Rheumatoid Arthritis

Major Finding: COPD was a comorbid condition in 8.9% of patients with RA compared with 4.4% of controls from the general population in one study (P less than .001), with 7.3% of the Norfolk Arthritis Register study population also found to have the respiratory disease.

Data Source: A case-control study of more than 30,000 individuals with or without rheumatoid arthritis and data from a 15-year follow up of 435 patients with inflammatory polyarthritis or RA in the Norfolk Arthritis Register.

Disclosures: NOAR is funded by Arthritis Research UK. Dr. Verstappen and Dr. Amital and colleagues had no conflicts of interest to declare.

LONDON – Patients with rheumatoid arthritis have a high risk of concomitant chronic obstructive pulmonary disease, according to data from two studies.

In one of the studies – which involved more than 15,000 patients with rheumatoid arthritis (RA) and 15,000 healthy individuals as case-matched controls – the risk of the long-term lung condition was 8.9% and 4.4%, respectively (P less than .001).

Other data, from the Norfolk Arthritis Register (NOAR) showed that the prevalence of chronic obstructive pulmonary disease (COPD) in patients with inflammatory polyarthritis (IP) or RA was 7.3% (n = 425) at 15 years' follow-up. Prevalence of the respiratory disease was again doubled when compared to the general population.

“Lung involvement is a common extra-articular manifestation in rheumatoid arthritis,” said Dr. Suzanne Verstappen, who presented the findings from the NOAR at the congress.

“As could be expected, age and gender were associated with obstructive and restrictive lung disease,” said Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester, England, where the NOAR is coordinated.

Validated spirometry parameters and the Medical Research Council respiratory symptoms questionnaire were used to identify patients with IP or RA who also had COPD. The latter was distinguished from restrictive lung disease. The prevalence of restrictive lung disease was 9.7%.

COPD was observed in 7.3% of the population at 15 years, with higher prevalence rates found in men versus women over the age of 45 years (12.7% vs. 6%, respectively) in a crude comparison.

Published rates for the U.K. general population without IP or RA are 6.8% and 3.9% (Popul. Health Metr. 2007;5:8).

Like RA, COPD is a chronic and often debilitating disease. The disease manifests later in life and treatment is symptomatic rather than curative, as the obstruction in the airways is permanent and not usually reversible with bronchodilator therapy.

Unlike RA, however, which has multiple etiologic factors and autoimmunity at its root, COPD is almost always caused by smoking.

In the NOAR analysis, 53% of the 425 patients were ex-smokers and 13% were current smokers; 34% had never smoked.

Data from the first study, presented during a poster session by Dr. Howard Amital of Sheba Medical Centre in Tel Hashomer, Israel, showed, however, that even with smoking out of the equation, the risk of COPD in patients with RA was higher than in the general population.

Indeed, multivariate analysis demonstrated that RA was associated with COPD after the researchers controlled for confounding factors such as age, gender, smoking, obesity, and socioeconomic status.

“The strength of the association increased,” Dr. Amital and colleagues reported, with an adjusted odds ratio of 2.015 (95% confidence interval 1.83-2.22; P less than .001) and an unadjusted OR of 1.89 (95% CI 1.74-2.05, P less than .0001).

The case-control study involved 15,766 patients with RA and 15,240 age- and sex-matched healthy individuals without RA.

The study also found higher rates of other chronic disease in patients versus controls, including diabetes (23.9% vs. 19.8%, P less than .0001), ischemic heart disease (19.5% vs. 15.4%, P less than .0001), and heart failure (6.3% vs. 4.3%, P less than .0001).

“This study corroborates the hypothesis that COPD and RA are closely interrelated,” Dr. Amital and his team concluded.

This frontal view of the chest shows chronic obstructive pulmonary disease.

Source ©Living Art Enterprises, LLC/Photo Researchers, Inc.

Major Finding: COPD was a comorbid condition in 8.9% of patients with RA compared with 4.4% of controls from the general population in one study (P less than .001), with 7.3% of the Norfolk Arthritis Register study population also found to have the respiratory disease.

Data Source: A case-control study of more than 30,000 individuals with or without rheumatoid arthritis and data from a 15-year follow up of 435 patients with inflammatory polyarthritis or RA in the Norfolk Arthritis Register.

Disclosures: NOAR is funded by Arthritis Research UK. Dr. Verstappen and Dr. Amital and colleagues had no conflicts of interest to declare.

LONDON – Patients with rheumatoid arthritis have a high risk of concomitant chronic obstructive pulmonary disease, according to data from two studies.

In one of the studies – which involved more than 15,000 patients with rheumatoid arthritis (RA) and 15,000 healthy individuals as case-matched controls – the risk of the long-term lung condition was 8.9% and 4.4%, respectively (P less than .001).

Other data, from the Norfolk Arthritis Register (NOAR) showed that the prevalence of chronic obstructive pulmonary disease (COPD) in patients with inflammatory polyarthritis (IP) or RA was 7.3% (n = 425) at 15 years' follow-up. Prevalence of the respiratory disease was again doubled when compared to the general population.

“Lung involvement is a common extra-articular manifestation in rheumatoid arthritis,” said Dr. Suzanne Verstappen, who presented the findings from the NOAR at the congress.

“As could be expected, age and gender were associated with obstructive and restrictive lung disease,” said Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester, England, where the NOAR is coordinated.

Validated spirometry parameters and the Medical Research Council respiratory symptoms questionnaire were used to identify patients with IP or RA who also had COPD. The latter was distinguished from restrictive lung disease. The prevalence of restrictive lung disease was 9.7%.

COPD was observed in 7.3% of the population at 15 years, with higher prevalence rates found in men versus women over the age of 45 years (12.7% vs. 6%, respectively) in a crude comparison.

Published rates for the U.K. general population without IP or RA are 6.8% and 3.9% (Popul. Health Metr. 2007;5:8).

Like RA, COPD is a chronic and often debilitating disease. The disease manifests later in life and treatment is symptomatic rather than curative, as the obstruction in the airways is permanent and not usually reversible with bronchodilator therapy.

Unlike RA, however, which has multiple etiologic factors and autoimmunity at its root, COPD is almost always caused by smoking.

In the NOAR analysis, 53% of the 425 patients were ex-smokers and 13% were current smokers; 34% had never smoked.

Data from the first study, presented during a poster session by Dr. Howard Amital of Sheba Medical Centre in Tel Hashomer, Israel, showed, however, that even with smoking out of the equation, the risk of COPD in patients with RA was higher than in the general population.

Indeed, multivariate analysis demonstrated that RA was associated with COPD after the researchers controlled for confounding factors such as age, gender, smoking, obesity, and socioeconomic status.

“The strength of the association increased,” Dr. Amital and colleagues reported, with an adjusted odds ratio of 2.015 (95% confidence interval 1.83-2.22; P less than .001) and an unadjusted OR of 1.89 (95% CI 1.74-2.05, P less than .0001).

The case-control study involved 15,766 patients with RA and 15,240 age- and sex-matched healthy individuals without RA.

The study also found higher rates of other chronic disease in patients versus controls, including diabetes (23.9% vs. 19.8%, P less than .0001), ischemic heart disease (19.5% vs. 15.4%, P less than .0001), and heart failure (6.3% vs. 4.3%, P less than .0001).

“This study corroborates the hypothesis that COPD and RA are closely interrelated,” Dr. Amital and his team concluded.

This frontal view of the chest shows chronic obstructive pulmonary disease.

Source ©Living Art Enterprises, LLC/Photo Researchers, Inc.

Major Finding: COPD was a comorbid condition in 8.9% of patients with RA compared with 4.4% of controls from the general population in one study (P less than .001), with 7.3% of the Norfolk Arthritis Register study population also found to have the respiratory disease.

Data Source: A case-control study of more than 30,000 individuals with or without rheumatoid arthritis and data from a 15-year follow up of 435 patients with inflammatory polyarthritis or RA in the Norfolk Arthritis Register.

Disclosures: NOAR is funded by Arthritis Research UK. Dr. Verstappen and Dr. Amital and colleagues had no conflicts of interest to declare.

LONDON – Patients with rheumatoid arthritis have a high risk of concomitant chronic obstructive pulmonary disease, according to data from two studies.

In one of the studies – which involved more than 15,000 patients with rheumatoid arthritis (RA) and 15,000 healthy individuals as case-matched controls – the risk of the long-term lung condition was 8.9% and 4.4%, respectively (P less than .001).

Other data, from the Norfolk Arthritis Register (NOAR) showed that the prevalence of chronic obstructive pulmonary disease (COPD) in patients with inflammatory polyarthritis (IP) or RA was 7.3% (n = 425) at 15 years' follow-up. Prevalence of the respiratory disease was again doubled when compared to the general population.

“Lung involvement is a common extra-articular manifestation in rheumatoid arthritis,” said Dr. Suzanne Verstappen, who presented the findings from the NOAR at the congress.

“As could be expected, age and gender were associated with obstructive and restrictive lung disease,” said Dr. Verstappen, a research fellow at the Arthritis Research UK Epidemiology Unit at the University of Manchester, England, where the NOAR is coordinated.

Validated spirometry parameters and the Medical Research Council respiratory symptoms questionnaire were used to identify patients with IP or RA who also had COPD. The latter was distinguished from restrictive lung disease. The prevalence of restrictive lung disease was 9.7%.

COPD was observed in 7.3% of the population at 15 years, with higher prevalence rates found in men versus women over the age of 45 years (12.7% vs. 6%, respectively) in a crude comparison.

Published rates for the U.K. general population without IP or RA are 6.8% and 3.9% (Popul. Health Metr. 2007;5:8).

Like RA, COPD is a chronic and often debilitating disease. The disease manifests later in life and treatment is symptomatic rather than curative, as the obstruction in the airways is permanent and not usually reversible with bronchodilator therapy.

Unlike RA, however, which has multiple etiologic factors and autoimmunity at its root, COPD is almost always caused by smoking.

In the NOAR analysis, 53% of the 425 patients were ex-smokers and 13% were current smokers; 34% had never smoked.

Data from the first study, presented during a poster session by Dr. Howard Amital of Sheba Medical Centre in Tel Hashomer, Israel, showed, however, that even with smoking out of the equation, the risk of COPD in patients with RA was higher than in the general population.

Indeed, multivariate analysis demonstrated that RA was associated with COPD after the researchers controlled for confounding factors such as age, gender, smoking, obesity, and socioeconomic status.

“The strength of the association increased,” Dr. Amital and colleagues reported, with an adjusted odds ratio of 2.015 (95% confidence interval 1.83-2.22; P less than .001) and an unadjusted OR of 1.89 (95% CI 1.74-2.05, P less than .0001).

The case-control study involved 15,766 patients with RA and 15,240 age- and sex-matched healthy individuals without RA.

The study also found higher rates of other chronic disease in patients versus controls, including diabetes (23.9% vs. 19.8%, P less than .0001), ischemic heart disease (19.5% vs. 15.4%, P less than .0001), and heart failure (6.3% vs. 4.3%, P less than .0001).

“This study corroborates the hypothesis that COPD and RA are closely interrelated,” Dr. Amital and his team concluded.

This frontal view of the chest shows chronic obstructive pulmonary disease.

Source ©Living Art Enterprises, LLC/Photo Researchers, Inc.

