Sharon Worcester

WASHINGTON – A new model for estimating 10-year cardiovascular disease risk in patients with rheumatoid arthritis that draws on a combination of demographic factors, cardiovascular risk factors, and RA-related factors appears to more accurately predict risk than do currently available models.

The new model was developed based on findings from the prospective longitudinal CARRE study, Dr. Alper M. van Sijl reported at the annual meeting of the American College of Rheumatology.

In that study of 353 RA patients, 58 cardiovascular events occurred over 2,361 patient years of follow-up. The cardiovascular disease incidence was 16.4%, but existing, commonly used risk prediction models, including the Reynolds Risk Score, the Systemic Coronary Risk Evaluation (SCORE), and the Framingham Risk Score, underestimated the risk. At baseline, the SCORE and Framingham models, for example, estimated the incidence at 5.9% and 13%, respectively, said Dr. van Sijl of Jan van Breemen Research Institute, Reade, Amsterdam.

Using CARRE study information, including cardiovascular risk factors, RA-related factors, and surrogate markers of cardiovascular disease collected at baseline, predictive models using a number of variables alone or in combinations were tested. The new model for predicting risk in RA patients without prior cardiovascular disease that emerged included age, gender, use of statins and prednisone, body-mass index, diastolic blood pressure, low-density lipoprotein cholesterol, total cholesterol to high-density lipoprotein cholesterol ratio, C-reactive protein, Health Assessment Questionnaire scores, and erythrocyte sedimentation rate.

Using receiver operating curves analyses, the new model predicted cardiovascular disease incidence better than the other methods (area under the curve [AUC] 0.801 vs. 0.712), he said, noting that at a cutoff value of 10, the model had 85% sensitivity.

The findings are important because RA is associated with an increased risk of incident cardiovascular disease, which, according to the CARRE findings, has failed to decline significantly since 2000 despite the advent of effective anti-inflammatory therapies and the increased use of cardioprotective therapies. The risk is only partly explained by cardiovascular risk factors.

Additional external validation studies are needed to confirm these findings before the model can be implemented, and studies should also consider whether modification of existing risk models is necessary to improve the cardiovascular risk assessment of RA patients, he concluded.

Dr. van Sijl reported having no disclosures.

WASHINGTON – A new model for estimating 10-year cardiovascular disease risk in patients with rheumatoid arthritis that draws on a combination of demographic factors, cardiovascular risk factors, and RA-related factors appears to more accurately predict risk than do currently available models.

The new model was developed based on findings from the prospective longitudinal CARRE study, Dr. Alper M. van Sijl reported at the annual meeting of the American College of Rheumatology.

In that study of 353 RA patients, 58 cardiovascular events occurred over 2,361 patient years of follow-up. The cardiovascular disease incidence was 16.4%, but existing, commonly used risk prediction models, including the Reynolds Risk Score, the Systemic Coronary Risk Evaluation (SCORE), and the Framingham Risk Score, underestimated the risk. At baseline, the SCORE and Framingham models, for example, estimated the incidence at 5.9% and 13%, respectively, said Dr. van Sijl of Jan van Breemen Research Institute, Reade, Amsterdam.

Using CARRE study information, including cardiovascular risk factors, RA-related factors, and surrogate markers of cardiovascular disease collected at baseline, predictive models using a number of variables alone or in combinations were tested. The new model for predicting risk in RA patients without prior cardiovascular disease that emerged included age, gender, use of statins and prednisone, body-mass index, diastolic blood pressure, low-density lipoprotein cholesterol, total cholesterol to high-density lipoprotein cholesterol ratio, C-reactive protein, Health Assessment Questionnaire scores, and erythrocyte sedimentation rate.

Using receiver operating curves analyses, the new model predicted cardiovascular disease incidence better than the other methods (area under the curve [AUC] 0.801 vs. 0.712), he said, noting that at a cutoff value of 10, the model had 85% sensitivity.

The findings are important because RA is associated with an increased risk of incident cardiovascular disease, which, according to the CARRE findings, has failed to decline significantly since 2000 despite the advent of effective anti-inflammatory therapies and the increased use of cardioprotective therapies. The risk is only partly explained by cardiovascular risk factors.

Additional external validation studies are needed to confirm these findings before the model can be implemented, and studies should also consider whether modification of existing risk models is necessary to improve the cardiovascular risk assessment of RA patients, he concluded.

Dr. van Sijl reported having no disclosures.

WASHINGTON – A new model for estimating 10-year cardiovascular disease risk in patients with rheumatoid arthritis that draws on a combination of demographic factors, cardiovascular risk factors, and RA-related factors appears to more accurately predict risk than do currently available models.

The new model was developed based on findings from the prospective longitudinal CARRE study, Dr. Alper M. van Sijl reported at the annual meeting of the American College of Rheumatology.

In that study of 353 RA patients, 58 cardiovascular events occurred over 2,361 patient years of follow-up. The cardiovascular disease incidence was 16.4%, but existing, commonly used risk prediction models, including the Reynolds Risk Score, the Systemic Coronary Risk Evaluation (SCORE), and the Framingham Risk Score, underestimated the risk. At baseline, the SCORE and Framingham models, for example, estimated the incidence at 5.9% and 13%, respectively, said Dr. van Sijl of Jan van Breemen Research Institute, Reade, Amsterdam.

Using CARRE study information, including cardiovascular risk factors, RA-related factors, and surrogate markers of cardiovascular disease collected at baseline, predictive models using a number of variables alone or in combinations were tested. The new model for predicting risk in RA patients without prior cardiovascular disease that emerged included age, gender, use of statins and prednisone, body-mass index, diastolic blood pressure, low-density lipoprotein cholesterol, total cholesterol to high-density lipoprotein cholesterol ratio, C-reactive protein, Health Assessment Questionnaire scores, and erythrocyte sedimentation rate.

Using receiver operating curves analyses, the new model predicted cardiovascular disease incidence better than the other methods (area under the curve [AUC] 0.801 vs. 0.712), he said, noting that at a cutoff value of 10, the model had 85% sensitivity.

The findings are important because RA is associated with an increased risk of incident cardiovascular disease, which, according to the CARRE findings, has failed to decline significantly since 2000 despite the advent of effective anti-inflammatory therapies and the increased use of cardioprotective therapies. The risk is only partly explained by cardiovascular risk factors.

Additional external validation studies are needed to confirm these findings before the model can be implemented, and studies should also consider whether modification of existing risk models is necessary to improve the cardiovascular risk assessment of RA patients, he concluded.

Dr. van Sijl reported having no disclosures.

WASHINGTON – Rheumatoid arthritis–related autoantibodies are associated with subclinical and clinical atherosclerosis, according to findings from a prospective population-based study.

The results suggest that autoimmune factors play a role in the pathogenesis of atherosclerosis and cardiovascular disease (CVD) in rheumatoid arthritis (RA) patients, as well as in individuals without RA, Dr. Darcy S. Majka said at the annual meeting of the American College of Rheumatology.

Although the association between RA and CVD is well established, the exact mechanism is unknown.

"RA-related autoantibodies have been identified in individuals years before they develop RA, but most individuals with positive RA-related circulating autoantibodies do not develop clinical RA," said Dr. Majka of Northwestern University, Chicago.

In addition, preliminary data on stored serum samples from individuals without connective tissue disease demonstrated that circulating antiphospholipid antibodies measured in African Americans and whites were associated with subclinical atherosclerosis, she noted.

"This led us to develop the following conceptual model: We know that RA-related autoantibodies can produce inflammation and in some cases lead to possible progression to RA. In addition, the increased progression of subclinical atherosclerosis and cardiovascular events in RA is hypothesized to be mediated by the inflammation of clinically active RA. But we hypothesized that RA-related autoantibodies might be independently associated with subclinical atherosclerosis ... and this might potentially lead to progression to clinical cardiovascular events," she said, in describing the Multi-Ethnic Study of Atherosclerosis (MESA).

Indeed, in 6,557 middle-aged to elderly white, African American, Hispanic, and Chinese middle-aged to elderly adults who have been followed since 2000 as part of MESA, rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP-2) were associated with coronary artery calcium (CAC), a surrogate measure of subclinical atherosclerosis, in both white and African American women. The associations remained after investigators adjusted for traditional risk factors, including age, smoking status, blood pressure, body mass index, high-density lipoprotein cholesterol level, low-density lipoprotein cholesterol level, diabetes mellitus, aspirin use, and cholesterol and blood pressure medication use, she said.

A CAC level of at least 300 was present in 12.2% of participants at baseline, and after 7.1 years of follow-up, 3.0% experienced hard coronary heart disease (CHD) end points, including myocardial infarction, resuscitated cardiac arrest, and CHD death, and 4.8% experienced hard cardiovascular disease end points, including myocardial infarction, cardiac arrest, CHD death, stroke, and stroke death.

Rheumatoid factor (RF) IgM, RF IgA, and anti-CCP-2 were positive in 15.9%, 8.7%, and 2.0% of the MESA participants, respectively. In addition, 4.0% were positive for both RF IgM and RF IgA, and 20.6% were positive for one RF isotype.

The associations between baseline RF/anti-CCP and CAC were assessed and stratified based on race and sex, with adjustment for traditional cardiovascular risk factors.

Among the 1,323 white women in the study, those with RF IgA positivity, either RF IgM or RF IgA positivity, and/or anti-CCP-2 had an increased likelihood of having a CAC level greater than 300 (adjusted odds ratios of 2.3, 1.7, and 0.9 respectively, vs. a CAC of 0). Among 1,000 African American women in the study, those with RF IgA positivity or both RF IgM and RF IgA positivity had an increased likelihood of a CAC level between 100 and 300 (adjusted odds ratios, 2.2 and 2.7, respectively), and those with anti-CCP-2 had an increased likelihood of a CAC level greater than 300 (adjusted odds ratio, 4.0).

