Consensus statement on blocking the effects of interleukin-6 and in particular by interleukin-6 receptor inhibition in rheumatoid arthritis and other inflammatory conditions

BACKGROUND

Since approval of tocilizumab (TCZ) for treatment of rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA), interleukin 6 (IL-6) pathway inhibition was evaluated in trials of TCZ and other agents targeting the IL-6 receptor and ligand in various RA populations and other inflammatory diseases. This consensus document informs on interference with the IL-6 pathway based on evidence and expert opinion.

METHODS

Preparation of this document involved international experts in RA treatment and RA patients. A systematic literature search was performed that focused on TCZ and other IL6-pathway inhibitors in RA and other diseases. Subsequently, incorporating available published evidence and expert opinion, the steering committee and a broader expert committee (both including RA patients) formulated the current consensus statement.

RESULTS

The consensus statement covers use of TCZ as combination- or monotherapy in various RA populations and includes clinical, functional and structural aspects. The statement also addresses the second approved indication in Europe JIA and non-approved indications. Also early phase trials involving additional agents that target the IL-6 receptor or IL-6 were evaluated. Safety concerns, including haematological, hepatic and metabolic issues as well as infections, are addressed likewise.

CONCLUSIONS

The consensus statement identifies points to consider when using TCZ, regarding indications, contraindications, screening, dose, comedication, response evaluation and safety. The document is aimed at supporting clinicians and informing patients, administrators and payers on opportunities and limitations of IL-6 pathway inhibition.

Overview of epidemiology, pathophysiology, and diagnosis of rheumatoid arthritis

Rheumatoid arthritis (RA) is a common autoimmune systemic inflammatory disease affecting approximately 1% of the worldwide population. The interaction of genetic and environmental factors results in a cascade of immune reactions, which ultimately lead to the development of synovitis, joint damage, and structural bone damage. These, in turn, lead to pain, disability, and emotional, social, and economic challenges. A number of extraarticular manifestations and comorbidities are present in patients with RA, which result in increased mortality. The American College of Rheumatology and European League Against Rheumatism recently published updated disease classification criteria in an effort to identify RA earlier so that effective treatment can be employed to prevent irreversible changes.

Comparative effectiveness of current treatments for rheumatoid arthritis

An optimal treatment approach to rheumatoid arthritis (RA) is guided by the American College of Rheumatology (ACR) 2012 recommendations. RA should be diagnosed early in the disease process and treatment should be commensurate with the degree of disease activity and the presence or absence of predictors of poor prognosis. The Agency for Healthcare Research and Quality (AHRQ) has recently provided a comparative review of medication for RA. The treatment of RA with conventional disease-modifying antirheumatic drugs and biologic agents, including tumor necrosis factor (TNF) inhibitors and non-TNF biologics (abatacept, rituximab, tocilizumab) will be discussed in the context of the ACR recommendations and the AHRQ review.

Blocking the effects of interleukin-6 in rheumatoid arthritis and other inflammatory rheumatic diseases: systematic literature review and meta-analysis informing a consensus statement

Background

Suppression of the immunoinflammatory cascade by targeting interleukin 6 (IL-6) mediated effects constitutes a therapeutic option for chronic inflammatory diseases. Tocilizumab is the only IL-6 inhibitor (IL-6i) licensed for rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA), but also other agents targeting either IL-6 or its receptor are investigated in various indications.

Objective

To review published evidence on safety and efficacy of IL-6i in inflammatory diseases.

Methods

We performed systematic literature searches in Medline and Cochrane, screened EULAR and American College of Rheumatology meeting-abstracts, and accessed http://www.clinicaltrials.gov.

Results

Comprehensive evidence supports the efficacy of tocilizumab in RA in DMARD-naïve patients, and after DMARD- and TNFi-failure. Randomised comparisons demonstrate superiority of tocilizumab in JIA, but not ankylosing spondylitis (AS). Other indications are currently investigated. Additional IL-6i show similar efficacy; safety generally appears acceptable.

Conclusions

IL-6i is effective and safe in RA and JIA, but not in AS. Preliminary results in other indications need substantiation.

Need to develop new nonsteroidal anti-inflammatory drug formulations

BACKGROUND

In the management of pain, primary care physicians are often the first to diagnose and treat acute or chronic painful conditions. This places them in an important intersection to manage pain, in which safe and effective therapeutic options are paramount for their patients. For decades, NSAIDs have been routinely prescribed for relief of mild to moderate acute and chronic pain. Yet, safety and tolerability concerns associated with the use of this class of drugs continue to be an issue for patients and clinicians.

