Long-term outcomes of daily oral vs. pulsed intravenous cyclophosphamide in a non-trial setting in ANCA-associated vasculitis

We aimed to compare risk of death, relapse, neutropenia and infection requiring hospital admission between unselected ANCA-associated vasculitis (AAV) patients according to whether cyclophosphamide induction was by daily oral (PO) or pulse intravenous (IV) route. We identified all newly diagnosed AAV patients treated with PO or IV cyclophosphamide between March 2007 and June 2013. We used Cox and logistic regression models to compare mortality, relapse and adverse events and adjusted these for age, renal function and other significant confounders. Fifty-seven patients received PO and 57 received IV cyclophosphamide. One-year survival was 86.0% in PO and 98.2% in IV patients; all-time adjusted hazard ratio (HR) for PO compared to that of IV cyclophosphamide was 1.8 (95% CI 0.3–10.6, P = 0.54). One-year relapse-free survival was 80.7% in PO compared to 87.3% in IV patients, all-time adjusted HR 3.8 (0.2–846, P = 0.37). During the first 12 months, neutropenia of ≤ 0.5 × 10⁹/L occurred in 9 (16%) PO and 0 (0%) IV cyclophosphamide patients (P = 0.003). The number of patients admitted with one or more infections was 16 (28%) in the PO group and 9 (16%) in the IV group, adjusted OR 2.2 (0.6–8.6, P = 0.23). We observed an increased risk of neutropenia, a trend towards increased risk of death and an admission with infection with PO cyclophosphamide. This adds certainty to previous studies, indicating that PO administration induces greater marrow toxicity. Infection-related admissions within 12 months of starting cyclophosphamide were higher than those in clinical trials, possibly reflecting the unselected nature of this cohort.

Long-term persistence and adherence on urate-lowering treatment can be maintained in primary care-5-year follow-up of a proof-of-concept study

Objectives

To evaluate the persistence and adherence on urate-lowering treatment (ULT) in primary care 5 years after an initial nurse-led treatment of gout.

Methods

One hundred gout patients initiated on up-titrated ULT between March and July 2010 were sent a questionnaire that elicited information on current ULT, reasons for discontinuation of ULT if applicable, medication adherence and generic and disease-specific quality-of-life measures in 2015. They were invited for one visit at which height and weight were measured and blood was collected for serum uric acid measurement.

Results

Seventy-five patients, mean age 68.13 years ( s . d . 10.07) and disease duration 19.44 years ( s . d . 13), returned completed questionnaires. The 5-year persistence on ULT was 90.7% (95% CI 81.4, 91.6) and 85.3% of responders self-reported taking ULT ⩾6 days/week. Of the 65 patients who attended the study visit, the mean serum uric acid was 292.8 μmol/l ( s . d . 97.2).

Conclusion

An initial treatment that includes individualized patient education and involvement in treatment decisions results in excellent adherence and persistence on ULT >4 years after the responsibility of treatment is taken over by the patient's general practitioner, suggesting that this model of gout management should be widely adopted.

Does the initiation of urate-lowering treatment during an acute gout attack prolong the current episode and precipitate recurrent attacks: a systematic literature review

The aim of this study was to systematically review the literature on effect of initiating urate-lowering treatment (ULT) during an acute attack of gout on duration of index attack and persistence on ULT. OVID (Medline), EMBASE and AMED were searched to identify randomized controlled trials (RCTs) of ULT initiation during acute gout attack published in English language. Two reviewers appraised the study quality and extracted data independently. Standardized mean difference (SMD) and relative risk (RR) were used to pool continuous and categorical data. Meta-analysis was carried out using STATA version 14. A total of 537 studies were selected. A total of 487 titles and abstracts were reviewed after removing duplicates. Three RCTs were identified. There was evidence from two high-quality studies that early initiation of allopurinol did not increase pain severity at days 10–15 [SMD_pooled (95 % CI) 0.18 (−0.58, 0.93)]. Data from three studies suggested that initiation of ULT during an acute attack of gout did not associate with dropouts [RR_pooled (95 % CI) 1.16 (0.58, 2.31)]. There is moderate-quality evidence that the initiation of ULT during an acute attack of gout does not increase pain severity and risk of ULT discontinuation. Larger studies are required to confirm these findings so that patients with acute gout can be initiated on ULT with confidence.

First validation of the gout activity score against gout impact scale in a primary care based gout cohort

OBJECTIVES

To validate the gout activity score (GAS) against the gout impact scale in a primary care based gout cohort.

METHODS

This was a single-centre cross-sectional study. People with gout who participated in previous research at academic rheumatology, University of Nottingham, UK, and consented for participation in future studies were mailed a questionnaire in September 2015. Those returning completed questionnaires were invited to attend for a study visit at which blood was collected and musculoskeletal examination was performed. The Gout Assessment Questionnaire, which contains the gout impact scale (GIS), and short form (SF) 36v2 questionnaires were completed. The GAS_3-step-c score was calculated. Spearman's correlation coefficient was calculated to examine correlation between GAS and SF-36 v2, and GIS. Statistical analyses were performed using PASW v22.

RESULTS

One hundred and two (93% men) of the 150 participants who were mailed a questionnaire attended the study visit. Their mean (SD) age, body mass index, serum uric acid and GAS were 67.94 (9.93) years, 29.96 (4.57) kg/m², 5.25 (1.75) mg/dl, and 2.99 (0.74) respectively. There was moderate correlation between GAS and gout concern overall, unmet gout treatment need, and gout concern during an attack components of GIS (r=0.306 to 0.453), but no to poor correlation between GAS and summary scores and scales of SF-36 v2 (r=-0.090 to -0.251).

CONCLUSION

This first study to validate GAS against the GIS found moderate correlation. However, this study did not examine the predictive validity of GAS, and prospective studies are needed before GAS can be used widely.

Life-Threatening Bronchospasm

While Eosinophilic Asthma is frequently underdiagnosed, COPD is often misdiagnosed. This case focusses on a COPD misdiagnosis that had life-threatening consequences. The patient was a 59-year-old, male smoker, who presented to the Emergency Department with a week's history of increasing shortness of breath. On presentation, severe respiratory acidosis persisted acidotic despite Nebulisers, Oxygen, Steroids, and Magnesium. He was intubated for two weeks and had severe bronchospasm associated with type 2 respiratory failure. Eosinophils on admission were markedly elevated and remained so despite a week of intravenous steroids. As he missed the window for ECMO, we were advised to look at his diagnostic spirometry. Surprisingly, the spirometry done by his general practitioner, two years prior, showed Asthma not COPD. His blood eosinophils were elevated then, too. A revised diagnosis of Eosinophilic Asthma was given. Intravenous steroids were increased, and nebulised steroids were started. Soon thereafter, his condition improved, and he was stepped down from Intensive care. Hopefully, this case report increases physician knowledge of the different Asthma phenotypes and reduces incidences where correct treatment is only started during an avoidable life-threatening exacerbation.