Statin treatment for rheumatoid arthritis: a promising novel indication

The results of several cross-sectional trials suggest that patients with rheumatoid arthritis (RA) have increased vascular risk and cardiovascular mortality. It was demonstrated that inflammation plays a pivotal role in the pathogenesis of both RA and atherosclerosis. This association may explain the high incidence of cardiovascular disease in RA patients. A number of recent studies show that routine statin use in patients with RA offers considerable advantages. Statin treatment has been supported to exert a beneficial effect on disease activity, swollen joint count, endothelial dysfunction, and arterial stiffness in RA patients. These improvements are coupled with a mild to moderate improvement in plasma markers of inflammation, such as C-reactive protein and erythrocyte sedimentation rate. Statins have a satisfactory safety profile with relatively few adverse effects. In the absence of side effects and contraindications, it may be reasonable to consider statin use in selected cases, particularly in patients with a long history of active RA who are at increased cardiovascular risk.     

Thalidomide a promising new treatment for rheumatoid arthritis

In an open study, oral administration of thalidomide to 7 female patients with classic or definite rheumatoid arthritis, in doses ranging from 6.9 to 15 mg/kg/day, led to clinical improvement within several weeks. In 4 women, remission lasted long after discontinuation of the drug. All patients showed normalization or marked reduction of the erythrocyte sedimentation rate, and several showed a significant decrease in rheumatoid factor titer. Adverse side effects included drowsiness, constipation, and edema of the lower limbs, which disappeared after discontinuation of the drug.     

Thalidomide. A promising new treatment for rheumatoid arthritis

In an open study, oral administration of thalidomide to 7 female patients with classic or definite rheumatoid arthritis, in doses ranging from 6.9 to 15 mg/kg/day, led to clinical improvement within several weeks. In 4 women, remission lasted long after discontinuation of the drug. All patients showed normalization or marked reduction of the erythrocyte sedimentation rate, and several showed a significant decrease in rheumatoid factor titer. Adverse side effects included drowsiness, constipation, and edema of the lower limbs, which disappeared after discontinuation of the drug.     

Acupuncture for symptom management of rheumatoid arthritis: a pilot study

We investigated the feasibility of a future acupuncture trial in the symptom management of rheumatoid arthritis (RA). Twenty-five patients meeting the American College of Rheumatology (ACR) criteria were recruited and given 14 sessions of individualised acupuncture treatment for 6 weeks. Improvement in symptoms was assessed using ACR 20, 50 and 70; disease activity score (DAS28); tender joint count; swollen joint count; morning stiffness and health-related quality of life using the Korean Health Assessment Questionnaire and the SF-36 at baseline and after 6 weeks. Erythrocyte sedimentation rate (ESR) was also assessed. At 6 weeks, 44%, 20%, and 12% of patients achieved ACR 20, 50 and 70 responses, respectively. Acupuncture also produced statistically significant improvements in DAS28, pain and global activity, swollen joint count, health-related quality of life (SF-36) and ESR. No major acupuncture-related adverse events were reported. Acupuncture treatment as used in this pilot study was safe and well-tolerated. The use of acupuncture for symptom management in RA warrants further investigation.     

Ultrasonography in rheumatoid arthritis: a very promising method still needing more validation

PURPOSE OF REVIEW: Through recent technological advances, ultrasonography allows high-resolution visualization of inflammatory and destructive changes in the small superficial joints of hands and feet, and ultrasonography is increasingly used by rheumatologists for assessment of rheumatoid arthritis patients. It is, therefore, highly relevant to consider the validity of ultrasonographic measures of rheumatoid joint inflammation and damage. RECENT FINDINGS: Organized by type of validity, data on ultrasonography in rheumatoid arthritis are reviewed. Encouraging reports of high agreement of ultrasonographic findings between observers, with MRI and, in knee and hip joints, histopathologic assessments were recently published. New quantitative and semiquantitative evaluation methods have been suggested, and the first systematic follow-up studies suggest an ability of ultrasonography to monitor joint inflammation and damage. However, a number of essential issues are still largely unexplored, including interscanner variability, sensitivity to change, prognostic value, and value in the diagnosis of rheumatoid arthritis. Suggested areas of priority in research and development of ultrasonography in rheumatoid arthritis are outlined. SUMMARY: Ultrasonography is a very promising method in the assessment of rheumatoid arthritis joints, but still needs more validation before it can take up its expected role on a scientific basis as an important tool for diagnosis, monitoring, and prognostication of patients with rheumatoid arthritis and suspected rheumatoid arthritis.     

