Indonesian Journal of Rheumatology
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Efficacy and Safety of Low-Dose Cyclophosphamide vs Mycophenolatemofetil in Patients with Lupus Nephritis: A Systemic Review andMeta-Analysis
Get PDFBackground: Lupus Nephritis is still the most leading cause of morbidityand mortality in SLE (Systemic Lupus Erythematosus). Low-dose CYC(Cyclophosphamide) regimen was effective and had a higher safety profilethan standard CYC regimen. MMF (Mycophenolate Mofetil), a selectivelymphocyte antiproliferative agent, has been shown in several studies to bea safe and effective substitute to full dose CYC. The objective of this metaanalysis
was to compare the efficacy and safety of these low-dose CYC vsMMF subjects with LN (Lupus Nephritis). Methods: The authorssystematically searched CENTRAL, PubMed, and ScienceDirect from 2009to early 2024. Studies enrolled RCT (Randomized Controlled Trial), in whichpatients diagnosed with lupus nephritis were treated with low-doseintravenous CYC or oral MMF. Results: A total of 6 trials, including 787patients, were included in this meta-analysis. The analysis showed there isno different between low dose-CYC MMF and MMF. (RR 0.96 95% CI [0.96,1.27], p = 0.76, Tau2 = 0.00, Chi2 = 0.07, df =1 and I2 = 0%, p = 0.79).Conclusion: No significant difference was observed between the twotreatment regimens. Oral MMF was associated in increasing vomiting andalopecia rather than low-dose CYC. Both agents demonstrated modestefficacy. However, further research is required to definitively assess therelative effectiveness and safety in a large patient cohort.
Indonesian Rheumatology Association (IRA) Recommendations for Diagnosis and Management of Systemic Sclerosis
Get PDFBackground: Systemic Sclerosis (SSc) or Scleroderma is a systemic autoimmune rheumatic disease
characterized by dysregulation of the immune system, fibrosis of the skin and visceral organs and
vasculopathy. The global prevalence of SSc reaches 17.6 per 100,000 population and the incidence
reaches 1.4 per 100,000 people per year. The prevalence and incidence of SSc in Asia reaches 6.8
per 100,000 and 0.9 per 100,000, which is lower than other continents. Women have a prevalence
and incidence of SSc five times higher than men. The prevalence and incidence of SSc depends
greatly on the results of the study. There has not been much research on the epidemiological studies
of SSc in Indonesia.
Methods: Twelve selected rheumatologists from the Indonesian Rheumatologist Association (IRA)
made recommendations based on key questions formed by a steering committee from IRA. These
recommendation materials were taken from several online databases such as PubMed, Science
Direct, and Google Scholar. Level of evidence and grades of recommendation were then assigned, and
every member of the panelist team will assign a score for level of agreement.
Results: A total of 50 recommendations that discussed the diagnosis, pharmacological and non-
pharmacological therapy, and prognosis for SSc were made.
Conclusion: These recommendations can be used to help clinicians correctly diagnose and choose
the most suitable therapy for SSc patients. All recommendation statements were created with the
consideration of Indonesia’s clinical setting, facility, and drug availability
New Onset Systemic Sclerosis-Polymyositis Overlap Syndrome FollowingSecond Dose of COVID-19 Vaccine – A Case Report
Get PDFBackground: Coronavirus 2019 has been declared as a global emergency by theWorld Health Organization. Vaccination has been shown to be crucial during theCOVID-19 pandemic. However, as global vaccination programs are implemented,a number of COVID-19 vaccine-related side effects have lately been recorded,including new-onset autoimmune disease. Overlap syndrome is a medicaldisorder in which a patient has symptoms of at least two or more autoimmuneconnective tissue diseases that meet the clinical criteria. Case Presentation: A33-years-old woman with history of Graves’ disease presented with myalgia,proximal superior and inferior extremities muscle weakness, skin thickening inface and both superior and inferior extremities following the second dose ofinactivated whole virus COVID-19 vaccine. ANA test was found to be positive withno specific antibody related to disease and there was an increase in muscleenzyme. The patient was treated with combination of mycophenolic acid,methylprednisolone, nifedipine, vit D3 and curcuma. After 4 months of treatment,patient showed clinical improvement and decrease in muscle enzymes.Conclusion: Systemic Sclerosis-Polymyositis overlap syndrome is anautoimmune connective tissue disease that is frequently encountered inconjunction with myositis. The causes of autoimmune disease are multifaceted,involving genetic, environmental factors, and overstimulation of the immuneresponses. The relationship between COVID-19 vaccination and autoimmunedisease, especially systemic sclerosis-polymyositis overlap syndrome, stillrequires further study due to lack of reported evidence.