In addition, strong associations between RA-related autoantibodies and clinical cardiovascular disease events were seen in African American women in the study. For example, those with RF IgA positivity, either RF IgM or RF IgA positivity, or both RF isotypes were at increased risk of CHD hard end points (adjusted hazard ratios of 5, 2.5, and 4.5, respectively), Also, those with RF IgM positivity were at increased risk for CVD hard end points (adjusted hazard ratio, 2.1). Dr. Majka said.

No clear associations were seen between RA-related autoantibodies and CAC or CHD and CVD hard events in Hispanic and Chinese participants.

"RA-related autoantibodies appear to be independent risk factors for subclinical atherosclerosis and subsequent clinical CVD events," Dr. Majka concluded.

She reported having no relevant financial disclosures.

WASHINGTON – Rheumatoid arthritis–related autoantibodies are associated with subclinical and clinical atherosclerosis, according to findings from a prospective population-based study.

The results suggest that autoimmune factors play a role in the pathogenesis of atherosclerosis and cardiovascular disease (CVD) in rheumatoid arthritis (RA) patients, as well as in individuals without RA, Dr. Darcy S. Majka said at the annual meeting of the American College of Rheumatology.

Although the association between RA and CVD is well established, the exact mechanism is unknown.

"RA-related autoantibodies have been identified in individuals years before they develop RA, but most individuals with positive RA-related circulating autoantibodies do not develop clinical RA," said Dr. Majka of Northwestern University, Chicago.

In addition, preliminary data on stored serum samples from individuals without connective tissue disease demonstrated that circulating antiphospholipid antibodies measured in African Americans and whites were associated with subclinical atherosclerosis, she noted.

"This led us to develop the following conceptual model: We know that RA-related autoantibodies can produce inflammation and in some cases lead to possible progression to RA. In addition, the increased progression of subclinical atherosclerosis and cardiovascular events in RA is hypothesized to be mediated by the inflammation of clinically active RA. But we hypothesized that RA-related autoantibodies might be independently associated with subclinical atherosclerosis ... and this might potentially lead to progression to clinical cardiovascular events," she said, in describing the Multi-Ethnic Study of Atherosclerosis (MESA).

Indeed, in 6,557 middle-aged to elderly white, African American, Hispanic, and Chinese middle-aged to elderly adults who have been followed since 2000 as part of MESA, rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP-2) were associated with coronary artery calcium (CAC), a surrogate measure of subclinical atherosclerosis, in both white and African American women. The associations remained after investigators adjusted for traditional risk factors, including age, smoking status, blood pressure, body mass index, high-density lipoprotein cholesterol level, low-density lipoprotein cholesterol level, diabetes mellitus, aspirin use, and cholesterol and blood pressure medication use, she said.

A CAC level of at least 300 was present in 12.2% of participants at baseline, and after 7.1 years of follow-up, 3.0% experienced hard coronary heart disease (CHD) end points, including myocardial infarction, resuscitated cardiac arrest, and CHD death, and 4.8% experienced hard cardiovascular disease end points, including myocardial infarction, cardiac arrest, CHD death, stroke, and stroke death.

Rheumatoid factor (RF) IgM, RF IgA, and anti-CCP-2 were positive in 15.9%, 8.7%, and 2.0% of the MESA participants, respectively. In addition, 4.0% were positive for both RF IgM and RF IgA, and 20.6% were positive for one RF isotype.

The associations between baseline RF/anti-CCP and CAC were assessed and stratified based on race and sex, with adjustment for traditional cardiovascular risk factors.

Among the 1,323 white women in the study, those with RF IgA positivity, either RF IgM or RF IgA positivity, and/or anti-CCP-2 had an increased likelihood of having a CAC level greater than 300 (adjusted odds ratios of 2.3, 1.7, and 0.9 respectively, vs. a CAC of 0). Among 1,000 African American women in the study, those with RF IgA positivity or both RF IgM and RF IgA positivity had an increased likelihood of a CAC level between 100 and 300 (adjusted odds ratios, 2.2 and 2.7, respectively), and those with anti-CCP-2 had an increased likelihood of a CAC level greater than 300 (adjusted odds ratio, 4.0).

In addition, strong associations between RA-related autoantibodies and clinical cardiovascular disease events were seen in African American women in the study. For example, those with RF IgA positivity, either RF IgM or RF IgA positivity, or both RF isotypes were at increased risk of CHD hard end points (adjusted hazard ratios of 5, 2.5, and 4.5, respectively), Also, those with RF IgM positivity were at increased risk for CVD hard end points (adjusted hazard ratio, 2.1). Dr. Majka said.

No clear associations were seen between RA-related autoantibodies and CAC or CHD and CVD hard events in Hispanic and Chinese participants.

"RA-related autoantibodies appear to be independent risk factors for subclinical atherosclerosis and subsequent clinical CVD events," Dr. Majka concluded.

She reported having no relevant financial disclosures.

WASHINGTON – Rheumatoid arthritis–related autoantibodies are associated with subclinical and clinical atherosclerosis, according to findings from a prospective population-based study.

The results suggest that autoimmune factors play a role in the pathogenesis of atherosclerosis and cardiovascular disease (CVD) in rheumatoid arthritis (RA) patients, as well as in individuals without RA, Dr. Darcy S. Majka said at the annual meeting of the American College of Rheumatology.

Although the association between RA and CVD is well established, the exact mechanism is unknown.

"RA-related autoantibodies have been identified in individuals years before they develop RA, but most individuals with positive RA-related circulating autoantibodies do not develop clinical RA," said Dr. Majka of Northwestern University, Chicago.

In addition, preliminary data on stored serum samples from individuals without connective tissue disease demonstrated that circulating antiphospholipid antibodies measured in African Americans and whites were associated with subclinical atherosclerosis, she noted.

"This led us to develop the following conceptual model: We know that RA-related autoantibodies can produce inflammation and in some cases lead to possible progression to RA. In addition, the increased progression of subclinical atherosclerosis and cardiovascular events in RA is hypothesized to be mediated by the inflammation of clinically active RA. But we hypothesized that RA-related autoantibodies might be independently associated with subclinical atherosclerosis ... and this might potentially lead to progression to clinical cardiovascular events," she said, in describing the Multi-Ethnic Study of Atherosclerosis (MESA).

Indeed, in 6,557 middle-aged to elderly white, African American, Hispanic, and Chinese middle-aged to elderly adults who have been followed since 2000 as part of MESA, rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP-2) were associated with coronary artery calcium (CAC), a surrogate measure of subclinical atherosclerosis, in both white and African American women. The associations remained after investigators adjusted for traditional risk factors, including age, smoking status, blood pressure, body mass index, high-density lipoprotein cholesterol level, low-density lipoprotein cholesterol level, diabetes mellitus, aspirin use, and cholesterol and blood pressure medication use, she said.

A CAC level of at least 300 was present in 12.2% of participants at baseline, and after 7.1 years of follow-up, 3.0% experienced hard coronary heart disease (CHD) end points, including myocardial infarction, resuscitated cardiac arrest, and CHD death, and 4.8% experienced hard cardiovascular disease end points, including myocardial infarction, cardiac arrest, CHD death, stroke, and stroke death.

Rheumatoid factor (RF) IgM, RF IgA, and anti-CCP-2 were positive in 15.9%, 8.7%, and 2.0% of the MESA participants, respectively. In addition, 4.0% were positive for both RF IgM and RF IgA, and 20.6% were positive for one RF isotype.

The associations between baseline RF/anti-CCP and CAC were assessed and stratified based on race and sex, with adjustment for traditional cardiovascular risk factors.

Among the 1,323 white women in the study, those with RF IgA positivity, either RF IgM or RF IgA positivity, and/or anti-CCP-2 had an increased likelihood of having a CAC level greater than 300 (adjusted odds ratios of 2.3, 1.7, and 0.9 respectively, vs. a CAC of 0). Among 1,000 African American women in the study, those with RF IgA positivity or both RF IgM and RF IgA positivity had an increased likelihood of a CAC level between 100 and 300 (adjusted odds ratios, 2.2 and 2.7, respectively), and those with anti-CCP-2 had an increased likelihood of a CAC level greater than 300 (adjusted odds ratio, 4.0).

In addition, strong associations between RA-related autoantibodies and clinical cardiovascular disease events were seen in African American women in the study. For example, those with RF IgA positivity, either RF IgM or RF IgA positivity, or both RF isotypes were at increased risk of CHD hard end points (adjusted hazard ratios of 5, 2.5, and 4.5, respectively), Also, those with RF IgM positivity were at increased risk for CVD hard end points (adjusted hazard ratio, 2.1). Dr. Majka said.

No clear associations were seen between RA-related autoantibodies and CAC or CHD and CVD hard events in Hispanic and Chinese participants.

"RA-related autoantibodies appear to be independent risk factors for subclinical atherosclerosis and subsequent clinical CVD events," Dr. Majka concluded.

She reported having no relevant financial disclosures.

ATLANTA – Medical thoracoscopy is safe and feasible for performing lung biopsy in patients with diffuse parenchymal lung disease of unknown etiology on high-resolution computed tomography. And the approach could serve as an alternative to surgical biopsy in some patients, findings from a prospective study suggest.

In 10 patients who underwent medical thoracoscopic lung biopsies as part of the study, good biopsy specimens, with an average size of 0.5 x 0.4 cm were obtained, Dr. Mohamed Elnady said at the annual meeting of the American College of Chest Physicians.

Complications with this advanced technique included persistent air leak for 5-7 days in two patients, pneumothorax after removal of the intercostals tube in two patients, pain in six patients, and minor bleeding in one patient. The air leaks resolved spontaneously, and the pneumothoraces resolved with administration of high flow oxygen, said Dr. Elnady of Cairo (Egypt) University Hospitals.

The mean duration of intercostal tube placement was 3.1 days, with a range of 1-7 days; no infection, respiratory failure requiring intensive care unit admission, or mortality occurred within 30 days after the procedure, he noted.

Patients in the study included four women and six men with a mean age of 42 years. The lung biopsies obtained via medical thoracoscopy were sent for histopathologic examination, and patients underwent follow-up by chest x-ray for confirmation of lung expansion, as well as observation of the intercostal tube to detect complications. Among the ultimate diagnoses were metastatic adenocarcinoma, interstitial lung disease, and lymphangioleiomyomatosis.

"Thoracosopic lung biopsy by medical thoracoscopy is useful in the diagnosis of patient with diffuse pulmonary infiltrates of unknown etiology when lung biopsy is needed for an accurate diagnosis," Dr. Elnady concluded, noting that while the procedure does carry a risk of certain non–life-threatening complications, these can be minimized with good patient selection.

Commenting on the findings, Dr. Muthiah P. Muthiah, who moderated the session, said this novel approach to obtaining a lung biopsy is of interest, but also "something we still have to get comfortable with."

"I’m not ready to do this yet, but this is something to consider ... you will want to certainly do this with a surgeon’s back-up in your institution," said Dr. Muthiah of the University of Tennessee Health Science Center, Memphis.

Neither Dr. Muthiah nor Dr. Elnady had disclosures to report.

ATLANTA – Medical thoracoscopy is safe and feasible for performing lung biopsy in patients with diffuse parenchymal lung disease of unknown etiology on high-resolution computed tomography. And the approach could serve as an alternative to surgical biopsy in some patients, findings from a prospective study suggest.

In 10 patients who underwent medical thoracoscopic lung biopsies as part of the study, good biopsy specimens, with an average size of 0.5 x 0.4 cm were obtained, Dr. Mohamed Elnady said at the annual meeting of the American College of Chest Physicians.

Complications with this advanced technique included persistent air leak for 5-7 days in two patients, pneumothorax after removal of the intercostals tube in two patients, pain in six patients, and minor bleeding in one patient. The air leaks resolved spontaneously, and the pneumothoraces resolved with administration of high flow oxygen, said Dr. Elnady of Cairo (Egypt) University Hospitals.

The mean duration of intercostal tube placement was 3.1 days, with a range of 1-7 days; no infection, respiratory failure requiring intensive care unit admission, or mortality occurred within 30 days after the procedure, he noted.

Patients in the study included four women and six men with a mean age of 42 years. The lung biopsies obtained via medical thoracoscopy were sent for histopathologic examination, and patients underwent follow-up by chest x-ray for confirmation of lung expansion, as well as observation of the intercostal tube to detect complications. Among the ultimate diagnoses were metastatic adenocarcinoma, interstitial lung disease, and lymphangioleiomyomatosis.

"Thoracosopic lung biopsy by medical thoracoscopy is useful in the diagnosis of patient with diffuse pulmonary infiltrates of unknown etiology when lung biopsy is needed for an accurate diagnosis," Dr. Elnady concluded, noting that while the procedure does carry a risk of certain non–life-threatening complications, these can be minimized with good patient selection.

Commenting on the findings, Dr. Muthiah P. Muthiah, who moderated the session, said this novel approach to obtaining a lung biopsy is of interest, but also "something we still have to get comfortable with."

"I’m not ready to do this yet, but this is something to consider ... you will want to certainly do this with a surgeon’s back-up in your institution," said Dr. Muthiah of the University of Tennessee Health Science Center, Memphis.

Neither Dr. Muthiah nor Dr. Elnady had disclosures to report.

ATLANTA – Medical thoracoscopy is safe and feasible for performing lung biopsy in patients with diffuse parenchymal lung disease of unknown etiology on high-resolution computed tomography. And the approach could serve as an alternative to surgical biopsy in some patients, findings from a prospective study suggest.

In 10 patients who underwent medical thoracoscopic lung biopsies as part of the study, good biopsy specimens, with an average size of 0.5 x 0.4 cm were obtained, Dr. Mohamed Elnady said at the annual meeting of the American College of Chest Physicians.

Complications with this advanced technique included persistent air leak for 5-7 days in two patients, pneumothorax after removal of the intercostals tube in two patients, pain in six patients, and minor bleeding in one patient. The air leaks resolved spontaneously, and the pneumothoraces resolved with administration of high flow oxygen, said Dr. Elnady of Cairo (Egypt) University Hospitals.

The mean duration of intercostal tube placement was 3.1 days, with a range of 1-7 days; no infection, respiratory failure requiring intensive care unit admission, or mortality occurred within 30 days after the procedure, he noted.

Patients in the study included four women and six men with a mean age of 42 years. The lung biopsies obtained via medical thoracoscopy were sent for histopathologic examination, and patients underwent follow-up by chest x-ray for confirmation of lung expansion, as well as observation of the intercostal tube to detect complications. Among the ultimate diagnoses were metastatic adenocarcinoma, interstitial lung disease, and lymphangioleiomyomatosis.

"Thoracosopic lung biopsy by medical thoracoscopy is useful in the diagnosis of patient with diffuse pulmonary infiltrates of unknown etiology when lung biopsy is needed for an accurate diagnosis," Dr. Elnady concluded, noting that while the procedure does carry a risk of certain non–life-threatening complications, these can be minimized with good patient selection.

Commenting on the findings, Dr. Muthiah P. Muthiah, who moderated the session, said this novel approach to obtaining a lung biopsy is of interest, but also "something we still have to get comfortable with."

"I’m not ready to do this yet, but this is something to consider ... you will want to certainly do this with a surgeon’s back-up in your institution," said Dr. Muthiah of the University of Tennessee Health Science Center, Memphis.

Neither Dr. Muthiah nor Dr. Elnady had disclosures to report.

WASHINGTON – Opportunistic infections in children with juvenile idiopathic arthritis are rare, but they occur at a significantly higher rate in JIA patients than in unaffected children, according to findings from an analysis of national Medicaid claims data.

However, the association between these infections and the use of immunosuppressive treatments for JIA appears weak.

The findings, based on data from 2000 through 2005, show that 42 infections occurred in 8,503 children with JIA, and 584 infections occurred in 360,362 non-JIA comparators, for incidence rates of 300 and 125 per 100,000 person years, respectively, and an incident rate ratio (IRR) of 2.4, Dr. Timothy Beukelman reported at the annual meeting of the American College of Rheumatology.

After excluding herpes zoster, which was by far the most common infection among those with JIA, the rate of opportunistic infections was fourfold higher in the JIA cohort compared with the non-JIA cohort.

The infections that occurred at a higher rate in the JIA cohort were Coccidioides (3 infections, for an incidence rate of 21 per 100,000 and an IRR of 101.0), Salmonella (5 infections, for an incidence rate of 35 per 100,000 and an IRR of 3.8), and herpes zoster infections (32 infections for an incidence rate of 225 per 100,000 and an IRR of 2.1), said Dr. Beukelman of the University of Alabama at Birmingham.

One infection each with Nocardia, nontuberculosis mycobateria, Toxoplasma, and Pneumocystis occurred, for an incidence rate of 7 per 100,000 for each of these infections. Incidence rate ratios were not calculated.

No infections with Aspergillus, Blastomyces, Histoplasma, Cryptococcus, Legionella, Listeria, John Cunningham virus, or tuberculosis were identified in the JIA cohort.

These findings differ from those in adults with rheumatoid arthritis (RA).

"We know that adults with RA who are treated with certain biologics have an increased incidence of some opportunistic infections, in particular tuberculosis, endemic mycoses, Listeria, and Legionella," Dr. Beukelman said.

Among the children with JIA, 1,392 used tumor necrosis factor (TNF) inhibitors, and 3,491 used methotrexate during follow-up. An analysis of the association between these treatments and herpes zoster infection found only weak associations with respect to current use of methotrexate (IRR, 1.4 vs. no current methotrexate or TNF inhibitor use), TNF inhibitors (IRR, 2.2 vs. current methotrexate use without current TNF inhibitor use), or glucocorticoids (IRR, 1.8 vs. no current glucocorticoid use), Dr. Beukelman said.

With respect to the Coccidioides infections, the rate was unexpectedly high in the JIA cohort, but two of the patients had no current exposure to TNF inhibitors, methotrexate, or glucocorticoids, and one had exposure only to methotrexate at the time of the infection. None had been treated by TNF inhibitors at any time during the study.

The findings are the first from a controlled trial to address and characterize the incidence of opportunistic infections in JIA patients, Dr. Beukelman said, noting that very little is known about the incidence of opportunistic infections in children with JIA.

Prior studies have, however, demonstrated a twofold increase in the rate of hospitalized infections associated with JIA vs. without JIA in the absence of immunosuppressive infection, so it appears that the JIA disease process itself may predispose to serious bacterial infections.

"We wondered if there might be a similar situation with opportunistic infections," he said.

The findings of the current study suggest that is, indeed, the case.

JIA in this study was based on physician diagnosis codes and dispensed medication. The comparator cohort was composed of children diagnosed with attention deficit hyperactivity disorder. The cohorts had 14,370 and 490,939 person-years of follow-up, respectively.

All subjects had a 3-month baseline period prior to study follow-up during which they were assessed for prevalent opportunistic infections and medication exposures. Infections were identified using physician diagnosis or hospital discharge codes, with the exception of mycoses, tuberculosis, and herpes zoster, which also required evidence of treatment with specific antimicrobials.

"Future studies of the association between opportunistic infections and JIA medications must consider there’s likely an increased rate of opportunistic infections associated with JIA itself, and not just with the medications we use to treat it," Dr. Beukelman said.

