Rheumatoid Arthritis

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

AMSTERDAM — Treatment with etanercept for 2 years failed to inhibit structural progression of ankylosing spondylitis in the first controlled study to examine this key issue, Dr. Desiree M. van der Heijde said at the annual European Congress of Rheumatology.

“This suggests there may not be direct linkage between clinical disease activity, inflammation, and new bone formation in ankylosing spondylitis. It might be that syndesmophyte formation is tumor necrosis factor-independent,” added Dr. van der Heijde, professor of rheumatology at University Hospital Maastricht (the Netherlands).

Does etanercept's failure to inhibit structural damage in this study mean that clinicians should narrow their indications for anti-TNF therapy in ankylosing spondylitis (AS) patients? Certainly not, Dr. van der Heijde said.

She pointed out that this study and others have shown that these drugs provide many other worthwhile benefits, including improvement in clinical signs and symptoms, quality of life, and physical function, along with greater bone mineral density and reduced inflammation on MRI.

She reported on 257 AS patients who participated in a 24-week double-blind, placebo-controlled clinical trial of etanercept therapy and then continued on open-label etanercept. Spinal x-rays were taken at baseline and at 2 years, and will be obtained again at 4 years.

The comparison group consisted of 175 patients in the Outcome in Ankylosing Spondylitis International Study (OASIS), none of whom received a TNF inhibitor. The radiographs were analyzed by evaluators blinded to the origin of the films and the time order of the films.

The mean change over 2 years in radiographic structural disease progression as measured by the modified Stokes Ankylosing Spondylitis Spinal Score was 0.91 in the etanercept study participants, which wasn't significantly different from that noted in OASIS subjects, she reported.

Whether etanercept's lack of inhibition of radiographic disease progression is part of a class effect extending to infliximab and adalimumab is unknown. It is worth remembering, however, that the TNF blockers have differential efficacy in Crohn's disease and uveitis, the rheumatologist said.

One implication of this study might be that TNF inhibitors should be utilized much earlier in the disease process, before syndesmophytes have formed.

The idea—which is well worth pursuing in clinical trials, Dr. van der Heijde said—is to suppress inflammation before the structural damage has begun.

Rheumatologists at the University of Leuven (Belgium) have developed a hypothesis she finds attractive. They have shown, in mouse models of AS, that once new bone formation is triggered by inflammation it is a continuing process, even if the inflammation is taken away.

The Belgians have zeroed in on bone morphogenetic proteins as potentially playing a key role in this process.

These proteins are members of the transforming growth factor beta superfamily that induce a cascade of out-of-control bone formation. As such, bone morphogenetic protein signalling may be a potential new therapeutic target, she said.

Several audience members criticized Dr. van der Heijde's reliance upon historical controls from OASIS in the etanercept study. She replied that today a 2-year placebo-controlled trial of TNF blockers in AS patients is no longer ethical.

Dr. Robert D.M. Landewé commented that he considered Dr. van der Heijde's study “one of the most important presentations of the whole congress.”

The idea is to suppress inflammation before the structural damage has begun. DR. VAN DER HEIJDE

AMSTERDAM — Treatment with etanercept for 2 years failed to inhibit structural progression of ankylosing spondylitis in the first controlled study to examine this key issue, Dr. Desiree M. van der Heijde said at the annual European Congress of Rheumatology.

“This suggests there may not be direct linkage between clinical disease activity, inflammation, and new bone formation in ankylosing spondylitis. It might be that syndesmophyte formation is tumor necrosis factor-independent,” added Dr. van der Heijde, professor of rheumatology at University Hospital Maastricht (the Netherlands).

Does etanercept's failure to inhibit structural damage in this study mean that clinicians should narrow their indications for anti-TNF therapy in ankylosing spondylitis (AS) patients? Certainly not, Dr. van der Heijde said.

She pointed out that this study and others have shown that these drugs provide many other worthwhile benefits, including improvement in clinical signs and symptoms, quality of life, and physical function, along with greater bone mineral density and reduced inflammation on MRI.

She reported on 257 AS patients who participated in a 24-week double-blind, placebo-controlled clinical trial of etanercept therapy and then continued on open-label etanercept. Spinal x-rays were taken at baseline and at 2 years, and will be obtained again at 4 years.

The comparison group consisted of 175 patients in the Outcome in Ankylosing Spondylitis International Study (OASIS), none of whom received a TNF inhibitor. The radiographs were analyzed by evaluators blinded to the origin of the films and the time order of the films.

The mean change over 2 years in radiographic structural disease progression as measured by the modified Stokes Ankylosing Spondylitis Spinal Score was 0.91 in the etanercept study participants, which wasn't significantly different from that noted in OASIS subjects, she reported.

Whether etanercept's lack of inhibition of radiographic disease progression is part of a class effect extending to infliximab and adalimumab is unknown. It is worth remembering, however, that the TNF blockers have differential efficacy in Crohn's disease and uveitis, the rheumatologist said.

One implication of this study might be that TNF inhibitors should be utilized much earlier in the disease process, before syndesmophytes have formed.

The idea—which is well worth pursuing in clinical trials, Dr. van der Heijde said—is to suppress inflammation before the structural damage has begun.

Rheumatologists at the University of Leuven (Belgium) have developed a hypothesis she finds attractive. They have shown, in mouse models of AS, that once new bone formation is triggered by inflammation it is a continuing process, even if the inflammation is taken away.

The Belgians have zeroed in on bone morphogenetic proteins as potentially playing a key role in this process.

These proteins are members of the transforming growth factor beta superfamily that induce a cascade of out-of-control bone formation. As such, bone morphogenetic protein signalling may be a potential new therapeutic target, she said.

Several audience members criticized Dr. van der Heijde's reliance upon historical controls from OASIS in the etanercept study. She replied that today a 2-year placebo-controlled trial of TNF blockers in AS patients is no longer ethical.

Dr. Robert D.M. Landewé commented that he considered Dr. van der Heijde's study “one of the most important presentations of the whole congress.”

The idea is to suppress inflammation before the structural damage has begun. DR. VAN DER HEIJDE

AMSTERDAM — Treatment with etanercept for 2 years failed to inhibit structural progression of ankylosing spondylitis in the first controlled study to examine this key issue, Dr. Desiree M. van der Heijde said at the annual European Congress of Rheumatology.

“This suggests there may not be direct linkage between clinical disease activity, inflammation, and new bone formation in ankylosing spondylitis. It might be that syndesmophyte formation is tumor necrosis factor-independent,” added Dr. van der Heijde, professor of rheumatology at University Hospital Maastricht (the Netherlands).

Does etanercept's failure to inhibit structural damage in this study mean that clinicians should narrow their indications for anti-TNF therapy in ankylosing spondylitis (AS) patients? Certainly not, Dr. van der Heijde said.

She pointed out that this study and others have shown that these drugs provide many other worthwhile benefits, including improvement in clinical signs and symptoms, quality of life, and physical function, along with greater bone mineral density and reduced inflammation on MRI.

She reported on 257 AS patients who participated in a 24-week double-blind, placebo-controlled clinical trial of etanercept therapy and then continued on open-label etanercept. Spinal x-rays were taken at baseline and at 2 years, and will be obtained again at 4 years.

The comparison group consisted of 175 patients in the Outcome in Ankylosing Spondylitis International Study (OASIS), none of whom received a TNF inhibitor. The radiographs were analyzed by evaluators blinded to the origin of the films and the time order of the films.

