Nancy Walsh

GLASGOW, SCOTLAND — Data from a large cohort of patients with rheumatoid arthritis receiving anti-tumor necrosis factor-α therapy has determined that those with a history of malignancy are at heightened risk for additional cancers, and therefore such treatment should be used “with extreme caution” in these patients, according to Kath D. Watson, Ph.D.

Because anti-tumor necrosis factor (anti-TNF) plays an important role in the immune system's tumor surveillance, its blockade could potentially increase the risk of cancer, Dr. Watson said at the annual meeting of the British Society for Rheumatology. Although there have been reports of malignancies such as lymphoma associated with biologic response modifiers, the data thus far have been insufficient to precisely quantify the degree of risk—or to sort out risks deriving from treatment from those inherent in the disease process.

Analysis of data from the British Society for Rheumatology biologics registry is now beginning to clarify these concerns, as cancer incidence among 9,999 first-exposure anti-TNF-treated patients was compared with that of 1,877 biologic-naive rheumatoid arthritis patients taking traditional disease-modifying antirheumatic drugs (DMARDs), according to Dr. Watson of the Arthritis Research Campaign's epidemiology unit, University of Manchester, England.

Participants were followed from the date of their registration through September 2005, and reports on cancer cases were obtained from the Office for National Statistics or from 6-monthly physician questionnaires. Incidence rate ratios were adjusted for age, gender, disease severity, and smoking history.

The incidence of new malignancies among the anti-TNF-treated patients overall was not elevated, compared with that of the DMARD-treated group, with a relative risk of 0.7, Dr. Watson said.

But patients treated with biologics who had previous malignancies had an increased risk of developing a further malignancy after commencing therapy, with an incidence rate ratio of 2.5. This increased risk was higher than that for DMARD-treated patients who had had previous cancers. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GLASGOW, SCOTLAND — Data from a large cohort of patients with rheumatoid arthritis receiving anti-tumor necrosis factor-α therapy has determined that those with a history of malignancy are at heightened risk for additional cancers, and therefore such treatment should be used “with extreme caution” in these patients, according to Kath D. Watson, Ph.D.

Because anti-tumor necrosis factor (anti-TNF) plays an important role in the immune system's tumor surveillance, its blockade could potentially increase the risk of cancer, Dr. Watson said at the annual meeting of the British Society for Rheumatology. Although there have been reports of malignancies such as lymphoma associated with biologic response modifiers, the data thus far have been insufficient to precisely quantify the degree of risk—or to sort out risks deriving from treatment from those inherent in the disease process.

Analysis of data from the British Society for Rheumatology biologics registry is now beginning to clarify these concerns, as cancer incidence among 9,999 first-exposure anti-TNF-treated patients was compared with that of 1,877 biologic-naive rheumatoid arthritis patients taking traditional disease-modifying antirheumatic drugs (DMARDs), according to Dr. Watson of the Arthritis Research Campaign's epidemiology unit, University of Manchester, England.

Participants were followed from the date of their registration through September 2005, and reports on cancer cases were obtained from the Office for National Statistics or from 6-monthly physician questionnaires. Incidence rate ratios were adjusted for age, gender, disease severity, and smoking history.

The incidence of new malignancies among the anti-TNF-treated patients overall was not elevated, compared with that of the DMARD-treated group, with a relative risk of 0.7, Dr. Watson said.

But patients treated with biologics who had previous malignancies had an increased risk of developing a further malignancy after commencing therapy, with an incidence rate ratio of 2.5. This increased risk was higher than that for DMARD-treated patients who had had previous cancers. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GLASGOW, SCOTLAND — Data from a large cohort of patients with rheumatoid arthritis receiving anti-tumor necrosis factor-α therapy has determined that those with a history of malignancy are at heightened risk for additional cancers, and therefore such treatment should be used “with extreme caution” in these patients, according to Kath D. Watson, Ph.D.

Because anti-tumor necrosis factor (anti-TNF) plays an important role in the immune system's tumor surveillance, its blockade could potentially increase the risk of cancer, Dr. Watson said at the annual meeting of the British Society for Rheumatology. Although there have been reports of malignancies such as lymphoma associated with biologic response modifiers, the data thus far have been insufficient to precisely quantify the degree of risk—or to sort out risks deriving from treatment from those inherent in the disease process.

Analysis of data from the British Society for Rheumatology biologics registry is now beginning to clarify these concerns, as cancer incidence among 9,999 first-exposure anti-TNF-treated patients was compared with that of 1,877 biologic-naive rheumatoid arthritis patients taking traditional disease-modifying antirheumatic drugs (DMARDs), according to Dr. Watson of the Arthritis Research Campaign's epidemiology unit, University of Manchester, England.

Participants were followed from the date of their registration through September 2005, and reports on cancer cases were obtained from the Office for National Statistics or from 6-monthly physician questionnaires. Incidence rate ratios were adjusted for age, gender, disease severity, and smoking history.

The incidence of new malignancies among the anti-TNF-treated patients overall was not elevated, compared with that of the DMARD-treated group, with a relative risk of 0.7, Dr. Watson said.

But patients treated with biologics who had previous malignancies had an increased risk of developing a further malignancy after commencing therapy, with an incidence rate ratio of 2.5. This increased risk was higher than that for DMARD-treated patients who had had previous cancers. (See box.)

ELSEVIER GLOBAL MEDICAL NEWS

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-α therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary, identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, mean age was 43 years, and mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics. The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Prompt referral to a podiatry service is necessary if onychocryptosis develops in a patient. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines, and should work closely with the rheumatology team, wrote Ms. Davys.

Toenail surgery by a podiatrist is often required to repair onychocryptosis. Eight of the nine rheumatoid arthritis patients in the study had to undergo partial or total nail avulsion. All outcomes were successful, allowing reinstitution of biologic therapy. Photos courtesy Heidi J. Davys

Some Biologic Response Modifiers, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue.

Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

Published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-α therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary, identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, mean age was 43 years, and mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics. The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Prompt referral to a podiatry service is necessary if onychocryptosis develops in a patient. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines, and should work closely with the rheumatology team, wrote Ms. Davys.