Major Finding: The odds ratio for patients who were HLA-B27 positive and achieved ASDAS major improvement (greater than or equal to 2.0) at 3 months was 6.72, compared with those who were not (95% CI, 1.33-33.87; P = .02).

Data Source: Longitudinal, observational study of 171 patients with AS who were treated with an anti-TNF agent for the first time and were enrolled in NOR-DMARD, a register of adult patients with inflammatory arthropathies who were treated at five rheumatology centers in Norway.

Disclosures: Dr. Fagerli disclosed receiving a speaker's fee from Pfizer in the past.

LONDON – In the everyday setting, HLA-B27 positivity is the strongest predictor of an early, good response to the first use of an anti–tumor necrosis factor agent in patients with ankylosing spondylitis, according to the results of a longitudinal, observational study.

Other “real-world” and independent predictors of a good response using the ankylosing spondylitis disease activity score (ASDAS) are younger age, male sex, a higher baseline C-reactive protein (CRP) level, and a higher baseline patient global assessment score.

“TNF [tumor necrosis factor] inhibitors are effective in reducing symptoms in ankylosing spondylitis [AS], but not all patients have a response, and [they] sometimes have side effects, and the medication is expensive,” said Karen Fagerli, Ph.D., of the department of rheumatology at Diakonhjemmet Hospital in Oslo.

“So we want to identify characteristics of patients who will have a response in order to potentially utilize this knowledge when selecting patients for TNF-inhibitor therapy, and [therefore] treat patients with an optimized benefit-to-risk ratio,” Dr. Fagerli added. ASDAS was used as the main outcome measure, which may be the first time it has been used in an observational study setting.

Using data from the NOR-DMARD (Norway–Disease-Modifying Antirheumatic Drug) register, researchers identified a study population of 171 patients with AS who were starting a TNF inhibitor for the first time.

NOR-DMARD is a large, observational register that includes all patients with inflammatory arthropathies who are starting treatment with a DMARD for the first time at five rheumatology centers in Norway. Patients are routinely assessed at baseline, then after 3, 6, and 12 months, and then annually.

ASDAS major improvement was defined as a change in score of 2 or more; this was achieved by 32.7% of patients after 3 months of anti-TNF therapy.

Several parameters that had been identified as predictors of response in univariate analysis did not hold up as being statistically significant in a multivariate analysis model; these included the number of swollen joints, physician's global score, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and the Bath Ankylosing Spondylitis Functional Activity Index (BASFAI)

Patients who were HLA-B27 positive had a much higher chance of achieving ASDAS major improvement at 3 months than did those who were HLA-B27 negative (odds ratio, 6.72; 95% confidence interval, 1.33-33.87; P = .02).

Baseline CRP levels higher than 10 mg/L were also significantly predictive of an early treatment response (OR, 5.31; 95% CI, 2.23-12.42; P less than .001).

The next strongest predictor was male sex, with men almost three times more likely than women to show a benefit of anti-TNF treatment at 3 months (OR, 2.69; 95% CI, 1.04-7.00; P less than .04). However, the majority of the study population (73.4%) was male.

For every 1-year increase in age, the likelihood of achieving ASDAS major improvement declined, with young patients faring the best overall (OR, 0.95; 95% CI, 0.91-1.00; P less than .03). Furthermore, for every 10-mm increase in a 0- to 100-mm visual analog scale of patient global assessment, the chance of a good response improved (OR, 1.75; 95% CI, 1.40-2.19; P less than .0001).

Taken together, these data could help clinicians to identify patients who not only may respond to anti-TNF inhibitors but also should be prioritized for such treatment. However, “this is on a crude level; we don't know to what extent we can use [this information] on an individual level,” Dr. Fagerli said in an interview.

“We know for certain that there are patients who have none of these characteristics that I've talked about, who do get a response, so this is not the full truth; this is a little piece of the puzzle.”

Major Finding: The odds ratio for patients who were HLA-B27 positive and achieved ASDAS major improvement (greater than or equal to 2.0) at 3 months was 6.72, compared with those who were not (95% CI, 1.33-33.87; P = .02).

Data Source: Longitudinal, observational study of 171 patients with AS who were treated with an anti-TNF agent for the first time and were enrolled in NOR-DMARD, a register of adult patients with inflammatory arthropathies who were treated at five rheumatology centers in Norway.

Disclosures: Dr. Fagerli disclosed receiving a speaker's fee from Pfizer in the past.

LONDON – In the everyday setting, HLA-B27 positivity is the strongest predictor of an early, good response to the first use of an anti–tumor necrosis factor agent in patients with ankylosing spondylitis, according to the results of a longitudinal, observational study.

Other “real-world” and independent predictors of a good response using the ankylosing spondylitis disease activity score (ASDAS) are younger age, male sex, a higher baseline C-reactive protein (CRP) level, and a higher baseline patient global assessment score.

“TNF [tumor necrosis factor] inhibitors are effective in reducing symptoms in ankylosing spondylitis [AS], but not all patients have a response, and [they] sometimes have side effects, and the medication is expensive,” said Karen Fagerli, Ph.D., of the department of rheumatology at Diakonhjemmet Hospital in Oslo.

“So we want to identify characteristics of patients who will have a response in order to potentially utilize this knowledge when selecting patients for TNF-inhibitor therapy, and [therefore] treat patients with an optimized benefit-to-risk ratio,” Dr. Fagerli added. ASDAS was used as the main outcome measure, which may be the first time it has been used in an observational study setting.

Using data from the NOR-DMARD (Norway–Disease-Modifying Antirheumatic Drug) register, researchers identified a study population of 171 patients with AS who were starting a TNF inhibitor for the first time.

NOR-DMARD is a large, observational register that includes all patients with inflammatory arthropathies who are starting treatment with a DMARD for the first time at five rheumatology centers in Norway. Patients are routinely assessed at baseline, then after 3, 6, and 12 months, and then annually.

ASDAS major improvement was defined as a change in score of 2 or more; this was achieved by 32.7% of patients after 3 months of anti-TNF therapy.

Several parameters that had been identified as predictors of response in univariate analysis did not hold up as being statistically significant in a multivariate analysis model; these included the number of swollen joints, physician's global score, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and the Bath Ankylosing Spondylitis Functional Activity Index (BASFAI)

Patients who were HLA-B27 positive had a much higher chance of achieving ASDAS major improvement at 3 months than did those who were HLA-B27 negative (odds ratio, 6.72; 95% confidence interval, 1.33-33.87; P = .02).

Baseline CRP levels higher than 10 mg/L were also significantly predictive of an early treatment response (OR, 5.31; 95% CI, 2.23-12.42; P less than .001).

The next strongest predictor was male sex, with men almost three times more likely than women to show a benefit of anti-TNF treatment at 3 months (OR, 2.69; 95% CI, 1.04-7.00; P less than .04). However, the majority of the study population (73.4%) was male.

For every 1-year increase in age, the likelihood of achieving ASDAS major improvement declined, with young patients faring the best overall (OR, 0.95; 95% CI, 0.91-1.00; P less than .03). Furthermore, for every 10-mm increase in a 0- to 100-mm visual analog scale of patient global assessment, the chance of a good response improved (OR, 1.75; 95% CI, 1.40-2.19; P less than .0001).

Taken together, these data could help clinicians to identify patients who not only may respond to anti-TNF inhibitors but also should be prioritized for such treatment. However, “this is on a crude level; we don't know to what extent we can use [this information] on an individual level,” Dr. Fagerli said in an interview.

“We know for certain that there are patients who have none of these characteristics that I've talked about, who do get a response, so this is not the full truth; this is a little piece of the puzzle.”

Major Finding: The odds ratio for patients who were HLA-B27 positive and achieved ASDAS major improvement (greater than or equal to 2.0) at 3 months was 6.72, compared with those who were not (95% CI, 1.33-33.87; P = .02).

Data Source: Longitudinal, observational study of 171 patients with AS who were treated with an anti-TNF agent for the first time and were enrolled in NOR-DMARD, a register of adult patients with inflammatory arthropathies who were treated at five rheumatology centers in Norway.

Disclosures: Dr. Fagerli disclosed receiving a speaker's fee from Pfizer in the past.

LONDON – In the everyday setting, HLA-B27 positivity is the strongest predictor of an early, good response to the first use of an anti–tumor necrosis factor agent in patients with ankylosing spondylitis, according to the results of a longitudinal, observational study.

Other “real-world” and independent predictors of a good response using the ankylosing spondylitis disease activity score (ASDAS) are younger age, male sex, a higher baseline C-reactive protein (CRP) level, and a higher baseline patient global assessment score.

“TNF [tumor necrosis factor] inhibitors are effective in reducing symptoms in ankylosing spondylitis [AS], but not all patients have a response, and [they] sometimes have side effects, and the medication is expensive,” said Karen Fagerli, Ph.D., of the department of rheumatology at Diakonhjemmet Hospital in Oslo.

“So we want to identify characteristics of patients who will have a response in order to potentially utilize this knowledge when selecting patients for TNF-inhibitor therapy, and [therefore] treat patients with an optimized benefit-to-risk ratio,” Dr. Fagerli added. ASDAS was used as the main outcome measure, which may be the first time it has been used in an observational study setting.

Using data from the NOR-DMARD (Norway–Disease-Modifying Antirheumatic Drug) register, researchers identified a study population of 171 patients with AS who were starting a TNF inhibitor for the first time.

NOR-DMARD is a large, observational register that includes all patients with inflammatory arthropathies who are starting treatment with a DMARD for the first time at five rheumatology centers in Norway. Patients are routinely assessed at baseline, then after 3, 6, and 12 months, and then annually.

ASDAS major improvement was defined as a change in score of 2 or more; this was achieved by 32.7% of patients after 3 months of anti-TNF therapy.

Several parameters that had been identified as predictors of response in univariate analysis did not hold up as being statistically significant in a multivariate analysis model; these included the number of swollen joints, physician's global score, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and the Bath Ankylosing Spondylitis Functional Activity Index (BASFAI)

Patients who were HLA-B27 positive had a much higher chance of achieving ASDAS major improvement at 3 months than did those who were HLA-B27 negative (odds ratio, 6.72; 95% confidence interval, 1.33-33.87; P = .02).

Baseline CRP levels higher than 10 mg/L were also significantly predictive of an early treatment response (OR, 5.31; 95% CI, 2.23-12.42; P less than .001).

The next strongest predictor was male sex, with men almost three times more likely than women to show a benefit of anti-TNF treatment at 3 months (OR, 2.69; 95% CI, 1.04-7.00; P less than .04). However, the majority of the study population (73.4%) was male.

For every 1-year increase in age, the likelihood of achieving ASDAS major improvement declined, with young patients faring the best overall (OR, 0.95; 95% CI, 0.91-1.00; P less than .03). Furthermore, for every 10-mm increase in a 0- to 100-mm visual analog scale of patient global assessment, the chance of a good response improved (OR, 1.75; 95% CI, 1.40-2.19; P less than .0001).

Taken together, these data could help clinicians to identify patients who not only may respond to anti-TNF inhibitors but also should be prioritized for such treatment. However, “this is on a crude level; we don't know to what extent we can use [this information] on an individual level,” Dr. Fagerli said in an interview.

“We know for certain that there are patients who have none of these characteristics that I've talked about, who do get a response, so this is not the full truth; this is a little piece of the puzzle.”

The burden of pain among older patients is great, and its consequences can be “serious and significant,” according to a presentation by Dr. Perry G. Fine.