The mean change over 2 years in radiographic structural disease progression as measured by the modified Stokes Ankylosing Spondylitis Spinal Score was 0.91 in the etanercept study participants, which wasn't significantly different from that noted in OASIS subjects, she reported.

Whether etanercept's lack of inhibition of radiographic disease progression is part of a class effect extending to infliximab and adalimumab is unknown. It is worth remembering, however, that the TNF blockers have differential efficacy in Crohn's disease and uveitis, the rheumatologist said.

One implication of this study might be that TNF inhibitors should be utilized much earlier in the disease process, before syndesmophytes have formed.

The idea—which is well worth pursuing in clinical trials, Dr. van der Heijde said—is to suppress inflammation before the structural damage has begun.

Rheumatologists at the University of Leuven (Belgium) have developed a hypothesis she finds attractive. They have shown, in mouse models of AS, that once new bone formation is triggered by inflammation it is a continuing process, even if the inflammation is taken away.

The Belgians have zeroed in on bone morphogenetic proteins as potentially playing a key role in this process.

These proteins are members of the transforming growth factor beta superfamily that induce a cascade of out-of-control bone formation. As such, bone morphogenetic protein signalling may be a potential new therapeutic target, she said.

Several audience members criticized Dr. van der Heijde's reliance upon historical controls from OASIS in the etanercept study. She replied that today a 2-year placebo-controlled trial of TNF blockers in AS patients is no longer ethical.

Dr. Robert D.M. Landewé commented that he considered Dr. van der Heijde's study “one of the most important presentations of the whole congress.”

The idea is to suppress inflammation before the structural damage has begun. DR. VAN DER HEIJDE

Microfracture is an effective first-line treatment for knee articular cartilage lesions in athletes who participate in high-impact sports, Dr. Kai Mithoefer and associates reported.

Microfracture is a relatively simple technique in which penetration of the subchondral bone induces clot formation containing marrow-derived mesenchymal stem cells, which produce a mixed fibrocartilage repair tissue containing varying amounts of type II collagen. It has become a popular treatment option for knee articular cartilage lesions in athletes, due to its low associated morbidity and rapid postoperative rehabilitation time.

Outcome data on athletes who perform high-impact sports with marked mechanical demands have been limited, said Dr. Mithoefer of Harvard Vanguard Orthopedics and Sports Medicine and Brigham and Women's Hospital, Boston, and associates (Am. J. Sports Med. 2006;34:1413–8).

The study population comprised 32 patients, mean age 38, with single cartilage lesions of the femur. Their mean symptom duration was 28 months. All had regularly participated in high-impact, pivoting sports, including basketball (14), tennis (13), football (9), downhill skiing (7), and soccer (5). All underwent microfracture arthroplasty performed by a fellowship-trained orthopedic surgeon. Seven patients with meniscus tears also received partial meniscectomy.

At a mean follow-up of 41 months, 21 of the athletes reported good or excellent results on the Brittenberg rating of knee function; significant improvements were seen on the activity-based Marx activity rating scale and Tegner scores. Improvements occurred in the activities of daily living scale in 71% of patients, on the Marx scale in 58%, and in Tegner scores in 72%. After an initial increase, declines in activity scores were observed in 15 athletes, Dr. Mithoefer and associates reported.

A total of 14 athletes (44%) returned to participation in high-impact sports after microfracture. Functional outcome score increases were lower among those who did not return to the sport. Two-thirds of the patients who had been symptomatic for 12 months or less before microfracture were able to return to their high-impact sport, compared with just 14% who had been symptomatic for more than a year before the procedure.

Athletes who received microfracture as first-line treatment were far more likely to return to their sports than were those who had had previous procedures, but concomitant meniscectomy did not have a significant impact on the ability to return to the sport. Patients with lesions of 200 mm

Microfracture is an effective first-line treatment for knee articular cartilage lesions in athletes who participate in high-impact sports, Dr. Kai Mithoefer and associates reported.

Microfracture is a relatively simple technique in which penetration of the subchondral bone induces clot formation containing marrow-derived mesenchymal stem cells, which produce a mixed fibrocartilage repair tissue containing varying amounts of type II collagen. It has become a popular treatment option for knee articular cartilage lesions in athletes, due to its low associated morbidity and rapid postoperative rehabilitation time.

Outcome data on athletes who perform high-impact sports with marked mechanical demands have been limited, said Dr. Mithoefer of Harvard Vanguard Orthopedics and Sports Medicine and Brigham and Women's Hospital, Boston, and associates (Am. J. Sports Med. 2006;34:1413–8).

The study population comprised 32 patients, mean age 38, with single cartilage lesions of the femur. Their mean symptom duration was 28 months. All had regularly participated in high-impact, pivoting sports, including basketball (14), tennis (13), football (9), downhill skiing (7), and soccer (5). All underwent microfracture arthroplasty performed by a fellowship-trained orthopedic surgeon. Seven patients with meniscus tears also received partial meniscectomy.

At a mean follow-up of 41 months, 21 of the athletes reported good or excellent results on the Brittenberg rating of knee function; significant improvements were seen on the activity-based Marx activity rating scale and Tegner scores. Improvements occurred in the activities of daily living scale in 71% of patients, on the Marx scale in 58%, and in Tegner scores in 72%. After an initial increase, declines in activity scores were observed in 15 athletes, Dr. Mithoefer and associates reported.

A total of 14 athletes (44%) returned to participation in high-impact sports after microfracture. Functional outcome score increases were lower among those who did not return to the sport. Two-thirds of the patients who had been symptomatic for 12 months or less before microfracture were able to return to their high-impact sport, compared with just 14% who had been symptomatic for more than a year before the procedure.

Athletes who received microfracture as first-line treatment were far more likely to return to their sports than were those who had had previous procedures, but concomitant meniscectomy did not have a significant impact on the ability to return to the sport. Patients with lesions of 200 mm

Microfracture is an effective first-line treatment for knee articular cartilage lesions in athletes who participate in high-impact sports, Dr. Kai Mithoefer and associates reported.

Microfracture is a relatively simple technique in which penetration of the subchondral bone induces clot formation containing marrow-derived mesenchymal stem cells, which produce a mixed fibrocartilage repair tissue containing varying amounts of type II collagen. It has become a popular treatment option for knee articular cartilage lesions in athletes, due to its low associated morbidity and rapid postoperative rehabilitation time.

Outcome data on athletes who perform high-impact sports with marked mechanical demands have been limited, said Dr. Mithoefer of Harvard Vanguard Orthopedics and Sports Medicine and Brigham and Women's Hospital, Boston, and associates (Am. J. Sports Med. 2006;34:1413–8).

The study population comprised 32 patients, mean age 38, with single cartilage lesions of the femur. Their mean symptom duration was 28 months. All had regularly participated in high-impact, pivoting sports, including basketball (14), tennis (13), football (9), downhill skiing (7), and soccer (5). All underwent microfracture arthroplasty performed by a fellowship-trained orthopedic surgeon. Seven patients with meniscus tears also received partial meniscectomy.

At a mean follow-up of 41 months, 21 of the athletes reported good or excellent results on the Brittenberg rating of knee function; significant improvements were seen on the activity-based Marx activity rating scale and Tegner scores. Improvements occurred in the activities of daily living scale in 71% of patients, on the Marx scale in 58%, and in Tegner scores in 72%. After an initial increase, declines in activity scores were observed in 15 athletes, Dr. Mithoefer and associates reported.

