Sally Koch Kubetin

SANTA MONICA, CALIF. – Social media provides a way for physicians to engage with their patients and the community, whether the physician practices in an HMO or privately, according to Dr. Jeffrey Benabio, a dermatologist at Kaiser Permanente in San Diego.

Moreover, physicians in private practice could find social media useful in building their practices, Dr. Benabio said at a meeting sponsored by Rheumatology News and Skin Disease Education Foundation.

No matter what the specialty, the principles of using social media such as blogs, Facebook, Twitter, and Web sites as tools for improving patient care will apply.

"Online patient communities are an ascendant means for patients to learn about their disease, and seek advice and comfort from [other] patients like them. Physicians can be part of this conversation and contribute to it. Who better to [advise] patients [on] how to live with pain, live with deformity, deal with insurance companies, than physicians?" noted Dr. Benabio in an interview.

It takes no money but lots of time to build online networks. So why bother to do it? Dr. Benabio offered several reasons.

"Patients are going online to interact with their physicians, and we are not there.

"Physicians are losing [their] status as the sole source of medical knowledge. Whereas patients always had to come to us to learn about disease and health, now they get most of their information online. Our absence online perpetuates a trend of diminishing importance of our profession. Patients are online; physicians need to be where they are, he said.

As with much in life, the secret to being effective online comes down to showing up.

"A physician becomes a trusted member of the community by being present. Over time, regular blog posts, Facebook updates, and Tweets allow the audience to become familiar with the physician. To know that he or she is there, is listening, is part of the community.

"Physicians should blog and have Facebook pages. They should post things that are helpful and informative for their audience. They can report news, but it must be within the law. Physicians can talk about drugs and about non-FDA–approved uses of drugs as long as they are not giving actual medical advice, and are clear about any disclosures and disclaimers," Dr. Benabio said.

They should Google themselves and see what they find – though they might not like it. The only content you can control is the content you create, he asserted.

Google has 400 million queries daily and 75%-80% of adults have sought medical information on line. The nature of information on the Internet is collaborative, and physicians need to be part of that. Otherwise, the public might be offered information that is inaccurate and biased, he said.

"It is as important to be a trusted member of the online community as it is to be a trusted member of your actual community," Dr. Benabio said. Starting a blog and making it part of your practice's Web site will have the additional benefit of marketing the practice at the same time you are offering the public a reliable perspective on medical developments within your specialty.

Those who are interested in marketing their practices should remember that using social media is free but time consuming. But getting your name out online, making sure it is associated with reliable information, and being available as a caring, informed physician are all effective marketing strategies that are literally at your fingertips in the form of social media tools. Some would say this is becoming the first choice in marketing, and that traditional marketing is dying.

Dr. Benabio warned that others will usurp their role as providers of health information unless physicians get online to counter that trend. Certainly alternative health providers are on social media, building relationships with patients, and boosting their status among patients. Just as a patient who has no access to a dermatologist will see a nurse or naturopath, patients online seek information from nonphysicians, he noted.

Physicians are on a slippery slope in this age of the Internet information highway. "This is a critical time when we are trying to demonstrate our value as practitioners," he said. "The more comfortable people are with nonphysicians, the more difficult it will be for us to fight nonphysicians' expansion of their scope of practice."

SDEF and this news organization are owned by Elsevier. Dr. Benabio disclosed that he is a consultant for Livestrong.com and a full-time employee of the Southern California Permanente Medical Group.

SANTA MONICA, CALIF. – Social media provides a way for physicians to engage with their patients and the community, whether the physician practices in an HMO or privately, according to Dr. Jeffrey Benabio, a dermatologist at Kaiser Permanente in San Diego.

Moreover, physicians in private practice could find social media useful in building their practices, Dr. Benabio said at a meeting sponsored by Rheumatology News and Skin Disease Education Foundation.

No matter what the specialty, the principles of using social media such as blogs, Facebook, Twitter, and Web sites as tools for improving patient care will apply.

"Online patient communities are an ascendant means for patients to learn about their disease, and seek advice and comfort from [other] patients like them. Physicians can be part of this conversation and contribute to it. Who better to [advise] patients [on] how to live with pain, live with deformity, deal with insurance companies, than physicians?" noted Dr. Benabio in an interview.

It takes no money but lots of time to build online networks. So why bother to do it? Dr. Benabio offered several reasons.

"Patients are going online to interact with their physicians, and we are not there.

"Physicians are losing [their] status as the sole source of medical knowledge. Whereas patients always had to come to us to learn about disease and health, now they get most of their information online. Our absence online perpetuates a trend of diminishing importance of our profession. Patients are online; physicians need to be where they are, he said.

As with much in life, the secret to being effective online comes down to showing up.

"A physician becomes a trusted member of the community by being present. Over time, regular blog posts, Facebook updates, and Tweets allow the audience to become familiar with the physician. To know that he or she is there, is listening, is part of the community.

"Physicians should blog and have Facebook pages. They should post things that are helpful and informative for their audience. They can report news, but it must be within the law. Physicians can talk about drugs and about non-FDA–approved uses of drugs as long as they are not giving actual medical advice, and are clear about any disclosures and disclaimers," Dr. Benabio said.

They should Google themselves and see what they find – though they might not like it. The only content you can control is the content you create, he asserted.

Google has 400 million queries daily and 75%-80% of adults have sought medical information on line. The nature of information on the Internet is collaborative, and physicians need to be part of that. Otherwise, the public might be offered information that is inaccurate and biased, he said.

"It is as important to be a trusted member of the online community as it is to be a trusted member of your actual community," Dr. Benabio said. Starting a blog and making it part of your practice's Web site will have the additional benefit of marketing the practice at the same time you are offering the public a reliable perspective on medical developments within your specialty.

Those who are interested in marketing their practices should remember that using social media is free but time consuming. But getting your name out online, making sure it is associated with reliable information, and being available as a caring, informed physician are all effective marketing strategies that are literally at your fingertips in the form of social media tools. Some would say this is becoming the first choice in marketing, and that traditional marketing is dying.

Dr. Benabio warned that others will usurp their role as providers of health information unless physicians get online to counter that trend. Certainly alternative health providers are on social media, building relationships with patients, and boosting their status among patients. Just as a patient who has no access to a dermatologist will see a nurse or naturopath, patients online seek information from nonphysicians, he noted.

Physicians are on a slippery slope in this age of the Internet information highway. "This is a critical time when we are trying to demonstrate our value as practitioners," he said. "The more comfortable people are with nonphysicians, the more difficult it will be for us to fight nonphysicians' expansion of their scope of practice."

SDEF and this news organization are owned by Elsevier. Dr. Benabio disclosed that he is a consultant for Livestrong.com and a full-time employee of the Southern California Permanente Medical Group.

SANTA MONICA, CALIF. – Social media provides a way for physicians to engage with their patients and the community, whether the physician practices in an HMO or privately, according to Dr. Jeffrey Benabio, a dermatologist at Kaiser Permanente in San Diego.

Moreover, physicians in private practice could find social media useful in building their practices, Dr. Benabio said at a meeting sponsored by Rheumatology News and Skin Disease Education Foundation.

No matter what the specialty, the principles of using social media such as blogs, Facebook, Twitter, and Web sites as tools for improving patient care will apply.

"Online patient communities are an ascendant means for patients to learn about their disease, and seek advice and comfort from [other] patients like them. Physicians can be part of this conversation and contribute to it. Who better to [advise] patients [on] how to live with pain, live with deformity, deal with insurance companies, than physicians?" noted Dr. Benabio in an interview.

It takes no money but lots of time to build online networks. So why bother to do it? Dr. Benabio offered several reasons.

"Patients are going online to interact with their physicians, and we are not there.

"Physicians are losing [their] status as the sole source of medical knowledge. Whereas patients always had to come to us to learn about disease and health, now they get most of their information online. Our absence online perpetuates a trend of diminishing importance of our profession. Patients are online; physicians need to be where they are, he said.

As with much in life, the secret to being effective online comes down to showing up.

"A physician becomes a trusted member of the community by being present. Over time, regular blog posts, Facebook updates, and Tweets allow the audience to become familiar with the physician. To know that he or she is there, is listening, is part of the community.

"Physicians should blog and have Facebook pages. They should post things that are helpful and informative for their audience. They can report news, but it must be within the law. Physicians can talk about drugs and about non-FDA–approved uses of drugs as long as they are not giving actual medical advice, and are clear about any disclosures and disclaimers," Dr. Benabio said.