Behcet Disease: When Laryngeal Tuberculosis Unforeseably Strikes
Get PDFBehçet disease (BD) is a chronic vasculitis that can affect all organs, particularly
the skin, mucous membranes, eyes and joints. It can lead to severe complications
requiring immunosuppressive therapy (IS). Although the prescription of IS is
indisputable and life-saving, they carry a significant risk of opportunistic
infections. Tuberculosis is an infectious disease primarily caused by the bacterium
Mycobacterium tuberculosis, also known as Koch\u27s bacillus. It predominantly
affects the lungs due to airborne transmission and favorable conditions for the
bacillus\u27s survival in this area; however, it can also affect other sites to a lesser
extent, such as the brain, bones, skin and « ear, nose and throat » (ENT) regions.
Laryngeal tuberculosis (LT) is a rare and underdiagnosed localization that often
occurs in immunocompromised patients. This article reports the case of a patient
with BD under IS who developed LT secondary to subclinical pulmonary
tuberculosis. The outcome after discontinuing azathioprine and initiating
antituberculous treatment was favorable. The case report aims to shed light on
the rare and underrecognized presentation of tuberculosis in BD and in case of
immune vulnerability, unraveling the intricate interplay between
immunosuppression and opportunistic infections. Its significance lies in
underscoring the critical need for heightened clinical vigilance, as LT can
masquerade as BD-related manifestations, posing diagnostic dilemmas
Early Detection Of Thalassemia Carrier In Patients With SystemicLupus Erythematous: The Use of Shine and Lal Index
Get PDFBackground: Anemia in systemic lupus erythematous (SLE) is common due toimpaired erythropoietin response and the presence of antibodies that attackerythropoietin. Various anemia in SLE include autoimmune hemolytic anemia (AIHA),anemia of chronic disease (ACD), or iron deficiency anemia (IDA). Interestingly,Indonesia lies in thalassemia belt area and it is estimated to harboring around 6-10%thalassemia carrier in its population. Therefore, anemia in SLE patients should befurther examined for its possibility for thalassemia carrier. This study aimed todetermine whether a simple erythrocyte index could be used for thalassemia carrierearly detection of SLE patients living in Indonesia. Methods: This study had aretrospective and cross-sectional design, collecting hematology data of SLE patientsregistered at Dr. Hasan Sadikin General Hospital. Erythrocyte indices, includingMentzer index (MCV/RBC) and Shine & Lal index (MCV.MCH.MCH/100), wereassessed to determine IDA or thalassemia carrier. Results: Of 259 hematology datafrom SLE patients included, predominantly female (95.8%), aged 34 years old (median;range 17-65 years) and single (27%), of whom 45.2% had anemia. However, most ofthem were anemia normocytic or normochromic. Interestingly, Mentzer index (<13) wasfound in 2.7% and Shine & Lal index (<1530) in 10% patients, suggesting considerthalassemia carrier. Conclusion: Although Shine & Lal index has lower sensitivitycompared with Mentzer index, Shine & Lal Index might serve a broader screening toolas an early detection for thalassemia carrier.