Toenail surgery by a podiatrist is often required to repair onychocryptosis. Eight of the nine rheumatoid arthritis patients in the study had to undergo partial or total nail avulsion. All outcomes were successful, allowing reinstitution of biologic therapy. Photos courtesy Heidi J. Davys

Some Biologic Response Modifiers, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue.

Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

Published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-α therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary, identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, mean age was 43 years, and mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics. The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Prompt referral to a podiatry service is necessary if onychocryptosis develops in a patient. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines, and should work closely with the rheumatology team, wrote Ms. Davys.

Toenail surgery by a podiatrist is often required to repair onychocryptosis. Eight of the nine rheumatoid arthritis patients in the study had to undergo partial or total nail avulsion. All outcomes were successful, allowing reinstitution of biologic therapy. Photos courtesy Heidi J. Davys

Some Biologic Response Modifiers, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue.

Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

Published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.

The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.

The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.

Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.

Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.

Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.

The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.

Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.

“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.

GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.

The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.

The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.

Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.

Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.

Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.

The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.

Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.

“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.

GLASGOW, SCOTLAND — Treatment with a biologic agent may be life- and sight-saving in cases of refractory necrotizing scleritis, as was the case for a 60-year-old man with a 10-year history of rheumatoid arthritis and a 2-week history of red, painful eyes and blurred vision.

The usual treatment involves systemic corticosteroids and immunosuppressants. Cyclophosphamide is the immunosuppressive drug of choice, Dr. Ismael Atchia explained in a poster session at the annual meeting of the British Society for Rheumatology.

The patient in question had joint stiffness and swelling, vasculitic lesions on the fingers, and the articular deformities typical of chronic RA, according to Dr. Atchia of the rheumatology department, Sunderland (England) Royal Hospital. He appeared cachectic and had several decubitus ulcers. He had been treated with nonsteroidal anti-inflammatory drugs, but had never received any disease-modifying antirheumatic drugs.

Ocular examination revealed intense bilateral inflammation manifesting as fulminating, necrotizing scleritis with severe bilateral peripheral ulcerative keratitis that threatened corneal perforation. Laboratory investigations revealed elevated inflammatory markers, with an erythrocyte sedimentation rate of 139 mm/hr, a C-reactive protein measurement of 149 mg/L, and a positive rheumatoid factor titer of 1:640.

Treatment of the ocular symptoms consisted of intensive topical lubrication with carmellose as well as prophylactic chloramphenicol and autologous serum eyedrops. He also received temporary punctual plugs and underwent bilateral temporary lateral tarsorrhaphies.

Systemic therapy included pulses of intravenous methylprednisolone plus oral prednisone (60 mg/day) along with cyclophosphamide (15 mg/kg) with mesna coverage on three occasions during the ensuing 6 weeks, Dr. Atchia noted. The vasculitic skin lesions cleared with the immunosuppressive treatment, but ocular deterioration continued until the right eye perforated at the temporal limbus.

The patient then received intravenous infliximab (3 mg/kg), plus oral methotrexate (10 mg weekly) and continued treatment with oral prednisone. Additional doses of infliximab were given at weeks 2 and 6.

Within 2 weeks of the first infliximab dose, the patient's eyes improved dramatically, according to Dr. Atchia.

“This case suggests that biologic agents may be considered in refractory cases of sight- and life-threatening scleritis. However, these agents are expensive and have potentially serious side effects, so their long-term efficacy and safety for use in inflammatory eye disease remain to be determined,” he concluded.

GLASGOW, SCOTLAND — When acute nonspecific symptoms might represent neuropsychiatric lupus, it is necessary to carefully review a patient's past medical history, because the presenting symptoms of systemic lupus erythematosus are manifold, may mimic other disorders, and can evolve over time, Dr. Hala Y. Sadik reported in a poster.

This is particularly the case when the onset is acute, as happened in a case treated by Dr. Sadik of the Academic Rheumatology Unit, University Hospital Aintree, Liverpool, England.

In August 2005, a 57-year-old woman presented with hypothermia, bradycardia, confusion, a low score on the Glasgow Coma Scale, and hyponatremia.

The patient's plasma sodium level was low (120 mmol/L), as well as her plasma osmolality (235 mOsm/kg), while urinary sodium and osmolality levels were both high. A diagnosis of inappropriate antidiuretic hormone secretion was made, Dr. Sadik reported in a poster session at the annual meeting of the British Society for Rheumatology.

Initial management included fluid restriction and administration of double-strength normal saline, which normalized the plasma sodium level, reported Dr. Sadik.

Initial MRI of the head raised the possibility of neurosarcoidosis, but serum angiotensin-converting enzyme levels and chest x-ray were normal.

A repeat MRI with gadolinium suggested demyelinating disease or systemic lupus erythematosus. Immunology profile findings included positive antinuclear antibody (ANA) and double-stranded DNA antibody. Thrombocytopenia and lymphopenia also were present.

Upon review, her previous case records from another hospital revealed that she had been admitted in 1992 with a 2-week history of arthralgias, Raynaud's phenomenon, thrombocytopenia, lymphopenia, and positive ANA.

A diagnosis of lupus had been considered at that time, and she was followed for several years as an outpatient, but ANA remained weakly positive and double-stranded DNA was persistently negative, so the diagnosis had been dismissed, Dr. Sadik wrote.

With improvements on the Glasgow Coma Scale during her current admission, it became apparent that the patient was profoundly depressed, so she was treated with mirtazapine.

Following a diagnosis of neuropsychiatric lupus, the patient began treatment with intravenous methylprednisolone and cyclophosphamide.

Significant improvements were seen in her disabling depression, and her hematologic parameters normalized, reported Dr. Sadik.

GLASGOW, SCOTLAND — When acute nonspecific symptoms might represent neuropsychiatric lupus, it is necessary to carefully review a patient's past medical history, because the presenting symptoms of systemic lupus erythematosus are manifold, may mimic other disorders, and can evolve over time, Dr. Hala Y. Sadik reported in a poster.

This is particularly the case when the onset is acute, as happened in a case treated by Dr. Sadik of the Academic Rheumatology Unit, University Hospital Aintree, Liverpool, England.

In August 2005, a 57-year-old woman presented with hypothermia, bradycardia, confusion, a low score on the Glasgow Coma Scale, and hyponatremia.