A total of 14 athletes (44%) returned to participation in high-impact sports after microfracture. Functional outcome score increases were lower among those who did not return to the sport. Two-thirds of the patients who had been symptomatic for 12 months or less before microfracture were able to return to their high-impact sport, compared with just 14% who had been symptomatic for more than a year before the procedure.

Athletes who received microfracture as first-line treatment were far more likely to return to their sports than were those who had had previous procedures, but concomitant meniscectomy did not have a significant impact on the ability to return to the sport. Patients with lesions of 200 mm

Intra-articular injections of hyaluronic acid relieved pain and produced functional improvements lasting at least 6 months in a pilot study of 75 patients with ankle osteoarthritis, reported Dr. Shu-Fen Sun of Veterans General Hospital, Kaohsiung, Taiwan, and associates.

Researchers have reported success with hyaluronic acid injections in osteoarthritic knees, so Dr. Sun and colleagues assessed the efficacy and safety of these injections in an open-label prospective clinical trial involving 41 men and 34 women with mild to moderate unilateral ankle osteoarthritis (OA). “To date there is only limited published literature on its use in the ankle,” and it is approved for clinical use only in the knee, they noted.

OA reduces the concentration of hyaluronic acid in the synovial fluid of affected joints. Intra-articular injections are thought to restore viscosity and elasticity in that fluid, as well as to normalize endogenous synthesis of hyaluronic acid and inhibit its degradation, the investigators said (Osteoarthritis Cartilage 2006;14:867-74).

Study subjects received five weekly intra-articular injections. Beneficial effects were noted within 1 week of completing the series of injections and persisted through a 6-month follow-up. On the Ankle Osteoarthritis Scale, a patient-rated measure that addresses pain and function in the affected joint, scores decreased significantly beginning at 1 week after treatment and continuing through 1-month, 3-month, and 6-month follow-up visits.

Similarly, on the physician-rated 100-point measure of the American Orthopaedic Foot and Ankle Society, which assesses pain, function, and alignment, mean scores improved from 64 at baseline to 75 at 1 week and 78 at all subsequent follow-ups.

The treatment decreased the patients' use of rescue analgesics. Acetaminophen use dropped from an average of 14 tablets per week at baseline to 3 tablets per week at 1-month, 3-month, and 6-month follow-up visits.

Ankle sagittal range of motion did not change significantly with treatment.

Given that surgical treatment of ankle OA “is often quite painful,” intra-articular hyaluronic acid injections may offer a new option to patients who have not responded to traditional pain therapies, Dr. Sun and associates said.

These findings support the idea that the treatment's mechanism of action exceeds simple replacement of viscous joint fluid. “Temporary restoration of the rheologic homeostasis may trigger normal native hyaluronic acid metabolism. Hyaluronic acid also fulfills an anti-inflammatory role by reducing white cell aggregation and activation. With this postulated disease-modifying behavior, its clinical effects may persist beyond its physical duration within the joint,” the researchers noted.

Intra-articular injections of hyaluronic acid relieved pain and produced functional improvements lasting at least 6 months in a pilot study of 75 patients with ankle osteoarthritis, reported Dr. Shu-Fen Sun of Veterans General Hospital, Kaohsiung, Taiwan, and associates.

Researchers have reported success with hyaluronic acid injections in osteoarthritic knees, so Dr. Sun and colleagues assessed the efficacy and safety of these injections in an open-label prospective clinical trial involving 41 men and 34 women with mild to moderate unilateral ankle osteoarthritis (OA). “To date there is only limited published literature on its use in the ankle,” and it is approved for clinical use only in the knee, they noted.

OA reduces the concentration of hyaluronic acid in the synovial fluid of affected joints. Intra-articular injections are thought to restore viscosity and elasticity in that fluid, as well as to normalize endogenous synthesis of hyaluronic acid and inhibit its degradation, the investigators said (Osteoarthritis Cartilage 2006;14:867-74).

Study subjects received five weekly intra-articular injections. Beneficial effects were noted within 1 week of completing the series of injections and persisted through a 6-month follow-up. On the Ankle Osteoarthritis Scale, a patient-rated measure that addresses pain and function in the affected joint, scores decreased significantly beginning at 1 week after treatment and continuing through 1-month, 3-month, and 6-month follow-up visits.

Similarly, on the physician-rated 100-point measure of the American Orthopaedic Foot and Ankle Society, which assesses pain, function, and alignment, mean scores improved from 64 at baseline to 75 at 1 week and 78 at all subsequent follow-ups.

The treatment decreased the patients' use of rescue analgesics. Acetaminophen use dropped from an average of 14 tablets per week at baseline to 3 tablets per week at 1-month, 3-month, and 6-month follow-up visits.

Ankle sagittal range of motion did not change significantly with treatment.

Given that surgical treatment of ankle OA “is often quite painful,” intra-articular hyaluronic acid injections may offer a new option to patients who have not responded to traditional pain therapies, Dr. Sun and associates said.

These findings support the idea that the treatment's mechanism of action exceeds simple replacement of viscous joint fluid. “Temporary restoration of the rheologic homeostasis may trigger normal native hyaluronic acid metabolism. Hyaluronic acid also fulfills an anti-inflammatory role by reducing white cell aggregation and activation. With this postulated disease-modifying behavior, its clinical effects may persist beyond its physical duration within the joint,” the researchers noted.

Intra-articular injections of hyaluronic acid relieved pain and produced functional improvements lasting at least 6 months in a pilot study of 75 patients with ankle osteoarthritis, reported Dr. Shu-Fen Sun of Veterans General Hospital, Kaohsiung, Taiwan, and associates.

Researchers have reported success with hyaluronic acid injections in osteoarthritic knees, so Dr. Sun and colleagues assessed the efficacy and safety of these injections in an open-label prospective clinical trial involving 41 men and 34 women with mild to moderate unilateral ankle osteoarthritis (OA). “To date there is only limited published literature on its use in the ankle,” and it is approved for clinical use only in the knee, they noted.

OA reduces the concentration of hyaluronic acid in the synovial fluid of affected joints. Intra-articular injections are thought to restore viscosity and elasticity in that fluid, as well as to normalize endogenous synthesis of hyaluronic acid and inhibit its degradation, the investigators said (Osteoarthritis Cartilage 2006;14:867-74).

Study subjects received five weekly intra-articular injections. Beneficial effects were noted within 1 week of completing the series of injections and persisted through a 6-month follow-up. On the Ankle Osteoarthritis Scale, a patient-rated measure that addresses pain and function in the affected joint, scores decreased significantly beginning at 1 week after treatment and continuing through 1-month, 3-month, and 6-month follow-up visits.

Similarly, on the physician-rated 100-point measure of the American Orthopaedic Foot and Ankle Society, which assesses pain, function, and alignment, mean scores improved from 64 at baseline to 75 at 1 week and 78 at all subsequent follow-ups.

The treatment decreased the patients' use of rescue analgesics. Acetaminophen use dropped from an average of 14 tablets per week at baseline to 3 tablets per week at 1-month, 3-month, and 6-month follow-up visits.

Ankle sagittal range of motion did not change significantly with treatment.

Given that surgical treatment of ankle OA “is often quite painful,” intra-articular hyaluronic acid injections may offer a new option to patients who have not responded to traditional pain therapies, Dr. Sun and associates said.

These findings support the idea that the treatment's mechanism of action exceeds simple replacement of viscous joint fluid. “Temporary restoration of the rheologic homeostasis may trigger normal native hyaluronic acid metabolism. Hyaluronic acid also fulfills an anti-inflammatory role by reducing white cell aggregation and activation. With this postulated disease-modifying behavior, its clinical effects may persist beyond its physical duration within the joint,” the researchers noted.