Patients with Sjogren\u27s Syndrome and Depression Who Got MenometrorraghiaAfter Receiving Antidepressant
No full textBackground: Sjogren\u27s Syndrome (SS) is a systemic autoimmune diseasethat attacks the mucous glands and other organs of the body. SS can alsomanifest in neuropsychiatric forms such as fatigue, depression, andanxiety. Case presentation: Whether the menometrorrhagia that occurs inSS patients who has depression is caused by the disease or caused by theadministration of antidepressant and which antidepressant is appropriatefor patient. The method is by searching for scientific evidence throughtrusted databases, such as PubMEd, Cochrane, Scholar, Springer andMedscape using The Boolean Operator method using keywords with filtersfor journal publications in the last 15 years, human research subjects andEnglish language. There were 6 studies that matched the clinical question.Conclusion: There is an evidence that meno/metrorrhagia in SS patientscan be caused by the disease itself and the antidepressant that were taking.It preferable to be substituted the antidepressants with less bleedingincidence such as Clomipramine, Fluvoxamine, and Mirtazapine.
The Characteristics of Septic Arthritis Patients at Dr. Kariadi Hospital Semarang
Get PDFBackground: Septic arthritis is an inflammatory disease caused by microbial infections such as
bacteria, fungi, and viruses. Late diagnosis can lead to permanent joint damage, while overdiagnosis
may result in unnecessary medical procedures. Although the incidence is relatively low, septic
arthritis remains a medical concern due to its impact on joint function and patient quality of life.
Determining the characteristics is needed to improve the diagnosis, treatment strategies, and
prognosis of septic arthritis.
Methods: This descriptive study utilized a retrospective design and was conducted on adult patients
diagnosed with septic arthritis at dr. Kariadi General Hospital, Semarang, from January 2017 to
August 2023. The analyzed variables included clinical manifestations, comorbidities, laboratory test
results, synovial fluid analysis, synovial fluid culture, and antibiotic resistance.
Results: Among the 49 patients, most were under 60 years old (67.4%) and male (61.2%). The knee
joint was the most commonly affected site (87.8%) with the main symptoms such as joint pain,
edema, and reduced range of motion (100%), along with inflammatory signs such as joint warmth
(89.9%) and redness (83.7%). Synovial fluid analysis revealed that 53.06% of patients had cloudy
and foul-smelling synovial fluid, with an average white blood cell count of 93,679.43/mm³ and a
predominance of neutrophils (80.37%). Synovial fluid culture identified Staphylococcus aureus as
the most common pathogen (34.7%), followed by Klebsiella pneumoniae (4.1%) and Salmonella sp.
(2%). Antibiotic sensitivity tests showed Ampicillin/Sulbactam as the most effective treatment, while
antibiotic resistance was observed in Gentamicin, Penicillin, and Linezolid.
Conclusion: Staphylococcus aureus is the dominant pathogen, and rising antibiotic resistance
remains a concern. Early diagnosis and targeted therapy are crucial for better patient outcomes
Evidence Based Case Report: Secukinumab versus golimumab for Ankylosing Spondylitis Patients
Get PDFBackground: Ankylosing spondylitis is a chronic inflammation of the axial spine and joints that can
lead to a wide spectrum of clinical manifestations, with chronic back pain and progressive vertebrae
stiffness being two hallmark symptoms. The choice of medication for ankylosing spondylitis depends
on both efficacy and cost. This study aims to compare Secukinumab, the cheapest and only available
anti-interleukin-17, against Golimumab, a TNF-alpha inhibitor, in terms of efficacy and cost.
Methods: A systematic search was conducted until October 30th, 2023, using keywords such as
ankylosing spondylitis, secukinumab, golimumab, ASAS20, and their synonyms on databases
including PubMed, Embase, SCOPUS, and Cochrane to find relevant studies. Critical appraisal of
included studies was performed using the Oxford Center of Evidence-based Medicine (CEBM) tools
for harm scenarios.
