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Nozawa T, Pullenayegum EM, Bell-Peter A, Marcuz JA, Whitney K, Vinik O, Shupak R, Dover S, Feldman BM. Disease activity trajectories in juvenile dermatomyositis from childhood to adulthood. Rheumatology (Oxford) 2024:keae027. [PMID: 38216715 DOI: 10.1093/rheumatology/keae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/17/2023] [Accepted: 12/25/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVES To assess whether there are identifiable subgroups of disease activity trajectory in a population of juvenile dermatomyositis (JDM) patients-followed throughout childhood and into adulthood-and determine factors that predict those trajectory groupings. METHODS This is a retrospective, longitudinal inception cohort of patients with idiopathic inflammatory myopathies, largely JDM. We sought to identify baseline factors that predict membership into different groups (latent classes) of disease activity trajectory. RESULTS A total of 172 patients (64% females), with median age at diagnosis of 7.7 years, were analyzed. We studied 4,725 visits (1,471 patient-years). We identified 3 latent classes of longitudinal disease activity, as measured by the modified disease activity score (DASm), with distinct class trajectories predicted by DASm at baseline, and by the changes of DASm from either baseline to 3 months or baseline to 6 months (early response to therapy). In the analysis in which DASm at baseline and the changes of DASm from baseline to 6 months are included as predictors, Class 1 (10%) has persistently high disease activity, Class 2 (34%) is characterized by moderate disease activity, and Class 3 (56%) is characterized by individuals with a high early disease activity but an apparently good response to treatment and long-term low disease activity. CONCLUSION High early disease activity, and treatment resistance in the first few months, predict a more chronic longitudinal course of JDM.
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Affiliation(s)
- Tomo Nozawa
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan
| | - Eleanor M Pullenayegum
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Audrey Bell-Peter
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jo-Anne Marcuz
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kristi Whitney
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ophir Vinik
- Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada
| | - Rachel Shupak
- Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada
| | - Saunya Dover
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Brian M Feldman
- Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
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Nozawa T, Bell-Peter A, Marcuz JA, Whitney K, Vinik O, Shupak R, Dover S, Feldman BM. Early abnormal nailfold capillary changes are predictive of calcinosis development in juvenile dermatomyositis. J Rheumatol 2022; 49:1250-1255. [PMID: 35914785 DOI: 10.3899/jrheum.220249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The long-term outcomes of juvenile dermatomyositis (JDM) are more favorable in recent years. However, calcinosis is still among the complications that can cause serious functional impairment. Little is known about the pathogenesis and risk factors of calcinosis. The aim of this study is to determine risk factors for the development of calcinosis in JDM. METHODS This was a single-center, retrospective cohort study. All patients were diagnosed and followed at The Hospital for Sick Children's multidisciplinary JDM clinic, from January 1, 1989 until May 31, 2018. To investigate predictors of incident calcinosis, Cox regression analysis was performed. RESULTS A total of 172 patients met inclusion criteria, median age at diagnosis of 7.7 years (interquartile range [IQR] 4.9-12.1), median follow-up of 8.5 years (IQR 8.5-12.6, range 0.13-28.3). The only risk factor significantly associated with the development of calcinosis in the univariate analysis was nailfold abnormality at baseline (hazard ratio [HR] 4.857, p = 0.029), and the other variables had no significant relationship with calcinosis. In multivariable analysis, including nailfold abnormality, age of diagnosis, sex, and duration from onset to diagnosis, the only statistically significant risk factor for calcinosis was the presence of nailfold abnormalities (HR 4.975, p = 0.027). Furthermore, calcinosis was significantly increased in patients with a chronic course (chi-square 25.8, p = 0.00001). CONCLUSION The presence of abnormal nailfold capillary changes at baseline is predictive for the development of calcinosis in children with idiopathic inflammatory myopathies.
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Affiliation(s)
- Tomo Nozawa
- The source(s) of support in the form of grants or industrial support: Tomo Nozawa was supported by research fellowships of Japan Society of Allergology, Mochida Memorial Foundation, and Gushinkai. Brian Feldman is supported by the Ho Family Chair in Autoimmune Diseases. Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada. Conflict of Interests: The authors have no potential conflicts of interest relevant to this article to disclose. Corresponding author: Tomo Nozawa MD, Department of Pediatrics, Yokohama City University Graduate School of Medicine, Address: 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Audrey Bell-Peter
- The source(s) of support in the form of grants or industrial support: Tomo Nozawa was supported by research fellowships of Japan Society of Allergology, Mochida Memorial Foundation, and Gushinkai. Brian Feldman is supported by the Ho Family Chair in Autoimmune Diseases. Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada. Conflict of Interests: The authors have no potential conflicts of interest relevant to this article to disclose. Corresponding author: Tomo Nozawa MD, Department of Pediatrics, Yokohama City University Graduate School of Medicine, Address: 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Jo-Anne Marcuz
- The source(s) of support in the form of grants or industrial support: Tomo Nozawa was supported by research fellowships of Japan Society of Allergology, Mochida Memorial Foundation, and Gushinkai. Brian Feldman is supported by the Ho Family Chair in Autoimmune Diseases. Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada. Conflict of Interests: The authors have no potential conflicts of interest relevant to this article to disclose. Corresponding author: Tomo Nozawa MD, Department of Pediatrics, Yokohama City University Graduate School of Medicine, Address: 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Kristi Whitney
- The source(s) of support in the form of grants or industrial support: Tomo Nozawa was supported by research fellowships of Japan Society of Allergology, Mochida Memorial Foundation, and Gushinkai. Brian Feldman is supported by the Ho Family Chair in Autoimmune Diseases. Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada. Conflict of Interests: The authors have no potential conflicts of interest relevant to this article to disclose. Corresponding author: Tomo Nozawa MD, Department of Pediatrics, Yokohama City University Graduate School of Medicine, Address: 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Ophir Vinik
- The source(s) of support in the form of grants or industrial support: Tomo Nozawa was supported by research fellowships of Japan Society of Allergology, Mochida Memorial Foundation, and Gushinkai. Brian Feldman is supported by the Ho Family Chair in Autoimmune Diseases. Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada. Conflict of Interests: The authors have no potential conflicts of interest relevant to this article to disclose. Corresponding author: Tomo Nozawa MD, Department of Pediatrics, Yokohama City University Graduate School of Medicine, Address: 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Rachel Shupak
- The source(s) of support in the form of grants or industrial support: Tomo Nozawa was supported by research fellowships of Japan Society of Allergology, Mochida Memorial Foundation, and Gushinkai. Brian Feldman is supported by the Ho Family Chair in Autoimmune Diseases. Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada. Conflict of Interests: The authors have no potential conflicts of interest relevant to this article to disclose. Corresponding author: Tomo Nozawa MD, Department of Pediatrics, Yokohama City University Graduate School of Medicine, Address: 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Saunya Dover
- The source(s) of support in the form of grants or industrial support: Tomo Nozawa was supported by research fellowships of Japan Society of Allergology, Mochida Memorial Foundation, and Gushinkai. Brian Feldman is supported by the Ho Family Chair in Autoimmune Diseases. Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada. Conflict of Interests: The authors have no potential conflicts of interest relevant to this article to disclose. Corresponding author: Tomo Nozawa MD, Department of Pediatrics, Yokohama City University Graduate School of Medicine, Address: 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Brian M Feldman
- The source(s) of support in the form of grants or industrial support: Tomo Nozawa was supported by research fellowships of Japan Society of Allergology, Mochida Memorial Foundation, and Gushinkai. Brian Feldman is supported by the Ho Family Chair in Autoimmune Diseases. Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama City, Kanagawa, Japan; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Rheumatology, Saint Michael's Hospital, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada; Departments of Pediatrics and Institute of Health Policy Management & Evaluation, University of Toronto, Toronto, Ontario, Canada. Conflict of Interests: The authors have no potential conflicts of interest relevant to this article to disclose. Corresponding author: Tomo Nozawa MD, Department of Pediatrics, Yokohama City University Graduate School of Medicine, Address: 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
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Abstract
BACKGROUND Tophi develop in untreated or uncontrolled gout. This is an update of a Cochrane Review first published in 2014. OBJECTIVES: To assess the benefits and harms of non-surgical and surgical treatments for the management of tophi in gout. SEARCH METHODS We updated the search of Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase databases to 28 August 2020. SELECTION CRITERIA We included all published randomised controlled trials (RCTs) or controlled clinical trials examining interventions for tophi in gout in adults. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included one trial in our original review. We added four more trials (1796 participants) in this update. One had three arms; pegloticase infusion every two weeks (biweekly), monthly pegloticase infusion (pegloticase infusion alternating with placebo infusion every two weeks) and placebo. Two studies looked at lesinurad 200 mg or 400 mg in combination with allopurinol. One trial studied lesinurad 200 mg or 400 mg in combination with febuxostat. One trial compared febuxostat 80 mg and 120 mg to allopurinol. Two trials were at unclear risk of performance and detection bias due to lack of information on blinding of participants and personnel. All other trials were at low risk of bias. Moderate-certainty evidence (downgraded for imprecision; one study; 79 participants) showed that biweekly pegloticase resolved tophi in 21/52 participants compared with 2/27 on placebo (risk ratio (RR) 5.45, 95% confidence interval (CI) 1.38 to 21.54; number needed to treat for a benefit (NNTB) 3, 95% CI 2 to 6). Similar proportions of participants receiving biweekly pegloticase (80/85) had an adverse event compared to placebo (41/43) (RR 0.99, 95% CI 0.91 to 1.07). However, more participants on biweekly pegloticase (15/85) withdrew due to an adverse event compared to placebo (1/43) (RR 7.59, 95% CI 1.04 to 55.55; number needed to treat for a harm (NNTH) 7, 95% CI 4 to 16). More participants on monthly pegloticase (11/52) showed complete resolution of tophi compared with placebo (2/27) (RR 2.86, 95% CI 0.68 to 11.97; NNTB 8, 95% CI 4 to 91). Similar numbers of participants on monthly pegloticase (84/84) had an adverse event compared to placebo (41/43) (RR 1.05, 95% CI 0.98 to 1.14). More participants on monthly pegloticase (16/84) withdrew due to adverse events compared to placebo (1/43) (RR 8.19, 95% CI 1.12 to 59.71; NNTH 6, 95% CI 4 to 14). Infusion reaction was the most common reason for withdrawal. Moderate-certainty evidence (2 studies; 103 participants; downgraded for imprecision) showed no clinically significant difference for complete resolution of target tophus in the lesinurad 200 mg plus allopurinol arm (11/53) compared to the placebo plus allopurinol arm (16/50) (RR 0.40, 95% CI 0.04 to 4.57), or in the lesinurad 400 mg plus allopurinol arm (12/48) compared to the placebo plus allopurinol arm (16/50) (RR 0.79, 95% CI 0.42 to 1.49). An extension study examined lesinurad 200 mg or 400 mg in combination with febuxostat, or placebo (low-certainty evidence, downgraded for indirectness and imprecision). Participants on lesinurad in the original study continued (CONT) on the same dose. Lesinurad 400 mg plus febuxostat may be beneficial for tophi resolution; 43/65 in the lesinurad 400 mg CONT arm compared to 38/64 in the lesinurad 200 mg CONT arm had tophi resolution (RR 1.11, 95% CI 0.85 to 1.46). Lesinurad 400 mg plus febuxostat may result in no difference in adverse events; 57/65 in the lesinurad 400 mg CONT arm had an adverse event compared to 50/64 in lesinurad 200 mg CONT arm (RR 1.12, 95% CI 0.96 to 1.32). Lesinurad 400 mg plus febuxostat may result in no difference in withdrawals due to adverse events; 10/65 participants in the lesinurad 400 mg CONT arm withdrew due to an adverse event compared to 10/64 participants in the lesinurad 200 mg CONT arm (RR 0.98, 95% CI 0.44 to 2.20). Lesinurad 400 mg plus febuxostat may result in no difference in mean serum uric acid (sUA), which was 3 mg/dl in the lesinurad 400 mg CONT group compared to 3.9 mg/dl in the lesinurad 200 mg CONT group (mean difference -0.90, 95% CI -1.51 to -0.29). Participants who were not on lesinurad in the original study were randomised (CROSS) to lesinurad 200 mg or 400 mg, both in combination with febuxostat. Low-certainty evidence downgraded for indirectness and imprecision showed that lesinurad 400 mg (CROSS) may result in tophi resolution (17/34) compared to lesinurad 200 mg (CROSS) (14/33) (RR 1.18, 95% CI 0.70 to 1.98). Lesinurad 400 mg in combination with febuxostat may result in no difference in adverse events (33/34 in the lesinurad 400 mg CROSS arm compared to 27/33 in the lesinurad 200 mg (CROSS); RR 1.19, 95% CI 1.00 to 1.41). Lesinurad 400 mg plus febuxostat may result in no difference in withdrawals due to adverse events, 5/34 in the lesinurad 400 mg CROSS arm withdrew compared to 2/33 in the lesinurad 200 mg CROSS arm (RR 2.43, 95% CI 0.51 to 11.64). Lesinurad 400 mg plus febuxostat results in no difference in sUA (4.2 mg/dl in lesinurad 400 mg CROSS) compared to lesinurad 200 mg (3.8 mg/dl in lesinurad 200 mg CROSS), mean difference 0.40 mg/dl, 95% CI -0.75 to 1.55. AUTHORS' CONCLUSIONS Moderate-certainty evidence showed that pegloticase is probably beneficial for resolution of tophi in gout. Although there was little difference in adverse events when compared to placebo, participants on pegloticase had more withdrawals due to adverse events. Lesinurad 400 mg plus febuxostat may be beneficial for tophi resolution compared with lesinurad 200 mg plus febuxostat; there was no difference in adverse events between these groups. We were unable to determine whether lesinurad plus febuxostat is more effective than placebo. Lesinurad (400 mg or 200 mg) plus allopurinol is probably not beneficial for tophi resolution, and there was no difference in adverse events between these groups. RCTs on interventions for managing tophi in gout are needed, and the lack of trial data is surprising given that allopurinol is a well-established treatment for gout.
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Affiliation(s)
- Melonie K Sriranganathan
- Rheumatology Service, Department of General Medicine, Changi General Hospital, Singapore City, Singapore
| | - Ophir Vinik
- Division of Rheumatology, St Michael's Hospital, Toronto, Canada
| | - Jordi Pardo Pardo
- Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
| | - Claire Bombardier
- Toronto General Research Institute, University Health Network, Toronto, Canada
| | - Christopher J Edwards
- Department of Rheumatology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Koppikar S, Al-Dabie G, Jerome D, Vinik O. Eosinophilic granulomatosis with polyangiitis presenting with myositis: case based review. Rheumatol Int 2020; 40:1163-1170. [PMID: 32270295 DOI: 10.1007/s00296-020-04567-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
Eosinophilic granulomatosis with polyangitis (EGPA) is a systemic necrotizing small-vessel vasculitis that presents heterogeneously as a multi-organ disease. EGPA evolves through three phases: (1) prodromic phase with asthma, atopy and sinusitis, (2) eosinophilic phase characterized by peripheral eosinophilia and eosinophilic infiltration without necrosis, and (3) vasculitic phase involving organ damage. EGPA often presents with asthma, mononeuritis multiplex, lung infiltrates, sinusitis and constitutional symptoms. Although myalgias are common, EGPA rarely presents with true weakness with elevated creatinine kinase (CK). We describe a rare case of a patient presenting with eosinophilic myositis, who subsequently developed fulminant EGPA. The patient's diagnosis was supported by an initial clinical presentation of weakness and elevated CK, followed by fleeting pulmonary infiltrates and mononeuritis multiplex, peripheral eosinophilia, and strongly positive myeloperoxidase anti-cytoplasmic antibody (MPO-ANCA). Muscle biopsy revealed eosinophilic myositis. The patient responded well to high-dose glucocorticoids and cyclophosphamide with improved symptoms and biochemical markers. Based on our literature review, there are only seven similar cases reported of EGPA presenting with myositis and confirmatory muscle biopsies. There is significant heterogeneity in their clinical findings, histopathology and treatments that were used. Our case report and literature review highlights the importance of recognizing myositis as an initial presenting symptom of EGPA, providing an opportunity for early diagnosis and treatment to reduce risk of further disease progression and morbidity.
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Affiliation(s)
- Sahil Koppikar
- Division of Rheumatology, University of Toronto, Toronto, ON, Canada. .,Division of Rheumatology, Women's College Hospital, University of Toronto, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
| | - Ghaydaa Al-Dabie
- Division of Rheumatology, University of Toronto, Toronto, ON, Canada
| | - Dana Jerome
- Division of Rheumatology, University of Toronto, Toronto, ON, Canada.,Division of Rheumatology, Women's College Hospital, University of Toronto, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Ophir Vinik
- Division of Rheumatology, University of Toronto, Toronto, ON, Canada.,Division of Rheumatology, St. Michael's Hospital, Toronto, ON, Canada
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Hu T, Vinik O. Dermatomyositis and malignancy. Can Fam Physician 2019; 65:409-411. [PMID: 31189628 PMCID: PMC6738379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Tina Hu
- Family medicine resident at St Michael's Hospital at the University of Toronto in Ontario.
| | - Ophir Vinik
- Staff rheumatologist at St Michael's Hospital and Assistant Professor of Medicine at the University of Toronto
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Gao AF, Vinik O, Munoz DG. A 45-Year-Old Woman with Rash and Severe Weakness. Brain Pathol 2019; 29:303-304. [PMID: 30821028 DOI: 10.1111/bpa.12705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Andrew F Gao
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.,Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Canada
| | - Ophir Vinik
- Division of Rheumatology, Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - David G Munoz
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.,Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Canada
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Smith M, Hendren E, Vinik O. A Case of Preventable Vision Loss. JAMA Intern Med 2018; 178:840. [PMID: 29630686 DOI: 10.1001/jamainternmed.2018.0713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Meghan Smith
- MD Undergraduate Program, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Elizabeth Hendren
- Postgraduate Medical Education, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ophir Vinik
- Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Gao AF, Saleh PA, Kassardjian CD, Vinik O, Munoz DG. Brachio-cervical inflammatory myopathy with associated scleroderma phenotype and lupus serology. Neurol Neuroimmunol Neuroinflamm 2018; 5:e410. [PMID: 29114565 PMCID: PMC5663630 DOI: 10.1212/nxi.0000000000000410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 09/05/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Andrew F Gao
- Department of Laboratory Medicine and Pathobiology (A.F.G., D.G.M.), University of Toronto; Division of Neurology (P.A.S., C.D.K.) and Division of Rheumatology (O.V.), Department of Medicine, St. Michael's Hospital; and Department of Laboratory Medicine (A.F.G., D.G.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - Philip A Saleh
- Department of Laboratory Medicine and Pathobiology (A.F.G., D.G.M.), University of Toronto; Division of Neurology (P.A.S., C.D.K.) and Division of Rheumatology (O.V.), Department of Medicine, St. Michael's Hospital; and Department of Laboratory Medicine (A.F.G., D.G.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - Charles D Kassardjian
- Department of Laboratory Medicine and Pathobiology (A.F.G., D.G.M.), University of Toronto; Division of Neurology (P.A.S., C.D.K.) and Division of Rheumatology (O.V.), Department of Medicine, St. Michael's Hospital; and Department of Laboratory Medicine (A.F.G., D.G.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ophir Vinik
- Department of Laboratory Medicine and Pathobiology (A.F.G., D.G.M.), University of Toronto; Division of Neurology (P.A.S., C.D.K.) and Division of Rheumatology (O.V.), Department of Medicine, St. Michael's Hospital; and Department of Laboratory Medicine (A.F.G., D.G.M.), St. Michael's Hospital, Toronto, Ontario, Canada
| | - David G Munoz
- Department of Laboratory Medicine and Pathobiology (A.F.G., D.G.M.), University of Toronto; Division of Neurology (P.A.S., C.D.K.) and Division of Rheumatology (O.V.), Department of Medicine, St. Michael's Hospital; and Department of Laboratory Medicine (A.F.G., D.G.M.), St. Michael's Hospital, Toronto, Ontario, Canada
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Abstract
A 49-year-old woman presents with an extensive violaceous rash, rapidly progressive proximal muscle weakness, and dysphagia to solids, consistent with a diagnosis of dermatomyositis. Two weeks later, she palpates a mass in her left breast and is diagnosed with her2-positive metastatic invasive ductal carcinoma of the breast. There is a well-established association between dermatomyositis and malignancy. However, the specific association between breast cancer and dermatomyositis has not been well characterized. No guideline for oncologists managing these patients has been established. Recently, 3 cases of breast cancer and dermatomyositis were diagnosed at our institution. A review of the literature was pursued to characterize the association between breast cancer and dermatomyositis. A review of 178 papers identified 22 cases of breast cancer with dermatomyositis. Most patients (71%) presented with stage iii or iv breast cancer. The median time between the diagnosis of breast cancer and the onset of dermatomyositis symptoms was 1 month. Three quarters of the patients were steroid-responsive and able to taper. Half the women with follow-up data experienced a documented cancer relapse associated with a new flare of cutaneous symptoms. The presence of dermatomyositis appears to be associated with more-advanced breast cancer stage and is most commonly associated with invasive ductal carcinoma. In our review, treatment of cancer alone is insufficient to adequately control the cutaneous and myopathic manifestations of dermatomyositis, which can significantly affect quality of life. A multidisciplinary approach, including close collaboration with rheumatologists and dermatologists, is therefore important in the diagnosis and management of oncology patients with dermatomyositis.
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Affiliation(s)
- E Hendren
- Postgraduate Medical Education, Department of Medicine, University of Toronto
| | - O Vinik
- Division of Rheumatology, Department of Medicine, St. Michael's Hospital
| | - H Faragalla
- Department of Pathology, St. Michael's Hospital; and
| | - R Haq
- Division of Hematology Oncology, Department of Medicine, St. Michael's Hospital, Toronto, ON
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Vinik O, Wechalekar MD, Falzon L, Buchbinder R, van der Heijde DM, Bombardier C. Treatment of asymptomatic hyperuricemia for the prevention of gouty arthritis, renal disease, and cardiovascular events: a systematic literature review. J Rheumatol Suppl 2015; 92:70-4. [PMID: 25180131 DOI: 10.3899/jrheum.140465] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To systematically review available literature on treatment of hyperuricemia (HU) as a measure of preventing gouty arthritis, renal disease, or cardiovascular events in asymptomatic patients. METHODS A systematic literature search was conducted in the Cochrane Library, Medline, Embase, clinical trials registries of the World Health Organization and the US National Institutes of Health, and abstracts from American College of Rheumatology/European League Against Rheumatism meetings, for interventional studies involving adults with no history of gouty arthritis, who were treated for HU. Outcomes of interest included gouty arthritis, renal disease (i.e., renal insufficiency, urate nephropathy, nephrolithiasis), and cardiovascular events (i.e., myocardial infarction, heart failure, ischemic stroke). RESULTS A total of 3 studies met the inclusion criteria, 2 studies assessing the prevention of renal disease and 1 study evaluating the potential for delaying progression of preexisting renal disease. In hyperuricemic patients without renal disease, treatment resulted in increased estimated glomerular filtration rate. In hyperuricemic patients with preexisting renal disease, treatment resulted in no significant elevation of serum creatinine over a 1-year followup. However, differences in renal function between the treatment and no-treatment groups were not statistically significant in any of the identified studies. CONCLUSION Very limited data are available on the treatment of HU in asymptomatic patients. There is currently insufficient empiric evidence to suggest that lowering serum uric acid level in asymptomatic patients with HU can prevent gouty arthritis, renal disease, or cardiovascular events.
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Affiliation(s)
- Ophir Vinik
- From the Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Rheumatology Research Unit, Repatriation General Hospital, Daw Park; Flinders University, Bedford Park, South Australia, Australia; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; and Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada.O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; M.D. Wechalekar, MD, FRACP, Rheumatology Research Unit, Repatriation General Hospital; and Flinders University; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; R. Buchbinder, MBBS (Hons), MSc, PhD, FRACP, Director, Monash Department of Clinical Epidemiology, Cabrini Hospital, and Professor, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital.
| | - Mihir D Wechalekar
- From the Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Rheumatology Research Unit, Repatriation General Hospital, Daw Park; Flinders University, Bedford Park, South Australia, Australia; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; and Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada.O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; M.D. Wechalekar, MD, FRACP, Rheumatology Research Unit, Repatriation General Hospital; and Flinders University; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; R. Buchbinder, MBBS (Hons), MSc, PhD, FRACP, Director, Monash Department of Clinical Epidemiology, Cabrini Hospital, and Professor, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital
| | - Louise Falzon
- From the Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Rheumatology Research Unit, Repatriation General Hospital, Daw Park; Flinders University, Bedford Park, South Australia, Australia; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; and Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada.O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; M.D. Wechalekar, MD, FRACP, Rheumatology Research Unit, Repatriation General Hospital; and Flinders University; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; R. Buchbinder, MBBS (Hons), MSc, PhD, FRACP, Director, Monash Department of Clinical Epidemiology, Cabrini Hospital, and Professor, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital
| | - Rachelle Buchbinder
- From the Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Rheumatology Research Unit, Repatriation General Hospital, Daw Park; Flinders University, Bedford Park, South Australia, Australia; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; and Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada.O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; M.D. Wechalekar, MD, FRACP, Rheumatology Research Unit, Repatriation General Hospital; and Flinders University; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; R. Buchbinder, MBBS (Hons), MSc, PhD, FRACP, Director, Monash Department of Clinical Epidemiology, Cabrini Hospital, and Professor, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital
| | - Désirée M van der Heijde
- From the Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Rheumatology Research Unit, Repatriation General Hospital, Daw Park; Flinders University, Bedford Park, South Australia, Australia; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; and Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada.O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; M.D. Wechalekar, MD, FRACP, Rheumatology Research Unit, Repatriation General Hospital; and Flinders University; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; R. Buchbinder, MBBS (Hons), MSc, PhD, FRACP, Director, Monash Department of Clinical Epidemiology, Cabrini Hospital, and Professor, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital
| | - Claire Bombardier
- From the Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Rheumatology Research Unit, Repatriation General Hospital, Daw Park; Flinders University, Bedford Park, South Australia, Australia; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; and Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada.O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; M.D. Wechalekar, MD, FRACP, Rheumatology Research Unit, Repatriation General Hospital; and Flinders University; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; R. Buchbinder, MBBS (Hons), MSc, PhD, FRACP, Director, Monash Department of Clinical Epidemiology, Cabrini Hospital, and Professor, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital
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Sriranganathan MK, Vinik O, Falzon L, Bombardier C, van der Heijde DM, Edwards CJ. Interventions for tophi in gout: a Cochrane systematic literature review. J Rheumatol Suppl 2015; 92:63-9. [PMID: 25180130 DOI: 10.3899/jrheum.140464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To systematically review the available literature on the management of tophi in gout. This article is based on the Cochrane Review Interventions for Tophi in Gout published in the Cochrane Database of Systematic Reviews. METHODS Medline, Embase, and The Cochrane Library were searched using a strategy developed with an experienced librarian. We also searched American College of Rheumatology and European League Against Rheumatism conference abstracts from 2010-2011. Included articles were reviewed in detail and a risk of bias (using the Cochrane tool) and quality assessment were performed. RESULTS In total, 3206 references were recovered. Of these, 72 articles were selected based on our inclusion criteria. This included 1 report of 2 randomized controlled trials, 2 nonrandomized studies, and 69 case series and reports. The study with 2 randomized controlled trials looked at pegloticase. This showed improvement in tophi with treatment. One observational prospective trial looked at allopurinol and benzbromarone individually and in combination. It noted that achieving lower serum urate levels was associated with a faster reduction of tophi. An open-label extension trial noted that longterm maintenance of serum uric acid < 6.0 mg/dl with febuxostat led to a reduction in tophi. The case series and reports looked at surgical, pharmacological, and other interventions, as well as combination therapies. All surgical interventions reported improvement in pain and/or function. No report had objective measures of outcome. CONCLUSION Treatment with urate-lowering therapy such as allopurinol, benzbromarone, allopurinol + benzbromarone in combination, febuxostat, or pegloticase can lead to reduction in tophi. There is some evidence that achieving a lower serum urate level leads to a faster rate of tophi reduction.
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Affiliation(s)
- Melonie K Sriranganathan
- From the Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; and the Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.M.K. Sriranganathan, MBBS, MRCP, Specialist Registrar in Rheumatology and General Internal Medicine, Rheumatology Department, University Hospital Southampton NHS Foundation Trust; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C.J. Edwards, MBBS, MD, FRCP, Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust.
| | - Ophir Vinik
- From the Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; and the Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.M.K. Sriranganathan, MBBS, MRCP, Specialist Registrar in Rheumatology and General Internal Medicine, Rheumatology Department, University Hospital Southampton NHS Foundation Trust; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C.J. Edwards, MBBS, MD, FRCP, Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust
| | - Louise Falzon
- From the Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; and the Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.M.K. Sriranganathan, MBBS, MRCP, Specialist Registrar in Rheumatology and General Internal Medicine, Rheumatology Department, University Hospital Southampton NHS Foundation Trust; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C.J. Edwards, MBBS, MD, FRCP, Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust
| | - Claire Bombardier
- From the Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; and the Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.M.K. Sriranganathan, MBBS, MRCP, Specialist Registrar in Rheumatology and General Internal Medicine, Rheumatology Department, University Hospital Southampton NHS Foundation Trust; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C.J. Edwards, MBBS, MD, FRCP, Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust
| | - Desiree M van der Heijde
- From the Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; and the Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.M.K. Sriranganathan, MBBS, MRCP, Specialist Registrar in Rheumatology and General Internal Medicine, Rheumatology Department, University Hospital Southampton NHS Foundation Trust; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C.J. Edwards, MBBS, MD, FRCP, Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust
| | - Christopher J Edwards
- From the Rheumatology Department, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; and the Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.M.K. Sriranganathan, MBBS, MRCP, Specialist Registrar in Rheumatology and General Internal Medicine, Rheumatology Department, University Hospital Southampton NHS Foundation Trust; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; L. Falzon, PGDipInf, Center for Behavioral Cardiovascular Health, Columbia University Medical Center; C. Bombardier, MD, FRCPC, Professor, Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital; D.M. van der Heijde, MD, PhD, Professor of Rheumatology, Rheumatology Department, Leiden University Medical Center; C.J. Edwards, MBBS, MD, FRCP, Department of Rheumatology and NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust
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Wechalekar MD, Vinik O, Moi JHY, Sivera F, van Echteld IAAM, van Durme C, Falzon L, Bombardier C, Carmona L, Aletaha D, Landewé RB, van der Heijde DMFM, Buchbinder R. The efficacy and safety of treatments for acute gout: results from a series of systematic literature reviews including Cochrane reviews on intraarticular glucocorticoids, colchicine, nonsteroidal antiinflammatory drugs, and interleukin-1 inhibitors. J Rheumatol Suppl 2015; 92:15-25. [PMID: 25180124 DOI: 10.3899/jrheum.140458] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of glucocorticoids (GC), colchicine, nonsteroidal antiinflammatory drugs (NSAID), interleukin-1 (IL-1) inhibitors, and paracetamol to treat acute gout. METHODS We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials to September 2011. Randomized controlled trials (RCT) or quasi-RCT in adults with acute gout that compared GC, colchicine, NSAID, IL-1 inhibitors, and paracetamol to no treatment, placebo, another intervention, or combination therapy were included. Two authors independently extracted data and assessed risk of bias. Primary endpoints were pain and adverse events. Data were pooled where appropriate. RESULTS Twenty-six trials evaluating GC (N = 5), NSAID (N = 21), colchicine (N = 2), and canakinumab (N = 1) were included. No RCT assessed paracetamol or intraarticular (IA) GC. No RCT compared systemic GC with placebo. Moderate quality evidence (3 trials) concluded that systemic GC were as effective as NSAID but safer. Low quality evidence (1 trial) showed that both high- and low-dose colchicine were more effective than placebo, and low-dose colchicine was no different to placebo with respect to safety but safer than high-dose colchicine. Low quality evidence (1 trial) showed no difference between NSAID and placebo with regard to pain or inflammation. No NSAID was superior to another. Moderate quality evidence (1 trial) found that 150 mg canakinumab was more effective than a single dose of intramuscular GC (40 mg triamcinolone) and equally safe. CONCLUSION GC, NSAID, low-dose colchicine, and canakinumab all effectively treat acute gout. There was insufficient evidence to rank them. Systemic GC appeared safer than NSAID and lower-dose colchicine was safer than higher-dose colchicine.
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Affiliation(s)
- Mihir D Wechalekar
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Ophir Vinik
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - John H Y Moi
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Francisca Sivera
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Irene A A M van Echteld
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Caroline van Durme
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Louise Falzon
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Claire Bombardier
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Loreto Carmona
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Daniel Aletaha
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Robert B Landewé
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Désirée M F M van der Heijde
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
| | - Rachelle Buchbinder
- From the Rheumatology Research Unit, Repatriation General Hospital, Daw Park, South Australia; and Flinders University, Bedford Park, South Australia, Australia; Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; Department of Rheumatology, Hospital General Universitario Elda, Alicante, Spain; Rheumatology Department, St. Elisabeth Hospital, Tilburg, The Netherlands; Rheumatology Department, Maastricht University Medical Centre, Maastricht, The Netherlands; and Rheumatology Department, Centre Hospitalier Universitaire, Liège, Belgium; Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA; Division of Rheumatology and Institute of Health Policy, Management, and Evaluation, University of Toronto; and Toronto General Research Institute, University Health Network; Institute for Work and Health, Mount Sinai Hospital, Toronto, Ontario, Canada; Facultad de Ciencias de la Salud, Universidad Camilo Jose Cela, Madrid, Spain; Internal Medicine, Rheumatology Department, Medical University of Vienna, Vienna, Austria; Department of Clinical Immunology and Rheumatology, Academic Medical Center, Amsterdam, The Netherlands; and Atrium Medical Center; Rheumatology Department, Leiden University Medical Center, Leiden, The Netherlands; Monash Department of Clinical Epidemiology, Cabrini Hospital, Malvern, Victoria, Australia; and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Malvern, Victoria, Australia.M.D. Wechalekar, MD, FRACP, Rheumatology Unit, Repatriation General Hospital, Daw Park, South Australia, Australia; and Flinders University; O. Vinik, MD, FRCPC, Division of Rheumatology, University of Toronto; J.H.Y. Moi, BPhysio (Hons), MBBS (Hons), FRACP, Rheumatologist, Department of Rheumatology, The Royal Melbourne Hospital, Melbourne, Australia; F. Sivera, MD
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14
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Abstract
BACKGROUND Tophi develop in untreated or uncontrolled gout. Their presence can lead to severe and potentially fatal complications. To date there have been no systematic reviews focused on the management of tophi in gout. OBJECTIVES To assess the benefits and harms of non-surgical and surgical treatments for the management of tophi in gout. SEARCH METHODS We searched three databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE. We handsearched American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts from 2010 to 2011, references from included studies and trial registries. We completed the most recent search on 20 May 2013. SELECTION CRITERIA All published randomised controlled trials (RCTs) or controlled clinical trials with quasi-randomised methods of allocating participants to treatment examining interventions for tophi in gout in adults. Possible interventions included urate-lowering pharmacological treatment (e.g. benzbromarone, probenecid, allopurinol, febuxostat, pegloticase), surgical removal or other interventions such as haemodialysis. DATA COLLECTION AND ANALYSIS Two review authors extracted data from titles, abstracts and selected studies for detailed review, and extracted data and risk of bias independently. Major outcomes were number of participants with complete resolution of tophi, number of study participant withdrawals due to adverse events, joint pain reduction, function, quality of life, serum urate normalisation and total adverse events. MAIN RESULTS Only one study, at low risk of all biases, met the inclusion criteria. This was the pooled results from two RCTs (225 participants, 145 with tophi at baseline) randomised to one of three arms; pegloticase infusion every two weeks (biweekly), monthly pegloticase infusion (pegloticase infusion alternating with placebo infusion every two weeks) and placebo. Moderate-quality evidence from one study indicated that biweekly pegloticase 8 mg infusion reduced tophi in the subset of participants with tophi, but increased withdrawals due to adverse events in all participants, and monthly infusion appeared to result in less benefit.Biweekly pegloticase treatment resulted in resolution of tophi in 21/52 participants compared with 2/27 who received placebo (risk ratio (RR) 5.45, 95% confidence intervals (CI) 1.38 to 21.54; number needed to treat for an additional beneficial outcome (NNTB) 3 (95% CI 2 to 6).Eleven of 52 participants with monthly pegloticase treatment had complete resolution of one or more tophi compared with 2/27 who received placebo (RR 2.86, 95% CI 0.68 to 11.97).Participant-reported pain relief of 30% or greater, function, quality of life, serum urate normalisation, were reported for all participants but not separately for those with tophi; therefore, we did not include the results.Pegloticase administered biweekly resulted in more withdrawals due to adverse events compared with