The patient's plasma sodium level was low (120 mmol/L), as well as her plasma osmolality (235 mOsm/kg), while urinary sodium and osmolality levels were both high. A diagnosis of inappropriate antidiuretic hormone secretion was made, Dr. Sadik reported in a poster session at the annual meeting of the British Society for Rheumatology.

Initial management included fluid restriction and administration of double-strength normal saline, which normalized the plasma sodium level, reported Dr. Sadik.

Initial MRI of the head raised the possibility of neurosarcoidosis, but serum angiotensin-converting enzyme levels and chest x-ray were normal.

A repeat MRI with gadolinium suggested demyelinating disease or systemic lupus erythematosus. Immunology profile findings included positive antinuclear antibody (ANA) and double-stranded DNA antibody. Thrombocytopenia and lymphopenia also were present.

Upon review, her previous case records from another hospital revealed that she had been admitted in 1992 with a 2-week history of arthralgias, Raynaud's phenomenon, thrombocytopenia, lymphopenia, and positive ANA.

A diagnosis of lupus had been considered at that time, and she was followed for several years as an outpatient, but ANA remained weakly positive and double-stranded DNA was persistently negative, so the diagnosis had been dismissed, Dr. Sadik wrote.

With improvements on the Glasgow Coma Scale during her current admission, it became apparent that the patient was profoundly depressed, so she was treated with mirtazapine.

Following a diagnosis of neuropsychiatric lupus, the patient began treatment with intravenous methylprednisolone and cyclophosphamide.

Significant improvements were seen in her disabling depression, and her hematologic parameters normalized, reported Dr. Sadik.

GLASGOW, SCOTLAND — When acute nonspecific symptoms might represent neuropsychiatric lupus, it is necessary to carefully review a patient's past medical history, because the presenting symptoms of systemic lupus erythematosus are manifold, may mimic other disorders, and can evolve over time, Dr. Hala Y. Sadik reported in a poster.

This is particularly the case when the onset is acute, as happened in a case treated by Dr. Sadik of the Academic Rheumatology Unit, University Hospital Aintree, Liverpool, England.

In August 2005, a 57-year-old woman presented with hypothermia, bradycardia, confusion, a low score on the Glasgow Coma Scale, and hyponatremia.

The patient's plasma sodium level was low (120 mmol/L), as well as her plasma osmolality (235 mOsm/kg), while urinary sodium and osmolality levels were both high. A diagnosis of inappropriate antidiuretic hormone secretion was made, Dr. Sadik reported in a poster session at the annual meeting of the British Society for Rheumatology.

Initial management included fluid restriction and administration of double-strength normal saline, which normalized the plasma sodium level, reported Dr. Sadik.

Initial MRI of the head raised the possibility of neurosarcoidosis, but serum angiotensin-converting enzyme levels and chest x-ray were normal.

A repeat MRI with gadolinium suggested demyelinating disease or systemic lupus erythematosus. Immunology profile findings included positive antinuclear antibody (ANA) and double-stranded DNA antibody. Thrombocytopenia and lymphopenia also were present.

Upon review, her previous case records from another hospital revealed that she had been admitted in 1992 with a 2-week history of arthralgias, Raynaud's phenomenon, thrombocytopenia, lymphopenia, and positive ANA.

A diagnosis of lupus had been considered at that time, and she was followed for several years as an outpatient, but ANA remained weakly positive and double-stranded DNA was persistently negative, so the diagnosis had been dismissed, Dr. Sadik wrote.

With improvements on the Glasgow Coma Scale during her current admission, it became apparent that the patient was profoundly depressed, so she was treated with mirtazapine.

Following a diagnosis of neuropsychiatric lupus, the patient began treatment with intravenous methylprednisolone and cyclophosphamide.

Significant improvements were seen in her disabling depression, and her hematologic parameters normalized, reported Dr. Sadik.

TORONTO — Risk factors for fractures in later life are already present in middle age, and their early identification can provide a window of opportunity for intervention, Dr. Anna H. Holmberg said at a world congress on osteoporosis.

Diabetes and mental health problems were among the factors found to be predictive of an increased likelihood of later-life fractures in the Malmö Preventive Project, which was a prospective study that followed 22,444 men and 10,902 women from 1974 through 1999. The primary focus of the project was cardiovascular health, but the investigators also collected data on all low-energy, or fragility, fractures as well as fractures of the forearm, vertebrae, proximal humerus, and ankle, said Dr. Holmberg of the department of orthopedics, Malmö (Sweden) University Hospital.

During follow-up, which averaged 19 years for men and 15 years for women, 1,262 men (5.6%) had 1,975 low-energy fractures, while 1,257 women (11.5%) had 1,805 low-energy fractures.

Among men, the risk factor with the highest impact on later fragility fracture was diabetes, with a relative risk (RR) of 2.38. Other strong risk factors among men were prior hospitalization for mental health problems (RR 1.92), poor appetite (RR 1.72), sleep disturbances (RR 1.53), and poor self-rated health (RR 1.25).

An indirect measure of alcohol consumption, serum γ-glutamyl transferase level, also was associated with an increased fracture risk in men at all sites except the forearm. High body mass index in men was protective against fractures in general (RR 0.88), Dr. Holmberg said at the meeting, which was sponsored by the International Osteoporosis Foundation.

Diabetes also was a strong risk factor for fractures in general among women (RR 1.87), and specifically was a significant risk factor for vertebral, ankle, and hip fractures. Previous fracture also was a risk factor for fracture in general (RR 2.00), and for all fracture types except that of the proximal humerus. Hormone therapy decreased fracture risk by 30%, she noted.

TORONTO — Risk factors for fractures in later life are already present in middle age, and their early identification can provide a window of opportunity for intervention, Dr. Anna H. Holmberg said at a world congress on osteoporosis.

Diabetes and mental health problems were among the factors found to be predictive of an increased likelihood of later-life fractures in the Malmö Preventive Project, which was a prospective study that followed 22,444 men and 10,902 women from 1974 through 1999. The primary focus of the project was cardiovascular health, but the investigators also collected data on all low-energy, or fragility, fractures as well as fractures of the forearm, vertebrae, proximal humerus, and ankle, said Dr. Holmberg of the department of orthopedics, Malmö (Sweden) University Hospital.

