New oral medication for Rheumatoid arthritis not available yet in Dubai or UAE

Researchers studied the effectiveness and safety of tofacitinib (brand name Xeljanz) in combination with non-biologic DMARDs. Tofacitinib is a JAK (Janus kinase) inhibitor. There were 792 patients with active rheumatoid arthritis involved in the study which was conducted in 114 centers in 19 countries. The study participants were randomly assigned oral tofacitinib (5 mg or 10 mg twice daily) or placebo. At 3 months, patients in the placebo group who did not respond were blindly switched to 5 or 10 mg. tofacitinib twice daily.

Results, published August 20, 2013 in the Annals of Internal Medicine, revealed that response at 6 months was 21% greater for patients taking 5 mg. tofacitinib and 26% greater for patients taking 10 mg. tofacitinib compared to patients who were on placebo for 3 months and then switched to tofacitinib. Optimistic results, yes -- but the study had limitations. Placebo groups were smaller than the tofacitinib groups. Placebo was given for a shorter duration. Patients primarily received methotrexate, not other non-biologic DMARDs. Plus, the assessment of drug combinations other than tofacitinib plus methotrexate was limited. For example, patients were allowed to continue taking corticosteroids during the study.

Do you have steroids for arthritis?

You may have heard people with arthritis talk about what it was like to wean or taper off of prednisone. They describe varying degrees of withdrawal symptoms. For some, it was a nightmare.

It can be worse for people who took the drug for a long time or at a high dose. Prednisone is not a drug that can be stopped abruptly. It must be tapered gradually on a schedule determined by your doctor. Still, there may be withdrawal symptoms.

What has been your experience with discontinuing prednisone?

Doctors treating back pain incorrectly

According to a study published Monday in JAMA Internal Medicine, more physicians are ignoring national guidelines from the American College of Physicians when treating patients with back pain. The group recommends the use of “use of nonsteroidal anti-inflammatory drugs (NSAIDs),” such as ibuprofen and aspirin, combined with physical therapy. However, the study says physicians are instead, “increasingly” prescribing patients with back pain “narcotic drugs, ordering expensive imaging tests or referring them to other physicians.” Furthermore, the study’s lead author, John Mafi, a chief medical resident at Boston’s Beth Israel Deaconess Medical Center, claims that the guidelines “caution against early imaging or other aggressive treatments, except in rare cases.”

Fibromyalgia treatment

According to a Chicago Tribune report, there have been studies that suggested fibromyalgia patients have decreased levels of creatine in their brain and muscle tissues. One previous study suggested that creatine supplements improved fibromyalgia symptoms, but the quality of the study was questioned.

A research team conducted a 16-week double-blind, randomized, controlled trial to evaluate the effect of taking creatine supplements versus placebo. In the study, published online April 1, 2013 in Arthritis Care & Research, creatine supplementation was found to improve muscle strength modestly. But, it had no impact on pain, cognitive function, quality of sleep, or overall quality of life. While the study concluded that creatine supplementation is a "useful dietary intervention" to improve muscle function in fibromyalgia patients, it is important that fibromyalgia patients realize creatine is no panacea.

Stem Cells for arthritis. Posted by Rheumatologist in Dubai.

Stems cells taken from just a few grams of body fat are a promising weapon against the crippling effects of osteoarthritis.  This interview is from the Chicago Tribune.

For the past two decades, knee, hip or other joint replacements have been the standard treatment for the deterioration of joint cartilage and the underlying bone. But artificial joints only last about 15 years and are difficult to repair once they fail.

Stem cell injections may offer a new type of therapy by either stopping the degenerative process or by regenerating the damaged cartilage, said pioneering researcher Dr. Farshid Guilak, a professor of orthopedic surgery and director of orthopedic research at Duke University.

Guilak, one of the first researchers to grow cartilage from fat, explains why stem cells are a bright light in osteoarthritis research and why widespread clinical use is still years away. Below is an edited transcript of the interview.

Q: How are stem cell injections purported to help?

A: Several studies in animals show that stem cell injections may help by reducing the inflammation in the joint. Stem cells appear to have a natural capacity to produce anti-inflammatory molecules, and once injected in the joint, can slow down the degenerative process in osteoarthritis.

(Since this interview, research published in Stem Cells Translational Medicine has found that stem cells may also be an effective way to deliver therapeutic proteins for pain relief related to rheumatoid arthritis.)

Q: Does the bulk of research look at how stem cells heal traumatic injuries, or does it look at degenerative conditions such as arthritis?

A: Nearly all previous studies on stem cell therapies in joints have focused on trying to repair small "focal" damage to the cartilage. Only a few recent studies have begun to examine the possibility for treating the whole joint, either to grow enough cartilage to resurface the entire joint or to use stem cells to prevent further degeneration.

Q: Meaning one day, entire joint surfaces such as hips and knees could be grown in a lab?

