Vincent Richer

The effects of tumour necrosis factor inhibitors, methotrexate, non-steroidal anti-inflammatory drugs and corticosteroids on cardiovascular events in rheumatoid arthritis, psoriasis and psoriatic arthritis: a systematic review and meta-analysis

The objective of this systematic literature review was to determine the association between cardiovascular events (CVEs) and antirheumatic drugs in rheumatoid arthritis (RA) and psoriatic arthritis (PsA)/psoriasis (Pso). Systematic searches were performed of MEDLINE, EMBASE and Cochrane databases (1960 to December 2012) and proceedings from major relevant congresses (2010-2012) for controlled studies and randomised trials reporting confirmed CVEs in patients with RA or PsA/Pso treated with antirheumatic drugs. Random-effects meta-analyses were performed on extracted data. Out of 2630 references screened, 34 studies were included: 28 in RA and 6 in PsA/Pso. In RA, a reduced risk of all CVEs was reported with tumour necrosis factor inhibitors (relative risk (RR), 0.70; 95% CI 0.54 to 0.90; p=0.005) and methotrexate (RR, 0.72; 95% CI 0.57 to 0.91; p=0.007). Non-steroidal anti-inflammatory drugs (NSAIDs) increased the risk of all CVEs (RR, 1.18; 95% CI 1.01 to 1.38; p=0.04), which may have been specifically related to the effects of rofecoxib. Corticosteroids increased the risk of all CVEs (RR, 1.47; 95% CI 1.34 to 1.60; p<0.001). In PsA/Pso, systemic therapy decreased the risk of all CVEs (RR, 0.75; 95% CI 0.63 to 0.91; p=0.003). In RA, tumour necrosis factor inhibitors and methotrexate are associated with a decreased risk of all CVEs while corticosteroids and NSAIDs are associated with an increased risk. Targeting inflammation with tumour necrosis factor inhibitors or methotrexate may have positive cardiovascular effects in RA. In PsA/Pso, limited evidence suggests that systemic therapies are associated with a decrease in all CVE risk.

Evidence-based Recommendations for the Management of Comorbidities in Rheumatoid Arthritis, Psoriasis, and Psoriatic Arthritis: Expert Opinion of the Canadian Dermatology-Rheumatology Comorbidity Initiative

Objective. Comorbidities such as cardiovascular diseases (CVD), cancer, osteoporosis, and depression are often underrecognized in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or psoriasis (PsO). Recommendations may improve identification and treatment of comorbidities. The Canadian Dermatology-Rheumatology Comorbidity Initiative reviewed the literature to develop practical evidence-based recommendations for management of comorbidities in patients with RA, PsA, and PsO. Methods. Eight main topics regarding comorbidities in RA, PsA, and PsO were developed. MEDLINE, EMBASE, and the Cochrane Library (1960–12/2012), together with abstracts from major rheumatology and dermatology congresses (2010–2012), were searched for relevant publications. Selected articles were analyzed and metaanalyses performed whenever possible. A meeting including rheumatologists, dermatologists, trainees/fellows, and invited experts was held to develop consensus-based recommendations using a Delphi process with prespecified cutoff agreement. Level of agreement was measured using a 10-point Likert scale (1 = no agreement, 10 = full agreement) and the potential effect of recommendations on daily clinical practice was considered. Grade of recommendation (ranging from A to D) was determined according to the Oxford Centre for Evidence-Based Medicine evidence levels. Results. A total of 17,575 articles were identified, of which 407 were reviewed. Recommendations were synthesized into 19 final recommendations ranging mainly from grade C to D, and relating to a large spectrum of comorbidities observed in clinical practice: CVD, obesity, osteoporosis, depression, infections, and cancer. Level of agreement ranged from 80.9% to 95.8%. Conclusion. These practical evidence-based recommendations can guide management of comorbidities in patients with RA, PsA, and PsO and optimize outcomes.

Effect of biologics on depressive symptoms in patients with psoriasis: a systematic review.

Twenty to fifty percent of patients with psoriasis have depressive symptoms.

Meta-analysis of tumor necrosis factor inhibitors and glucocorticoids on bone density in rheumatoid arthritis and ankylosing spondylitis trials.

To examine the impact of antirheumatic drugs on bone mineral density (BMD) in rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), and psoriasis using a systematic review.

Psoriasis and Smoking A Systematic Literature Review and Meta-Analysis With Qualitative Analysis of Effect of Smoking on Psoriasis Severity

Background: Smoking has been associated with psoriasis prevalence and severity. Objective: To evaluate prevalence of smoking in patients with psoriasis and to examine the relationship between smoking and psoriasis severity. Methods: MEDLINE, EMBASE, and Cochrane databases (1960-2012) and conference proceedings (2010-2012) were systematically searched using keywords relevant to psoriasis and smoking. Controlled studies addressing psoriasis and smoking status were included. A meta-analysis for the relative risk of smoking in psoriasis patients was performed. Results: Meta-analysis identified a significant association between smoking and psoriasis with a relative risk of 1.88 (95% CI, 1.66-2.13) for smoking in patients with psoriasis versus patients without psoriasis. Eight articles of 11 with data on smoking and psoriasis severity suggested that severity increases with smoking status. Conclusions: This literature review is in favor of a positive association between the prevalence of smoking and psoriasis as well as an association between smoking and severity of psoriasis.