OBJECTIVE

The objective of this review was to discuss the unmet medical needs of patients in the management of pain and inflammation, review the dose-dependent safety data associated with use of NSAIDs, and discuss the need to develop new NSAID formulations to improve safety and tolerability while maintaining efficacy.

METHODS

We performed literature searches of the PubMed and Cochrane Library databases through December 2012 for articles in English that reported dose-dependent safety and tolerability data associated with use of NSAIDs.

RESULTS

The risk of serious, dose-dependent adverse events involving the gastrointestinal tract, cardiovascular system, and kidneys is associated with use of NSAIDs. On the basis of these findings, the US Food and Drug Administration has requested that the package insert for all NSAIDs be revised to include a boxed warning highlighting the potential increased risk of cardiovascular events and the risk of serious, and potentially life-threatening, gastrointestinal tract bleeding. While using lower dosages of a particular NSAID may be associated with lower rates of adverse events, maintaining the clinical efficacy of standard NSAID dosages remains a challenge.

CONCLUSIONS

There is a need to develop new and effective NSAID formulations to minimize the safety and tolerability concerns associated with currently available NSAIDs, yet maintain efficacy in management of inflammation and pain.

The pharmacokinetic parameters of a single dose of a novel nano-formulated, lower-dose oral diclofenac

INTRODUCTION

There is a clinical need for new nonsteroidal anti-inflammatory drugs (NSAIDs) and/or new formulations that, at minimum, retain the established efficacy of standard NSAIDs while minimizing their associated adverse events. This phase 1 clinical trial characterizes the pharmacokinetic (PK) profile of an investigational, proprietary, nano-formulated, lower-dose oral diclofenac (nano-formulated diclofenac) compared with oral diclofenac in healthy subjects.

METHODS

A single-center, single-dose, randomized, open-label, 5-period, 5-treatment, 10-sequence crossover study was completed in 30 healthy subjects. Subjects received either nano-formulated diclofenac 18 mg or 35 mg or diclofenac 50 mg in fed and fasting states. The maximum measured plasma concentration (Cmax), time to maximum measured concentration (Tmax), terminal elimination half-life (T1/2), and area under the concentration time curve (AUC), along with safety and tolerability, were assessed.

RESULTS

Mean (± standard deviation) Tmax for nano-formulated diclofenac 18 (0.62 ± 0.35 h) and 35 mg (0.59 ± 0.20 h) demonstrated faster absorption than diclofenac 50 mg (0.80 ± 0.50 h). The T1/2 was similar between nano-formulated diclofenac 35 mg and diclofenac 50 mg (1.85 ± 0.45 h vs 1.92 ± 0.38 h, respectively). The Cmax for nano-formulated diclofenac 35 mg and diclofenac 50 mg was comparable in fasted subjects (1347 ± 764 ng/mL vs 1316 ± 577 ng/mL, respectively), but lower in fed subjects (524 ± 222 ng/mL vs 951 ± 391 ng/mL, respectively). As anticipated, there was a 19% reduction in drug exposure (AUC0(-∞)) when subjects received nano-formulated diclofenac 35 mg compared with diclofenac 50 mg under fasting conditions (1225 ± 322 h*ng/mL vs 1511 ± 389 h*ng/mL, respectively). Safety and tolerability were comparable between nano-formulated diclofenac and diclofenac.

CONCLUSION

The novel nano-formulated, lower-dose diclofenac demonstrated lower systemic exposure, comparable Cmax, and faster absorption compared with diclofenac. In light of the advisory issued by worldwide regulatory agencies regarding use of lowest effective doses, these data may permit use of lower NSAID doses that improve safety and tolerability while, at minimum, relieving pain similar to standard formulations.

A comparative effectiveness study of adalimumab, etanercept and infliximab in biologically naive and switched rheumatoid arthritis patients: results from the US CORRONA registry

PURPOSE

To compare the effectiveness of anti-tumour necrosis factor (TNF) agents in biologically naive and 'switched' rheumatoid arthritis (RA) patients.

