Frank McKenna

COX-2 specific inhibitors in the management of osteoarthritis of the knee: a placebo-controlled, randomized, double-blind study.

COX-2 specific inhibitors have demonstrated significant safety advantages and comparable efficacy in osteoarthritis (OA) compared with conventional nonsteroidal anti-inflammatory drugs (NSAIDs), but no direct comparative trials between COX-2 specific inhibitors have been published. In this double-blind, placebo-controlled, parallel group, multicenter study, 182 patients (≥40 years old) with OA of the knee were randomly assigned to treatment with celecoxib 200 mg q.d. (n = 63), rofecoxib 25 mg q.d. (n = 59), or placebo (n = 60) for 6 weeks. Arthritis assessments were performed at baseline and Weeks 3 and 6, or at early termination. At Week 6, celecoxib and rofecoxib treatment resulted in similar mean changes from baseline (p > 0.55) in arthritis pain visual analogue scale, patients global assessment, and total score for WOMAC; all changes were superior to placebo (p < 0.05). In the patients global assessment of arthritis pain at Week 6, 79% of celecoxib-treated and 78% of rofecoxib-treated patients improved by ≥1 grade, compared with 50% of placebo patients (celecoxib, p = 0.025; rofecoxib, p = 0.020). Adverse event incidences were similar among the active comparators; however, celecoxib-treated patients had significantly fewer adverse gastrointestinal symptoms compared with rofecoxib-treated patients, which suggests that celecoxib may have a better gastrointestinal tolerability profile than rofecoxib at these doses. Adverse events that prompted withdrawal occurred in fewer than 7% of patients, and the overall incidences were similar between the active agents. Once-daily doses of celecoxib 200 mg and rofecoxib 25 mg offer comparable efficacy and are an effective alternative to conventional NSAIDs in the management of OA.

The problem in differentiation between psoriatic-related polyenthesitis and fibromyalgia

The recognition of the primacy of enthesitis in animal models of spondyloarthritis and the prevalence of clinically occult enthesopathy in psoriatic subjects and of persistent joint pain in PsA subjects who have ostensibly good reduction of joint swelling under biological therapy has highlighted the potential impact of polyenthesitis in psoriatic disease. In daily practice, the formal demonstration of enthesitis is challenging for the following reasons: the relatively avascular nature of enthesis, often leading to the absence of overt clinical inflammatory signs; the frequent lack of elevation of inflammatory markers; and finally, the limitations of current imaging techniques to provide supportive evidence for inflammation in these areas. Consequently, enthesitis may present as widespread pain indistinguishable from FM or may emerge as the dominant feature after successful biological therapy for suppression of synovitis. The unmet needs in the differentiation between FM and enthesitis in psoriatic disease patients are highlighted and critically evaluated in this article.

Comparison of sleep structure and psychometric profiles in patients with fibromyalgia, osteoarthritis and healthy controls

While research indicates that both the macro‐ and microstructure of sleep may be altered in fibromyalgia syndrome, few studies have controlled for symptom duration or included pain‐control participants (i.e. patients with chronic pain and sleep disturbance not associated with fibromyalgia syndrome). A frequently reported alteration found in the sleep microstructure of patients with fibromyalgia syndrome is the alpha‐delta sleep anomaly. Although alpha waves have been observed during N3 sleep in healthy individuals, it has been proposed that there is an increase in alpha wave activity during slow‐wave sleep in fibromyalgia syndrome. Originally considered a possible neurological contribution to fibromyalgia syndrome, whether the alpha‐delta sleep anomaly is fundamental to the development of fibromyalgia syndrome, or results mainly from the pain experience remains unknown. The present study was designed to compare sleep macro‐ and microstructure, and psychometric profiles, in three broadly age‐matched groups of female participants: patients with fibromyalgia syndrome (n = 19); patients with osteoarthritis with sleep disturbance (n = 17); and healthy adults (n = 10). Patients with fibromyalgia syndrome met the American College of Rheumatology diagnostic criteria and were recruited within 6 months of diagnosis. Subjective sleep quality was significantly lowest, and levels of anxiety and depressive symptoms were significantly highest for patients with fibromyalgia syndrome. However, the groups showed no significant differences in polysomnographic measures of total sleep time, sleep latency and total wake after sleep onset. Levels of alpha‐delta sleep were statistically similar in both clinical (fibromyalgia syndrome and osteoarthritis) groups, indicating that it is not a specific abnormality of fibromyalgia syndrome. Overall, subjective measurements of anxiety, depression, fatigue and sleep quality better discriminated between the three groups than did objective measurements of sleep variables.

Diagnosis and management of rheumatoid arthritis in adults: summary of updated NICE guidance

### What you need to knownnRheumatoid arthritis is a chronic, disabling autoimmune disease characterised by synovitis of small and large joints causing swelling, stiffness, pain, and progressive joint destruction. About 1% of the UK population have rheumatoid arthritis, and approximately 15% of these people have severe disease. It affects roughly three times as many women as men. People tend to develop rheumatoid arthritis between 40 and 60 years of age, although it can arise at any age. The early signs of rheumatoid arthritis are often encountered in primary care, where people present with joint pain and swelling. Fast and accurate referral to rheumatology services is important to achieve early remission and prevent or reduce disability.1nnThis article summarises the update of the National Institute for Health and Care Excellence (NICE) guideline for the diagnosis and management of rheumatoid arthritis in adults.2 The management of rheumatoid arthritis has evolved in the nine years since the previous NICE guideline on rheumatoid arthritis was published, with greater emphasis on a treat-to-target strategy rather than specific drug regimens,3 and debate about the merit of initiating treatment with combination drug therapy.4 Technologies such as ultrasound have been increasingly used for diagnosis and monitoring of synovitis where it is unclear from clinical examination.5 These aspects of management were investigated by the Guideline Committee, and …