A 2-week course of ibuprofen after total hip replacement or revision surgery can reduce ectopic bone growth, but does not reduce pain or improve mobility significantly several months after surgery and can lead to serious postoperative bleeding, a randomized study has found.

Routine prophylaxis with nonsteroidal anti-inflammatory drugs after hip surgery is believed to reduce the occurrence of ectopic bone growth, which occurs in one-third of all hip-replacement patients. Physicians believe ectopic bone growth is a determinant in the risk of long-term pain or disability. The researchers in this study examined whether postsurgical ibuprofen led to reduced pain and improved mobility 6-12 months after surgery.

Marlene Fransen of the University of Sydney, Australia, and her associates compared outcomes for 898 patients (mean age 66) in Australia and New Zealand undergoing the surgery at 20 hospitals between February 2002 and May 2004. Half were randomized to receive ibuprofen (two doses of 200 mg taken three times daily), the other half to placebo. Treatment began within 24 hours of surgery and lasted for 14 days (BMJ 2006;333:519-23).

Of the patients who received follow-up examinations 6-12 months after surgery, the 391 patients in the ibuprofen group had significantly reduced risk of developing ectopic bone of any grade (risk ratio 0.7) and severe ectopic bone (0.4), compared with the 407 patients in the placebo group.

Compared with patients on placebo, those on ibuprofen showed no statistically significant improvements in pain and physical function, such as physical activity, ability to get out of the house, walking speed, time taken to stand up from sitting in a chair, and use of analgesics.

The risks of bleeding were higher with ibuprofen. During the hospital admission, patients in the ibuprofen group were twice as likely (risk ratio 2.1) to experience a bleeding complication.

“Our results provide no evidence of clinical benefit 6 to 12 months postoperatively and raise concerns about the safety of ibuprofen for the prevention of ectopic bone formation after hip arthroplasty,” the authors wrote.

In an accompanying editorial, Fraser Birrell, consultant and senior lecturer in rheumatology, Northumbria Healthcare National Health Service Trust and School of Clinical Medical Sciences, University of Newcastle upon Tyne (England), and Stefan Lohmander, senior lecturer Department of Orthopaedics, University Hospital in Lund, Sweden, wrote that while it has been shown that use of ibuprofen and other NSAIDs reduce ectopic bone growth, the study demonstrates the risk of this practice (BMJ 2006;333:506-7).

A 2-week course of ibuprofen after total hip replacement or revision surgery can reduce ectopic bone growth, but does not reduce pain or improve mobility significantly several months after surgery and can lead to serious postoperative bleeding, a randomized study has found.

Routine prophylaxis with nonsteroidal anti-inflammatory drugs after hip surgery is believed to reduce the occurrence of ectopic bone growth, which occurs in one-third of all hip-replacement patients. Physicians believe ectopic bone growth is a determinant in the risk of long-term pain or disability. The researchers in this study examined whether postsurgical ibuprofen led to reduced pain and improved mobility 6-12 months after surgery.

Marlene Fransen of the University of Sydney, Australia, and her associates compared outcomes for 898 patients (mean age 66) in Australia and New Zealand undergoing the surgery at 20 hospitals between February 2002 and May 2004. Half were randomized to receive ibuprofen (two doses of 200 mg taken three times daily), the other half to placebo. Treatment began within 24 hours of surgery and lasted for 14 days (BMJ 2006;333:519-23).

Of the patients who received follow-up examinations 6-12 months after surgery, the 391 patients in the ibuprofen group had significantly reduced risk of developing ectopic bone of any grade (risk ratio 0.7) and severe ectopic bone (0.4), compared with the 407 patients in the placebo group.

Compared with patients on placebo, those on ibuprofen showed no statistically significant improvements in pain and physical function, such as physical activity, ability to get out of the house, walking speed, time taken to stand up from sitting in a chair, and use of analgesics.

The risks of bleeding were higher with ibuprofen. During the hospital admission, patients in the ibuprofen group were twice as likely (risk ratio 2.1) to experience a bleeding complication.

“Our results provide no evidence of clinical benefit 6 to 12 months postoperatively and raise concerns about the safety of ibuprofen for the prevention of ectopic bone formation after hip arthroplasty,” the authors wrote.

In an accompanying editorial, Fraser Birrell, consultant and senior lecturer in rheumatology, Northumbria Healthcare National Health Service Trust and School of Clinical Medical Sciences, University of Newcastle upon Tyne (England), and Stefan Lohmander, senior lecturer Department of Orthopaedics, University Hospital in Lund, Sweden, wrote that while it has been shown that use of ibuprofen and other NSAIDs reduce ectopic bone growth, the study demonstrates the risk of this practice (BMJ 2006;333:506-7).

A 2-week course of ibuprofen after total hip replacement or revision surgery can reduce ectopic bone growth, but does not reduce pain or improve mobility significantly several months after surgery and can lead to serious postoperative bleeding, a randomized study has found.

Routine prophylaxis with nonsteroidal anti-inflammatory drugs after hip surgery is believed to reduce the occurrence of ectopic bone growth, which occurs in one-third of all hip-replacement patients. Physicians believe ectopic bone growth is a determinant in the risk of long-term pain or disability. The researchers in this study examined whether postsurgical ibuprofen led to reduced pain and improved mobility 6-12 months after surgery.

Marlene Fransen of the University of Sydney, Australia, and her associates compared outcomes for 898 patients (mean age 66) in Australia and New Zealand undergoing the surgery at 20 hospitals between February 2002 and May 2004. Half were randomized to receive ibuprofen (two doses of 200 mg taken three times daily), the other half to placebo. Treatment began within 24 hours of surgery and lasted for 14 days (BMJ 2006;333:519-23).

Of the patients who received follow-up examinations 6-12 months after surgery, the 391 patients in the ibuprofen group had significantly reduced risk of developing ectopic bone of any grade (risk ratio 0.7) and severe ectopic bone (0.4), compared with the 407 patients in the placebo group.

Compared with patients on placebo, those on ibuprofen showed no statistically significant improvements in pain and physical function, such as physical activity, ability to get out of the house, walking speed, time taken to stand up from sitting in a chair, and use of analgesics.

The risks of bleeding were higher with ibuprofen. During the hospital admission, patients in the ibuprofen group were twice as likely (risk ratio 2.1) to experience a bleeding complication.

“Our results provide no evidence of clinical benefit 6 to 12 months postoperatively and raise concerns about the safety of ibuprofen for the prevention of ectopic bone formation after hip arthroplasty,” the authors wrote.

In an accompanying editorial, Fraser Birrell, consultant and senior lecturer in rheumatology, Northumbria Healthcare National Health Service Trust and School of Clinical Medical Sciences, University of Newcastle upon Tyne (England), and Stefan Lohmander, senior lecturer Department of Orthopaedics, University Hospital in Lund, Sweden, wrote that while it has been shown that use of ibuprofen and other NSAIDs reduce ectopic bone growth, the study demonstrates the risk of this practice (BMJ 2006;333:506-7).

WINNIPEG, MAN. — The clinicians wondered whether this patient had

rheumatic nodules, gout, or some other disease process.

The rheumatologist suggested that blood tests, x-rays, an MRI, and a number of other tests would be needed to determine the cause of the finger nodules. These suggested procedures would require a return visit from the patient several weeks later.

“I was watching this and wondering whether there was an easier way” to make the diagnosis, Dr. Benjamin K. Fisher said at the annual conference of the Canadian Dermatology Association.

