Arthritis Drugs & New Medications-2001 Meeting (cont.)

PLAQUENIL (hydroxychloroquine)

Plaquenil is commonly used to treat rheumatoid arthritis and systemic lupus erythematosus.

Plaquenil protects against both heart and kidney damage in lupus patients. Another paper also found protection for nervous system damage.

Dr. Shiel's Perspective: Earlier studies had suggested this protective effect years ago. I tend to favor long-term usage of Plaquenil for such preventative purposes.

ALEFACEPT

Alefacept is an experimental drug that is not commercially available. Alefacept was given intravenously weekly for 12 weeks to 11 patients with psoriatic arthritis. It was found to improve joint symptoms and reduce the psoriasis.

Dr. Shiel's Perspective: This is a very preliminary study. I feel its primary interest lies in the fact that psoriasis and psoriatic arthritis are both significantly affected by T cell action. This drug blocks T cell activation and this likely explains its effects. While this report is encouraging, more studies will be required to verify the drug's safety and effectiveness of treatment in larger numbers of patients.

PROZAC

At this meeting, Prozac (fluoxetine) was demonstrated to be effective in relieving the symptoms of fibromyalgia in a study from the University of Cincinnati Medical Center. It seemed to significantly help the pain and fatigue, as well as associated depression. The patients studied were all female and were 18 years of age or older.

Dr. Shiel's Perspective: In speaking with the presenter of this paper, she told me that on average patients seemed to require higher than the starting doses of Prozac for best results. She adjusted up the doses at 2 week intervals. Prozac has been reported to be beneficial in the past when taken together with Elavil. This study documents that some patients will find Prozac helpful if taken alone.

ULTRACET

Ulracet was effective and well tolerated in relieving the pain symptoms of fibromyalgia. 313 patients were studied and 94% were female.

Dr. Shiel's Perspective: I am not surprised by this study, which was performed by one of the national experts in fibromyalgia from Oregon. I have been using Ultram for some time and finding it helpful for many, but not all, patients with fibromyalgia. Ultracet is a combination pill that contains both the main ingredient in Ultram and acetaminophen (Tylenol).

COLCHICINE INTRAVENOUSLY

21 deaths from intravenous (given in the vein) colchicine were reported. The causes of death included bone marrow suppression and kidney failure.

Dr. Shiel's Perspective: Colchicine is commonly used to treat both gout and pseudogout. Although this drug is typically given by mouth, occasionally there is no other method of administration in certain patients except to give it by vein (intravenously). This study strongly emphasizes that when it used in this manner, colchicine can be dangerous if the doses exceed the maximum recommended cumulative dose of treatment of 4 milligrams. The doses must also be reduced in patients with kidney or liver dysfunction and in the elderly.

CYTOXAN (cyclophosphamide)

Lung scarring (pulmonary fibrosis) did not progress in most patients with systemic sclerosis, even without cyclophosphamide (Cytoxan), over 6 years.

Dr. Shiel's Perspective: Lung scarring conditions can seriously damage the lung. Although Cytoxan can improve many lung scarring conditions, it is now difficult to recommend this potentially toxic drug for the scarring form of scleroderma lung (pulmonary fibrosis). This form of lung disease must be distinguished from inflammation of the lungs' tiny air sacs (alveolitis), as in the next report below.

The inflammation of the lungs' tiny air sacs (alveolitis) stabilized or improved in scleroderma patients treated with cyclophosphamide (Cytoxan) and prednisone.

Dr. Shiel's Perspective: This form of lung disease (as compared to the one described in the report above) actually did respond to Cytoxan. The key element seems to be inflammation. If inflammation is present in the lungs, it may be helped by Cytoxan treatments (typically given as a monthly intravenous infusion). The exact form of lung disease requires a lung biopsy for a precise diagnosis.

For patients with Wegener's Granulomatosis, cytoxan (cyclophosphamide) that is taken by mouth with prednisone until the condition is in remission and then switched to methotrexate for 2 years and tapered off was effective and less toxic than the traditional long-term Cytoxan treatment.

Dr. Shiel's Perspective: This was an important paper presented at this meeting. Methotrexate has recently been introduced as a drug for Cytoxan treatment failures. I have several patients doing very well on it for this purpose in my practice. The significance of this paper is twofold. First, while Cytoxan is very effective, it is also toxic. It now appears that Cytoxan will not be necessary in order to maintain long-term remission in Wegener's Granulomatosis and that doctors can convert to the less toxic methotrexate for maintenance. Secondly, the report also demonstrates that methotrexate can eventually be tapered off entirely after 2 years. This is good news for patients with Wegener's granulomatosis.



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