They should Google themselves and see what they find – though they might not like it. The only content you can control is the content you create, he asserted.

Google has 400 million queries daily and 75%-80% of adults have sought medical information on line. The nature of information on the Internet is collaborative, and physicians need to be part of that. Otherwise, the public might be offered information that is inaccurate and biased, he said.

"It is as important to be a trusted member of the online community as it is to be a trusted member of your actual community," Dr. Benabio said. Starting a blog and making it part of your practice's Web site will have the additional benefit of marketing the practice at the same time you are offering the public a reliable perspective on medical developments within your specialty.

Those who are interested in marketing their practices should remember that using social media is free but time consuming. But getting your name out online, making sure it is associated with reliable information, and being available as a caring, informed physician are all effective marketing strategies that are literally at your fingertips in the form of social media tools. Some would say this is becoming the first choice in marketing, and that traditional marketing is dying.

Dr. Benabio warned that others will usurp their role as providers of health information unless physicians get online to counter that trend. Certainly alternative health providers are on social media, building relationships with patients, and boosting their status among patients. Just as a patient who has no access to a dermatologist will see a nurse or naturopath, patients online seek information from nonphysicians, he noted.

Physicians are on a slippery slope in this age of the Internet information highway. "This is a critical time when we are trying to demonstrate our value as practitioners," he said. "The more comfortable people are with nonphysicians, the more difficult it will be for us to fight nonphysicians' expansion of their scope of practice."

SDEF and this news organization are owned by Elsevier. Dr. Benabio disclosed that he is a consultant for Livestrong.com and a full-time employee of the Southern California Permanente Medical Group.

SANTA MONICA, CALIF. – Social media provides a way for physicians to engage with their patients and the community, whether the physician practices in an HMO or privately, according to Dr. Jeffrey Benabio, a dermatologist at Kaiser Permanente in San Diego.

Moreover, physicians in private practice could find social media useful in building their practices, Dr. Benabio said at a meeting sponsored by Skin Disease Education Foundation and the University of Louisville.

No matter what the specialty, the principles of using social media such as blogs, Facebook, Twitter, and Web sites as tools for improving patient care will apply.

"Online patient communities are an ascendant means for patients to learn about their disease, and seek advice and comfort from [other] patients like them. Physicians can be part of this conversation and contribute to it. Who better to [advise] patients [on] how to live with pain, live with deformity, deal with insurance companies, than physicians?" noted Dr. Benabio in an interview.

It takes no money but lots of time to build online networks. So why bother to do it? Dr. Benabio offered several reasons.

"Patients are going online to interact with their physicians, and we are not there.

"Physicians are losing [their] status as the sole source of medical knowledge. Whereas patients always had to come to us to learn about disease and health, now they get most of their information online. Our absence online perpetuates a trend of diminishing importance of our profession. Patients are online; physicians need to be where they are, he said.

As with much in life, the secret to being effective online comes down to showing up.

"A physician becomes a trusted member of the community by being present. Over time, regular blog posts, Facebook updates, and Tweets allow the audience to become familiar with the physician. To know that he or she is there, is listening, is part of the community.

"Physicians should blog and have Facebook pages. They should post things that are helpful and informative for their audience. They can report news, but it must be within the law. Physicians can talk about drugs and about non-FDA–approved uses of drugs as long as they are not giving actual medical advice, and are clear about any disclosures and disclaimers," Dr. Benabio said.

They should Google themselves and see what they find – though they might not like it. The only content you can control is the content you create, he asserted.

Google has 400 million queries daily and 75%-80% of adults have sought medical information on line. The nature of information on the Internet is collaborative, and physicians need to be part of that. Otherwise, the public might be offered information that is inaccurate and biased, he said.

"It is as important to be a trusted member of the online community as it is to be a trusted member of your actual community," Dr. Benabio said. Starting a blog and making it part of your practice's Web site will have the additional benefit of marketing the practice at the same time you are offering the public a reliable perspective on medical developments within your specialty.

Those who are interested in marketing their practices should remember that using social media is free but time consuming. But getting your name out online, making sure it is associated with reliable information, and being available as a caring, informed physician are all effective marketing strategies that are literally at your fingertips in the form of social media tools. Some would say this is becoming the first choice in marketing, and that traditional marketing is dying.

Dr. Benabio warned that others will usurp their role as providers of health information unless physicians get online to counter that trend. Certainly alternative health providers are on social media, building relationships with patients, and boosting their status among patients. Just as a patient who has no access to a dermatologist will see a nurse or naturopath, patients online seek information from nonphysicians, he noted.

Physicians are on a slippery slope in this age of the Internet information highway. "This is a critical time when we are trying to demonstrate our value as practitioners," he said. "The more comfortable people are with nonphysicians, the more difficult it will be for us to fight nonphysicians' expansion of their scope of practice."

SDEF and this news organization are owned by Elsevier. Dr. Benabio disclosed that he is a consultant for Livestrong.com and a full-time employee of the Southern California Permanente Medical Group.

SANTA MONICA, CALIF. – Social media provides a way for physicians to engage with their patients and the community, whether the physician practices in an HMO or privately, according to Dr. Jeffrey Benabio, a dermatologist at Kaiser Permanente in San Diego.

Moreover, physicians in private practice could find social media useful in building their practices, Dr. Benabio said at a meeting sponsored by Skin Disease Education Foundation and the University of Louisville.

No matter what the specialty, the principles of using social media such as blogs, Facebook, Twitter, and Web sites as tools for improving patient care will apply.

"Online patient communities are an ascendant means for patients to learn about their disease, and seek advice and comfort from [other] patients like them. Physicians can be part of this conversation and contribute to it. Who better to [advise] patients [on] how to live with pain, live with deformity, deal with insurance companies, than physicians?" noted Dr. Benabio in an interview.

It takes no money but lots of time to build online networks. So why bother to do it? Dr. Benabio offered several reasons.

"Patients are going online to interact with their physicians, and we are not there.

"Physicians are losing [their] status as the sole source of medical knowledge. Whereas patients always had to come to us to learn about disease and health, now they get most of their information online. Our absence online perpetuates a trend of diminishing importance of our profession. Patients are online; physicians need to be where they are, he said.

As with much in life, the secret to being effective online comes down to showing up.

"A physician becomes a trusted member of the community by being present. Over time, regular blog posts, Facebook updates, and Tweets allow the audience to become familiar with the physician. To know that he or she is there, is listening, is part of the community.

"Physicians should blog and have Facebook pages. They should post things that are helpful and informative for their audience. They can report news, but it must be within the law. Physicians can talk about drugs and about non-FDA–approved uses of drugs as long as they are not giving actual medical advice, and are clear about any disclosures and disclaimers," Dr. Benabio said.

They should Google themselves and see what they find – though they might not like it. The only content you can control is the content you create, he asserted.

Google has 400 million queries daily and 75%-80% of adults have sought medical information on line. The nature of information on the Internet is collaborative, and physicians need to be part of that. Otherwise, the public might be offered information that is inaccurate and biased, he said.

"It is as important to be a trusted member of the online community as it is to be a trusted member of your actual community," Dr. Benabio said. Starting a blog and making it part of your practice's Web site will have the additional benefit of marketing the practice at the same time you are offering the public a reliable perspective on medical developments within your specialty.

Those who are interested in marketing their practices should remember that using social media is free but time consuming. But getting your name out online, making sure it is associated with reliable information, and being available as a caring, informed physician are all effective marketing strategies that are literally at your fingertips in the form of social media tools. Some would say this is becoming the first choice in marketing, and that traditional marketing is dying.

Dr. Benabio warned that others will usurp their role as providers of health information unless physicians get online to counter that trend. Certainly alternative health providers are on social media, building relationships with patients, and boosting their status among patients. Just as a patient who has no access to a dermatologist will see a nurse or naturopath, patients online seek information from nonphysicians, he noted.

Physicians are on a slippery slope in this age of the Internet information highway. "This is a critical time when we are trying to demonstrate our value as practitioners," he said. "The more comfortable people are with nonphysicians, the more difficult it will be for us to fight nonphysicians' expansion of their scope of practice."

SDEF and this news organization are owned by Elsevier. Dr. Benabio disclosed that he is a consultant for Livestrong.com and a full-time employee of the Southern California Permanente Medical Group.

SANTA MONICA, CALIF. – Social media provides a way for physicians to engage with their patients and the community, whether the physician practices in an HMO or privately, according to Dr. Jeffrey Benabio, a dermatologist at Kaiser Permanente in San Diego.

Moreover, physicians in private practice could find social media useful in building their practices, Dr. Benabio said at a meeting sponsored by Skin Disease Education Foundation and the University of Louisville.

No matter what the specialty, the principles of using social media such as blogs, Facebook, Twitter, and Web sites as tools for improving patient care will apply.

"Online patient communities are an ascendant means for patients to learn about their disease, and seek advice and comfort from [other] patients like them. Physicians can be part of this conversation and contribute to it. Who better to [advise] patients [on] how to live with pain, live with deformity, deal with insurance companies, than physicians?" noted Dr. Benabio in an interview.

It takes no money but lots of time to build online networks. So why bother to do it? Dr. Benabio offered several reasons.

"Patients are going online to interact with their physicians, and we are not there.

"Physicians are losing [their] status as the sole source of medical knowledge. Whereas patients always had to come to us to learn about disease and health, now they get most of their information online. Our absence online perpetuates a trend of diminishing importance of our profession. Patients are online; physicians need to be where they are, he said.

As with much in life, the secret to being effective online comes down to showing up.

"A physician becomes a trusted member of the community by being present. Over time, regular blog posts, Facebook updates, and Tweets allow the audience to become familiar with the physician. To know that he or she is there, is listening, is part of the community.

"Physicians should blog and have Facebook pages. They should post things that are helpful and informative for their audience. They can report news, but it must be within the law. Physicians can talk about drugs and about non-FDA–approved uses of drugs as long as they are not giving actual medical advice, and are clear about any disclosures and disclaimers," Dr. Benabio said.

They should Google themselves and see what they find – though they might not like it. The only content you can control is the content you create, he asserted.

Google has 400 million queries daily and 75%-80% of adults have sought medical information on line. The nature of information on the Internet is collaborative, and physicians need to be part of that. Otherwise, the public might be offered information that is inaccurate and biased, he said.

"It is as important to be a trusted member of the online community as it is to be a trusted member of your actual community," Dr. Benabio said. Starting a blog and making it part of your practice's Web site will have the additional benefit of marketing the practice at the same time you are offering the public a reliable perspective on medical developments within your specialty.

Those who are interested in marketing their practices should remember that using social media is free but time consuming. But getting your name out online, making sure it is associated with reliable information, and being available as a caring, informed physician are all effective marketing strategies that are literally at your fingertips in the form of social media tools. Some would say this is becoming the first choice in marketing, and that traditional marketing is dying.

Dr. Benabio warned that others will usurp their role as providers of health information unless physicians get online to counter that trend. Certainly alternative health providers are on social media, building relationships with patients, and boosting their status among patients. Just as a patient who has no access to a dermatologist will see a nurse or naturopath, patients online seek information from nonphysicians, he noted.

Physicians are on a slippery slope in this age of the Internet information highway. "This is a critical time when we are trying to demonstrate our value as practitioners," he said. "The more comfortable people are with nonphysicians, the more difficult it will be for us to fight nonphysicians' expansion of their scope of practice."

SDEF and this news organization are owned by Elsevier. Dr. Benabio disclosed that he is a consultant for Livestrong.com and a full-time employee of the Southern California Permanente Medical Group.

Insurance payers now have detailed guidance on the appropriate use and coverage of biologic agents in the management of rheumatoid arthritis, thanks to a document prepared by the American College of Rheumatology.

“Insurance companies would like to put the various biologics on the market in rank order,” according to Dr. Karen S. Kolba, chair of the ACR's Committee on Rheumatologic Care.

Although the Food and Drug Administration and the agents' labels do indeed spell out which patients are candidates for which agents, insurers would like to make that determination more formal and binding, such that a patient must fail to respond to drug A and drug B before receiving drug C.

In the case of rituximab (Rituxan), the FDA recommends that a patient with RA must have failed to respond to a tumor necrosis factor–blocking agent before being considered as a candidate for this B cell–depleting therapy, a position that most rheumatologists would find reasonable.

Problems arise when an insurer decrees that patients may receive rituximab only when they have failed to respond to all other biologic therapies.

“Some [agents] are given subcutaneously and some are self-administered. The self-administered agents may be less expensive, depending on the dose needed. But rituximab is a reasonable choice for some patients, even though it is infused,” said Dr. Kolba, who is in private practice in Santa Maria, Calif.

The ACR's Model Biologics Policy 2010, which is available to members through the ACR Web site, lists the HCPCS (Healthcare Common Procedure Coding System) code sets for each biologic.

Also listed are the CPT codes for the drugs' routes of administration and the ICD-9 diagnosis codes for every clinical conditions for which a biologic agent is an appropriate, indicated treatment.

The policy also details the medically necessary, FDA-approved indications for each biologic.

For example, adalimumab (Humira) has the following indications: rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, and plaque psoriasis.

The ACR's policy notes that special considerations with the use of adalimumab include the need to test for active or latent tuberculosis, to monitor hepatitis B virus carriers during treatment for reactivation, and to monitor those patients who are taking concomitant anti-TNF-alpha therapy such as anakinra (Kineret) or abatacept (Orencia), which would increase the risk of infection.

The policy lists the possible off-label uses for the agents as well as information on the route of administration and dosing.

Regarding etanercept, the policy notes that the agent may be used in combination with methotrexate or as monotherapy in RA. Golimumab (Simponi) must be used in combination with methotrexate.

The use of anakinra is appropriate in patients with severely active RA who have failed to respond to at least one disease-modifying antirheumatic drug.

Dr. Kolba added that insurance companies are already in the habit of seeking the ACR's guidance on issues relating to the appropriate use of biologics, so there is a precedent of their following these recommendations.

With this guidance document, the ACR continues to show insurers that the college remains a fair and reasonable source of information on the medications “that are best for our patients,” Dr. Kolba told Rheumatology News. “Expensive drugs may prove to be the most cost effective because they control disease activity and prevent joint destruction.”

The policy is available online at www.rheumatology.org/practice/office/insurance/Model_Biologics_Policy.pdf

Insurance payers now have detailed guidance on the appropriate use and coverage of biologic agents in the management of rheumatoid arthritis, thanks to a document prepared by the American College of Rheumatology.

“Insurance companies would like to put the various biologics on the market in rank order,” according to Dr. Karen S. Kolba, chair of the ACR's Committee on Rheumatologic Care.

Although the Food and Drug Administration and the agents' labels do indeed spell out which patients are candidates for which agents, insurers would like to make that determination more formal and binding, such that a patient must fail to respond to drug A and drug B before receiving drug C.

In the case of rituximab (Rituxan), the FDA recommends that a patient with RA must have failed to respond to a tumor necrosis factor–blocking agent before being considered as a candidate for this B cell–depleting therapy, a position that most rheumatologists would find reasonable.

Problems arise when an insurer decrees that patients may receive rituximab only when they have failed to respond to all other biologic therapies.

“Some [agents] are given subcutaneously and some are self-administered. The self-administered agents may be less expensive, depending on the dose needed. But rituximab is a reasonable choice for some patients, even though it is infused,” said Dr. Kolba, who is in private practice in Santa Maria, Calif.

The ACR's Model Biologics Policy 2010, which is available to members through the ACR Web site, lists the HCPCS (Healthcare Common Procedure Coding System) code sets for each biologic.

Also listed are the CPT codes for the drugs' routes of administration and the ICD-9 diagnosis codes for every clinical conditions for which a biologic agent is an appropriate, indicated treatment.

The policy also details the medically necessary, FDA-approved indications for each biologic.

For example, adalimumab (Humira) has the following indications: rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, and plaque psoriasis.

The ACR's policy notes that special considerations with the use of adalimumab include the need to test for active or latent tuberculosis, to monitor hepatitis B virus carriers during treatment for reactivation, and to monitor those patients who are taking concomitant anti-TNF-alpha therapy such as anakinra (Kineret) or abatacept (Orencia), which would increase the risk of infection.

The policy lists the possible off-label uses for the agents as well as information on the route of administration and dosing.

Regarding etanercept, the policy notes that the agent may be used in combination with methotrexate or as monotherapy in RA. Golimumab (Simponi) must be used in combination with methotrexate.

The use of anakinra is appropriate in patients with severely active RA who have failed to respond to at least one disease-modifying antirheumatic drug.

Dr. Kolba added that insurance companies are already in the habit of seeking the ACR's guidance on issues relating to the appropriate use of biologics, so there is a precedent of their following these recommendations.

With this guidance document, the ACR continues to show insurers that the college remains a fair and reasonable source of information on the medications “that are best for our patients,” Dr. Kolba told Rheumatology News. “Expensive drugs may prove to be the most cost effective because they control disease activity and prevent joint destruction.”

The policy is available online at www.rheumatology.org/practice/office/insurance/Model_Biologics_Policy.pdf

Insurance payers now have detailed guidance on the appropriate use and coverage of biologic agents in the management of rheumatoid arthritis, thanks to a document prepared by the American College of Rheumatology.

“Insurance companies would like to put the various biologics on the market in rank order,” according to Dr. Karen S. Kolba, chair of the ACR's Committee on Rheumatologic Care.

Although the Food and Drug Administration and the agents' labels do indeed spell out which patients are candidates for which agents, insurers would like to make that determination more formal and binding, such that a patient must fail to respond to drug A and drug B before receiving drug C.

In the case of rituximab (Rituxan), the FDA recommends that a patient with RA must have failed to respond to a tumor necrosis factor–blocking agent before being considered as a candidate for this B cell–depleting therapy, a position that most rheumatologists would find reasonable.

Problems arise when an insurer decrees that patients may receive rituximab only when they have failed to respond to all other biologic therapies.

“Some [agents] are given subcutaneously and some are self-administered. The self-administered agents may be less expensive, depending on the dose needed. But rituximab is a reasonable choice for some patients, even though it is infused,” said Dr. Kolba, who is in private practice in Santa Maria, Calif.

The ACR's Model Biologics Policy 2010, which is available to members through the ACR Web site, lists the HCPCS (Healthcare Common Procedure Coding System) code sets for each biologic.

Also listed are the CPT codes for the drugs' routes of administration and the ICD-9 diagnosis codes for every clinical conditions for which a biologic agent is an appropriate, indicated treatment.

The policy also details the medically necessary, FDA-approved indications for each biologic.

For example, adalimumab (Humira) has the following indications: rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, and plaque psoriasis.

The ACR's policy notes that special considerations with the use of adalimumab include the need to test for active or latent tuberculosis, to monitor hepatitis B virus carriers during treatment for reactivation, and to monitor those patients who are taking concomitant anti-TNF-alpha therapy such as anakinra (Kineret) or abatacept (Orencia), which would increase the risk of infection.

The policy lists the possible off-label uses for the agents as well as information on the route of administration and dosing.

Regarding etanercept, the policy notes that the agent may be used in combination with methotrexate or as monotherapy in RA. Golimumab (Simponi) must be used in combination with methotrexate.

The use of anakinra is appropriate in patients with severely active RA who have failed to respond to at least one disease-modifying antirheumatic drug.

Dr. Kolba added that insurance companies are already in the habit of seeking the ACR's guidance on issues relating to the appropriate use of biologics, so there is a precedent of their following these recommendations.

With this guidance document, the ACR continues to show insurers that the college remains a fair and reasonable source of information on the medications “that are best for our patients,” Dr. Kolba told Rheumatology News. “Expensive drugs may prove to be the most cost effective because they control disease activity and prevent joint destruction.”

The policy is available online at www.rheumatology.org/practice/office/insurance/Model_Biologics_Policy.pdf

Insurance payers now have detailed guidance on the appropriate use and coverage of biologic agents in the management of rheumatoid arthritis, thanks to a document prepared by the American College of Rheumatology.

“Insurance companies would like to put the various biologics on the market in rank order,” according to Dr. Karen S. Kolba, chair of the ACR’s Committee on Rheumatologic Care. Although the Food and Drug Administration and the agents’ labels do indeed spell out which patients are candidates for which agents, insurers would like to make that determination more formal and binding, such that a patient must fail to respond to drug A and drug B before receiving drug C.

In the case of rituximab (Rituxan), the FDA recommends that a patient with RA must have failed to respond to a tumor necrosis factor blocking agent before being considered as a candidate for this B cell–depleting therapy, a position that most rheumatologists would find reasonable.

Problems arise when an insurer decrees that patients may receive rituximab only when they have failed to respond to all other biologic therapies.

“Some [agents] are given subcutaneously and some are self-administered. The self-administered agents may be less expensive, depending on the dose needed. But rituximab is a reasonable choice for some patients, even though it is infused,” said Dr. Kolba, who is in private practice in Santa Maria, Calif.

The ACR’s Model Biologics Policy 2010, which is available to members through the ACR Web site, lists the HCPCS (Healthcare Common Procedure Coding System) code sets for each biologic, as well as the CPT codes for the drugs’ routes of administration and the ICD-9 diagnosis codes for the clinical conditions for which a biologic agent is an appropriate treatment.

The policy also details the medically necessary, FDA-approved indications for each biologic.

For example, adalimumab (Humira) has the following indications: rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, and plaque psoriasis. The policy notes that special considerations with the use of adalimumab include the need to test for active or latent tuberculosis, to monitor hepatitis B virus carriers during treatment for reactivation, and to monitor those patients who are taking concomitant anti-TNF-alpha therapy such as anakinra (Kineret) or abatacept (Orencia), which would increase the risk of infection. The policy lists the possible off-label uses for the agents as well as information on the route of administration and dosing.

Regarding etanercept, the policy notes that the agent may be used in combination with methotrexate or as monotherapy in RA.

Golimumab (Simponi) must be used in combination with methotrexate.

The use of anakinra is appropriate in patients with severely active RA who have failed to respond to at least one disease-modifying antirheumatic drug.

Dr. Kolba added that insurance companies are already in the habit of seeking the ACR’s guidance on issues relating to the appropriate use of biologics, so there is a precedent of their following these recommendations.

By developing such a guidance document, the ACR continues to show insurers that the college remains a fair and reasonable source of information on the medications “that are best for our patients,” she said. “Expensive drugs may prove to be the most cost effective because they control disease activity and prevent joint destruction.”

Insurance payers now have detailed guidance on the appropriate use and coverage of biologic agents in the management of rheumatoid arthritis, thanks to a document prepared by the American College of Rheumatology.

“Insurance companies would like to put the various biologics on the market in rank order,” according to Dr. Karen S. Kolba, chair of the ACR’s Committee on Rheumatologic Care. Although the Food and Drug Administration and the agents’ labels do indeed spell out which patients are candidates for which agents, insurers would like to make that determination more formal and binding, such that a patient must fail to respond to drug A and drug B before receiving drug C.

In the case of rituximab (Rituxan), the FDA recommends that a patient with RA must have failed to respond to a tumor necrosis factor blocking agent before being considered as a candidate for this B cell–depleting therapy, a position that most rheumatologists would find reasonable.

Problems arise when an insurer decrees that patients may receive rituximab only when they have failed to respond to all other biologic therapies.

“Some [agents] are given subcutaneously and some are self-administered. The self-administered agents may be less expensive, depending on the dose needed. But rituximab is a reasonable choice for some patients, even though it is infused,” said Dr. Kolba, who is in private practice in Santa Maria, Calif.

The ACR’s Model Biologics Policy 2010, which is available to members through the ACR Web site, lists the HCPCS (Healthcare Common Procedure Coding System) code sets for each biologic, as well as the CPT codes for the drugs’ routes of administration and the ICD-9 diagnosis codes for the clinical conditions for which a biologic agent is an appropriate treatment.

The policy also details the medically necessary, FDA-approved indications for each biologic.

For example, adalimumab (Humira) has the following indications: rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, and plaque psoriasis. The policy notes that special considerations with the use of adalimumab include the need to test for active or latent tuberculosis, to monitor hepatitis B virus carriers during treatment for reactivation, and to monitor those patients who are taking concomitant anti-TNF-alpha therapy such as anakinra (Kineret) or abatacept (Orencia), which would increase the risk of infection. The policy lists the possible off-label uses for the agents as well as information on the route of administration and dosing.

Regarding etanercept, the policy notes that the agent may be used in combination with methotrexate or as monotherapy in RA.

Golimumab (Simponi) must be used in combination with methotrexate.