The prevalence of pain ranges from 25% to 50% in the older population, and it increases with age, he said.

Indeed, among older nursing home residents, the prevalence is estimated at 45%-80%. In one study, 20% of individuals aged 65 and older admitted to having a day-long bout of pain in the past month, and about 60% said they had experienced pain for a year or more, said Dr. Fine, professor of anesthesiology at the University of Utah, Salt Lake City.

The sources of pain in these patients are many and varied, and the consequences can include mood disorders, sleep disturbances, decreased socialization, increased health care utilization and costs, limitations in activities of daily living, comorbidities, and polypharmacy, all of which can lead to diminished function and quality of life.

Further complicating the problem is the fact that studies have repeatedly shown that pain in older adults is frequently undertreated, Dr. Fine said.

This may be the result of one or more of the numerous, identified barriers to the management of pain in older patients.

These include language and cultural barriers, fear of judgment, fear of addiction, cognitive impairment, sensory impairment, and adverse effects such as fear of falling, constipation, sedation, and drug-drug interactions.

Barriers for clinicians can include the lack of objective measures of pain and pain response, concerns regarding addiction and/or drug seeking, fear of causing harm from medication-related adverse effects, lack of time in the office setting, and lack of pain management training, according to findings from two studies on the topic (Clin. J. Pain 2007;23[suppl. 1]:S1-43; J. Adv. Nurs. 2009;65:2-10).

Following a list of 10 “universal precautions” in pain management can help with overcoming some of these barriers, Dr. Fine said (Pain Med. 2005;6:107-12). These include the following:

▸ Making a diagnosis with appropriate differential diagnoses.

▸ Performing psychological assessment, including evaluation for risk of addictive disorders.

▸ Obtaining informed consent.

▸ Developing treatment agreements.

▸ Performing pain and function assessments.

▸ Using pain medication – and particularly opioids – on a trial basis.

▸ Reassessing pain, function, and behavior.

▸ Regularly reassessing the “Four As” (analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors).

▸ Periodically reviewing diagnosis and comorbidities.

▸ Documenting thoroughly.

Also, keep in mind that aging results in a number of physiological changes that will influence both pharmacokinetics and pharmacodynamics, including changes in body composition; decreases in gastrointestinal motility, hepatic metabolism, renal clearance, and protein binding; and increased central nervous system sensitivity to noxious stimuli and medication effects, Dr. Fine said (Neurobiol. Aging 2010; 31:494-503; Clin. J. Pain 2004;20:220-6).

While speaking at the Congress of Clinical Rheumatology, Dr. Fine listed the following general principles to follow when it comes to pharmacotherapy in light of these changes and the needs of older adults:

▸ Titrate according to individual circumstances.

▸ Anticipate and monitor for adverse effects, prevent them when possible, and treat them when necessary.

▸ Practice synergy by combining lower doses of drugs that mediate analgesia via different mechanisms.

▸ Know and understand the distinctions among tolerance, dependence, addiction, and pseudoaddiction.

In those with cognitive impairment, in whom pain assessment can be particularly challenging, clinicians should consider alternatives to standard numeric rating scales for pain assessment.

Patients who have difficulty reporting pain based on these types of scales may do better with the Iowa Pain Thermometer, which allows a patient to rate pain using increments on a picture of a thermometer (Pain Med. 2007;8:585-600), or with the Brief Pain Inventory. Reports from caregivers may also be useful, Dr. Fine said.

Dr. Fine reported having no conflicts of interest that were relevant to his presentation.

The burden of pain among older patients is great, and its consequences can be “serious and significant,” according to a presentation by Dr. Perry G. Fine.

The prevalence of pain ranges from 25% to 50% in the older population, and it increases with age, he said.

Indeed, among older nursing home residents, the prevalence is estimated at 45%-80%. In one study, 20% of individuals aged 65 and older admitted to having a day-long bout of pain in the past month, and about 60% said they had experienced pain for a year or more, said Dr. Fine, professor of anesthesiology at the University of Utah, Salt Lake City.

The sources of pain in these patients are many and varied, and the consequences can include mood disorders, sleep disturbances, decreased socialization, increased health care utilization and costs, limitations in activities of daily living, comorbidities, and polypharmacy, all of which can lead to diminished function and quality of life.

Further complicating the problem is the fact that studies have repeatedly shown that pain in older adults is frequently undertreated, Dr. Fine said.

This may be the result of one or more of the numerous, identified barriers to the management of pain in older patients.

These include language and cultural barriers, fear of judgment, fear of addiction, cognitive impairment, sensory impairment, and adverse effects such as fear of falling, constipation, sedation, and drug-drug interactions.

Barriers for clinicians can include the lack of objective measures of pain and pain response, concerns regarding addiction and/or drug seeking, fear of causing harm from medication-related adverse effects, lack of time in the office setting, and lack of pain management training, according to findings from two studies on the topic (Clin. J. Pain 2007;23[suppl. 1]:S1-43; J. Adv. Nurs. 2009;65:2-10).

Following a list of 10 “universal precautions” in pain management can help with overcoming some of these barriers, Dr. Fine said (Pain Med. 2005;6:107-12). These include the following:

▸ Making a diagnosis with appropriate differential diagnoses.

▸ Performing psychological assessment, including evaluation for risk of addictive disorders.

▸ Obtaining informed consent.

▸ Developing treatment agreements.

▸ Performing pain and function assessments.

▸ Using pain medication – and particularly opioids – on a trial basis.

▸ Reassessing pain, function, and behavior.

▸ Regularly reassessing the “Four As” (analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors).

▸ Periodically reviewing diagnosis and comorbidities.

▸ Documenting thoroughly.

Also, keep in mind that aging results in a number of physiological changes that will influence both pharmacokinetics and pharmacodynamics, including changes in body composition; decreases in gastrointestinal motility, hepatic metabolism, renal clearance, and protein binding; and increased central nervous system sensitivity to noxious stimuli and medication effects, Dr. Fine said (Neurobiol. Aging 2010; 31:494-503; Clin. J. Pain 2004;20:220-6).

While speaking at the Congress of Clinical Rheumatology, Dr. Fine listed the following general principles to follow when it comes to pharmacotherapy in light of these changes and the needs of older adults:

▸ Titrate according to individual circumstances.

▸ Anticipate and monitor for adverse effects, prevent them when possible, and treat them when necessary.

▸ Practice synergy by combining lower doses of drugs that mediate analgesia via different mechanisms.

▸ Know and understand the distinctions among tolerance, dependence, addiction, and pseudoaddiction.

In those with cognitive impairment, in whom pain assessment can be particularly challenging, clinicians should consider alternatives to standard numeric rating scales for pain assessment.

Patients who have difficulty reporting pain based on these types of scales may do better with the Iowa Pain Thermometer, which allows a patient to rate pain using increments on a picture of a thermometer (Pain Med. 2007;8:585-600), or with the Brief Pain Inventory. Reports from caregivers may also be useful, Dr. Fine said.

Dr. Fine reported having no conflicts of interest that were relevant to his presentation.

The burden of pain among older patients is great, and its consequences can be “serious and significant,” according to a presentation by Dr. Perry G. Fine.

The prevalence of pain ranges from 25% to 50% in the older population, and it increases with age, he said.

Indeed, among older nursing home residents, the prevalence is estimated at 45%-80%. In one study, 20% of individuals aged 65 and older admitted to having a day-long bout of pain in the past month, and about 60% said they had experienced pain for a year or more, said Dr. Fine, professor of anesthesiology at the University of Utah, Salt Lake City.

The sources of pain in these patients are many and varied, and the consequences can include mood disorders, sleep disturbances, decreased socialization, increased health care utilization and costs, limitations in activities of daily living, comorbidities, and polypharmacy, all of which can lead to diminished function and quality of life.

Further complicating the problem is the fact that studies have repeatedly shown that pain in older adults is frequently undertreated, Dr. Fine said.

This may be the result of one or more of the numerous, identified barriers to the management of pain in older patients.

These include language and cultural barriers, fear of judgment, fear of addiction, cognitive impairment, sensory impairment, and adverse effects such as fear of falling, constipation, sedation, and drug-drug interactions.

Barriers for clinicians can include the lack of objective measures of pain and pain response, concerns regarding addiction and/or drug seeking, fear of causing harm from medication-related adverse effects, lack of time in the office setting, and lack of pain management training, according to findings from two studies on the topic (Clin. J. Pain 2007;23[suppl. 1]:S1-43; J. Adv. Nurs. 2009;65:2-10).

Following a list of 10 “universal precautions” in pain management can help with overcoming some of these barriers, Dr. Fine said (Pain Med. 2005;6:107-12). These include the following:

▸ Making a diagnosis with appropriate differential diagnoses.

▸ Performing psychological assessment, including evaluation for risk of addictive disorders.

▸ Obtaining informed consent.

▸ Developing treatment agreements.

▸ Performing pain and function assessments.

▸ Using pain medication – and particularly opioids – on a trial basis.

▸ Reassessing pain, function, and behavior.

▸ Regularly reassessing the “Four As” (analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors).

▸ Periodically reviewing diagnosis and comorbidities.

▸ Documenting thoroughly.

Also, keep in mind that aging results in a number of physiological changes that will influence both pharmacokinetics and pharmacodynamics, including changes in body composition; decreases in gastrointestinal motility, hepatic metabolism, renal clearance, and protein binding; and increased central nervous system sensitivity to noxious stimuli and medication effects, Dr. Fine said (Neurobiol. Aging 2010; 31:494-503; Clin. J. Pain 2004;20:220-6).

While speaking at the Congress of Clinical Rheumatology, Dr. Fine listed the following general principles to follow when it comes to pharmacotherapy in light of these changes and the needs of older adults:

▸ Titrate according to individual circumstances.

▸ Anticipate and monitor for adverse effects, prevent them when possible, and treat them when necessary.

▸ Practice synergy by combining lower doses of drugs that mediate analgesia via different mechanisms.

▸ Know and understand the distinctions among tolerance, dependence, addiction, and pseudoaddiction.

In those with cognitive impairment, in whom pain assessment can be particularly challenging, clinicians should consider alternatives to standard numeric rating scales for pain assessment.

Patients who have difficulty reporting pain based on these types of scales may do better with the Iowa Pain Thermometer, which allows a patient to rate pain using increments on a picture of a thermometer (Pain Med. 2007;8:585-600), or with the Brief Pain Inventory. Reports from caregivers may also be useful, Dr. Fine said.

Dr. Fine reported having no conflicts of interest that were relevant to his presentation.

Major Finding: The incidence rate of newly diagnosed rheumatoid arthritis rises with age, peaking among people in their 70s with an incidence of 73 new cases per 100,000 population annually.

Data Source: Review of Swedish national patient registers for 2006-2008, which identified about 10,000 newly diagnosed cases of RA.

Disclosures: Mr. Eriksson said he had no disclosures.

LONDON – The incidence of rheumatoid arthritis rises with age in both men and women and shows the biggest jump during the sixth decade of life, when the incidence among adults in their 50s nearly doubles compared with those in their 40s, based on findings from an analysis of about 10,000 Swedish patients diagnosed for the first time during 2006-2008.