After the clinicians finished discussing the case, with the agreement of his colleagues and the patient, Dr. Fisher incised one of the nodules and pressed against it with the side of the scalpel. Out came yellow toothpaste-like matter that he smeared on a slide and placed under a microscope.

“I'd never done it that way before, and I didn't know if I'd see anything,” said Dr. Fisher, professor of dermatology at the University of Tel Aviv and the University of Toronto.

And then, “Lo and behold, there were all these [uric acid] crystals, and obviously this patient had gout,” he said.

This very simple procedure sped up the diagnosis by at least 3 weeks and saved the patient the time, cost, and hassle of undergoing further testing.

“This is a procedure that any one of you can do in your office,” Dr. Fisher pointed out.

A pasty exudate gained by incising one of the hand nodules showed crystals.

Polarized light microscopy showed crystals that were consistent with gout. Photos courtesy Dr. Benjamin K. Fisher

WINNIPEG, MAN. — The clinicians wondered whether this patient had

rheumatic nodules, gout, or some other disease process.

The rheumatologist suggested that blood tests, x-rays, an MRI, and a number of other tests would be needed to determine the cause of the finger nodules. These suggested procedures would require a return visit from the patient several weeks later.

“I was watching this and wondering whether there was an easier way” to make the diagnosis, Dr. Benjamin K. Fisher said at the annual conference of the Canadian Dermatology Association.

After the clinicians finished discussing the case, with the agreement of his colleagues and the patient, Dr. Fisher incised one of the nodules and pressed against it with the side of the scalpel. Out came yellow toothpaste-like matter that he smeared on a slide and placed under a microscope.

“I'd never done it that way before, and I didn't know if I'd see anything,” said Dr. Fisher, professor of dermatology at the University of Tel Aviv and the University of Toronto.

And then, “Lo and behold, there were all these [uric acid] crystals, and obviously this patient had gout,” he said.

This very simple procedure sped up the diagnosis by at least 3 weeks and saved the patient the time, cost, and hassle of undergoing further testing.

“This is a procedure that any one of you can do in your office,” Dr. Fisher pointed out.

A pasty exudate gained by incising one of the hand nodules showed crystals.

Polarized light microscopy showed crystals that were consistent with gout. Photos courtesy Dr. Benjamin K. Fisher

WINNIPEG, MAN. — The clinicians wondered whether this patient had

rheumatic nodules, gout, or some other disease process.

The rheumatologist suggested that blood tests, x-rays, an MRI, and a number of other tests would be needed to determine the cause of the finger nodules. These suggested procedures would require a return visit from the patient several weeks later.

“I was watching this and wondering whether there was an easier way” to make the diagnosis, Dr. Benjamin K. Fisher said at the annual conference of the Canadian Dermatology Association.

After the clinicians finished discussing the case, with the agreement of his colleagues and the patient, Dr. Fisher incised one of the nodules and pressed against it with the side of the scalpel. Out came yellow toothpaste-like matter that he smeared on a slide and placed under a microscope.

“I'd never done it that way before, and I didn't know if I'd see anything,” said Dr. Fisher, professor of dermatology at the University of Tel Aviv and the University of Toronto.

And then, “Lo and behold, there were all these [uric acid] crystals, and obviously this patient had gout,” he said.

This very simple procedure sped up the diagnosis by at least 3 weeks and saved the patient the time, cost, and hassle of undergoing further testing.

“This is a procedure that any one of you can do in your office,” Dr. Fisher pointed out.

A pasty exudate gained by incising one of the hand nodules showed crystals.

Polarized light microscopy showed crystals that were consistent with gout. Photos courtesy Dr. Benjamin K. Fisher

Physicians can access an online version of the Epocrates Rx mobile drug and formulary guide. The guide provides information on more than 3,300 drugs, including dosing, pricing, potential drug interactions, and Medicare Part D formulary coverage. For more information, contact Epocrates Inc. by visiting www2.epocrates.com

Physicians can access an online version of the Epocrates Rx mobile drug and formulary guide. The guide provides information on more than 3,300 drugs, including dosing, pricing, potential drug interactions, and Medicare Part D formulary coverage. For more information, contact Epocrates Inc. by visiting www2.epocrates.com

Physicians can access an online version of the Epocrates Rx mobile drug and formulary guide. The guide provides information on more than 3,300 drugs, including dosing, pricing, potential drug interactions, and Medicare Part D formulary coverage. For more information, contact Epocrates Inc. by visiting www2.epocrates.com

LA JOLLA, CALIF. — Fluoroscopy is more reliable than a surgeon's estimate or goniometric measurement to assess range of motion of the first metatarsophalangeal joint in patients with hallux rigidus treated with cheilectomy, a small study showed.

While fluoroscopy showed a 23-degree improvement in dorsiflexion intraoperatively, only 11 degrees of motion improvement was maintained at 6 months, Dr. Richard M. Marks said at the annual meeting of the American Orthopaedic Foot and Ankle Society.

“I think there are several questions that still need to be raised from this study,” said Dr. Marks, director of the foot and ankle surgery division at the Medical College of Wisconsin in Milwaukee. “Does motion continue to diminish over time? Does motion correlate with a patient's outcome? Does this motion correlate with the grade of arthritis preoperatively?”

He and his associate, Dr. Michael Khazzam, studied 25 patients who underwent cheilectomy through a dorsal incision for the treatment of hallux rigidus. The average age of patients was 46 years, and 15 were female.

A single surgeon performed the cheilectomy and evaluated the range of motion in the first metatarsophalangeal joint. Range of motion evaluations were obtained by surgeon's estimate, by direct goniometric measurement, and by fluoroscopic measurement preoperatively, immediately after surgery, and 6 months postoperatively.

The surgeon's estimated range of motion showed a 39.8-degree improvement intraoperatively vs. preoperatively, a 21.2-degree improvement 6 months postoperatively vs. preoperatively, and an 18.6-degree decrease in range of motion postoperatively vs. intraoperatively.

The goniometric range of motion measurements showed a 28.4-degree improvement intraoperatively vs. preoperatively, a 10-degree improvement 6 months postoperatively vs. preoperatively, and an 18.4-degree decrease in range of motion postoperatively vs. intraoperatively.

The fluoroscopic range of motion measurements showed a 22.9-degree improvement intraoperatively vs. preoperatively, an 11-degree improvement 6 months postoperatively vs. preoperatively, and an 11.9-degree decrease in range of motion postoperatively vs. intraoperatively.

“We found fluoroscopy to be the reliable measurement tool,” Dr. Marks said. Fluoroscopy showed that “we were able to achieve 23 degrees more motion intraoperatively up to a peak of 68 degrees. However, at 6 months 12 degrees were lost, so we had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.”

Limitations of the study, he added, include the small number of patients and the small time frame of follow-up.

Questions still remain, such as 'Does motion continue to diminish over time?' DR. MARKS

Shown above are radiographic findings precheilectomy (left) and postcheilectomy (right) in 1 of the 25 study participants. “We found fluoroscopy to be the reliable measurement tool,” Dr. Richard M. Marks said. “We had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.” Photos courtesy Dr. Richard M. Marks

LA JOLLA, CALIF. — Fluoroscopy is more reliable than a surgeon's estimate or goniometric measurement to assess range of motion of the first metatarsophalangeal joint in patients with hallux rigidus treated with cheilectomy, a small study showed.