The use of anakinra is appropriate in patients with severely active RA who have failed to respond to at least one disease-modifying antirheumatic drug.

Dr. Kolba added that insurance companies are already in the habit of seeking the ACR’s guidance on issues relating to the appropriate use of biologics, so there is a precedent of their following these recommendations.

By developing such a guidance document, the ACR continues to show insurers that the college remains a fair and reasonable source of information on the medications “that are best for our patients,” she said. “Expensive drugs may prove to be the most cost effective because they control disease activity and prevent joint destruction.”

Insurance payers now have detailed guidance on the appropriate use and coverage of biologic agents in the management of rheumatoid arthritis, thanks to a document prepared by the American College of Rheumatology.

“Insurance companies would like to put the various biologics on the market in rank order,” according to Dr. Karen S. Kolba, chair of the ACR’s Committee on Rheumatologic Care. Although the Food and Drug Administration and the agents’ labels do indeed spell out which patients are candidates for which agents, insurers would like to make that determination more formal and binding, such that a patient must fail to respond to drug A and drug B before receiving drug C.

In the case of rituximab (Rituxan), the FDA recommends that a patient with RA must have failed to respond to a tumor necrosis factor blocking agent before being considered as a candidate for this B cell–depleting therapy, a position that most rheumatologists would find reasonable.

Problems arise when an insurer decrees that patients may receive rituximab only when they have failed to respond to all other biologic therapies.

“Some [agents] are given subcutaneously and some are self-administered. The self-administered agents may be less expensive, depending on the dose needed. But rituximab is a reasonable choice for some patients, even though it is infused,” said Dr. Kolba, who is in private practice in Santa Maria, Calif.

The ACR’s Model Biologics Policy 2010, which is available to members through the ACR Web site, lists the HCPCS (Healthcare Common Procedure Coding System) code sets for each biologic, as well as the CPT codes for the drugs’ routes of administration and the ICD-9 diagnosis codes for the clinical conditions for which a biologic agent is an appropriate treatment.

The policy also details the medically necessary, FDA-approved indications for each biologic.

For example, adalimumab (Humira) has the following indications: rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, and plaque psoriasis. The policy notes that special considerations with the use of adalimumab include the need to test for active or latent tuberculosis, to monitor hepatitis B virus carriers during treatment for reactivation, and to monitor those patients who are taking concomitant anti-TNF-alpha therapy such as anakinra (Kineret) or abatacept (Orencia), which would increase the risk of infection. The policy lists the possible off-label uses for the agents as well as information on the route of administration and dosing.

Regarding etanercept, the policy notes that the agent may be used in combination with methotrexate or as monotherapy in RA.

Golimumab (Simponi) must be used in combination with methotrexate.

The use of anakinra is appropriate in patients with severely active RA who have failed to respond to at least one disease-modifying antirheumatic drug.

Dr. Kolba added that insurance companies are already in the habit of seeking the ACR’s guidance on issues relating to the appropriate use of biologics, so there is a precedent of their following these recommendations.

By developing such a guidance document, the ACR continues to show insurers that the college remains a fair and reasonable source of information on the medications “that are best for our patients,” she said. “Expensive drugs may prove to be the most cost effective because they control disease activity and prevent joint destruction.”

NEW YORK — A single enzyme, peptidylarginine deiminase, may trigger the autoimmune process that results in rheumatoid arthritis among some people with periodontitis, Dr. Gerald Weissmann said at a rheumatology meeting sponsored by New York University.

Researchers established the association between rheumatoid arthritis and periodontal disease a decade ago (Eur. J. Med. Res. 1998;3:387–92). The same investigators went on to confirm the link, and found that the severity of RA based on a variety of markers—such as swollen joint counts, health assessment questionnaire scores, levels of C-reactive protein, and erythrocyte sedimentation rates—was directly related to the extent of periodontal bone loss in these patients (J. Periodontol. 2001;72:779–87).

The metabolic link that associates the two disorders appears to be a specific family of citrullinated proteins. These proteins have been suggested to act as an auto-antigen in RA, and autoantibodies to these proteins (anti-CCP) are highly specific for RA, according to Dr. Weissmann.

Proteins become citrullinated by the enzyme peptidylarginine deiminase, which is secreted by neutrophils, macrophages, and endothelium. Interestingly, only one bacterium, the oral pathogen Porphyromonas gingivalis the major cause of periodontal disease, produces this enzyme.

One of these citrullinated proteins (deiminated fibrin) may become a systemic immunogen in people who are predisposed to periodontal disease, leading to both periodontal and intra-articular inflammation. The ensuing events—involving the cascade of complement activation, phagocyte stimulation via Fc and C5a receptors, and the release of cytokines, metalloproteinases, and reactive oxygen species—ultimately result in the erosion of bone surrounding teeth and joints.

As further evidence of the link, anti-CCP titers are more predictive of joint damage at 5 years than are rheumatoid factor (RF) titers. Depletion of B cells by rituximab also lowers anti-CCP titers, and to a greater extent than it reduces RF titers (Arthritis Res. 2000;2:249–51), said Dr. Weissmann, research professor of medicine and director of the biotechnology study center at New York University.

Dr. Weissmann traced the rise of rheumatoid diseases in both England and the American colonies to the increased affordability of sugar in the late 18th and early 19th centuries. Before 1773, it was unlikely that working-class residents of the American colonies or London either had access to sugar or developed rheumatoid diseases. Access to sugar became the norm and rheumatoid arthritis became widespread only after the sugar tax was abolished in 1874, he said.

Disclosures: Dr. Weissmann reported no relevant financial relationships.

NEW YORK — A single enzyme, peptidylarginine deiminase, may trigger the autoimmune process that results in rheumatoid arthritis among some people with periodontitis, Dr. Gerald Weissmann said at a rheumatology meeting sponsored by New York University.

Researchers established the association between rheumatoid arthritis and periodontal disease a decade ago (Eur. J. Med. Res. 1998;3:387–92). The same investigators went on to confirm the link, and found that the severity of RA based on a variety of markers—such as swollen joint counts, health assessment questionnaire scores, levels of C-reactive protein, and erythrocyte sedimentation rates—was directly related to the extent of periodontal bone loss in these patients (J. Periodontol. 2001;72:779–87).

The metabolic link that associates the two disorders appears to be a specific family of citrullinated proteins. These proteins have been suggested to act as an auto-antigen in RA, and autoantibodies to these proteins (anti-CCP) are highly specific for RA, according to Dr. Weissmann.

Proteins become citrullinated by the enzyme peptidylarginine deiminase, which is secreted by neutrophils, macrophages, and endothelium. Interestingly, only one bacterium, the oral pathogen Porphyromonas gingivalis the major cause of periodontal disease, produces this enzyme.

One of these citrullinated proteins (deiminated fibrin) may become a systemic immunogen in people who are predisposed to periodontal disease, leading to both periodontal and intra-articular inflammation. The ensuing events—involving the cascade of complement activation, phagocyte stimulation via Fc and C5a receptors, and the release of cytokines, metalloproteinases, and reactive oxygen species—ultimately result in the erosion of bone surrounding teeth and joints.

As further evidence of the link, anti-CCP titers are more predictive of joint damage at 5 years than are rheumatoid factor (RF) titers. Depletion of B cells by rituximab also lowers anti-CCP titers, and to a greater extent than it reduces RF titers (Arthritis Res. 2000;2:249–51), said Dr. Weissmann, research professor of medicine and director of the biotechnology study center at New York University.

Dr. Weissmann traced the rise of rheumatoid diseases in both England and the American colonies to the increased affordability of sugar in the late 18th and early 19th centuries. Before 1773, it was unlikely that working-class residents of the American colonies or London either had access to sugar or developed rheumatoid diseases. Access to sugar became the norm and rheumatoid arthritis became widespread only after the sugar tax was abolished in 1874, he said.

Disclosures: Dr. Weissmann reported no relevant financial relationships.

NEW YORK — A single enzyme, peptidylarginine deiminase, may trigger the autoimmune process that results in rheumatoid arthritis among some people with periodontitis, Dr. Gerald Weissmann said at a rheumatology meeting sponsored by New York University.