The nationwide data also showed that peak RA incidence occurs among men and women in their 70s, with a new-onset rate of at least 73 cases per 100,000 population annually, Jonas Eriksson said. h

The nationwide Swedish data that allowed analysis of about 10,000 cases far exceeded the scope of previous incidence estimates, enabling Mr. Eriksson and his associates in the clinical epidemiology unit at the Karolinska Institute, Stockholm, to estimate incidence rates by age and sex. They said they used data collected by the Swedish Rheumatology Quality Register, the National Patient Register, and the Prescribed Drug Register.

To assess incident RA cases, the investigators used three different definitions of new-onset disease. The most restrictive definition involved patients who met all of five separate defining criteria:

▸ A first-ever inpatient visit, a specialist outpatient visit, or inclusion in the Swedish Rheumatology Quality Register with a RA diagnosis during 2006-2008;

▸ At least one visit to a rheumatology or internal medicine department;

▸ At least two visits with a diagnosis of RA during 2006-2008;

▸ A second visit with a RA diagnosis within 1 year after a first visit; and

▸ Exclusion of patients treated with a disease-modifying antirheumatic drug more than 6 months before the first visit with a RA diagnosis, pain in joints, or an unspecified diagnosis.

Applying these criteria to the databases for 2006-2008 identified 7,953 patients with a presumed first-time diagnosis of RA, which resulted in a calculated incidence rate of 35 cases/100,000 population per year. Broken down by gender, the rates were 22 cases/100,000 in men and 48 cases/100,000 in women. Mr. Eriksson also reported incidence rates among men and women broken down by age. (See table.) The peak new-onset rates occurred in people aged 70-79 years, with rates of 60 cases/100,000 per year among men and 86 cases/100,000 per year in women.

To further broaden the analysis, the researchers calculated incidence rates using two less stringent definitions. They applied a “medium” definition that eliminated the exclusion portion of their initial, strict definition. This identified 9,133 new-onset cases during the 3 years studied, with an overall incidence rate of 41 cases/100,000 per year and rates of 25 cases/100,000 per year in men and 55 cases/100,000 per year in women.

A third, “liberal” definition of RA limited the identifying criteria to the first two elements from the original list of five: a first-ever inpatient visit, a specialist outpatient visit, or inclusion in the Swedish Rheumatology Quality Register during 2006-2008; and at least one visit to a rheumatology or internal medicine department. This identified 11,715 new-onset cases in 2006-2008, an overall rate of 52/100,000 per year, with rates of 33/100,000 per year in men and 71/100,000 per year in women, he said.

Vitals

Source Elsevier Global Medical News

Major Finding: The incidence rate of newly diagnosed rheumatoid arthritis rises with age, peaking among people in their 70s with an incidence of 73 new cases per 100,000 population annually.

Data Source: Review of Swedish national patient registers for 2006-2008, which identified about 10,000 newly diagnosed cases of RA.

Disclosures: Mr. Eriksson said he had no disclosures.

LONDON – The incidence of rheumatoid arthritis rises with age in both men and women and shows the biggest jump during the sixth decade of life, when the incidence among adults in their 50s nearly doubles compared with those in their 40s, based on findings from an analysis of about 10,000 Swedish patients diagnosed for the first time during 2006-2008.

The nationwide data also showed that peak RA incidence occurs among men and women in their 70s, with a new-onset rate of at least 73 cases per 100,000 population annually, Jonas Eriksson said. h

The nationwide Swedish data that allowed analysis of about 10,000 cases far exceeded the scope of previous incidence estimates, enabling Mr. Eriksson and his associates in the clinical epidemiology unit at the Karolinska Institute, Stockholm, to estimate incidence rates by age and sex. They said they used data collected by the Swedish Rheumatology Quality Register, the National Patient Register, and the Prescribed Drug Register.

To assess incident RA cases, the investigators used three different definitions of new-onset disease. The most restrictive definition involved patients who met all of five separate defining criteria:

▸ A first-ever inpatient visit, a specialist outpatient visit, or inclusion in the Swedish Rheumatology Quality Register with a RA diagnosis during 2006-2008;

▸ At least one visit to a rheumatology or internal medicine department;

▸ At least two visits with a diagnosis of RA during 2006-2008;

▸ A second visit with a RA diagnosis within 1 year after a first visit; and

▸ Exclusion of patients treated with a disease-modifying antirheumatic drug more than 6 months before the first visit with a RA diagnosis, pain in joints, or an unspecified diagnosis.

Applying these criteria to the databases for 2006-2008 identified 7,953 patients with a presumed first-time diagnosis of RA, which resulted in a calculated incidence rate of 35 cases/100,000 population per year. Broken down by gender, the rates were 22 cases/100,000 in men and 48 cases/100,000 in women. Mr. Eriksson also reported incidence rates among men and women broken down by age. (See table.) The peak new-onset rates occurred in people aged 70-79 years, with rates of 60 cases/100,000 per year among men and 86 cases/100,000 per year in women.

To further broaden the analysis, the researchers calculated incidence rates using two less stringent definitions. They applied a “medium” definition that eliminated the exclusion portion of their initial, strict definition. This identified 9,133 new-onset cases during the 3 years studied, with an overall incidence rate of 41 cases/100,000 per year and rates of 25 cases/100,000 per year in men and 55 cases/100,000 per year in women.

A third, “liberal” definition of RA limited the identifying criteria to the first two elements from the original list of five: a first-ever inpatient visit, a specialist outpatient visit, or inclusion in the Swedish Rheumatology Quality Register during 2006-2008; and at least one visit to a rheumatology or internal medicine department. This identified 11,715 new-onset cases in 2006-2008, an overall rate of 52/100,000 per year, with rates of 33/100,000 per year in men and 71/100,000 per year in women, he said.

Vitals

Source Elsevier Global Medical News

Major Finding: The incidence rate of newly diagnosed rheumatoid arthritis rises with age, peaking among people in their 70s with an incidence of 73 new cases per 100,000 population annually.

Data Source: Review of Swedish national patient registers for 2006-2008, which identified about 10,000 newly diagnosed cases of RA.

Disclosures: Mr. Eriksson said he had no disclosures.

LONDON – The incidence of rheumatoid arthritis rises with age in both men and women and shows the biggest jump during the sixth decade of life, when the incidence among adults in their 50s nearly doubles compared with those in their 40s, based on findings from an analysis of about 10,000 Swedish patients diagnosed for the first time during 2006-2008.

The nationwide data also showed that peak RA incidence occurs among men and women in their 70s, with a new-onset rate of at least 73 cases per 100,000 population annually, Jonas Eriksson said. h

The nationwide Swedish data that allowed analysis of about 10,000 cases far exceeded the scope of previous incidence estimates, enabling Mr. Eriksson and his associates in the clinical epidemiology unit at the Karolinska Institute, Stockholm, to estimate incidence rates by age and sex. They said they used data collected by the Swedish Rheumatology Quality Register, the National Patient Register, and the Prescribed Drug Register.

To assess incident RA cases, the investigators used three different definitions of new-onset disease. The most restrictive definition involved patients who met all of five separate defining criteria:

▸ A first-ever inpatient visit, a specialist outpatient visit, or inclusion in the Swedish Rheumatology Quality Register with a RA diagnosis during 2006-2008;

▸ At least one visit to a rheumatology or internal medicine department;

▸ At least two visits with a diagnosis of RA during 2006-2008;

▸ A second visit with a RA diagnosis within 1 year after a first visit; and

▸ Exclusion of patients treated with a disease-modifying antirheumatic drug more than 6 months before the first visit with a RA diagnosis, pain in joints, or an unspecified diagnosis.

Applying these criteria to the databases for 2006-2008 identified 7,953 patients with a presumed first-time diagnosis of RA, which resulted in a calculated incidence rate of 35 cases/100,000 population per year. Broken down by gender, the rates were 22 cases/100,000 in men and 48 cases/100,000 in women. Mr. Eriksson also reported incidence rates among men and women broken down by age. (See table.) The peak new-onset rates occurred in people aged 70-79 years, with rates of 60 cases/100,000 per year among men and 86 cases/100,000 per year in women.

To further broaden the analysis, the researchers calculated incidence rates using two less stringent definitions. They applied a “medium” definition that eliminated the exclusion portion of their initial, strict definition. This identified 9,133 new-onset cases during the 3 years studied, with an overall incidence rate of 41 cases/100,000 per year and rates of 25 cases/100,000 per year in men and 55 cases/100,000 per year in women.

A third, “liberal” definition of RA limited the identifying criteria to the first two elements from the original list of five: a first-ever inpatient visit, a specialist outpatient visit, or inclusion in the Swedish Rheumatology Quality Register during 2006-2008; and at least one visit to a rheumatology or internal medicine department. This identified 11,715 new-onset cases in 2006-2008, an overall rate of 52/100,000 per year, with rates of 33/100,000 per year in men and 71/100,000 per year in women, he said.

Vitals

Source Elsevier Global Medical News

Major Finding: One vascularized enthesis seen on ultrasound predicted SpA within 2 years with a sensitivity of 76% and a specificity of 81%. An ultrasound finding of a nonvascularized enthesis, combined with positive Amor criteria, predicted the disorder at 2 years with a sensitivity of 90% and a specificity of 77%.

Data Source: A prospective cohort study of 118 patients with symptoms suggestive of spondyloarthritis.

Disclosures: The study was supported by a grant from the French Society of Rheumatology. None of the authors had any financial disclosures.

A power Doppler ultrasound examination may provide the most accurate early diagnosis of spondyloarthritis, with a sensitivity of 76% and a specificity of 81% upon the visualization of at least one vascularized enthesis.

The finding may be particularly valuable to rheumatologists because the existing spondyloarthritis diagnostic criteria have, at best, a limited ability to accurately identify the disease in its earliest stages, Dr. Maria Antoinette D'Agostino and her colleagues wrote.

Although the test itself is a “delicate technique,” it is within the reach of most ultrasound technicians, said Dr. D'Agostino of Versailles Saint-Quentin-en-Yveline (France) University.

The 2-year prospective cohort study comprised 118 patients with symptoms suggestive of spondyloarthritis. These included inflammatory back pain (48); arthritis or arthralgia (38); enthesitis or dactylitis (12); and HLA B27 plus acute anterior uveitis (20). Their median age was 40 years; the median disease duration at baseline was 2 years.

All patients underwent a standard clinical examination by a rheumatologist who was blinded to the diagnosis of the referring physician. All had provided a pelvic x-ray not more than 6 months old for the scoring of sacroiliitis; if the radiologic findings were equivocal or if there was persistent buttock pain, the patients underwent a pelvic CT scan.

Every patient had a power Doppler ultrasound examination of peripheral entheses by a sonographer who was blinded to the patients' data. Areas examined included plantar fascia, Achilles tendon, patellar ligament on the patella apex, quadriceps femoris, gluteus medius tendon, and the common extensor and common flexor tendons on the lateral and medial epicondyle of the elbow.

Important findings included any morphologic or structural abnormalities and vascularization at bony insertion points. The study evaluated three criteria: any vascularized enthesis, the number of abnormal entheses, and the global ultrasound score.

The referring physician's diagnosis was used as the clinical standard in evaluating ultrasound's diagnostic capability; after 2 years, the patients were reevaluated for a final diagnosis, which the investigators then compared with the original diagnosis to compute ultrasound's diagnostic capability. At the end of the follow-up period, patients were reclassified by their referring rheumatologist (51 diagnosed with SpA, 48 not diagnosed as SpA, and 19 unclassified).

