Rheumatoid Arthritis

ATLANTA – Correcting for age can increase the diagnostic accuracy of some lab tests used to make the diagnosis of rheumatoid arthritis or other rheumatic disorders, according to Dr. Mark Wener and Dr. Robert Lightfoot.

Dr. Wener, director of the immunology division and a member of the rheumatology division at the University of Washington, Seattle, shared his clinical pearls for how to maximize the value of lab tests for inflammation.

A patient’s erythrocyte sedimentation rate (ESR) can be used to assess inflammation, but results can be deceiving, he said, because they are affected by factors including fibrinogen, globulins, albumin, and hematocrit.

In cases of acute inflammation, increased fibrinogen in turn increases the ESR, just as increased immunoglobulins that are present in chronic inflammation increase the ESR, Dr. Wener said. In addition, malnutrition, multiple myeloma, and malignancy and other noninflammatory conditions can raise the ESR.

The 2010 ACR/EULAR diagnostic criteria for rheumatoid arthritis (RA) recommend that clinicians take age and gender into account when using ESR. However, most labs don’t adjust for age, Dr. Wener said. For example, the incident inflammation asso ciated with age-related gingivitis can elevate the ESR even if no other inflammation is present.

[Check out our coverage of the American College of Rheumatology's annual meeting.]

Although most labs do not include age-adjusted reference ranges in their reports, clinicians can correct for age at the bedside by using a simple formula, said Dr. Wener. Use of a formula to determine the upper limit of the reference range for ESR can help physicians obtain an age-adjusted ESR (BMJ 1983;286:266):

• Men: Upper limit of normal ESR = age/2.

• Women: Upper limit of normal ESR = (age +10)/2.

Age and gender also play a role in the elevation of C-reactive protein levels, Dr. Wener said (J. Rheum. 2000;27:2351-9). He shared a similar formula to adjust for age and gender when considering CRP levels as an indicator of rheumatic disease.

• Men: Upper limit of normal CRP (mg/L) = age/5

• Women: Upper limit of normal CRP (mg/L) = (age + 30)/5

In general, ESR and CRP are elevated in patients with active RA, inflammatory RA, or polymyalgia rheumatica, Dr. Wener said. In contrast, patients with osteoarthritis and fibromyalgia rarely have elevated ESR and CRP levels, although age alone can increase both values, he emphasized. In addition, some patients with localized, noninflammatory disease or localized OA might have normal ESR and CRP values, and ESR and CRP levels vary in patients with chronic bursitis and in gout or other crystal diseases.

The most practical uses for ESR and CRP are for confirmation of inflammatory disease and for monitoring inflammation in cases of RA, although these tests are less reliable as measures of RA disease activity, said Dr. Wener. However, ESR and CRP have shown high sensitivity rates (92% and 100%, respectively) in identifying giant cell arteritis, he added.

Dr. Lightfoot, professor of medicine in the rheumatology division at the University of Kentucky, Lexington, added his clinical pearls for using the antinuclear antibody test (ANA) to diagnose rheumatic disease. "There are between 100 and 150 different antigens in the nucleus that can be detected in the indirect immunofluorescent ANA," said Dr. Lightfoot. "But we only know what about 10 of those antigens are."

The same ANA results might occur in both a healthy person and someone with confirmed RA, Dr. Lightfoot said. Make sure an IFA ANA is done as part of any ANA screening, especially if findings from an ANA panel show a negative ANA, or if an ANA is positive without a titer, he said.

In addition, it’s important to know the reliability of an anti-nDNA assay, because a positive anti-nDNA is often a false positive, said Dr. Lightfoot. "The biggest problem with all anti-nDNA assays is contamination of the antigen with single-stranded portions," he said. "Antibodies to single-stranded DNA are less specific than the ESR."

Dr. Wener has served as a consultant for Takeda Pharmaceuticals, and he has a contract for lab testing and imaging with Bio-Rad Laboratories. Dr. Lightfoot had no financial conflicts to disclose.

ATLANTA – Correcting for age can increase the diagnostic accuracy of some lab tests used to make the diagnosis of rheumatoid arthritis or other rheumatic disorders, according to Dr. Mark Wener and Dr. Robert Lightfoot.

Dr. Wener, director of the immunology division and a member of the rheumatology division at the University of Washington, Seattle, shared his clinical pearls for how to maximize the value of lab tests for inflammation.

A patient’s erythrocyte sedimentation rate (ESR) can be used to assess inflammation, but results can be deceiving, he said, because they are affected by factors including fibrinogen, globulins, albumin, and hematocrit.

In cases of acute inflammation, increased fibrinogen in turn increases the ESR, just as increased immunoglobulins that are present in chronic inflammation increase the ESR, Dr. Wener said. In addition, malnutrition, multiple myeloma, and malignancy and other noninflammatory conditions can raise the ESR.

The 2010 ACR/EULAR diagnostic criteria for rheumatoid arthritis (RA) recommend that clinicians take age and gender into account when using ESR. However, most labs don’t adjust for age, Dr. Wener said. For example, the incident inflammation asso ciated with age-related gingivitis can elevate the ESR even if no other inflammation is present.

[Check out our coverage of the American College of Rheumatology's annual meeting.]

Although most labs do not include age-adjusted reference ranges in their reports, clinicians can correct for age at the bedside by using a simple formula, said Dr. Wener. Use of a formula to determine the upper limit of the reference range for ESR can help physicians obtain an age-adjusted ESR (BMJ 1983;286:266):

• Men: Upper limit of normal ESR = age/2.

• Women: Upper limit of normal ESR = (age +10)/2.

Age and gender also play a role in the elevation of C-reactive protein levels, Dr. Wener said (J. Rheum. 2000;27:2351-9). He shared a similar formula to adjust for age and gender when considering CRP levels as an indicator of rheumatic disease.

• Men: Upper limit of normal CRP (mg/L) = age/5

• Women: Upper limit of normal CRP (mg/L) = (age + 30)/5

In general, ESR and CRP are elevated in patients with active RA, inflammatory RA, or polymyalgia rheumatica, Dr. Wener said. In contrast, patients with osteoarthritis and fibromyalgia rarely have elevated ESR and CRP levels, although age alone can increase both values, he emphasized. In addition, some patients with localized, noninflammatory disease or localized OA might have normal ESR and CRP values, and ESR and CRP levels vary in patients with chronic bursitis and in gout or other crystal diseases.

The most practical uses for ESR and CRP are for confirmation of inflammatory disease and for monitoring inflammation in cases of RA, although these tests are less reliable as measures of RA disease activity, said Dr. Wener. However, ESR and CRP have shown high sensitivity rates (92% and 100%, respectively) in identifying giant cell arteritis, he added.

Dr. Lightfoot, professor of medicine in the rheumatology division at the University of Kentucky, Lexington, added his clinical pearls for using the antinuclear antibody test (ANA) to diagnose rheumatic disease. "There are between 100 and 150 different antigens in the nucleus that can be detected in the indirect immunofluorescent ANA," said Dr. Lightfoot. "But we only know what about 10 of those antigens are."

The same ANA results might occur in both a healthy person and someone with confirmed RA, Dr. Lightfoot said. Make sure an IFA ANA is done as part of any ANA screening, especially if findings from an ANA panel show a negative ANA, or if an ANA is positive without a titer, he said.

In addition, it’s important to know the reliability of an anti-nDNA assay, because a positive anti-nDNA is often a false positive, said Dr. Lightfoot. "The biggest problem with all anti-nDNA assays is contamination of the antigen with single-stranded portions," he said. "Antibodies to single-stranded DNA are less specific than the ESR."

Dr. Wener has served as a consultant for Takeda Pharmaceuticals, and he has a contract for lab testing and imaging with Bio-Rad Laboratories. Dr. Lightfoot had no financial conflicts to disclose.

ATLANTA – Correcting for age can increase the diagnostic accuracy of some lab tests used to make the diagnosis of rheumatoid arthritis or other rheumatic disorders, according to Dr. Mark Wener and Dr. Robert Lightfoot.

Dr. Wener, director of the immunology division and a member of the rheumatology division at the University of Washington, Seattle, shared his clinical pearls for how to maximize the value of lab tests for inflammation.

A patient’s erythrocyte sedimentation rate (ESR) can be used to assess inflammation, but results can be deceiving, he said, because they are affected by factors including fibrinogen, globulins, albumin, and hematocrit.

In cases of acute inflammation, increased fibrinogen in turn increases the ESR, just as increased immunoglobulins that are present in chronic inflammation increase the ESR, Dr. Wener said. In addition, malnutrition, multiple myeloma, and malignancy and other noninflammatory conditions can raise the ESR.

The 2010 ACR/EULAR diagnostic criteria for rheumatoid arthritis (RA) recommend that clinicians take age and gender into account when using ESR. However, most labs don’t adjust for age, Dr. Wener said. For example, the incident inflammation asso ciated with age-related gingivitis can elevate the ESR even if no other inflammation is present.

[Check out our coverage of the American College of Rheumatology's annual meeting.]

Although most labs do not include age-adjusted reference ranges in their reports, clinicians can correct for age at the bedside by using a simple formula, said Dr. Wener. Use of a formula to determine the upper limit of the reference range for ESR can help physicians obtain an age-adjusted ESR (BMJ 1983;286:266):

• Men: Upper limit of normal ESR = age/2.

• Women: Upper limit of normal ESR = (age +10)/2.

Age and gender also play a role in the elevation of C-reactive protein levels, Dr. Wener said (J. Rheum. 2000;27:2351-9). He shared a similar formula to adjust for age and gender when considering CRP levels as an indicator of rheumatic disease.

• Men: Upper limit of normal CRP (mg/L) = age/5

• Women: Upper limit of normal CRP (mg/L) = (age + 30)/5

In general, ESR and CRP are elevated in patients with active RA, inflammatory RA, or polymyalgia rheumatica, Dr. Wener said. In contrast, patients with osteoarthritis and fibromyalgia rarely have elevated ESR and CRP levels, although age alone can increase both values, he emphasized. In addition, some patients with localized, noninflammatory disease or localized OA might have normal ESR and CRP values, and ESR and CRP levels vary in patients with chronic bursitis and in gout or other crystal diseases.