During follow-up, which averaged 19 years for men and 15 years for women, 1,262 men (5.6%) had 1,975 low-energy fractures, while 1,257 women (11.5%) had 1,805 low-energy fractures.

Among men, the risk factor with the highest impact on later fragility fracture was diabetes, with a relative risk (RR) of 2.38. Other strong risk factors among men were prior hospitalization for mental health problems (RR 1.92), poor appetite (RR 1.72), sleep disturbances (RR 1.53), and poor self-rated health (RR 1.25).

An indirect measure of alcohol consumption, serum γ-glutamyl transferase level, also was associated with an increased fracture risk in men at all sites except the forearm. High body mass index in men was protective against fractures in general (RR 0.88), Dr. Holmberg said at the meeting, which was sponsored by the International Osteoporosis Foundation.

Diabetes also was a strong risk factor for fractures in general among women (RR 1.87), and specifically was a significant risk factor for vertebral, ankle, and hip fractures. Previous fracture also was a risk factor for fracture in general (RR 2.00), and for all fracture types except that of the proximal humerus. Hormone therapy decreased fracture risk by 30%, she noted.

TORONTO — Risk factors for fractures in later life are already present in middle age, and their early identification can provide a window of opportunity for intervention, Dr. Anna H. Holmberg said at a world congress on osteoporosis.

Diabetes and mental health problems were among the factors found to be predictive of an increased likelihood of later-life fractures in the Malmö Preventive Project, which was a prospective study that followed 22,444 men and 10,902 women from 1974 through 1999. The primary focus of the project was cardiovascular health, but the investigators also collected data on all low-energy, or fragility, fractures as well as fractures of the forearm, vertebrae, proximal humerus, and ankle, said Dr. Holmberg of the department of orthopedics, Malmö (Sweden) University Hospital.

During follow-up, which averaged 19 years for men and 15 years for women, 1,262 men (5.6%) had 1,975 low-energy fractures, while 1,257 women (11.5%) had 1,805 low-energy fractures.

Among men, the risk factor with the highest impact on later fragility fracture was diabetes, with a relative risk (RR) of 2.38. Other strong risk factors among men were prior hospitalization for mental health problems (RR 1.92), poor appetite (RR 1.72), sleep disturbances (RR 1.53), and poor self-rated health (RR 1.25).

An indirect measure of alcohol consumption, serum γ-glutamyl transferase level, also was associated with an increased fracture risk in men at all sites except the forearm. High body mass index in men was protective against fractures in general (RR 0.88), Dr. Holmberg said at the meeting, which was sponsored by the International Osteoporosis Foundation.

Diabetes also was a strong risk factor for fractures in general among women (RR 1.87), and specifically was a significant risk factor for vertebral, ankle, and hip fractures. Previous fracture also was a risk factor for fracture in general (RR 2.00), and for all fracture types except that of the proximal humerus. Hormone therapy decreased fracture risk by 30%, she noted.

GLASGOW, SCOTLAND — Chemotherapy for lymphoma should be recognized as a risk factor for the development of osteoporosis, Dr. Bhaskar Dasgupta reported in a poster session at the annual meeting of the British Society for Rheumatology.

Patients with lymphoma have greatly improved survival rates because of advances in treatment, but their quality of life may be compromised by long-term complications of chemotherapy, reported Dr. Dasgupta, director of rheumatology, Southend Hospital NHS Trust, Westcliff on Sea, England. Osteoporosis is one such potential complication that can result from treatment with alkylating agents and the steroids that are often given with chemotherapy.

Height loss as a surrogate marker for vertebral osteoporosis was evaluated in a study of patients attending a lymphoma clinic. A total of 25 patients, 8 with Hodgkin's and 17 with non-Hodgkin's lymphoma, were enrolled. Mean age was 57.6 years, and 13 of the patients were female, reported Dr. Dasgupta.

Exclusion criteria included a previous osteoporosis diagnosis, lymphoma with spinal involvement, and previous corticosteroid treatment.

When baseline height was compared with height 24 months or more after chemotherapy, the mean loss was found to be 22.8 mm, according to Dr. Dasgupta.

The degree of height loss increased with age—every 10-year increase in age was associated with a 5.2-mm decrease in height, he reported. No association was seen between height loss and gender, and none of the patients had other risk factors for osteoporosis, according to questionnaires they had filled out.

Case notes were examined for cumulative steroid dose and the type of chemotherapy received, with no height loss association found. Patients whose height loss exceeded 40 mm were more likely to be symptomatic. Two patients whose height loss was 50 mm or more reported disabling back pain and poor quality of life.

Despite the fact that significant height loss was seen in this group of patients, none had received bisphosphonates or vitamin D, and only one patient was taking a calcium supplement, Dr. Dasgupta noted. Also, none of the patients had had a bone mineral density determination.

“Our findings suggest that larger studies of osteoporosis and its complications following chemo-therapy are needed, and that appropriate investigations and prophylactic management are indicated, especially in the elderly,” Dr. Dasgupta concluded.

GLASGOW, SCOTLAND — Chemotherapy for lymphoma should be recognized as a risk factor for the development of osteoporosis, Dr. Bhaskar Dasgupta reported in a poster session at the annual meeting of the British Society for Rheumatology.

Patients with lymphoma have greatly improved survival rates because of advances in treatment, but their quality of life may be compromised by long-term complications of chemotherapy, reported Dr. Dasgupta, director of rheumatology, Southend Hospital NHS Trust, Westcliff on Sea, England. Osteoporosis is one such potential complication that can result from treatment with alkylating agents and the steroids that are often given with chemotherapy.

Height loss as a surrogate marker for vertebral osteoporosis was evaluated in a study of patients attending a lymphoma clinic. A total of 25 patients, 8 with Hodgkin's and 17 with non-Hodgkin's lymphoma, were enrolled. Mean age was 57.6 years, and 13 of the patients were female, reported Dr. Dasgupta.

Exclusion criteria included a previous osteoporosis diagnosis, lymphoma with spinal involvement, and previous corticosteroid treatment.

When baseline height was compared with height 24 months or more after chemotherapy, the mean loss was found to be 22.8 mm, according to Dr. Dasgupta.