In building the prediction model, the investigators examined the ultrasound findings in light of the final diagnoses. Ultrasound found at least one abnormal enthesis in 88 (75%) of the patients; the enthesis was vascularized in 56 of these patients. At least one vascularized enthesis occurred in 76% of those with an SpA diagnosis, 19% of those with a non-SpA diagnosis, and 42% of unclassified patients (Ann. Rheum. Dis. 2011;70:1433-40).

Ultrasound detected significantly more abnormal and vascularized entheses in SpA patients than in non-SpA patients. Those with a SpA diagnosis also had significantly higher ultrasound global scores than did the other groups.

Overall, two factors independently predicted a final diagnosis of SpA: Patients who had at least one vascularized enthesis on ultrasound were 12 times more likely to have a final diagnosis of SpA, and patients with an Amor criteria score of 6 or greater were nearly nine times more likely to have SpA than patients with a lower score. Further analysis confirmed that the baseline presence of at least one vascularized enthesis predicted SpA at 2 years with a 76.5% sensitivity and an 81% specificity. If there were no vascularized entheses at baseline, SpA could still be predicted with a combination of ultrasound and positive Amor criteria score, the authors said; this method yielded a sensitivity of 90% for SpA and a specificity of 77%. “Strikingly, we confirmed that vascularization of the enthesis insertion by [ultrasound] is a landmark feature for SpA, even in suspected cases,” the authors said.

Major Finding: One vascularized enthesis seen on ultrasound predicted SpA within 2 years with a sensitivity of 76% and a specificity of 81%. An ultrasound finding of a nonvascularized enthesis, combined with positive Amor criteria, predicted the disorder at 2 years with a sensitivity of 90% and a specificity of 77%.

Data Source: A prospective cohort study of 118 patients with symptoms suggestive of spondyloarthritis.

Disclosures: The study was supported by a grant from the French Society of Rheumatology. None of the authors had any financial disclosures.

A power Doppler ultrasound examination may provide the most accurate early diagnosis of spondyloarthritis, with a sensitivity of 76% and a specificity of 81% upon the visualization of at least one vascularized enthesis.

The finding may be particularly valuable to rheumatologists because the existing spondyloarthritis diagnostic criteria have, at best, a limited ability to accurately identify the disease in its earliest stages, Dr. Maria Antoinette D'Agostino and her colleagues wrote.

Although the test itself is a “delicate technique,” it is within the reach of most ultrasound technicians, said Dr. D'Agostino of Versailles Saint-Quentin-en-Yveline (France) University.

The 2-year prospective cohort study comprised 118 patients with symptoms suggestive of spondyloarthritis. These included inflammatory back pain (48); arthritis or arthralgia (38); enthesitis or dactylitis (12); and HLA B27 plus acute anterior uveitis (20). Their median age was 40 years; the median disease duration at baseline was 2 years.

All patients underwent a standard clinical examination by a rheumatologist who was blinded to the diagnosis of the referring physician. All had provided a pelvic x-ray not more than 6 months old for the scoring of sacroiliitis; if the radiologic findings were equivocal or if there was persistent buttock pain, the patients underwent a pelvic CT scan.

Every patient had a power Doppler ultrasound examination of peripheral entheses by a sonographer who was blinded to the patients' data. Areas examined included plantar fascia, Achilles tendon, patellar ligament on the patella apex, quadriceps femoris, gluteus medius tendon, and the common extensor and common flexor tendons on the lateral and medial epicondyle of the elbow.

Important findings included any morphologic or structural abnormalities and vascularization at bony insertion points. The study evaluated three criteria: any vascularized enthesis, the number of abnormal entheses, and the global ultrasound score.

The referring physician's diagnosis was used as the clinical standard in evaluating ultrasound's diagnostic capability; after 2 years, the patients were reevaluated for a final diagnosis, which the investigators then compared with the original diagnosis to compute ultrasound's diagnostic capability. At the end of the follow-up period, patients were reclassified by their referring rheumatologist (51 diagnosed with SpA, 48 not diagnosed as SpA, and 19 unclassified).

In building the prediction model, the investigators examined the ultrasound findings in light of the final diagnoses. Ultrasound found at least one abnormal enthesis in 88 (75%) of the patients; the enthesis was vascularized in 56 of these patients. At least one vascularized enthesis occurred in 76% of those with an SpA diagnosis, 19% of those with a non-SpA diagnosis, and 42% of unclassified patients (Ann. Rheum. Dis. 2011;70:1433-40).

Ultrasound detected significantly more abnormal and vascularized entheses in SpA patients than in non-SpA patients. Those with a SpA diagnosis also had significantly higher ultrasound global scores than did the other groups.

Overall, two factors independently predicted a final diagnosis of SpA: Patients who had at least one vascularized enthesis on ultrasound were 12 times more likely to have a final diagnosis of SpA, and patients with an Amor criteria score of 6 or greater were nearly nine times more likely to have SpA than patients with a lower score. Further analysis confirmed that the baseline presence of at least one vascularized enthesis predicted SpA at 2 years with a 76.5% sensitivity and an 81% specificity. If there were no vascularized entheses at baseline, SpA could still be predicted with a combination of ultrasound and positive Amor criteria score, the authors said; this method yielded a sensitivity of 90% for SpA and a specificity of 77%. “Strikingly, we confirmed that vascularization of the enthesis insertion by [ultrasound] is a landmark feature for SpA, even in suspected cases,” the authors said.

Major Finding: One vascularized enthesis seen on ultrasound predicted SpA within 2 years with a sensitivity of 76% and a specificity of 81%. An ultrasound finding of a nonvascularized enthesis, combined with positive Amor criteria, predicted the disorder at 2 years with a sensitivity of 90% and a specificity of 77%.

Data Source: A prospective cohort study of 118 patients with symptoms suggestive of spondyloarthritis.

Disclosures: The study was supported by a grant from the French Society of Rheumatology. None of the authors had any financial disclosures.

A power Doppler ultrasound examination may provide the most accurate early diagnosis of spondyloarthritis, with a sensitivity of 76% and a specificity of 81% upon the visualization of at least one vascularized enthesis.

The finding may be particularly valuable to rheumatologists because the existing spondyloarthritis diagnostic criteria have, at best, a limited ability to accurately identify the disease in its earliest stages, Dr. Maria Antoinette D'Agostino and her colleagues wrote.

Although the test itself is a “delicate technique,” it is within the reach of most ultrasound technicians, said Dr. D'Agostino of Versailles Saint-Quentin-en-Yveline (France) University.

The 2-year prospective cohort study comprised 118 patients with symptoms suggestive of spondyloarthritis. These included inflammatory back pain (48); arthritis or arthralgia (38); enthesitis or dactylitis (12); and HLA B27 plus acute anterior uveitis (20). Their median age was 40 years; the median disease duration at baseline was 2 years.

All patients underwent a standard clinical examination by a rheumatologist who was blinded to the diagnosis of the referring physician. All had provided a pelvic x-ray not more than 6 months old for the scoring of sacroiliitis; if the radiologic findings were equivocal or if there was persistent buttock pain, the patients underwent a pelvic CT scan.

Every patient had a power Doppler ultrasound examination of peripheral entheses by a sonographer who was blinded to the patients' data. Areas examined included plantar fascia, Achilles tendon, patellar ligament on the patella apex, quadriceps femoris, gluteus medius tendon, and the common extensor and common flexor tendons on the lateral and medial epicondyle of the elbow.

Important findings included any morphologic or structural abnormalities and vascularization at bony insertion points. The study evaluated three criteria: any vascularized enthesis, the number of abnormal entheses, and the global ultrasound score.

The referring physician's diagnosis was used as the clinical standard in evaluating ultrasound's diagnostic capability; after 2 years, the patients were reevaluated for a final diagnosis, which the investigators then compared with the original diagnosis to compute ultrasound's diagnostic capability. At the end of the follow-up period, patients were reclassified by their referring rheumatologist (51 diagnosed with SpA, 48 not diagnosed as SpA, and 19 unclassified).

In building the prediction model, the investigators examined the ultrasound findings in light of the final diagnoses. Ultrasound found at least one abnormal enthesis in 88 (75%) of the patients; the enthesis was vascularized in 56 of these patients. At least one vascularized enthesis occurred in 76% of those with an SpA diagnosis, 19% of those with a non-SpA diagnosis, and 42% of unclassified patients (Ann. Rheum. Dis. 2011;70:1433-40).

Ultrasound detected significantly more abnormal and vascularized entheses in SpA patients than in non-SpA patients. Those with a SpA diagnosis also had significantly higher ultrasound global scores than did the other groups.

Overall, two factors independently predicted a final diagnosis of SpA: Patients who had at least one vascularized enthesis on ultrasound were 12 times more likely to have a final diagnosis of SpA, and patients with an Amor criteria score of 6 or greater were nearly nine times more likely to have SpA than patients with a lower score. Further analysis confirmed that the baseline presence of at least one vascularized enthesis predicted SpA at 2 years with a 76.5% sensitivity and an 81% specificity. If there were no vascularized entheses at baseline, SpA could still be predicted with a combination of ultrasound and positive Amor criteria score, the authors said; this method yielded a sensitivity of 90% for SpA and a specificity of 77%. “Strikingly, we confirmed that vascularization of the enthesis insertion by [ultrasound] is a landmark feature for SpA, even in suspected cases,” the authors said.

Major Finding: Medical practices in the United States spend nearly $83,000 per year per physician to deal with health insurance plans; practices in Ontario spend about $22,200 per physician per year to interact with Canada's single-payer health care system.

Data Source: Surveys of physician practices in Ontario and in the United States, as well as 37 interviews with physicians, health plan executives, and practice administrators.

Disclosures: The authors reported no financial conflicts of interest for the study, which was funded by the Robert Wood Johnson Foundation and the Commonwealth Fund.

Physician practices in the United States spend four times as much money as do those in Ontario, Canada, to cope with paperwork and communications involving health insurers and payers, according to a study.

The investigators found that medical practices in the United States spend nearly $83,000 per year per physician to deal with health plans. In contrast, physician practices in Ontario spend about $22,200 to interact with Canada's single-payer health care system. The report adjusted the figures slightly to account for exchange rates and specialty mix.

“If U.S. physicians had similar administrative costs to Ontario physicians, the total savings would be approximately $27.6 billion per year,” wrote Dr. Dante Morra, assistant professor of medicine at the University of Toronto, and his colleagues (Health Aff. 2011 [doi:10.1377/hlthaff. 2010.0893]).

Most of the problems U.S. physicians face relate to the fact that they're trying to cope with multiple payers, while Canadian physicians must deal with only one, said Dr. Morra and colleagues, who added that U.S. insurers could help by taking steps to improve the efficiency of transactions, such as implementing electronic transactions.

The differences in staff time spent on insurance issues started with the physicians themselves. U.S. physicians spent an average of 3.4 hours per week interacting with multiple insurers, while Canadian physicians spent an average of 2.2 hours per week dealing with that country's single payer. The main difference in time is the 1 hour per week that U.S. physicians spent obtaining prior authorizations, which accounted for most of the difference in the results, the study said.

In addition, practice staff members in the United States spent far more time on insurance issues than did their Canadian peers, according to the study, which called the differences “striking.” U.S. nursing staff, including medical assistants, spent 20.6 hours per physician in the practice per week interacting with payers, nearly 10 times the 2.5 hours per week spent by Ontario nursing staff.