The most practical uses for ESR and CRP are for confirmation of inflammatory disease and for monitoring inflammation in cases of RA, although these tests are less reliable as measures of RA disease activity, said Dr. Wener. However, ESR and CRP have shown high sensitivity rates (92% and 100%, respectively) in identifying giant cell arteritis, he added.

Dr. Lightfoot, professor of medicine in the rheumatology division at the University of Kentucky, Lexington, added his clinical pearls for using the antinuclear antibody test (ANA) to diagnose rheumatic disease. "There are between 100 and 150 different antigens in the nucleus that can be detected in the indirect immunofluorescent ANA," said Dr. Lightfoot. "But we only know what about 10 of those antigens are."

The same ANA results might occur in both a healthy person and someone with confirmed RA, Dr. Lightfoot said. Make sure an IFA ANA is done as part of any ANA screening, especially if findings from an ANA panel show a negative ANA, or if an ANA is positive without a titer, he said.

In addition, it’s important to know the reliability of an anti-nDNA assay, because a positive anti-nDNA is often a false positive, said Dr. Lightfoot. "The biggest problem with all anti-nDNA assays is contamination of the antigen with single-stranded portions," he said. "Antibodies to single-stranded DNA are less specific than the ESR."

Dr. Wener has served as a consultant for Takeda Pharmaceuticals, and he has a contract for lab testing and imaging with Bio-Rad Laboratories. Dr. Lightfoot had no financial conflicts to disclose.

SANTA MONICA, CALIF. — Exercise and cognitive-behavioral therapy complement rather than replace pharmacology in the management of fibromyalgia, according to Dr. Philip J. Mease.

Findings from several studies have shown that such nonpharmacologic treatments may lessen the primary symptoms of fibromyalgia while helping to correct some maladaptive behaviors, mood disturbance, and deconditioning.

Not all nonpharmacologic therapies are equally effective. The literature suggests that aerobic exercise, cognitive-behavioral therapy, and patient education all lessen pain and improve function. The same benefits are not reported with strength training, acupuncture, biofeedback, balneotherapy, and hypnotherapy, Dr. Mease said at the meeting, sponsored by Skin Disease Education Foundation (SDEF) and the University of Louisville.

This year the American College of Rheumatology published diagnostic criteria for fibromyalgia that shifted the emphasis from tender point examination and focused instead on the other symptoms that cause misery in these patients, such as sleep disturbance and fatigue (Arthritis Care Res. 2010;62:600–10).

Specifically, the diagnostic criteria are composed of two parts: a widespread pain index (WPI) that establishes the absence or presence of pain in up to 19 body areas but does not require the physician to press on those areas, and the symptom severity (SS) scale, that grades the patient's fatigue, sleep, and cognition and the patient's overall symptom burden.

Patients who have an overall symptom burden of 7 or more on the WPI and an SS score of 5 or more or a WPI score of 3–6 and an SS score of 9 or more fell within the fibromyalgia domain; the scores correlated well with the tender point score on the ACR's 1990 classification criteria.

Data from recent, unpublished research out of the National Data Bank of Rheumatic Diseases show that 20% of patients with rheumatoid arthritis have scores that indicate concomitant fibromyalgia and 10% of patients with osteoarthritis have scores consistent with fibromyalgia, according to Dr. Mease.

In addition to the recognized role for nonpharmacologic therapies, there has been a sea change in pharmacologic management of fibromyalgia. “I am intrigued by the emergence of a better understanding of the neurobiologic basis of central pain, central fatigue, and central dyscognition as they relate to fibromyalgia, irritable bowel syndrome, and even some of our rheumatoid and lupus patients,” said Dr. Mease, a rheumatologist at the University of Washington, Seattle, as well as director of the division of rheumatology research at the Swedish Medical Center there.

Findings from functional MRI studies have shown that, even at rest, the brain of patients with fibromyalgia has increased connectivity within multiple brain networks that may explain both the patients' experience of spontaneous pain and fluctuations in pain that are unrelated to activity. In addition, the increased connectivity may have implications for cognition (Arthritis Rheum. 2010;62:2545–55).

Dr. Mease reported that he presented data from a study of 363 patients with fibromyalgia who were treated with either pregabalin alone or in combination with milnacipran at the annual meeting of the European League Against Rheumatism earlier this year. Those treated with the combination therapy (pregabalin at 150–225 mg twice daily plus 50 mg of milnacipran) for 11 weeks showed a 20-point improvement on the visual analog scale (VAS) for pain assessment. In addition, 51% considered themselves “very much improved” on the Patient Global Impression of Change (PGIC) scale.

In contrast, patients on monotherapy showed a 5-point improvement on the VAS, and 24% considered themselves very much improved on the PGIC. About one-third of the patients did not finish the trial.

SDEF and this news organization are owned by Elsevier. Dr. Mease disclosed that he has financial relationships with Cypress Bioscience, Forest, Lilly, Pfizer, and UCB.

SANTA MONICA, CALIF. — Exercise and cognitive-behavioral therapy complement rather than replace pharmacology in the management of fibromyalgia, according to Dr. Philip J. Mease.

Findings from several studies have shown that such nonpharmacologic treatments may lessen the primary symptoms of fibromyalgia while helping to correct some maladaptive behaviors, mood disturbance, and deconditioning.

Not all nonpharmacologic therapies are equally effective. The literature suggests that aerobic exercise, cognitive-behavioral therapy, and patient education all lessen pain and improve function. The same benefits are not reported with strength training, acupuncture, biofeedback, balneotherapy, and hypnotherapy, Dr. Mease said at the meeting, sponsored by Skin Disease Education Foundation (SDEF) and the University of Louisville.

This year the American College of Rheumatology published diagnostic criteria for fibromyalgia that shifted the emphasis from tender point examination and focused instead on the other symptoms that cause misery in these patients, such as sleep disturbance and fatigue (Arthritis Care Res. 2010;62:600–10).

Specifically, the diagnostic criteria are composed of two parts: a widespread pain index (WPI) that establishes the absence or presence of pain in up to 19 body areas but does not require the physician to press on those areas, and the symptom severity (SS) scale, that grades the patient's fatigue, sleep, and cognition and the patient's overall symptom burden.

Patients who have an overall symptom burden of 7 or more on the WPI and an SS score of 5 or more or a WPI score of 3–6 and an SS score of 9 or more fell within the fibromyalgia domain; the scores correlated well with the tender point score on the ACR's 1990 classification criteria.

Data from recent, unpublished research out of the National Data Bank of Rheumatic Diseases show that 20% of patients with rheumatoid arthritis have scores that indicate concomitant fibromyalgia and 10% of patients with osteoarthritis have scores consistent with fibromyalgia, according to Dr. Mease.

In addition to the recognized role for nonpharmacologic therapies, there has been a sea change in pharmacologic management of fibromyalgia. “I am intrigued by the emergence of a better understanding of the neurobiologic basis of central pain, central fatigue, and central dyscognition as they relate to fibromyalgia, irritable bowel syndrome, and even some of our rheumatoid and lupus patients,” said Dr. Mease, a rheumatologist at the University of Washington, Seattle, as well as director of the division of rheumatology research at the Swedish Medical Center there.

Findings from functional MRI studies have shown that, even at rest, the brain of patients with fibromyalgia has increased connectivity within multiple brain networks that may explain both the patients' experience of spontaneous pain and fluctuations in pain that are unrelated to activity. In addition, the increased connectivity may have implications for cognition (Arthritis Rheum. 2010;62:2545–55).

Dr. Mease reported that he presented data from a study of 363 patients with fibromyalgia who were treated with either pregabalin alone or in combination with milnacipran at the annual meeting of the European League Against Rheumatism earlier this year. Those treated with the combination therapy (pregabalin at 150–225 mg twice daily plus 50 mg of milnacipran) for 11 weeks showed a 20-point improvement on the visual analog scale (VAS) for pain assessment. In addition, 51% considered themselves “very much improved” on the Patient Global Impression of Change (PGIC) scale.

In contrast, patients on monotherapy showed a 5-point improvement on the VAS, and 24% considered themselves very much improved on the PGIC. About one-third of the patients did not finish the trial.

SDEF and this news organization are owned by Elsevier. Dr. Mease disclosed that he has financial relationships with Cypress Bioscience, Forest, Lilly, Pfizer, and UCB.

SANTA MONICA, CALIF. — Exercise and cognitive-behavioral therapy complement rather than replace pharmacology in the management of fibromyalgia, according to Dr. Philip J. Mease.

Findings from several studies have shown that such nonpharmacologic treatments may lessen the primary symptoms of fibromyalgia while helping to correct some maladaptive behaviors, mood disturbance, and deconditioning.

Not all nonpharmacologic therapies are equally effective. The literature suggests that aerobic exercise, cognitive-behavioral therapy, and patient education all lessen pain and improve function. The same benefits are not reported with strength training, acupuncture, biofeedback, balneotherapy, and hypnotherapy, Dr. Mease said at the meeting, sponsored by Skin Disease Education Foundation (SDEF) and the University of Louisville.

This year the American College of Rheumatology published diagnostic criteria for fibromyalgia that shifted the emphasis from tender point examination and focused instead on the other symptoms that cause misery in these patients, such as sleep disturbance and fatigue (Arthritis Care Res. 2010;62:600–10).

Specifically, the diagnostic criteria are composed of two parts: a widespread pain index (WPI) that establishes the absence or presence of pain in up to 19 body areas but does not require the physician to press on those areas, and the symptom severity (SS) scale, that grades the patient's fatigue, sleep, and cognition and the patient's overall symptom burden.

Patients who have an overall symptom burden of 7 or more on the WPI and an SS score of 5 or more or a WPI score of 3–6 and an SS score of 9 or more fell within the fibromyalgia domain; the scores correlated well with the tender point score on the ACR's 1990 classification criteria.

Data from recent, unpublished research out of the National Data Bank of Rheumatic Diseases show that 20% of patients with rheumatoid arthritis have scores that indicate concomitant fibromyalgia and 10% of patients with osteoarthritis have scores consistent with fibromyalgia, according to Dr. Mease.

In addition to the recognized role for nonpharmacologic therapies, there has been a sea change in pharmacologic management of fibromyalgia. “I am intrigued by the emergence of a better understanding of the neurobiologic basis of central pain, central fatigue, and central dyscognition as they relate to fibromyalgia, irritable bowel syndrome, and even some of our rheumatoid and lupus patients,” said Dr. Mease, a rheumatologist at the University of Washington, Seattle, as well as director of the division of rheumatology research at the Swedish Medical Center there.

