Steroids are a greater risk than methotrexate

In a study published in Annals of Rheumatic disease (feb 2012) the authors conclude that patients who use long term steroids are at a higher risk of non serious infections than patients who use methotrexate.  The risk of infections increases with increased steroid use.

How do you know if your arthritis medications are working?

If you have Rheumatoid Arthritis your Rheumatologist will prescribe medications called disease modifying drus.  In Dubai about 70 percent of Rheumatoid arthritis patients are eventually started on methotrexate.  How do we know if these medications are working?  The Rheumatologist should listen to your symptoms, and ask about you pain levels.  She should then do a thorough joint examination and make a note of how many swollen and inflamed joints you have.  A blood test called ESR and CRP is also used to track inflammation.  All these factors are then put into a computerized scoring system to give a DAS28 or disease activity 28 score.  A score < 2.6 means disease remission and < 3.2 means low disease activity.

Gastritis medications can increase your risk of fracture

According to a National Institutes of Health-funded study published online in the BMJ, "postmenopausal women who use proton pump inhibitors (medicines such as omeprazole, pantoprozole nexium etc) regularly are at increased risk for hip fracture, particularly if they have ever smoked. This is of concern especially in Dubai and the United Arab Emirates where people buy and use these gastritis medications over the counter.  In addition, women here have high levels of vitamin D deficiency and osteoporosis. " In fact, "the risk of hip fracture was increased by 35% among women who used these drugs for at least two years, compared with women who never used them (age-adjusted HR 1.35, 95% CI 1.12 to 1.62, P<0.01 for trend)." What's more, "the risk for fracture rose by more than 50% among women with a history of smoking (multivariate HR 1.51, 95% CI 1.20 to 1.91)," the study found.         For the study, researchers "collected data on almost 80,000 postmenopausal women. "Over the course of eight years, from 2000 to 2008, almost 900 hip fractures occurred -- a 35 percent increased risk for women using PPIs compared to women who didn't take the drugs.

Pomegranate juice good for Rheumatoid arthritis

A new study suggests" that pomegranates "may help relieve symptoms of rheumatoid arthritis. ... In a recent study from Case Western Reserve University School of Medicine," two-thirds of mice given "a daily dose of pomegranate extract" developed chemically induced rheumatoid arthritis (RA), whereas the mice given only water all developed RA. Other research suggests that pomegranate juice "may help reduce the buildup of plaque in arteries and lower blood pressure." and "that when men with prostate cancer drank a cup of pomegranate juice daily, the increase in their levels of prostate-specific antigen (PSA), a marker of disease progress, slowed. Still more preliminary studies hint that pomegranate juice may help manage diabetes and erectile dysfunction." Previous studies have shown that cherry juice concentrate is excellent for gout and decreases flares of gout.

Diagnosing Rheumatoid arthritis

Last week I saw a 50 year old lady from the UK and she had a 6 week history of pain and swelling in her right index finger and also toes.  When I examined her I found swelling and tenderness of 1 joint in the right 2nd finger (PIP) and 2 joints of the toes (MTP).  The signs were so minimal and even though she had a high titer positive Rheumatoid factor I did not believe she had full blown rheumatoid arthritis.  I repeated the rheumatoid factor which came back very high and she also had a positive test for anti- CCP.  Although she had minimal symtoms she was classified as early rheumatoid arthritis and we started her on methotrexate .  In this case the positive tests helped the diagnosis. 

Another patients I saw today had a 6 month history of swelling and tenderness of fingers and toes.  Many joints were involved but she had normal ESR CRP Rheumatoid factor and anti-CCP.  She was told she did not have rheumatoid arthritis.  I told her she has definite rheumatoid arthritis and she was started on treatment.  In this case the clinical signs are more important than the blood tests.

Classification criteria for RA (score-based algorithm: add score of categories A–D; a score of ≥6/10 is needed for classification of a patient as having definite RA)‡
A. Joint involvement §
1 large joint¶	0
2-10 large joints	1
1-3 small joints (with or without involvement of large joints)#	2
4-10 small joints (with or without involvement of large joints)	3
>10 joints (at least 1 small joint)**	5
B. Serology (at least 1 test result is needed for classification)††
Negative RF and negative ACPA	0
Low-positive RF or low-positive ACPA	2
High-positive RF or high-positive ACPA	3
C. Acute-phase reactants (at least 1 test result is needed for classification)‡‡
Normal CRP and normal ESR	0
Abnormal CRP or abnormal ESR	1
D. Duration of symptoms§§
<6 weeks	0
≥6 weeks	1

Milk powder can prevent gout flares. Posted by Rheumatologist in Dubai.