The study found that the U.S. nursing staff members spent more time in every possible category, including prior authorizations, which cost them 13.1 hours per physician in the practice per week. In Canada, nursing staff members spent no time on prior authorizations.

Clerical staff members worked 53.1 hours per physician per week in the United States, mainly on billing issues and obtaining prior authorizations, the study said. Meanwhile, clerical staff members in Canada worked only 15.9 hours per week, and only on claims and billing issues.

Standardizing transactions and conducting them electronically holds the potential for reducing some of these administrative costs in the United States, the study concluded.

Major Finding: Medical practices in the United States spend nearly $83,000 per year per physician to deal with health insurance plans; practices in Ontario spend about $22,200 per physician per year to interact with Canada's single-payer health care system.

Data Source: Surveys of physician practices in Ontario and in the United States, as well as 37 interviews with physicians, health plan executives, and practice administrators.

Disclosures: The authors reported no financial conflicts of interest for the study, which was funded by the Robert Wood Johnson Foundation and the Commonwealth Fund.

Physician practices in the United States spend four times as much money as do those in Ontario, Canada, to cope with paperwork and communications involving health insurers and payers, according to a study.

The investigators found that medical practices in the United States spend nearly $83,000 per year per physician to deal with health plans. In contrast, physician practices in Ontario spend about $22,200 to interact with Canada's single-payer health care system. The report adjusted the figures slightly to account for exchange rates and specialty mix.

“If U.S. physicians had similar administrative costs to Ontario physicians, the total savings would be approximately $27.6 billion per year,” wrote Dr. Dante Morra, assistant professor of medicine at the University of Toronto, and his colleagues (Health Aff. 2011 [doi:10.1377/hlthaff. 2010.0893]).

Most of the problems U.S. physicians face relate to the fact that they're trying to cope with multiple payers, while Canadian physicians must deal with only one, said Dr. Morra and colleagues, who added that U.S. insurers could help by taking steps to improve the efficiency of transactions, such as implementing electronic transactions.

The differences in staff time spent on insurance issues started with the physicians themselves. U.S. physicians spent an average of 3.4 hours per week interacting with multiple insurers, while Canadian physicians spent an average of 2.2 hours per week dealing with that country's single payer. The main difference in time is the 1 hour per week that U.S. physicians spent obtaining prior authorizations, which accounted for most of the difference in the results, the study said.

In addition, practice staff members in the United States spent far more time on insurance issues than did their Canadian peers, according to the study, which called the differences “striking.” U.S. nursing staff, including medical assistants, spent 20.6 hours per physician in the practice per week interacting with payers, nearly 10 times the 2.5 hours per week spent by Ontario nursing staff.

The study found that the U.S. nursing staff members spent more time in every possible category, including prior authorizations, which cost them 13.1 hours per physician in the practice per week. In Canada, nursing staff members spent no time on prior authorizations.

Clerical staff members worked 53.1 hours per physician per week in the United States, mainly on billing issues and obtaining prior authorizations, the study said. Meanwhile, clerical staff members in Canada worked only 15.9 hours per week, and only on claims and billing issues.

Standardizing transactions and conducting them electronically holds the potential for reducing some of these administrative costs in the United States, the study concluded.

Major Finding: Medical practices in the United States spend nearly $83,000 per year per physician to deal with health insurance plans; practices in Ontario spend about $22,200 per physician per year to interact with Canada's single-payer health care system.

Data Source: Surveys of physician practices in Ontario and in the United States, as well as 37 interviews with physicians, health plan executives, and practice administrators.

Disclosures: The authors reported no financial conflicts of interest for the study, which was funded by the Robert Wood Johnson Foundation and the Commonwealth Fund.

Physician practices in the United States spend four times as much money as do those in Ontario, Canada, to cope with paperwork and communications involving health insurers and payers, according to a study.

The investigators found that medical practices in the United States spend nearly $83,000 per year per physician to deal with health plans. In contrast, physician practices in Ontario spend about $22,200 to interact with Canada's single-payer health care system. The report adjusted the figures slightly to account for exchange rates and specialty mix.

“If U.S. physicians had similar administrative costs to Ontario physicians, the total savings would be approximately $27.6 billion per year,” wrote Dr. Dante Morra, assistant professor of medicine at the University of Toronto, and his colleagues (Health Aff. 2011 [doi:10.1377/hlthaff. 2010.0893]).

Most of the problems U.S. physicians face relate to the fact that they're trying to cope with multiple payers, while Canadian physicians must deal with only one, said Dr. Morra and colleagues, who added that U.S. insurers could help by taking steps to improve the efficiency of transactions, such as implementing electronic transactions.

The differences in staff time spent on insurance issues started with the physicians themselves. U.S. physicians spent an average of 3.4 hours per week interacting with multiple insurers, while Canadian physicians spent an average of 2.2 hours per week dealing with that country's single payer. The main difference in time is the 1 hour per week that U.S. physicians spent obtaining prior authorizations, which accounted for most of the difference in the results, the study said.

In addition, practice staff members in the United States spent far more time on insurance issues than did their Canadian peers, according to the study, which called the differences “striking.” U.S. nursing staff, including medical assistants, spent 20.6 hours per physician in the practice per week interacting with payers, nearly 10 times the 2.5 hours per week spent by Ontario nursing staff.

The study found that the U.S. nursing staff members spent more time in every possible category, including prior authorizations, which cost them 13.1 hours per physician in the practice per week. In Canada, nursing staff members spent no time on prior authorizations.

Clerical staff members worked 53.1 hours per physician per week in the United States, mainly on billing issues and obtaining prior authorizations, the study said. Meanwhile, clerical staff members in Canada worked only 15.9 hours per week, and only on claims and billing issues.

Standardizing transactions and conducting them electronically holds the potential for reducing some of these administrative costs in the United States, the study concluded.

The jury is still out on just how cardiovascular risk should be screened for and managed in rheumatoid arthritis patients, but it is clear that the risk is increased and must be addressed.

In one study, silent myocardial infarction was shown to occur more often in RA patients than controls, and sudden death was also more likely in the RA patients (Arthritis Rheum. 2005;52:402-11). In another study, survival among patients with acute cardiac syndrome was substantially reduced in patients with RA versus those without (Ann. Rheum. Dis. 2006; 65:348-53).

The European League Against Rheumatism has proposed that conventional cardiovascular risk models be multiplied by 1.5 when assessing risk in RA patients (Ann. Rheum. Dis. 2010;69:325-31). This approach is not well validated, and Dr. Joan Bathon, director of the division of rheumatology at Columbia University, New York, said she is not sure it is being widely used at this point.

The proposal illustrates the importance of focusing on cardiovascular risk in RA patients, and it suggests that considering RA as a risk factor equivalent to diabetes mellitus – at least for decision making regarding low-density lipoprotein goals – is a reasonable strategy, Dr. Bathon said at the annual congress of clinical rheumatology.

She also said a potential screening strategy involves yearly cardiovascular risk assessments. The benefits of using imaging and biomarkers for screening are unclear, and no guidelines are currently in place, but some data suggest that the use of carotid ultrasound scans to look for plaques and to assess intima-media thickness, and the calculation of a coronary artery calcium score calculated on computed tomography findings may be useful in patients over age 40 years.

As for potential management strategies, aspirin therapy might be beneficial, but it should be considered in the context of other medications the patient is taking. Statins are also a potential management tool, but questions remain about whether all RA patients should be treated regardless of LDL level, she said.

Definite treatment strategies for RA patients include weight management for overweight patients, which will help reduce inflammation, and exercise for all RA patients, because good quality muscle building will help restore insulin sensitivity and reduce fat deposits that are the most inflammatory. Tight blood pressure control and tight RA control are also imperative, she said.

Dr. Bathon had no relevant disclosures.

The jury is still out on just how cardiovascular risk should be screened for and managed in rheumatoid arthritis patients, but it is clear that the risk is increased and must be addressed.

In one study, silent myocardial infarction was shown to occur more often in RA patients than controls, and sudden death was also more likely in the RA patients (Arthritis Rheum. 2005;52:402-11). In another study, survival among patients with acute cardiac syndrome was substantially reduced in patients with RA versus those without (Ann. Rheum. Dis. 2006; 65:348-53).

The European League Against Rheumatism has proposed that conventional cardiovascular risk models be multiplied by 1.5 when assessing risk in RA patients (Ann. Rheum. Dis. 2010;69:325-31). This approach is not well validated, and Dr. Joan Bathon, director of the division of rheumatology at Columbia University, New York, said she is not sure it is being widely used at this point.

The proposal illustrates the importance of focusing on cardiovascular risk in RA patients, and it suggests that considering RA as a risk factor equivalent to diabetes mellitus – at least for decision making regarding low-density lipoprotein goals – is a reasonable strategy, Dr. Bathon said at the annual congress of clinical rheumatology.

She also said a potential screening strategy involves yearly cardiovascular risk assessments. The benefits of using imaging and biomarkers for screening are unclear, and no guidelines are currently in place, but some data suggest that the use of carotid ultrasound scans to look for plaques and to assess intima-media thickness, and the calculation of a coronary artery calcium score calculated on computed tomography findings may be useful in patients over age 40 years.

As for potential management strategies, aspirin therapy might be beneficial, but it should be considered in the context of other medications the patient is taking. Statins are also a potential management tool, but questions remain about whether all RA patients should be treated regardless of LDL level, she said.

Definite treatment strategies for RA patients include weight management for overweight patients, which will help reduce inflammation, and exercise for all RA patients, because good quality muscle building will help restore insulin sensitivity and reduce fat deposits that are the most inflammatory. Tight blood pressure control and tight RA control are also imperative, she said.

Dr. Bathon had no relevant disclosures.

The jury is still out on just how cardiovascular risk should be screened for and managed in rheumatoid arthritis patients, but it is clear that the risk is increased and must be addressed.

In one study, silent myocardial infarction was shown to occur more often in RA patients than controls, and sudden death was also more likely in the RA patients (Arthritis Rheum. 2005;52:402-11). In another study, survival among patients with acute cardiac syndrome was substantially reduced in patients with RA versus those without (Ann. Rheum. Dis. 2006; 65:348-53).

The European League Against Rheumatism has proposed that conventional cardiovascular risk models be multiplied by 1.5 when assessing risk in RA patients (Ann. Rheum. Dis. 2010;69:325-31). This approach is not well validated, and Dr. Joan Bathon, director of the division of rheumatology at Columbia University, New York, said she is not sure it is being widely used at this point.

The proposal illustrates the importance of focusing on cardiovascular risk in RA patients, and it suggests that considering RA as a risk factor equivalent to diabetes mellitus – at least for decision making regarding low-density lipoprotein goals – is a reasonable strategy, Dr. Bathon said at the annual congress of clinical rheumatology.

She also said a potential screening strategy involves yearly cardiovascular risk assessments. The benefits of using imaging and biomarkers for screening are unclear, and no guidelines are currently in place, but some data suggest that the use of carotid ultrasound scans to look for plaques and to assess intima-media thickness, and the calculation of a coronary artery calcium score calculated on computed tomography findings may be useful in patients over age 40 years.

As for potential management strategies, aspirin therapy might be beneficial, but it should be considered in the context of other medications the patient is taking. Statins are also a potential management tool, but questions remain about whether all RA patients should be treated regardless of LDL level, she said.

Definite treatment strategies for RA patients include weight management for overweight patients, which will help reduce inflammation, and exercise for all RA patients, because good quality muscle building will help restore insulin sensitivity and reduce fat deposits that are the most inflammatory. Tight blood pressure control and tight RA control are also imperative, she said.