While fluoroscopy showed a 23-degree improvement in dorsiflexion intraoperatively, only 11 degrees of motion improvement was maintained at 6 months, Dr. Richard M. Marks said at the annual meeting of the American Orthopaedic Foot and Ankle Society.

“I think there are several questions that still need to be raised from this study,” said Dr. Marks, director of the foot and ankle surgery division at the Medical College of Wisconsin in Milwaukee. “Does motion continue to diminish over time? Does motion correlate with a patient's outcome? Does this motion correlate with the grade of arthritis preoperatively?”

He and his associate, Dr. Michael Khazzam, studied 25 patients who underwent cheilectomy through a dorsal incision for the treatment of hallux rigidus. The average age of patients was 46 years, and 15 were female.

A single surgeon performed the cheilectomy and evaluated the range of motion in the first metatarsophalangeal joint. Range of motion evaluations were obtained by surgeon's estimate, by direct goniometric measurement, and by fluoroscopic measurement preoperatively, immediately after surgery, and 6 months postoperatively.

The surgeon's estimated range of motion showed a 39.8-degree improvement intraoperatively vs. preoperatively, a 21.2-degree improvement 6 months postoperatively vs. preoperatively, and an 18.6-degree decrease in range of motion postoperatively vs. intraoperatively.

The goniometric range of motion measurements showed a 28.4-degree improvement intraoperatively vs. preoperatively, a 10-degree improvement 6 months postoperatively vs. preoperatively, and an 18.4-degree decrease in range of motion postoperatively vs. intraoperatively.

The fluoroscopic range of motion measurements showed a 22.9-degree improvement intraoperatively vs. preoperatively, an 11-degree improvement 6 months postoperatively vs. preoperatively, and an 11.9-degree decrease in range of motion postoperatively vs. intraoperatively.

“We found fluoroscopy to be the reliable measurement tool,” Dr. Marks said. Fluoroscopy showed that “we were able to achieve 23 degrees more motion intraoperatively up to a peak of 68 degrees. However, at 6 months 12 degrees were lost, so we had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.”

Limitations of the study, he added, include the small number of patients and the small time frame of follow-up.

Questions still remain, such as 'Does motion continue to diminish over time?' DR. MARKS

Shown above are radiographic findings precheilectomy (left) and postcheilectomy (right) in 1 of the 25 study participants. “We found fluoroscopy to be the reliable measurement tool,” Dr. Richard M. Marks said. “We had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.” Photos courtesy Dr. Richard M. Marks

LA JOLLA, CALIF. — Fluoroscopy is more reliable than a surgeon's estimate or goniometric measurement to assess range of motion of the first metatarsophalangeal joint in patients with hallux rigidus treated with cheilectomy, a small study showed.

While fluoroscopy showed a 23-degree improvement in dorsiflexion intraoperatively, only 11 degrees of motion improvement was maintained at 6 months, Dr. Richard M. Marks said at the annual meeting of the American Orthopaedic Foot and Ankle Society.

“I think there are several questions that still need to be raised from this study,” said Dr. Marks, director of the foot and ankle surgery division at the Medical College of Wisconsin in Milwaukee. “Does motion continue to diminish over time? Does motion correlate with a patient's outcome? Does this motion correlate with the grade of arthritis preoperatively?”

He and his associate, Dr. Michael Khazzam, studied 25 patients who underwent cheilectomy through a dorsal incision for the treatment of hallux rigidus. The average age of patients was 46 years, and 15 were female.

A single surgeon performed the cheilectomy and evaluated the range of motion in the first metatarsophalangeal joint. Range of motion evaluations were obtained by surgeon's estimate, by direct goniometric measurement, and by fluoroscopic measurement preoperatively, immediately after surgery, and 6 months postoperatively.

The surgeon's estimated range of motion showed a 39.8-degree improvement intraoperatively vs. preoperatively, a 21.2-degree improvement 6 months postoperatively vs. preoperatively, and an 18.6-degree decrease in range of motion postoperatively vs. intraoperatively.

The goniometric range of motion measurements showed a 28.4-degree improvement intraoperatively vs. preoperatively, a 10-degree improvement 6 months postoperatively vs. preoperatively, and an 18.4-degree decrease in range of motion postoperatively vs. intraoperatively.

The fluoroscopic range of motion measurements showed a 22.9-degree improvement intraoperatively vs. preoperatively, an 11-degree improvement 6 months postoperatively vs. preoperatively, and an 11.9-degree decrease in range of motion postoperatively vs. intraoperatively.

“We found fluoroscopy to be the reliable measurement tool,” Dr. Marks said. Fluoroscopy showed that “we were able to achieve 23 degrees more motion intraoperatively up to a peak of 68 degrees. However, at 6 months 12 degrees were lost, so we had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.”

Limitations of the study, he added, include the small number of patients and the small time frame of follow-up.

Questions still remain, such as 'Does motion continue to diminish over time?' DR. MARKS

Shown above are radiographic findings precheilectomy (left) and postcheilectomy (right) in 1 of the 25 study participants. “We found fluoroscopy to be the reliable measurement tool,” Dr. Richard M. Marks said. “We had a net gain of 11 degrees of motion, or an increase of 48% compared to our intraoperative findings.” Photos courtesy Dr. Richard M. Marks

AMSTERDAM — Initial therapy using traditional disease-modifying anti-rheumatic drugs—even early, aggressively, and in combination—is inadequate for a significant proportion of patients with inflammatory arthritis, according to preliminary data from a prospective Canadian study.

In rheumatoid arthritis (RA), joint damage and the resulting disability occur during the first years of disease, and current therapeutic strategies aim to be aggressive in minimizing inflammation and preventing irreversible damage.

But among a cohort of 79 patients followed for 12 months in a real-world setting, fewer than half achieved remission with disease-modifying antirheumatic drug (DMARD) treatment, Dr. Vivian P. Bykerk said at the annual European Congress of Rheumatology.

For inclusion in the Toronto Early Arthritis Cohort, patients were required to be at least 16 years old and to have had symptoms for at least 6 weeks but less than 1 year. They had to have at least two swollen joints or one swollen metacarpophalangeal joint or proximal interphalangeal joint and to have more than one of the following characteristics: rheumatoid factor positive, anti-CCP positive, morning stiffness exceeding 45 minutes' duration, a response to nonsteroidal anti-inflammatory drugs, and a painful metatarsophalangeal joint squeeze test.

At baseline the mean patient age was 45.5 years, and 80% were female. Median duration of symptoms was 161 days at the time of evaluation.

Mean erythrocyte sedimentation rate was 28 mm/h, and mean C-reactive protein level was 13 mg/L. The mean tender joint count was 19, mean swollen joint count was 11, and mean Disease Activity Score (DAS) was 5.3. A total of 28% of patients were rheumatoid factor positive, and 67% met the criteria for RA. In addition, 26% already had erosions present in the hands or feet.

Recommended initial treatment for RA in Canada involves combination therapy, but only 60% of patients in this cohort were started on more than one DMARD. This probably reflects a lower disease burden and also possibly patient preference, said Dr. Bykerk of Mount Sinai Hospital, Toronto.

When combination therapy was used, it generally was methotrexate plus hydroxychloroquine or sulfasalazine. The methotrexate dose was 15–25 mg/week, the mean dose at 12 months was 18 mg/week, and for two-thirds of patients the dose exceeded 20 mg/week. A third of the patients opted to take their methotrexate subcutaneously, she said. “In Canada we are strong proponents of subcutaneous methotrexate in doses of 20–25 mg early on,” she said.

The sulfasalazine dose was 2 g/day, and the hydroxychloroquine dose was 400 mg/day.

