Aim: To study the clinical efficacy and adverse events of weekly single dose of leflunomide in patients with refractory rheumatoid arthritis in comparison with conventional daily regimen. Methods: Patients with refractory rheumatoid arthritis were taken up for the study; 91 patients were enlisted of whom 3 became non-compliant and were excluded. A concurrent parallel study was designed with the patients divided into two groups and efficacy and adverse events recorded at third and sixth months. Results: A total of 88 patients were included in the study and were divided into two groups. At the end of 6 months, in the daily group 37 (82.2%) out of 45 patients had disease activity score (DAS) less than 3.2 indicating a low disease activity and 8 patients (17.8%) had moderate disease activity. None had high disease activity. In the weekly group, 36 (83.7%) out of 43 patients had low disease activity and 7 (16.3%) had moderate disease. None had high disease activity. Four (8.9%) patients developed adverse reactions in the daily group. One patient (2.2%) had alopecia and the other (2.2%) had diarrhoea and were withdrawn from the study. Two (4.4%) patients had elevated liver enzymes and the drug was stopped at 6 months. None in the weekly group reported any adverse events. Conclusions: Weekly regimen was found to be better in terms of compliance and had a lower adverse effect profile. The result was statistically significant. Clinical efficacy of weekly therapy was found to be similar to that of conventional therapy in terms of DAS.

Objectives: To evaluate the long-term clinical response to infliximab in patients with inflammatory arthritis and to document any undesirable effects on follow-up. Methods: This study was conducted in Command Hospital (Eastern Command) between June 2002 and May 2006. Cases of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA) and juvenile idiopathic arthritis (JIA) who received infliximab after screening for tuberculosis and concurrent infections were followed up for a minimum period of 2 years after therapy. Infliximab was administered at a dose of 3 mg/kg for RA and JIA, and 5 mg/kg for spondyloarthropathy (SpA) at 0, 2 and 6 weeks. Few patients received additional 8 weekly doses. Twelve patients with AS received only 3 mg/kg dose at 8-12 week intervals due to shortage of drug. Disease modifying antirheumatic drugs were continued in all. Monthly follow-up was done to assess the disease activity and document any adverse effects. Results: There were 52 patients in total (32 males, 20 females). Of these, 18 had RA, 27 had AS, 4 had JIA and 1 had PsA. All except two showed subjective improvement lasting 6 weeks to 7 months. Adverse effects during infusion and in the immediate post-infusion period were few and not clinically significant. One patient had hypersensitivity reaction following the second dose. However, seven cases of tuberculosis (14%) occurred in the follow-up period from 6 weeks to 1 year after the commencement of infliximab therapy. All patients responded to 6 months of antitu- berculosis treatment. Two years after the last dose of infliximab, all patients had active arthritis and four patients had to undergo total hip replacement during that period. Conclusions: Anti-TNF-α (tumour necrosis factor-α) agent infliximab is effective in the management of inflamma- tory arthritis but the improvement can be sustained only by continuing its administration at intervals of 8-20 weeks. In our country, its long-term use may be limited by the high incidence of tuberculosis as shown in our study (14%). Close monitoring for tuberculosis is essential.

Vasculitis is characterized by inflammation of the wall of blood vessels. It involves immunologically mediated responses to usually unknown antigens, which result in vessel wall damage. Weakening of the vessel wall can lead to aneurysms, dissections or bleeding and narrowing of the lumen (caused by vasculitis per se and complicating thrombosis and embolization) resulting in ischemic damage and necrosis of the affected end organs and tissues. The first part of this four-part review describes the red flags and stop signs, which could help the busy doctor to stop and to start to think of the possibility of vasculitis. This is particularly important as many of these syndromes are life- threatening and hence their diagnostics can be compared to "a rheumatologic treasure hunt" as the treasured life of the patient is often at stake. Everything starts with simple measures, namely taking the patient history and conduct- ing a complete physical examination. This is often enough for the identification of triggering factors as causes as well as targets of therapy in secondary vasculitides. They are often also enough for the right diagnosis, which only needs to be confirmed, perhaps by specialists, with more elaborate and expensive methodology.

Osteomalacia is a metabolic bone disease frequently seen by rheumatologists. The primary defect in this disorder lies in inadequate mineralization of normally formed osteoid leading to soft bones, which are easily deformed. The common cause is vitamin D deficiency due to inadequate exposure to sunlight, malabsorption, intake of drugs like phenytoin and chronic renal and hepatic disease. The exact prevalence of this disease is not known. However, vitamin D defi- ciency has been shown to be extremely common in Indians. Certain groups like adolescents, elderly, pregnant and lactating women and those confined indoors, are more prone to develop osteomalacia. Osteomalacia usually pres- ents with generalized bone pain, proximal muscle weakness and non-specific constitutional features. It is often con- fused with hypothyroidism, inflammatory myopathies, multiple myeloma and even arthritis. The gold standard of diagnosis, bone biopsy, is rarely performed. Diagnosis rests on a combination of clinical, laboratory (elevated alkaline phosphatase, low serum calcium) and radiological findings (diffuse demineralization, Looser's zones). With early institution of treatment with vitamin D and calcium, most patients recover in 3-6 months. Diet is a very poor source of vitamin D. Increased exposure to sunlight and supplementation of vitamin D in susceptible populations are impor- tant measures to prevent osteomalacia.

Interstitial lung disease (ILD) is now the major cause of mortality in patients with systemic sclerosis (scleroderma) after dramatic reduction in death caused by scleroderma renal crisis, because of the regular use of angiotensin- converting enzyme inhibitors. Treatment of ILD in scleroderma has been somewhat haphazard and treatment protocol often been borrowed from the experience gained from treating ILD of unknown aetiology. The purpose of this review is to outline recent advances and current concepts regarding the management of these ILDs.