Captopril: a new treatment for rheumatoid arthritis?

Captopril, an inhibitor of angiotensin converting enzyme, is prescribed for hypertension. Its molecular structure shares features with D-penicillamine, in that both agents contain a thiol group. In addition, captopril has immunosuppressant activity. Captopril was therefore considered a potential slow-acting drug for treating rheumatoid arthritis. In an open study 15 patients with active arthritis were treated with captopril and followed for 48 weeks. Two-thirds of the patients reported improved arthritis symptoms, and significant changes were seen in several clinical and biochemical measurements, notably Ritchie articular index, clinical score, plasma viscosity, and C-reactive protein. Side-effects were generally mild and included transient taste loss, rashes, and hypotension. Only 2 patients withdrew as a result of drug intolerance.

Shoulder-hand syndrome and symmetrical arthralgia in patients with tubo-ovarian carcinoma

Two cases of bilateral shoulder-hand syndrome and symmetrical arthralgia are described in patients with tubo-ovarian carcinoma. Swelling and contracture of the hands continued to develop despite oral corticosteroid therapy, and one patient underwent surgery in an attempt to prevent the development of further deformity.

Forces in the knee joint whilst rising from a seated position

Knee joint forces were determined by kinesiological techniques, using a high speed cine camera, a force platform, a specially constructed dynamometerized chair, and EMG recorders; so that a comparison could be made for rising from a normal chair with and without the aid of arms, and for rising from high and low chairs. For rising from the seated position, the knee joint forces parallel to the long axis of the tibia at the point of contact between the tibia and femur were found to be up to seven times body weight at about the time when the body left contact with the chair. When rising from a chair with the aid of arms, the knee joint forces were reduced to less than three times body weight. Knee joint and muscle forces were also reduced when rising from a high seat compared with rising from a low seat.

Attempt to modify klebsiella carriage in ankylosing spondylitic patients by diet: correlation of klebsiella carriage with disease activity

Patients with ankylosing spondylitis were asked to follow a 'klebsiella exclusion diet' for 5 months of a 10-month study. The same percentage of faecal samples were positive for klebsiella whether the patients were on or off the experimental diet. The diet also failed to influence variability of klebsiella serotypes. We found no correlation between acquisition of klebsiella and deterioration of disease symptoms, as recorded by the patients. Furthermore, carriage of klebsiella did not correlate with any of the following parameters of disease activity measured in the outpatient clinic: morning stiffness, pain measured on a visual analogue scale, analgesic consumption, ESR, total serum IgA. We found no evidence, therefore, that faecal klebsiella is involved in disease exacerbations of ankylosing spondylitis.

Comparison of 12 different containers for dispensing anti-inflammatory drugs

Twelve containers manufactured by 10 pharmaceutical companies for dispensing anti-inflammatory drugs, 10 of which are currently in use in the United Kingdom, have been compared in 99 patients with arthritis of the hands. Patients were given the containers in random order and were asked to open them, extract the tablets, and close them. Patients were questioned on ease of handling at each stage and were then timed on reopening and closing each container. Finally, the patients were asked which container was the best and which was the worst. There was a wide variation in popularity of containers. One was judged outstanding on almost every attribute, and four were preferred over the others on most attributes. A successful container for arthritic hands is likely to have a sharply angulated or "wing" cap placed on a tall slim base that is also angulated. Flip off tops, tops with long threads requiring many turns, very small containers, and glass were regarded as unfavourable. Manufacturers should take note of these findings and, where necessary, consider redesigning the containers.

A single-blind comparative study of auranofin and hydroxychloroquine in patients with rheumatoid arthritis

Forty patients with rheumatoid arthritis were randomly allocated to treatment with auranofin 3 mg b.d. or hydroxychloroquine 200 mg b.d. Twenty patients received each drug. Efficacy was analysed by comparing patients with available data at weeks 12, 24, 36 and 48 with baseline within each treatment group, and between treatment groups at each of these same time points. There were statistically significant improvements in all measured parameters of clinical efficacy among hydroxychloroquine treated patients, and in all efficacy parameters except one (time to onset of fatigue) in the auranofin treatment group. There were no significant differences between the treatment groups for any parameter of clinical efficacy. Of the laboratory parameters measured, only auranofin treatment produced statistically significant decreases in the concentration of IgA, IgG and IgM, with significant differences between treatments being detected in the case of IgA and IgG. Eight auranofin-treated and three hydroxychloroquine-treated patients were withdrawn because of adverse reactions before completing 48 weeks treatment. The commonest reason for stopping auranofin treatment was diarrhoea (5 cases). Three hydroxychloroquine-treated and two auranofin-treated patients were withdrawn from the study because of inefficacy of the trial drug. Auranofin had a more 'potent' biochemical profile than hydroxychloroquine, although more patients tolerated one year of treatment with the latter drug.

Use of electromyography to study leg muscle activity in patients with arthritis and in normal subjects during rising from a chair

A previous study indicated the need for patients with arthritis to have an armchair from which it is easy to rise. To determine criteria for such a chair a greater understanding of the rising activity and the objective assessment of chair design is required. The major muscle groups of the leg were monitored by electromyography (EMG) in normal subjects and for patients with arthritis during rising from a chair. The effects on EMG patterns of changes of seat height, foot position, and the use of armrests were studied. This paper outlines the practical difficulties that must be borne in mind when designing an EMG study on arthritic and elderly subjects. The results did not illustrate any differences in the pattern of muscle activity between arthritic and normal subjects, nor did they show any differences caused by changing the variables of chair design.