THU0548 Sleep Architecture and Clinical Parameters in fibromyalgia and Osteoarthritis

Background Non restorative sleep (NRS) is a characteristic symptom of fibromyalgia (FM). A number of studies have reported abnormalities of sleep architecture on polysomnography (PSG) including alpha wave intrusion (AWI) during delta wave sleep (DWS). However, AWI in DWS has also been reported in other conditions including depression or in chronic fatigue. We have compared FM patients with patients who had sleep disturbance from osteoarthritis (OA) and a group of normal healthy control subjects (NHC) to determine if there are specific abnormalities of sleep architecture in FM related to clinical parameters. Methods We studied 19 newly diagnosed FM patients (mean age 41yrs, range 19–58yrs), 17 with OA (mean age 46yrs, range 19–63yrs) with localized pain and sleep disturbance, and ten NHC (mean age 38yrs, range 23–61yrs). All participants were female. The diagnosis was confirmed by a consultant rheumatologist. None were being treated for anxiety or depression or had taken antidepressant, psychoactive or sedative drugs for at least 2 weeks prior to analysis. All completed pain score (VAS), Brief Pain Inventory (BPI), Fatigue Severity Scale (FSS), Epworth Sleepiness Scale (EPS), Pittsburgh Sleep Quality Index (PSQI), Centre for Epidemiologic Studies Depression Scale (CESD), State and Trait Anxiety Scale (STAS), Multidimensional Scales of Health Locus of Control and Perceived Social Support (HLC), and 2 weeks actigraphy and 2 consecutive nights of polysomnography (PSG) at home, scored by a trained sleep researcher. Each frequency band was decomposed and power averaged using spectral analysis. Results Sleep efficiency was significantly worse in FM and OA (p=0.025). Sleep stage transitions (SST) were significantly increased in FM and OA (p=0.019) with a marked increase in SST per hour (p=0.002) compared with NHC with no significant difference between FM and OA. Alpha waves were increased during stage 3 sleep (DWS) in both FM and OA compared with NHC but also with no difference between FM and OA. There was a numerical increase in spindle frequency during non REM sleep compared with NHC, more in FM than OA but with wide variation (1.12 ± 0.8; 0.98 ± 0.39; 0.61 ± 0.27 mpl). Pain scores in FM and OA groups were significantly different to NHC; mean difference in BPI of 6.07 and 4.83 respectively (p<.001). FM had significantly greater fatigue and EPS than OA (M diff14.41, p<.001; 3.42, p=.033) and NHC (M diff=29.87, p<.001; 3.99, p=0.34). PSQI was significantly greater than HC in both FM and OA (10.19 and 7.18, p<.001). The difference between FM and OA was significant (p=.023). There were highly significant differences between the 3 groups for CESD (FM 23.11; OA16.06; NHC4.8, p<0.001), STAS (49.6; 39.8; 31.9, p<0.001), HLC (p<0.001), and neuroticism (15.7; 13.5; 9.3 p<0.01). Conclusions Patients with FM had a similar duration of sleep to this group of OA patients but had a significant difference in subjective sleep quality, with significantly increased fatigue and sleepiness. They also had more anxiety, depression and neuroticism. AWI in DWS in FM is not specific and is similar in disturbed sleep from OA, but increased spindle frequency may be a feature of FM. We hypothesise that psychological factors in FM are linked to both sleep quality and fatigue and NRS may result from an increased rate of SST with frequent fluctuation between light and deep sleep. Disclosure of Interest None declared

AB0864 Fatigue in Fibromyalgia Syndrome and Patients with Osteoarthritis

Background Compared to other clinical groups with chronic pain, people with fibromyalgia syndrome (FMS) report higher levels of fatigue. It is not known whether this is driven by pain, psychological mechanisms or sleep disturbance. This study compared fatigue outcomes in patients with FMS and osteoarthritis (OA). The patients were part of a larger clinical assessment of psychosocial and polysomnographic variables. Objectives To determine the factors causing fatigue in FMS Methods 20 recently diagnosed FMS patients (all females; M=40.45, SD=11.21 range 19-58yrs) and 15 patients with OA (all females; M=44.60, SD=11.01 range 19-60yrs) exhibiting localized joint pain and sleep disturbance and were recruited from a single rheumatology unit at Trafford General Hospital, UK. All patients with FM fulfilled the 2010 ACR criteria for the diagnosis, confirmed by an experienced rheumatologist. All patients with OA had radiographic abnormality requiring surgical intervention. All participants completed self-reported sleep scores (Pittsburgh Sleep Quality Index), pain (VAS), fatigue (Fatigue Severity Scale), depression and anxiety measures (Hospital Anxiety and Depression score). All patients had 2 weeks actigraphic assessment of sleep. Multiple regression analysis was conducted with fatigue as the dependent variable and sleep, pain, depression and anxiety measures as predictors. Correlation with fatigue was evaluated compared with actigraphic parameters. Results The mean fatigue score in FMS was 51±8.40 and 38.27±10.92 in OA. The regression model was significant overall, F(21,10)=4.63, p=0.002, r2=0.54. After controlling for sleep quality, pain severity, pain interference, depression and anxiety, group membership was the only significant predictor of fatigue, B=-7.55, t=-2.40, p=0.026. Fatigue in FMS was correlated with duration of waking after sleep onset and number of awakenings on actigraphy (p=0.034). Conclusions This data shows that differences in fatigue noted in these two clinical groups are not solely driven by psychological factors. Other factors related to sleep structure may play a larger role in driving these differences. The number and duration of awakenings during sleep contribute to fatigue in FMS but not in OA. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6010