This study was supported by the Agency for Healthcare Research and Quality. Dr. Beukelman disclosed that he has received a research grant from Pfizer, and consulting fees and/or other remuneration from Novartis Pharmaceutical Corporation, and Genentech and Biogen IDEC Inc.

WASHINGTON – Opportunistic infections in children with juvenile idiopathic arthritis are rare, but they occur at a significantly higher rate in JIA patients than in unaffected children, according to findings from an analysis of national Medicaid claims data.

However, the association between these infections and the use of immunosuppressive treatments for JIA appears weak.

The findings, based on data from 2000 through 2005, show that 42 infections occurred in 8,503 children with JIA, and 584 infections occurred in 360,362 non-JIA comparators, for incidence rates of 300 and 125 per 100,000 person years, respectively, and an incident rate ratio (IRR) of 2.4, Dr. Timothy Beukelman reported at the annual meeting of the American College of Rheumatology.

After excluding herpes zoster, which was by far the most common infection among those with JIA, the rate of opportunistic infections was fourfold higher in the JIA cohort compared with the non-JIA cohort.

The infections that occurred at a higher rate in the JIA cohort were Coccidioides (3 infections, for an incidence rate of 21 per 100,000 and an IRR of 101.0), Salmonella (5 infections, for an incidence rate of 35 per 100,000 and an IRR of 3.8), and herpes zoster infections (32 infections for an incidence rate of 225 per 100,000 and an IRR of 2.1), said Dr. Beukelman of the University of Alabama at Birmingham.

One infection each with Nocardia, nontuberculosis mycobateria, Toxoplasma, and Pneumocystis occurred, for an incidence rate of 7 per 100,000 for each of these infections. Incidence rate ratios were not calculated.

No infections with Aspergillus, Blastomyces, Histoplasma, Cryptococcus, Legionella, Listeria, John Cunningham virus, or tuberculosis were identified in the JIA cohort.

These findings differ from those in adults with rheumatoid arthritis (RA).

"We know that adults with RA who are treated with certain biologics have an increased incidence of some opportunistic infections, in particular tuberculosis, endemic mycoses, Listeria, and Legionella," Dr. Beukelman said.

Among the children with JIA, 1,392 used tumor necrosis factor (TNF) inhibitors, and 3,491 used methotrexate during follow-up. An analysis of the association between these treatments and herpes zoster infection found only weak associations with respect to current use of methotrexate (IRR, 1.4 vs. no current methotrexate or TNF inhibitor use), TNF inhibitors (IRR, 2.2 vs. current methotrexate use without current TNF inhibitor use), or glucocorticoids (IRR, 1.8 vs. no current glucocorticoid use), Dr. Beukelman said.

With respect to the Coccidioides infections, the rate was unexpectedly high in the JIA cohort, but two of the patients had no current exposure to TNF inhibitors, methotrexate, or glucocorticoids, and one had exposure only to methotrexate at the time of the infection. None had been treated by TNF inhibitors at any time during the study.

The findings are the first from a controlled trial to address and characterize the incidence of opportunistic infections in JIA patients, Dr. Beukelman said, noting that very little is known about the incidence of opportunistic infections in children with JIA.

Prior studies have, however, demonstrated a twofold increase in the rate of hospitalized infections associated with JIA vs. without JIA in the absence of immunosuppressive infection, so it appears that the JIA disease process itself may predispose to serious bacterial infections.

"We wondered if there might be a similar situation with opportunistic infections," he said.

The findings of the current study suggest that is, indeed, the case.

JIA in this study was based on physician diagnosis codes and dispensed medication. The comparator cohort was composed of children diagnosed with attention deficit hyperactivity disorder. The cohorts had 14,370 and 490,939 person-years of follow-up, respectively.

All subjects had a 3-month baseline period prior to study follow-up during which they were assessed for prevalent opportunistic infections and medication exposures. Infections were identified using physician diagnosis or hospital discharge codes, with the exception of mycoses, tuberculosis, and herpes zoster, which also required evidence of treatment with specific antimicrobials.

"Future studies of the association between opportunistic infections and JIA medications must consider there’s likely an increased rate of opportunistic infections associated with JIA itself, and not just with the medications we use to treat it," Dr. Beukelman said.

This study was supported by the Agency for Healthcare Research and Quality. Dr. Beukelman disclosed that he has received a research grant from Pfizer, and consulting fees and/or other remuneration from Novartis Pharmaceutical Corporation, and Genentech and Biogen IDEC Inc.

WASHINGTON – Opportunistic infections in children with juvenile idiopathic arthritis are rare, but they occur at a significantly higher rate in JIA patients than in unaffected children, according to findings from an analysis of national Medicaid claims data.

However, the association between these infections and the use of immunosuppressive treatments for JIA appears weak.

The findings, based on data from 2000 through 2005, show that 42 infections occurred in 8,503 children with JIA, and 584 infections occurred in 360,362 non-JIA comparators, for incidence rates of 300 and 125 per 100,000 person years, respectively, and an incident rate ratio (IRR) of 2.4, Dr. Timothy Beukelman reported at the annual meeting of the American College of Rheumatology.

After excluding herpes zoster, which was by far the most common infection among those with JIA, the rate of opportunistic infections was fourfold higher in the JIA cohort compared with the non-JIA cohort.

The infections that occurred at a higher rate in the JIA cohort were Coccidioides (3 infections, for an incidence rate of 21 per 100,000 and an IRR of 101.0), Salmonella (5 infections, for an incidence rate of 35 per 100,000 and an IRR of 3.8), and herpes zoster infections (32 infections for an incidence rate of 225 per 100,000 and an IRR of 2.1), said Dr. Beukelman of the University of Alabama at Birmingham.

One infection each with Nocardia, nontuberculosis mycobateria, Toxoplasma, and Pneumocystis occurred, for an incidence rate of 7 per 100,000 for each of these infections. Incidence rate ratios were not calculated.

No infections with Aspergillus, Blastomyces, Histoplasma, Cryptococcus, Legionella, Listeria, John Cunningham virus, or tuberculosis were identified in the JIA cohort.

These findings differ from those in adults with rheumatoid arthritis (RA).

"We know that adults with RA who are treated with certain biologics have an increased incidence of some opportunistic infections, in particular tuberculosis, endemic mycoses, Listeria, and Legionella," Dr. Beukelman said.

Among the children with JIA, 1,392 used tumor necrosis factor (TNF) inhibitors, and 3,491 used methotrexate during follow-up. An analysis of the association between these treatments and herpes zoster infection found only weak associations with respect to current use of methotrexate (IRR, 1.4 vs. no current methotrexate or TNF inhibitor use), TNF inhibitors (IRR, 2.2 vs. current methotrexate use without current TNF inhibitor use), or glucocorticoids (IRR, 1.8 vs. no current glucocorticoid use), Dr. Beukelman said.

With respect to the Coccidioides infections, the rate was unexpectedly high in the JIA cohort, but two of the patients had no current exposure to TNF inhibitors, methotrexate, or glucocorticoids, and one had exposure only to methotrexate at the time of the infection. None had been treated by TNF inhibitors at any time during the study.

The findings are the first from a controlled trial to address and characterize the incidence of opportunistic infections in JIA patients, Dr. Beukelman said, noting that very little is known about the incidence of opportunistic infections in children with JIA.

Prior studies have, however, demonstrated a twofold increase in the rate of hospitalized infections associated with JIA vs. without JIA in the absence of immunosuppressive infection, so it appears that the JIA disease process itself may predispose to serious bacterial infections.

"We wondered if there might be a similar situation with opportunistic infections," he said.

The findings of the current study suggest that is, indeed, the case.

JIA in this study was based on physician diagnosis codes and dispensed medication. The comparator cohort was composed of children diagnosed with attention deficit hyperactivity disorder. The cohorts had 14,370 and 490,939 person-years of follow-up, respectively.

All subjects had a 3-month baseline period prior to study follow-up during which they were assessed for prevalent opportunistic infections and medication exposures. Infections were identified using physician diagnosis or hospital discharge codes, with the exception of mycoses, tuberculosis, and herpes zoster, which also required evidence of treatment with specific antimicrobials.

"Future studies of the association between opportunistic infections and JIA medications must consider there’s likely an increased rate of opportunistic infections associated with JIA itself, and not just with the medications we use to treat it," Dr. Beukelman said.

This study was supported by the Agency for Healthcare Research and Quality. Dr. Beukelman disclosed that he has received a research grant from Pfizer, and consulting fees and/or other remuneration from Novartis Pharmaceutical Corporation, and Genentech and Biogen IDEC Inc.

WASHINGTON – Subcutaneous nodules in patients with rheumatoid arthritis signal a significantly increased risk of cardiovascular disease, based on findings from the CORRONA database.

Although subcutaneous nodules are associated with more severe rheumatoid arthritis (RA), and RA is known to be associated with an increased risk of cardiovascular disease, the findings are the first to demonstrate a link between these "conspicuous, accessible, and assessable clinical markers" and cardiovascular morbidity in RA, Dr. Prashant Kaushik reported at the annual meeting of the American College of Rheumatology.

In 23,327 RA patients included in the CORRONA (Consortium of Rheumatology Researchers of North America) database who were evaluated at 182,201 individual visits between October 2001 and September 2011, the presence of subcutaneous nodules was found to confer a 44% increase in the risk of cardiovascular disease (hazard ratio, 1.44). The association remained significant after the investigators adjusted for age, sex, age of onset of RA, presence of diabetes mellitus, hypertension, smoking, alcohol consumption, and the use of a lipid-lowering agent (adjusted hazard ratio, 1.25), said Dr. Kaushik, who is rheumatology section chief at the Stratton VA Medical Center, Albany, N.Y.

