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Nonpharmacological treatments in early rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion. Joint Bone Spine. 2006 Mar 20;
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OBJECTIVE: To develop clinical practice guidelines for the use of nonpharmacological treatments in patients with early rheumatoid arthritis (RA), using the evidence-based approach and expert opinion.
METHODS: A scientific committee used a Delphi prioritization procedure to select five questions. Evidence providing answers to the five questions was sought in the literature and presented to a panel of rheumatologists. The panel developed five detailed recommendations, filling gaps in evidence with their expert opinion. The strength of each recommendation was determined.
RESULTS: Of the 565 publications retrieved by the literature review, 198 were included in the analysis. The five recommendations on nonpharmacological treatments for early RA were validated by a final vote among all participants. The recommendations are as follows: (1) physicians may decide to provide joint protection education to patients with potentially severe early RA, with the knowledge that structured joint protection programs have not been found effective; (2) physical exercise and sports can be recommended to patients with early RA; muscle strength exercises are advisable; (3) in patients with early RA, metatarsal pain and/or foot alignment abnormalities should be looked for regularly, and appropriate insoles should be prescribed if needed; (4) dietary measures and nutritional supplements are not indicated as part of the treatment of early RA; (5) elimination diets, particularly those with low intakes of dairy products, should be discouraged in patients with early RA.
CONCLUSION: These recommendations should help to improve practice uniformity and, ultimately, to improve the management of RA.
Science Daily are reporting: A New Approach To Rheumatoid Arthritis
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Rheumatoid arthritis drugs work better, at least in arthritic rats, when delivered into the central nervous system, Gary Firestein and colleagues (University of California San Diego) now report in the international open-access medical journal PLoS Medicine.
Rheumatoid arthritis (RA) is a disease marked by chronic inflammation, leading to joint pain and destruction. Pain and inflammation in the joints are constantly monitored by the central nervous system (CNS, i.e. the brain and spinal cord). Scientists have long suspected that the CNS can regulate inflammation and immune responses in the body's "periphery", but little is known about how this works. Firestein and colleagues focused on a protein called p38, which is involved in a number of cellular processes critical to the development of RA. Several substances that block the action of p38 are effective in animal models of arthritis and are currently being tested in clinical trials in patients with RA.
Based on the observation by other scientists that p38 is activated in the CNS in response to peripheral pain, and on Firestein and colleagues' own finding that this is true in response to inflammation as well, the researchers blocked p38 with drugs directly delivered to the spinal cord of the arthritic rats. They found that the treated rats had substantially less inflammation, arthritis, and joint destruction, compared with rats that had undergone the same treatment but received no active drug. Treatment of arthritic rats with the same amount of drugs given directly under the skin (the "systemic treatment" that is currently being tested in RA patients, but with much higher doses) did not have any beneficial effect on the joints.
These findings suggest that spinal cord administration might reduce the side effects (and possibly the costs) of p38 inhibitors without compromising the benefits to patients. And if future studies confirm that the action of these drugs on the CNS is essential to achieve a response even when administered as a systemic treatment, designing drugs that get into the CNS easier might improve the effectiveness and/or make it possible to use lower doses systemically.
Re: Recommendations for early rheumatoid arthritis management
Press Release: Promising New Therapy Being Studied to Treat Rheumatoid Arthritis
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A potential new therapy called certolizumab pegol, when used in combination with methotrexate, may be safe and effective at treating active rheumatoid arthritis, according to research presented recently at the American College of Rheumatology Annual Scientific Meeting in Boston.
Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 2.1 million Americans have RA, most of them women.
Investigators followed 982 adult patients in a Phase III, multicenter, double-blind, placebo-controlled, 52-week study. Primary endpoints were clinical improvement according to a composite measure of disease activity, the ACR20, at week 24 and an improvement in the radiographic findings in joint x-rays (Sharp score) from the start to the end of the study.
Secondary endpoints included ACR20 at week 52 and the more demanding ACR 50/ACR70 response rates at weeks 24 and 52. The ACR 20/50/70 scoring criteria measures improvement in tender and swollen joint count and improvement in at least three of the following five criteria: pain; level of disability; overall self-assessment; overall physician assessment; and acute phase reactant (e.g., C-reactive protein).
Patients received certolizumab pegol in three 400 mg doses given every two weeks, followed by doses of 200 mg or 400 mg every two weeks, or placebo. All patients were taking methotrexate therapy. Patients receiving certolizumab at either dose combined with methotrexate had significant improvement compared to patients taking only methotrexate, with up to 60% an ACR20 response and at least 20% an ACR70 response at weeks 24 and 52. Adverse events, including injection site reactions, were reported in both groups, the majority of which were considered mild to moderate.
“A unique aspect of certolizumab pegol is the rapid attainment of the high hurdle ACR50 and ACR70 responses by 12-16 weeks, compared to other TNF inhibitors which achieve these responses by about 24 weeks or more,” said Edward Keystone, MD, University of Toronto, and lead investigator in the study. “Whether this is a reflection of the rapid entry of the pegylated molecule in the joint, remains unclear.”
Re: Recommendations for early rheumatoid arthritis management
Yahoo! are reporting: Rheumatoid Arthritis Treatment Guidelines Updated
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New recommendations for the use of disease-modifying anti-rheumatic drugs (DMARDs) in the treatment of rheumatoid arthritis (RA) have been developed by the American College of Rheumatology.
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The recommendations include:
* Methotrexate or leflunomide therapy is recommended for most RA patients.
* Methotrexate plus hydroxychloroquine is endorsed for patients with moderate to high disease activity.
* The triple DMARD combination of methotrexate plus hydroxychloroquine plus sulfasalazine for patients with poor prognostic features and moderate to high levels of disease activity.
* Prescribing anti-TNF agents -- etanercept, infliximab, or adalimumab -- along with methotrexate in early RA (less than 3 months) only for patients with high disease activity who had never received DMARDs. In intermediate- and longer-duration RA, anti-TNF agents are recommended for patients who had failed to respond adequately to methotrexate therapy.
* Reserving the fusion protein abatacept and the B-cell antibody rituximab for patients with at least moderate disease activity and poor disease prognosis for whom methotrexate in combination with or sequential administration of other nonbiologic DMARDs led to an inadequate response.
* Avoiding the initiation or resumption of treatment with methotrexate, leflunomide, or biologic agents for patients with active bacterial infection, active herpes-zoster viral infection, active or latent tuberculosis, or acute or chronic hepatitis B or C.
* Not prescribing anti-TNF agents to patients with a history of heart failure, with a history of lymphoma, or with multiple sclerosis or demyelinating disorders.
* Avoiding the initiation or resumption of methotrexate, leflunomide, or minocycline for RA patients planning for pregnancy and throughout the duration of pregnancy and breastfeeding.
Recommendations for early rheumatoid arthritis management
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