Between 2007 and June 2010 June, 366 RA patients were evaluated at the Georgetown Division of Rheumatology

Between 2007 and June 2010 June, 366 RA patients were evaluated at the Georgetown Division of Rheumatology. of healing (values were always two tailed, and a hydroxychloroquine, non-biologic disease modifying antirheumatic Prkwnk1 drug, anti-tumor necrosis factor- agent Discussion The period prevalence of leg ulcers in this cohort of patients with RA was 4.37% and after RKI-1447 a mean of 22.76 months of follow-up, only 31.25% had healed. These data indicate that although ulcer prevalence has improved since the advent of more effective therapies for RA, ulcers remain an important clinical problem. Similar to other investigators [1, 3], we found that even in a center experienced in the management of autoimmune ulcers, pathologic features of vasculitis were not always evident on tissue biopsy of RA ulcers. However, this cohort of RA patients with ulcers all had radiographic evidence of erosive disease, and 63% were seropositive, suggesting that extra-articular rheumatoid disease contributes to the development of these lesions. In conjunction with the Center for Wound healing, we adopt a multidisciplinary approach to the management of complex wounds. This includes comprehensive evaluation for venous and arterial disease and RKI-1447 aggressive management of diabetes. While we found four of the 16 patients (25%) with ulcers had concomitant venous or arterial disease, these ulcers did not heal in response to vascular intervention alone. Similarly, both patients with diabetes had well-controlled hemoglobin A1c levels (6.2% and 6.9%), so the ulcers were not thought to be due purely to diabetes. Lower extremity ulcers are seen in other autoimmune diseases and have been reported to be associated with antiphospholipid antibodies and other prothrombotic states [12]. In our cohort of patients with scleroderma-associated leg ulcers, we found 50% RKI-1447 with clinically significant titers of antiphospholipid antibodies [13]. In contrast, in this group of patients with RA-associated ulcers, none had significantly elevated antiphospholipid antibody titers and frequency of genetic prothrombotic states were similar to that reported in the general population. At the time of presentation with leg ulceration, less RKI-1447 than half of the patients in this study were in clinical remission from their RA based on DAS-28 score 3.2. Concern regarding infection risk often makes clinicians hesitant about aggressive immunosuppression in such patients. Indeed, until recently, active lower extremity ulceration was considered an absolute contraindication to treatment with anti-TNF therapy in the United Kingdom [14]. The British biologics register has reported a significant increase in the rate of serious skin and soft tissue infections in patients treated with anti-TNF therapy [15], and reported an association between extra-articular manifestations of RA and increased risk of infection. In the current study, none of the 366 patients followed with RA developed ulceration resulting from infection related to anti-TNF or other DMARD therapy. One patient with an established ulcer developed a wound infection while receiving anti-TNF therapy, and as a result, the anti-TNF therapy was discontinued. This relatively low incidence of infection may again be reflective of the multidisciplinary approach to wound care in our center and we recognize that it may not be reflective of the experiences of community-based practices. One of the major limitations of this study is the small sample size. Our data show that RA-associated ulcers remain challenging to treat with less than one third healed after almost 2 years of follow-up. Based on data from the diabetic literature, in response to effective therapy, most leg ulcers will heal at a rate of 10% reduction in surface area per week [16]. Notably, in the cohort of RA patients with leg ulcers studied here, even the patients who ultimately healed had mean a time to RKI-1447 healing of 32.7 months. While the sample size was small, we did find that ulcer healing was significantly more likely to occur in patients treated with biologic anti-TNF agents, and that the.