The degree of height loss increased with age—every 10-year increase in age was associated with a 5.2-mm decrease in height, he reported. No association was seen between height loss and gender, and none of the patients had other risk factors for osteoporosis, according to questionnaires they had filled out.

Case notes were examined for cumulative steroid dose and the type of chemotherapy received, with no height loss association found. Patients whose height loss exceeded 40 mm were more likely to be symptomatic. Two patients whose height loss was 50 mm or more reported disabling back pain and poor quality of life.

Despite the fact that significant height loss was seen in this group of patients, none had received bisphosphonates or vitamin D, and only one patient was taking a calcium supplement, Dr. Dasgupta noted. Also, none of the patients had had a bone mineral density determination.

“Our findings suggest that larger studies of osteoporosis and its complications following chemo-therapy are needed, and that appropriate investigations and prophylactic management are indicated, especially in the elderly,” Dr. Dasgupta concluded.

GLASGOW, SCOTLAND — Chemotherapy for lymphoma should be recognized as a risk factor for the development of osteoporosis, Dr. Bhaskar Dasgupta reported in a poster session at the annual meeting of the British Society for Rheumatology.

Patients with lymphoma have greatly improved survival rates because of advances in treatment, but their quality of life may be compromised by long-term complications of chemotherapy, reported Dr. Dasgupta, director of rheumatology, Southend Hospital NHS Trust, Westcliff on Sea, England. Osteoporosis is one such potential complication that can result from treatment with alkylating agents and the steroids that are often given with chemotherapy.

Height loss as a surrogate marker for vertebral osteoporosis was evaluated in a study of patients attending a lymphoma clinic. A total of 25 patients, 8 with Hodgkin's and 17 with non-Hodgkin's lymphoma, were enrolled. Mean age was 57.6 years, and 13 of the patients were female, reported Dr. Dasgupta.

Exclusion criteria included a previous osteoporosis diagnosis, lymphoma with spinal involvement, and previous corticosteroid treatment.

When baseline height was compared with height 24 months or more after chemotherapy, the mean loss was found to be 22.8 mm, according to Dr. Dasgupta.

The degree of height loss increased with age—every 10-year increase in age was associated with a 5.2-mm decrease in height, he reported. No association was seen between height loss and gender, and none of the patients had other risk factors for osteoporosis, according to questionnaires they had filled out.

Case notes were examined for cumulative steroid dose and the type of chemotherapy received, with no height loss association found. Patients whose height loss exceeded 40 mm were more likely to be symptomatic. Two patients whose height loss was 50 mm or more reported disabling back pain and poor quality of life.

Despite the fact that significant height loss was seen in this group of patients, none had received bisphosphonates or vitamin D, and only one patient was taking a calcium supplement, Dr. Dasgupta noted. Also, none of the patients had had a bone mineral density determination.

“Our findings suggest that larger studies of osteoporosis and its complications following chemo-therapy are needed, and that appropriate investigations and prophylactic management are indicated, especially in the elderly,” Dr. Dasgupta concluded.

TORONTO — A single intravenous dose of zoledronic acid reduced markers of bone resorption in postmenopausal women more rapidly and to a greater extent than did weekly oral alendronate, Dr. Kenneth Saag reported in a poster session at a world congress on osteoporosis.

Zoledronic acid is the most powerful of the available bisphosphonates, and its long duration of effect now has been demonstrated in a multicenter double-blind trial that randomized 118 women aged 45–79 years to a single infusion of 5 mg zoledronic acid or 70 mg weekly oral alendronate for 24 weeks. Patients receiving intravenous zoledronic acid also received oral placebo, and those receiving oral alendronate also received intravenous placebo.

In the zoledronic acid group, mean urine cross-linked N-telopeptide of type I collagen (NTx) fell from 46.1 to 15.2 nmol/bone collagen equivalent (BCE)/mmol creatinine at 1 week, while the level of this marker of bone turnover decreased from 45.8 to 35.5 nmol BCE/mmol creatinine in the alendronate group at 1 week. This relative change from baseline in NTx was significantly different between the two groups, and the greater reduction in urine NTx with zoledronic acid persisted throughout the 24 weeks of the study, according to Dr. Saag of the division of rheumatology, University of Alabama, Birmingham.

Levels of bone-specific alkaline phosphatase (BSAP) also decreased from baseline through week 24 in both groups. While reductions in BASP levels were significantly greater in the zoledronic acid group at week 12, levels in both groups were within the premenopausal range of 6.2 to 12.8 ng/mL.

Overall, a comparable proportion of patients in each treatment arm reported adverse events, with 91% of those in the zoledronic acid group and 86% of those in the alendronate group experiencing any adverse event. During the first 3 days after drug initiation, flulike symptoms led to a greater frequency of adverse events in the zoledronic acid group compared with the alendronate group (64% versus 37%), but after 3 days the adverse event rates were similar in the two groups, Dr. Saag reported.

Serious adverse events were reported by two patients in the zoledronic acid group (one report of osteoarthritis and one of chest pain) and by three in the alendronate group (one patella fracture and two reports of osteoarthritis). None were considered to be treatment related.

Patient preferences for the treatments also were analyzed, with study participants expressing a “strong preference” for the single infusion compared with the weekly regimen (66% versus 20%), Dr. Robert Lindsay noted in another poster session at the meeting, which was sponsored by the International Osteoporosis Foundation.

Even among patients who experienced adverse events during the 3 days following the infusion, 74% expressed an overall preference for the single-dose treatment, according to Dr. Lindsay of the clinical research center, Helen Hayes Hospital, West Haverstraw, N.Y.

The study was funded by Novartis Pharma AG, Basel, Switzerland.

Early on, zoledronicgroup patients were more likely to have adverse events associated with flulike symptoms. DR. SAAG

TORONTO — A single intravenous dose of zoledronic acid reduced markers of bone resorption in postmenopausal women more rapidly and to a greater extent than did weekly oral alendronate, Dr. Kenneth Saag reported in a poster session at a world congress on osteoporosis.

Zoledronic acid is the most powerful of the available bisphosphonates, and its long duration of effect now has been demonstrated in a multicenter double-blind trial that randomized 118 women aged 45–79 years to a single infusion of 5 mg zoledronic acid or 70 mg weekly oral alendronate for 24 weeks. Patients receiving intravenous zoledronic acid also received oral placebo, and those receiving oral alendronate also received intravenous placebo.