placebo (15/85 participants with pegloticase versus 1/43 participants with placebo; RR 7.59, 95% CI 1.04 to 55.55; number needed to treat for an additional harmful outcome (NNTH) 7, 95% CI 4 to 17). Pegloticase administered monthly also resulted in more withdrawals due to adverse events than placebo (16/84 participants with pegloticase versus 1/43 participants with placebo; RR 8.19, 95% CI 1.12 to 59.71; NNTH 6, 95% CI 4 to 14). Most withdrawals were due to infusion reactions.Total adverse events were high in all treatment groups: 80/85 participants administered pegloticase biweekly reported an adverse event compared with 41/43 from the placebo group (RR 0.99, 95% CI 0.91 to 1.07); 84/84 participants administered pegloticase monthly reported an adverse event versus 41/43 in the placebo group (RR 1.05, 95% CI 0.98 to 1.14). As 80% of adverse events were due to flares of gout, probably unrelated to the drug treatment per se, this may explain the high rate of adverse events in the placebo group - who were essentially untreated. AUTHORS' CONCLUSIONS This study showed pegloticase is probably beneficial in the management of tophi in gout, in terms of resolution of tophi, but with a high risk of adverse infusion reactions. However, there is a need for more RCT data considering other interventions, including surgical removal of tophi.
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Affiliation(s)
- Melonie K Sriranganathan
- Department of Rheumatology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire, UK, SO16 6YD
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15
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Sivera F, Andrés M, Carmona L, Kydd ASR, Moi J, Seth R, Sriranganathan M, van Durme C, van Echteld I, Vinik O, Wechalekar MD, Aletaha D, Bombardier C, Buchbinder R, Edwards CJ, Landewé RB, Bijlsma JW, Branco JC, Burgos-Vargas R, Catrina AI, Elewaut D, Ferrari AJL, Kiely P, Leeb BF, Montecucco C, Müller-Ladner U, Ostergaard M, Zochling J, Falzon L, van der Heijde DM. Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative. Ann Rheum Dis 2013; 73:328-35. [PMID: 23868909 PMCID: PMC3913257 DOI: 10.1136/annrheumdis-2013-203325] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We aimed to develop evidence-based multinational recommendations for the diagnosis and management of gout. Using a formal voting process, a panel of 78 international rheumatologists developed 10 key clinical questions pertinent to the diagnosis and management of gout. Each question was investigated with a systematic literature review. Medline, Embase, Cochrane CENTRAL and abstracts from 2010-2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, rheumatologists from 14 countries (Europe, South America and Australasia) developed national recommendations. After rounds of discussion and voting, multinational recommendations were formulated. Each recommendation was graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. Combining evidence and clinical expertise, 10 recommendations were produced. One recommendation referred to the diagnosis of gout, two referred to cardiovascular and renal comorbidities, six focused on different aspects of the management of gout (including drug treatment and monitoring), and the last recommendation referred to the management of asymptomatic hyperuricaemia. The level of agreement with the recommendations ranged from 8.1 to 9.2 (mean 8.7) on a 1-10 scale, with 10 representing full agreement. Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, enhancing their utility in clinical practice.
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Affiliation(s)
- Francisca Sivera
- Department Reumatologia, Hospital General Universitario de Elda, , Elda, Spain
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16
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Abstract
BACKGROUND Although intra-articular glucocorticoids are a commonly used intervention in the treatment of acute gout, there is little evidence to support their safety and efficacy in this setting. OBJECTIVES To evaluate the safety and efficacy of intra-articular glucocorticoids in the treatment of acute gout. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE and Ovid EMBASE for studies to 16th October 2012. We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of articles considered for inclusion. SELECTION CRITERIA Studies were eligible for inclusion if they were randomised controlled trials (RCTs) or controlled clinical trials (CCTs) that used quasi-randomisation methods to allocate participants to treatment and compared intra-articular glucocorticoids to another therapy (active or placebo) in adults with acute gout. Outcomes selected for inclusion were pain, the proportion of participant withdrawals due to adverse events, inflammation, function, patient global assessment of treatment success, quality of life and proportion of particpants with serious adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently selected the studies for inclusion and planned to extract the data and perform a risk of bias assessment. MAIN RESULTS No trials were identified that evaluated the efficacy and safety of intra-articular glucocorticoids for acute gout. AUTHORS' CONCLUSIONS There is presently no evidence from randomised trials to support the use of intra-articular glucocorticoid treatment in acute gout. Evidence suggests intra-articular glucocorticoids may be a safe and effective treatment in osteoarthritis and rheumatoid arthritis. These results may be generalisable to people with acute gout, and the treatment may be especially useful in people when non-steroidal anti-inflammatory drugs or colchicine are contraindicated.
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