PONE-D-23-10597Comparative Analysis of Multiorgan Toxicity Induced by Long Term Use of Disease Modifying Anti-Rheumatic DrugsPLOS ONE

Dear Dr. Mumtaz,

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We look forward to receiving your revised manuscript.

Kind regards,

Samiullah Khan, Ph. D

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear author,

Revise carefully the whole manuscript keeping in view the comments and suggestions of both reviewers. The revised version of article should be submitted accordingly.

Thanks

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Title was “Comparative Analysis of Multiorgan Toxicity Induced by Long Term Use of Disease Modifying Anti-Rheumatic Drugs”, ideally title should Indicate the study’s design with a commonly used term in the title or the abstract

Study objective is not properly specified, state specific objectives, including any pre-specified hypotheses. There is no clear statement of objective, its just mentioned “Keeping in mind the above-mentioned points, this comprehensively designed research was carried out to sort out the lowest destructive drug with great benefits for treatment of RA”

The title, objective and rationale of the study are not aligned. Rationale states “The risk to benefit ration of MTX and LEF by comparing the efficacy and toxicity of these drugs”.while title was “Comparative Analysis of Multiorgan Toxicity Induced by Long Term Use of Disease Modifying Anti-Rheumatic Drugs”.

The literature says “if data are available at no extra cost, then we may recruit multiple controls for each case. However, if it is expensive to collect exposure and outcome information from cases and controls, then the optimal ratio is 4 controls: 1 case”. On the contrary in this study number of controls was half as compared to a number of cases.

Matching is often used in case-control control studies to ensure that the cases and controls are similar in certain characteristics. However there was no matching done as it is mentioned that “50 subjects from random population as control”. Control must be matched for certain variables like sex and age while in this case no matching was done and controls were selected randomy from the general population .

The eligibility criteria, and the sources and methods of case ascertainment and control selection is not clear . There were three groups in total and matching is not group wise that makes the validity of results doubtful. The rationale for the choice of cases and controls in two groups is ambiguous . DMARDS, Methotrexate (MTX) and Leflunomide (LEF) is used interchangeably . The comparability of assessment methods is not mentioned in more than than one group. The outcomes, exposures, predictors, potential confounders, and effect modifiers are not catered for .

There is no explanation about how the study size was arrived. Data handling of quantitative variables is not explained properly. Statistical analysis lacks an explanation of how confounding subgroups and interactions are handled ,how missing data were addressed. how matching of cases and controls was addressed any sensitivity analyses. Its better to report numbers of individuals at each stage of study eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed, reasons for non-participation at each stage, consider use of a flow diagram to make it clear and explicit . In confounder-adjusted estimates and their precision (eg, 95% confidence interval) is not explained. Percentage variation is not done for control group, justification for using Mean , SEM and significance of statistical difference is not clear . Conclusion do not supports overall interpretation of results considering objectives, limitations, results from similar studies, and other relevant evidence.

Reviewer #2: Dear Editor,

The article " Comparative Analysis of Multiorgan Toxicity Induced by Long Term Use of Disease

Modifying Anti-Rheumatic Drugs" was reviewed. It is a good study. The authors describe the potential of both drugs prescribed as treatment of arthritis. I recommend the publication of manuscript after some revision.

The authors have done the good research work and their work is appreciable. But I find some of the points according to my knowledge.

I have appended below some comments that the authors may wish to consider:

it has been attached as a file review report.

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Reviewer #1: Yes: Khola Noreen

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Review Report PONE-D-23-10597.docx

PONE-D-23-10597R1Comparative Analysis of Multiorgan Toxicity Induced by Long Term Use of Disease Modifying Anti-Rheumatic DrugsPLOS ONE

Dear Dr. Mumtaz, 

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 18 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Samiullah Khan, Ph. D

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear Author,

The manuscript has been thoroughly revised but reviewer 1 suggested some valid minor corrections. The author should re-revise the manuscript and incorporate the reviewer's suggestion. The author should also include some recent relevant (2021-2023) references in the introduction as well as in the discussion section.

Thanks

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Objective: The constant use of disease modifying anti rheumatic drugs affects the functioning

of multiple organs inside the body. Some drugs are more toxic than others. The present case

control investigation was designed to evaluate the comparative toxicity of methotrexate and

leflunomide on multiple organs. in rheumatoid arthritis patients. For this purpose, 100 subjects ..............

There are few points to be consider in abstract section;

1. Reviewer wrote all of the abstract under heading of objective ....statement starting from for this purpose ....is part of methodology rather than objective...

2. Abstract is unstructured , all has been written under one heading heading

3. in abstract its mentioned "Participants of the study were categorized into three groups,1) Rheumatoid arthritis patients on methotrexate treatment, 2) Rheumatoid arthritis patients on leflunomide treatment 3) healthy subjects". (Number of participants allocated to each group must be mentioned ...there should be a clear description as how 100 cases and 50 controls were allocated into different group specially mentioning the number of each group , since its a case control study , this information is very pertinent as ratio of allocation of cases to control and for matched studies, its important to give matching criteria and the number of controls per case which is not clear even in revised manuscript .

In methodology section its mentioned " This is a case control study comprises hundred (100) subjects diagnosed with rheumatoid arthritis and fifty (50) age and sex matched healthy subjects from random population as control." even this does not describe methods of case ascertainment into each group.

4. In line 94, 95 its mentioned "chosen rheumatoid arthritis subjects were categorized into two subgroups based on oral administration of two different types of DMARDs (Group 1: methotrexate (n=50), Group 2: leflunomide (n=50) "however this statement has no mention of allocation of controls into each group.

Sample size estimation is still not done as per statistical rule , sample size calculation in statistical terms is based on determination of the required number of cases and controls is based on consideration of the strength of the relationship between the disease and exposure to the putative cause, the variability in exposure within the population under study, and the desired size and power of the statistical test, which is still missing .

Issues raised in bullet point 8 & 9 are still not described

Results: under heading of result ..line 127 , its mentioned "Overall, 80% patients (n=80) were treated with comparatively low dose (10 mg)" author should mention the potential confounding effect of variation in doses

side effects mentioned in line 138 "Both methotrexate and leflunomide had some side effects such as fatigue,

139 headache, alopecia, teeth pain, rash, dizziness, sleep problem, cough, depression, breathing

140 problem and muscle stretching" are quite vague , author should operationally define these terms and explicitly mention how these complaints were measured

in line 174 and 175 " patients have high heart rates that may be attributed to other co morbidities like obesity, insulin resistance etc" these are potential confounders which need to be control during participants recruitment phase

Reviewer #2: (No Response)

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Dr Khola Noreen

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Reviewer coments RA paper agaIN 2023.docx

Comparative Analysis of Multiorgan Toxicity Induced by Long Term Use of Disease Modifying Anti-Rheumatic Drugs

PONE-D-23-10597R2

Dear Dr. Tamseela,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Samiullah Khan, Ph. D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: