No increased risk of malignancies and mortality in cyclosporin A-treated patients with rheumatoid arthritis

OBJECTIVE

To evaluate the cyclosporin A (CSA)-attributed risk of developing malignancies in general and malignant lymphoproliferative diseases (LPDs) and skin cancers in particular, as well as the CSA-attributed incidence of mortality in patients with rheumatoid arthritis (RA).

METHODS

In a retrospective, controlled cohort study, the incidence of malignancies and mortality was evaluated in 208 CSA-treated patients with RA compared with 415 matched control patients with RA between 1984 and 1995. Patients were followed up for a median of 5.0 years (range 1.4-12.0).

RESULTS

Forty-eight cases of malignancy (8 in the CSA group and 40 in the control group; relative risk [RR] 0.40, 95% confidence interval [95% CI] 0.19-0.84) were identified, of which 8 were malignant LPDs (2 CSA versus 6 control; RR 0.67, 95% CI 0.14-3.27) and 14 were skin cancers (2 CSA versus 12 control; RR 0.33, 95% CI 0.08-1.47). Seventy-three patients died (16 CSA versus 57 control; RR 0.56, 95% CI 0.33-0.95) due primarily to cardiovascular diseases (4 CSA versus 22 control; RR 0.36, 95% CI 0.13-1.04) or a malignancy (3 CSA versus 8 control; RR 0.67, 95% CI 0.18-2.43). Proportional hazards regression analysis with correction for potential confounding factors did not significantly change the results.

CONCLUSION

The study findings suggest that CSA treatment in RA patients does not increase the risk of malignancies in general or the risk of malignant LPDs or skin cancers in particular. Moreover, the incidence of mortality in CSA-treated RA patients was comparable to that in matched control RA patients.

Human parvovirus B19 infection is not followed by inflammatory joint disease during long term follow-up. A retrospective study of 54 patients

OBJECTIVE

To investigate whether recent human parvovirus B19 (B19) infection provokes inflammatory arthritis, we assessed the outcome of 54 patients with recent B19 infection who were referred to the Department of Rheumatology.

METHODS

Consecutive patients referred between 1985 and 1995 and found to have a recent B19 infection were studied retrospectively by sending a questionnaire and, if necessary, by physical examination.

RESULTS

In the acute phase of B19 infection, all patients had arthralgia and many also complained of myalgia and malaise. Arthritis was found in 61% of the patients, skin rash in 72% and fever in 64%. Except for the arthralgia and malaise, most of the symptoms resolved rapidly. After a mean followup of 5 years (SD 2.9 yrs.) none of the patients reported persistence of joint swelling or restricted motion.

CONCLUSION

None of the 54 patients with recent B19 infection developed chronic arthritis.

[Pharmacological prevention of osteoporosis in patients on corticosteroid medication]

Twenty-five per cent of the patients using corticosteroids for long periods of time develops at least one fracture. Corticosteroids lead to osteoporosis through increase of renal calcium excretion and decrease of intestinal calcium absorption, bone formation by osteoblasts and serum levels of sex hormones. In spite of guidelines according to which patients protractedly using corticosteroids should take sufficient calcium and cholecalciferol, only about one-tenth of them takes any form of medication to prevent osteoporosis. It seems advisable to prescribe additional anti-osteoporosis medication for patients using > or = 7.5 mg prednisone during at least 3 months and who have a low mineral density of bone; only of biphosphonates a preventive effect clearly has been demonstrated. For postmenopausal women, hormonal supplementation therapy may offer additional benefit, reducing the risk of cardiovascular disease.

Sleep apnoea caused by rheumatoid arthritis

Sleep apnoea syndrome (SAS) is a rarely documented, but possibly lethal, complication of the instability of the cervical spine in rheumatoid arthritis. Five patients with SAS of a central or peripheral origin are presented, and the problems of recognizing and diagnosing the syndrome are discussed. We hope that clinicians will become more aware of the existence and the different aetiologies of SAS, thus improving early recognition and appropriate treatment. Adequate treatment has proven to increase survival in peripheral SAS and seems to be successful in doing so in central SAS.

Combination therapy in recent onset rheumatoid arthritis: a randomized double blind trial of the addition of low dose cyclosporine to patients treated with low dose chloroquine

OBJECTIVE

To investigate whether there is interaction between chloroquine and cyclosporine (CyA) at the level of efficacy and toxicity in patients with recent onset rheumatoid arthritis (RA).