Additionally, an age-sex interaction was found for women, who had a steeper increase in risk with age, compared with men. The hazard ratios per year of age for men and women were 1.01 and 1.03, but the hazard ratio for women vs. men at age 40 was 0.39, and at age 70 was 0.59, he noted.

Patients included in the CORRONA database had an average follow-up of 3 years and 70,455 patient-years. Nearly a third had subcutaneous nodules, and 795 had a cardiovascular event including a myocardial infarction, stroke or transient ischemic attack, heart failure, and/or cardiovascular death.

While the precise mechanism of the biologic association still needs to be ascertained, these findings indicate that subcutaneous nodules, which are the most common extra-articular manifestation of RA, should serve as a red flag for clinicians, Dr. Kaushik said.

"Subcutaneous nodules may be thought of as a clinical indicator of cardiovascular disease in RA," he concluded.

Dr. Kaushik reported having no relevant financial disclosures.

WASHINGTON – Subcutaneous nodules in patients with rheumatoid arthritis signal a significantly increased risk of cardiovascular disease, based on findings from the CORRONA database.

Although subcutaneous nodules are associated with more severe rheumatoid arthritis (RA), and RA is known to be associated with an increased risk of cardiovascular disease, the findings are the first to demonstrate a link between these "conspicuous, accessible, and assessable clinical markers" and cardiovascular morbidity in RA, Dr. Prashant Kaushik reported at the annual meeting of the American College of Rheumatology.

In 23,327 RA patients included in the CORRONA (Consortium of Rheumatology Researchers of North America) database who were evaluated at 182,201 individual visits between October 2001 and September 2011, the presence of subcutaneous nodules was found to confer a 44% increase in the risk of cardiovascular disease (hazard ratio, 1.44). The association remained significant after the investigators adjusted for age, sex, age of onset of RA, presence of diabetes mellitus, hypertension, smoking, alcohol consumption, and the use of a lipid-lowering agent (adjusted hazard ratio, 1.25), said Dr. Kaushik, who is rheumatology section chief at the Stratton VA Medical Center, Albany, N.Y.

Additionally, an age-sex interaction was found for women, who had a steeper increase in risk with age, compared with men. The hazard ratios per year of age for men and women were 1.01 and 1.03, but the hazard ratio for women vs. men at age 40 was 0.39, and at age 70 was 0.59, he noted.

Patients included in the CORRONA database had an average follow-up of 3 years and 70,455 patient-years. Nearly a third had subcutaneous nodules, and 795 had a cardiovascular event including a myocardial infarction, stroke or transient ischemic attack, heart failure, and/or cardiovascular death.

While the precise mechanism of the biologic association still needs to be ascertained, these findings indicate that subcutaneous nodules, which are the most common extra-articular manifestation of RA, should serve as a red flag for clinicians, Dr. Kaushik said.

"Subcutaneous nodules may be thought of as a clinical indicator of cardiovascular disease in RA," he concluded.

Dr. Kaushik reported having no relevant financial disclosures.

WASHINGTON – Subcutaneous nodules in patients with rheumatoid arthritis signal a significantly increased risk of cardiovascular disease, based on findings from the CORRONA database.

Although subcutaneous nodules are associated with more severe rheumatoid arthritis (RA), and RA is known to be associated with an increased risk of cardiovascular disease, the findings are the first to demonstrate a link between these "conspicuous, accessible, and assessable clinical markers" and cardiovascular morbidity in RA, Dr. Prashant Kaushik reported at the annual meeting of the American College of Rheumatology.

In 23,327 RA patients included in the CORRONA (Consortium of Rheumatology Researchers of North America) database who were evaluated at 182,201 individual visits between October 2001 and September 2011, the presence of subcutaneous nodules was found to confer a 44% increase in the risk of cardiovascular disease (hazard ratio, 1.44). The association remained significant after the investigators adjusted for age, sex, age of onset of RA, presence of diabetes mellitus, hypertension, smoking, alcohol consumption, and the use of a lipid-lowering agent (adjusted hazard ratio, 1.25), said Dr. Kaushik, who is rheumatology section chief at the Stratton VA Medical Center, Albany, N.Y.

Additionally, an age-sex interaction was found for women, who had a steeper increase in risk with age, compared with men. The hazard ratios per year of age for men and women were 1.01 and 1.03, but the hazard ratio for women vs. men at age 40 was 0.39, and at age 70 was 0.59, he noted.

Patients included in the CORRONA database had an average follow-up of 3 years and 70,455 patient-years. Nearly a third had subcutaneous nodules, and 795 had a cardiovascular event including a myocardial infarction, stroke or transient ischemic attack, heart failure, and/or cardiovascular death.

While the precise mechanism of the biologic association still needs to be ascertained, these findings indicate that subcutaneous nodules, which are the most common extra-articular manifestation of RA, should serve as a red flag for clinicians, Dr. Kaushik said.

"Subcutaneous nodules may be thought of as a clinical indicator of cardiovascular disease in RA," he concluded.

Dr. Kaushik reported having no relevant financial disclosures.

WASHINGTON – The advent of effective anti-inflammatory therapies and the increased use of cardioprotective therapies in recent years have failed to reduce the risk of incident cardiovascular disease in patients with rheumatoid arthritis, according to findings from the prospective longitudinal CARRE study.

During the 10-year Dutch study, 58 cardiovascular events occurred in 353 patients with more than 2,361 patient-years of follow-up, for an incidence rate of 25.3/1,000 patient-years. This did not differ significantly from the incidence rate of 22.8/1,000 patient-years between 3 years and 10 years of follow-up, Dr. Alper M. van Sijl reported at the annual meeting of the American College of Rheumatology.

Nonetheless, the findings do suggest that improving disease activity and inflammatory markers over time might mitigate cardiovascular risk, said Dr. van Sijl of the Jan van Breemen Research Institute, Reade, Amsterdam.

Patients with RA have a twofold increase in the risk of mortality compared with the general population, and this is largely attributable to cardiovascular disease, he said, noting that it has been unclear what role cardiovascular risk factors vs. the underlying inflammatory processes of RA play in this.

"Most research only accounts for cardiovascular risk factors at baseline, and does not look at longitudinal data," he said.

To evaluate whether the increased use of anti-inflammatory and cardioprotective medications has reduced the risk, Dr. van Sijl and his colleagues compared changes in cardiovascular risk factors, RA-related factors, and medication use over time based on whether study participants did or did not develop cardiovascular disease during follow-up. The investigators found that general cardiovascular risk increased over time, as did the use of antihypertensives, statins, and tumor necrosis factor inhibitors, while RA-related factors improved significantly over time.

For example, with respect to cardiovascular disease risk, changes in markers such as intima-media thickness and cardiovascular risk score were seen. Intima-media thickness increased by 0.030 mm between baseline and 3-year follow-up, and decreased by 0.006 mm between 3 and 10 years. Ten-year CV risk (SCORE) increased by 0.5 points between baseline and 3-year follow-up, and by 4.4 points between 3 and 10 years. Antihypertensive use increased by 4% and 11% during the same periods (from 24% at baseline), respectively; statin use increased by 3% and 5% (from 9% at baseline) during the same periods; and use of biologic agents increased 9% and 14% (from 2% at baseline).

As for RA-related factors, improvements were seen in erythrocyte sedimentation rate in those who did not develop cardiovascular disease, while the rate increased in those who did develop cardiovascular disease. Similarly, disease activity scores (DAS28) improved in both groups between baseline and 3 years, then increased between the assessment done at 3 and that done at 10 years in those who developed cardiovascular disease, while they continued to decrease in those who did not.

The use of biologics increased significantly more over time in those without cardiovascular disease, compared with those with cardiovascular disease (to about 35% vs. 15%).

Generalized estimating equation analysis demonstrated a positive association between the use of tumor necrosis factor inhibitors and a reduction in incident cardiovascular disease, Dr. van Sijl said.

The findings suggest that more aggressive cardioprotective and anti-inflammatory treatment might mitigate the burden of cardiovascular disease in patients with RA, he said.

CARRE study participants were enrolled beginning in 2000. All fulfilled ACR 1987 criteria for RA, and had a mean disease duration of 7 years. Most were women in their 60s with high levels of disease activity, Dr. van Sijl said.

"In summary, the risk of incident cardiovascular disease persists in RA despite incremental use of cardioprotective medication and/or TNF blocking agents. At baseline, cardiovascular risk factors such as blood pressure and renal function were more associated with incident cardiovascular disease than RA-related factors, and changes in RA-related factors during follow-up were associated with an increased risk of incident cardiovascular disease," he said. Although traditional cardiovascular risk factors remain relevant in the risk of cardiovascular disease in RA patients, improving disease activity and inflammatory markers over time might positively influence this risk, he added.

Dr. van Sijl reported having no disclosures.

WASHINGTON – The advent of effective anti-inflammatory therapies and the increased use of cardioprotective therapies in recent years have failed to reduce the risk of incident cardiovascular disease in patients with rheumatoid arthritis, according to findings from the prospective longitudinal CARRE study.

During the 10-year Dutch study, 58 cardiovascular events occurred in 353 patients with more than 2,361 patient-years of follow-up, for an incidence rate of 25.3/1,000 patient-years. This did not differ significantly from the incidence rate of 22.8/1,000 patient-years between 3 years and 10 years of follow-up, Dr. Alper M. van Sijl reported at the annual meeting of the American College of Rheumatology.

Nonetheless, the findings do suggest that improving disease activity and inflammatory markers over time might mitigate cardiovascular risk, said Dr. van Sijl of the Jan van Breemen Research Institute, Reade, Amsterdam.

Patients with RA have a twofold increase in the risk of mortality compared with the general population, and this is largely attributable to cardiovascular disease, he said, noting that it has been unclear what role cardiovascular risk factors vs. the underlying inflammatory processes of RA play in this.

