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Cardiovascular risk in rheumatoid arthritis.

The objectives of this review are to discuss data on the cardiovascular risk increase associated with rheumatoid arthritis (RA), the effects of RA treatments on the cardiovascular risk level, and the management of cardiovascular risk factors in patients with RA. Overall, the risk of cardiovascular disease is increased 2-fold in RA patients compared to the general population, due to the combined effects of RA and conventional risk factors. There is some evidence that the cardiovascular risk increase associated with nonsteroidal anti-inflammatory drug therapy may be smaller in RA patients than in the general population. Glucocorticoid therapy increases the cardiovascular risk in proportion to both the current dose and the cumulative dose. Methotrexate and TNFα antagonists diminish cardiovascular morbidity and mortality rates. The management of dyslipidemia remains suboptimal. Risk equations may perform poorly in RA patients even when corrected using the multiplication factors suggested by the EUropean League Against Rheumatism (EULAR) (multiply the score by 1.5 when two of the following three criteria are met: disease duration longer than 10 years, presence of rheumatoid factor or anti-cyclic citrullinated peptide (CCP) antibodies, and extraarticular manifestations). Doppler ultrasonography of the carotid arteries in patients at moderate cardiovascular risk may allow a more aggressive approach to dyslipidemia management via reclassification into the high-risk category of patients with an intima-media thickness greater than 0.9 mm or atheroma plaque.

The SAPHO syndrome: a single-center study of 41 adult patients.

Objective. The SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) is a rare disease and only a few series have been published about it. We describe the experience of a rheumatology department with a focus on the therapeutic aspects. Methods. All cases of SAPHO fulfilling the Benhamou criteria and seen between 1992 and 2013 in our unit were retrospectively included. Results. Forty-one patients (11 men and 30 women) were included. The average age was 45 years (20–80 yrs) at the time of diagnosis. Nineteen patients had palmoplantar pustulosis, 3 had psoriasis vulgaris, 3 had severe acne, and 15 had no dermatological involvement. Bone symptoms involved mainly the anterior chest wall (n = 28, 68%), followed by the spine (n = 16, 39%) and sacroiliac joints (n = 12, 29%). Four patients had peripheral osteitis and 2 had mandibular osteitis. Ten patients had peripheral arthritis affecting mainly the knees and wrists. None of the 36 patients tested was HLA-B27–positive. At least a partial response was achieved with colchicine, methotrexate, or sulfasalazine in 0/6, 2/4, and 1/6 of patients, respectively. Antibiotic therapy (azithromycin, n = 7; doxycycline, n = 2) was effective in 2/9 patients. Pamidronate was prescribed in 26 patients with bone involvement and 18/22 patients evaluable at 6 months responded to this therapy. Two patients were treated with tumor necrosis factor blockers: 1 with infliximab and 1 with adalimumab, followed by etanercept. Conclusion. Based on our experience, SAPHO can be diagnosed in the elderly. It was not associated with HLA-B27. Soft tissue involvement was common and the bisphosphonates were generally effective on bone involvement.

Vascular effects of nonsteroidal antiinflammatory drugs

The effect of nonsteroidal antiinflammatory drugs (NSAIDs) on the risk of cardiovascular events remains controversial. Among NSAIDs, only low-dose aspirin exerts protective vascular effects. Low-dose aspirin has been proven effective for secondary prevention. For primary prevention, the usefulness of low-dose aspirin is debated, as illustrated by the differences in recommendations across countries. NSAIDs other than aspirin, whether COX-2 selective or nonselective, increase the risk of cardiovascular events. Among them, naproxen is associated with the smallest risk increase. In patients with a history of coronary artery disease, diclofenac seems to carry the greatest risk, but all NSAIDs should be avoided. Uncertainties persist about aspirin interactions with other NSAIDs and with proton pump inhibitors. An adverse effect of acetaminophen on the risk of cardiovascular disease cannot be completely ruled out.

Overview of biologic treatments in the elderly

As life expectancies rise, the number of elderly people with inflammatory rheumatic diseases will continue to grow. Treatment of this frail population, whose clinical features differ from those of younger subjects, poses new challenges to healthcare systems. However, this issue is rarely addressed in the current literature. Thanks to their targeted mechanism of action, biologics represent one of the major therapeutic advances of the last 15 years, but their use in the elderly has been slow in developing. Published data, derived mainly from cohorts, focus on the use of TNF inhibitors in rheumatoid arthritis and show that these treatments are effective and generally well tolerated. Nevertheless, the risk of infection and cancer, particularly skin and lymphoid malignancies, must not be neglected. The use of these biologics as second-line treatment improves patient outcomes and comfort, while reducing consumption of the widely used and more deleterious drugs such as glucocorticoids and non-steroidal anti-inflammatory drugs. Additional studies on biologics, focusing on the longer term and in indications apart from anti-TNF therapies in rheumatoid arthritis should help overcome some of the reluctance and promote the rational use of these drugs in the elderly.