METHODS

Eighty-eight patients with recent onset RA, who had shown a suboptimal clinical response on low dose chloroquine monotherapy, were randomly assigned to additional treatment with placebo, CyA 1.25 mg/kg/day, or CyA 2.50 mg/kg/day (fixed doses) for another 24 weeks. The tender joint count was the primary outcome assessment of efficacy and the serum creatinine of toxicity. The 1995 preliminary ACR response criteria for improvement were applied to evaluate individual clinical responses.

RESULTS

Two patients in the placebo group (n = 29), 7 patients in the CyA 1.25 mg group (n = 29), and 8 patients in the CyA 2.50 mg group (n = 30) (p = 0.06) discontinued study medication prematurely for inefficacy or adverse events. The intention-to-treat analysis revealed that the tender joint count decreased 2.2 +/- 6.1 (mean +/- SD) joints in the placebo group, 2.2 +/- 6.6 joints in the CyA 1.25 mg group, and 5.0 +/- 5.8 joints in the CyA 2.50 mg group (p = 0.04). The 1995 preliminary ACR response criteria for clinical improvement were met by 8 (28%) patients in the placebo group, 10 (34%) patients in the CyA 1.25 mg group, and 15 (50%) patients in the CyA 2.50 mg group (p = 0.07). The serum creatinine increased 2 +/- 7 micromol/l in the placebo group, decreased 1 +/- 8 micromol/l in the CyA 1.25 mg group, and increased 10 +/- 15 micromol/l in the CyA 2.50 mg group (p < 0.001).

CONCLUSION

The addition of low dose CyA is moderately effective in patients with early RA already treated with low dose chloroquine, but results in statistically significant renal function loss.

Laboratory screening for side effects of disease modifying antirheumatic drugs in daily rheumatological practice

To observe the actual laboratory screening for side effects of disease modifying antirheumatic drugs (DMARDs) in daily rheumatological practice, a retrospective multi-center cohort study was performed on the laboratory tests in DMARD treated rheumatoid arthritis (RA) patients. RA patients were investigated by chart review if they started with a DMARD (cohort 1) or were treated with a DMARD for at least one year (cohort 2). Hematological, hepatic, and renal tests were collected. In cohort 1 and 2, 513 and 1209 patients were included, respectively. A fairly outlined screening profile was observed for each DMARD studied. Except for antimalarials, the testing frequency decreased with time in cohort 1. For all DMARDs the testing frequency in cohort 1 was higher than in cohort 2. In general, rheumatologists requested laboratory tests less frequently than is internationally recommended. This discrepancy raises questions about the relation between the efficacy and costs of laboratory screening for side effects of DMARDs in patients with RA.

Methotrexate reduces inflammatory cell numbers, expression of monokines and of adhesion molecules in synovial tissue of patients with rheumatoid arthritis

Methotrexate (MTX) is one of the most widely prescribed drugs in the treatment of rheumatoid arthritis (RA). The mechanism by which MTX exerts its anti-rheumatic effect has not yet been defined. The aim of the present study was to investigate the effect of MTX treatment (7.5-15 mg/week) on synovial tissue in RA. For this purpose, synovial biopsies were taken from 11 RA patients before and 16 weeks after initiation of MTX therapy. Immunohistochemistry was performed using monoclonal antibodies (MAb) specific for CD3, CD4, CD8, CD22, CD25, CD38, CD68, MAb67, Ki67, interferon gamma (IFN-gamma), interleukin (IL)-1alpha, IL-1beta, tumour necrosis factor alpha (TNF-alpha), E-selectin, ICAM-1 and VCAM-1. All parameters for disease activity improved during the period of treatment. Immunohistochemical analysis revealed a statistically significant decrease in scores for CD3, CD8, CD38, CD68, Ki67, IL-1beta, TNF-alpha and the adhesion molecules E-selectin and VCAM-1. The observed decrease in synovial scores for inflammatory cells, monokines and adhesion molecules suggests that the anti-inflammatory effect of MTX is, in part, dependent on a reduction in monokine-inducible vascular adhesion molecules and subsequent reduction of cell traffic into joints.