Findings from functional MRI studies have shown that, even at rest, the brain of patients with fibromyalgia has increased connectivity within multiple brain networks that may explain both the patients' experience of spontaneous pain and fluctuations in pain that are unrelated to activity. In addition, the increased connectivity may have implications for cognition (Arthritis Rheum. 2010;62:2545–55).

Dr. Mease reported that he presented data from a study of 363 patients with fibromyalgia who were treated with either pregabalin alone or in combination with milnacipran at the annual meeting of the European League Against Rheumatism earlier this year. Those treated with the combination therapy (pregabalin at 150–225 mg twice daily plus 50 mg of milnacipran) for 11 weeks showed a 20-point improvement on the visual analog scale (VAS) for pain assessment. In addition, 51% considered themselves “very much improved” on the Patient Global Impression of Change (PGIC) scale.

In contrast, patients on monotherapy showed a 5-point improvement on the VAS, and 24% considered themselves very much improved on the PGIC. About one-third of the patients did not finish the trial.

SDEF and this news organization are owned by Elsevier. Dr. Mease disclosed that he has financial relationships with Cypress Bioscience, Forest, Lilly, Pfizer, and UCB.

More than a decade after receiving autologous chondrocyte implants for treatment of full-thickness chondral lesions of the knee, nearly 75% of patients reported continued improvement or stability at their last follow-up, and 90% said they would have the procedure again.

Patients had significant improvement over baseline by objective clinical measures, although there was a slight but significant decline in function from the first to second follow-up period, according to Dr. Haris S. Vasiliadis and colleagues from the University of Gothenburg (Sweden) and the University of Ioannina (Greece).

Neither concomitant injuries to the knee nor prior bone marrow–stimulating surgeries appeared to decrease the overall benefit of chondrocyte implantation at long-term follow-up, the investigators wrote (Osteoarthritis Cartilage 2010 May 5 [doi:10.1016/j.joca.2010.04.003]).

They assessed responses from 224 patients who were treated with ACI in 1988–1998. At intermediate follow-up, the Lysholm scores (on a 0- to 95-point scale, with higher scores equating with better function) had improved by a mean of 14.8 points, compared with baseline (P = .0003). The mean change over baseline at 10 years was a 10-point improvement (P = .0016). Brittberg-Peterson scores (on a 0- to 130-point scale, with 0 being no pain and best function) were significantly lower at final follow-up than at baseline (mean decrease, 14 points; P = .004).

The investigators said no financial support was provided for the study, and they had no conflicts of interest.

More than a decade after receiving autologous chondrocyte implants for treatment of full-thickness chondral lesions of the knee, nearly 75% of patients reported continued improvement or stability at their last follow-up, and 90% said they would have the procedure again.

Patients had significant improvement over baseline by objective clinical measures, although there was a slight but significant decline in function from the first to second follow-up period, according to Dr. Haris S. Vasiliadis and colleagues from the University of Gothenburg (Sweden) and the University of Ioannina (Greece).

Neither concomitant injuries to the knee nor prior bone marrow–stimulating surgeries appeared to decrease the overall benefit of chondrocyte implantation at long-term follow-up, the investigators wrote (Osteoarthritis Cartilage 2010 May 5 [doi:10.1016/j.joca.2010.04.003]).

They assessed responses from 224 patients who were treated with ACI in 1988–1998. At intermediate follow-up, the Lysholm scores (on a 0- to 95-point scale, with higher scores equating with better function) had improved by a mean of 14.8 points, compared with baseline (P = .0003). The mean change over baseline at 10 years was a 10-point improvement (P = .0016). Brittberg-Peterson scores (on a 0- to 130-point scale, with 0 being no pain and best function) were significantly lower at final follow-up than at baseline (mean decrease, 14 points; P = .004).

The investigators said no financial support was provided for the study, and they had no conflicts of interest.

More than a decade after receiving autologous chondrocyte implants for treatment of full-thickness chondral lesions of the knee, nearly 75% of patients reported continued improvement or stability at their last follow-up, and 90% said they would have the procedure again.

Patients had significant improvement over baseline by objective clinical measures, although there was a slight but significant decline in function from the first to second follow-up period, according to Dr. Haris S. Vasiliadis and colleagues from the University of Gothenburg (Sweden) and the University of Ioannina (Greece).

Neither concomitant injuries to the knee nor prior bone marrow–stimulating surgeries appeared to decrease the overall benefit of chondrocyte implantation at long-term follow-up, the investigators wrote (Osteoarthritis Cartilage 2010 May 5 [doi:10.1016/j.joca.2010.04.003]).

They assessed responses from 224 patients who were treated with ACI in 1988–1998. At intermediate follow-up, the Lysholm scores (on a 0- to 95-point scale, with higher scores equating with better function) had improved by a mean of 14.8 points, compared with baseline (P = .0003). The mean change over baseline at 10 years was a 10-point improvement (P = .0016). Brittberg-Peterson scores (on a 0- to 130-point scale, with 0 being no pain and best function) were significantly lower at final follow-up than at baseline (mean decrease, 14 points; P = .004).

The investigators said no financial support was provided for the study, and they had no conflicts of interest.

Major Finding: In Sweden during 1998–2007, use of high-tibial osteotomy to treat severe knee osteoarthritis fell, to a 2% rate of all knee repair surgeries in 2007. Concurrently, use of total-knee arthroplasty rose, especially in patients younger than 55 years.

Data Source: Review of 3,196 knee surgeries during 1998–2007, using data from the Swedish national health agency.

Disclosures: Dr. W-Dahl had no disclosures.

BRUSSELS — Use of high-tibial osteotomy as surgical treatment for knee osteoarthritis dwindled during the decade ending in 2007, according to data collected on nearly 2,900 Swedish patients during the 10-year period.

During the same decade, use of total-knee arthroplasty (TKA) for knee osteoarthritis increased, especially in patients younger than 55 years, said Annette W-Dahl, Ph.D.

Despite diminished use, the revision rate following high-tibial osteotomy (HTO) remained modest, with a 29% rate after 10 years. That performance record for HTO suggests that using it first has the potential to delay significantly the need for TKA in patients with severe knee osteoarthritis, making HTO an attractive option for younger patients, said Dr. W-Dahl, a researcher in the department of orthopedics at Lund (Sweden) University.

During 1998–2007, HTO use in Sweden fell from about 5% of primary knee reconstructions for osteoarthritis in 1998 to about 2% 10 years later. In contrast, use of TKA rose from 78% in 1998 to about 90% in 2007. Use of a third surgical option, unicompartmental knee arthroplasty, also dropped during the decade studied, from 17% in 1998 to 8% in 2007.

Use of HTO also lags today in the United States, with an annual rate probably similar to Sweden's, commented Dr. Jeffrey N. Katz, professor of medicine at Harvard Medical School in Boston and director of the orthopedics and arthritis center for outcomes research at Brigham and Women's Hospital in that city. It remains unclear whether use of HTO actually delays the time when a patient with severe osteoarthritis needs TKA, he added.

The new analysis used data collected by the Swedish National Board of Health and Welfare. During the decade reviewed, surgeons performed 3,196 HTOs in 2,893 patients. Two-thirds were men, and their average age was 52 years, with 62% of the patients being younger than 55 years, and 97% aged 65 years or younger. The annual tally of HTOs fell from nearly 400 in 1998 to about 260 in 2007.

Analysis of patients younger than 55 years showed that use of TKA in this age group jumped from about 100 in 1998 to more than 500 in 2007. Concurrently, use of HTO dropped from about 230 in 1998 to about 180 in 2007; use of unicompartmental knee arthroplasty remained relatively stable throughout the decade, with about 100 cases done each year, Dr. W-Dahl said at the congress, which was organized by the Osteoarthritis Research Society International.

The cumulative need for revision surgery in patients who initially underwent HTO surgery ran 29% during the period studied, with women having a statistically significant 30% higher revision rate, compared with men, after adjustment for age and year of surgery.

Among patients younger than 65 years, 27% of the HTO patients required a revision, compared with 16% of patients who underwent unicompartmental knee arthroplasty and 8% with a TKA.

Women who underwent high-tibial osteotomy had a 30% higher revision rate than men.

Source DR. W-DAHL

Major Finding: In Sweden during 1998–2007, use of high-tibial osteotomy to treat severe knee osteoarthritis fell, to a 2% rate of all knee repair surgeries in 2007. Concurrently, use of total-knee arthroplasty rose, especially in patients younger than 55 years.

Data Source: Review of 3,196 knee surgeries during 1998–2007, using data from the Swedish national health agency.

Disclosures: Dr. W-Dahl had no disclosures.

BRUSSELS — Use of high-tibial osteotomy as surgical treatment for knee osteoarthritis dwindled during the decade ending in 2007, according to data collected on nearly 2,900 Swedish patients during the 10-year period.

During the same decade, use of total-knee arthroplasty (TKA) for knee osteoarthritis increased, especially in patients younger than 55 years, said Annette W-Dahl, Ph.D.

Despite diminished use, the revision rate following high-tibial osteotomy (HTO) remained modest, with a 29% rate after 10 years. That performance record for HTO suggests that using it first has the potential to delay significantly the need for TKA in patients with severe knee osteoarthritis, making HTO an attractive option for younger patients, said Dr. W-Dahl, a researcher in the department of orthopedics at Lund (Sweden) University.

During 1998–2007, HTO use in Sweden fell from about 5% of primary knee reconstructions for osteoarthritis in 1998 to about 2% 10 years later. In contrast, use of TKA rose from 78% in 1998 to about 90% in 2007. Use of a third surgical option, unicompartmental knee arthroplasty, also dropped during the decade studied, from 17% in 1998 to 8% in 2007.

Use of HTO also lags today in the United States, with an annual rate probably similar to Sweden's, commented Dr. Jeffrey N. Katz, professor of medicine at Harvard Medical School in Boston and director of the orthopedics and arthritis center for outcomes research at Brigham and Women's Hospital in that city. It remains unclear whether use of HTO actually delays the time when a patient with severe osteoarthritis needs TKA, he added.

The new analysis used data collected by the Swedish National Board of Health and Welfare. During the decade reviewed, surgeons performed 3,196 HTOs in 2,893 patients. Two-thirds were men, and their average age was 52 years, with 62% of the patients being younger than 55 years, and 97% aged 65 years or younger. The annual tally of HTOs fell from nearly 400 in 1998 to about 260 in 2007.

Analysis of patients younger than 55 years showed that use of TKA in this age group jumped from about 100 in 1998 to more than 500 in 2007. Concurrently, use of HTO dropped from about 230 in 1998 to about 180 in 2007; use of unicompartmental knee arthroplasty remained relatively stable throughout the decade, with about 100 cases done each year, Dr. W-Dahl said at the congress, which was organized by the Osteoarthritis Research Society International.

The cumulative need for revision surgery in patients who initially underwent HTO surgery ran 29% during the period studied, with women having a statistically significant 30% higher revision rate, compared with men, after adjustment for age and year of surgery.

Among patients younger than 65 years, 27% of the HTO patients required a revision, compared with 16% of patients who underwent unicompartmental knee arthroplasty and 8% with a TKA.

Women who underwent high-tibial osteotomy had a 30% higher revision rate than men.

Source DR. W-DAHL

Major Finding: In Sweden during 1998–2007, use of high-tibial osteotomy to treat severe knee osteoarthritis fell, to a 2% rate of all knee repair surgeries in 2007. Concurrently, use of total-knee arthroplasty rose, especially in patients younger than 55 years.

Data Source: Review of 3,196 knee surgeries during 1998–2007, using data from the Swedish national health agency.

Disclosures: Dr. W-Dahl had no disclosures.

BRUSSELS — Use of high-tibial osteotomy as surgical treatment for knee osteoarthritis dwindled during the decade ending in 2007, according to data collected on nearly 2,900 Swedish patients during the 10-year period.

During the same decade, use of total-knee arthroplasty (TKA) for knee osteoarthritis increased, especially in patients younger than 55 years, said Annette W-Dahl, Ph.D.

Despite diminished use, the revision rate following high-tibial osteotomy (HTO) remained modest, with a 29% rate after 10 years. That performance record for HTO suggests that using it first has the potential to delay significantly the need for TKA in patients with severe knee osteoarthritis, making HTO an attractive option for younger patients, said Dr. W-Dahl, a researcher in the department of orthopedics at Lund (Sweden) University.

During 1998–2007, HTO use in Sweden fell from about 5% of primary knee reconstructions for osteoarthritis in 1998 to about 2% 10 years later. In contrast, use of TKA rose from 78% in 1998 to about 90% in 2007. Use of a third surgical option, unicompartmental knee arthroplasty, also dropped during the decade studied, from 17% in 1998 to 8% in 2007.

Use of HTO also lags today in the United States, with an annual rate probably similar to Sweden's, commented Dr. Jeffrey N. Katz, professor of medicine at Harvard Medical School in Boston and director of the orthopedics and arthritis center for outcomes research at Brigham and Women's Hospital in that city. It remains unclear whether use of HTO actually delays the time when a patient with severe osteoarthritis needs TKA, he added.

The new analysis used data collected by the Swedish National Board of Health and Welfare. During the decade reviewed, surgeons performed 3,196 HTOs in 2,893 patients. Two-thirds were men, and their average age was 52 years, with 62% of the patients being younger than 55 years, and 97% aged 65 years or younger. The annual tally of HTOs fell from nearly 400 in 1998 to about 260 in 2007.

Analysis of patients younger than 55 years showed that use of TKA in this age group jumped from about 100 in 1998 to more than 500 in 2007. Concurrently, use of HTO dropped from about 230 in 1998 to about 180 in 2007; use of unicompartmental knee arthroplasty remained relatively stable throughout the decade, with about 100 cases done each year, Dr. W-Dahl said at the congress, which was organized by the Osteoarthritis Research Society International.

The cumulative need for revision surgery in patients who initially underwent HTO surgery ran 29% during the period studied, with women having a statistically significant 30% higher revision rate, compared with men, after adjustment for age and year of surgery.

Among patients younger than 65 years, 27% of the HTO patients required a revision, compared with 16% of patients who underwent unicompartmental knee arthroplasty and 8% with a TKA.

Women who underwent high-tibial osteotomy had a 30% higher revision rate than men.

Source DR. W-DAHL

Major Finding: The number of total knee replacements done on Americans aged 45–64 rose from 68,000 in 1997 to 221,000 in 2007, more than tripling. The number done in Americans aged 65–84 rose from 183,000 in 1997 to 303,000 in 2007, a 66% increase.

Data Source: The Nationwide Inpatient Sample, annual data collection sponsored by the Agency for Healthcare Research and Quality.

Disclosures: Dr. Losina and Dr. Katz had no relevant disclosures.

BRUSSELS — Middle-aged Americans seem to have embraced total knee replacement, with the number of surgeries more than tripling from 68,000 in 1997 to 221,000 in 2007, according to data collected in the Nationwide Inpatient Sample.

This increase, which helped to drive an overall doubling of all U.S. total knee replacements during 1997–2007, did not result merely from the growing prevalence of obesity and the demographic growth of the 45- to 64-year-old age group, judging from the findings from further analysis of the data.

Those two factors accounted for, at most, a quarter of the increase, Elena Losina, Ph.D., reported in a poster at the congress.

A combination of additional factors may explain the rest of the rise, Dr. Losina said in an interview. These include:

▸ A rise in sports injuries that have led to posttraumatic arthritis, a trend exacerbated by the increased sports participation that began in the late 20th century.

▸ Increased willingness of surgeons to perform total knee replacement on patients younger than 65.

▸ Increased familiarity and comfort with the surgery – which did not become available until the late 1970s – leading to increased demand by younger patients.

“It's a combination of more early, advanced arthritis, shifting indications, and more willingness to operate,” said Dr. Losina, codirector of the Orthopedics and Arthritis Center for Outcomes Research at Brigham and Women's Hospital in Boston. hMore and more patients have been referred and at least consider surgery.”

“Are patients in the [45- to 64-year-old] age group being offered surgery and accepting surgery more often? Is it because there is more osteoarthritis because of injury? Does it reflect patient demand in that age group? It's all speculation,” agreed Dr. Jeffrey N. Katz, director of the center, and professor of medicine and orthopedic surgery at Harvard Medical School in Boston.

Some of the same factors also drove increased knee-replacement rates in patients aged 65–84 years, but the slope of the rise was not nearly as steep. In the group aged 65–84 years old, the number of U.S. total knee replacement surgeries rose 66% from 183,000 in 1997 to 303,000 in 2007. The absolute rise of 120,000 additional surgeries in the elderly clearly trailed the 153,000 increase in middle-aged U.S. adults.

But these numbers may not remain on their current trajectory. The surgery is not sustainable, Dr. Losina said at the congress, which was sponsored by the Osteoarthritis Research Society International.

“I think the growth will level off. I think Medicare will be capped, forcing patients to pay for knee replacement out of pocket, and eligibility criteria will tighten,” she said. Currently, “we don't know what proportion of the surgery is appropriate,” she added.

Another unknown is what middle-aged patients who receive knee replacements can expect about the eventual need for revision surgery. “It would be very surprising if revision rates were not higher in younger patients,” said Dr. Katz, who coauthored the poster.

Younger patients sometimes try to resume the activities that initially drove them to knee surgery. “We need to study [revision] data from younger patients. The burden of revision in younger patients is unknown; it hasn't been studied.” Dr. Losina said.

“We know that prosthetic knees are durable in older patients, but in older patients there is a strong, competing risk from mortality,” she said. In the elderly, the revision rate for total knee replacement is roughly 1% per year following surgery.

“It's a very successful surgery. People are miserable and can't move and function because of their knee problems and total knee replacement brings them back to life. I think that explains the greater willingness” to use knee surgery on younger patients. “But we need to understand the societal and population implications of the trend we see,” Dr. Losina said.

Her study used data collected in the Nationwide Inpatient Sample by the Agency for Healthcare Research and Quality, which currently collects data from more than 1,000 hospitals in 42 states.

The data showed a doubling of knee surgery overall from 1997 to a national total of 550,000 in 2007, a period when the U.S. population grew by just 15%.

To watch an interview with Dr. Elena Losina on knee surgery rates, visit

Source Mitchel L. Zoler/Elsevier Global Medical Newswww.rheumatologynews.com

Major Finding: The number of total knee replacements done on Americans aged 45–64 rose from 68,000 in 1997 to 221,000 in 2007, more than tripling. The number done in Americans aged 65–84 rose from 183,000 in 1997 to 303,000 in 2007, a 66% increase.

Data Source: The Nationwide Inpatient Sample, annual data collection sponsored by the Agency for Healthcare Research and Quality.

Disclosures: Dr. Losina and Dr. Katz had no relevant disclosures.

BRUSSELS — Middle-aged Americans seem to have embraced total knee replacement, with the number of surgeries more than tripling from 68,000 in 1997 to 221,000 in 2007, according to data collected in the Nationwide Inpatient Sample.

This increase, which helped to drive an overall doubling of all U.S. total knee replacements during 1997–2007, did not result merely from the growing prevalence of obesity and the demographic growth of the 45- to 64-year-old age group, judging from the findings from further analysis of the data.

Those two factors accounted for, at most, a quarter of the increase, Elena Losina, Ph.D., reported in a poster at the congress.

A combination of additional factors may explain the rest of the rise, Dr. Losina said in an interview. These include:

▸ A rise in sports injuries that have led to posttraumatic arthritis, a trend exacerbated by the increased sports participation that began in the late 20th century.

▸ Increased willingness of surgeons to perform total knee replacement on patients younger than 65.

▸ Increased familiarity and comfort with the surgery – which did not become available until the late 1970s – leading to increased demand by younger patients.

“It's a combination of more early, advanced arthritis, shifting indications, and more willingness to operate,” said Dr. Losina, codirector of the Orthopedics and Arthritis Center for Outcomes Research at Brigham and Women's Hospital in Boston. hMore and more patients have been referred and at least consider surgery.”

“Are patients in the [45- to 64-year-old] age group being offered surgery and accepting surgery more often? Is it because there is more osteoarthritis because of injury? Does it reflect patient demand in that age group? It's all speculation,” agreed Dr. Jeffrey N. Katz, director of the center, and professor of medicine and orthopedic surgery at Harvard Medical School in Boston.

Some of the same factors also drove increased knee-replacement rates in patients aged 65–84 years, but the slope of the rise was not nearly as steep. In the group aged 65–84 years old, the number of U.S. total knee replacement surgeries rose 66% from 183,000 in 1997 to 303,000 in 2007. The absolute rise of 120,000 additional surgeries in the elderly clearly trailed the 153,000 increase in middle-aged U.S. adults.

But these numbers may not remain on their current trajectory. The surgery is not sustainable, Dr. Losina said at the congress, which was sponsored by the Osteoarthritis Research Society International.

“I think the growth will level off. I think Medicare will be capped, forcing patients to pay for knee replacement out of pocket, and eligibility criteria will tighten,” she said. Currently, “we don't know what proportion of the surgery is appropriate,” she added.

Another unknown is what middle-aged patients who receive knee replacements can expect about the eventual need for revision surgery. “It would be very surprising if revision rates were not higher in younger patients,” said Dr. Katz, who coauthored the poster.

Younger patients sometimes try to resume the activities that initially drove them to knee surgery. “We need to study [revision] data from younger patients. The burden of revision in younger patients is unknown; it hasn't been studied.” Dr. Losina said.

“We know that prosthetic knees are durable in older patients, but in older patients there is a strong, competing risk from mortality,” she said. In the elderly, the revision rate for total knee replacement is roughly 1% per year following surgery.

“It's a very successful surgery. People are miserable and can't move and function because of their knee problems and total knee replacement brings them back to life. I think that explains the greater willingness” to use knee surgery on younger patients. “But we need to understand the societal and population implications of the trend we see,” Dr. Losina said.

Her study used data collected in the Nationwide Inpatient Sample by the Agency for Healthcare Research and Quality, which currently collects data from more than 1,000 hospitals in 42 states.

The data showed a doubling of knee surgery overall from 1997 to a national total of 550,000 in 2007, a period when the U.S. population grew by just 15%.

To watch an interview with Dr. Elena Losina on knee surgery rates, visit

Source Mitchel L. Zoler/Elsevier Global Medical Newswww.rheumatologynews.com

Major Finding: The number of total knee replacements done on Americans aged 45–64 rose from 68,000 in 1997 to 221,000 in 2007, more than tripling. The number done in Americans aged 65–84 rose from 183,000 in 1997 to 303,000 in 2007, a 66% increase.

Data Source: The Nationwide Inpatient Sample, annual data collection sponsored by the Agency for Healthcare Research and Quality.

Disclosures: Dr. Losina and Dr. Katz had no relevant disclosures.

BRUSSELS — Middle-aged Americans seem to have embraced total knee replacement, with the number of surgeries more than tripling from 68,000 in 1997 to 221,000 in 2007, according to data collected in the Nationwide Inpatient Sample.

This increase, which helped to drive an overall doubling of all U.S. total knee replacements during 1997–2007, did not result merely from the growing prevalence of obesity and the demographic growth of the 45- to 64-year-old age group, judging from the findings from further analysis of the data.

Those two factors accounted for, at most, a quarter of the increase, Elena Losina, Ph.D., reported in a poster at the congress.

A combination of additional factors may explain the rest of the rise, Dr. Losina said in an interview. These include:

▸ A rise in sports injuries that have led to posttraumatic arthritis, a trend exacerbated by the increased sports participation that began in the late 20th century.

▸ Increased willingness of surgeons to perform total knee replacement on patients younger than 65.

▸ Increased familiarity and comfort with the surgery – which did not become available until the late 1970s – leading to increased demand by younger patients.

“It's a combination of more early, advanced arthritis, shifting indications, and more willingness to operate,” said Dr. Losina, codirector of the Orthopedics and Arthritis Center for Outcomes Research at Brigham and Women's Hospital in Boston. hMore and more patients have been referred and at least consider surgery.”

“Are patients in the [45- to 64-year-old] age group being offered surgery and accepting surgery more often? Is it because there is more osteoarthritis because of injury? Does it reflect patient demand in that age group? It's all speculation,” agreed Dr. Jeffrey N. Katz, director of the center, and professor of medicine and orthopedic surgery at Harvard Medical School in Boston.

Some of the same factors also drove increased knee-replacement rates in patients aged 65–84 years, but the slope of the rise was not nearly as steep. In the group aged 65–84 years old, the number of U.S. total knee replacement surgeries rose 66% from 183,000 in 1997 to 303,000 in 2007. The absolute rise of 120,000 additional surgeries in the elderly clearly trailed the 153,000 increase in middle-aged U.S. adults.

But these numbers may not remain on their current trajectory. The surgery is not sustainable, Dr. Losina said at the congress, which was sponsored by the Osteoarthritis Research Society International.

“I think the growth will level off. I think Medicare will be capped, forcing patients to pay for knee replacement out of pocket, and eligibility criteria will tighten,” she said. Currently, “we don't know what proportion of the surgery is appropriate,” she added.

Another unknown is what middle-aged patients who receive knee replacements can expect about the eventual need for revision surgery. “It would be very surprising if revision rates were not higher in younger patients,” said Dr. Katz, who coauthored the poster.

Younger patients sometimes try to resume the activities that initially drove them to knee surgery. “We need to study [revision] data from younger patients. The burden of revision in younger patients is unknown; it hasn't been studied.” Dr. Losina said.

“We know that prosthetic knees are durable in older patients, but in older patients there is a strong, competing risk from mortality,” she said. In the elderly, the revision rate for total knee replacement is roughly 1% per year following surgery.

“It's a very successful surgery. People are miserable and can't move and function because of their knee problems and total knee replacement brings them back to life. I think that explains the greater willingness” to use knee surgery on younger patients. “But we need to understand the societal and population implications of the trend we see,” Dr. Losina said.

Her study used data collected in the Nationwide Inpatient Sample by the Agency for Healthcare Research and Quality, which currently collects data from more than 1,000 hospitals in 42 states.

The data showed a doubling of knee surgery overall from 1997 to a national total of 550,000 in 2007, a period when the U.S. population grew by just 15%.

To watch an interview with Dr. Elena Losina on knee surgery rates, visit

Source Mitchel L. Zoler/Elsevier Global Medical Newswww.rheumatologynews.com

Major Finding: A 3-month program of intensive knee rehabilitation produced a significant, 30% improvement in knee extension and flexion in patients with articular cartilage lesions who were scheduled for repair surgery. After the program ended, 64% of participants said they no longer needed immediate surgery.

Data Source: Single-center study of 48 patients with articular cartilage lesions.

Disclosures: Dr. Risberg said she had no conflicts of interest.

BRUSSELS — A carefully designed, 3-month program of rehabilitation exercise and education in patients with articular cartilage lesions who were scheduled for cartilage repair surgery led to significant improvements in knee function in a single-center study with 48 patients.

Following the 3-month rehabilitation intervention, 64% of the patients said they no longer needed immediate surgery, said May Arna Risberg, Ph.D.

“I believe this [rehabilitation] program works for these patients. We will publish the program, and continue to use it ourselves, and we hope others will use it,” said Dr. Risberg, professor of sports medicine at the Norwegian School of Sport Sciences in Oslo. Gradually increasing knee loading using an individualized schedule may explain the rehab program's success, she said.“P

“Patients with cartilage lesions are very different from osteoarthritis patients. You need to go much slower with progression of their knee loading. Rehab for cartilage needs to be slow and long,” she said in an interview.

All 48 patients in the study had undergone prior rehab sessions run by other clinicians using different protocols. But aside from the focus on a gradual pace, an emphasis on using knee loading to guide the program's intensity, and a strong education component, the rehab program tested by Dr. Risberg didn't involve any novel approaches or exercise regimens.

Participating patients attended rehab sessions of the Oslo CARE (cartilage, active, rehab, and education) program an average of twice a week. Sessions included warm-up stretches, gait retraining, neuromuscular exercises, step-up and step-down exercises, and strength exercise for knee and hip muscles. Both the step and strength exercises featured gradually increasing loading over time. The program also included educational sessions and materials.

The study enrolled patients who had a focal femoral-condyle defect in the articular cartilage of one knee, diagnosed by arthroscopy, and who were scheduled for repair surgery. Their age averaged 34 years, (range, 17–50); 70% were men, and 84% had a medial femoral-condyle lesion. Participants had had their symptoms for an average of 47 months prior to the study.

Analysis of training diaries and responses in biweekly questionnaires showed that 79% of participants adhered to their rehab regimens, and 88% had follow-up assessments an average of 104 days after they entered the study.

At follow-up, participants averaged a 30% improvement over baseline in both extension and flexion of their injured knee, Dr. Risberg reported at the meeting, sponsored by the Osteoarthritis Research Society International. They also averaged improvements of 21%, 31%, and 37% in the triple, crossover, and one-leg hop tests, respectively, compared with baseline, all statistically significant increases.

They also had significant improvements in measures of pain, activity, and quality of life. Dr. Risberg cited the finding that nearly two-thirds of patients said they no longer needed immediate knee surgery as the best demonstration of their improvement.

She cautioned that despite completing the 3-month program, some patients had no significant response to their rehabilitation, and that additional studies should test the program in more patients with longer follow-up.

Major Finding: A 3-month program of intensive knee rehabilitation produced a significant, 30% improvement in knee extension and flexion in patients with articular cartilage lesions who were scheduled for repair surgery. After the program ended, 64% of participants said they no longer needed immediate surgery.

Data Source: Single-center study of 48 patients with articular cartilage lesions.

Disclosures: Dr. Risberg said she had no conflicts of interest.

BRUSSELS — A carefully designed, 3-month program of rehabilitation exercise and education in patients with articular cartilage lesions who were scheduled for cartilage repair surgery led to significant improvements in knee function in a single-center study with 48 patients.

Following the 3-month rehabilitation intervention, 64% of the patients said they no longer needed immediate surgery, said May Arna Risberg, Ph.D.

“I believe this [rehabilitation] program works for these patients. We will publish the program, and continue to use it ourselves, and we hope others will use it,” said Dr. Risberg, professor of sports medicine at the Norwegian School of Sport Sciences in Oslo. Gradually increasing knee loading using an individualized schedule may explain the rehab program's success, she said.“P

“Patients with cartilage lesions are very different from osteoarthritis patients. You need to go much slower with progression of their knee loading. Rehab for cartilage needs to be slow and long,” she said in an interview.