An assessment of faecal blood loss from Ro 21-5521, a novel non-steroidal anti-inflammatory agent, in normal volunteers

Faecal blood loss arising from Ro 21-5521, a novel non-steroidal anti-inflammatory agent with a long plasma half-life of about 41 hours, was evaluated in a double-blind crossover study against matched placebo in 12 volunteers. After a 1-week run-in period to determine baseline values, subjects were allocated at random to receive either 250 mg Ro 21-5521 per day or placebo for 2 weeks before being crossed over to the alternative treatment for 2 weeks. They were then followed-up for a further 2 weeks. Blood loss was calculated from 51Chromium tagged red blood cells in stools collected for a 96-hour period during each week of the study. Plasma levels of Ro 21-5521 were also measured twice weekly throughout the study. The results showed that with a drug of this long half-life, faecal blood loss may continue for at least 4 weeks after cessation of trial therapy of 2 weeks. It is recommended that in the evaluation of faecal blood loss resulting from drugs with a long half-life, a parallel group study, each group receiving only one drug (or one drug crossed against placebo), is the study design of choice.

C-reactive protein in the serial assessment of disease activity in rheumatoid arthritis

C-reactive protein (CRP) levels were measured in 105 patients with rheumatoid arthritis (RA) during treatment with slow-acting anti-rheumatoid drugs D-penicillamine, alclofenac, hydroxychloroquine, gold, sulphasalazine and azathioprine. A control group treated with aspirin alone was also included. Patients were assessed clinically (pain score, articular index and summated change score) and in terms of acute-phase reactants (CRP, haptoglobin, fibrinogen, ESR and plasma viscosity) at eight separate clinic visits during the 6-month treatment period. The estimation of CRP was found to be more useful than haptoglobin, fibrinogen or ESR as an index of disease activity.

Factors that may influence the prescribing habits of rheumatologists

Questionnaire replies were received from 86% of all members of the British Association for Rheumatology and Rehabilitation soliciting opinions regarding influences and attitudes to prescribing. The importance and quality of information sources for new drugs were assessed and the importance of various aspects of information considered to be necessary for inclusion in a data card were investigated. The results indicated the professional journals and independent sources such as the Prescribers Journal are highly thought of by Rheumatologists and that advertisements and 'popular' journals are less likely to be important in the transmission of awareness of a new drug. The most important aspects of information considered to be necessary for inclusion in a data card or information bulletin were adverse- or side-effects. Specific details of the drug formulation or presentation are considered to be of much less importance. Rheumatologists prefer to prescribe by generic name and are likely to use two or three drugs in the treatment of a patient.

Pathogenesis of seronegative arthritis

The concept of seronegative spondarthritis, linking several diseases around ankylosing spondylitis, has received considerable clinical and genetic support, especially through the discovery of a high frequency of HLA-B27 in these disorders. Exogenous factors would appear to be responsible for some manifestations of the disease, but the role of Klebsiella micro-organisms is equivocal, and dietary control does not affect clinical manifestations. Increased serum and salivary IgA antibodies in active ankylosing spondylitis patients tend to suggest that IgA may act as an acute-phase reactant.

A comparison of platelet count and acute phase proteins in the measurement of disease activity in rheumatoid arthritis

Platelet count (PC) was compared with standard acute phase reactants (ESR, plasma viscosity and C-reactive protein) and clinical measurements to assess its usefulness as a measure of disease activity in 165 patients with active rheumatoid arthritis. Although PC was elevated (greater than 400 X 10(9) 1(-1) in 45% of patients and was seen to fall under the influence of second-line drugs, it was considered to be unsuitable as an indication of disease activity since levels fall for reasons other than disease improvement.

Comparison between penicillamine and sulphasalazine in rheumatoid arthritis: Leeds-Birmingham trial

Sulphasalazine was first formulated by Svartz in the early 1940s, specifically for use as a remission inducing drug in rheumatoid arthritis. After the publication of an unfavourable trial, however, the drug was restricted to patients with ulcerative colitis. In the late 1970s sulphasalazine was re-examined in rheumatoid arthritis and favourable results reported in "open" trials. A double blind controlled trial was therefore conducted comparing enteric coated sulphasalazine and D-penicillamine in patients with active rheumatoid arthritis. A total of 63 patients were recruited in two centres; 31 were treated with sulphasalazine and 32 received penicillamine. After 16 weeks' treatment both drugs had produced significant improvements in clinical score, pain score measured on a visual analogue scale, grip strength, Ritchie articular index, erythrocyte sedimentation rate, and serum C reactive protein concentration. Nausea was the major side effect in the sulphasalazine treated group. No potentially dangerous effects of sulphasalazine were encountered in contrast with those seen in the penicillamine group. The results suggest that sulphasalazine is an effective and safe drug capable of producing remissions in active rheumatoid arthritis. They also lend confidence to the use of preliminary "open" trials as a means of screening for remission inducing drugs in rheumatoid arthritis.