Treatment of nail psoriasis with intralesional triamcinolone acetonide using a needle-free jet injector: a prospective trial.

Background: Treating nail psoriasis is challenging. Corticosteroid matrix injection with needle is a conventional treatment but pain is often a limitation. Objective: Evaluate efficacy and safety of triamcinolone acetonide needle-free injection with the Med-Jet MBX in psoriatic fingernail. Methods: Seventeen patients were enrolled between January 2012 and January 2013. Four treatments sessions were scheduled every 4 ± 1 weeks. Clinical efficacy was evaluated according to Nail Psoriasis Severity Index (NAPSI) score of target nail differences before and after the treatment. Results: Mean baseline NAPSI score was 6.5 on an 8-point scale (95% confidence interval [CI] 5.652–7.348) and mean final NAPSI score was 2.8 on an 8-point scale (95% CI 1.859–3.741), demonstrating statistically significant treatment efficacy (p=.0007). NAPSI score for target nail from baseline to end of treatment was decreased by 46.25%. Conclusion: Treatment with triamcinolone acetonide delivered by Med-Jet MBX is a safe, minimally painful and effective treatment for nail psoriasis.

Response to: ‘Drugs and cardiovascular risk in inflammatory arthritis: another case of glucocorticoid-bashing?’ by Dr Boers

We thank Dr Boers for the interesting comments1 on our paper2. First, the decision to exclude studies reporting less than 400 patients was made after noticing that most of these studies had less than 1u2005year of follow-up or had large drop-outs with few remaining patients at or beyond 1u2005year. We also reviewed the abstract by Tarp et al .3 Among a total of 4831 subjects, 1944 were specifically analysed for …

Acute blistering diseases on the burn ward: Beyond Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

OBJECTIVEnStevens-Johnson Syndrome and Toxic Epidermal Necrolysis are on a spectrum of rare reactions primarily attributable to drugs. Timely diagnosis, cessation of the offending drug and burn center care are associated with favorable outcomes. Acute blistering disease has a wide differential diagnosis, including autoimmune bullous disease and other drug reactions. The aim of our study was to identify the final diagnosis in patients transferred for widespread blistering disease and to identify clinical features at admission predicting final diagnosis.nnnMETHODSnWe performed a 5-year retrospective chart review (2006-2011) of the clinical features at admission of patients transferred to a burn ward with widespread blistering disease. Clinical features at admission were compared between patients.nnnRESULTSn12 patients had a final diagnosis of Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis and 7 patients had an alternative final diagnosis. Skin detachment surface area at admission was superior in the Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis group. Presence of tense bullae and pustules was associated with an alternative final diagnosis.nnnCONCLUSIONnExtensive skin detachment surface and morphological features (tense bullae, pustules) were statistically significant clinical clues to final diagnosis. Patients transferred for widespread blistering disease should be thoroughly evaluated in order to exclude other causes of acute blistering disease.

Treatment of Palmar Hyperhidrosis With Needle Injection Versus Low-Pressure Needle-Free Jet Injection of OnabotulinumtoxinA: An Open-Label Prospective Study.

BACKGROUND OnabotulinumtoxinA (OnabotA) injections are effective to treat palmar hyperhidrosis (HH) but are quite painful. OBJECTIVE To evaluate efficacy and pain of OnabotA injection using a needle-free jet apparatus compared with the traditional needle injection to treat palmar HH. METHODS Twenty patients were recruited for a prospective open-label study. Their right hand was injected with 1% lidocaine with a jet injector, after which OnabotA was injected with a needle. The left hand was injected with OnabotA directly using the jet injector. Pain scores were recorded for both techniques. At 0, 1, 3, and 6 months, severity of palmar HH was evaluated with the Hyperhidrosis Disease Severity Scale (HDSS). RESULTS One point reduction in the HDSS score at 1 month showed no statistical difference between both hands (p = .451). However, the HDSS score at 1 month from baseline dropped by 1.6 for the hand treated with traditional needle injection of OnabotA compared with 1.25 for the hand treated with jet injections (p = .031). There was no statistical difference in the pain on injection with both techniques (p = .1925). CONCLUSION This study demonstrates effective and relatively painless use of a low-pressure jet injector for OnabotA in palmar HH.

Dr. Roubille, et al reply

To the Editor: nnWe thank Castaneda, et al 1 for their comments on our article2. We do support comorbidity management in rheumatoid arthritis (RA), psoriatic arthritis (PsA), and psoriasis (PsO) in daily practice to ensure optimal care and outcomes, and completely agree with the recently published Spanish recommendations3. Given that patients with RA have increased risk of cardiovascular (CV) morbidity and mortality4, CV monitoring appears critical. In the CARMA (CARdiovascular in rheuMAtology) study, Castaneda, et al 5 reported that patients with RA, PsA, and PsO had higher prevalence of CV events while receiving biological therapy despite being in low disease activity for almost half of the patients. Notably, almost half of the patients also received nonsteroidal antiinflammatory drugs and/or glucocorticoids (patients with RA), which may have increased CV risk6. Regardless of the other confounding factors, these data reinforce the importance of CV monitoring and … nnAddress correspondence to Dr. C. Roubille, University of Montreal Hospital Research Center (CRCHUM), Notre-Dame Hospital, Montreal, Quebec H2L 1S6, Canada. E-mail: camille.roubille{at}gmail.com