SULPHASALAZINE IN THE MANAGEMENT OF PSORIATIC ARTHRITIS

There are few ‘second-line’ drugs available forthe treatment of PSA and their use is often limited by toxicity.Thirty-nine patients with active PSA recruited from two rheumatologyunits were randomly allocated to either enteric-coated sulphasalazine(SASP) or placebo and followed for 24 wk. Six patients in theSASP group and 11 on placebo discontinued therapy before 24wk. Evaluation of effect of treatment revealed significant improvementsin articular index in both groups at 12 wk. By 24 wk the articularindex in placebo group was still showing benefit. In additionto articular index the SASP group improved significantly interms of visual analogue scale, duration of morning stiffnessand ESR. SASP is effective in PSA but the partial clinical response toplacebo indicates the importance of placebo-controlled studiesin this variable disease. KEY WORDS: Skin, Arthritis, Treatment     

THE PHYSIOLOGICAL COST OF GAIT (PCG): A NEW TECHNIQUE FOR EVALUATING NONSTEROIDAL ANTI-INFLAMMATORY DRUGS IN RHEUMATOID ARTHRITIS

The physiological cost of gait (PCG) provides a technique forreproducibly quantifying the physical disabilities occasionedby inflammatory joint disease. The preferred walking speed (PWS)and the physiological cost index (PCI) related to achievingthat PWS are shown to be abnormal in rheumatoid arthritis (RA)and objective improvement can be demonstrated with naproxenand indomethacin, two commonly-used nonsteroidal anti-inflammatorydrugs (NSAIDs). Twenty patients with active RA were studied by double-blindcross-over technique and 16 completed the two-month study. ReliablePCG data obtained in 13 patients showed statistically significantimprovement in PWS and PCI with NSAID therapy. Improvement wasnot correlated with conventional clinical measures of jointinflammation such as pain score, articular index, haemoglobinor ESR but the trends were similar. PCG may offer a reproducible,objective method of quantifying disability and response to treatment. KEY WORDS: Rheumatoid arthritis, NSAID evaluation, Physiological testing     

A MULTICENTRE DOUBLE-BLIND COMPARISON OF AURANOFIN, INTRAMUSCULAR GOLD THIOMALATE AND PLACEBO IN PATIENTS WITH PSORIATIC ARTHRITIS

The efficacy and safety of the oral gold compound auranofinand intramuscular gold thiomalate have been compared in a placebo-controlled,double-blind, four-centre trial in 82 patients with psoriaticarthritis requiring remittive drug therapy. There were statisticallysignificant falls in Ritchie articular index, visual analoguepain score and ESR at 12 and 24 weeks following i.m. gold butno significant changes in the auranofin group. Intramusculargold was safe and more effective than auranofin as a second-line,suppressive antirheumatic agent for patients with psoriaticarthritis when followed for 6 months. KEY WORDS: Second-line treatment, Oral gold, Toxicity, Effectiveness     

ALTERATION OF THIOL AND SUPEROXIDE DISMUTASE STATUS IN RHEUMATOID ARTHRITIS TREATED WITH SULPHASALAZINE

Intracellular thiols (LSH), superoxide dismutase (SOD) and plasmathiols (PSH) are thought to have an important role in the protectionof tissues from damage by oxygen-derived free radicals. Thechange in the levels of activity of these substances in patientswith active rheumatoid arthritis treated with sulphasalazinefor 6 months was assessed in 22 patients. Over this time therewas a marked improvement in disease activity. This was accompaniedby an early increase in red cell LSH and decrease in SOD, althoughby 6 months these changes had completely reversed. In additionthe negative correlation between these indices at week 0 haddisappeared by week 6. Over the 6 months there was a steadyrise in PSH. The change in PSH is slow and is thus more likelyto reflect a change in the disease process rather than an activerole for the thiol, but the early changes in intracellular parametersmay be of importance in the action of this drug. These changesare similar to changes found with other second-line drugs. It is also of interest that a drug which does not itself possessa thiol group is capable of altering the thiol status of cells. KEY WORDS: Free radical scavenging, Second-line antirheumatic drugs, Sulphydryl groups.     