In the zoledronic acid group, mean urine cross-linked N-telopeptide of type I collagen (NTx) fell from 46.1 to 15.2 nmol/bone collagen equivalent (BCE)/mmol creatinine at 1 week, while the level of this marker of bone turnover decreased from 45.8 to 35.5 nmol BCE/mmol creatinine in the alendronate group at 1 week. This relative change from baseline in NTx was significantly different between the two groups, and the greater reduction in urine NTx with zoledronic acid persisted throughout the 24 weeks of the study, according to Dr. Saag of the division of rheumatology, University of Alabama, Birmingham.

Levels of bone-specific alkaline phosphatase (BSAP) also decreased from baseline through week 24 in both groups. While reductions in BASP levels were significantly greater in the zoledronic acid group at week 12, levels in both groups were within the premenopausal range of 6.2 to 12.8 ng/mL.

Overall, a comparable proportion of patients in each treatment arm reported adverse events, with 91% of those in the zoledronic acid group and 86% of those in the alendronate group experiencing any adverse event. During the first 3 days after drug initiation, flulike symptoms led to a greater frequency of adverse events in the zoledronic acid group compared with the alendronate group (64% versus 37%), but after 3 days the adverse event rates were similar in the two groups, Dr. Saag reported.

Serious adverse events were reported by two patients in the zoledronic acid group (one report of osteoarthritis and one of chest pain) and by three in the alendronate group (one patella fracture and two reports of osteoarthritis). None were considered to be treatment related.

Patient preferences for the treatments also were analyzed, with study participants expressing a “strong preference” for the single infusion compared with the weekly regimen (66% versus 20%), Dr. Robert Lindsay noted in another poster session at the meeting, which was sponsored by the International Osteoporosis Foundation.

Even among patients who experienced adverse events during the 3 days following the infusion, 74% expressed an overall preference for the single-dose treatment, according to Dr. Lindsay of the clinical research center, Helen Hayes Hospital, West Haverstraw, N.Y.

The study was funded by Novartis Pharma AG, Basel, Switzerland.

Early on, zoledronicgroup patients were more likely to have adverse events associated with flulike symptoms. DR. SAAG

TORONTO — A single intravenous dose of zoledronic acid reduced markers of bone resorption in postmenopausal women more rapidly and to a greater extent than did weekly oral alendronate, Dr. Kenneth Saag reported in a poster session at a world congress on osteoporosis.

Zoledronic acid is the most powerful of the available bisphosphonates, and its long duration of effect now has been demonstrated in a multicenter double-blind trial that randomized 118 women aged 45–79 years to a single infusion of 5 mg zoledronic acid or 70 mg weekly oral alendronate for 24 weeks. Patients receiving intravenous zoledronic acid also received oral placebo, and those receiving oral alendronate also received intravenous placebo.

In the zoledronic acid group, mean urine cross-linked N-telopeptide of type I collagen (NTx) fell from 46.1 to 15.2 nmol/bone collagen equivalent (BCE)/mmol creatinine at 1 week, while the level of this marker of bone turnover decreased from 45.8 to 35.5 nmol BCE/mmol creatinine in the alendronate group at 1 week. This relative change from baseline in NTx was significantly different between the two groups, and the greater reduction in urine NTx with zoledronic acid persisted throughout the 24 weeks of the study, according to Dr. Saag of the division of rheumatology, University of Alabama, Birmingham.

Levels of bone-specific alkaline phosphatase (BSAP) also decreased from baseline through week 24 in both groups. While reductions in BASP levels were significantly greater in the zoledronic acid group at week 12, levels in both groups were within the premenopausal range of 6.2 to 12.8 ng/mL.

Overall, a comparable proportion of patients in each treatment arm reported adverse events, with 91% of those in the zoledronic acid group and 86% of those in the alendronate group experiencing any adverse event. During the first 3 days after drug initiation, flulike symptoms led to a greater frequency of adverse events in the zoledronic acid group compared with the alendronate group (64% versus 37%), but after 3 days the adverse event rates were similar in the two groups, Dr. Saag reported.

Serious adverse events were reported by two patients in the zoledronic acid group (one report of osteoarthritis and one of chest pain) and by three in the alendronate group (one patella fracture and two reports of osteoarthritis). None were considered to be treatment related.

Patient preferences for the treatments also were analyzed, with study participants expressing a “strong preference” for the single infusion compared with the weekly regimen (66% versus 20%), Dr. Robert Lindsay noted in another poster session at the meeting, which was sponsored by the International Osteoporosis Foundation.

Even among patients who experienced adverse events during the 3 days following the infusion, 74% expressed an overall preference for the single-dose treatment, according to Dr. Lindsay of the clinical research center, Helen Hayes Hospital, West Haverstraw, N.Y.

The study was funded by Novartis Pharma AG, Basel, Switzerland.

Early on, zoledronicgroup patients were more likely to have adverse events associated with flulike symptoms. DR. SAAG

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-? therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, their mean age was 43 years, and the mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics.

The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Promptly referring the patient to a podiatry service is considered necessary if onychocryptosis develops in a patient on biologic therapy. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines and should work closely with the rheumatology team, wrote Ms. Davys.

Surgery by a podiatrist is often required to repair onychocryptosis. Courtesy Heidi J. Davys

Some Biologics, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue, requiring a balance between maintaining disease control and avoiding potential morbidities such as infection. Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

The published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical trial data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. No human data are available. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-? therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, their mean age was 43 years, and the mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics.

The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Promptly referring the patient to a podiatry service is considered necessary if onychocryptosis develops in a patient on biologic therapy. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines and should work closely with the rheumatology team, wrote Ms. Davys.

Surgery by a podiatrist is often required to repair onychocryptosis. Courtesy Heidi J. Davys

Some Biologics, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue, requiring a balance between maintaining disease control and avoiding potential morbidities such as infection. Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

The published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical trial data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. No human data are available. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

GLASGOW, SCOTLAND — Onychocryptosis poses a particular risk to patients with rheumatoid arthritis being treated with biologics, so vigilance should be practiced in the foot care of these patients, reported Heidi J. Davys.