"Most research only accounts for cardiovascular risk factors at baseline, and does not look at longitudinal data," he said.

To evaluate whether the increased use of anti-inflammatory and cardioprotective medications has reduced the risk, Dr. van Sijl and his colleagues compared changes in cardiovascular risk factors, RA-related factors, and medication use over time based on whether study participants did or did not develop cardiovascular disease during follow-up. The investigators found that general cardiovascular risk increased over time, as did the use of antihypertensives, statins, and tumor necrosis factor inhibitors, while RA-related factors improved significantly over time.

For example, with respect to cardiovascular disease risk, changes in markers such as intima-media thickness and cardiovascular risk score were seen. Intima-media thickness increased by 0.030 mm between baseline and 3-year follow-up, and decreased by 0.006 mm between 3 and 10 years. Ten-year CV risk (SCORE) increased by 0.5 points between baseline and 3-year follow-up, and by 4.4 points between 3 and 10 years. Antihypertensive use increased by 4% and 11% during the same periods (from 24% at baseline), respectively; statin use increased by 3% and 5% (from 9% at baseline) during the same periods; and use of biologic agents increased 9% and 14% (from 2% at baseline).

As for RA-related factors, improvements were seen in erythrocyte sedimentation rate in those who did not develop cardiovascular disease, while the rate increased in those who did develop cardiovascular disease. Similarly, disease activity scores (DAS28) improved in both groups between baseline and 3 years, then increased between the assessment done at 3 and that done at 10 years in those who developed cardiovascular disease, while they continued to decrease in those who did not.

The use of biologics increased significantly more over time in those without cardiovascular disease, compared with those with cardiovascular disease (to about 35% vs. 15%).

Generalized estimating equation analysis demonstrated a positive association between the use of tumor necrosis factor inhibitors and a reduction in incident cardiovascular disease, Dr. van Sijl said.

The findings suggest that more aggressive cardioprotective and anti-inflammatory treatment might mitigate the burden of cardiovascular disease in patients with RA, he said.

CARRE study participants were enrolled beginning in 2000. All fulfilled ACR 1987 criteria for RA, and had a mean disease duration of 7 years. Most were women in their 60s with high levels of disease activity, Dr. van Sijl said.

"In summary, the risk of incident cardiovascular disease persists in RA despite incremental use of cardioprotective medication and/or TNF blocking agents. At baseline, cardiovascular risk factors such as blood pressure and renal function were more associated with incident cardiovascular disease than RA-related factors, and changes in RA-related factors during follow-up were associated with an increased risk of incident cardiovascular disease," he said. Although traditional cardiovascular risk factors remain relevant in the risk of cardiovascular disease in RA patients, improving disease activity and inflammatory markers over time might positively influence this risk, he added.

Dr. van Sijl reported having no disclosures.

WASHINGTON – The advent of effective anti-inflammatory therapies and the increased use of cardioprotective therapies in recent years have failed to reduce the risk of incident cardiovascular disease in patients with rheumatoid arthritis, according to findings from the prospective longitudinal CARRE study.

During the 10-year Dutch study, 58 cardiovascular events occurred in 353 patients with more than 2,361 patient-years of follow-up, for an incidence rate of 25.3/1,000 patient-years. This did not differ significantly from the incidence rate of 22.8/1,000 patient-years between 3 years and 10 years of follow-up, Dr. Alper M. van Sijl reported at the annual meeting of the American College of Rheumatology.

Nonetheless, the findings do suggest that improving disease activity and inflammatory markers over time might mitigate cardiovascular risk, said Dr. van Sijl of the Jan van Breemen Research Institute, Reade, Amsterdam.

Patients with RA have a twofold increase in the risk of mortality compared with the general population, and this is largely attributable to cardiovascular disease, he said, noting that it has been unclear what role cardiovascular risk factors vs. the underlying inflammatory processes of RA play in this.

"Most research only accounts for cardiovascular risk factors at baseline, and does not look at longitudinal data," he said.

To evaluate whether the increased use of anti-inflammatory and cardioprotective medications has reduced the risk, Dr. van Sijl and his colleagues compared changes in cardiovascular risk factors, RA-related factors, and medication use over time based on whether study participants did or did not develop cardiovascular disease during follow-up. The investigators found that general cardiovascular risk increased over time, as did the use of antihypertensives, statins, and tumor necrosis factor inhibitors, while RA-related factors improved significantly over time.

For example, with respect to cardiovascular disease risk, changes in markers such as intima-media thickness and cardiovascular risk score were seen. Intima-media thickness increased by 0.030 mm between baseline and 3-year follow-up, and decreased by 0.006 mm between 3 and 10 years. Ten-year CV risk (SCORE) increased by 0.5 points between baseline and 3-year follow-up, and by 4.4 points between 3 and 10 years. Antihypertensive use increased by 4% and 11% during the same periods (from 24% at baseline), respectively; statin use increased by 3% and 5% (from 9% at baseline) during the same periods; and use of biologic agents increased 9% and 14% (from 2% at baseline).

As for RA-related factors, improvements were seen in erythrocyte sedimentation rate in those who did not develop cardiovascular disease, while the rate increased in those who did develop cardiovascular disease. Similarly, disease activity scores (DAS28) improved in both groups between baseline and 3 years, then increased between the assessment done at 3 and that done at 10 years in those who developed cardiovascular disease, while they continued to decrease in those who did not.

The use of biologics increased significantly more over time in those without cardiovascular disease, compared with those with cardiovascular disease (to about 35% vs. 15%).

Generalized estimating equation analysis demonstrated a positive association between the use of tumor necrosis factor inhibitors and a reduction in incident cardiovascular disease, Dr. van Sijl said.

The findings suggest that more aggressive cardioprotective and anti-inflammatory treatment might mitigate the burden of cardiovascular disease in patients with RA, he said.

CARRE study participants were enrolled beginning in 2000. All fulfilled ACR 1987 criteria for RA, and had a mean disease duration of 7 years. Most were women in their 60s with high levels of disease activity, Dr. van Sijl said.

"In summary, the risk of incident cardiovascular disease persists in RA despite incremental use of cardioprotective medication and/or TNF blocking agents. At baseline, cardiovascular risk factors such as blood pressure and renal function were more associated with incident cardiovascular disease than RA-related factors, and changes in RA-related factors during follow-up were associated with an increased risk of incident cardiovascular disease," he said. Although traditional cardiovascular risk factors remain relevant in the risk of cardiovascular disease in RA patients, improving disease activity and inflammatory markers over time might positively influence this risk, he added.

Dr. van Sijl reported having no disclosures.

WASHINGTON – Tocilizumab for the treatment of systemic juvenile idiopathic arthritis was associated with significant catch-up growth at 2-year follow-up in the vast majority of children who participated in the pivotal phase III TENDER study.

Treatment with the interleukin-6 (IL-6) receptor inhibitor, which is marketed as Actemra, also significantly increased insulinlike growth factor-1 (IGF-1) levels and osteocalcin/C-telopeptide of type 1 collagen (OC/CTX-1) ratios, suggesting that the therapy has beneficial effects on growth hormone axis and bone metabolism, reported Dr. Fabrizio De Benedetti, speaking at the annual meeting of the American College of Rheumatology.

The findings are important because systemic juvenile idiopathic arthritis (sJIA) has a significant impact on the growing skeleton and is associated with impaired linear growth and systemic osteoporosis, he explained.

Height measurements at baseline in 112 children aged 2-17 years who were enrolled in the study showed profound growth failure, with most having height velocity well below normal for age and gender. However, during treatment, most patients had above normal height velocities: 85% of girls and 73% of boys experienced catch-up growth, said Dr. De Benedetti of Ospedale Pediatrico Bambino Gesu, Rome.

In 86 children from the study who were below Tanner stage 4 development at baseline, the 0.61 mean improvement in height standard deviation score at 2-year follow-up was statistically significant, and although mean corticosteroid dose was higher in the first year of treatment (0.13 mg/kg per day vs. 0.05 mg/kg per day), mean height velocities were comparable in both years, at 5.8 cm and 6.3 cm, respectively, he noted.

IGF-1 standard deviation score increased from a mean of –1.1 at baseline to 0.0 at 2 years, and OC/CTX-1 ratio increased significantly, suggesting an increase in osteoblast activity relative to osteoclast activity.

Improvements in the Juvenile Arthritis Disease Activity Score–71 (JADAS-71) during the first year correlated with increases in height velocities during that year, as did younger age at baseline.

Tocilizumab, which was approved by the U.S. Food and Drugs Administration in 2010 for the treatment of rheumatoid arthritis, received an expanded approval for the treatment of sJIA in April 2011, based on 12-week results from the randomized, placebo-controlled TENDER study. Treatment was shown in that phase, as well as in an open-label long-term extension phase, to be safe and effective for the management of sJIA. Two-year findings of the study, which included children with active refractory disease, were reported at the 2011 annual meeting of the American College of Rheumatology.

Data collection will continue through 5 years of follow-up, allowing a more comprehensive analysis of growth outcomes, said Dr. De Benedetti, the lead investigator for the TENDER study.

Dr. De Benedetti disclosed that he has received research grants and/or consulting fees from Abbott, BMS, Novartis, NovImmune, Pfizer, Roche Pharmaceuticals, and Sobi. The TENDER study was sponsored by Roche, the maker of tocilizumab.

WASHINGTON – Tocilizumab for the treatment of systemic juvenile idiopathic arthritis was associated with significant catch-up growth at 2-year follow-up in the vast majority of children who participated in the pivotal phase III TENDER study.

Treatment with the interleukin-6 (IL-6) receptor inhibitor, which is marketed as Actemra, also significantly increased insulinlike growth factor-1 (IGF-1) levels and osteocalcin/C-telopeptide of type 1 collagen (OC/CTX-1) ratios, suggesting that the therapy has beneficial effects on growth hormone axis and bone metabolism, reported Dr. Fabrizio De Benedetti, speaking at the annual meeting of the American College of Rheumatology.