Sulfasalazine in the treatment of juvenile chronic arthritis: a randomized, double-blind, placebo-controlled, multicenter study. Dutch Juvenile Chronic Arthritis Study Group

OBJECTIVE

To assess the efficacy, tolerability, and safety of sulfasalazine (SSZ) in the treatment of juvenile chronic arthritis (JCA).

METHODS

We conducted a 24-week randomized, placebo-controlled, double-blind, multicenter study of patients with active JCA of both oligoarticular and polyarticular onset. Patients were treated with a dosage of 50 mg/kg/day of SSZ (maximum 2,000 mg/day) or placebo. The efficacy variables were joint scores, physician's, parents', and patient's overall assessments, and laboratory parameters of inflammation.

RESULTS

Of the 69 patients enrolled, 52 (75%) completed the trial. Six patients (18%) withdrew from the placebo group, and 11 (31%) withdrew from the SSZ group (P = 0.18). In the intention-to-treat analysis of end point efficacy, between-group differences were significant for the overall articular severity score (P = 0.02), all global assessments (P = 0.01), and the laboratory parameters (P < 0.001). Adverse events occurred more frequently in the SSZ group and were the main reason for withdrawal (P < 0.001), but in all instances, these events were transient or reversible upon cessation of treatment.

CONCLUSION

The results of this first placebo-controlled study show that SSZ is effective and safe in the treatment of children with oligoarticular- and polyarticular-onset JCA, although it was not well tolerated in one-third of the patients.

Tranexamic acid, an inhibitor of plasminogen activation, reduces urinary collagen cross-link excretion in both experimental and rheumatoid arthritis

The plasminogen activation system is one of the enzyme systems held responsible for bone and cartilage degradation in rheumatoid arthritis (RA). In this study, we evaluated the effect of tranexamic acid (TEA), an inhibitor of plasminogen activation, on urinary collagen cross-link excretion and radiological joint damage in rat adjuvant arthritis (AA) and on urinary collagen cross-link excretion in patients with RA. In the animal study, adjuvant arthritis was induced in male Lewis rats. From day 7 onward, high-dose TEA (500 mg/kg body weight, once daily) or placebo was administered orally. Study groups consisted of TEA-treated normal rats (C + TEA), placebo-treated normal rats (C + plac), AA rats treated with TEA (AA + TEA) or with placebo (AA + plac). To monitor joint destruction, urinary collagen cross-link excretion (pyridinoline, HP; deoxypyridinoline, LP) was measured by high-performance liquid chromatography at days 14 and 21. Radiological evaluation of joints was performed at day 21. In the patient study, TEA was administered to nine patients with RA as adjuvant medication (approximately 20 mg/kg body weight, three times daily) for 12 weeks. Urinary HP and LP excretion levels were measured before and during TEA treatment, and 4 weeks after the cessation of TEA treatment. In AA + TEA rats, a significant reduction of HP and a tendency towards a reduction of LP excretion were found compared with AA + plac rats (P < 0.05), at day 14, whereas the HP/LP ratio did not change. No difference was observed in HP, LP excretion, HP/LP ratio and radiological damage score between the TEA- and placebo-treated AA rats at day 21. In RA patients, a significant reduction of HP and LP excretion was found during the TEA treatment period (P < 0.05). After the cessation of TEA treatment, HP and LP excretion increased towards baseline levels. No effect on disease activity was observed. The plasmin antagonist TEA reduced the excretion of collagen pyridinoline cross-links in both experimental and rheumatoid arthritis. As such, this study not only supports the involvement of the plasminogen activation system in the destructive phase of arthritis, but also suggests a beneficial effect of therapeutic strategies directed against inhibition of matrix proteolysis.

Variations in the monitoring and management of the side effects of antirheumatic drugs by means of laboratory tests

OBJECTIVE

To ascertain the strategies Dutch rheumatologists would employ in the monitoring of side effects of non-steroidal anti-inflammatory drugs (NSAIDs) and disease modifying antirheumatic drugs (DMARDs) by means of laboratory tests, and in the management of detected toxicity.

METHODS

A questionnaire was sent to all practicing Dutch rheumatologists concerning NSAIDs and the following DMARDs: antimalarials (AMALs), intramuscular gold (Au), d-penicillamine (DPEN), sulfasalazine (SASP), methotrexate (MTX) and azathioprine (AZA).