FIBRINOLYSIS IN SYSTEMIC LUPUS ERYTHEMATOSUS: EFFECT OF DESAMINO D-ARGININE VASOPRESSIN INFUSION

In systemic lupus erythematosus (SLE) the lupus anticoagulantis known to be associated with thrombosis. However, this anticoagulantonly occurs in a small percentage of patients. Histopathologicalstudies suggest a more generalized thrombotic tendency withplatelets and fibrin within the microvasculature. Fibrinogenis elevated in SLE and this may lead to the fibrin depositiondescribed. We wondered if decreased fibrinolysis contributedto this and we infused desamino D-arginine vasopressin (DDAVP)into ten patients with SLE and eight controls. DDAVP stimulatesendothelial production of plasminogen activator (PA) and factorVIII. Baseline results showed a significant decrease in PA activitywith a concomitant increase in fibrinogen in SLE. The t-PA andinhibitor levels were normal but factor VIII was increased.After infusion of DDAVP, results indicated that, despite baselineresults, SLE patients were able to respond to stimulation andthe increase in PA activity produced a decrease in plasma fibrinogenlevels. These findings may have therapeutic implications. KEY WORDS: Systemic lupus erythematosus, Fibrinolysis, Factor VIII     

EVENING PRIMROSE OIL IN PATIENTS WITH RHEUMATOID ARTHRITIS AND SIDE-EFFECTS OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS

Forty patients with rheumatoid arthritis and upper gastrointestinallesions due to non-steroidal anti-inflammatory drugs entereda prospective 6-month double-blind placebo controlled studyof dietary supplementation with gamma-linolenic acid 540 mg/day.Nineteen patients received active therapy (as evening primroseoil 6g/day) and 21 received placebo (olive oil 6g/day). No patientstopped non-steroidal anti-inflammatory therapy but three patientsin each group reduced their dose. Other results showed a significantreduction in morning stiffness with gamma-linolenic acid at3 months and reduction in pain and articular index at 6 monthswith olive oil. Whilst gamma-linolenic acid may produce mildimprovement in rheumatoid arthritis, olive oil may itself havehitherto unrecognized benefits. KEY WORDS: Rheumatoid arthritis, Inflammation, Evening primrose oil, NSAIDs, Peptic ulcer, Gastritis     

Degree and Extent of Response to Sulphasalazine or Penicillamine Therapy for Rheumatoid Arthritis: Results from a Routine Clinical Environment over a Two-Year Period

An attempt was made to audit the clinical usefulness of sulphasalazineand penicillamine in patients with rheumatoid arthritis (RA)managed in a routine out-patient setting with assistance fromgeneral practitioners and to ascertain whether clinically significantdifferences can be shown between these two ‘second-line’agents. The degree and extent of change in, and the usefulnessof, various parameters of disease activity were also evaluated.Two hundred patients with active rheumatoid arthritis were randomlyallocated to either sulphasalazine or penicillamine and monitoredfor a minimum of two years. Fifty-one percent of the 102 patientswho received sulphasalazine continued treatment for two years,compared with 40 per cent of the 98 patients allocated to penicillamine.The proportion of patients stopping therapy because of adversereactions or due to lack or loss of effect was similar in thetwo groups. There was no difference between the two groups inthe extent of improvement in clinical and laboratory variablesat one and two years. The majority of patients showed improvementin most measured parameters; very few showed global improvement.The degree of improvement varied with the parameter assessed,being greatest in relatively easily measured variables suchas duration of morning stiffness and ESR, and least for functionalindex. The effect and toxicity of these two agents in this settingwas as anticipated. No clinically relevant difference couldbe demonstrated between the two drugs.     

AN ACUTE ARTHRITIS CLINIC--ONE YEAR'S EXPERIENCE

Over a 12-month period, 150 patients were seen at an acute arthritisclinic to assess the type of case not usually seen in our chronicservice, where delays of up to 24 weeks may occur before patientscan be investigated. The majority of patients in whom the diagnosiscould confidently be made had either gout or reactive arthritis,and, while the former diagnosis was unlikely to be missed, manypractitioners seemed unaware of the type of presentation andvariety of organisms that can cause reactive arthritis. Despiteintensive investigation, a diagnosis could not be made in somecases. Those with septic arthritis had a better prognosis thanpatients in a previous series from this centre. Early referralleading to prompt diagnosis of this serious complication mayhave been an important factor in the improved outcome. KEY WORDS: Acute arthritis, Clinic, Gout, Reactive arthritis, Septic arthritis