“Very few patients received biologics at the outset, because it's very difficult to access these drugs in our province and country using public health drug coverage,” she said at the meeting, sponsored by the European League Against Rheumatism. Only after 6–9 months can patients in Canada begin to access biologics, she said.

By 12 months, only 47% of patients achieved remission as defined as a DAS28 less than 2.6, even when receiving an aggressive DMARD strategy followed by biologic therapies in patients whose disease responded inadequately at 6 months.

“Although the data are still preliminary, for a significant proportion of patients with early RA or inflammatory arthritis, a different strategy than early DMARD therapy may be required,” she said.

Studies are needed to validate that the earlier use of biologics is more effective in protecting the joint against the destruction of RA and inflammatory arthritis and to identify prognostic factors or biomarkers that can predict who will not respond to an initial DMARD strategy including high-dose methotrexate, according to Dr. Bykerk.

AMSTERDAM — Initial therapy using traditional disease-modifying anti-rheumatic drugs—even early, aggressively, and in combination—is inadequate for a significant proportion of patients with inflammatory arthritis, according to preliminary data from a prospective Canadian study.

In rheumatoid arthritis (RA), joint damage and the resulting disability occur during the first years of disease, and current therapeutic strategies aim to be aggressive in minimizing inflammation and preventing irreversible damage.

But among a cohort of 79 patients followed for 12 months in a real-world setting, fewer than half achieved remission with disease-modifying antirheumatic drug (DMARD) treatment, Dr. Vivian P. Bykerk said at the annual European Congress of Rheumatology.

For inclusion in the Toronto Early Arthritis Cohort, patients were required to be at least 16 years old and to have had symptoms for at least 6 weeks but less than 1 year. They had to have at least two swollen joints or one swollen metacarpophalangeal joint or proximal interphalangeal joint and to have more than one of the following characteristics: rheumatoid factor positive, anti-CCP positive, morning stiffness exceeding 45 minutes' duration, a response to nonsteroidal anti-inflammatory drugs, and a painful metatarsophalangeal joint squeeze test.

At baseline the mean patient age was 45.5 years, and 80% were female. Median duration of symptoms was 161 days at the time of evaluation.

Mean erythrocyte sedimentation rate was 28 mm/h, and mean C-reactive protein level was 13 mg/L. The mean tender joint count was 19, mean swollen joint count was 11, and mean Disease Activity Score (DAS) was 5.3. A total of 28% of patients were rheumatoid factor positive, and 67% met the criteria for RA. In addition, 26% already had erosions present in the hands or feet.

Recommended initial treatment for RA in Canada involves combination therapy, but only 60% of patients in this cohort were started on more than one DMARD. This probably reflects a lower disease burden and also possibly patient preference, said Dr. Bykerk of Mount Sinai Hospital, Toronto.

When combination therapy was used, it generally was methotrexate plus hydroxychloroquine or sulfasalazine. The methotrexate dose was 15–25 mg/week, the mean dose at 12 months was 18 mg/week, and for two-thirds of patients the dose exceeded 20 mg/week. A third of the patients opted to take their methotrexate subcutaneously, she said. “In Canada we are strong proponents of subcutaneous methotrexate in doses of 20–25 mg early on,” she said.

The sulfasalazine dose was 2 g/day, and the hydroxychloroquine dose was 400 mg/day.

“Very few patients received biologics at the outset, because it's very difficult to access these drugs in our province and country using public health drug coverage,” she said at the meeting, sponsored by the European League Against Rheumatism. Only after 6–9 months can patients in Canada begin to access biologics, she said.

By 12 months, only 47% of patients achieved remission as defined as a DAS28 less than 2.6, even when receiving an aggressive DMARD strategy followed by biologic therapies in patients whose disease responded inadequately at 6 months.

“Although the data are still preliminary, for a significant proportion of patients with early RA or inflammatory arthritis, a different strategy than early DMARD therapy may be required,” she said.

Studies are needed to validate that the earlier use of biologics is more effective in protecting the joint against the destruction of RA and inflammatory arthritis and to identify prognostic factors or biomarkers that can predict who will not respond to an initial DMARD strategy including high-dose methotrexate, according to Dr. Bykerk.

AMSTERDAM — Initial therapy using traditional disease-modifying anti-rheumatic drugs—even early, aggressively, and in combination—is inadequate for a significant proportion of patients with inflammatory arthritis, according to preliminary data from a prospective Canadian study.

In rheumatoid arthritis (RA), joint damage and the resulting disability occur during the first years of disease, and current therapeutic strategies aim to be aggressive in minimizing inflammation and preventing irreversible damage.

But among a cohort of 79 patients followed for 12 months in a real-world setting, fewer than half achieved remission with disease-modifying antirheumatic drug (DMARD) treatment, Dr. Vivian P. Bykerk said at the annual European Congress of Rheumatology.

For inclusion in the Toronto Early Arthritis Cohort, patients were required to be at least 16 years old and to have had symptoms for at least 6 weeks but less than 1 year. They had to have at least two swollen joints or one swollen metacarpophalangeal joint or proximal interphalangeal joint and to have more than one of the following characteristics: rheumatoid factor positive, anti-CCP positive, morning stiffness exceeding 45 minutes' duration, a response to nonsteroidal anti-inflammatory drugs, and a painful metatarsophalangeal joint squeeze test.

At baseline the mean patient age was 45.5 years, and 80% were female. Median duration of symptoms was 161 days at the time of evaluation.

Mean erythrocyte sedimentation rate was 28 mm/h, and mean C-reactive protein level was 13 mg/L. The mean tender joint count was 19, mean swollen joint count was 11, and mean Disease Activity Score (DAS) was 5.3. A total of 28% of patients were rheumatoid factor positive, and 67% met the criteria for RA. In addition, 26% already had erosions present in the hands or feet.

Recommended initial treatment for RA in Canada involves combination therapy, but only 60% of patients in this cohort were started on more than one DMARD. This probably reflects a lower disease burden and also possibly patient preference, said Dr. Bykerk of Mount Sinai Hospital, Toronto.

When combination therapy was used, it generally was methotrexate plus hydroxychloroquine or sulfasalazine. The methotrexate dose was 15–25 mg/week, the mean dose at 12 months was 18 mg/week, and for two-thirds of patients the dose exceeded 20 mg/week. A third of the patients opted to take their methotrexate subcutaneously, she said. “In Canada we are strong proponents of subcutaneous methotrexate in doses of 20–25 mg early on,” she said.

The sulfasalazine dose was 2 g/day, and the hydroxychloroquine dose was 400 mg/day.

“Very few patients received biologics at the outset, because it's very difficult to access these drugs in our province and country using public health drug coverage,” she said at the meeting, sponsored by the European League Against Rheumatism. Only after 6–9 months can patients in Canada begin to access biologics, she said.

By 12 months, only 47% of patients achieved remission as defined as a DAS28 less than 2.6, even when receiving an aggressive DMARD strategy followed by biologic therapies in patients whose disease responded inadequately at 6 months.

“Although the data are still preliminary, for a significant proportion of patients with early RA or inflammatory arthritis, a different strategy than early DMARD therapy may be required,” she said.

Studies are needed to validate that the earlier use of biologics is more effective in protecting the joint against the destruction of RA and inflammatory arthritis and to identify prognostic factors or biomarkers that can predict who will not respond to an initial DMARD strategy including high-dose methotrexate, according to Dr. Bykerk.

