsuccessful as were local steroid injections. Penicillamine, 250 mg daily, was started and the dose increased every 4 weeks. After 4 months of treatment
(daily dosage: 1.0 g) his condition improved, the inflammatory signs disappeared, and he could walk without difficulty. On followup of 9 months, no signs ofjoint
inflammation were noticed.
No conclusion can be drawn from a single case.
Golding stressed the influence of the drug on sacroiliitis
(1). We are not aware of other trials of penicillamine for
treating AS with peripheral arthritis. The promising results of Golding and the good response in the present
case stress the need for further trials before the role of
penicillamine in the treatment of severe peripheral arthritis in AS can be established.
noted that there are practically no well documented
cases of blacks getting hydralazine-induced lupus (2).
2. The 2 black patients had the drug for only 5 and 9
months respectively. As the authors point out and we
agree, it usually takes a longer period of exposure to
the drug to develop the SLE-like symptoms (2).
3. Acetylation rates would have been of interest here, as
it is the slow acetylators who appear t o be predisposed to develop hydralazine-SLE (3). We have
found the incidence of slow acetylators in idiopathic
SLE to be about 66% (4).Therefore at best 3 of the 5
white patients might be slow acetylators and thus
predisposed to develop the syndrome, which has an
approximate incidence of 10% in patients receiving
high doses of the drug who are white and slow
acetylators.
4. Another point to remember is that drug-induced SLE
is characterized not by antibodies to native DNA but
by an increased incidence of antibodies to DNP and
single-stranded DNA ( 5 , 6).
5 . Antibodies to single-stranded DNA were not measured in this study, and thus the data concerning complement, which is usually normal in hydralazine syndrome, and antibodies to native DNA are not
relevant to h ydralazine-induced disease.
6. All of the patients were receiving therapy and it is
well known that hydralazine SLE does respond clinically to steroids. It is therefore possible that therapy
may have masked any clinical signs of SLE produced
by the hydralazine.
REFERENCE
1. Golding DN: Abstracts VIII, European Rheumatology
Congress, Scand J Rheumatol (suppl 8)
Y. SCHARF,
M.D.
M . NAHIR,
M.D.
The B. Shine Rhewnatology Department
Rambam University Hospital
Haifa, Israel
Hydralazine Therapy in Idiopathic SLE
To the Editor:
We would like to make a few comments on the
interesting article on “Hydralazine Therapy in Hyper-
We think it is the impression of many physicians
who are responsible for the care of patients with SLE,
including ourselves, that the so-called lupus-provoking
drugs such as hydralazine, procainamide, INH, and
many of the others that are related to the occurrence of
antinuclear factors, may be used in lupus patients if
there are very specific indications and if the patients are
followed carefully. In the present state of knowledge, it
is quite possible that the population at risk from druginduced lupus is different from that at risk from idiopathic lupus in terms of etiology, pathogenetic mechanisms, genetic responses, and metabolic pathways. We
would therefore encourage the study of a larger number
of patients, employing the procedures relevant to druginduced lupus, so that the safety of such drugs in idiopathic SLE can be confirmed.
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ankylosis, penicillamine, spondylitis
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