Dr. Bathon had no relevant disclosures.

Major Finding: Odds ratios for the prescription of aspirin, a statin, and beta-blockers 30 days after a first MI were 0.75, 0.68, and 0.76, respectively.

Data Source: Danish registry study of 66,389 patients – 875 (1.3%) with RA – who had a first MI between 2002 and 2009.

Disclosures: Dr. Lindhardsen and Dr. Schett had no conflicts of interest to declare.

LONDON – Patients with rheumatoid arthritis who have had a heart attack for the first time do not appear to be getting medications recommended to prevent a further cardiovascular event, according to the findings of a large Danish study.

Aspirin, statins, and beta-blockers – cardioprotective medications that are given as the standard of care to most patients immediately following a myocardial infarction – were all less frequently prescribed to patients with rheumatoid arthritis (RA) than to members of the general patient population.

Indeed, 1 month after an MI, the odds ratios for the prescription of these drugs were 0.75 (95% confidence interval, 0.63-0.90) for aspirin, 0.68 (95% CI, 0.57-0.82) for a statin, and 0.76 (95% CI, 0.63-0.91) for beta-blockers. These results did not change greatly at follow-ups of 3 months, 6 months, or 1 year.

The increased risk of cardiovascular disease in RA is well known and could result from a number of causes, including the presence of classical risk factors such as dyslipidemia and hypertension, possible adverse effects of RA treatment, and an accelerated atherosclerotic process driven by the high levels of inflammation characteristic of the rheumatic disease.

“What's not been considered, [however,] and perhaps the simplest explanation, is whether or not there is undertreatment of [RA] patients,” Dr. Jesper Lindhardsen, of the cardiology department at Gentofte University Hospital, Copenhagen, said at a press briefing during the congress.

To determine whether patients with RA were being given standard cardioprotective medications after a first MI, he and his colleagues analyzed data from several Danish patient registries, including those giving prescription records, details of comorbidities, and income.

The study population consisted of 66,389 patients who had had a first heart attack between 2002 and 2009. Of these, 875 (1.3%) had RA. The median age was 72.6 years for RA patients and 69.4 years for patients without RA.

At baseline, the use of cardioprotective medications by patients with and without RA were relatively similar or the same, at 27% and 25.1%, respectively, for aspirin; 19.1% and 19.1% for a statin; 23.9% and 22.5% for a beta-blocker; and 3.3% and 2.2% for clopidogrel.

Although aspirin, statin, and beta-blocker use was later found to be lower in the RA patients than in the non-RA patients throughout the early post-MI period, there was no significant difference in the prescription of clopidogrel at 1, 3, or 6 months or at 1 year.

Commenting on the findings in an interview, Dr. Lindhardsen conceded that it's not known what medications patients were taking before they had their heart attack, which could influence the findings.

Dr. Georg Schett, who is chief of rheumatology at the University of Erlangen-Nuremberg, Germany, but was not involved in the study, said the findings illustrate that the high cardiovascular risk in patients with RA is still not being taken seriously enough.

Indeed, Dr. Lindhardsen and his colleagues recently published data showing that RA is associated with the same risk of MI as diabetes (Ann. Rheum. Dis. 2011;70:929-34).

Major Finding: Odds ratios for the prescription of aspirin, a statin, and beta-blockers 30 days after a first MI were 0.75, 0.68, and 0.76, respectively.

Data Source: Danish registry study of 66,389 patients – 875 (1.3%) with RA – who had a first MI between 2002 and 2009.

Disclosures: Dr. Lindhardsen and Dr. Schett had no conflicts of interest to declare.

LONDON – Patients with rheumatoid arthritis who have had a heart attack for the first time do not appear to be getting medications recommended to prevent a further cardiovascular event, according to the findings of a large Danish study.

Aspirin, statins, and beta-blockers – cardioprotective medications that are given as the standard of care to most patients immediately following a myocardial infarction – were all less frequently prescribed to patients with rheumatoid arthritis (RA) than to members of the general patient population.

Indeed, 1 month after an MI, the odds ratios for the prescription of these drugs were 0.75 (95% confidence interval, 0.63-0.90) for aspirin, 0.68 (95% CI, 0.57-0.82) for a statin, and 0.76 (95% CI, 0.63-0.91) for beta-blockers. These results did not change greatly at follow-ups of 3 months, 6 months, or 1 year.

The increased risk of cardiovascular disease in RA is well known and could result from a number of causes, including the presence of classical risk factors such as dyslipidemia and hypertension, possible adverse effects of RA treatment, and an accelerated atherosclerotic process driven by the high levels of inflammation characteristic of the rheumatic disease.

“What's not been considered, [however,] and perhaps the simplest explanation, is whether or not there is undertreatment of [RA] patients,” Dr. Jesper Lindhardsen, of the cardiology department at Gentofte University Hospital, Copenhagen, said at a press briefing during the congress.

To determine whether patients with RA were being given standard cardioprotective medications after a first MI, he and his colleagues analyzed data from several Danish patient registries, including those giving prescription records, details of comorbidities, and income.

The study population consisted of 66,389 patients who had had a first heart attack between 2002 and 2009. Of these, 875 (1.3%) had RA. The median age was 72.6 years for RA patients and 69.4 years for patients without RA.

At baseline, the use of cardioprotective medications by patients with and without RA were relatively similar or the same, at 27% and 25.1%, respectively, for aspirin; 19.1% and 19.1% for a statin; 23.9% and 22.5% for a beta-blocker; and 3.3% and 2.2% for clopidogrel.

Although aspirin, statin, and beta-blocker use was later found to be lower in the RA patients than in the non-RA patients throughout the early post-MI period, there was no significant difference in the prescription of clopidogrel at 1, 3, or 6 months or at 1 year.

Commenting on the findings in an interview, Dr. Lindhardsen conceded that it's not known what medications patients were taking before they had their heart attack, which could influence the findings.

Dr. Georg Schett, who is chief of rheumatology at the University of Erlangen-Nuremberg, Germany, but was not involved in the study, said the findings illustrate that the high cardiovascular risk in patients with RA is still not being taken seriously enough.

Indeed, Dr. Lindhardsen and his colleagues recently published data showing that RA is associated with the same risk of MI as diabetes (Ann. Rheum. Dis. 2011;70:929-34).

Major Finding: Odds ratios for the prescription of aspirin, a statin, and beta-blockers 30 days after a first MI were 0.75, 0.68, and 0.76, respectively.

Data Source: Danish registry study of 66,389 patients – 875 (1.3%) with RA – who had a first MI between 2002 and 2009.

Disclosures: Dr. Lindhardsen and Dr. Schett had no conflicts of interest to declare.

LONDON – Patients with rheumatoid arthritis who have had a heart attack for the first time do not appear to be getting medications recommended to prevent a further cardiovascular event, according to the findings of a large Danish study.

Aspirin, statins, and beta-blockers – cardioprotective medications that are given as the standard of care to most patients immediately following a myocardial infarction – were all less frequently prescribed to patients with rheumatoid arthritis (RA) than to members of the general patient population.

Indeed, 1 month after an MI, the odds ratios for the prescription of these drugs were 0.75 (95% confidence interval, 0.63-0.90) for aspirin, 0.68 (95% CI, 0.57-0.82) for a statin, and 0.76 (95% CI, 0.63-0.91) for beta-blockers. These results did not change greatly at follow-ups of 3 months, 6 months, or 1 year.

The increased risk of cardiovascular disease in RA is well known and could result from a number of causes, including the presence of classical risk factors such as dyslipidemia and hypertension, possible adverse effects of RA treatment, and an accelerated atherosclerotic process driven by the high levels of inflammation characteristic of the rheumatic disease.

“What's not been considered, [however,] and perhaps the simplest explanation, is whether or not there is undertreatment of [RA] patients,” Dr. Jesper Lindhardsen, of the cardiology department at Gentofte University Hospital, Copenhagen, said at a press briefing during the congress.

To determine whether patients with RA were being given standard cardioprotective medications after a first MI, he and his colleagues analyzed data from several Danish patient registries, including those giving prescription records, details of comorbidities, and income.

The study population consisted of 66,389 patients who had had a first heart attack between 2002 and 2009. Of these, 875 (1.3%) had RA. The median age was 72.6 years for RA patients and 69.4 years for patients without RA.

At baseline, the use of cardioprotective medications by patients with and without RA were relatively similar or the same, at 27% and 25.1%, respectively, for aspirin; 19.1% and 19.1% for a statin; 23.9% and 22.5% for a beta-blocker; and 3.3% and 2.2% for clopidogrel.

Although aspirin, statin, and beta-blocker use was later found to be lower in the RA patients than in the non-RA patients throughout the early post-MI period, there was no significant difference in the prescription of clopidogrel at 1, 3, or 6 months or at 1 year.

Commenting on the findings in an interview, Dr. Lindhardsen conceded that it's not known what medications patients were taking before they had their heart attack, which could influence the findings.

Dr. Georg Schett, who is chief of rheumatology at the University of Erlangen-Nuremberg, Germany, but was not involved in the study, said the findings illustrate that the high cardiovascular risk in patients with RA is still not being taken seriously enough.

Indeed, Dr. Lindhardsen and his colleagues recently published data showing that RA is associated with the same risk of MI as diabetes (Ann. Rheum. Dis. 2011;70:929-34).

If patients in early stages of rheumatoid arthritis have foot problems, it is “crucial” to refer them to podiatrists, according to recent findings.

Roughly 90% of people with RA eventually develop foot or ankle symptoms, according to investigator Marike van der Leeden, Ph.D., a senior researcher and project leader at Reade, rehabilitation and rheumatology in Amsterdam.

Prescription foot orthoses is one of the ways to manage the patients' foot problems.

However, “indications for foot orthoses are not clear, and the effectiveness of the intervention is highly variable among patients,” according to the study.

To determine the clinical and demographic factors that predict the outcome of customized foot orthoses on related pain and disability, researchers conducted a prospective cohort study, which included 135 RA patients who were given customized foot orthoses made by a podiatrist.

Pain and disability were measured before and after the intervention period using a Numeric Rating Scale (NRS) for foot pain, the Foot Function Index (FFI), the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and a 10-meter walking time test, according to the study.

The intervention period included one or more podiatrist appointments during which the foot problem was diagnosed and managed.

The results showed that the duration of RA was negatively associated with score changes in NRS foot pain (P = .018), WOMAC pain (P = .001), FFI disability (P = .003), and WOMAC physical function (P = .002).

Age was negatively associated with the change score in 10-meter walking time (P = .008).

Statistically significant improvements after the intervention with foot orthoses were found on all outcome measures (P less than .001), according to the study.

“Shorter disease duration predicted greater improvements in self-reported foot pain and disability after intervention with foot orthoses,” the authors concluded.

“Younger age predicted greater improvements in walking time. Referral for conservative management with foot orthoses in the early stage of RA seems important when aiming to achieve reduction in pain and improvement in daily activities.”

“To date, no evidence is available for which types of foot orthoses are most effective for RA. Further research is needed for evidence-based prescription protocols for foot problems in RA.” Dr. van der Leeden said.

The authors reported no financial disclosures.

To date there are no data on the most effective type of foot orthoses for patients with RA-induced foot pain.