Three-decade trends in the distribution of organisms causing septic arthritis in native joints: Single-center study of 374 cases

OBJECTIVE A rise in the incidence of septic arthritis due to methicillin-resistant Staphylococcus aureus (MRSA) has been reported in several parts of the world. Here, our objective was to look for changes over the last 30years in the distribution and antibiotic susceptibility profiles of organisms responsible for septic arthritis. METHODS We conducted a single-center retrospective study of all cases of septic arthritis documented by joint specimens and/or blood cultures between 1979 and 2008. Prosthetic joint infections were excluded. RESULTS We enrolled 374 patients, of whom 127, 136, and 111 were included during each decade, respectively. We detected no significant time trends in the proportions of staphylococci (67%, 65%, and 64%), streptococci (14%, 21%, and 17%), or Gram-negative rods (7%, 10%, and 14%). Tuberculosis was more common during the earliest decade (1979-1988, n=10, 4, 2%; P<0.05). No significant changes occurred in the proportions of methicillin-resistant staphylococci or MRSA (13%, 11%, 15%). Age and prevalence of risk factors for infection increased over time. CONCLUSION The distribution and susceptibility of organisms causing septic arthritis has changed little over time. Our findings do not support the use of broader-spectrum antibiotics when empirical treatment is deemed necessary at our center.

Application of the European Society of Cardiology, Adult Treatment Panel III and American College of Cardiology/American Heart Association guidelines for cardiovascular risk management in a French cohort of rheumatoid arthritis

BACKGROUND Patients with rheumatoid arthritis (RA) have greater rates of cardiovascular mortality and RA is an independent cardiovascular risk factor. For the management of cholesterol, the American College of Cardiology/American Heart Association (ACC/AHA) developed new guidelines for the general population. None of the European or American guidelines are specific to RA. The European League Against Rheumatism (EULAR) recommends applying a coefficient to cardiovascular risk equations based on the characteristics of RA. Our objective was to compare the three different sets of guidelines for the eligibility of statin therapy in RA-specific population with very high risk of cardiovascular disease. METHODS AND RESULTS We calculated the proportion of patients eligible for statins according to the guidelines of the European Society of Cardiology (ESC), the Adult Treatment Panel III (ATP-III) and the ACC/AHA in a French cohort of statin-naïve RA patients at least 40 years age. Of the 547 women and 130 men analyzed, statins would be recommended for 9.1% of the women and 26.4% of the men, 15.6% of the women and 53.1% of the men, 38.8% of the women and 78.5% of the men, according to the ESC, ATP-III and ACC/AHA guidelines respectively. CONCLUSIONS In RA patients, as has been observed in the general population, discordance in risk assessment and cholesterol treatment was observed between the three sets of guidelines. The use of the new ACC/AHA guidelines would expand the eligibility for statins and may be applied to RA population a condition at very high risk of cardiovascular disease.

Frequency of concomitant fibromyalgia in rheumatic diseases: Monocentric study of 691 patients

OBJECTIVE Fibromyalgia (FM) is a confounding factor for diagnosing and assessing rheumatic disease activity. This study sought to assess the extent of this syndrome in rheumatism patients at a French rheumatology department. METHOD This monocentric epidemiological study enrolled all patients consulting due to rheumatoid arthritis (RA), spondyloarthritis (SpA), or connective tissue disease (CTD). FM diagnosis was confirmed or excluded according to the rheumatologist opinion and the 1990 American College of Rheumatology (ACR) criteria. RESULTS We enrolled 691 patients, including 451 women (65.3%), with a mean age of 55.8 years (18-93). Of the enrolled patients, 325 presented with RA, 298 SpA [59 psoriatic arthritis (PsA), 137 ankylosing spondylitis (AS), 64 non-radiographic SpA (nr-SpA), and 38 peripheral SpA], and 71 CTD. The rheumatologist established FM diagnosis in 97 patients (14%), while 55 (8%) fulfilled the 1990 ACR criteria. The frequency of FM was lower in RA patients (4.9% by 1990 ACR criteria; 7.7% by expert opinion) compared to SpA (11.1% by 1990 ACR, p < 0.05; 17.5% by expert opinion, p < 0.003) and CTD (11.3% by 1990 ACR, non-significant; 28.2% by expert opinion, p < 0.001). In the SpA subgroups, FM was more common in the nr-SpA than in PsA or AS (23.9%, 9.6%, and 6.4%, by 1990 ACR, p = 0.001; 37.3%, 13.5%, and 7.2%, by expert opinion, p < 0.001). CONCLUSION FM-like symptoms are commonly associated with rheumatic diseases. The frequency of FM is particularly high in non-radiographic axial SpA, thus raising questions about the specificity of the Assessment of SpondyloArthritis International Society (ASAS) classification criteria.