AMSTERDAM — The rate of 1-year adherence to tumor necrosis factor-inhibitor therapy was significantly better among patients with ankylosing spondylitis than in those with either rheumatoid arthritis or psoriatic arthritis, judging from the findngs of a large observational registry, Dr. Marte S. Heiberg reported at the annual European Congress of Rheumatology.

Among rheumatoid arthritis patients—and among psoriatic arthritis patients—rates of adherence to anti-tumor necrosis factor (TNF) therapy were significantly greater in those on concomitant methotrexate than with TNF-blocker monotherapy (see chart).

Ankylosing spondylitis patients, however, were different.

Rate of adherence to anti-TNF therapy among patients with ankylosing spondylitis were identically good regardless of whether the treatment was administered as monotherapy or given in combination with methotrexate, noted Dr. Heiberg of the University of Oslo.

She presented an update from the Norwegian Disease-Modifying Anti-Rheumatic Drug (NOR-DMARD) study, a longitudinal observational study that includes consecutive patients with inflammatory arthropathies placed on DMARD therapy in any of five Norwegian rheumatology departments.

NOR-DMARD is designed to provide comparative information regarding the real-world performance of DMARDs outside the restrictive randomized trial setting.

To date 5,281 patients have been enrolled. During her presentation, Dr. Heiberg focused on 1-year treatment adherence rates among patients with ankylosing spondylitis, rheumatoid arthritis, or psoriatic arthritis placed on etanercept, infliximab, or adalimumab.

Unadjusted 1-year adherence to anti-TNF therapy was 82% in ankylosing spondylitis patients, 78% in those with psoriatic arthritis, and 67% in rheumatoid arthritis patients.

Female gender and older age were associated with lower treatment adherence, in a Cox multivariate regression analysis. Concomitant methotrexate was associated with increased adherence—except among patients with ankylosing spondylitis.

One-year adherence wasn't significantly influenced by which TNF inhibitor a patient was being treated with.

The adjusted relative risk of anti-TNF treatment discontinuation for any reason within the first year was 37% less in ankylosing spondylitis patients and 21% less in psoriatic arthritis patients than in those with rheumatoid arthritis.

Women were 63% more likely to stop therapy than were men. Patients on concomitant methotrexate had a 44% reduction in treatment termination.

Psoriatic arthritis patients were more likely than others to discontinue anti-TNF therapy due to adverse events and least likely to do so because of lack of efficacy, Dr. Heiberg noted at the congress sponsored by the European League Against Rheumatism.

ELSEVIER GLOBAL MEDICAL NEWS

AMSTERDAM — The rate of 1-year adherence to tumor necrosis factor-inhibitor therapy was significantly better among patients with ankylosing spondylitis than in those with either rheumatoid arthritis or psoriatic arthritis, judging from the findngs of a large observational registry, Dr. Marte S. Heiberg reported at the annual European Congress of Rheumatology.

Among rheumatoid arthritis patients—and among psoriatic arthritis patients—rates of adherence to anti-tumor necrosis factor (TNF) therapy were significantly greater in those on concomitant methotrexate than with TNF-blocker monotherapy (see chart).

Ankylosing spondylitis patients, however, were different.

Rate of adherence to anti-TNF therapy among patients with ankylosing spondylitis were identically good regardless of whether the treatment was administered as monotherapy or given in combination with methotrexate, noted Dr. Heiberg of the University of Oslo.

She presented an update from the Norwegian Disease-Modifying Anti-Rheumatic Drug (NOR-DMARD) study, a longitudinal observational study that includes consecutive patients with inflammatory arthropathies placed on DMARD therapy in any of five Norwegian rheumatology departments.

NOR-DMARD is designed to provide comparative information regarding the real-world performance of DMARDs outside the restrictive randomized trial setting.

To date 5,281 patients have been enrolled. During her presentation, Dr. Heiberg focused on 1-year treatment adherence rates among patients with ankylosing spondylitis, rheumatoid arthritis, or psoriatic arthritis placed on etanercept, infliximab, or adalimumab.

Unadjusted 1-year adherence to anti-TNF therapy was 82% in ankylosing spondylitis patients, 78% in those with psoriatic arthritis, and 67% in rheumatoid arthritis patients.

Female gender and older age were associated with lower treatment adherence, in a Cox multivariate regression analysis. Concomitant methotrexate was associated with increased adherence—except among patients with ankylosing spondylitis.

One-year adherence wasn't significantly influenced by which TNF inhibitor a patient was being treated with.

The adjusted relative risk of anti-TNF treatment discontinuation for any reason within the first year was 37% less in ankylosing spondylitis patients and 21% less in psoriatic arthritis patients than in those with rheumatoid arthritis.

Women were 63% more likely to stop therapy than were men. Patients on concomitant methotrexate had a 44% reduction in treatment termination.

Psoriatic arthritis patients were more likely than others to discontinue anti-TNF therapy due to adverse events and least likely to do so because of lack of efficacy, Dr. Heiberg noted at the congress sponsored by the European League Against Rheumatism.

ELSEVIER GLOBAL MEDICAL NEWS

AMSTERDAM — The rate of 1-year adherence to tumor necrosis factor-inhibitor therapy was significantly better among patients with ankylosing spondylitis than in those with either rheumatoid arthritis or psoriatic arthritis, judging from the findngs of a large observational registry, Dr. Marte S. Heiberg reported at the annual European Congress of Rheumatology.

Among rheumatoid arthritis patients—and among psoriatic arthritis patients—rates of adherence to anti-tumor necrosis factor (TNF) therapy were significantly greater in those on concomitant methotrexate than with TNF-blocker monotherapy (see chart).

Ankylosing spondylitis patients, however, were different.

Rate of adherence to anti-TNF therapy among patients with ankylosing spondylitis were identically good regardless of whether the treatment was administered as monotherapy or given in combination with methotrexate, noted Dr. Heiberg of the University of Oslo.

She presented an update from the Norwegian Disease-Modifying Anti-Rheumatic Drug (NOR-DMARD) study, a longitudinal observational study that includes consecutive patients with inflammatory arthropathies placed on DMARD therapy in any of five Norwegian rheumatology departments.

NOR-DMARD is designed to provide comparative information regarding the real-world performance of DMARDs outside the restrictive randomized trial setting.

To date 5,281 patients have been enrolled. During her presentation, Dr. Heiberg focused on 1-year treatment adherence rates among patients with ankylosing spondylitis, rheumatoid arthritis, or psoriatic arthritis placed on etanercept, infliximab, or adalimumab.

Unadjusted 1-year adherence to anti-TNF therapy was 82% in ankylosing spondylitis patients, 78% in those with psoriatic arthritis, and 67% in rheumatoid arthritis patients.

Female gender and older age were associated with lower treatment adherence, in a Cox multivariate regression analysis. Concomitant methotrexate was associated with increased adherence—except among patients with ankylosing spondylitis.

One-year adherence wasn't significantly influenced by which TNF inhibitor a patient was being treated with.

The adjusted relative risk of anti-TNF treatment discontinuation for any reason within the first year was 37% less in ankylosing spondylitis patients and 21% less in psoriatic arthritis patients than in those with rheumatoid arthritis.

Women were 63% more likely to stop therapy than were men. Patients on concomitant methotrexate had a 44% reduction in treatment termination.

Psoriatic arthritis patients were more likely than others to discontinue anti-TNF therapy due to adverse events and least likely to do so because of lack of efficacy, Dr. Heiberg noted at the congress sponsored by the European League Against Rheumatism.

ELSEVIER GLOBAL MEDICAL NEWS