Human leucocyte antigen phenotypes and gold-induced remissions in patients with rheumatoid arthritis

To assess possible associations between human leucocyte antigens (HLA) and the achievement of remission during gold treatment, HLA typing was performed in 67 rheumatoid arthritis (RA) patients with a gold-induced remission and in 25 control RA patients who discontinued gold therapy because of lack of efficacy. Both groups of RA patients showed a significantly higher frequency of DR4 antigen and lower frequency of DR6 than a control population. There were no significant differences in HLA antigens between remission-responders and non-responders. It is concluded that HLA typing is not helpful in predicting the therapeutic response to parenteral gold therapy.

Prednisone treatment of elderly-onset rheumatoid arthritis. Disease activity and bone mass in comparison with chloroquine treatment

OBJECTIVE

Prednisone is frequently used in the treatment of elderly-onset rheumatoid arthritis (RA), but the balance between efficacy and toxicity, including the effect on bone mass, has not been investigated in long-term studies. This prospective, randomized study was undertaken to compare disease activity and bone mass during long-term treatment with prednisone versus chloroquine in this patient population.

METHODS

Patients with active RA diagnosed at age > or = 60 were randomized to receive prednisone (15 mg/day for 1 month, with the dosage tapered as low as possible thereafter) (n = 28) or chloroquine (n = 28). Patients who did not show a response received other second-line drugs as an adjunct to prednisone or as a replacement for chloroquine. Bone mass was measured by dual-energy x-ray absorptiometry. The study duration was 2 years.

RESULTS

During the 2 years, treatment with other second-line drugs was needed for 12 patients in the prednisone group (43%) and 8 in the chloroquine group (29%). Functional capacity and disease activity improved significantly in both groups and did not differ significantly between the groups, except for a greater improvement in the prednisone group at 1 month. Radiographic scores for joint destruction progressed similarly in both groups. There was a nonsignificant excess bone loss of 1.8% in the spine and 1.5% in the hip in the prednisone group, compared with the chloroquine group.

CONCLUSION

Neither treatment was entirely satisfactory since a significant number of patients needed an additional second-line drug over the 2-year period.

Relative bioavailability of a new oral form of cyclosporin A in patients with rheumatoid arthritis

The relative bioavailability of cyclosporin A (CsA) from a new microemulsion oral formulation (NEO) and the currently used soft gelatine capsule (SGC) was determined at steady state in 12 patients with rheumatoid arthritis. The AUC(0,12 h) values of cyclosporin A were significantly greater after NEO than SGC (2873 +/- 848 ng ml-1 h (mean +/- s.d.) vs 2355 +/- 1128 ng ml-1 h; P = 0.02, 95% CI (confidence interval of the difference: 81 to 955 ng ml-1 h). Cmax values were significantly higher after NEO than after SGC (811 +/- 244 ng ml-1 vs 495 +/- 291 ng ml-1, P < 0.0001, 95% CI of the difference: 209 to 422 ng ml-1).

Safety aspects of cyclosporin in rheumatoid arthritis

While cyclosporin has an established role in the management of patients with rheumatoid arthritis, its use can be accompanied by various adverse events. In daily practice, the potential for cyclosporin to induce nephropathy is of most concern and has, to some extent, limited the use of this drug. However, these effects on renal function are dose dependent. Two international meetings have resulted in the publication of guidelines aimed at limiting the risk of adverse events when cyclosporin is used in patients with rheumatoid arthritis. The 1994 International Consensus guidelines with respect to renal safety recommend the principal dosage regimen of 'go low, go slow', which requires starting patients on a daily dose of between 2.5 and 3.5 mg/kg with the maximum daily dose not exceeding 5 mg/kg. The cyclosporin dosage chosen should be titrated against the highest acceptable increase in serum creatinine, i.e. a 30% increase over the baseline value. Renal biopsy data support these guidelines, and when the latter are followed by physicians, it is very unlikely that histological damage will occur. The new oral microemulsion-based formulation of cyclosporin (Neoral) has a more predictable absorption and a 20% greater bioavailability than the conventional formulation (Sandimmun). Therefore, the microemulsion formulation may enable more patients to receive effective treatment at lower doses. This could have interesting safety and pharmacoeconomic implications.

Antimalarial drug induced decrease in creatinine clearance

OBJECTIVE

To confirm the antimalarial drug induced increase of creatinine to determine the factors contributing to this effect.

METHODS

Patients with rheumatoid arthritis (RA) (n = 118) who have used or still use antimalarials (chloroquine or hydroxychloroquine). Serum creatinines prior to antimalarials and serum creatinines during antimalarials were recorded and the creatinine clearance was estimated.

RESULTS

The mean creatinine clearance decreased from 99 ml/min to 92 ml/min (p < 0.001) after the start of antimalarial drugs. Fifty-five percent of the patients with chloroquine compared to 15% of the patients with hydroxychloroquine (chi 2 = 17.8; p < 0.001) had more than 10% decrease of the creatinine clearance. Age (beta = 0.004; p = 0.0002) and the kind of antimalarial (beta = 0.095; p = 0.0002) were strong independent predictors of the decrease of the creatinine clearance in the multiple regression analysis. For patients using chloroquine the mean age adjusted decrease of creatinine clearance was 11.2%.

CONCLUSION

Antimalarials cause a significant reduction of the creatinine clearance. The use of chloroquine and older age were associated with decreased creatinine clearance. Whether antimalarials affect glomerular filtration or tubular excretion of creatinine remains to be investigated.

Serum values of pepsinogens and antibodies to Helicobacter pylori in relation to a history of peptic ulcer disease and NSAID use

The present study was undertaken to investigate whether patients with a history of peptic ulcer disease (PUD) have serological features indicative of the presence of more severe gastritis, compared to patients without a history of PUD. In addition we investigated whether current chronic use of non steroidal anti-inflammatory drugs (NSAIDs) was associated with serological features indicative of a chemical (type C) gastritis. In total 850 consecutive outclinic patients were interviewed by a standard questionnaire with emphasis on demographic data, diagnosis, chronic use of NSAID, and history of PUD. Serum pepsinogen A (PgA) and pepsinogen C (PgC), the PgA:PgC ratio, and IgA and IgG antibodies to H. pylori were measured in all patients. After controlling for age, sex, H. pylori seropositivity, and presence of RA, a correlation was found between a decreased pepsinogen A:C ratio and the use of NSAID. Patients with a history of PUD have serological features indicative of a persistently more severe gastritis. Secondly we found serological evidence for the existence of a chemical (type C) gastritis in NSAID users.

NSAID-associated upper gastrointestinal damage in patients with rheumatoid arthritis

AIM OF THE STUDY

The main aim of the present study was to identify the patient with rheumatoid arthritis (RA) taking non-steroidal anti-inflammatory drugs (NSAIDs) at risk for peptic ulcer disease (PUD) and its life-threatening complications.

PATIENTS AND METHODS

During a retrospective study in which more than 1000 patients were interviewed, current gastrointestinal (GI) complaints were of no use in detecting current PUD.

RESULTS

A history of PUD was an important predictor of current PUD, while the predictive value of serologic parameters, such as serum values of pepsinogen and antibodies to Helicobacter pylori, was disappointingly low. A prospective study in which 81 consecutive RA patients underwent a gastroscopy revealed 16% PUD; again a history of PUD was the most important predictive parameter. Since no study had been undertaken into the effects of a NSAID on intragastric pH we performed such a study, the main conclusion being that indomethacin does not influence the intragastric pH of RA patients. A placebo-controlled study of ranitidine 300 mg b.i.d. for the prevention of recurrent PUD in RA patients on NSAIDs is underway.

Clinical and biochemical response to single infusion of pamidronate in patients with active rheumatoid arthritis: a double blind placebo controlled study

OBJECTIVE

To assess the effects of 3-amino-1-hydroxypropylidine-1,1-bisphosphonate (pamidronate) in rheumatoid arthritis (RA).

METHODS

Thirty patients with active RA were randomly allocated to receive a single intravenous infusion of placebo, 20 mg pamidronate, or 40 mg pamidronate.

RESULTS

Pamidronate treatment resulted in a rapid and sustained reduction in urinary calcium and hydroxyproline excretions. A sustained reduction in serum corrected calcium was only noted in the group treated with 40 mg pamidronate. In both groups treated with pamidronate a temporary increase in serum parathyroid hormone was noted. Compared to the placebo group clinical variables of disease activity improved significantly in both groups treated with aminohydroxypropylidine bisphosphonate. The erythrocyte sedimentation rate and serum C-reactive protein levels improved significantly in patients treated with 40 mg pamidronate. No serious side effects were documented.

CONCLUSION

A single infusion of pamidronate in patients with RA is safe, suppresses bone resorption, and reduces disease activity. It is suggested that the effect on disease activity is dose dependent.

Oral calcitriol as a new therapeutic modality for generalized morphea

BACKGROUND

None of the commonly used drugs for the treatment of scleroderma appears to significantly influence the fibrotic stage of this disorder. Recently, a beneficial effect of the treatment with oral calcitriol (1,25 dihydroxyvitamin D3) in 10 patients with systemic sclerosis and four patients with morphea was described. This fact could be ascribed to the immunoregulatory effects of calcitriol observed in vitro and to inhibition of fibroblast growth. We treated three patients with extensive morphea with remarkable results.

OBSERVATION

Three patients with generalized morphea were treated with calcitriol in an oral daily dose of 0.50 to 0.75 microgram. After 3 to 7 months of treatment, the mobility of the joints improved and the skin extensibility increased. No adverse effects were observed. The improvement persisted after discontinuation of therapy during a follow-up period of 1 to 2 years.

CONCLUSION

Calcitriol showed a beneficial effect in generalized morphea during an open study. Double-blind, placebo-controlled trials are needed to assess its therapeutic value.

[Comparison of azathioprine and methotrexate in rheumatoid arthritis: an open-randomized clinical study]

Thirty-eight patients with active rheumatoid arthritis (RA) were entered in an open randomized 24-week study comparing azathioprine (AZA; initial daily dose 1 mg/kg) with methotrexate (MTX; initial weekly dose 7.5 mg). The patients had previously been treated with antimalarials, gold salts and/or D-penicillamine. The groups were well balanced in baseline characteristics. There were three premature withdrawals in each group, all of which were due to toxicity. The present study did not show any significant differences between AZA and MTX in ability to reduce activity in RA after 24 weeks of treatment.

Cyclosporine in common clinical practice: an estimation of the benefit/risk ratio in patients with rheumatoid arthritis

OBJECTIVE

To investigate in common clinical practice the toxicity/efficacy ratio of low dose cyclosporine A (CsA) in patients with advanced rheumatoid arthritis (RA) after 12 months CsA administration.

METHODS

One hundred and two patients with RA were included in the study. The initial dose of CsA was 2.5 mg/kg/day, the mean maximum dose was 3.2 mg/kg/day and the dose at 12 months was 2.8 mg/kg/day.