All 48 patients in the study had undergone prior rehab sessions run by other clinicians using different protocols. But aside from the focus on a gradual pace, an emphasis on using knee loading to guide the program's intensity, and a strong education component, the rehab program tested by Dr. Risberg didn't involve any novel approaches or exercise regimens.

Participating patients attended rehab sessions of the Oslo CARE (cartilage, active, rehab, and education) program an average of twice a week. Sessions included warm-up stretches, gait retraining, neuromuscular exercises, step-up and step-down exercises, and strength exercise for knee and hip muscles. Both the step and strength exercises featured gradually increasing loading over time. The program also included educational sessions and materials.

The study enrolled patients who had a focal femoral-condyle defect in the articular cartilage of one knee, diagnosed by arthroscopy, and who were scheduled for repair surgery. Their age averaged 34 years, (range, 17–50); 70% were men, and 84% had a medial femoral-condyle lesion. Participants had had their symptoms for an average of 47 months prior to the study.

Analysis of training diaries and responses in biweekly questionnaires showed that 79% of participants adhered to their rehab regimens, and 88% had follow-up assessments an average of 104 days after they entered the study.

At follow-up, participants averaged a 30% improvement over baseline in both extension and flexion of their injured knee, Dr. Risberg reported at the meeting, sponsored by the Osteoarthritis Research Society International. They also averaged improvements of 21%, 31%, and 37% in the triple, crossover, and one-leg hop tests, respectively, compared with baseline, all statistically significant increases.

They also had significant improvements in measures of pain, activity, and quality of life. Dr. Risberg cited the finding that nearly two-thirds of patients said they no longer needed immediate knee surgery as the best demonstration of their improvement.

She cautioned that despite completing the 3-month program, some patients had no significant response to their rehabilitation, and that additional studies should test the program in more patients with longer follow-up.

Major Finding: A 3-month program of intensive knee rehabilitation produced a significant, 30% improvement in knee extension and flexion in patients with articular cartilage lesions who were scheduled for repair surgery. After the program ended, 64% of participants said they no longer needed immediate surgery.

Data Source: Single-center study of 48 patients with articular cartilage lesions.

Disclosures: Dr. Risberg said she had no conflicts of interest.

BRUSSELS — A carefully designed, 3-month program of rehabilitation exercise and education in patients with articular cartilage lesions who were scheduled for cartilage repair surgery led to significant improvements in knee function in a single-center study with 48 patients.

Following the 3-month rehabilitation intervention, 64% of the patients said they no longer needed immediate surgery, said May Arna Risberg, Ph.D.

“I believe this [rehabilitation] program works for these patients. We will publish the program, and continue to use it ourselves, and we hope others will use it,” said Dr. Risberg, professor of sports medicine at the Norwegian School of Sport Sciences in Oslo. Gradually increasing knee loading using an individualized schedule may explain the rehab program's success, she said.“P

“Patients with cartilage lesions are very different from osteoarthritis patients. You need to go much slower with progression of their knee loading. Rehab for cartilage needs to be slow and long,” she said in an interview.

All 48 patients in the study had undergone prior rehab sessions run by other clinicians using different protocols. But aside from the focus on a gradual pace, an emphasis on using knee loading to guide the program's intensity, and a strong education component, the rehab program tested by Dr. Risberg didn't involve any novel approaches or exercise regimens.

Participating patients attended rehab sessions of the Oslo CARE (cartilage, active, rehab, and education) program an average of twice a week. Sessions included warm-up stretches, gait retraining, neuromuscular exercises, step-up and step-down exercises, and strength exercise for knee and hip muscles. Both the step and strength exercises featured gradually increasing loading over time. The program also included educational sessions and materials.

The study enrolled patients who had a focal femoral-condyle defect in the articular cartilage of one knee, diagnosed by arthroscopy, and who were scheduled for repair surgery. Their age averaged 34 years, (range, 17–50); 70% were men, and 84% had a medial femoral-condyle lesion. Participants had had their symptoms for an average of 47 months prior to the study.

Analysis of training diaries and responses in biweekly questionnaires showed that 79% of participants adhered to their rehab regimens, and 88% had follow-up assessments an average of 104 days after they entered the study.

At follow-up, participants averaged a 30% improvement over baseline in both extension and flexion of their injured knee, Dr. Risberg reported at the meeting, sponsored by the Osteoarthritis Research Society International. They also averaged improvements of 21%, 31%, and 37% in the triple, crossover, and one-leg hop tests, respectively, compared with baseline, all statistically significant increases.

They also had significant improvements in measures of pain, activity, and quality of life. Dr. Risberg cited the finding that nearly two-thirds of patients said they no longer needed immediate knee surgery as the best demonstration of their improvement.

She cautioned that despite completing the 3-month program, some patients had no significant response to their rehabilitation, and that additional studies should test the program in more patients with longer follow-up.

EDINBURGH — Depression is common, underdiagnosed, and undertreated in patients with psoriatic arthritis.

Psychiatric evaluation of 50 consecutive patients at the University of Glasgow psoriatic arthritis clinic indicated that 15 patients (30%) were depressed. Three were rated as severely depressed based on their scores on the Hospital Anxiety and Depression Scale (HADS); 12 others had moderate depression, Dr. Rajeev Krishnadas reported.

This high prevalence of depression in psoriatic arthritis patients is consistent with reports in the dermatologic literature (Br. J. Dermatol. 2008;159:704–10).

Of note, none of the depressed Scottish patients was on a therapeutic dose of an antidepressant, added Dr. Krishnadas of the Sackler Institute of Psychobiological Research, Southern General Hospital, Glasgow.

This study is part of a larger ongoing investigation into the relationship between systemic inflammation and depression in patients with rheumatoid arthritis or psoriatic arthritis. In this portion of the study, a positive association was noted between HADS scores and C-reactive protein levels in the psoriatic arthritis cohort, although it must be noted that CRP scores accounted for only 7% of the overall variance in HADS scores. Higher HADS scores were associated with worse quality of life as assessed by the Dermatology Quality of Life Questionnaire as well as with higher scores on a self-rated pain scale.

A negative correlation was found between HADS scores and emotional intelligence as measured by the Trait Emotional Intelligence Questionnaire – Short Form. High trait emotional intelligence reflects greater awareness of one's own feelings as well as the feelings of others. Individuals with high emotional intelligence are better able to regulate their emotions than are those with lower trait emotional intelligence.

Patients who scored high in trait emotional intelligence had higher quality of life scores, lower CRP levels, and lower scores on the pain scale.

These findings are consistent with the hypothesis that a poor ability to be aware of and regulate one's emotions predisposes to depression in the presence of a chronic medical condition or other major stressor, said to Dr. Krishnadas, who declared having no conflicts of interest.

EDINBURGH — Depression is common, underdiagnosed, and undertreated in patients with psoriatic arthritis.

Psychiatric evaluation of 50 consecutive patients at the University of Glasgow psoriatic arthritis clinic indicated that 15 patients (30%) were depressed. Three were rated as severely depressed based on their scores on the Hospital Anxiety and Depression Scale (HADS); 12 others had moderate depression, Dr. Rajeev Krishnadas reported.

This high prevalence of depression in psoriatic arthritis patients is consistent with reports in the dermatologic literature (Br. J. Dermatol. 2008;159:704–10).

Of note, none of the depressed Scottish patients was on a therapeutic dose of an antidepressant, added Dr. Krishnadas of the Sackler Institute of Psychobiological Research, Southern General Hospital, Glasgow.

This study is part of a larger ongoing investigation into the relationship between systemic inflammation and depression in patients with rheumatoid arthritis or psoriatic arthritis. In this portion of the study, a positive association was noted between HADS scores and C-reactive protein levels in the psoriatic arthritis cohort, although it must be noted that CRP scores accounted for only 7% of the overall variance in HADS scores. Higher HADS scores were associated with worse quality of life as assessed by the Dermatology Quality of Life Questionnaire as well as with higher scores on a self-rated pain scale.

A negative correlation was found between HADS scores and emotional intelligence as measured by the Trait Emotional Intelligence Questionnaire – Short Form. High trait emotional intelligence reflects greater awareness of one's own feelings as well as the feelings of others. Individuals with high emotional intelligence are better able to regulate their emotions than are those with lower trait emotional intelligence.

Patients who scored high in trait emotional intelligence had higher quality of life scores, lower CRP levels, and lower scores on the pain scale.

These findings are consistent with the hypothesis that a poor ability to be aware of and regulate one's emotions predisposes to depression in the presence of a chronic medical condition or other major stressor, said to Dr. Krishnadas, who declared having no conflicts of interest.

EDINBURGH — Depression is common, underdiagnosed, and undertreated in patients with psoriatic arthritis.

Psychiatric evaluation of 50 consecutive patients at the University of Glasgow psoriatic arthritis clinic indicated that 15 patients (30%) were depressed. Three were rated as severely depressed based on their scores on the Hospital Anxiety and Depression Scale (HADS); 12 others had moderate depression, Dr. Rajeev Krishnadas reported.

This high prevalence of depression in psoriatic arthritis patients is consistent with reports in the dermatologic literature (Br. J. Dermatol. 2008;159:704–10).

Of note, none of the depressed Scottish patients was on a therapeutic dose of an antidepressant, added Dr. Krishnadas of the Sackler Institute of Psychobiological Research, Southern General Hospital, Glasgow.

This study is part of a larger ongoing investigation into the relationship between systemic inflammation and depression in patients with rheumatoid arthritis or psoriatic arthritis. In this portion of the study, a positive association was noted between HADS scores and C-reactive protein levels in the psoriatic arthritis cohort, although it must be noted that CRP scores accounted for only 7% of the overall variance in HADS scores. Higher HADS scores were associated with worse quality of life as assessed by the Dermatology Quality of Life Questionnaire as well as with higher scores on a self-rated pain scale.

A negative correlation was found between HADS scores and emotional intelligence as measured by the Trait Emotional Intelligence Questionnaire – Short Form. High trait emotional intelligence reflects greater awareness of one's own feelings as well as the feelings of others. Individuals with high emotional intelligence are better able to regulate their emotions than are those with lower trait emotional intelligence.

Patients who scored high in trait emotional intelligence had higher quality of life scores, lower CRP levels, and lower scores on the pain scale.

These findings are consistent with the hypothesis that a poor ability to be aware of and regulate one's emotions predisposes to depression in the presence of a chronic medical condition or other major stressor, said to Dr. Krishnadas, who declared having no conflicts of interest.