A: That has been one of our primary research goals, so that people with arthritis can simply resurface the cartilage in their joints without having a total joint replacement. To do this, we have developed a fabric "scaffold" that can be created in the exact shape of the joint, while allowing stem cells to form new cartilage. One of our most exciting findings was the discovery that fat tissue contained large numbers of stem cells that could form cartilage and bone. In this way, we could easily get enough cells from a small liposuction procedure to completely resurface a person's worn-out hip or knee.

Q: Is it legal to get stem cell treatment for osteoarthritis in the U.S.?

A: While there is great promise for stem cell therapies, there's little clinical evidence supporting it for arthritis; we don't yet know if this type of treatment is safe in humans, or for that matter, that it even works. Some physicians are offering these treatments without FDA approval, but I feel it is irresponsible and potentially dangerous to perform such a procedure without having a clear understanding of the possible risks and benefits. Several clinical trials are planned and ongoing, mostly outside the U.S.

New test for Rheumatoid arthritis not available in UAE

The only tests available for Rheumatoid arthritis in UAE are rheumatoid factor and anti-CCP>
The 14-3-3eta lab-developed test is based on the 14-3-3eta protein biomarker through an exclusive license agreement in the United States with Augurex Life Sciences. One test provides results of 14-3-3eta blood levels, while a comprehensive panel provides results of blood levels of the novel marker as well as the conventional RA markers CCP antibodies and RF.

Physicians may consider results of RF, CCP antibody and 14-3-3eta tests, along with a medical evaluation and X-rays, to diagnose RA.

Quest Diagnostics already provides the RF and CCP antibody tests, and a panel that incorporates these assays as well as 14-3-3eta has certain advantages, including potentially higher sensitivity for detecting RA, than any of the three markers can provide alone. A panel also allows a physician to test a patient only once and receive a single report.

This “one blood draw, one report” approach is significantly more convenient for the patient and clinician in those cases where a physician may believe consideration of results of all three tests would aid diagnosis.

On the other hand, a physician may not believe results of all three tests are required for a reliable diagnosis or perhaps a patient received certain tests already, perhaps under care of a different doctor, and additional testing would be redundant and unnecessary. In these cases, single tests may be more appropriate.

How do these novel tests allow for early diagnosis of RA?
Research shows that elevated blood levels of the 14-3-3eta biomarker outperform conventional RF or CCP antibody testing for RA. When physicians consider results of all three markers, the sensitivity improves even further.

In addition, co-morbid conditions, such as type 1 diabetes, osteoporosis and gout, do not abnormally raise blood levels of 14-3-3eta.

What to ask your doctor regarding your Lupus?

1. Do I have kidney or other organ involvement?

2. How active is my SLE presently?  Are my C3 C4 low and dsDNA high as these can be signs of active lupus?

3. Should I take calcium and Vitamin D supplements?

4.  I have heard lupus patients are at high risk for heart disease.  Do I need to have my cholesterol checked?

5.  I have heard a medication called Hydroxycholoroquine can reduce lupus flare.  Should I take this?

6.  Should I have a bone density test?

Back pain treatment

(HealthDay News) – Injection of autologous, bone marrow mesenchymal cell concentrate (BMAC) into degenerated lumbar discs may relieve low back pain of discogenic origin, according to research presented at the American Academy of Pain Medicine's 29th Annual Meeting, April 11–14, in Fort Lauderdale, FL.

D. Joseph Meyer Jr., MD, PhD, of the Columbia Interventional Pain Center in Columbia, MO, and colleagues conducted a retrospective study of 24 consecutive patients treated with injections of autologous BMAC into degenerated lumbar discs for pain relief.

According to the researchers, of the 24 patients treated with BMAC injections, 12 patients received only one treatment, and 12 patients received one or more lumbar injections or surgical treatments. None of the patients reported worsening of pain after BMAC injections. Of the 12 patients who received only one treatment of lumbar disc BMAC, 10 patients reported to have pain relief at two to four months. Long-term efficacy and safety results are pending.

"The results of our case review are encouraging," said Meyer in a statement. "Currently, when conservative treatment measures fail, therapeutic options are limited for individuals with back pain due to disc degeneration. Many resort to disc surgery or spinal fusion with mediocre results. Our goal is to help develop a safe, natural method to boost the body's own capacity to heal discogenic pain."

Coffee decreases gout attacks

According to researchers from Boston University and Harvard Medical School, four cups of coffee per day can halve the chances of gout in women.

The latest findings were published in the American Journal of Clinical Nutrition.
The report comes after a long-term study that included almost 90,000 female nurses in the US for over a 26-year period during which researchers monitored their health and dietary habits.
Almost 900 nurses developed gout during that time.

While analyzing the beverage intake, researchers found that women who had consumed larger amounts of coffee during that period were at less risk.
Researchers did not know the reason of the positive effect of coffee however the theory is that it can reduce the insulin level in the blood.

“Long-term consumption of coffee is associated with a lower risk of gout in women”, researchers said.
Gout develops when uric acid, a natural byproduct, is not disposed properly by the body. And it is known that there is a link between higher insulin and higher uric acid.

Although there is a genetic predisposition to it, diet and excess in alcoholic drinks can also trigger the condition.
Gout attacks can produce unbearable pain and can last up to a week.
There are also studies that suggest that gout could be an early warning of heart disease.