METHODS

RA patients enrolled in the CORRONA registry newly prescribed adalimumab (n=874), etanercept (n=640), or infliximab (n=728) were stratified based on previous anti-TNF use. Clinical effectiveness at 6, 12 and 24 months was examined using the modified American College of Rheumatology response criteria (mACR20/50/70) and achievement of remission (28-joint disease activity score (DAS28) and clinical disease activity index (CDAI)) in unadjusted and adjusted analyses. The persistence of anti-TNF treatment was examined using Cox proportional hazard models.

RESULTS

Among 2242 patients (1475 biologically naive, 767 switchers), mACR20, 50 and 70 responses were similar (p>0.05) for adalimumab, etanercept and infliximab at all time points, as were rates of CDAI and DAS28 remission (p>0.05). Response and remission outcomes were consistently inferior for switched versus biologically naive patients. The adjusted OR for achieving an mACR20 response was 0.54 (95% CI 0.38 to 0.76) in first-time switchers and 0.42 (95% CI 0.23 to 0.78) in second-time switchers versus biologically naive patients at 6 months. The adjusted OR for achieving DAS28 remission were 0.29 (95% CI 0.15 to 0.58) for first-time switchers and 0.26 (95% CI 0.08 to 0.84) for second-time switchers. Persistence was higher in biologically naive patients, for whom persistence was highest with infliximab.

CONCLUSIONS

No differences in rates of drug response or remission were observed among the three anti-TNF. Infliximab was associated with greater persistence in biologically naive patients. Response, remission and persistence outcomes were diminished for patients who switched anti-TNF.

Treating Rheumatoid Arthritis to Target: multinational recommendations assessment questionnaire

AIM

To measure the level of agreement and application of 10 international recommendations for treating rheumatoid arthritis (RA) to a target of remission/low disease activity.

METHODS

A 10-point Likert scale (1=fully disagree, 10=fully agree) measured the level of agreement with each of 10 recommendations. A 4-point Likert scale (never, not very often, very often, always) assessed the degree to which each recommendation was being applied in current daily practice. If respondents answered 'never' or 'not very often', they were asked whether they would change their practice according to the particular recommendation.

RESULTS

A total of 1901 physicians representing 34 countries participated. Both agreement with and application of recommendations was high. With regard to application of recommendations in daily practice, the majority of responses were 'always' and 'very often'. A significant percentage of participants who were currently not applying these recommendations in clinical practice were willing to change their practice according to the recommendations.

CONCLUSION

The results of this survey demonstrated great support of 'Treating RA to Target' recommendations among the international rheumatology community. Additional efforts may be needed to encourage application of the recommendations among certain clinicians who are resistant to changing their practice.

Persistence with anti-tumor necrosis factor therapies in patients with rheumatoid arthritis: observations from the RADIUS registry

OBJECTIVE

To evaluate persistence with anti-tumor necrosis factor (TNF) therapy and predictors of discontinuation in patients with rheumatoid arthritis (RA).

METHODS

This retrospective analysis used data from RADIUS 1, a 5-year observational registry of patients with RA, to determine time to first- and second-course discontinuation of etanercept, infliximab, and adalimumab. First-course therapy was defined as first exposure to anti-TNF therapy, and second-course therapy was defined as exposure to anti-TNF therapy after the first discontinuation. Kaplan-Meier survival analysis was used to assess persistence, log-rank tests were used to compare therapies, and Cox proportional hazards models were used to assess potential predictors of treatment discontinuation.

RESULTS

This analysis included 2418 patients. Mean persistence rates were similar among treatments [first-course: etanercept, 51%; infliximab, 48%; adalimumab, 48% (followup was 54 weeks for etanercept and infliximab and 42 weeks for adalimumab); second-course: 56%, 50%, 46%, respectively (followup was 36 weeks for etanercept and infliximab and 30 weeks for adalimumab)]. Discontinuations of first-course therapy due to ineffectiveness were similar among treatments (etanercept, 19%; infliximab, 19%; adalimumab, 20%) and discontinuations due to adverse events were significantly (p = 0.0006) lower for etanercept than for infliximab (etanercept, 14%; infliximab, 22%; adalimumab, 17%). Predictors from univariable analysis of first- or second-course therapy discontinuation included increased comorbidities (etanercept), female sex (infliximab), Clinical Disease Activity Index > 22 (infliximab), and a Stanford Health Assessment Questionnaire score > 0.5 (adalimumab).

CONCLUSION

In this population, first- and second-course persistence was similar among anti-TNF therapies. First-course discontinuation due to adverse events was lower with etanercept compared with infliximab.