Onychocryptosis can be accompanied by local sepsis, which is a serious concern in patients on anti-tumor necrosis factor-? therapy, Ms. Davys noted in a poster session at the annual meeting of the British Society for Rheumatology.

The full extent and impact of foot problems in these patients is not clear, but a retrospective 14-month audit in the rheumatology foot clinic at Leeds (England) General Infirmary identified nine cases of onychocryptosis developing in rheumatoid arthritis (RA) patients on biologic therapy.

Five of the affected patients were female, their mean age was 43 years, and the mean disease duration was 10.9 years. Etanercept was the drug being used in seven cases, and infliximab and abatacept each were being used by one patient.

None of the patients had experienced previous episodes of onychocryptosis. The mean time between commencement of biologic therapy and symptom onset was 20 weeks, wrote Ms. Davys, who is a specialist in rheumatologic podiatry, Leeds Teaching Hospitals NHS Trust.

Therapy with the biologic was suspended in all patients prior to nail treatment for an average duration of 2 weeks, until healing was complete. Eight of the patients underwent partial or total nail avulsion, three with matrix phenolization to prevent regrowth. All patients also were treated with systemic antibiotics.

The outcome was successful in all nine patients, allowing reinstitution of biologic therapy.

Promptly referring the patient to a podiatry service is considered necessary if onychocryptosis develops in a patient on biologic therapy. Podiatrists performing surgical procedures such as avulsion should be aware of current perioperative guidelines and should work closely with the rheumatology team, wrote Ms. Davys.

Surgery by a podiatrist is often required to repair onychocryptosis. Courtesy Heidi J. Davys

Some Biologics, Surgery Don't Mix

Perioperative management of patients taking immunosuppressive drugs has been a challenging issue, requiring a balance between maintaining disease control and avoiding potential morbidities such as infection. Concerns are particularly significant with the biologic response modifiers, because of the risk of serious infection associated with their use.

The published treatment guidelines are based on the perioperative use of infliximab among patients with Crohn's disease and on animal model and tissue culture investigations. Until more evidence-based clinical trial data are available, the following are considered reasonable:

▸ Infliximab. This drug can be continued without interruption or discontinued 1 week before surgery and resumed 1–2 weeks after.

▸ Etanercept and anakinra. No human data are available. Experiments in animal models suggest that these drugs should be withdrawn the week of the procedure and resumed 1–2 weeks later.

▸ Adalimumab and rituximab. No data are available. These agents should be discontinued at least 1 week before surgery and resumed 1–2 weeks later.

Source: Curr. Opin. Rheumatol. 2004;16:192–8.

TORONTO — Risk factors for fractures in later life are already present in middle age, and their early identification can provide a window of opportunity for intervention, Dr. Anna H. Holmberg said at a world congress on osteoporosis.

The Malmö Preventive Project was a prospective study that followed 22,444 men and 10,902 women from 1974 through 1999, said Dr. Holmberg of the department of orthopedics, Malmö (Sweden) University Hospital.

During follow-up, which averaged 19 years for men and 15 years for women, 1,262 men (5.6%) had 1,975 low-energy fractures, while 1,257 women (11.5%) had 1,805 low-energy fractures.

Among men, the risk factor with the highest impact on later fragility fracture was diabetes, with a relative risk (RR) of 2.38. Other strong risk factors among men were prior hospitalization for mental health problems (RR 1.92), poor appetite (RR 1.72), sleep disturbances (RR 1.53), and poor self-rated health (RR 1.25), Dr. Holmberg said at the meeting, which was sponsored by the International Osteoporosis Foundation.

Diabetes also was a strong risk factor for fractures in general among women (RR 1.87), and specifically was a significant risk factor for vertebral, ankle, and hip fractures.

TORONTO — Risk factors for fractures in later life are already present in middle age, and their early identification can provide a window of opportunity for intervention, Dr. Anna H. Holmberg said at a world congress on osteoporosis.

The Malmö Preventive Project was a prospective study that followed 22,444 men and 10,902 women from 1974 through 1999, said Dr. Holmberg of the department of orthopedics, Malmö (Sweden) University Hospital.

During follow-up, which averaged 19 years for men and 15 years for women, 1,262 men (5.6%) had 1,975 low-energy fractures, while 1,257 women (11.5%) had 1,805 low-energy fractures.

Among men, the risk factor with the highest impact on later fragility fracture was diabetes, with a relative risk (RR) of 2.38. Other strong risk factors among men were prior hospitalization for mental health problems (RR 1.92), poor appetite (RR 1.72), sleep disturbances (RR 1.53), and poor self-rated health (RR 1.25), Dr. Holmberg said at the meeting, which was sponsored by the International Osteoporosis Foundation.

Diabetes also was a strong risk factor for fractures in general among women (RR 1.87), and specifically was a significant risk factor for vertebral, ankle, and hip fractures.

TORONTO — Risk factors for fractures in later life are already present in middle age, and their early identification can provide a window of opportunity for intervention, Dr. Anna H. Holmberg said at a world congress on osteoporosis.

The Malmö Preventive Project was a prospective study that followed 22,444 men and 10,902 women from 1974 through 1999, said Dr. Holmberg of the department of orthopedics, Malmö (Sweden) University Hospital.

During follow-up, which averaged 19 years for men and 15 years for women, 1,262 men (5.6%) had 1,975 low-energy fractures, while 1,257 women (11.5%) had 1,805 low-energy fractures.

Among men, the risk factor with the highest impact on later fragility fracture was diabetes, with a relative risk (RR) of 2.38. Other strong risk factors among men were prior hospitalization for mental health problems (RR 1.92), poor appetite (RR 1.72), sleep disturbances (RR 1.53), and poor self-rated health (RR 1.25), Dr. Holmberg said at the meeting, which was sponsored by the International Osteoporosis Foundation.

Diabetes also was a strong risk factor for fractures in general among women (RR 1.87), and specifically was a significant risk factor for vertebral, ankle, and hip fractures.

GLASGOW – When acute nonspecific symptoms might represent neuropsychiatric lupus, it is necessary to carefully review a patient's past medical history, because the presenting symptoms of systemic lupus erythematosus are manifold, may mimic other disorders, and can evolve over time, Dr. Hala Y. Sadik reported in a poster.