Sulfasalazine for the management of juvenile rheumatoid arthritis

OBJECTIVE: Sulfasalazine (SSZ) has regulatory approval for treatment of inflammatory bowel disease in children and adults, and for use as a slow acting agent in adult rheumatoid arthritis (RA). This report surveys the literature for experience with SSZ in juvenile RA. METHODS: Medline, Excerpta Medica, and Derwent were searched under the terms juvenile, rheumatoid, arthritis, and sulfasalazine. RESULTS: The search found reports of experience in 550 patients, of whom about half had pauciarticular and nearly one-third polyarticular disease. The studies generally reported at least some drug associated benefit in all subtypes. Some identified late onset pauciarticular disease as most responsive, but others reported poly- and pauciarticular response rates about the same. Systemic onset disease responded poorly and showed a substantial incidence of intolerance in the form of serum sickness. Most studies showed useful disease control in spondylitis. Overall, the patterns of toxicity and intolerance were close to those seen in adult SSZ recipients, with the possible exception of the serum sickness-like response. CONCLUSION: SSZ has demonstrated useful antirheumatic activity and can contribute to the care of selected patients.     

Early rheumatoid arthritis: strategies for prevention and management

The treatment of rheumatoid arthritis (RA) has changed considerably in the past few years since new tools and new concepts have been developed and validated highlighting the need for guidelines focused on early RA. The treatment goal should now be to achieve clinical remission, in order to prevent structural damage and long-term disability. A very early use of effective disease-modifying anti-rheumatic drugs (DMARDs) is a key point in patients at risk of developing persistent and erosive arthritis. Intensive treatment such as combination DMARDs plus steroids or biological therapies can induce a high rate of remission, control of radiological progression and provide better outcome than DMARD monotherapy in early RA and should be considered in at risk patients. Regarding the risk:benefit ratio and the cost-effectiveness of these strategies, a reasonable course of action in early RA should be initial DMARD monotherapy such as methotrexate. However, a close monitoring of disease activity and radiographic progression is mandatory in order to change DMARD therapy and strategy if necessary. Systemic glucocorticoids are effective in the short-term relief of pain and swelling and should be considered, but mainly as a temporary therapy part of the DMARD strategy. Information and education for patients, as well as some non-pharmacological interventions, can be proposed as treatment adjuncts. Finally, the reduction or stopping of smoking, which could prevent the development and progression of early RA, is the only prevention tool currently available.     

Naturopathic management of rheumatoid arthritis

Complementary and alternative medicines (CAM) are widely used by those with pain and/or musculoskeletal problems, and previous research has shown that high proportions of individuals with rheumatoid arthritis have used these therapies. One of the largest CAM modalities is that of naturopathy, which combines nutritional, herbal, and other complementary practices to treat such conditions. In this review, evidence is examined in relation to those factors which naturopaths believe are significant contributors to rheumatoid arthritis, and are hence the main focus of therapeutic management. These factors include food allergy, increased gut permeability, increased circulating immune complexes, excessive inflammatory processes, and increased oxidative stress. Naturopathic treatment attempts to alleviate symptoms by altering these factors through dietary modification, manipulation of dietary fats, and use of antioxidants and proteolytic enzymes. An understanding of the rationale for these treatments and evaluation of the evidence from their use in clinical settings will assist with the integration of complementary and conventional practices in the treatment of rheumatoid arthritis.     

Naturopathic management of rheumatoid arthritis

Abstract

Complementary and alternative medicines (CAM) are widely used by those with pain and/or musculoskeletal problems, and previous research has shown that high proportions of individuals with rheumatoid arthritis have used these therapies. One of the largest CAM modalities is that of naturopathy, which combines nutritional, herbal, and other complementary practices to treat such conditions. In this review, evidence is examined in relation to those factors which naturopaths believe are significant contributors to rheumatoid arthritis, and are hence the main focus of therapeutic management. These factors include food allergy, increased gut permeability, increased circulating immune complexes, excessive inflammatory processes, and increased oxidative stress. Naturopathic treatment attempts to alleviate symptoms by altering these factors through dietary modification, manipulation of dietary fats, and use of antioxidants and proteolytic enzymes. An understanding of the rationale for these treatments and evaluation of the evidence from their use in clinical settings will assist with the integration of complementary and conventional practices in the treatment of rheumatoid arthritis.     