Outcome measures in placebo-controlled trials of osteoarthritis: responsiveness to treatment effects in the REPORT database

INTRODUCTION

Treatment response in randomized clinical trials (RCT) of osteoarthritis (OA) has been assessed by multiple primary and secondary outcomes, including pain, function, patient and clinician global measures of status and response to treatment, and various composite and responder measures. Identifying outcome measures with greater responsiveness to treatment is important to increase the assay sensitivity of RCTs.

OBJECTIVE

To assess and compare the responsiveness of different outcome measures used in placebo-controlled RCTs of OA.

SEARCH STRATEGY

The Resource for Evaluating Procedures and Outcomes of Randomized Trials database includes placebo-controlled clinical trials of pharmacologic treatments (oral, topical, or transdermal) for OA identified from a systematic literature search of RCTs published or publicly available before August 5, 2009, which was conducted using PubMed, the Cochrane collaboration, publicly-available websites, and reference lists of retrieved publications.

DATA COLLECTION AND ANALYSIS

Data collected included: (1) pain assessed with single-item ratings and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale; (2) patient and clinician global measures of status, improvement, and treatment response; (3) function assessed by the WOMAC function subscale; (4) stiffness assessed by the WOMAC stiffness subscale; and (5) the WOMAC and Lequesne Algofunctional Index composite outcomes. Measures were grouped according to the total number of response categories (i.e., <10 categories or ≥10 categories). The treatment effect (difference in mean change from baseline between the placebo and active therapy arms) and standardized effect size (SES) were estimated for each measure in a meta-analysis using a random effects model.

RESULTS

There were 125 RCTs with data to compute the treatment effect for at least one measure; the majority evaluated non-steroidal anti-inflammatory drugs (NSAIDs), followed by opioids, glucosamine and/or chondroitin, and acetaminophen. In general, the patient-reported pain outcome measures had comparable responsiveness to treatment as shown by the estimates of treatment effects and SES. Treatment effects and SESs were generally higher for patient-reported global measures compared with clinician-rated global measures but generally similar for the WOMAC and Lequesne composite measures.

CONCLUSIONS

Comparing different outcome measures using meta-analysis and selecting those that have the greatest ability to identify efficacious treatments may increase the efficiency of clinical trials of treatments for OA. Improvements in the quality of the reporting of clinical trial results are needed to facilitate meta-analyses to evaluate the responsiveness of outcome measures and to also address other issues related to assay sensitivity.

Rheumatoid arthritis disease-modifying antirheumatic drug intervention and utilization study: safety and etanercept utilization analyses from the RADIUS 1 and RADIUS 2 registries

OBJECTIVE

to report the rates of serious adverse events (SAE), serious infectious events (SIE), and events of medical interest (EMI) in patients receiving etanercept; to identify the risk factors for SAE, SIE, and EMI; and to report time to switching from etanercept therapy, reasons for switching, and time to restarting treatment with etanercept in patients with rheumatoid arthritis (RA) in US clinical practice.

METHODS

adults ≥ 18 years of age who fulfilled the 1987 American Rheumatism Association criteria for RA were eligible for enrollment in 2 prospective, 5-year, multicenter, observational registries. RADIUS 1 (Rheumatoid Arthritis DMARD Intervention and Utilization Study) enrolled patients with RA who required a change in treatment [either an addition or a switch of a biologic or nonbiologic disease-modifying antirheumatic drug (DMARD)]. In RADIUS 2, patients with RA were required to start etanercept therapy at entry. Patients were seen at a frequency determined by their rheumatologist. RADIUS 1 and RADIUS 2 were registered under the US National Institutes of Health ClinicalTrials.gov identifiers NCT00116714 and NCT00116727, respectively.

RESULTS

in these patients, SAE, SIE, and EMI occurred at rates comparable to those seen in clinical trials. No unexpected safety signals were observed. Rates for SAE, SIE, and EMI in etanercept-treated patients were comparable to rates observed in patients receiving methotrexate monotherapy and did not increase with greater exposure to etanercept therapy.

CONCLUSION

the RADIUS registries provide a better understanding of the safety of etanercept in patients with RA in the US practice setting.

Efficacy and tolerability of valdecoxib in treating the signs and symptoms of severe rheumatoid arthritis: A 12-week, multicenter, randomized, double-blind, placebo-controlled study

OBJECTIVE

This study compared the efficacy and tolerability of the cyclooxygenase-2-selective inhibitor valdecoxib with the nonselective NSAID naproxen and with placebo in treating severe rheumatoid arthritis (RA).