Researchers established the association between rheumatoid arthritis and periodontal disease a decade ago (Eur. J. Med. Res. 1998;3:387–92). The same investigators went on to confirm the link, and found that the severity of RA based on a variety of markers—such as swollen joint counts, health assessment questionnaire scores, levels of C-reactive protein, and erythrocyte sedimentation rates—was directly related to the extent of periodontal bone loss in these patients (J. Periodontol. 2001;72:779–87).

The metabolic link that associates the two disorders appears to be a specific family of citrullinated proteins. These proteins have been suggested to act as an auto-antigen in RA, and autoantibodies to these proteins (anti-CCP) are highly specific for RA, according to Dr. Weissmann.

Proteins become citrullinated by the enzyme peptidylarginine deiminase, which is secreted by neutrophils, macrophages, and endothelium. Interestingly, only one bacterium, the oral pathogen Porphyromonas gingivalis the major cause of periodontal disease, produces this enzyme.

One of these citrullinated proteins (deiminated fibrin) may become a systemic immunogen in people who are predisposed to periodontal disease, leading to both periodontal and intra-articular inflammation. The ensuing events—involving the cascade of complement activation, phagocyte stimulation via Fc and C5a receptors, and the release of cytokines, metalloproteinases, and reactive oxygen species—ultimately result in the erosion of bone surrounding teeth and joints.

As further evidence of the link, anti-CCP titers are more predictive of joint damage at 5 years than are rheumatoid factor (RF) titers. Depletion of B cells by rituximab also lowers anti-CCP titers, and to a greater extent than it reduces RF titers (Arthritis Res. 2000;2:249–51), said Dr. Weissmann, research professor of medicine and director of the biotechnology study center at New York University.

Dr. Weissmann traced the rise of rheumatoid diseases in both England and the American colonies to the increased affordability of sugar in the late 18th and early 19th centuries. Before 1773, it was unlikely that working-class residents of the American colonies or London either had access to sugar or developed rheumatoid diseases. Access to sugar became the norm and rheumatoid arthritis became widespread only after the sugar tax was abolished in 1874, he said.

Disclosures: Dr. Weissmann reported no relevant financial relationships.

NEW YORK — High-dose steroid therapy only rarely lessened the degree of congenital heart block in one study of 30 affected pregnancies, according to Dr. Jill P. Buyon.

In a prospective, multicenter, observational study, 30 pregnancies involving a fetus with some degree of autoimmune-associated congenital heart block were treated with 4 mg/day of dexamethasone. In all, 22 of the fetuses had third-degree heart block, 6 had second-degree heart block, and 2 had first-degree heart block. Another 10 similar pregnancies that were not treated with dexamethasone served as the control group, in which nine fetuses had third-degree heart block and one had first-degree heart block. Initial median ventricular rates, age at diagnosis, and degree of cardiac dysfunction were similar between groups, said Dr. Buyon, professor of medicine at New York University.

Although this was initially intended to be a randomized, controlled trial, that plan was not feasible, so the decision to treat with dexamethasone was made by the managing physicians.

Six deaths occurred in the group that was treated with dexamethasone, and four deaths occurred in utero, one at 15 months post partum and the other at 2 years of age.

None of the 40 fetuses experienced a reversal of third-degree block, either with therapy or spontaneously. In fetuses who were treated with dexamethasone, one in six with second-degree block progressed to third-degree block, and three remained in second-degree block at birth. After birth, one child was given a pacemaker; two others progressed to third-degree block. At birth, two babies with second-degree heart block converted to normal sinus rhythm. While one maintained sinus rhythm, the other reverted to second-degree heart block. Of the two fetuses with first-degree heart block, both converted to normal sinus rhythm at birth and maintained it throughout follow-up (Am. J. Cardiol. 2009;103:1102–6).

Among the 10 fetuses in the control group, 9 with third-degree block in utero maintained it, and 1 with first-degree block converted to sinus rhythm, Dr. Buyon said at a rheumatology meeting sponsored by the university. These findings do not preclude ever using dexamethasone in such pregnancies, she said. Physicians who elect to use dexamethasone in affected pregnancies should stop the therapy if it proves ineffective, which can be ascertained using serial echocardiograms. Physicians need to remember that every case is individual and the guidelines may be of limited applicability.

A fetus who is found to have a third-degree block of more than 1 week's duration should be followed with weekly echocardiograms and obstetric ultrasound, but no therapy, she said. When the third-degree block is shorter than 1 week in duration, the baby should be given 4 mg of dexamethasone daily for 1-2 weeks. Therapy should be discontinued if the baby's condition does not improve. However, if the baby's heart block reverses to second degree or even milder, the treating physician should consider continuing daily dexamethasone for 4-6 weeks and continuing weekly echocardiograms.

Disclosures: Dr. Buyon said she had no relevant financial relationships to disclose except for support from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the American Heart Association, the Kirkland Center, the Alliance for Lupus Research, and a gift from the Lee family of Brooklyn, N.Y.

NEW YORK — High-dose steroid therapy only rarely lessened the degree of congenital heart block in one study of 30 affected pregnancies, according to Dr. Jill P. Buyon.

In a prospective, multicenter, observational study, 30 pregnancies involving a fetus with some degree of autoimmune-associated congenital heart block were treated with 4 mg/day of dexamethasone. In all, 22 of the fetuses had third-degree heart block, 6 had second-degree heart block, and 2 had first-degree heart block. Another 10 similar pregnancies that were not treated with dexamethasone served as the control group, in which nine fetuses had third-degree heart block and one had first-degree heart block. Initial median ventricular rates, age at diagnosis, and degree of cardiac dysfunction were similar between groups, said Dr. Buyon, professor of medicine at New York University.

Although this was initially intended to be a randomized, controlled trial, that plan was not feasible, so the decision to treat with dexamethasone was made by the managing physicians.

Six deaths occurred in the group that was treated with dexamethasone, and four deaths occurred in utero, one at 15 months post partum and the other at 2 years of age.

None of the 40 fetuses experienced a reversal of third-degree block, either with therapy or spontaneously. In fetuses who were treated with dexamethasone, one in six with second-degree block progressed to third-degree block, and three remained in second-degree block at birth. After birth, one child was given a pacemaker; two others progressed to third-degree block. At birth, two babies with second-degree heart block converted to normal sinus rhythm. While one maintained sinus rhythm, the other reverted to second-degree heart block. Of the two fetuses with first-degree heart block, both converted to normal sinus rhythm at birth and maintained it throughout follow-up (Am. J. Cardiol. 2009;103:1102–6).

Among the 10 fetuses in the control group, 9 with third-degree block in utero maintained it, and 1 with first-degree block converted to sinus rhythm, Dr. Buyon said at a rheumatology meeting sponsored by the university. These findings do not preclude ever using dexamethasone in such pregnancies, she said. Physicians who elect to use dexamethasone in affected pregnancies should stop the therapy if it proves ineffective, which can be ascertained using serial echocardiograms. Physicians need to remember that every case is individual and the guidelines may be of limited applicability.

A fetus who is found to have a third-degree block of more than 1 week's duration should be followed with weekly echocardiograms and obstetric ultrasound, but no therapy, she said. When the third-degree block is shorter than 1 week in duration, the baby should be given 4 mg of dexamethasone daily for 1-2 weeks. Therapy should be discontinued if the baby's condition does not improve. However, if the baby's heart block reverses to second degree or even milder, the treating physician should consider continuing daily dexamethasone for 4-6 weeks and continuing weekly echocardiograms.

Disclosures: Dr. Buyon said she had no relevant financial relationships to disclose except for support from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the American Heart Association, the Kirkland Center, the Alliance for Lupus Research, and a gift from the Lee family of Brooklyn, N.Y.

NEW YORK — High-dose steroid therapy only rarely lessened the degree of congenital heart block in one study of 30 affected pregnancies, according to Dr. Jill P. Buyon.

In a prospective, multicenter, observational study, 30 pregnancies involving a fetus with some degree of autoimmune-associated congenital heart block were treated with 4 mg/day of dexamethasone. In all, 22 of the fetuses had third-degree heart block, 6 had second-degree heart block, and 2 had first-degree heart block. Another 10 similar pregnancies that were not treated with dexamethasone served as the control group, in which nine fetuses had third-degree heart block and one had first-degree heart block. Initial median ventricular rates, age at diagnosis, and degree of cardiac dysfunction were similar between groups, said Dr. Buyon, professor of medicine at New York University.

Although this was initially intended to be a randomized, controlled trial, that plan was not feasible, so the decision to treat with dexamethasone was made by the managing physicians.