RESULTS

Sixty-nine (68%) patients completed 12 months of treatment. Seventeen (17%) patients discontinued for lack of efficacy and 16 (16%) for toxicity (of which 50% for gastrointestinal intolerance). The clinical efficacy variables improved significantly by 36-42% between entry and Month 6 and remained stable thereafter. The C-reactive protein decreased from 43 U/ml at entry to 22 U/ml (p < 0.0001) at 12 months. Forty-four percent of the patients and 47% of the physicians judged the efficacy as good or very good. The median number of adverse events/patient was 3 but most adverse events were either not clinically important or disappeared after dose reduction. Gastrointestinal (GI) intolerance and nephrotoxicity (> 30% increase in serum creatinine) each occurred in 50% of the patients. GI intolerance was transient in 80% of the patients but accounted for 50% of the premature discontinuations for toxicity. Nephrotoxicity persisted in the 50% of the patients in whom it occurred, despite dose reduction. The mean serum creatinine rose from 70 (13) mumol/l at entry to 86 (23) mumol/l at 12 months (23% increase; p < 0.0001), and this increase had been entirely reached after 3 months. Variables that could significantly predict the occurrence of nephrotoxicity could not be identified.

CONCLUSION

CsA can be safely and effectively administered to patients with RA for a duration of at least 12 months. An acceptable renal function at entry, close monitoring of the serum creatinine concentration and dose reductions when appropriate are prerequisities.

No effect of intramuscular gold therapy on serological parameters of Helicobacter pylori infection in patients with rheumatoid arthritis: a 12 month prospective study

OBJECTIVES

To assess prospectively the influence of intramuscular gold therapy on Helicobacter pylori serology in patients with rheumatoid arthritis (RA).

METHODS

Fifty patients with RA were started on intramuscular gold or chloroquine, as the control group and were followed serologically for H pylori infection for 12 months.

RESULTS

Twelve patients treated with gold and eight control patients treated with chloroquine, all with serological evidence for H pylori infection, showed no significant decline of IgA and IgG anti-H pylori antibody levels or serum pepsinogen A and C levels. Total serum IgA and IgG levels declined significantly during gold therapy, while they remained unchanged during chloroquine therapy.

CONCLUSIONS

Intramuscular gold therapy in patients with RA does not influence the serological parameters of H pylori infection.

Hypersensitivity pneumonitis during minocycline treatment

A patient is reported who developed dyspnoea, fever, pleuritic chest pain and a non-productive cough following treatment with minocycline for 9 days. The chest radiograph showed an interstitial pattern and there was a peripheral eosinophilia. A diagnosis of hypersensitivity pneumonitis attributable to minocycline was made. The disease responded quickly to withdrawal of the drug. This observation shows that minocycline, despite its mild toxicity profile, can give rise to serious adverse effects.

A gastroscopic study of the predictive value of risk factors for non-steroidal anti-inflammatory drug-associated ulcer disease in rheumatoid arthritis patients

Peptic ulcer disease (PUD) in RA patients is associated with NSAID use. This study aimed to validate the predictive value of presumed risk factors for NSAID-associated PUD in a prospective gastroscopic study in RA patients. Eighty-one NSAID using RA patients were prospectively divided into four presumed risk groups according to Helicobacter pylori status and history of PUD. As additional risk factors the following were analysed: upper gastrointestinal GI complaints; disability; daily dose of NSAID and antral gastritis. The presence of PUD in the four risk groups did not differ. Additionally it was found that a history of PUD was predictive for current PUD [odds ratio (OR) 3.9; 95% CI 1.1-14]. H. pylori status was not predictive. Transformation from one ulcer type to another was rare. NSAID dose was not a risk factor, while disability was of borderline importance (OR 2.1; 95% CI 1-4.8). Current upper GI complaints were bad predictors. PUD only occurred with a concomitant antral gastritis. A history of PUD, disability and antral gastritis were the most important predictors for current PUD. When an ulcer relapsed it was of the same ulcer type as had been present earlier. This may have practical implications for prophylaxis enabling stratification by previous ulcer type.

A randomized, double-blind, 24-week controlled study of low-dose cyclosporine versus chloroquine for early rheumatoid arthritis

OBJECTIVE

To investigate whether low-dose cyclosporin A (CSA) is safe and effective in comparison with chloroquine (CQ) in patients with early rheumatoid arthritis (RA).