METHODS

This 12-week, multicenter, randomized, double-blind, placebo-controlled study compared the efficacy and tolerability of valdecoxib 10 mg QD (n = 170) or naproxen 500 mg BID (n = 167) with placebo (n = 171) in treating the signs and symptoms of severe RA. Study patients were aged >or=18 years and were diagnosed as having RA for >or=6 months that was stable due to a treatment regimen. Severe RA was defined as a physician's and patient's global assessment of disease activity of fair, poor, or very poor at baseline; >or=6 tender or painful joints; >or=3 swollen joints; >or=45 minutes of morning stiffness; a visual analog scale pain rating of >or=40 mm; or increases since baseline in these measures. Efficacy outcome measures included the percentage of patients achieving an American College of Rheumatology Responder Index 20% (ACR-20) at weeks 1, 6 and 12. Adverse events (AEs) were graded by the investigator as mild, moderate, or severe at weeks 1, 6, and 12.

RESULTS

Of the 508 patients randomized, 340 completed the study. The study groups were comparable for age, ethnic origin, weight, height, and concomitant medications, but the naproxen group had significantly more men (29% [49/167]) than the valdecoxib (18% [31/170]) and placebo (16% [27/171]) groups. The percentage of patients achieving an ACR-20 response was significantly greater in the valdecoxib and naproxen treatment groups (58.8% [100/170] and 60.8% [101/166], respectively) than in the placebo group (39.6% [67/169]) at week 12 (both, P < 0.001). The percentage of patients achieving an ACR-20 response was significantly greater in the naproxen group than in the placebo group at both week 1 (53.6% [89/166] vs 37.9% [64/169]; P = 0.003) and week 6 (64.5% [107/166] vs 46.7% [79/169]; P = 0.001), and in the valdecoxib group compared with placebo at week 1 (52.9% [90/170]; P = 0.008) but not at week 6. Patients in the valdecoxib and naproxen groups had significantly improved efficacy compared with placebo in most of the other secondary assessments of inflammation, pain, and function. The incidence of AEs was similar in all groups (valdecoxib, 54.1% [92/170]; naproxen, 55.4% [92/166]; and placebo, 52.9% [90/170]).

CONCLUSION

Valdecoxib 10 mg QD administered over 12 weeks was significantly better than placebo and similar to naproxen 500 mg BID in treating the signs and symptoms of severe RA in these patients.

Combination therapy for rheumatoid arthritis in the era of biologicals

Early, aggressive disease management is critical for halting disease progression and joint destruction in patients with rheumatoid arthritis. Combination therapy with at least two disease-modifying antirheumatic drugs, such as methotrexate (MTX), sulfasalazine, or hydroxychloroquine, is often more effective than monotherapy in reducing disease activity. Biologic therapies represent more effective and tolerable treatment options that, when combined with MTX, have been shown to dramatically reduce inflammation, inhibit radiographic progression, and induce remission. Although several types of treatment strategies are used in clinical practice, the most aggressive approaches that target early disease have shown the most promise in reversing disease progression and reducing disease-related costs.

Real-world utilization of DMARDs and biologics in rheumatoid arthritis: the RADIUS (Rheumatoid Arthritis Disease-Modifying Anti-Rheumatic Drug Intervention and Utilization Study) study

OBJECTIVE

Rheumatoid Arthritis (RA) Disease-Modifying Anti-Rheumatic Drug (DMARD) Intervention and Utilization Study (RADIUS) is a unique, real-world, prospective, 5-year, observational study of over 10 000 patients with RA. RADIUS provides a snapshot of use patterns, effectiveness, and safety of DMARDs, biologics, and combination therapies used to manage RA in clinical practice.

RESEARCH DESIGN AND METHODS

Patients with RA requiring a new DMARD or biologic (addition or switch) were eligible for the RADIUS study. Two separate patient cohorts were enrolled; RADIUS 1 patients initiated any new therapy at entry, and RADIUS 2 patients initiated etanercept at entry. Patient demographics and disease activity measures were collected at study entry, and baseline characteristics were summarized for various subgroups. Effectiveness, safety, and patterns of use will be tracked for therapies utilized during the 5-year study.