Six deaths occurred in the group that was treated with dexamethasone, and four deaths occurred in utero, one at 15 months post partum and the other at 2 years of age.

None of the 40 fetuses experienced a reversal of third-degree block, either with therapy or spontaneously. In fetuses who were treated with dexamethasone, one in six with second-degree block progressed to third-degree block, and three remained in second-degree block at birth. After birth, one child was given a pacemaker; two others progressed to third-degree block. At birth, two babies with second-degree heart block converted to normal sinus rhythm. While one maintained sinus rhythm, the other reverted to second-degree heart block. Of the two fetuses with first-degree heart block, both converted to normal sinus rhythm at birth and maintained it throughout follow-up (Am. J. Cardiol. 2009;103:1102–6).

Among the 10 fetuses in the control group, 9 with third-degree block in utero maintained it, and 1 with first-degree block converted to sinus rhythm, Dr. Buyon said at a rheumatology meeting sponsored by the university. These findings do not preclude ever using dexamethasone in such pregnancies, she said. Physicians who elect to use dexamethasone in affected pregnancies should stop the therapy if it proves ineffective, which can be ascertained using serial echocardiograms. Physicians need to remember that every case is individual and the guidelines may be of limited applicability.

A fetus who is found to have a third-degree block of more than 1 week's duration should be followed with weekly echocardiograms and obstetric ultrasound, but no therapy, she said. When the third-degree block is shorter than 1 week in duration, the baby should be given 4 mg of dexamethasone daily for 1-2 weeks. Therapy should be discontinued if the baby's condition does not improve. However, if the baby's heart block reverses to second degree or even milder, the treating physician should consider continuing daily dexamethasone for 4-6 weeks and continuing weekly echocardiograms.

Disclosures: Dr. Buyon said she had no relevant financial relationships to disclose except for support from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the American Heart Association, the Kirkland Center, the Alliance for Lupus Research, and a gift from the Lee family of Brooklyn, N.Y.

PHILADELPHIA — Combining once-a-year zoledronic acid and daily teriparatide significantly increased bone mass in key skeletal sites in postmenopausal women with osteoporosis, according to a study presented at the annual meeting of the American College of Rheumatology.

The trial included 412 postmenopausal women considered to be at high risk for fracture. They were diagnosed with osteoporosis on the strength of having a T score that was 2.5 standard deviations below peak bone mass, or having a slightly better T score but a history of at least one fracture. The women were randomized to one of three treatment groups: treatment with zoledronic acid alone (137), with both zoledronic acid and teriparatide (137), and with teriparatide alone (138). The zoledronic acid dosage was 5 mg intravenously once per year. Teriparatide was given daily in a subcutaneous dose of 20 mcg.

Use of the two drugs in combination increased bone mineral density (BMD) at the spine more than did teriparatide alone, and at the hip more than did zoledronic acid alone, according to study presenter Dr. Kenneth G. Saag, the Jane Knight Lowe Chair of Medicine in Rheumatology at the University of Alabama at Birmingham.

BMD at the spine increased 7.51%, 7.05%, and 4.37% in the combination arm, teriparatide arm, and zoledronic acid arm, respectively. Combination therapy significantly increased lumbar spine BMD at weeks 13 and 26 and total hip BMD at weeks 13, 26, and 52, compared with teriparatide alone.

The incidence of serious adverse events was 9.5%, 14.6%, and 10.9% in the combination, zoledronic acid, and teriparatide arms, respectively.

Disclosures: Dr. Saag disclosed financial relationships with Eli Lilly & Co., maker of teriparatide (Forteo), and Novartis, maker of zoledronic acid (Reclast).

PHILADELPHIA — Combining once-a-year zoledronic acid and daily teriparatide significantly increased bone mass in key skeletal sites in postmenopausal women with osteoporosis, according to a study presented at the annual meeting of the American College of Rheumatology.

The trial included 412 postmenopausal women considered to be at high risk for fracture. They were diagnosed with osteoporosis on the strength of having a T score that was 2.5 standard deviations below peak bone mass, or having a slightly better T score but a history of at least one fracture. The women were randomized to one of three treatment groups: treatment with zoledronic acid alone (137), with both zoledronic acid and teriparatide (137), and with teriparatide alone (138). The zoledronic acid dosage was 5 mg intravenously once per year. Teriparatide was given daily in a subcutaneous dose of 20 mcg.

Use of the two drugs in combination increased bone mineral density (BMD) at the spine more than did teriparatide alone, and at the hip more than did zoledronic acid alone, according to study presenter Dr. Kenneth G. Saag, the Jane Knight Lowe Chair of Medicine in Rheumatology at the University of Alabama at Birmingham.

BMD at the spine increased 7.51%, 7.05%, and 4.37% in the combination arm, teriparatide arm, and zoledronic acid arm, respectively. Combination therapy significantly increased lumbar spine BMD at weeks 13 and 26 and total hip BMD at weeks 13, 26, and 52, compared with teriparatide alone.

The incidence of serious adverse events was 9.5%, 14.6%, and 10.9% in the combination, zoledronic acid, and teriparatide arms, respectively.

Disclosures: Dr. Saag disclosed financial relationships with Eli Lilly & Co., maker of teriparatide (Forteo), and Novartis, maker of zoledronic acid (Reclast).

PHILADELPHIA — Combining once-a-year zoledronic acid and daily teriparatide significantly increased bone mass in key skeletal sites in postmenopausal women with osteoporosis, according to a study presented at the annual meeting of the American College of Rheumatology.

The trial included 412 postmenopausal women considered to be at high risk for fracture. They were diagnosed with osteoporosis on the strength of having a T score that was 2.5 standard deviations below peak bone mass, or having a slightly better T score but a history of at least one fracture. The women were randomized to one of three treatment groups: treatment with zoledronic acid alone (137), with both zoledronic acid and teriparatide (137), and with teriparatide alone (138). The zoledronic acid dosage was 5 mg intravenously once per year. Teriparatide was given daily in a subcutaneous dose of 20 mcg.

Use of the two drugs in combination increased bone mineral density (BMD) at the spine more than did teriparatide alone, and at the hip more than did zoledronic acid alone, according to study presenter Dr. Kenneth G. Saag, the Jane Knight Lowe Chair of Medicine in Rheumatology at the University of Alabama at Birmingham.

BMD at the spine increased 7.51%, 7.05%, and 4.37% in the combination arm, teriparatide arm, and zoledronic acid arm, respectively. Combination therapy significantly increased lumbar spine BMD at weeks 13 and 26 and total hip BMD at weeks 13, 26, and 52, compared with teriparatide alone.

The incidence of serious adverse events was 9.5%, 14.6%, and 10.9% in the combination, zoledronic acid, and teriparatide arms, respectively.

Disclosures: Dr. Saag disclosed financial relationships with Eli Lilly & Co., maker of teriparatide (Forteo), and Novartis, maker of zoledronic acid (Reclast).

SANTA MONICA, CALIF. — How to treat a patient with concurrent inflammatory bowel disease and rheumatic disease depends on which condition is “hot” and which is quiescent.

Using standard anti-inflammatory agents to treat the rheumatic disease is problematic because it may exacerbate the IBD. Conventional NSAIDs are associated with reversible colitis and ulceration in patients without IBD, and NSAID enteropathy—often subclinical—is present in up to 60% of patients who take these agents, according to Dr. Bennett E. Roth, director of the digestive disease center and chief of clinical gastroenterology at the University of California, Los Angeles.

Data do support the use of available cyclo-oxygenase-2 (COX-2) inhibitors in patients with both active IBD and active joint disease, Dr. Roth said at a meeting sponsored by

Why some patients develop both IBD and arthritis is not fully understood, Dr. Roth noted. Possible explanations include the potential relocation of the immune reaction from the intestine to the joints; the activation of immune cells in the gut, draining lymphocytes that localize in the joints; and the overlap of expression of adhesion molecules that have been observed on the surface of intestinal epithelial cells and in synovial fluid. Other possibilities include the potential reactivation of T cells at the articular levels and possible T-helper 17 (Th17) cell–mediated response aided by tumor necrosis factor (TNF).

IBD arthropathy can take two forms: spondyloarthropathy (SpA) and peripheral arthropathy. Each has its own course and relationship to IBD, Dr. Roth said.

The degree of SpA activity in IBD patients is independent of the IBD activity.