RESULTS

The response rate was 72% (83/114). Except for AMALs, at least 90% of rheumatologists determined the haemoglobin concentration during NSAID or DMARD therapy, the white blood cell (WBC) and platelet count during DMARD, serum creatinine and transaminases during MTX, and proteinuria during Au and DPEN therapy. At least 88% did not request a urinalysis when prescribing AMALs, and serum bilirubin and albumin when prescribing all drugs. The majority used monitoring intervals of < 3 months when prescribing DMARDs (except for AMALs) during the induction phase of therapy and during the maintenance phase in the case of Au and MTX treatment. For all DMARDs except AMALs, 65% to 75% would change the treatment when the WBC count was 2.5-3.4 x 10(9)/l. When the platelet count was 100-150 x 10(9)/l, 67% to 85% would not. The percentage of rheumatologists that would change the medication when the transaminase levels were 2 to 3 times the upper limit of normal or when proteinuria was 0.5-1.0 g/l varied considerably irrespective of the drug involved.

CONCLUSIONS

The strategies that Dutch rheumatologists would employ showed uniformity in the choice for some laboratory tests, but also showed considerable variation in the case of other tests, the monitoring intervals, and treatment interventions.

The limited value of the Health Assessment Questionnaire as an outcome measure in short term exercise trials

OBJECTIVE

To examine the value of the Health Assessment Questionnaire (HAQ) as an outcome measure in short term exercise trials. We studied the association of the objectives of exercise, namely joint mobility, muscle strength, and physical condition, with the HAQ.

METHODS

Data for 100 patients with rheumatoid arthritis (RA) included in a study to examine the effect of exercise therapy were used for secondary analysis. Disease activity was determined by the disease activity score (DAS3), pain was scored on a visual analog scale (VAS), and depression was measured by the Dutch Arthritis Impact Measurement Scale. Aerobic capacity (VO2max) estimated from a submaximal ergometer test, grip strength (kPa), isokinetic muscle strength of the knee (Nm/kg), and the Escola Paulista de Medicina range of motion (EPM-ROM) score, a measure of general flexibility, were used as indicators for physical impairments. All variables were entered in a forward multiple regression analysis with the HAQ as dependent variable.

RESULTS

The HAQ was significantly correlated with the DAS3 score (r = 0.53), pain (r = 0.51), depression (r = 0.40), joint mobility (r = 0.27), quadriceps strength (r = -0.35), and grip strength (r = -0.50), but not with physical condition. The DAS3 score was first entered in the multiple regression analysis model, followed by pain, quadriceps strength, and grip strength (R2 = 0.45). After 12 weeks of exercise therapy changes in the HAQ were significantly correlated with changes in pain (r = 0.41), in depression (r = 0.33), and in quadriceps strength (r = -0.25), but not with changes in joint mobility or physical condition.

CONCLUSION

Physical impairments are weakly associated with the HAQ. The HAQ is not an appropriate instrument to detect changes in physical impairments due to short term exercise therapy.

Sesame oil in injectable gold: two drugs in one?

To investigate the potential anti-inflammatory effects of sesame oil, which is present in the injectable gold preparation Auromyose, the synthesis of tumour necrosis factor alpha (TNF-alpha), prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) by in vitro stimulated blood cells was measured before, during and after 12 weeks of dietary supplementation with 18 g of sesame oil daily in 11 healthy male volunteers. Neither TNF-alpha, PGE2 nor LTB4 production levels showed statistically significant changes during the 12 weeks of dietary supplementation with sesame oil. These results do not suggest an anti-inflammatory effect of sesame oil as present in injectable gold preparations which are used in the treatment of rheumatoid arthritis.

Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis

BACKGROUND

The value of intensive combination therapy in early rheumatoid arthritis is unproven. In a multicentre, double-blind, randomised trial (COBRA), we compared the combination of sulphasalazine (2 g/day), methotrexate (7.5 mg/week), and prednisolone (initially 60 mg/day, tapered in 6 weekly steps to 7.5 mg/day) with sulphasalazine alone.

METHODS

155 patients with early rheumatoid arthritis (median duration 4 months) were randomly assigned combined treatment (76) or sulphasalazine alone (79). Prednisolone and methotrexate were tapered and stopped after 28 and 40 weeks, respectively. The main outcomes were the pooled index (a weighted change score of five disease activity measures) and the Sharp/Van der Heijde radiographic damage score in hands and feet. Independent health-care professionals assessed the main outcomes without knowledge of treatment allocation.