METHODS

We performed a randomized, double-blind study comparing CSA with CQ in patients with early RA (duration < 2 years) who had had active disease for at least 3 months. Forty-four RA patients with a mean disease duration of 6 months were randomly allocated to receive CSA (initial dosage 2.5 mg/kg/day, maintenance dosage 3.6 mg/kg/day) or CQ (initial dosage 300 mg/day, maintenance dosage 100 mg/day) for 24 weeks.

RESULTS

Five patients (2 taking CSA and 3 taking CQ) discontinued the study prematurely. Intention-to-treat analysis disclosed a decrease in the swollen joint count by 7 in both groups. The erythrocyte sedimentation rate and C-reactive protein level did not change significantly. CSA and CQ were tolerated equally well, although mild paraesthesia occurred more frequently in the CSA-treated group. The serum creatinine level increased by 13 mumoles/liter (95% confidence interval [95% CI] 4, 22) in the CSA group and by 6 mumoles/liter (95% CI 1, 11) in the CQ group (difference not statistically significant).

CONCLUSION

Both CSA and CQ are effective in alleviating the symptoms of active early RA. There is only slightly impaired renal function after 24 weeks of drug administration of either drug in patients with early RA.

Minocycline in active rheumatoid arthritis. A double-blind, placebo-controlled trial

OBJECTIVE

To determine the efficacy of minocycline in the treatment of rheumatoid arthritis (RA).

METHODS

Minocycline (maximal oral daily dose 200 mg) or placebo was administered in a 26-week, randomized, double-blind study to 80 patients with active RA, who were treated or had previously been treated with at least one disease-modifying antirheumatic drug.

RESULTS

There were 15 premature discontinuations: 6 (5 taking minocycline) because of adverse effects, 8 (all taking placebo) because of lack of efficacy, and 1 (taking placebo) because of intercurrent illness. There was a statistically significant improvement in the minocycline group over the placebo group. There was a pronounced improvement in laboratory parameters of disease activity; however, improvement in clinical parameters was less impressive. The observed adverse effects attributable to minocycline were mainly gastrointestinal symptoms and dizziness.

CONCLUSION

The results of the present study suggest that minocycline is beneficial and relatively safe in RA patients.

Achlorhydria does not protect against benign upper gastrointestinal ulcers during NSAID use

It is widely accepted that the absence of acid-peptic activity excludes the presence of a benign upper gastrointestinal ulcer. We assessed the frequency of a history of benign upper gastrointestinal ulcer disease in patients with and without serological evidence of achlorhydria with reference to the use of nonsteroidal antiinflammatory drugs (NSAIDs). In total 857 patients were interviewed, using a standard questionnaire with emphasis on demographic data, chronic use of NSAID, and history of upper gastrointestinal ulcers. The frequency of achlorhydria was determined by extremely low serum levels of pepsinogen A (PgA < 17 micrograms/liter). Of the total group of patients, 36 patients (4.2%; 95% CI 2.9-5.5) had a PgA lower than 17 micrograms/liter. A history of benign upper gastrointestinal ulcer was found in 57/827 (6.9%) of patients with serum PgA higher than 17 micrograms/liter and in 3/36 (8.3%) of patients with serum PgA lower than 17 micrograms/liter (NS). The three patients with upper gastrointestinal ulcer and PgA lower than 17 micrograms/liter were known to have pernicious anemia (PA) before (two patients) or simultaneously (one patient) with the diagnosis of the upper gastrointestinal ulcer and were using NSAIDs at that time. The presence of gastric acid is not obligatory for the development of ulcers during NSAID use.

Increased prevalence of spondylarthropathies in parents of children with pauciarticular juvenile chronic arthritis, type 1

Using a standard questionnaire, parents of 70 children with type 1 pauciarticular juvenile chronic arthritis were asked about inflammatory back-pain. When the answer was positive, the parents were seen by a rheumatologist who used the preliminary criteria of the European Spondylarthropathy Study Group to decide whether the parent had spondylarthropathy or not. A diagnosis of spondylarthropathy was established in 6 out of 138 parents (4%). This is considerably higher than the expected prevalence of spondylarthropathy, which should not exceed 0.25%. This finding sheds a new light on pauciarticular JCA, type 1, since no adult counterpart has as yet been described.

