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◎ Club Rhumatismes et Inflammation (CRI：フランス)：Joint Bone Spine 72 (2005) (Suppl), pp. 49–50
通常の虫歯治療やインプラント導入状態では、必ずしもTNF阻害療法の休薬や中止は必要ないかもしれない。抜歯など感染の可能性のある処置では、休薬と抗生剤投与が薦められる。
[Usual care (caries, scaling)]
There are no data justifying discontinuation of anti-TNFa. therapy, but prophylactic antibiotics may be considered. [Dental care with a risk of infection (extraction, apical granuloma, abscess, etc.)]
Discontinuation of anti-TNFw. therapy is recommended and prophylactic antibiotics should be proposed.
[ Implants]
There is no definite indication to discontinue anti-TNFa therapy, but caution should be exercised with regard to the potential risks of infection.
○ www.australianprescriber.com/magazine/29/3/67/70/
"Minor surgery such as dental procedures does not require cessation of therapy."
? http://www.bad.org.uk/public/leaflets/etanercept.asp (British association of dermatologists)
I am planning to have an operation / dental surgery – what should I do?
Etanercept may increase your risk of getting an infection after a surgical procedure. You must tell the doctor or dentist that you are taking etanercept.
× Treatment with infliximab: Implications in oral surgery? A case report. British Journal of Oral and Maxillofacial Surgery
Volume 45, Issue 6, September 2007, Pages 507-510（英国）. レミケード使用中の外科的なextractionでmandibular osteomyelitisをきたした一例. ただし、mandibular osteomyelitisは抜歯後（抗生剤前投与やステロイドカバーをしている：under local anaesthesia and prophylactic amoxicillin 3 g orally 1 h preoperatively and hydrocortisone 50 mg intramuscularly）すぐに生じたわけではないので、著者らは抜歯の影響は少なく、レミケードのadverse eventであると考えている。
△ http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a602013.htmlでは、外科手術（歯科を含む）では担当医にエンブレルを使っていることを申告するようにと患者アドバイスを記載している。
一般にはMTXとバクタの併用は避けるべきと記載されることが多い（あるいはとても注意して併用するように）
（Kelley's Textbook of Rheumatology, 7th ed. 59章）.
Trimethoprim-sulfamethoxazole should be avoided, or used with extreme caution, because of possible hematologic toxicity with MTX.
[Thomas MH, Gutterman LA: Methotrexate toxicity in a patient receiving trimethoprim-sulfamethoxazole. J Rheumatol 1986; 13:440]
Mechanisms for this toxicity include：
① an additive antifolate effect from trimethoprim
② decreased MTX clearance due to inhibition of tubular secretion by sulfamethoxazole,
③ altered MTX plasma protein binding.
一方、メイヨーのThomas CFとLimper AHはメトトレキサート服用患者のカリニ肺炎の予防にST合剤（sulfamethoxazole-trimethoprim）を用いることは禁忌であるという考えは古いかもしれないとNEJM June 10、2487-3498, 2004に記載している(p2489)。
引用文献はLangford CAらのAm J Med 2003; 114:463-9である。この論文で、Langford CAらは週25mgのMTX投与患者（42 patients with active Wegener's granulomatosis：Use of a cyclophosphamide-induction methotrexate-maintenance regimen for the treatment of Wegener's granulomatosis: extended follow-up and rate of relapse）にST合剤予防投与を行ったが、重篤な血液障害は認められなかった（ただし、副作用対策として、葉酸は1mg/日で連日投与またはthe day after receiving MTXにロイコボリンを投与し、血算と肝機能検査は注意深くフォローされていた）
J Neuroinflammation : Published online 2008 January 9. doi: 10.1186/1742-2094-5-2.
著者等は2006年に15例程度のパイロット試験を行っているが、この論文では、Rapid clinical improvement following perispinal extrathecal administration of etanercept in the posterior neck (delivery of etanercept to the brain via the cerebrospinal venous system)を一例報告している。
◎ Seo P: Pregnancy and vasculitis. Rheum Dis Clin North Am. 2007 May;33(2):299-317（The Johns Hopkins University）.
・J Gynecol Obstet Biol Reprod (Paris). 1995;24(7):747-50.Links
[Association of Takayasu's arteritis, pregnancy and Still's disease]
◎ 妊娠中に発症したAOSDの2例（20週・22週：ともに除外診断後ステロイド治療）Pan VL, Haruyama AZ, Guberman C, Kitridou RC, Wing DA. Newly diagnosed adult-onset Still disease in pregnancy. Obstet Gynecol. 2003 May;101(5 Pt 2):1112-6（米国）
◎ PREGNANCY AND RHEUMATOID ARTHRITIS. Rheumatic Diseases Clinics of North America - Volume 23, Issue 1 (February 1997)
この1997年のレビューはRA合併妊娠に関するものであるが、AOSDについても触れている。To conclude, in all 21 pregnancies reported, no consistent pattern of the interaction between pregnancy and Still's disease emerged. Acute flares can occur during and after pregnancy, requiring high doses of salicylates or prednisone. RAのように妊娠中に軽快するという傾向はなさそうである。
◎ E. Liozon, K. Ly, Y. Aubard 1 and E. Vidal. Intravenous immunoglobulins for adult Still's disease and pregnancy. Rheumatology 1999; 38: 1024-1025（フランス）
この1999年の報告（レター）時点で、著者等は成人スチル病に合併した33妊娠（24症例）の文献報告を引用している。AOSDの治療の主流はグルココルチコイドであり、妊娠合併AOSDにも有効で比較的安全に使えると記載している。彼らの症例はhepatic toxicity of salicylates・excessive weight gain early in pregnancy（a high risk of developing diabetes gestationis）からIVIGが選択された。
その他
・Polyserositis in adult Still's disease with onset during pregnancy(一例報告） Clin Rheumatol. 1994 Sep;13(3):513-7.