RESULTS

RADIUS 1 enrolled 4959 patients, and RADIUS 2 enrolled 5102 patients, mostly at community private practices (88%). In RADIUS 1, most patients initiated methotrexate (MTX) monotherapy, followed by MTX in combination with a biologic (e.g. infliximab plus MTX) or other DMARD. In RADIUS 2, most patients initiated etanercept in combination with MTX, followed by etanercept monotherapy. When a new therapy was required, physicians tended to add another therapy versus switching therapies. Patients initiating a biologic had a longer duration of RA and more severe disease compared with patients initiating non-biologic therapy.

CONCLUSIONS

These real-world data provide evidence of the prescribing practices of rheumatologists in 2001-2003. Future analyses will allow evidence-based comparisons of the long-term safety and effectiveness of DMARDs, biologics, and combination therapies to assist physicians in clinical decision-making.

Real-world effectiveness of select biologic and DMARD monotherapy and combination therapy in the treatment of rheumatoid arthritis: results from the RADIUS observational registry

OBJECTIVE

To evaluate the effectiveness of select biologics, methotrexate (MTX), and other disease-modifying anti-rheumatic drugs (DMARDs) in the management of adult rheumatoid arthritis (RA) in routine clinical practice.

RESEARCH DESIGN AND METHODS

RADIUS (Rheumatoid Arthritis DMARD Intervention and Utilization Study) comprises two prospective, 5-year, observational registries of over 10 000 patients. Over 4600 patients who initiated MTX or a biologic regimen (etanercept [ETN], infliximab [INF], ETN + MTX, and INF + MTX) and who had at least one on-regimen, follow-up evaluation, were included in this analysis. Adalimumab was not included because it had not yet received FDA approval at RADIUS initiation. Other common DMARD regimens (N = 762) were also compared with MTX. Patients who initiated less commonly used regimens, such as anakinra or cyclosporine, and those who did not have at least one on-regimen, follow-up evaluation, were not eligible for this analysis. Because ESR/CRP measurements were often not available, a modified ACR20 response (mACR20), defined as three out of four response criteria excluding ESR/CRP, was used to assess response at 12 months. Logistic regression analysis was performed to control for baseline covariates that may affect outcomes.

MAIN OUTCOME MEASURES

The primary endpoint was the proportion of patients who achieved a mACR20 response at 12 months post-RADIUS entry.

RESULTS

After adjusting for baseline covariates, patients receiving either ETN + MTX or ETN monotherapy were more likely to achieve a mACR20 response at 12 months than patients receiving MTX alone (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.09-1.52; p < 0.01 and OR 1.23, 95% CI 1.02-1.47; p < 0.05, respectively). Conversely, patients treated with MTX + leflunomide (LEF) were less likely to achieve a mACR20 response than those receiving MTX alone (OR 0.68, 95% CI 0.48-0.96; p < 0.05). Significant differences were not observed between patients receiving MTX alone and either INF + MTX, MTX + hydroxychloroquine, MTX + hydroxychloroquine + sulfasalazine, INF monotherapy, or LEF monotherapy.

CONCLUSION

These data from routine rheumatology clinical practice settings highlight the effectiveness of common biologic and DMARD therapies, and provide additional data beyond those of randomized, controlled trials.

An analysis of recent antitrust issues affecting specialty practice: is dermatology immune?

In the healthcare industry, the rules of regulation and competition often collide. Despite the view of Medicine as a "learned profession", it is clear that physicians will be subject to the same legal restrictions against sharing price information as those in place for any other industry. Thus, the relevant provisions of antitrust law will apply to most activities of physicians. Although recent case law has involved actions undertaken by physicians in other specialties of Medicine (e.g. oncology) the activities reviewed will likely be applicable to Dermatologists as well.

Patient Preference for Placebo, Acetaminophen (paracetamol) or Celecoxib Efficacy Studies (PACES): two randomised, double blind, placebo controlled, crossover clinical trials in patients with knee or hip osteoarthritis

BACKGROUND

Acetaminophen (paracetamol) is recommended as the initial pharmacological treatment for knee or hip osteoarthritis. However, survey and clinical trial data indicate greater efficacy for non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 specific inhibitors.

DESIGN

Two randomised, double blind, placebo controlled, crossover multicentre clinical trials, Patient Preference for Placebo, Acetaminophen or Celecoxib Efficacy Studies (PACES).

PATIENTS

Osteoarthritis of knee or hip.

INTERVENTION

"Wash out" of treatment; randomisation; 6 weeks of celecoxib 200 mg/day, acetaminophen 1000 mg four times a day, or placebo; second "wash out;" crossover to 6 weeks of second treatment.