"Daily consumption of enriched skim milk powder could help prevent gout flares," according to a proof-of-conceptstudy published in the Annals of the Rheumatic Diseases. "Compared with patients randomized to receive control treatment with simple powdered lactose, those given enriched skim milk powder had greater reductions in flares of gout during a three-month period (P=0.044), according to Nicola Dalbeth, MD, of the University of Auckland in New Zealand, and colleagues." But "there was no difference in flare frequency for patients given plain skim milk powder rather than the enriched formulation, compared with those given lactose (P=0.81)," the study found.

        "In this study, researchers at the University of Auckland in New Zealand looked at the effects of drinking a skim milk powder enriched with two dairy components, glycomacropeptide (GMP) and G600 milk fat extract (G600), on the frequency of gout attacks in 102 people," WebMD (1/24, Warner) adds. "The people were divided into three groups" and "drank either the enriched milk powder, a plain skim milk powder, or a lactose powder mixed with water as a vanilla-flavored shake each day." The study found that "after three months, the frequency of gout attacks dropped in all three groups" but "those who drank the enriched skim milk had a significantly bigger reduction in gout attacks than those in the other two groups."

Knee replacements on the rise.

A new study published online on 17 January in the journal Arthritis & Rheumatism reports that rates of knee replacement surgery in Finland's 30 to 59-year-olds soared between 1980 and 2006, with women being the more common recipients throughout. Lead author Dr. Jarkko Leskinen, an orthopedic surgeon at Helsinki University Central Hospital, and colleagues also report that the greatest increase was among those aged between 50 and 59.

Knee replacement surgery is the common term for partial and total knee arthroplasty, an operation where part or all of the diseased or damaged surfaces of the knee joint are replaced with metal and plastic parts shaped to allow the patient to move the knee normally.

Arthroplasty is often the only treatment option for people who have severe osteoarthritis (OA) of the knee, as Leskinen explained the press:

"OA risk is shown to increase with age and for severe knee OA arthroplasty is a commonly used treatment option when patients are unresponsive to more conservative therapies."

But although arthroplasty has become increasingly more common, we don't have much information on rates among different parts of the population, and its effects in younger patients.

For their study, Leskinen and collegues looked at records of all unicondylar (partial) and total knee replacements performed between 1980 and 2006 in Finland. These records are kept by the Finnish Arthroplasty Registry.

They looked at how incidence rates of arthroplasty for knee osteoarthritis varied by gender, age, and hospital volume.

Their main findings show that:

• Rates of total knee replacement among those aged 30 to 59 went up 130-fold in the 27-year period.


• The incidence went up from 0.5 procedures per 100,000 of Finland's population to 65 per 100,000.


• The fastest rise happenend between 2001 and 2006 (from 18 to 65 per 100,000).


• There was a similar rapid rise in partial knee replacements: from 0.2 to 10 procedures per 100,000 of the population.


• In the last ten years of the study (1997 to 2006), the rate of total knee replacements was 1.6 to 2.4 times higher in women than in men.


• The rates of total and partial knee replacements were highest among 50 to 59-year-olds.

The researchers conclude that their study demonstrates "the rapid increase in incidences of arthroplasty among patients with primary knee osteoarthritis in Finland, especially in age group of 50 to 59 years of aged."

"There was no single explanatory factor behind this phenomenon though some of the growth might be due to the increase of incidences observed in low and intermediate volume hospitals," they note.

Leskinen said:

"Given that younger patients may be at higher risk of artificial knee joint failure and thus in need of a second replacement surgery, long-term data are needed before widespread use of total knee arthroplasty is recommended for this patient population."

In an accompanying editorial, Dr. Elena Losina, of Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, agrees with Leskinen. She writes that total knee replacement is an effective treatment for OA in older patients, those in their 60s, 70s and 80s.

"However, past performance may not guarantee future success, and with an increasing number of knee replacement recipients under 60 years old, more intensive study of arthroplasty outcomes in younger patients is warranted," she urges.

According to the World Health Organization (WHO), osteoarthritis is the fourth leading cause of years lived with disability worldwide.

Experts estimate that around 10 million people are living with osteoarthritis in the US, where over 600,000 knee replacements were carried out in 2009, according to a report from the Agency for Healthcare Research and Quality. A previous study estimated that by 2030 the number of such procedures could grow by over 670% to nearly 3.5 million a year.