The findings are important because systemic juvenile idiopathic arthritis (sJIA) has a significant impact on the growing skeleton and is associated with impaired linear growth and systemic osteoporosis, he explained.

Height measurements at baseline in 112 children aged 2-17 years who were enrolled in the study showed profound growth failure, with most having height velocity well below normal for age and gender. However, during treatment, most patients had above normal height velocities: 85% of girls and 73% of boys experienced catch-up growth, said Dr. De Benedetti of Ospedale Pediatrico Bambino Gesu, Rome.

In 86 children from the study who were below Tanner stage 4 development at baseline, the 0.61 mean improvement in height standard deviation score at 2-year follow-up was statistically significant, and although mean corticosteroid dose was higher in the first year of treatment (0.13 mg/kg per day vs. 0.05 mg/kg per day), mean height velocities were comparable in both years, at 5.8 cm and 6.3 cm, respectively, he noted.

IGF-1 standard deviation score increased from a mean of –1.1 at baseline to 0.0 at 2 years, and OC/CTX-1 ratio increased significantly, suggesting an increase in osteoblast activity relative to osteoclast activity.

Improvements in the Juvenile Arthritis Disease Activity Score–71 (JADAS-71) during the first year correlated with increases in height velocities during that year, as did younger age at baseline.

Tocilizumab, which was approved by the U.S. Food and Drugs Administration in 2010 for the treatment of rheumatoid arthritis, received an expanded approval for the treatment of sJIA in April 2011, based on 12-week results from the randomized, placebo-controlled TENDER study. Treatment was shown in that phase, as well as in an open-label long-term extension phase, to be safe and effective for the management of sJIA. Two-year findings of the study, which included children with active refractory disease, were reported at the 2011 annual meeting of the American College of Rheumatology.

Data collection will continue through 5 years of follow-up, allowing a more comprehensive analysis of growth outcomes, said Dr. De Benedetti, the lead investigator for the TENDER study.

Dr. De Benedetti disclosed that he has received research grants and/or consulting fees from Abbott, BMS, Novartis, NovImmune, Pfizer, Roche Pharmaceuticals, and Sobi. The TENDER study was sponsored by Roche, the maker of tocilizumab.

WASHINGTON – Tocilizumab for the treatment of systemic juvenile idiopathic arthritis was associated with significant catch-up growth at 2-year follow-up in the vast majority of children who participated in the pivotal phase III TENDER study.

Treatment with the interleukin-6 (IL-6) receptor inhibitor, which is marketed as Actemra, also significantly increased insulinlike growth factor-1 (IGF-1) levels and osteocalcin/C-telopeptide of type 1 collagen (OC/CTX-1) ratios, suggesting that the therapy has beneficial effects on growth hormone axis and bone metabolism, reported Dr. Fabrizio De Benedetti, speaking at the annual meeting of the American College of Rheumatology.

The findings are important because systemic juvenile idiopathic arthritis (sJIA) has a significant impact on the growing skeleton and is associated with impaired linear growth and systemic osteoporosis, he explained.

Height measurements at baseline in 112 children aged 2-17 years who were enrolled in the study showed profound growth failure, with most having height velocity well below normal for age and gender. However, during treatment, most patients had above normal height velocities: 85% of girls and 73% of boys experienced catch-up growth, said Dr. De Benedetti of Ospedale Pediatrico Bambino Gesu, Rome.

In 86 children from the study who were below Tanner stage 4 development at baseline, the 0.61 mean improvement in height standard deviation score at 2-year follow-up was statistically significant, and although mean corticosteroid dose was higher in the first year of treatment (0.13 mg/kg per day vs. 0.05 mg/kg per day), mean height velocities were comparable in both years, at 5.8 cm and 6.3 cm, respectively, he noted.

IGF-1 standard deviation score increased from a mean of –1.1 at baseline to 0.0 at 2 years, and OC/CTX-1 ratio increased significantly, suggesting an increase in osteoblast activity relative to osteoclast activity.

Improvements in the Juvenile Arthritis Disease Activity Score–71 (JADAS-71) during the first year correlated with increases in height velocities during that year, as did younger age at baseline.

Tocilizumab, which was approved by the U.S. Food and Drugs Administration in 2010 for the treatment of rheumatoid arthritis, received an expanded approval for the treatment of sJIA in April 2011, based on 12-week results from the randomized, placebo-controlled TENDER study. Treatment was shown in that phase, as well as in an open-label long-term extension phase, to be safe and effective for the management of sJIA. Two-year findings of the study, which included children with active refractory disease, were reported at the 2011 annual meeting of the American College of Rheumatology.

Data collection will continue through 5 years of follow-up, allowing a more comprehensive analysis of growth outcomes, said Dr. De Benedetti, the lead investigator for the TENDER study.

Dr. De Benedetti disclosed that he has received research grants and/or consulting fees from Abbott, BMS, Novartis, NovImmune, Pfizer, Roche Pharmaceuticals, and Sobi. The TENDER study was sponsored by Roche, the maker of tocilizumab.

WASHINGTON – Exposure to angiotensin-converting enzyme inhibitors prior to the onset of renal crisis in patients with scleroderma increases the risk of death, according to 1-year findings from the prospective observational International Scleroderma Renal Crisis Survey.

The findings, which contrast with those from a preliminary analysis reported last year, suggest that clinicians caring for patients with systemic scleroderma should exercise caution when prescribing angiotensin-converting enzyme (ACE) inhibitors, Dr. Marie Hudson said at the annual meeting of the American College of Rheumatology, where she reported the survey results.

Of 75 patients who experienced scleroderma renal crisis (SRC) in the course of the study, 16 were taking an ACE inhibitor prior to onset of SRC. At the 1-year follow-up, 27 (36%) of the patients had died and 25% remained on dialysis. After adjusting for differences in prednisone exposure and history of systemic hypertension, ACE inhibitor exposure prior to SRC, compared with no such exposure, was associated with significantly increased risk of death (adjusted hazard ratio, 2.52), said Dr. Hudson of the division of rheumatology at McGill University, Montreal.

SRC is a rare but life-threatening complication of systemic sclerosis that typically presents with malignant hypertension and acute renal failure.

"Prior to the advent of ACE inhibitors, it was almost a universally deadly complication of scleroderma, but since the advent of ACE inhibitors, the outcomes of patients with scleroderma renal crisis have improved tremendously," Dr. Hudson said, noting also that some evidence suggest that the incidence of SRC has decreased over the past two decades as well – due, perhaps, to more liberal use of ACE inhibitors.

"So, given the benefits of ACE inhibitors to treat SRC along with this perceived decrease in the incidence of SRC, the prophylactic use of ACE inhibitors to prevent SRC has been considered. However, some would argue that there’s no clear physiologic rationale for this," she said, explaining that most patients with SRC are not hyperreninemic prior to renal crisis and that prophylactic treatment could mask hypertension and delay diagnosis, thus leading to worse outcomes in those who develop SRC.

In fact, recent retrospective data support the idea that those exposed prior to SRC may have worse outcomes, she noted.

The findings of this survey, which are important given the widespread availability of ACE inhibitors, confirm that, she said.

Patients included in the study were identified by physicians from numerous practices around the world who had agreed to participate in the survey. A total of 589 physicians were asked biweekly if they had made a diagnosis of SRC, and if so, they filled out a short case report form at that time and then submitted another 1 year later.

The patients had a mean age of 52 years, and 67% were women. Most (76%) had diffuse systemic scleroderma with a median disease duration of 1.5 years. SRC was hypertensive in 71 patients; only 5 patients had normotensive SRC, she noted.

The rate of prednisone use was surprisingly high at nearly 50% overall, but, more importantly, the mean daily dose was twice as high in the group of patients who were not exposed to ACE inhibitors prior to SRC (mean dose of 18 mg/day vs. 9 mg/day in the exposed group), Dr. Hudson said.

However, even after adjusting for prednisone use, the risk of death in exposed patients was more than twice that of nonexposed patients, and the difference was statistically significant, she said.

Although the precise risk of death after SRC remains uncertain, it does appear that caution when using ACE inhibitors in these patients is warranted, especially early in disease when the risk of SRC is the greatest, she said.

Dr. Hudson had no disclosures to report.

WASHINGTON – Exposure to angiotensin-converting enzyme inhibitors prior to the onset of renal crisis in patients with scleroderma increases the risk of death, according to 1-year findings from the prospective observational International Scleroderma Renal Crisis Survey.

The findings, which contrast with those from a preliminary analysis reported last year, suggest that clinicians caring for patients with systemic scleroderma should exercise caution when prescribing angiotensin-converting enzyme (ACE) inhibitors, Dr. Marie Hudson said at the annual meeting of the American College of Rheumatology, where she reported the survey results.

Of 75 patients who experienced scleroderma renal crisis (SRC) in the course of the study, 16 were taking an ACE inhibitor prior to onset of SRC. At the 1-year follow-up, 27 (36%) of the patients had died and 25% remained on dialysis. After adjusting for differences in prednisone exposure and history of systemic hypertension, ACE inhibitor exposure prior to SRC, compared with no such exposure, was associated with significantly increased risk of death (adjusted hazard ratio, 2.52), said Dr. Hudson of the division of rheumatology at McGill University, Montreal.

SRC is a rare but life-threatening complication of systemic sclerosis that typically presents with malignant hypertension and acute renal failure.

"Prior to the advent of ACE inhibitors, it was almost a universally deadly complication of scleroderma, but since the advent of ACE inhibitors, the outcomes of patients with scleroderma renal crisis have improved tremendously," Dr. Hudson said, noting also that some evidence suggest that the incidence of SRC has decreased over the past two decades as well – due, perhaps, to more liberal use of ACE inhibitors.