Source DR. VAN DER LEEDEN

If patients in early stages of rheumatoid arthritis have foot problems, it is “crucial” to refer them to podiatrists, according to recent findings.

Roughly 90% of people with RA eventually develop foot or ankle symptoms, according to investigator Marike van der Leeden, Ph.D., a senior researcher and project leader at Reade, rehabilitation and rheumatology in Amsterdam.

Prescription foot orthoses is one of the ways to manage the patients' foot problems.

However, “indications for foot orthoses are not clear, and the effectiveness of the intervention is highly variable among patients,” according to the study.

To determine the clinical and demographic factors that predict the outcome of customized foot orthoses on related pain and disability, researchers conducted a prospective cohort study, which included 135 RA patients who were given customized foot orthoses made by a podiatrist.

Pain and disability were measured before and after the intervention period using a Numeric Rating Scale (NRS) for foot pain, the Foot Function Index (FFI), the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and a 10-meter walking time test, according to the study.

The intervention period included one or more podiatrist appointments during which the foot problem was diagnosed and managed.

The results showed that the duration of RA was negatively associated with score changes in NRS foot pain (P = .018), WOMAC pain (P = .001), FFI disability (P = .003), and WOMAC physical function (P = .002).

Age was negatively associated with the change score in 10-meter walking time (P = .008).

Statistically significant improvements after the intervention with foot orthoses were found on all outcome measures (P less than .001), according to the study.

“Shorter disease duration predicted greater improvements in self-reported foot pain and disability after intervention with foot orthoses,” the authors concluded.

“Younger age predicted greater improvements in walking time. Referral for conservative management with foot orthoses in the early stage of RA seems important when aiming to achieve reduction in pain and improvement in daily activities.”

“To date, no evidence is available for which types of foot orthoses are most effective for RA. Further research is needed for evidence-based prescription protocols for foot problems in RA.” Dr. van der Leeden said.

The authors reported no financial disclosures.

To date there are no data on the most effective type of foot orthoses for patients with RA-induced foot pain.

Source DR. VAN DER LEEDEN

If patients in early stages of rheumatoid arthritis have foot problems, it is “crucial” to refer them to podiatrists, according to recent findings.

Roughly 90% of people with RA eventually develop foot or ankle symptoms, according to investigator Marike van der Leeden, Ph.D., a senior researcher and project leader at Reade, rehabilitation and rheumatology in Amsterdam.

Prescription foot orthoses is one of the ways to manage the patients' foot problems.

However, “indications for foot orthoses are not clear, and the effectiveness of the intervention is highly variable among patients,” according to the study.

To determine the clinical and demographic factors that predict the outcome of customized foot orthoses on related pain and disability, researchers conducted a prospective cohort study, which included 135 RA patients who were given customized foot orthoses made by a podiatrist.

Pain and disability were measured before and after the intervention period using a Numeric Rating Scale (NRS) for foot pain, the Foot Function Index (FFI), the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and a 10-meter walking time test, according to the study.

The intervention period included one or more podiatrist appointments during which the foot problem was diagnosed and managed.

The results showed that the duration of RA was negatively associated with score changes in NRS foot pain (P = .018), WOMAC pain (P = .001), FFI disability (P = .003), and WOMAC physical function (P = .002).

Age was negatively associated with the change score in 10-meter walking time (P = .008).

Statistically significant improvements after the intervention with foot orthoses were found on all outcome measures (P less than .001), according to the study.

“Shorter disease duration predicted greater improvements in self-reported foot pain and disability after intervention with foot orthoses,” the authors concluded.

“Younger age predicted greater improvements in walking time. Referral for conservative management with foot orthoses in the early stage of RA seems important when aiming to achieve reduction in pain and improvement in daily activities.”

“To date, no evidence is available for which types of foot orthoses are most effective for RA. Further research is needed for evidence-based prescription protocols for foot problems in RA.” Dr. van der Leeden said.

The authors reported no financial disclosures.

To date there are no data on the most effective type of foot orthoses for patients with RA-induced foot pain.

Source DR. VAN DER LEEDEN

Being younger, being male, or having an elevated C-reactive protein level are just a few of the factors that are likely to predict whether patients with ankylosing spondylitis will improve when taking tumor necrosis factor inhibitors for the first time, according to new data.

Dr. Karen M. Fagerli of the Diakonh-jemmet Hospital in Oslo, and her associates identified several independent predictors of major improvement in ASDAS (Ankylosing Spondylitis Disease Activity Score) in patients with ankylosing spondylitis (AS) after 3 months of taking a TNF inhibitor.

The independent predictors are younger age, male sex, C-reactive protein (CRP) level greater than 10 mg/L, HLA-B27 positivity, and a higher baseline patient global assessment score.

The results confirm findings from previous studies that both age and elevated CRP are predictors of success with TNF inhibitors. They could be used in selecting patients most likely to respond to treatment, especially in countries with limited access to TNF inhibitors.

Clinicians should exercise caution in applying the other predictors found in the study to a clinical setting, Dr. Fagerli stressed in an interview.

Other studies have not found gender to be a significant predictor, and few other studies have shown HLA-B27 positivity to be a predictive factor.

“The independent predictors identified in this model give information about which patients are most likely to show a good clinical response on a group level, but may have limited value for use on the individual patient level,” Dr. Fagerli said.

The researchers extracted data from the Norwegian DMARD (NOR-DMARD) register, a repository of data on adult patients with inflammatory arthropathies who are starting a new disease-modifying antirheumatic drug treatment. The patients are consecutively included from across five rheumatology departments in Norway.

The current analysis included 171 AS patients who were being treated with their first TNF inhibitor. The mean age of the patients in the sample was 42 years, more than 73% were male, and the average disease duration was 10 years. Nearly a third of the patients in the study achieved ASDAS major improvement on a TNF inhibitor at 3 months.

The researchers plan to repeat these analyses with an updated data set that includes more patients, Dr. Fagerli said.

She also noted that the results will need to be validated in other cohorts, particularly the findings related to gender, patient global assessment, and HLA-B27.

In general, more research is needed into new and more accurate predictors of response to TNF inhibitors in AS and other rheumatic diseases, Dr. Fagerli said. Pharmacogenetic studies have the potential to identify these predictors, and further research to find new soluble biomarkers as markers of response will also be important. In addition, the role of MRI in diagnosis, predicting response, and monitoring treatment will be an important field in the years to come.

Dr. Fagerli said she had no financial disclosures.

'The independent predictors identified … may have limited value for use on the individual patient level.'

Source DR. FAGERLI

Being younger, being male, or having an elevated C-reactive protein level are just a few of the factors that are likely to predict whether patients with ankylosing spondylitis will improve when taking tumor necrosis factor inhibitors for the first time, according to new data.

Dr. Karen M. Fagerli of the Diakonh-jemmet Hospital in Oslo, and her associates identified several independent predictors of major improvement in ASDAS (Ankylosing Spondylitis Disease Activity Score) in patients with ankylosing spondylitis (AS) after 3 months of taking a TNF inhibitor.

The independent predictors are younger age, male sex, C-reactive protein (CRP) level greater than 10 mg/L, HLA-B27 positivity, and a higher baseline patient global assessment score.

The results confirm findings from previous studies that both age and elevated CRP are predictors of success with TNF inhibitors. They could be used in selecting patients most likely to respond to treatment, especially in countries with limited access to TNF inhibitors.

Clinicians should exercise caution in applying the other predictors found in the study to a clinical setting, Dr. Fagerli stressed in an interview.

Other studies have not found gender to be a significant predictor, and few other studies have shown HLA-B27 positivity to be a predictive factor.

“The independent predictors identified in this model give information about which patients are most likely to show a good clinical response on a group level, but may have limited value for use on the individual patient level,” Dr. Fagerli said.

The researchers extracted data from the Norwegian DMARD (NOR-DMARD) register, a repository of data on adult patients with inflammatory arthropathies who are starting a new disease-modifying antirheumatic drug treatment. The patients are consecutively included from across five rheumatology departments in Norway.

The current analysis included 171 AS patients who were being treated with their first TNF inhibitor. The mean age of the patients in the sample was 42 years, more than 73% were male, and the average disease duration was 10 years. Nearly a third of the patients in the study achieved ASDAS major improvement on a TNF inhibitor at 3 months.

The researchers plan to repeat these analyses with an updated data set that includes more patients, Dr. Fagerli said.

She also noted that the results will need to be validated in other cohorts, particularly the findings related to gender, patient global assessment, and HLA-B27.

In general, more research is needed into new and more accurate predictors of response to TNF inhibitors in AS and other rheumatic diseases, Dr. Fagerli said. Pharmacogenetic studies have the potential to identify these predictors, and further research to find new soluble biomarkers as markers of response will also be important. In addition, the role of MRI in diagnosis, predicting response, and monitoring treatment will be an important field in the years to come.

Dr. Fagerli said she had no financial disclosures.

'The independent predictors identified … may have limited value for use on the individual patient level.'

Source DR. FAGERLI

Being younger, being male, or having an elevated C-reactive protein level are just a few of the factors that are likely to predict whether patients with ankylosing spondylitis will improve when taking tumor necrosis factor inhibitors for the first time, according to new data.

Dr. Karen M. Fagerli of the Diakonh-jemmet Hospital in Oslo, and her associates identified several independent predictors of major improvement in ASDAS (Ankylosing Spondylitis Disease Activity Score) in patients with ankylosing spondylitis (AS) after 3 months of taking a TNF inhibitor.

The independent predictors are younger age, male sex, C-reactive protein (CRP) level greater than 10 mg/L, HLA-B27 positivity, and a higher baseline patient global assessment score.

The results confirm findings from previous studies that both age and elevated CRP are predictors of success with TNF inhibitors. They could be used in selecting patients most likely to respond to treatment, especially in countries with limited access to TNF inhibitors.

Clinicians should exercise caution in applying the other predictors found in the study to a clinical setting, Dr. Fagerli stressed in an interview.

Other studies have not found gender to be a significant predictor, and few other studies have shown HLA-B27 positivity to be a predictive factor.

“The independent predictors identified in this model give information about which patients are most likely to show a good clinical response on a group level, but may have limited value for use on the individual patient level,” Dr. Fagerli said.

The researchers extracted data from the Norwegian DMARD (NOR-DMARD) register, a repository of data on adult patients with inflammatory arthropathies who are starting a new disease-modifying antirheumatic drug treatment. The patients are consecutively included from across five rheumatology departments in Norway.

The current analysis included 171 AS patients who were being treated with their first TNF inhibitor. The mean age of the patients in the sample was 42 years, more than 73% were male, and the average disease duration was 10 years. Nearly a third of the patients in the study achieved ASDAS major improvement on a TNF inhibitor at 3 months.

The researchers plan to repeat these analyses with an updated data set that includes more patients, Dr. Fagerli said.

She also noted that the results will need to be validated in other cohorts, particularly the findings related to gender, patient global assessment, and HLA-B27.

In general, more research is needed into new and more accurate predictors of response to TNF inhibitors in AS and other rheumatic diseases, Dr. Fagerli said. Pharmacogenetic studies have the potential to identify these predictors, and further research to find new soluble biomarkers as markers of response will also be important. In addition, the role of MRI in diagnosis, predicting response, and monitoring treatment will be an important field in the years to come.

Dr. Fagerli said she had no financial disclosures.

'The independent predictors identified … may have limited value for use on the individual patient level.'

Source DR. FAGERLI