Estrogen receptor actions in colitis

In recent years, researchers have demonstrated that estrogen and its receptors, aside from their role in regulating several biological functions, contribute to the development and progression/severity of inflammatory bowel diseases (IBDs). IBDs include both ulcerative colitis (UC) and Crohn’s disease (CD). Epidemiological data indicate a clear difference in the incidence, severity, and complications of IBDs between sexes. Men present a higher risk of developing colitis than women and a higher risk of developing colorectal cancer, a common complication of this condition. However, fluctuations of estrogen levels have yielded inconsistent data, where oral contraceptives and hormone replacement therapy have been associated with an increased risk of IBDs in premenopausal women but significantly reduce disease activity after menopause. Likewise, improvement of symptoms related to CD has been reported during pregnancy, but not in UC, who often experience worsening symptoms. In the colonic epithelium, estrogen receptor β (ERβ) is the predominant form of the protein expressed, and it helps maintain normal epithelial function and organization. Preclinical data suggest that ER expression and activation via estrogen confers different responses on disease severity depending on the model used to induce colitis, which may reflect what is observed in patients with IBDs. Hence, this review aims to provide an overview of estrogen and its receptors, particularly ERβ, in the pathophysiology of IBDs.

Real-world electronic health record identifies antimalarial underprescribing in patients with lupus nephritis

Antimalarials (AMs) reduce disease activity and improve survival in patients with systemic lupus erythematosus (SLE), but studies have reported low AM prescribing frequencies. Using a real-world electronic health record cohort, we examined if patient or provider characteristics impacted AM prescribing. We identified 977 SLE cases, 94% of whom were ever prescribed an AM. Older patients and patients with SLE nephritis were less likely to be on AMs. Current age (odds ratio = 0.97, p < 0.01) and nephritis (odds ratio = 0.16, p < 0.01) were both significantly associated with ever AM use after adjustment for sex and race. Of the 244 SLE nephritis cases, only 63% were currently on AMs. SLE nephritis subjects who were currently prescribed AMs were more likely to be followed by a rheumatologist than a nephrologist and less likely to have undergone dialysis or renal transplant (both p < 0.001). Non-current versus current SLE nephritis AM users had higher serum creatinine ( p < 0.001), higher urine protein ( p = 0.05), and lower hemoglobin levels ( p < 0.01). As AMs reduce disease damage and improve survival in patients with SLE, our results demonstrate an opportunity to target future efforts to improve prescribing rates among multi-specialty providers.

Exercise and Multiple Sclerosis

The Centers for Disease Control and Prevention has stated that significant health benefits are obtainable for persons with disability who engage in physical activity, recommending 30 to 40 minutes of daily, moderately intense activity. However, persons with MS are frequently physically inactive, with findings of a 6-month activity reduction rate of 6%. This progressive lessoning of physical activity over time is a major contributor to worsening of symptoms and ancillary medical complications such as cardiovascular disease, obesity, and impaired bone health, underpinning the importance of exercise and physical activity by persons with MS. In addition to its effect on endurance and body composition, exercise may also reduce disease activity in MS. A regular exercise program combining exercise and physical activity that is tailored to the patient’s individual condition should be an important part of the plan of care for patients with MS.

Antirheumatic drugs in pregnancy and lactation

Antirheumatic drugs in pregnancy and lactation are increasingly a common clinical dilemma. With the shift towards early, aggressive control of autoimmune diseases and with the advent of newer therapeutic agents, there is a need to understand the effects of these medicines in pregnancy and lactation, on fertility in both men and women, and on the process of spermatogenesis, in order to understand the risk of teratogenesis. Although there are some limited data available for the use of antirheumatic drugs in pregnancy and lactation, much of our knowledge is derived from animal models and from limited clinical experience in human pregnancy. The balance of therapeutic benefits and risks of harm to mother and fetus should always be carefully considered: it may vary between individuals and should be assessed on a case by case basis. Because of these issues, pregnancy should always be discussed and planned in advance, in part to reduce disease activity prior to conception but also to minimize risk to the fetus. In this chapter we use the available evidence to discuss medicines which are commonly used in the treatment of rheumatological autoimmune diseases, and cover disease-modifying antirheumatic drugs (DMARDS) and biological agents.