FINDINGS

At week 28, the mean pooled index was 1.4 (95% CI 1.2-1.6) in the combined treatment group and 0.8 (0.6-1.0) in the sulphasalazine group (p < 0.0001). At this time, 55 (72%) and 39 (49%) patients, respectively, were improved according to American College of Rheumatology criteria. The clinical difference between the groups decreased and was no longer significant after prednisolone was stopped, and there were no further changes after methotrexate was stopped. At 28 weeks, the radiographic damage score had increased by a median of 1 (range 0-28) in the combined-therapy group and 4 (0-44) in the sulphasalazine group (p < 0.0001). The increases at week 56 (2 [0-43] vs 6 [0-54], p = 0.004), and at week 80 (4 [0-80] vs 12 [0-72], p = 0.01) were also significant. Further analysis suggests that combined therapy immediately suppressed damage progression, whereas sulphasalazine did so less effectively and with a lag of 6 to 12 months. There were fewer withdrawals in the combined therapy than the sulphasalazine group (6 [8%] vs 23 [29%]), and they occurred later.

INTERPRETATION

This combined-therapy regimen offers additional disease control over and above that of sulphasalazine alone that persists for up to a year after corticosteroids are stopped. Although confirmatory studies and long-term follow-up are needed, this approach may prove useful in the treatment of early rheumatoid arthritis.

Incidence and sources of native and prosthetic joint infection: a community based prospective survey

OBJECTIVES

To determine the incidence and sources of bacterial arthritis in the Amsterdam health district and the maximum percentage of cases that theoretically would be preventable.

METHODS

Patients with bacterial arthritis diagnosed between 1 October 1990 and 1 October 1993 were prospectively reported to the study centre by all 12 hospitals serving the district. Data were gathered on previous health status, source of infection, and microorganisms involved.

RESULTS

188 episodes of bacterial arthritis were found in 186 patients. Most of the 38 children were previously healthy. Fifty per cent of the adults were 65 years or older. Of the adults 84% had an underlying disease, in 59% a joint disorder. Joint surgery constituted the largest part of direct infections (33%) and skin defects were the most important source of haematogenous infections (67%). Infection of joints containing prosthetic or osteosynthetic material by a known haematogenous source occurred 15 times (8%). Staphylococcus aureus was the causative organism in 44% of all positive cultures.

CONCLUSION

The incidence of bacterial arthritis was 5.7 per 100,000 inhabitants per year. Preventive measures directed to patients with prosthetic joints or osteosynthetic material, and a known haematogenous source would have prevented at most 8% of all cases.

Do patients with systemic sclerosis have abnormal gallbladder function?

OBJECTIVE

To determine gallbladder motility in patients with systemic sclerosis.

DESIGN

Case control study.

SETTING

University hospital, out-patient department of rheumatology.

PATIENTS

Ten patients with systemic sclerosis according to the criteria of the American Rheumatism Association with documented involvement of the gastrointestinal tract and 10 healthy controls matched for age, sex and body mass index.

INTERVENTION

Cephalic vagal cholinergic simulation by modified sham feeding and hormonal stimulation by infusion of cholecystokinin.

MEASUREMENTS

Gallbladder volume obtained by ultrasonography and determination of plasma cholecystokinin concentrations.

RESULTS

Fasting gallbladder volumes were not significantly different between patients with systemic sclerosis and controls (19.6 +/- 1.9 cm3 and 23.3 +/- 2.9 cm3, respectively, mean plus or minus standard error of the mean). Neither were there significant differences in reduction of gallbladder volume in response to modified sham feeding (35 +/- 4% and 33 +/- 4%, respectively) nor during cholecystokinin infusion (56 +/- 4% and 60 +/- 6%, respectively). The increase in plasma cholecystokinin levels during infusion was not different in the two groups.

CONCLUSION

Gallbladder motility in patients with systemic sclerosis is preserved in response to both cholinergic and hormonal stimulation, even when other gastrointestinal motor disturbances are present. These results suggest that patients with systemic sclerosis are not at increased risk for cholelithiasis because of gallbladder dysmotility.

Effect of resumption of second line drugs in patients with rheumatoid arthritis that flared up after treatment discontinuation

OBJECTIVE

To assess the effect of resumption of second line drugs in patients with rheumatoid arthritis (RA) that flared after treatment discontinuation.