MEASUREMENTS

Western Ontario McMaster Osteoarthritis Index (WOMAC), visual analogue pain scale, patient preference between two treatments.

RESULTS

Celecoxib was more efficacious than acetaminophen in both periods in both studies; WOMAC and pain scale scores differed at p<0.05 in period II and both periods combined of PACES-a and in periods I and II and both periods combined in PACES-b, but not in period I of PACES-a. Acetaminophen was more efficacious than placebo, generally p<0.05 in PACES-b, and >0.05 in PACES-a. Patient preferences were 53% celecoxib v 24% acetaminophen in PACES-a (p<0.001) and 50% v 32% in PACES-b (p = 0.009); 37% acetaminophen v 28% placebo in PACES-a (p = 0.340) and 48% v 24% in PACES-b (p = 0.007). No clinically or statistically significant differences were seen in adverse events or tolerability among the three treatment groups.

CONCLUSIONS

Greater efficacy was seen for celecoxib v acetaminophen v placebo, while adverse events and tolerability were similar. Variation in results and statistical significance in the two different trials are of interest.

Comparing the efficacy of cyclooxygenase 2-specific inhibitors in treating osteoarthritis: appropriate trial design considerations and results of a randomized, placebo-controlled trial

OBJECTIVE

To compare the efficacy of the cyclooxygenase 2 (COX-2)-specific inhibitors celecoxib and rofecoxib in treating the signs and symptoms of osteoarthritis (OA).

METHODS

In this randomized, placebo-controlled, double-blind, multicenter study, 475 patients with OA of the knee received either celecoxib 200 mg/day (n = 189), rofecoxib 25 mg/day (n = 190), or placebo (n = 96) for 6 weeks. Arthritis assessments were performed at baseline, week 3, and week 6 (or at the time of early termination).

RESULTS

In primary measures of efficacy (OA pain score on a 100-mm visual analog scale [VAS] and total domain score on the Western Ontario and McMaster Universities Osteoarthritis Index), celecoxib 200 mg/day and rofecoxib 25 mg/day demonstrated similar efficacy. At week 6, celecoxib was associated with a 34-mm mean improvement on the VAS for OA pain, compared with 31.6 mm for rofecoxib and 21.2 mm for placebo. The difference between celecoxib and rofecoxib was -2.5 mm, with an upper limit of the 95% confidence interval of 2.7 mm and within the prespecified definition of noninferiority. Secondary measures of efficacy showed similar results. All differences in primary and secondary measures of efficacy between the 2 active treatments and placebo were statistically significant (P < 0.02), whereas all of the comparisons of efficacy between celecoxib and rofecoxib met the predefined criteria for noninferiority. All treatments were well tolerated throughout the study, with similar proportions of patients withdrawing due to adverse events.

CONCLUSION

Celecoxib 200 mg/day and rofecoxib 25 mg/day are equally efficacious in treating the signs and symptoms of OA.

Clinical profiles of celecoxib and rofecoxib in the rheumatic diseases

Celecoxib and rofecoxib are highly specific cyclooxygenase-2 inhibitors. Both agents are as effective as conventional, non-selective non-steroidal anti-inflammatory drugs (NSAIDs) but they have a markedly reduced propensity to cause injury to the gastroduodenal mucosa compared with conventional NSAIDs. Celecoxib and rofecoxib are approved for treatment of both osteoarthritis and rheumatoid arthritis. This presentation reviews the mechanism of action of these agents, the clinical studies showing their effectiveness for treatment of arthritis, and the gastrointestinal side effect profiles compared with conventional NSAIDs.

A diagnostic approach to musculoskeletal pain

Musculoskeletal pain or inflammation is one of the most common causes of primary care office visits. Musculoskeletal disorders exact a high toll in distress, disability, and direct health care costs. Given the wide range of disorders that may cause or contribute to musculoskeletal symptoms, differential diagnosis is challenging and a systematic approach is necessary. Patient history is the single most valuable source of diagnostic information, followed by a careful physical examination. The history also suggests which laboratory tests and imaging studies, if any, are indicated. The chronology, duration, and pattern of pain distribution offer clues to establishing an accurate diagnosis, along with evidence of other organ system involvement or underlying disease. Helpful distinctions are those between articular and nonarticular pain, between monarthritis and multiple joint involvement, and between inflammatory and noninflammatory conditions.