"So, given the benefits of ACE inhibitors to treat SRC along with this perceived decrease in the incidence of SRC, the prophylactic use of ACE inhibitors to prevent SRC has been considered. However, some would argue that there’s no clear physiologic rationale for this," she said, explaining that most patients with SRC are not hyperreninemic prior to renal crisis and that prophylactic treatment could mask hypertension and delay diagnosis, thus leading to worse outcomes in those who develop SRC.

In fact, recent retrospective data support the idea that those exposed prior to SRC may have worse outcomes, she noted.

The findings of this survey, which are important given the widespread availability of ACE inhibitors, confirm that, she said.

Patients included in the study were identified by physicians from numerous practices around the world who had agreed to participate in the survey. A total of 589 physicians were asked biweekly if they had made a diagnosis of SRC, and if so, they filled out a short case report form at that time and then submitted another 1 year later.

The patients had a mean age of 52 years, and 67% were women. Most (76%) had diffuse systemic scleroderma with a median disease duration of 1.5 years. SRC was hypertensive in 71 patients; only 5 patients had normotensive SRC, she noted.

The rate of prednisone use was surprisingly high at nearly 50% overall, but, more importantly, the mean daily dose was twice as high in the group of patients who were not exposed to ACE inhibitors prior to SRC (mean dose of 18 mg/day vs. 9 mg/day in the exposed group), Dr. Hudson said.

However, even after adjusting for prednisone use, the risk of death in exposed patients was more than twice that of nonexposed patients, and the difference was statistically significant, she said.

Although the precise risk of death after SRC remains uncertain, it does appear that caution when using ACE inhibitors in these patients is warranted, especially early in disease when the risk of SRC is the greatest, she said.

Dr. Hudson had no disclosures to report.

WASHINGTON – Exposure to angiotensin-converting enzyme inhibitors prior to the onset of renal crisis in patients with scleroderma increases the risk of death, according to 1-year findings from the prospective observational International Scleroderma Renal Crisis Survey.

The findings, which contrast with those from a preliminary analysis reported last year, suggest that clinicians caring for patients with systemic scleroderma should exercise caution when prescribing angiotensin-converting enzyme (ACE) inhibitors, Dr. Marie Hudson said at the annual meeting of the American College of Rheumatology, where she reported the survey results.

Of 75 patients who experienced scleroderma renal crisis (SRC) in the course of the study, 16 were taking an ACE inhibitor prior to onset of SRC. At the 1-year follow-up, 27 (36%) of the patients had died and 25% remained on dialysis. After adjusting for differences in prednisone exposure and history of systemic hypertension, ACE inhibitor exposure prior to SRC, compared with no such exposure, was associated with significantly increased risk of death (adjusted hazard ratio, 2.52), said Dr. Hudson of the division of rheumatology at McGill University, Montreal.

SRC is a rare but life-threatening complication of systemic sclerosis that typically presents with malignant hypertension and acute renal failure.

"Prior to the advent of ACE inhibitors, it was almost a universally deadly complication of scleroderma, but since the advent of ACE inhibitors, the outcomes of patients with scleroderma renal crisis have improved tremendously," Dr. Hudson said, noting also that some evidence suggest that the incidence of SRC has decreased over the past two decades as well – due, perhaps, to more liberal use of ACE inhibitors.

"So, given the benefits of ACE inhibitors to treat SRC along with this perceived decrease in the incidence of SRC, the prophylactic use of ACE inhibitors to prevent SRC has been considered. However, some would argue that there’s no clear physiologic rationale for this," she said, explaining that most patients with SRC are not hyperreninemic prior to renal crisis and that prophylactic treatment could mask hypertension and delay diagnosis, thus leading to worse outcomes in those who develop SRC.

In fact, recent retrospective data support the idea that those exposed prior to SRC may have worse outcomes, she noted.

The findings of this survey, which are important given the widespread availability of ACE inhibitors, confirm that, she said.

Patients included in the study were identified by physicians from numerous practices around the world who had agreed to participate in the survey. A total of 589 physicians were asked biweekly if they had made a diagnosis of SRC, and if so, they filled out a short case report form at that time and then submitted another 1 year later.

The patients had a mean age of 52 years, and 67% were women. Most (76%) had diffuse systemic scleroderma with a median disease duration of 1.5 years. SRC was hypertensive in 71 patients; only 5 patients had normotensive SRC, she noted.

The rate of prednisone use was surprisingly high at nearly 50% overall, but, more importantly, the mean daily dose was twice as high in the group of patients who were not exposed to ACE inhibitors prior to SRC (mean dose of 18 mg/day vs. 9 mg/day in the exposed group), Dr. Hudson said.

However, even after adjusting for prednisone use, the risk of death in exposed patients was more than twice that of nonexposed patients, and the difference was statistically significant, she said.

Although the precise risk of death after SRC remains uncertain, it does appear that caution when using ACE inhibitors in these patients is warranted, especially early in disease when the risk of SRC is the greatest, she said.

Dr. Hudson had no disclosures to report.

ATLANTA  – Long-term nocturnal use of noninvasive positive pressure ventilation significantly reduced the likelihood of intensive care unit admission in patients with severe stable chronic obstructive pulmonary disease, according to findings from a systematic review of 582 patients in 13 randomized, controlled clinical trials.

After 1 year, noninvasive positive pressure ventilation (NIPPV) was associated with a significant decrease in ICU admissions (odds ratio, 0.41) compared with standard medical therapy. Patients using NIPPV for more than 3 months also had improvements in oxygenation (mean difference of -2.43 mm Hg), reduction in PCO₂ (mean difference, -2.96 mm Hg), and an improvement in 6-minute walk distance (mean difference 45.15 m), Dr. Monali Patil reported at the annual meeting of the American College of Chest Physicians.

A trend toward improved mortality at 1 year did not reach statistical significance, and no significant improvements in lung function were noted, said Dr. Patil of the University at Buffalo (N.Y.).

Dr. Patil selected the 13 trials from a review of more than 700 studies conducted between 1991 and 2011. The analysis included only randomized, controlled trials of COPD patients who had an FEV₁ less than 50% of predicted and a PCO₂ greater than 45 mm Hg and were receiving bilevel positive airway pressure (BIPAP). The patients in the studies were aged 18-75 years, and had no COPD exacerbations within 2 weeks prior to study enrollment.

The long-term use of NIPPV in patients with severe stable COPD has been controversial, but these findings demonstrate significant benefits.

"So NIPPV can be used as adjuvant treatment for management of severe stable COPD patients," she concluded.

Dr Patil reported having no financial disclosures.

ATLANTA  – Long-term nocturnal use of noninvasive positive pressure ventilation significantly reduced the likelihood of intensive care unit admission in patients with severe stable chronic obstructive pulmonary disease, according to findings from a systematic review of 582 patients in 13 randomized, controlled clinical trials.

After 1 year, noninvasive positive pressure ventilation (NIPPV) was associated with a significant decrease in ICU admissions (odds ratio, 0.41) compared with standard medical therapy. Patients using NIPPV for more than 3 months also had improvements in oxygenation (mean difference of -2.43 mm Hg), reduction in PCO₂ (mean difference, -2.96 mm Hg), and an improvement in 6-minute walk distance (mean difference 45.15 m), Dr. Monali Patil reported at the annual meeting of the American College of Chest Physicians.

A trend toward improved mortality at 1 year did not reach statistical significance, and no significant improvements in lung function were noted, said Dr. Patil of the University at Buffalo (N.Y.).

Dr. Patil selected the 13 trials from a review of more than 700 studies conducted between 1991 and 2011. The analysis included only randomized, controlled trials of COPD patients who had an FEV₁ less than 50% of predicted and a PCO₂ greater than 45 mm Hg and were receiving bilevel positive airway pressure (BIPAP). The patients in the studies were aged 18-75 years, and had no COPD exacerbations within 2 weeks prior to study enrollment.

The long-term use of NIPPV in patients with severe stable COPD has been controversial, but these findings demonstrate significant benefits.

"So NIPPV can be used as adjuvant treatment for management of severe stable COPD patients," she concluded.

Dr Patil reported having no financial disclosures.

ATLANTA  – Long-term nocturnal use of noninvasive positive pressure ventilation significantly reduced the likelihood of intensive care unit admission in patients with severe stable chronic obstructive pulmonary disease, according to findings from a systematic review of 582 patients in 13 randomized, controlled clinical trials.

After 1 year, noninvasive positive pressure ventilation (NIPPV) was associated with a significant decrease in ICU admissions (odds ratio, 0.41) compared with standard medical therapy. Patients using NIPPV for more than 3 months also had improvements in oxygenation (mean difference of -2.43 mm Hg), reduction in PCO₂ (mean difference, -2.96 mm Hg), and an improvement in 6-minute walk distance (mean difference 45.15 m), Dr. Monali Patil reported at the annual meeting of the American College of Chest Physicians.

A trend toward improved mortality at 1 year did not reach statistical significance, and no significant improvements in lung function were noted, said Dr. Patil of the University at Buffalo (N.Y.).

Dr. Patil selected the 13 trials from a review of more than 700 studies conducted between 1991 and 2011. The analysis included only randomized, controlled trials of COPD patients who had an FEV₁ less than 50% of predicted and a PCO₂ greater than 45 mm Hg and were receiving bilevel positive airway pressure (BIPAP). The patients in the studies were aged 18-75 years, and had no COPD exacerbations within 2 weeks prior to study enrollment.

The long-term use of NIPPV in patients with severe stable COPD has been controversial, but these findings demonstrate significant benefits.

"So NIPPV can be used as adjuvant treatment for management of severe stable COPD patients," she concluded.

Dr Patil reported having no financial disclosures.