METHODS

RA patients were studied whose RA flared up after discontinuation of second line treatment while being in remission and who received a second course of the drug. Disease activity parameters were prospectively assessed at the time of treatment discontinuation, during the period when the disease flared up, and three months thereafter. Furthermore the medical charts were reviewed at 12 months after treatment resumption.

RESULTS

There were 51 patients included in the study: 25 patients treated with antimalarial drugs, 10 with parenteral gold, four with d-penicillamine, eight with sulphasalazine, two with azathioprine, and two with methotrexate. Disease activity parameters showed significant improvement within three months of treatment resumption, but remained significantly worse when compared with that measured before treatment discontinuation. Within three months 47% of the patients fulfilled 20% response criteria. Disease activity 12 months after treatment resumption was considered to be absent in 35%, mild in 43%, and moderate or active in 22% of the patients. In four (8%) patients the resumed treatment was stopped because of lack of efficacy. Side effects were recorded in four patients, which did not result in treatment discontinuation.

CONCLUSIONS

Resumption of second line drugs in RA patients whose disease flared up after discontinuation of treatment is effective and safe in most patients. Half of the patients responded within three months after resumption of the second line drug.

Long-term prognosis in patients treated for erythema chronicum migrans and acrodermatitis chronica atrophicans

OBJECTIVE

To determine whether Lyme borreliosis persisted or had recurred in patients treated for erythema chronicum migrans and acrodermatitis chronica atrophicans.

DESIGN

Retrospective follow-up study. Mean time between treatment and follow-up study was 8.8 years (SD, 66.6 years).

SETTING

Department of dermatology.

PATIENTS

Patients (N = 52) treated from July 1964 to October 1992 for erythema chronicum migrans (ECM; n = 44) or acrodermatitis chronica atrophicans (ACA; n = 8). Fifty-two of the 56 successfully contacted and registered patients agreed to participate, for a response rate of 93%.

MAIN OUTCOME MEASURES

Signs and symptoms of Lyme borreliosis; serum antibodies to Borrelia burgdorferi.

RESULTS

The interval from the time of diagnosis to study entry was 0.8 to 28.7 years (mean, 8.2 years). No symptoms or signs of active Lyme borreliosis were observed in the 52 patients. Antibodies to B burgdorferi were found in the ECM group in 1 of the 23 patients who received a recommended treatment and 2 of the 21 patients who received other treatments; antibodies were found in the ACA group in all 5 adequately treated patients who received a recommended treatment and in 1 of the 3 patients who received other treatments.

CONCLUSIONS

There was no association between serologic results and type of treatment or between serologic results and complaints or symptoms at the time of the study in either of the patient groups. The prognosis in most patients with Lyme borreliosis is excellent.

Chloroquine and hydroxychloroquine equally affect tumor necrosis factor-alpha, interleukin 6, and interferon-gamma production by peripheral blood mononuclear cells

OBJECTIVE

The efficacy of both chloroquine and hydroxychloroquine in rheumatoid arthritis (RA) has been proved in controlled clinical trials. Despite similar chemical characteristics, it is believed the clinical efficacy of chloroquine is superior to that of hydroxychloroquine in patients with RA. Excessive production of proinflammatory cytokines was shown to contribute to the pathogenesis of RA. From different studies testing either chloroquine or hydroxychloroquine, it could be concluded that both drugs differentially inhibit cytokine production.

METHODS

We compared the effects of both chloroquine and hydroxychloroquine on stimulated peripheral blood mononuclear cells (PBMC) with respect to cytokine production. Therefore, PBMC were tested for tumor necrosis factor-alpha (TNF-alpha), interleukin 6 (IL-6), and interferon-gamma (IFN-gamma) by specific ELISA, after stimulation with phytohemagglutinin (PHA) or lipopolysaccharide (LPS) in the presence or absence of different concentrations of chloroquine or hydroxychloroquine.

RESULTS

We observed that chloroquine and hydroxychloroquine equally inhibit PHA induced TNF-alpha and IFN-gamma production, and LPS induced TNF-alpha and IL-6 production, while PHA induced IL-6 production was not affected.

CONCLUSION

Chloroquine and hydroxychloroquine display similar effects on PHA and LPS induced cytokine production by PBMC under identical in vitro conditions. These findings may help in understanding the mechanism of action of these drugs on RA.