Major Finding: Treatment with adalimumab lowered the disease activity score among a group of rheumatoid arthritis patients, but did not affect serum vitamin D levels.

Data Source: A prospective study of 170 consecutive patients with rheumatoid arthritis seen at an outpatient facility in Amsterdam.

Disclosures: The authors stated that they had no competing interests. The study was supported by the European League Against Rheumatism and the Jan van Breemen Institute, in Amsterdam.

Four months of treatment with the anti–tumor necrosis factor drug adalimumab did not affect serum vitamin D levels in rheumatoid arthritis patients, though it did ease symptoms.

The finding refutes the theory that systemic inflammation may negatively affect circulating serum 25-hydroxyvitamin D (25[OH]D) levels, wrote Dr. Paul Welsh and his colleagues.

Moreover, the data confirm a high prevalence of vitamin D insufficiency and frank deficiency among RA patients, they added.

According to Dr. Welsh of the British Heart Foundation Glasgow Cardiovascular Research Center at the University of Glasgow and his associates, there are several reasons why treatment with a potent anti-inflammatory medication, such as the tumor necrosis factor–alpha blocker adalimumab, might be hypothesized to increase vitamin D levels.

Data from a 2006 study showed an inverse relationship between serum vitamin D and DAS-28 scores (Clin. Exp. Rheumatol. 2006;24:702–4). “Furthermore, data for an apparent beneficial effect of statins on circulating 25[OH]D concentrations have been speculated to be attributable to statin 'pleiotropic' anti-inflammatory effects,” the researchers said. They also noted that serum vitamin D levels are known to drop in the acute phase following surgery, when inflammation is likely to be elevated.

To test the hypothesis that lowering inflammation would result in an increase of vitamin D, the researchers looked at 170 consecutive patients with RA seen at an outpatient clinic in Amsterdam (Ann. Rheum. Dis. 2010 [doi:10.1136/ard.2010.137265]).

Patients were treated either with adalimumab alone, at a dose of 40 mg administered every 2 weeks, or with adalimumab plus other disease-modifying antirheumatic drugs (DMARDs).

At baseline, 66 patients (39%) were vitamin D deficient, with a serum concentration of less than 15 ng/mL. Sixty-three patients (39%) had vitamin D insufficiency, with levels between 15 and 25 ng/mL. The remaining patients had adequate vitamin D levels.

After 16 weeks of treatment with adalimumab, patients' mean disease activity score-28 (DAS-28) had dropped significantly, from 5.1 to 3.2 (P less than .001). However, median circulating levels of vitamin D were not significantly altered, moving from 18.5 ng/mL at baseline to 19.0 ng/mL at the study's completion (P = .67). Nor did the prevalence of patients with vitamin D deficiency and insufficiency change after treatment, wrote the authors.

“Whether longer-term biological therapy has any beneficial effect on circulating 25[OH]D concentrations requires further study, although any such effect may be attributable to increased sunlight exposure rather than decreasing inflammation,” concluded the authors.

“Our observations also weaken the possibility that TNF-alpha blockers, which improve bone mineral density and potentially lower cardiovascular risk, do so via changes in 25[OH]D levels.”

They added: “Further research is needed to address determinants of poor 25[OH]D status in RA.”

Major Finding: Treatment with adalimumab lowered the disease activity score among a group of rheumatoid arthritis patients, but did not affect serum vitamin D levels.

Data Source: A prospective study of 170 consecutive patients with rheumatoid arthritis seen at an outpatient facility in Amsterdam.

Disclosures: The authors stated that they had no competing interests. The study was supported by the European League Against Rheumatism and the Jan van Breemen Institute, in Amsterdam.

Four months of treatment with the anti–tumor necrosis factor drug adalimumab did not affect serum vitamin D levels in rheumatoid arthritis patients, though it did ease symptoms.

The finding refutes the theory that systemic inflammation may negatively affect circulating serum 25-hydroxyvitamin D (25[OH]D) levels, wrote Dr. Paul Welsh and his colleagues.

Moreover, the data confirm a high prevalence of vitamin D insufficiency and frank deficiency among RA patients, they added.

According to Dr. Welsh of the British Heart Foundation Glasgow Cardiovascular Research Center at the University of Glasgow and his associates, there are several reasons why treatment with a potent anti-inflammatory medication, such as the tumor necrosis factor–alpha blocker adalimumab, might be hypothesized to increase vitamin D levels.

Data from a 2006 study showed an inverse relationship between serum vitamin D and DAS-28 scores (Clin. Exp. Rheumatol. 2006;24:702–4). “Furthermore, data for an apparent beneficial effect of statins on circulating 25[OH]D concentrations have been speculated to be attributable to statin 'pleiotropic' anti-inflammatory effects,” the researchers said. They also noted that serum vitamin D levels are known to drop in the acute phase following surgery, when inflammation is likely to be elevated.

To test the hypothesis that lowering inflammation would result in an increase of vitamin D, the researchers looked at 170 consecutive patients with RA seen at an outpatient clinic in Amsterdam (Ann. Rheum. Dis. 2010 [doi:10.1136/ard.2010.137265]).

Patients were treated either with adalimumab alone, at a dose of 40 mg administered every 2 weeks, or with adalimumab plus other disease-modifying antirheumatic drugs (DMARDs).

At baseline, 66 patients (39%) were vitamin D deficient, with a serum concentration of less than 15 ng/mL. Sixty-three patients (39%) had vitamin D insufficiency, with levels between 15 and 25 ng/mL. The remaining patients had adequate vitamin D levels.

After 16 weeks of treatment with adalimumab, patients' mean disease activity score-28 (DAS-28) had dropped significantly, from 5.1 to 3.2 (P less than .001). However, median circulating levels of vitamin D were not significantly altered, moving from 18.5 ng/mL at baseline to 19.0 ng/mL at the study's completion (P = .67). Nor did the prevalence of patients with vitamin D deficiency and insufficiency change after treatment, wrote the authors.

“Whether longer-term biological therapy has any beneficial effect on circulating 25[OH]D concentrations requires further study, although any such effect may be attributable to increased sunlight exposure rather than decreasing inflammation,” concluded the authors.

“Our observations also weaken the possibility that TNF-alpha blockers, which improve bone mineral density and potentially lower cardiovascular risk, do so via changes in 25[OH]D levels.”

They added: “Further research is needed to address determinants of poor 25[OH]D status in RA.”

Major Finding: Treatment with adalimumab lowered the disease activity score among a group of rheumatoid arthritis patients, but did not affect serum vitamin D levels.

Data Source: A prospective study of 170 consecutive patients with rheumatoid arthritis seen at an outpatient facility in Amsterdam.

Disclosures: The authors stated that they had no competing interests. The study was supported by the European League Against Rheumatism and the Jan van Breemen Institute, in Amsterdam.

Four months of treatment with the anti–tumor necrosis factor drug adalimumab did not affect serum vitamin D levels in rheumatoid arthritis patients, though it did ease symptoms.

The finding refutes the theory that systemic inflammation may negatively affect circulating serum 25-hydroxyvitamin D (25[OH]D) levels, wrote Dr. Paul Welsh and his colleagues.

Moreover, the data confirm a high prevalence of vitamin D insufficiency and frank deficiency among RA patients, they added.

According to Dr. Welsh of the British Heart Foundation Glasgow Cardiovascular Research Center at the University of Glasgow and his associates, there are several reasons why treatment with a potent anti-inflammatory medication, such as the tumor necrosis factor–alpha blocker adalimumab, might be hypothesized to increase vitamin D levels.

Data from a 2006 study showed an inverse relationship between serum vitamin D and DAS-28 scores (Clin. Exp. Rheumatol. 2006;24:702–4). “Furthermore, data for an apparent beneficial effect of statins on circulating 25[OH]D concentrations have been speculated to be attributable to statin 'pleiotropic' anti-inflammatory effects,” the researchers said. They also noted that serum vitamin D levels are known to drop in the acute phase following surgery, when inflammation is likely to be elevated.

To test the hypothesis that lowering inflammation would result in an increase of vitamin D, the researchers looked at 170 consecutive patients with RA seen at an outpatient clinic in Amsterdam (Ann. Rheum. Dis. 2010 [doi:10.1136/ard.2010.137265]).

Patients were treated either with adalimumab alone, at a dose of 40 mg administered every 2 weeks, or with adalimumab plus other disease-modifying antirheumatic drugs (DMARDs).

At baseline, 66 patients (39%) were vitamin D deficient, with a serum concentration of less than 15 ng/mL. Sixty-three patients (39%) had vitamin D insufficiency, with levels between 15 and 25 ng/mL. The remaining patients had adequate vitamin D levels.

After 16 weeks of treatment with adalimumab, patients' mean disease activity score-28 (DAS-28) had dropped significantly, from 5.1 to 3.2 (P less than .001). However, median circulating levels of vitamin D were not significantly altered, moving from 18.5 ng/mL at baseline to 19.0 ng/mL at the study's completion (P = .67). Nor did the prevalence of patients with vitamin D deficiency and insufficiency change after treatment, wrote the authors.

“Whether longer-term biological therapy has any beneficial effect on circulating 25[OH]D concentrations requires further study, although any such effect may be attributable to increased sunlight exposure rather than decreasing inflammation,” concluded the authors.

“Our observations also weaken the possibility that TNF-alpha blockers, which improve bone mineral density and potentially lower cardiovascular risk, do so via changes in 25[OH]D levels.”

They added: “Further research is needed to address determinants of poor 25[OH]D status in RA.”

SANTA MONICA, CALIF. — Gastroenterologists seem to be taking a page from the rheumatologists' playbook and are starting patients with inflammatory bowel disease on a biologic agent much sooner after diagnosis than has been standard practice.

By doing so, they hope to improve the natural history of the disease, just as rheumatologists have done in rheumatoid arthritis patients, according to Dr. Russell D. Cohen, who spoke at the meeting sponsored by Skin Disease Education Foundation (SDEF) and the University of Louisville.

Arthritis and inflammatory bowel disease (IBD) have more in common than the drugs used to treat them. Arthritis is the most common extraintestinal manifestation of IBD. Onset of joint symptoms may precede the onset of IBD, develop in parallel to it, or be unrelated, he said.