Assessment of the risk factors for impending fractures following radiotherapy for long bone metastases using CT scan-based virtual simulation: a retrospective study.

BackgroundRadiotherapy for long bone metastases (RTLB) can be complicated by fractures, which considerably increase morbidity and mortality. The aim of this study was to analyze the risk factors for impending fractures following radiotherapy for long bone metastases (RTLB) using CT scan-based virtual simulation.MethodsForty-seven (47) patients were treated with RTLB (18 lung, 11 breast, 10 prostate and 8 other cancers) for a period of 18 months. Two doctors analyzed the CT images prior to radiation therapy. The impending fractures were then monitored and the correlation between bone scan parameters and fracture occurrence was analyzed.ResultsThe male gender ratio was 0.57 and the mean age 62.8 (33–93) years. The average size of the metastatic lesions was 32 (8–87) x 2 (6–81) x 52 (7–408) mm with cortical involvement (CI) in 66% of cases. The site was in the upper third of the bone in 92% of cases (28 femoral, 17 humeral and two tibial).Ten fractures occurred: two during RTLB, seven after one month and one after 6.6 months. The fractured lesions measured 48 (17–87) x 34 (12–66) x 76 (38–408) mm. The predictive parameters for fracture were osteolytic (39% vs. 10%; p = 0.02) and permeative lesions (42% vs. 0%; p < 0.0005), a Mirels score ≥9 (42% vs. 0%; p < 0.0005), circumferential CI ≥30% (71% vs. 0%, p < 0.00001), CI ≥45 mm in height (67% vs. 0%, p < 0.00001) and CI in thickness =100% (40% vs. 0%; p = 0.0008). In the multivariate analysis, circumferential CI ≥30% was the only predictive parameter for fracture (p = 0.00035; OR = 62; CI 95%: 6.5-595). Overall survival was 91% and 40% at one month and twelve months respectively.ConclusionsProphylactic primary fixation surgery should always be considered when the circumferential CI ≥30%.

Should non-steroidal anti-inflammatory drugs be used continuously in ankylosing spondylitis?

OBJECTIVE The 2010 update of ASAS/EULAR recommendations for managing ankylosing spondylitis (AS) specify that continuous non-steroidal anti-inflammatory drug (NSAID) treatment should be preferred in patients with persistently active, symptomatic disease. Here, our objective was to assess whether continuous NSAID therapy improves disease control and influences radiographic progression compared to on-demand therapy. We also assessed the safety profiles of both regimens. METHODS We performed a review by searching the PubMed and Embase databases using two MeSH term combinations to compare continuous and on-demand NSAID therapy in terms of disease control, radiographic progression, and safety. RESULTS The only study evaluating the impact of continuous NSAID therapy on disease control showed no significant difference with on-demand therapy. In four studies, continuous treatment was associated with slower radiographic progression, as assessed in three studies using the modified Stoke Ankylosing Spondylitis Spinal Score (m-SASSS). Three studies compared the safety of continuous and on-demand celecoxib, two in osteoarthritis and one in AS, and found no significant differences regarding the usual side effects of Cox-2 inhibitors. CONCLUSIONS Several studies showed slower radiographic progression with continuous NSAID therapy in AS. No studies demonstrated superiority of continuous NSAID therapy regarding symptom control. Continuous NSAID therapy (at least with Cox-2 inhibitors) does not modify safety compared to on-demand therapy.

Prevalence of Renal Impairment in Patients With Rheumatoid Arthritis: Results From a Cross-Sectional Multicenter Study.

To assess the prevalence and associations of renal dysfunction in patients with rheumatoid arthritis (RA).