Assessment of shoulder function in rheumatoid arthritis

OBJECTIVE

(1) To develop a simple outcome measure of shoulder function in rheumatoid arthritis (RA), the Shoulder Function Assessment (SFA) Scale; (2) to compare the properties of this scale with those of 2 existing measures of shoulder function, the Constant Scale and the Hospital for Special Surgery (HSS) Scale.

METHODS

Fifty consecutive patients with RA participated in an inpatient multidisciplinary treatment program. The SFA Scale was constructed by selecting items considered simple to assess and relevant to shoulder function by a team consisting of a rheumatologist, an orthopedic surgeon, a physical therapist, and an occupational therapist. To examine the intra and interobserver reliability in 25 patients the SFA Scale, the Constant, and the HSS Scale were assessed twice by examiner CHME, in the other 25 patients once by examiner CHME, and once by examiner EMV. The validity of all 3 scales was determined by calculating the correlation with (1) the observed shoulder function, (2) the patient's opinion of shoulder function, and (3) shoulder joint deformity. A receiver operating characteristic curve was constructed to determine the accuracy of all scales to discriminate between differences in the shoulder function of the "best" and "worst" shoulder as reported by the patient.

RESULTS

The validity and the reliability of the SFA Scale were equivalent to or better than the validity and reliability of the Constant and the HSS scale. The discriminative ability of the SFA Scale was superior to both other scales.

CONCLUSION

The SFA Scale is a reliable, valid, and accurate measure of shoulder function in patients with RA that can be completed within 3 minutes.

An open study of pentoxyfylline and thalidomide as adjuvant therapy in the treatment of rheumatoid arthritis

OBJECTIVE

Dysregulation of tumour necrosis factor alpha (TNF alpha) production is thought to be important in rheumatoid arthritis. Since pentoxifylline and thalidomide inhibit endotoxin induced TNF production in vitro, these drugs were tested in an open study in rheumatoid arthritis patients to assess toxicity, the effect on TNF production, and the antiarthritic effects.

METHODS

12 patients with active rheumatoid arthritis were treated with 1200 mg pentoxifylline and 100 mg thalidomide a day during 12 weeks. In addition, TNF production was assessed by ex vivo whole blood cultures stimulated with endotoxin.

RESULTS

Adverse events such as xerostomia, drowsiness, and constipation occurred in almost all patients, which led to discontinuation in three. The drugs halved the TNF production capacity during treatment (ANOVA, P < 0.03) whereas production capacity of interleukin (IL) 6, IL-10, and IL-12 was not affected. Of the nine patients who completed the study, five fulfilled the ACR-20% response criteria after 12 weeks of treatment.

CONCLUSIONS

Although pentoxifylline/thalidomide reduced the production capacity of TNF, the benefit/side effects ratio was poor due to multiple adverse effects, while clinical observation suggests limited efficacy.

Comparison of high and low intensity training in well controlled rheumatoid arthritis. Results of a randomised clinical trial

OBJECTIVE

To investigate the benefit of intensive dynamic exercises in comparison to range of motion (ROM) and isometric exercises in rheumatoid arthritis.

METHODS

100 consecutive rheumatoid arthritis patients on stable medication were randomly assigned to (1) intensive dynamic group exercises which included full weight bearing exercises and conditioning exercises on a stationary bicycle while the heart rate was maintained at 70-85% of the age predicted maximum heart rate, (2) range of motion (ROM) exercises and isometric exercises in a group, (3) individual isometric and ROM exercises, and (4) home instructions for isometric and ROM exercises. Variables of physical condition, muscle strength, joint mobility, daily functioning (HAQ), and disease activity were assessed before and after the 12 week exercise course, and 12 weeks thereafter. An intention to treat analysis was performed.

RESULTS

Increases in aerobic capacity (n = 77), muscle strength, and joint mobility in the high intensity exercise programme were respectively 17%, 17% and 16% and differed significantly from the changes in aerobic capacity, muscle strength, and joint mobility in the other exercise groups. No deterioration of disease activity was observed. Twelve weeks after discontinuation of the exercise course the gain in physical capacity had disappeared.

CONCLUSIONS

Intensive dynamic training is more effective in increasing aerobic capacity, joint mobility, and muscle strength than ROM exercises and isometric training in rheumatoid arthritis patients with well controlled disease.