Results: Three eligible articles were collected, observing both Secukinumab and Golimumab with
different doses and administration routes. Chen et al.\u27s comparative analysis between secukinumab
150 mg and golimumab 50 mg revealed an odds ratio (OR) (95% confidence interval (CI)) of 1.19
(0.03-8.94), while secukinumab 150 mg against golimumab 100 mg presented an OR of 1.45 (0.03-
11.98). Zhang et al.\u27s comparison results between golimumab and secukinumab yielded an OR of
0.62 (0.20-1.89). Finally, Deodhar et al. analyzed different doses of secukinumab and golimumab
with an OR range of 1.04-1.15 (0.4-3.11).
Conclusion: Both secukinumab and golimumab showed comparable results in ASAS20, exhibiting
insignificant differences in the superiority of ASAS20 improvement. However, the cost-effectiveness
and personal drug choice need to be evaluated to add further considerations to the medication choice
5 Year Survival of Systemic Lupus Erythematosus (SLE) Patients at RSCM and Predispose Factors: A Retrospective Cohort Study
Get PDFBackground: Systemic Lupus Erythematosus (SLE) is an autoimmunerheumatic disease characterized by widespread inflammation involvingalmost all organ systems. This disease attacks young women with apeak incidence aged 15-40 years. The clinical manifestations of SLEvary depending on the organs involved. The risk of death in SLEpatients increases if it is not diagnosed and treated appropriately.Methods: This study is a retrospective cohort study using medicalrecord data from patients diagnosed with SLE for the first time in 20142019
at RSCM. Survival analysis was carried out on age, gender,hemolytic anemia, thrombocytopenia, NPSLE, high anti ds-DNA, lowC3 and C4, high dose glucocorticoids, lymphopenia, positive AntiCardiolipin Antibody (ACA), cardiovascular disease, and lupusnephritis. Multivariate analysis with cox regression was carried out.Results: There were 448 subjects studied. The five-year survival of SLEpatients at RSCM is 88%. Mean survival 56 months (95% CI : 55-57).In the multivariate analysis, it was found that NPSLE [p=0,000 ; HR3,595 (95%CI 1,932-6,688)], low C3 and C4 [p=0,004 ; HR 2,501(95%CI 1,330-4,701)], cardiovascular disease [p=0,018 ; HR 2,851(95%CI 1,198-6,787)], and hemolytic anemia [p=0,023 ; HR 2,106(95%CI 1,008-4,404)] had a significant effect on patient survival.Conclusion: The 5-year survival of SLE patients was 88% withneuropsychiatric lupus (NPSLE), low C3 dan C4, cardiovasculardisease, dan hemolytic anemia have a significant effect on the SLEsurvival patients at RSCM
Indonesian Rheumatology Association (IRA) Recommendations for Diagnosis and Management of Hyperuricemia and Gouty Arthritis
Get PDFBackground: Gout is a progressive systemic disease caused by deposition of monosodium urate
(MSU) crystals in various tissues such as joints, kidneys, and other connective tissues as a result of
chronic hyperuricemia. If this condition is not adequately treated, it may progress to chronic gout,
tophus formation, and even serious kidney function problems, which will lower quality of life. With
the emergence of new treatment options in the last several years, a better understanding of diagnosis
and management is required by every physician in Indonesia.
Methods: A panel of eighteen selected rheumatologists from the Indonesian Rheumatologist
Association (IRA) developed recommendations based on key questions formulated by a steering
committee from IRA. These recommendation materials were taken from several online databases
such as PubMed, Science Direct, and Google Scholar. Level of evidence and grades of
recommendation were then assigned, and each member of the panellist team will assign a score to
express their level of agreement.
Results: A total of 16 recommendations discussing the diagnosis, non-pharmacological and
pharmacological therapies, as well as monitoring for hyperuricemia and gouty arthritis were
formulated.
Conclusion: These recommendations can be used to help clinicians in accurately diagnosing
hyperuricemia and gouty arthritis and choosing the most suitable therapy for their patients. All
recommendation statements were tailored to the clinical setting, facility, and drug availability in
Indonesia