Arthritis is most likely to occur in IBD patients who have other extraintestinal manifestations such as dermatologic, ocular, or renal symptoms. The most commonly involved central joints are in the spine, where the arthritis takes the form of ankylosing spondylitis or sacroiliitis. Peripheral joints can develop arthropathies in IBD as well. About 5%-20% of IBD patients get arthritis.

The incidence of IBD in rheumatoid arthritis is not well defined. One of the few studies to address this question involved a review of the data sets from two large insurance companies involving 17 million people. The researchers found the odds ratio of having both IBD and RA was 2.1–2.7, and of having IBD and ankylosing spondylitis, about 5.8–7.8 (Inflamm. Bowel Dis. 2008;14:738–43).

The advent of biologics has changed the natural history of ulcerative colitis (UC). But before these agents became available, data from a Danish study showed that during the first year after diagnosis, 10% of UC patients lost their colon, about 23% had lost their colon after 10 years, and 31% had lost their colon 18 years out (Gut 1985;26:158–63).

In the prebiologic era, the natural history of Crohn's disease also was grim. Crohn's followed an inflammatory path for the first 5 years, then became penetrating with fistula formation between years 5 and 10 in a subset of patients; stricturing could develop after year 10 (Inflamm. Bowel Dis. 2002;8:244–50). “Virtually all Crohn's disease patients relapsed and most required one or more surgeries,” said Dr. Cohen, who is codirector of the inflammatory bowel disease center at the University of Chicago. An estimated 10% of Crohn's patients had their colons removed surgically within 1 year of their diagnosis with IBD.

Even today, most ulcerative colitis patients are treated with steroids, and many of these patients become steroid dependent. Findings from a study of 63 UC patients placed on steroids showed that at the end of 1 month, 34 achieved complete remission, 19 had a partial remission, and 10 had no response. Follow-up data at 1 year showed that 31 had a prolonged response, 14 were steroid dependent, and 18 needed surgery (Gastroenterology 2001;121:255–60). There is a move away from making steroids the first drug in the treatment regimen and instead starting with a biologic and adding a steroid only if necessary.

There is some overlap between the biologics used to treat rheumatologic diseases and those used to treat IBD. Recent data show that infliximab in combination with azathioprine induced a steroid-free clinical remission in 44 of 64 patients. In the same study, infliximab plus placebo induced remission in 37 of 65 patients, and azathioprine plus placebo induced remission in 21 of 75 patients. All of the patients had active IBD with a C-reactive protein level of 0.8 mg/dL or higher (N. Engl. J. Med. 2010;362:1383–95).

SDEF and this news organization are owned by Elsevier. Dr. Cohen disclosed financial relationships with Abbott Labs, Axcan Pharma, Elan, Centocor, Procter & Gamble, Prometheus Laboratories, Salix, Shire, UCB, and Warner Chilcott.

SANTA MONICA, CALIF. — Gastroenterologists seem to be taking a page from the rheumatologists' playbook and are starting patients with inflammatory bowel disease on a biologic agent much sooner after diagnosis than has been standard practice.

By doing so, they hope to improve the natural history of the disease, just as rheumatologists have done in rheumatoid arthritis patients, according to Dr. Russell D. Cohen, who spoke at the meeting sponsored by Skin Disease Education Foundation (SDEF) and the University of Louisville.

Arthritis and inflammatory bowel disease (IBD) have more in common than the drugs used to treat them. Arthritis is the most common extraintestinal manifestation of IBD. Onset of joint symptoms may precede the onset of IBD, develop in parallel to it, or be unrelated, he said.

Arthritis is most likely to occur in IBD patients who have other extraintestinal manifestations such as dermatologic, ocular, or renal symptoms. The most commonly involved central joints are in the spine, where the arthritis takes the form of ankylosing spondylitis or sacroiliitis. Peripheral joints can develop arthropathies in IBD as well. About 5%-20% of IBD patients get arthritis.

The incidence of IBD in rheumatoid arthritis is not well defined. One of the few studies to address this question involved a review of the data sets from two large insurance companies involving 17 million people. The researchers found the odds ratio of having both IBD and RA was 2.1–2.7, and of having IBD and ankylosing spondylitis, about 5.8–7.8 (Inflamm. Bowel Dis. 2008;14:738–43).

The advent of biologics has changed the natural history of ulcerative colitis (UC). But before these agents became available, data from a Danish study showed that during the first year after diagnosis, 10% of UC patients lost their colon, about 23% had lost their colon after 10 years, and 31% had lost their colon 18 years out (Gut 1985;26:158–63).

In the prebiologic era, the natural history of Crohn's disease also was grim. Crohn's followed an inflammatory path for the first 5 years, then became penetrating with fistula formation between years 5 and 10 in a subset of patients; stricturing could develop after year 10 (Inflamm. Bowel Dis. 2002;8:244–50). “Virtually all Crohn's disease patients relapsed and most required one or more surgeries,” said Dr. Cohen, who is codirector of the inflammatory bowel disease center at the University of Chicago. An estimated 10% of Crohn's patients had their colons removed surgically within 1 year of their diagnosis with IBD.

Even today, most ulcerative colitis patients are treated with steroids, and many of these patients become steroid dependent. Findings from a study of 63 UC patients placed on steroids showed that at the end of 1 month, 34 achieved complete remission, 19 had a partial remission, and 10 had no response. Follow-up data at 1 year showed that 31 had a prolonged response, 14 were steroid dependent, and 18 needed surgery (Gastroenterology 2001;121:255–60). There is a move away from making steroids the first drug in the treatment regimen and instead starting with a biologic and adding a steroid only if necessary.

There is some overlap between the biologics used to treat rheumatologic diseases and those used to treat IBD. Recent data show that infliximab in combination with azathioprine induced a steroid-free clinical remission in 44 of 64 patients. In the same study, infliximab plus placebo induced remission in 37 of 65 patients, and azathioprine plus placebo induced remission in 21 of 75 patients. All of the patients had active IBD with a C-reactive protein level of 0.8 mg/dL or higher (N. Engl. J. Med. 2010;362:1383–95).

SDEF and this news organization are owned by Elsevier. Dr. Cohen disclosed financial relationships with Abbott Labs, Axcan Pharma, Elan, Centocor, Procter & Gamble, Prometheus Laboratories, Salix, Shire, UCB, and Warner Chilcott.

SANTA MONICA, CALIF. — Gastroenterologists seem to be taking a page from the rheumatologists' playbook and are starting patients with inflammatory bowel disease on a biologic agent much sooner after diagnosis than has been standard practice.

By doing so, they hope to improve the natural history of the disease, just as rheumatologists have done in rheumatoid arthritis patients, according to Dr. Russell D. Cohen, who spoke at the meeting sponsored by Skin Disease Education Foundation (SDEF) and the University of Louisville.

Arthritis and inflammatory bowel disease (IBD) have more in common than the drugs used to treat them. Arthritis is the most common extraintestinal manifestation of IBD. Onset of joint symptoms may precede the onset of IBD, develop in parallel to it, or be unrelated, he said.

Arthritis is most likely to occur in IBD patients who have other extraintestinal manifestations such as dermatologic, ocular, or renal symptoms. The most commonly involved central joints are in the spine, where the arthritis takes the form of ankylosing spondylitis or sacroiliitis. Peripheral joints can develop arthropathies in IBD as well. About 5%-20% of IBD patients get arthritis.

The incidence of IBD in rheumatoid arthritis is not well defined. One of the few studies to address this question involved a review of the data sets from two large insurance companies involving 17 million people. The researchers found the odds ratio of having both IBD and RA was 2.1–2.7, and of having IBD and ankylosing spondylitis, about 5.8–7.8 (Inflamm. Bowel Dis. 2008;14:738–43).

The advent of biologics has changed the natural history of ulcerative colitis (UC). But before these agents became available, data from a Danish study showed that during the first year after diagnosis, 10% of UC patients lost their colon, about 23% had lost their colon after 10 years, and 31% had lost their colon 18 years out (Gut 1985;26:158–63).

In the prebiologic era, the natural history of Crohn's disease also was grim. Crohn's followed an inflammatory path for the first 5 years, then became penetrating with fistula formation between years 5 and 10 in a subset of patients; stricturing could develop after year 10 (Inflamm. Bowel Dis. 2002;8:244–50). “Virtually all Crohn's disease patients relapsed and most required one or more surgeries,” said Dr. Cohen, who is codirector of the inflammatory bowel disease center at the University of Chicago. An estimated 10% of Crohn's patients had their colons removed surgically within 1 year of their diagnosis with IBD.

Even today, most ulcerative colitis patients are treated with steroids, and many of these patients become steroid dependent. Findings from a study of 63 UC patients placed on steroids showed that at the end of 1 month, 34 achieved complete remission, 19 had a partial remission, and 10 had no response. Follow-up data at 1 year showed that 31 had a prolonged response, 14 were steroid dependent, and 18 needed surgery (Gastroenterology 2001;121:255–60). There is a move away from making steroids the first drug in the treatment regimen and instead starting with a biologic and adding a steroid only if necessary.

There is some overlap between the biologics used to treat rheumatologic diseases and those used to treat IBD. Recent data show that infliximab in combination with azathioprine induced a steroid-free clinical remission in 44 of 64 patients. In the same study, infliximab plus placebo induced remission in 37 of 65 patients, and azathioprine plus placebo induced remission in 21 of 75 patients. All of the patients had active IBD with a C-reactive protein level of 0.8 mg/dL or higher (N. Engl. J. Med. 2010;362:1383–95).

SDEF and this news organization are owned by Elsevier. Dr. Cohen disclosed financial relationships with Abbott Labs, Axcan Pharma, Elan, Centocor, Procter & Gamble, Prometheus Laboratories, Salix, Shire, UCB, and Warner Chilcott.

Rheumatoid arthritis patients who fail on a first-time trial of tumor necrosis factor inhibitor therapy should change to a biologic with a different mechanism of action, explains Dr. Daniel E. Furst.

View Video Now.

Rheumatoid arthritis patients who fail on a first-time trial of tumor necrosis factor inhibitor therapy should change to a biologic with a different mechanism of action, explains Dr. Daniel E. Furst.

View Video Now.

Rheumatoid arthritis patients who fail on a first-time trial of tumor necrosis factor inhibitor therapy should change to a biologic with a different mechanism of action, explains Dr. Daniel E. Furst.

View Video Now.