This is particularly the case when the onset is acute, as happened in a case treated by Dr. Sadik of the Academic Rheumatology Unit, University Hospital Aintree, Liverpool, England.

In August 2005, a 57-year-old woman presented with hypothermia, bradycardia, confusion, a low score on the Glasgow Coma Scale, and hyponatremia. The patient's plasma sodium level was low (120 mmol/L), as well as her plasma osmolality (235 mOsm/kg), while urinary sodium and osmolality levels were both high. A diagnosis of inappropriate antidiuretic hormone secretion was made, Dr. Sadik reported in a poster session at the annual meeting of the British Society for Rheumatology.

Initial management included fluid restriction and administration of double-strength normal saline, which normalized the plasma sodium level, reported Dr. Sadik. Initial MRI of the head raised the possibility of neurosarcoidosis, but serum angiotensin-converting enzyme levels and chest x-ray were normal. A repeat MRI with gadolinium suggested demyelinating disease or systemic lupus erythematosus. Immunology profile findings included positive antinuclear antibody (ANA) and double- stranded DNA antibody. Thrombocytopenia and lymphopenia also were present.

Upon review, her previous case records from another hospital revealed that she had been admitted in 1992 with a 2-week history of arthralgias, Raynaud's phenomenon, thrombocytopenia, lymphopenia, and positive ANA. A diagnosis of lupus had been considered at that time, and she was followed for several years as an outpatient, but ANA remained weakly positive and double-stranded DNA was persistently negative, so the diagnosis had been dismissed, Dr. Sadik wrote.

With improvements on the Glasgow Coma Scale during her current admission, it became apparent that the patient was profoundly depressed, so she was treated with mirtazapine.

After a diagnosis of neuropsychiatric lupus, the patient began treatment with intravenous methylprednisolone and cyclophosphamide. Significant improvements were seen in her disabling depression, and her hematologic parameters normalized.

GLASGOW – When acute nonspecific symptoms might represent neuropsychiatric lupus, it is necessary to carefully review a patient's past medical history, because the presenting symptoms of systemic lupus erythematosus are manifold, may mimic other disorders, and can evolve over time, Dr. Hala Y. Sadik reported in a poster.

This is particularly the case when the onset is acute, as happened in a case treated by Dr. Sadik of the Academic Rheumatology Unit, University Hospital Aintree, Liverpool, England.

In August 2005, a 57-year-old woman presented with hypothermia, bradycardia, confusion, a low score on the Glasgow Coma Scale, and hyponatremia. The patient's plasma sodium level was low (120 mmol/L), as well as her plasma osmolality (235 mOsm/kg), while urinary sodium and osmolality levels were both high. A diagnosis of inappropriate antidiuretic hormone secretion was made, Dr. Sadik reported in a poster session at the annual meeting of the British Society for Rheumatology.

Initial management included fluid restriction and administration of double-strength normal saline, which normalized the plasma sodium level, reported Dr. Sadik. Initial MRI of the head raised the possibility of neurosarcoidosis, but serum angiotensin-converting enzyme levels and chest x-ray were normal. A repeat MRI with gadolinium suggested demyelinating disease or systemic lupus erythematosus. Immunology profile findings included positive antinuclear antibody (ANA) and double- stranded DNA antibody. Thrombocytopenia and lymphopenia also were present.

Upon review, her previous case records from another hospital revealed that she had been admitted in 1992 with a 2-week history of arthralgias, Raynaud's phenomenon, thrombocytopenia, lymphopenia, and positive ANA. A diagnosis of lupus had been considered at that time, and she was followed for several years as an outpatient, but ANA remained weakly positive and double-stranded DNA was persistently negative, so the diagnosis had been dismissed, Dr. Sadik wrote.

With improvements on the Glasgow Coma Scale during her current admission, it became apparent that the patient was profoundly depressed, so she was treated with mirtazapine.

After a diagnosis of neuropsychiatric lupus, the patient began treatment with intravenous methylprednisolone and cyclophosphamide. Significant improvements were seen in her disabling depression, and her hematologic parameters normalized.

GLASGOW – When acute nonspecific symptoms might represent neuropsychiatric lupus, it is necessary to carefully review a patient's past medical history, because the presenting symptoms of systemic lupus erythematosus are manifold, may mimic other disorders, and can evolve over time, Dr. Hala Y. Sadik reported in a poster.

This is particularly the case when the onset is acute, as happened in a case treated by Dr. Sadik of the Academic Rheumatology Unit, University Hospital Aintree, Liverpool, England.

In August 2005, a 57-year-old woman presented with hypothermia, bradycardia, confusion, a low score on the Glasgow Coma Scale, and hyponatremia. The patient's plasma sodium level was low (120 mmol/L), as well as her plasma osmolality (235 mOsm/kg), while urinary sodium and osmolality levels were both high. A diagnosis of inappropriate antidiuretic hormone secretion was made, Dr. Sadik reported in a poster session at the annual meeting of the British Society for Rheumatology.

Initial management included fluid restriction and administration of double-strength normal saline, which normalized the plasma sodium level, reported Dr. Sadik. Initial MRI of the head raised the possibility of neurosarcoidosis, but serum angiotensin-converting enzyme levels and chest x-ray were normal. A repeat MRI with gadolinium suggested demyelinating disease or systemic lupus erythematosus. Immunology profile findings included positive antinuclear antibody (ANA) and double- stranded DNA antibody. Thrombocytopenia and lymphopenia also were present.

Upon review, her previous case records from another hospital revealed that she had been admitted in 1992 with a 2-week history of arthralgias, Raynaud's phenomenon, thrombocytopenia, lymphopenia, and positive ANA. A diagnosis of lupus had been considered at that time, and she was followed for several years as an outpatient, but ANA remained weakly positive and double-stranded DNA was persistently negative, so the diagnosis had been dismissed, Dr. Sadik wrote.

With improvements on the Glasgow Coma Scale during her current admission, it became apparent that the patient was profoundly depressed, so she was treated with mirtazapine.

After a diagnosis of neuropsychiatric lupus, the patient began treatment with intravenous methylprednisolone and cyclophosphamide. Significant improvements were seen in her disabling depression, and her hematologic parameters normalized.