Effect of therapy for thyroid dysfunction on musculoskeletal symptoms

Our purpose was to assess the long-term effect of treatment for thyroid dysfunction on musculoskeletal symptoms. Forty-six patients (37 with hypothyroidism, 9 with hyperthyroidism), who visited the outpatient clinic of rheumatology and had abnormal thyroid function tests on their first visit, cooperated in the study. They were interviewed with a structured questionnaire about their past and current musculoskeletal complaints. Thyroid dysfunction was considered the only explanation for the original musculoskeletal symptoms in 24 patients (Group I); in 19 patients an additional (rheumatological) diagnosis was made (Group II), and in 3 patients no apparent relation between musculoskeletal complaints and thyroid dysfunction was found. After treatment for thyroid dysfunction, the original complaints decreased in 52% and 47% of the patients in Group I and II, respectively. At the time of the follow-up study (mean follow-up duration 67 months) 91% of the patients had musculoskeletal symptoms, 80% of the patients said their present complaints were similar to their original symptoms. Treatment for thyroid dysfunction resulted in a temporary effect on musculoskeletal symptoms.

Effects of indomethacin on intragastric pH and meal-stimulated serum gastrin secretion in rheumatoid arthritis patients

The effects of oral indomethacin on intragastric pH and serum gastrin were investigated in rheumatoid arthritis patients. Nine patients (1 male, 8 female) without a history of peptic ulcer disease and 6 patients with a history of peptic ulcer disease (5 male, 1 female) were studied. To obviate Helicobacter pylori infection as a confounding factor, only patients with positive H. pylori serology were included. After a 5-day period of placebo treatment and after a 5-day period of indomethacin (50 mg t.d.s.; total dose 750 mg), 24-h intragastric pH and basal and meal-stimulated serum gastrin levels were measured in a double-blind placebo controlled cross-over study. There were no differences in the median 24-h pH values between placebo and indomethacin users irrespective of peptic ulcer disease history. Indomethacin resulted in a higher basal and stimulated gastrin response than placebo in patients with a history of peptic ulcer disease. The basal and incremental responses were lower in patients with a history of peptic ulcer disease than in patients without a history of peptic ulcer disease, both during indomethacin and placebo. The same basal and stimulated incremental serum gastrin responses were found during placebo and indomethacin treatment in patients without a history of peptic ulcer disease. No correlation was established between median 2-h post-prandial intragastric pH and post-prandial incremental serum gastrin concentration. We conclude that indomethacin does not influence the intragastric pH of rheumatoid arthritis patients irrespective of history of peptic ulcer disease.

Bone mineral density in ambulant, non-steroid treated female patients with rheumatoid arthritis

Bone mass measurements were performed in a group of 30 ambulant, non-steroid treated female patients with rheumatoid arthritis (RA) of relatively short duration (mean 4.9 years). The bone mineral density (BMD) of the lumbar spine and femoral neck was assessed by dual-energy x-ray absorptiometry (DEXA), and related to parameters of disease activity and severity. Lumbar BMD was within the range of normal while femoral BMD was decreased compared to age-matched controls. BMD values, expressed as the percentage of age-matched healthy controls (BMD%), were positively related to the body mass index and negatively related to the number of swollen joints, the erythrocyte sedimentation rate and the platelet count. No relation was found between the lumbar and femoral bone mass on the one hand and disease duration, number of disease modifying anti-rheumatic drugs ever used, Ritchie articular index, C-reactive protein, functional ability or radiological scores on the other. It is concluded that in ambulant non-steroid treated female RA patients lumbar bone mass as measured with DEXA is within the range of normal, while femoral bone mass is slightly reduced. Both lumbar and femoral bone mass are related to the body mass index and parameters of disease activity.