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Combination of Disease-Modifying Drugs Should Become Standard For Early Rheumatoid Arthritis

MD-FM Thursday October 31st, 2013



MD FM — Medical News from around the world with Peter Goodwin.


P1: RHEUMATOID ARTHRITIS: Combination of disease-modifying drugs better than monotherapy to treat early cases


PETER: Hello and with me is Sarah Maxwell. To begin with, news from the annual meeting of the American College of Rheumatology, in San Diego this week: For treating patients with early rheumatoid arthritis, a combination of three disease-modifying anti-rheumatic drugs together was better than using just methotrexate alone…


SARAH: That’s right – in a randomized trial with nearly 300 patients who had recent-onset RA, methotrexate with sulfa-salazine and hydroxy-chloroquine controlled the disease much faster than methotrexate alone — irrespective of the steroid regimen. Importantly: There were less treatment failures with triple therapy: so patients needed 40 per cent fewer biologics than those on monotherapy. And there were no differences in side effects between the two regimens. Pascal de Jong:


De Jong: “We think that because you give a much harder punch, the disease control was better achieved and we know that, if you have disease control early in the disease, later on, you need less medication to maintain that disease control. So every new patient where the diagnosis of RA is made, and who have not used prior DMARDS, should be started on a combination of DMARDS --that’s our advice”  

SARAH: That was lead study investigator, Dr. Pascal de Jong from Erasmus Medical Center in Amsterdam, speaking to MDFM at the San Diego meeting. Triple-therapy was also more cost-effective than monotherapy — because fewer expensive biologics were needed and patients ended up being more functional in their daily lives.

P2: Smoking associated with more radiographic damage in ankylosing spondylitis. 


PETER: Fresh data — also presented at the ACR meeting — showed that in people with ankylosing spondylitis, smoking can amplify the effect disease activity has on radiographically detected damage at least five-fold…


SARAH: Yes, and you can see new bone formation from this. And smoking appeared to increase the effects of inflammation on radiographic damage. Sofia Ramiro, presented these latest findings in San Diego:


Ramiro: “This is a bit of a change compared to what we were thinking… We thought that smoking could be the one that was causing the radiographic damage as such, now, what we see is that smoking is a factor that is increasing another relationship. We can hypothesize that either smoking is involved in the pathophysiology of the disease and is contributing to the development of bone formation, and we don’t exactly know why, or the alternative is that smoking stands here as a confounder --what we mean is that it stands in place of something else that is disturbing this relationship and it could be, for example, lower socioeconomic factors. But this is something that we haven’t really so far studied.”  


SARAH: That was Dr. Sofia Ramiro, from the Netherlands, whose team followed nearly 130 patients with ankylosing spondylitis over 12 years. Interestingly, they found that smoking was especially detrimental in younger men with the disease:


Ramiro: “In patients with a shorter symptom duration, symptoms of less than 18 years, this impact was 8 times higher than in patients who had a longer symptom duration. and in men who were smokers, this effect was 13.4 times higher compared to women who were non-smokers.”  


SARAH: Sofia Ramiro from the University of Amsterdam, who of course recommends smoking cessation, especially for young male patients.


 P3: Bracing improved pain and bone marrow lesions in knee osteoarthritis.


PETER: And our last piece of news from the ACR meeting: for patients with osteoarthritis of the knee, wearing a patellofemoral brace for six weeks improved knee pain and MRI-detected bone lesions. These are the results of a study looking at 126 patients randomly allocated either to wearing a brace for seven to eight hours a day, or to have no bracing.


P4: Can antiretrovirals be halted in some carefully selected pediatric patients?


PETER: Experts are currently considering whether you could stop antiretroviral therapy in some children born with HIV who achieve undetectable levels of the virus in their blood…


SARAH: Yes, in a study published in the New England Journal of Medicine, a child —the so called “Mississippi baby,” born to an HIV-infected, treatment-naïve mother — was put on an unconventionally aggressive anti retroviral therapy just 30 hours after birth. And although the parents stopped therapy after 18 months, to everyone’s surprise, the virus hasn’t shown up in blood tests! This finding follows observations made in the so-called Mississippi baby who was still doing well 12 months after stopping ART.


PETER: Sounds encouraging, so what do the experts think’s going on?


SARAH: Well, they say this heavy regimen was administered so early on, it actually prevented the virus from establishing its latent reservoir. The virus is present, but levels are too low for it to replicate. As you can imagine, these findings have rapidly inspired new research. Emily Erbelding, from Bethesda, Maryland,   :


Erbelding: “The first step is that clinical investigators need to develop a protocol that sort of tries to replicate the events that happened in this case exactly. We need to draw laboratory tests very early and then enroll them and start HIV therapy in a way that we could test later whether their viral reservoirs have HIV in them or not, and if it can’t be found, consider talking to the care providers and to the parents about whether HIV treatment can be safely interrupted. The IMPAACT network investigators --they are writing that protocol and getting required approvals right now, so it’s underway.”


SARAH: That was Dr. Emily Erbelding — from the National Institute of Allergy and Infectious Diseases in the USA.


P5: Medication and lifestyle changes better than stents for preventing recurrent stroke in patients with narrowed brain arteries.


PETER: An aggressive medical regimen and lifestyle changes are apparently safer and more effective than stenting to prevent recurrent stroke in patients with narrowed brain arteries…


SARAH: Yes, these are the long-term findings (32 months exactly) of a study that followed 450 patients who’d already had a stroke or a transient ischaemic attack. The trial’s initial findings had already shown that stenting wasn’t better than medication and lifestyle changes in the short-term. The investigators were actually surprised by these results and thought long-term outcomes might be different but, they weren’t:


Derdeyn. “There’s really some extremely powerful benefit from treating these patients right away, to lower their blood pressure, to get control of their cholesterol, to put them on two different agents to help prevent blood clots --aspirin and plavix --it’s better than angioplasty and stenting and it’s really a remarkable finding.”


SARAH: That was lead study author Dr. Colin Derdeyn, from Washington University School of Medicine in St. Louis. He said stents might still be beneficial in some unstable patients…


Derdeyn. “I think where the real future is is identifying some high risk groups that don’t do well with the medical therapies. You know we still had 12 or 14 people out of 100, at the end of two years, who had stroke and so there maybe a subgroup that’s at a very high risk, because of low flow or other kinds of factors, and who might benefit from angioplasty and stenting.”


SARAH: Colin Derdeyn from St. Louis, Missouri.


B1: Bariatric surgery better than non-surgical methods for treating obese patients. 

PETER: Finally, in brief: For people who are obese, bariatric surgery was more effective at reducing body weight than non-surgical methods, such as: behavioral therapy, dietary changes, increasing physical activity and the use of weight-loss medication. These are the conclusions of a meta-analysis — reported in the British Medical Journal — which showed that surgery also increased remission rates of type-2 diabetes and metabolic syndrome. And...


B2: On-the-spot tuberculosis diagnostic test not better than smear microscopy. 

PETER: An on-the-spot rapid diagnostic test for tuberculosis, known as the Xpert MTB/RIF test, gave quicker diagnoses and lead to patients starting treatment faster than with usual smear microscopy. However, it did not reduce illness. And by the end of the study — published in The Lancet — 8 per cent of patients in both groups had died. The authors of this first real-life evaluation of this test conclude: its potential long-term effect is probably overestimated.


PETER: That's all from MDFM for now. Sarah Maxwell and I will be back with more next week, so until then from me Peter Goodwin, goodbye!




Previous editions


Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)

Best of Science in Nutrition 2013: Yogurt for a healthier diet (EB & IUNS 2013)
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