Rheumatoid Arthritis Perspectives:2004 Ntl. Mtg. (cont.)
Abatacept was reported as effective and safe in treating patients with rheumatoid arthritis who had failed treatment with Remicade or Enbrel. Another paper reported that abatacept was effective in decreasing signs and symptoms of rheumatoid arthritis in patients failing methotrexate.
Dr. Shiel's Perspective: Abatacept may be a viable option in the near future for those patients who do not respond to Humira, Remicade, or Enbrel. Importantly, abatacept halted erosion of joints in the patients studied.
There was a fine lecture concerning folic acid given by American Cancer Society Clinical Research Professor, Dr. Barton A. Kamen. The lecture highlighted the importance of taking folic acid supplement, especially in persons taking methotrexate.
Dr. Shiel's Perspective: Rheumatologists have long been adding folic acid with methotrexate or sulfasalazine (Azulfadine) in order to minimize risks of side effects, including anemia and mouth sores. It turns out that the biochemistry of folic acid is such that it can decrease the risk of blood vessel disease (atherosclerosis) by lowering homocysteine levels! Moreover, it may have additional benefits in decreasing the risk of cancer and Alzheimer's disease!!
There were numerous reports that found a direct association between rheumatoid arthritis and blood vessel disease, including atherosclerosis as well as carotid and coronary artery disease.
Dr. Shiel's Perspective: This was big at this meeting. Patients with rheumatoid arthritis are at an increased risk for developing heart disease and heart attacks. It is very important for patients with rheumatoid arthritis to optimize their heart disease risk factors. This includes stopping cigarette smoking, controlling blood pressure, exercising regularly, weight reduction when necessary, and having evaluation of cholesterol profile, homocysteine levels, and blood sugar testing.
Researchers from Harvard and Spain reported data that clearly suggests that EARLY treatment is better, more effective, and that the effect is sustained over the long-term.
Dr. Shiel's Perspective: This report complements many like it that document the need for early diagnosis and aggressive treatment. The long-term benefit of early initiation of disease-modifying agents is clear as they can permanently alter the course of the disease.
Researchers from Spain found that the incidence of cancer in patients with rheumatoid arthritis who took biologic treatments, such as Remicade, Enbrel, and Humira, had no more cancer than rheumatoid arthritis patients who did not take these treatments.
Dr. Shiel's Perspective: While there is a theoretical increased risk of cancer, because of the method of action of these medications, this does not in fact seem to be the case.
Flu vaccine worked in rheumatoid arthritis patients inspite of immune suppressive medications such as prednisone, methotrexate, Plaquenil, Remicade, or Enbrel. The rheumatoid disease was not affected by the vaccination.
Dr. Shiel's Perspective: Well, now we can be assured that the flu vaccine works and it is safe in patients with rheumatoid arthritis. It is unfortunate that there is a severe shortage this year!
Citrulline antibody testing (anti-CCP antibody) was reported in several papers to be helpful in diagnosing early and more aggressive rheumatoid arthritis. It was also shown to be helpful in distinguishing rheumatoid arthritis from hepatitis C associated joint disease, which can be difficult. Another report noted that children with rheumatoid arthritis who had citrulline antibodies also were found to have more aggressive arthritis
Dr. Shiel's Perspective: Again, the earlier we hit this disease, the better. Furthermore, the presence of citrulline antibodies indicated rheumatoid arthritis with a greater than 95% accuracy! This confirms similar data presented at last year's meeting. Patients who had citrulline antibodies in their blood also had more aggressive rheumatoid arthritis. Researchers also found that some people had these antibodies present before the onset of rheumatoid arthritis and implied that citrulline antibody testing could predict who might develop the disease. I currently use the blood test not only to define more aggressive disease, but also to diagnose rheumatoid arthritis in patients that do not have the typical rheumatoid factor blood test (this occurs in approximately 20% of patients with rheumatoid arthritis) and in distinguishing rheumatoid from other forms of arthritis, such as that associated with hepatitis C virus infection.
Vioxx, a drug that has been used to quiet inflammation of arthritis and relieve pain, was withdrawn from the market by its maker, Merck, on September 30, 2004. The reason for the withdrawal was the occurrence of side effects noted in a study that Merck was conducting to see if Vioxx could prevent polyps of the colon and rectum. During this trial, it was noted that there was an increased risk for heart attack and stroke in patients continuing to take Vioxx longer than 18 months.
Dr. Shiel's Perspective: Vioxx is no longer available for use and those taking it should contact their physicians to consider alternative treatment. The risk of heart attack or stroke was small, but real. It is of note that there was no increased risk of stroke in patients taking Vioxx less than 18 months in the study. There has been no indication that any long term damage occurs once the drug is discontinued. The question of interest is a natural concern for inflammation medications of the same class as Vioxx. This class is referred to as Cox-2 inhibitors and includes Celebrex and Bextra NOTE: April 7, 2005, Pfizer agreed to suspend sales and marketing of Bextra in the U.S., pending further discussions with the with the FDA. For more information, please read the FDA press release. . At the national meeting, an FDA spokesperson commented that there is currently an ongoing trial of Celebrex in the prevention of colon polyps. The FDA asked that the 5 year study (now at 2 years) be opened to see if there were signs that Celebrex was increasing the risk of heart attacks or stroke in the study patients. The FDA has allowed the study to continue after reviewing the preliminary data. It therefore seems that not all Cox-2 antiinflammatory drugs are the same. The FDA spokesperson stated that there is no definitive evidence that Celebrex carries an increased risk for heart disease or stroke. It may be, in fact, that different Cox-2 drugs, having different powers of selective action on the Cox-2 enzyme, may have different potential for these blood vessel risks. More data will be forthcoming that will help to clarify risks of drugs used to treat inflammation. Interestingly, Merck has a drug now on the market outside of the U.S. that is used for pain and inflammation relief. The drug, etoricoxib (Arcoxia) was presented in 4 studies at the national meeting and shown to be safe and effective in treating gout, osteoarthritis, and ankylosing spondylitis. Etoricoxib (Arcoxia) is awaiting approval for use in the U.S. and while its maker notes that it has been shown to be safe, I believe it will undergo serious scrutiny of longer term studies prior to approval for the U.S. market.
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