The arthritogenic properties of microbial antigens. Their implications in disease states

The sharing of antigenic determinants between host and microbe is a common event and new microbial-tissue cross-reactions are being recognized each year. Almost every human organ has been implicated as a possible target. The purpose of this article is to examine the arthritogenic properties of these microbial antigens and to explore the mechanisms by which they induce pathologic damage and disease.

Rheumatic fever. The relationships between host, microbe, and genetics

Acute rheumatic fever is a delayed, nonsuppurative sequela of a pharyngeal infection with the group A streptococcus. The onset of the disease is usually characterized by an acute febrile illness; however, there may be chronic involvement of the heart and/or central nervous system. The article explores the relationship between the initial infection and host-microbial interactions that may be operative in disease pathogenesis.

The co-occurrence of acute rheumatic fever and AIDS

We describe a patient with advanced acquired immunodeficiency syndrome (AIDS) who presented with evidence of carditis, arthritis, and chorea in the setting of fever, and serologic evidence for recent streptococcal infection. Several features atypical for rheumatic fever were present and included persistently high titer of antistreptolysin O, the simultaneous occurrence of chorea and arthritis, and the presence of chorea in a sexually mature adult man. The differential diagnosis of arthritis in a host at risk for human immunodeficiency virus should be expanded to include acute rheumatic fever, which may manifest atypical features.

Liability issues in the treatment of patients with rheumatic diseases

In clinical practice, risk management focuses primarily on concerns regarding adverse occurrences and the possibility of resulting civil litigation. Tort law, one of the major branches of civil law, is most relevant to clinical risk management. Duty, breach, causation, and damages are the four elements of the tort of professional liability, i.e., medical malpractice. Liability concerns in clinical practice commonly involve adverse drug reactions. Other potential liability concerns include informed consent, adverse outcomes, and economic considerations.

Legal issues in allergy and clinical immunology

Clinical risk management for the allergist focuses primarily on concerns regarding adverse occurrences and the possibility of civil litigation as a result of negligence or professional liability. Risk is substantially reduced with an understanding of such predictable drug reactions as overdosage, side effects, secondary effects, and drug interactions. In addition, all clinicians who prescribe have a duty to disclose to their patients the possibility of unpredictable reactions, including intolerance, idiosyncrasy, and allergy or hypersensitivity. This disclosure should be part of a comprehensive discussion of the risks and benefits of, and alternatives to, therapeutic agents and procedures they recommend. The process of informed consent becomes even more critical with the increasing influence of hospital and managed care formularies on prescribing decisions. Although cost effectiveness is an important factor in prescribing decisions, the possibility of adverse effects, treatment failure, noncompliance, and other negative considerations must also be weighed.

Rheumatic fever and poststreptococcal reactive arthritis

Rheumatic fever is a catastrophic illness in many parts of the world, particularly in developing nations, where the incidence has been estimated to be between 10 and 15 million new cases each year. In the United States, rheumatic fever had become a rarity, having virtually disappeared by the mid 1960s. Of increasing concern, however, was the abrupt rise in the incidence of rheumatic fever in the United States in the mid 1980s, with reported "outbreaks" in middle-class communities in five cities and two military camps. Recently, a number of cases of poststreptococcal reactive arthritis have been reported. On close examination, however, these are most likely alternate clinical presentations of rheumatic fever. It is widely accepted that rheumatic fever occurs following an overactive immune response by a genetically susceptible host to oropharyngeal infection with group A beta-hemolytic streptococci. Nevertheless, details of pathogenesis at a level allowing more effective intervention remain obscure. The question of pathogenesis holds a deep interest, because rheumatic fever is one of the few autoimmune diseases with a known infectious etiology.

Marriage, social support, and adjustment to rheumatic disease

The family is an important source of support for the patient with RA. At the same time, the illness creates stresses for family members that may affect their well-being or inhibit their ability to provide support to the patient. In designing support interventions, one cannot assume that difficulties in adjusting to chronic illness reflect a lack of support from the family or that the patient should be the sole target of intervention.

Risk management in endoscopic practice

As illustrated, the practice of gastrointestinal endoscopy is not without risks. All physicians who perform endoscopy should be mindful of the tenets of risk management and how they apply to their endoscopic practices. Retrospective review of individual endoscopic practice habits should be performed yearly and modifications made where necessary. Hospital quality assurance committees should have gastrointestinal endoscopist representation. These committees should have as a component of their responsibilities a commitment to physician education.