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Insider Arthritis Tips Newsletter July 2010
July 15, 2010

"One of the things I learned the hard way was that it doesn't pay to get discouraged. Keeping busy and making optimism a way of life can restore your faith in yourself."

-- Lucille Ball, actress

I’ve been asked by some subscribers to mention some new advances. It just so happens that the European League Against Rheumatism (EULAR) meeting just took place in Rome. This is the European equivalent of our American College of Rheumatology meeting. Here are some highlights, kindly provided, in part, by reporter Alice Goodman at Medscape…

Kidney Safety of Anti-inflammatory Medicines Confirmed in Study of RA Patients.
The use of non-steroidal anti-inflammatory drugs (NSAIDs) did not adversely affect kidney function in patients with rheumatoid arthritis (RA), according to the results of one of the largest prospective studies to examine kidney toxicity in RA patients, Swiss investigators reported. The strengths of this study include its size and the fact that it is based on real-life data.
The authors stated NSAIDs should be used responsibly. NSAIDs should not be used in stage 4 or 5 chronic kidney disease.
(This is a surprising study… I still feel nervous using NSAIDS in RA patients on multiple medicines.)

Enbrel Outperforms Azulfidine in Patients With Active Spondyloarthritis
Enbrel achieved significantly more improvement in magnetic resonance imaging (MRI)-detected active inflammatory damage of the spine than Azulfidine in patients with early active spinal spondyloarthritis (SpA), according to the results of the 48-week randomized controlled ESTHER trial. Spondyloarthritis includes disease like psoriatic arthritis, ankylosing spondylitis, and Reiter’s disease.

Clinical data showed that 50% of the Enbrel group was in partial remission by the end of the study, according to Assessment of SpondyloArthritis scores, compared with 19% of the Azulfidine group.
(I’m not surprised. Europeans use a lot more Azulfidine than Americans. We don’t use it because its effects on rheumatoid arthritis are relatively mild.)

COMET: Remission Rate of 70% With Very Early Combination Treatment of RA
Very early treatment of patients with rheumatoid arthritis (RA) with a disease duration of 4 months or less is a superior strategy to treating patients with RA of 4 months to 2 years in duration, according to a 1-year analysis of the COMET (Combination of Methotrexate and Enbrel in Active Early Rheumatoid Arthritis) trial.
Very early treatment with the combination of Enbrel and methotrexate, in particular, halted the structural progression of the disease in approximately 80% of patients.
(I believe that these results could be replicated using any anti-TNF drug. The idea is that early treatment is key.)

Intensive Vitamin D Supplementation May Be Indicated for Patients With RA
Vitamin D deficiency is common in rheumatoid (RA) and other forms of arthritis, and the recommended daily dose of vitamin D did not normalize levels in patients with RA who had deficient levels of vitamin D, according to one study.
The authors stated, “Our preliminary results suggest that standard maintenance therapy for vitamin D deficiency may not be adequate in patients with RA."
But we still don't know whether arthritic disease leads to vitamin D deficiency, or [whether it is] the other way around.
(Chicken or egg)

Drinkers at Lower Risk for Rheumatoid Arthritis but Causality Should Not Be Inferred
Alcohol consumption is associated with a reduced risk for several arthritic conditions, including rheumatoid arthritis, osteoarthritis, and less common types of arthritis, according to another study. But researchers caution against any cause-and-effect conclusions. "There are several explanations. Perhaps people with arthritis don't feel well and don't drink alcohol. Or it is possible that alcohol suppresses inflammation and/or arthritis. We want to be careful about the message from this study. We are not suggesting that drinking alcohol will protect against rheumatoid arthritis."
(Be careful! This isn’t a license to overindulge.)

New Psoriatic Arthritis (PsA) Recommendations

The gist of the new recommendations is as follows:
• Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as first-line treatment for musculoskeletal signs and symptoms in PsA patients with joint involvement.
• Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate, Azulfidine, and Arava, should be considered early-stage treatment in patients with active disease and signs of joint damage plus inflammation.
• For active PsA, a DMARD that also improves psoriasis, such as methotrexate, should be considered.
• Patients with active PsA and an inadequate response to at least 1 DMARD, such as methotrexate, should be treated with a tumor necrosis factor (TNF) inhibitor.
• TNF inhibitors should be considered first-line treatment for patients with active joint or tendon inflammation, those with predominant spinal disease who have had an inadequate response to NSAIDs or local steroids, and patients with very active PsA, particularly those with swollen joints, joint damage in the presence of inflammation, and/or non-point complications, especially extensive skin involvement.
• Failure to respond to 1 TNF inhibitor warrants consideration of a switch to another TNF inhibitor.
• When adjusting therapy, apart from disease activity, other medical problems and safety issues should be addressed.

Selective COX-2 Inhibitors Cause Less GI Irritation Than NSAID Plus PPI
Patients with rheumatoid arthritis and osteoarthritis treated with a selective cyclooxygenase-2 (COX-2) inhibitor (eg., Celebrex) for inflammation and pain were 4 to 5 times less likely to develop clinically significant upper and lower gastrointestinal problems than those who were treated with diclofenac (Voltaren), a nonselective nonsteroidal anti-inflammatory drug, plus a proton pump inhibitor, according to results of the Celecoxib vs Omeprazole and Diclofenac in Patients With Osteoarthritis and Rheumatoid Arthritis (CONDOR) study.
(Despite the bad press with COX-2 drugs, Celebrex is a good NSAID)

Wei's World July 2010

This months Wei’s World is about my oldest son, Jeffrey. He just graduated from New York University’s Tisch School for the Performing Arts with a major in musical theater. His graduation ceremony took place at Madison Square Garden. It was a very entertaining event.

That Jeffrey chose to travel this route is not a surprise. Since he was about age two, he has always wanted to be on Broadway.

He currently auditions during the day and he also got a night job as waiter at an upscale sushi restaurant in Manhattan. Which is fortunate, since he loves sushi and is a natural performer… so he’s found waiting tables to be to his liking.

He’s learning how to deal with the public… which is important no matter what you choose to do.

Jeffrey is also going to be supporting himself. My wife and I have made it clear to all our children… we’ll help pay for them to go through college but once they graduate, they’re on their own and they can’t move back home.

What’s interesting is, he has never had any interest in medicine and we have never pushed him towards it either.

I think that it’s important for a person to follow their dream, their passion, and become the best they can be.

The life of a performer, though, is a bittersweet one because a lot of it is going to audition after audition, call back after call back, waiting for your chance to shine. There’s a lot of disappointment and frustration. An ability to roll with the punches and keep at it is so important. There’s an old Japanese proverb, which when loosely translated means, “Fall down seven times… get up eight.” That pretty much sums up what he has to do.

Jeffrey has been blessed with a ton of talent. He was born to perform on the stage. And now he needs the lucky break.

He’ll get it. Talent like his doesn’t come along very often. Even though he can get discouraged, I tell him to hang in there because he will become a superstar.

Remember… you heard it from me first!

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