・Gerald H. Stein, Bernard Cantor, Richard S. Panush, MD: Adult still's disease associated with pregnancy. Arthritis & Rheumatism Volume 23, Issue 2 , Pages 248 - 250、1980
・Adult-onset Still's disease: A case with onset during pregnancy(一例報告） Arthritis & Rheumatism Volume 28, Issue 8 , Pages 957 - 957,1985
その他
(1) Mok MY, Lo Y, Leung PY, Lau CS（香港）：Pregnancy outcome in patients with adult onset Still's disease. J Rheumatol. 2004 Nov;31(11):2307-9.
Pregnancy outcome of patients with adult onset Still's disease (AOSD) has not been addressed. We report the maternal and fetal morbidity of 5 pregnancies from 3 Chinese patients with AOSD and review another 17 pregnancies from 14 patients reported in the English literature. Nine patients had their first manifestation in the 5th to 6th gestational month. Disease relapse in patients with known AOSDoccurred most commonly in the post-partum period. Most did not respond satisfactorily to nonsteroidal antiinflammatory agents alone, but responded to administration of corticosteroids, especially in high doses.
(2) Le Loët X, Daragon A, Duval C, Thomine E, Lauret P, Humbert G.（フランス）: Adult onset Still's disease and pregnancy. J Rheumatol. 1993 Jul;20(7):1158-61.
The interactions between pregnancy and adult onset Still's disease (AOSD) are unclear. Between 1983 and 1990, 5 pregnancies occurred in 4 women with AOSD. AOSD occurred at the 5th and 6th month of the 1st pregnancy in 2 patients; a 2nd pregnancy occurring in one of them was not associated with a flare. In the other 2 patients pregnancy occurred 36 and 44 months after the AOSD; during gestation only transient arthralgia were observed in both cases. Pregnancy seems to have no effect on AOSD, and conversely, in our experience, AOSD has no influence on pregnancy, fetal growth or infant health.
(3) 成人スチル病合併妊娠の1症例 日本産科婦人科學會雜誌 Vol.48, No.6(19960601) pp. 431-434
Folate deficiency and cotrimoxazole prophylaxis during HIV infection.
Int Conf AIDS. 1993 Jun 6-11; 9: 387 OBJECTIVE: To evaluate the effect of long-term cotrimoxazole (TMP/SMX) prophylaxis on folate metabolism. METHODS: Open study concerns HIV1 seropositive adults, not supplemented with folic or folinic acid, at risk for Pneumocystis carinii pneumonia (CD4 count below 200/mm3 or < 20%), receiving since at least 3 months TMP/SMX (160 mg/800 mg twice a day) or aerosolized pentamidine (group control). Patients with initial low serum or/and erythrocyte folate level were excluded. RESULTS: Patients of the two groups (41 in TMP/SMX group, 36 in pentamidine group) were comparable for clinical features, initial CD4 count, zidovudine treatment and follow-up duration (3-26 months, mean 13). In group receiving TMP/SMX, severe folate deficiency (serum folate < 4 nmol/ml and/or erythrocyte folate < 300 nmol/ml) was observed in 15% (6 cases, all with wasting syndrome). Severe folate deficiency was not observed in pentamidine group (p < 0.05). CONCLUSION: These findings suggest that folinic acid should not be systematically added to prophylactic regimens using cotrimoxazole, except for patients with wasting syndrome.
Drug Approved. Is Disease Real? By ALEX BERENSON
NY TIMES Published: January 14, 2008
・Lyrica (Pfizer's drug pregabalin which is already a seller for seizures and diabetic nerve damages; Approved by FDA for FM in 2007 June; In November, Pfizer began a television ad campaign for Lyrica) and two other drugs (= Eli Lilly's Cymbalta and Forest Laboratories' milnacipran, both of which were originally developed as antidepressants) that may be approved this year
・Controversial; ACR, FDA and insurers recognize FM as a diagnosable disease. But doctors who are skeptical of FM think that vague complaints of chronic pain do not add up to a disease
Feng H, Shuda M, Chang Y, Moore PS. Clonal Integration of a Polyomavirus (=the seventh virus linked to human cancers) in Human Merkel Cell Carcinoma. Science 2008
They detected a fusion transcript between a previously undescribed virus T antigen and a human receptor tyrosine phosphatase in 80% of MCC vs 8-16% of controls.
Drug Has No Benefit in Trial, Makers Say By ALEX BERENSON
NY TIMES Published: January 14, 2008
New Questions on Treating Cholesterol By ALEX BERENSON
NY TIMES Published: January 17, 2008
理想的には外科手術の4週間前にアダリムマブを中止し、術後の再開は少なくとも2週間後待ち、創部に問題ないことを確認する（EULAR 2007 by Dixon et al）。
Adalimumab should ideally be stopped four weeks prior to surgery and recommenced at least two weeks post surgery or later if the wound is not closed and clean.