Initial management of rheumatoid arthritis

The prognosis for the patient with newly diagnosed rheumatoid arthritis (RA) has dramatically changed over the last two decades. If a patient is diagnosed and treated early by a rheumatologist with the goal of remission or low disease activity, half of patients can expect to achieve remission while taking their disease-modifying antirheumatic drugs. This article discusses the initial therapy in early RA and reviews the studies and trials available in the literature.     

Team management of rheumatoid arthritis

The main objectives of team management of rheumatoid arthritis are to stop structural damage of joints and to reduce functional, psychological, socioprofessional and economic consequences. Team management requires the collaboration, around the patient, of a rheumatologist, a nurse, a psychologist, a physiotherapist, an occupational therapist, an orthopaedic surgeon at the same time, in the same place. More and more patients wish to manage their disease by themselves. Team care should not be proposed to every patient; it must be reserved to patients whose condition required such an approach because of the severity of the disease, comorbidity, psychological or socioprofessionnal difficulties. Team management should be personalized. Utility of team management is now accepted; out-patient administration is as effective as in-patient one. A good educational program is very important. However, search is still needed to define optimal modalities of team management and tools to measure the efficiency of this approach.     

Characteristics of patients with rheumatoid arthritis presenting for physiotherapy management: a multicentre study

Objectives: To describe the characteristics of patients with rheumatoid arthritis (RA) attending for physiotherapy management in Ireland. Methods: Managers of physiotherapy departments in the 53 hospitals in Ireland were invited to participate in a multi‐centre observational study over a 6‐month period. Data on patients with RA the day of presentation for physiotherapy management were recorded. These data related to patient demographic details, disease management, aids and appliances, splint and orthoses usage and occupational issues. The Health Assessment Questionnaire was also recorded for each patient. Results: A total of 273 patients from eight physiotherapy departments participated in the survey (n = 199; 73% female). Mean age of the participants was 59.3 (SD 12.5) years with mean disease duration of 13.8 (SD 10.6) years. The majority of the patients were inpatients (n = 170, 62%). Sixty‐eight per cent of patients had attended for previous physiotherapy treatment and 98% were under current rheumatologist care. Biologic therapies were prescribed to 11% of patients. Use of splint and foot orthoses was high with 133 patients (49%) wearing splints and 75 (31%) wearing foot orthoses. The majority of patients had moderate (n = 119, 44%) or severe (n = 94, 35%) disability as per Health Assessment Questionnaire (HAQ) score. Mean HAQ score was 1.5, with HAQ scores showing increasing disability with increasing age, disease duration and erythrocyte sedimentation rate (ESR) levels. Conclusions: Patients with RA attending for physiotherapy management present with varied profiles. This study provides valuable information on the characteristics of patients with RA attending for physiotherapy management which will contribute to physiotherapy service planning and delivery and will optimize patient care. Copyright © 2006 John Wiley & Sons, Ltd.     

Developing multidisciplinary guidelines for the management of early rheumatoid arthritis

Objective: To develop an evidence based guideline, for the multidisciplinary management of early rheumatoid arthritis (RA). Methods: Recommendations were developed using both an evidence‐based approach and expert opinion. The scientific committee, composed of key members of the rheumatology multidisciplinary team used a Delphi approach to evaluate topics and standard statements, which formed the basis for developing recommendations for management of RA in the first 2 years of disease. Evidence taken from literature was used to support these recommendations. Results: 24 evidence based recommendations for the management of early RA, with a grade of recommendation from A to C, were developed. In addition an algorithm of care was designed to promote a clear multidisciplinary management pathway. A mechanism for audit was also identified. Conclusion: Involvement of the multidisciplinary rheumatology team has enabled a holistic guideline to be developed for the management of patients presenting with early RA. This guideline is based around best practice that is supported by published literature. Whilst most statements in the guideline are based on strong evidence, others have been formulated by expert consensus in the absence of data and should serve as an opportunity to improve current practice through future research and audit. The development and implementation of such a guideline should improve the care of patients with early RA. Copyright © 2007 John Wiley & Sons, Ltd.