Lupus test

The ANA test or anti-nuclear antibody is used to test for SLE or lupus.  Normal or healthy people can also test positive for ANA but in low titers.  ANA test greater than 1/160 are significant and need follow up tests.  Tests such as dsDNA or Smith can confirm lupus.  An antiRO and anti La test is suggestive of Sjogren's.  This test should only be done if there is a suspicion of connective tissue disease.

Osteoporosis in Dubai

Today while chairing the "Women's Health Conference " in Dubai and speaking about "Osteoporosis and Vitamin D deficiency" I noticed an overwhelming interest in this subject.  These are a few points I would like to highlight:

1) The daily requirement of calcium is 1000 mg / day.  Please get this through your diet.  One 200 ml glass of milk or yogurt has 300 mg of calcium.  If lactose intolerant try soya milk or alternatives.  One cup of green veggies has about 100 mg of calcium.

2) Vitamin D requirement is 1000 IU per day.  This for very fair skinned people can be obtained by 20 minutes of direct sunlight exposure per day.  If darker skinned may require 1 hour of sun!  If unable to expose to sun take a vitamin D supplement 1000 IU once daily.

Physiotherapy for torn meniscus. Posted by Rheumatologist in Dubai

A New England Journal of Medicine (NEJM) study showing that physical therapy is just as effective as surgery in patients with meniscal tears and arthritis of the knee should encourage many health care providers to reconsider their practices in the management of this common injury, according to the American Physical Therapy Association (APTA).

The study, published March 19, showed no significant differences in functional improvement after 6 months between patients who underwent surgery with postoperative physical therapy and those who received standardized physical therapy alone.
"This study demonstrates what physical therapists have long known," explained APTA President Paul A. Rockar Jr, PT, DPT, MS. "Surgery may not always be the best first course of action. A physical therapist, in many cases, can help patients avoid the often unnecessary risks and expenses of surgery. This study should help change practice in the management of symptomatic meniscal tears in patients with knee osteoarthritis."
According to lead physical therapist for the trial and American Physical Therapy Association (APTA) member Clare Safran-Norton, PT, PhD, OCS, "our findings suggest that a course of physical therapy in this patient population may be a good first choice since there were no group differences at 6 months and 12 months in this trial. These findings should help surgeons, physicians, physical therapists, and patients in decision-making regarding their treatment options."
Researchers at 7 major universities and orthopedic surgery centers around the country studied 351 patients aged 45 years or older who had a meniscal tear and mild-to-moderate osteoarthritis of the knee. Patients were randomly assigned to groups who received either surgery and postoperative physical therapy or standardized physical therapy. Within 6-12 months, patients who had physical therapy alone showed similar improvement in functional status and pain as those who had undergone arthroscopic partial meniscectomy surgery.
Patients who were given standardized physical therapy -- individualized treatment and a progressive home exercise program -- had the option of "crossing over" to surgery if substantial improvements were not achieved. Thirty percent of patients crossed over to surgery during the first 6 months. At 12 months these patients reported similar outcomes as those who initially had surgery. Seventy percent of patients remained with standardized physical therapy.
According to an accompanying editorial in NEJM,"millions of people are being exposed to potential risks associated with a treatment [surgery] that may or may not offer specific benefit, and the costs are substantial." Physical therapist and APTA member Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert MDT, chief of physical therapy at Harvard University, said, "Physical therapists are experts in improving mobility and restoring motion. The individualized treatment approach is very important in the early phases of rehabilitation in order to achieve desired functional outcomes and avoid setbacks or complications."

Meetings for Rheumatologists in Dubai, UAE

Upcoming meetings will be the Rheumatology Review Course in 09/2013 and Bone and Joint Conference in 10/2013

Rheumatoid arthritis treatment in Dubai

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Previous studies have shown that early, intensive intervention can help RA patients achieve remission, and reduce joint damage and disability. Treat-to-target (T2T) is a medical strategy that sets remission – or at the very least, low disease activity – as a goal; specific drugs and doses are stepped up systematically if remission is not reached within certain time periods.

Earlier findings of this Dutch study – called the DREAM trial – showed that remission can be achieved using the T2T strategy among patients with early RA (with symptom duration of one year or less) in the everyday world of daily clinical practice. But could the remission be sustained over the long-term?

A total of 342 patients from the DREAM trial had three-year follow up data for this phase of the analysis. Among them, nearly 62 percent were in remission at the three-year mark. Remission was defined as having a DAS28 score of less than 2.6. DAS28 measures disease activity in 28 key joints and certain blood markers.

Sustained DAS28 remission – defined as a DAS28 of less than 2.6 for six months or more – was achieved by more than 70 percent of patients at least once during the three years, with nearly 75 percent of those patients achieving a sustained remission for greater than a year. At the end of the three-year period, about 43 percent of the study subjects were in a period of sustained remission. The protocol called for a gradual decrease in medication for those experiencing sustained remission – and eventual discontinuation of drug therapy. At the three-year mark, a quarter of the subjects in the remission group were taking no medications.