Among patients with both conditions, 20%–25% have sacroiliitis on x-ray; 50% of cases of sacroiliitis in IBD are asymptomatic.

Ankylosing spondylitis (AS)—be it HLA-B27 negative or positive—has a prevalence of 3%-10% in this population, according to Dr. Roth.

Rheumatologists may be the first to see signs of IBD in some of these patients. Young patients who present with axial arthropathy may be candidates for a gastrointestinal evaluation, said Dr. Roth, who is also director of the center for esophageal disorders at UCLA.

The treatment regimen for AS includes physiotherapy, 5-aminosalicylic acid (5-ASA) or immunomodulatory therapy with agents such as 6-mercaptopurine or azathioprine (6MP/AZA), or methotrexate. Fallback treatments are short courses of steroids. If these are insufficient, biologic anti-TNF antibodies may be effective.

One large study showed that infliximab was efficacious in 61% of a group of IBD patients with peripheral arthritis (Am. J. Gastroenterol. 2002;97:2688-90). Infliximab has been shown to be effective in 53% of patients with AS, regardless of the presence of concurrent IBD (Lancet 2002;359:1187-93). Findings from randomized controlled trials of patients who had both AS and IBD and were treated with infliximab show a significant drop in BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) scores but not CDAI (Crohn's Disease Activity Index) scores (Ann. Rheum. Dis. 2004;63:1664-9).

Peripheral arthropathy is divided into types 1 and 2 for classification purposes. Type 1 peripheral arthropathy can involve the large joints, specifically ankles, knees, hips, elbows, and shoulders, in a pauciarticular pattern.

When it comes to the treatment of type 1, Dr. Roth said that as the IBD goes, “so goes the arthritis.” In other words, because the joint inflammation corresponds to the activity of the disease in the gut, there is likely to be a concomitant joint response once the bowel disease is placed into remission. Standard approaches to treating the IBD are employed, including anti-inflammatory agents such as 5-ASA and steroids with the additional use of immunosuppressants 6MP/AZA, or anti-TNF agents as needed.

Other options include a local steroid injection when possible and the use of simple analgesics. However, NSAIDs (with the possible exception of celecoxib) should be avoided.

Type 2 peripheral arthropathy involves the small joints of the hands, is persistent and polyarticular, and follows a course that is independent of the IBD course.

Treatment consists of physical therapy, simple analgesics, short courses of steroids with progression to immunosuppressive agents, and/or biologics as needed.

Disclosures: Dr. Roth reported that he has no financial disclosures that are relevant to the topic of his presentation. Skin Disease Education Foundation and

SANTA MONICA, CALIF. — How to treat a patient with concurrent inflammatory bowel disease and rheumatic disease depends on which condition is “hot” and which is quiescent.

Using standard anti-inflammatory agents to treat the rheumatic disease is problematic because it may exacerbate the IBD. Conventional NSAIDs are associated with reversible colitis and ulceration in patients without IBD, and NSAID enteropathy—often subclinical—is present in up to 60% of patients who take these agents, according to Dr. Bennett E. Roth, director of the digestive disease center and chief of clinical gastroenterology at the University of California, Los Angeles.

Data do support the use of available cyclo-oxygenase-2 (COX-2) inhibitors in patients with both active IBD and active joint disease, Dr. Roth said at a meeting sponsored by

Why some patients develop both IBD and arthritis is not fully understood, Dr. Roth noted. Possible explanations include the potential relocation of the immune reaction from the intestine to the joints; the activation of immune cells in the gut, draining lymphocytes that localize in the joints; and the overlap of expression of adhesion molecules that have been observed on the surface of intestinal epithelial cells and in synovial fluid. Other possibilities include the potential reactivation of T cells at the articular levels and possible T-helper 17 (Th17) cell–mediated response aided by tumor necrosis factor (TNF).

IBD arthropathy can take two forms: spondyloarthropathy (SpA) and peripheral arthropathy. Each has its own course and relationship to IBD, Dr. Roth said.

The degree of SpA activity in IBD patients is independent of the IBD activity.

Among patients with both conditions, 20%–25% have sacroiliitis on x-ray; 50% of cases of sacroiliitis in IBD are asymptomatic.

Ankylosing spondylitis (AS)—be it HLA-B27 negative or positive—has a prevalence of 3%-10% in this population, according to Dr. Roth.

Rheumatologists may be the first to see signs of IBD in some of these patients. Young patients who present with axial arthropathy may be candidates for a gastrointestinal evaluation, said Dr. Roth, who is also director of the center for esophageal disorders at UCLA.

The treatment regimen for AS includes physiotherapy, 5-aminosalicylic acid (5-ASA) or immunomodulatory therapy with agents such as 6-mercaptopurine or azathioprine (6MP/AZA), or methotrexate. Fallback treatments are short courses of steroids. If these are insufficient, biologic anti-TNF antibodies may be effective.

One large study showed that infliximab was efficacious in 61% of a group of IBD patients with peripheral arthritis (Am. J. Gastroenterol. 2002;97:2688-90). Infliximab has been shown to be effective in 53% of patients with AS, regardless of the presence of concurrent IBD (Lancet 2002;359:1187-93). Findings from randomized controlled trials of patients who had both AS and IBD and were treated with infliximab show a significant drop in BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) scores but not CDAI (Crohn's Disease Activity Index) scores (Ann. Rheum. Dis. 2004;63:1664-9).

Peripheral arthropathy is divided into types 1 and 2 for classification purposes. Type 1 peripheral arthropathy can involve the large joints, specifically ankles, knees, hips, elbows, and shoulders, in a pauciarticular pattern.

When it comes to the treatment of type 1, Dr. Roth said that as the IBD goes, “so goes the arthritis.” In other words, because the joint inflammation corresponds to the activity of the disease in the gut, there is likely to be a concomitant joint response once the bowel disease is placed into remission. Standard approaches to treating the IBD are employed, including anti-inflammatory agents such as 5-ASA and steroids with the additional use of immunosuppressants 6MP/AZA, or anti-TNF agents as needed.

Other options include a local steroid injection when possible and the use of simple analgesics. However, NSAIDs (with the possible exception of celecoxib) should be avoided.

Type 2 peripheral arthropathy involves the small joints of the hands, is persistent and polyarticular, and follows a course that is independent of the IBD course.

Treatment consists of physical therapy, simple analgesics, short courses of steroids with progression to immunosuppressive agents, and/or biologics as needed.

Disclosures: Dr. Roth reported that he has no financial disclosures that are relevant to the topic of his presentation. Skin Disease Education Foundation and

SANTA MONICA, CALIF. — How to treat a patient with concurrent inflammatory bowel disease and rheumatic disease depends on which condition is “hot” and which is quiescent.

Using standard anti-inflammatory agents to treat the rheumatic disease is problematic because it may exacerbate the IBD. Conventional NSAIDs are associated with reversible colitis and ulceration in patients without IBD, and NSAID enteropathy—often subclinical—is present in up to 60% of patients who take these agents, according to Dr. Bennett E. Roth, director of the digestive disease center and chief of clinical gastroenterology at the University of California, Los Angeles.

Data do support the use of available cyclo-oxygenase-2 (COX-2) inhibitors in patients with both active IBD and active joint disease, Dr. Roth said at a meeting sponsored by

Why some patients develop both IBD and arthritis is not fully understood, Dr. Roth noted. Possible explanations include the potential relocation of the immune reaction from the intestine to the joints; the activation of immune cells in the gut, draining lymphocytes that localize in the joints; and the overlap of expression of adhesion molecules that have been observed on the surface of intestinal epithelial cells and in synovial fluid. Other possibilities include the potential reactivation of T cells at the articular levels and possible T-helper 17 (Th17) cell–mediated response aided by tumor necrosis factor (TNF).

IBD arthropathy can take two forms: spondyloarthropathy (SpA) and peripheral arthropathy. Each has its own course and relationship to IBD, Dr. Roth said.

The degree of SpA activity in IBD patients is independent of the IBD activity.

Among patients with both conditions, 20%–25% have sacroiliitis on x-ray; 50% of cases of sacroiliitis in IBD are asymptomatic.

Ankylosing spondylitis (AS)—be it HLA-B27 negative or positive—has a prevalence of 3%-10% in this population, according to Dr. Roth.

Rheumatologists may be the first to see signs of IBD in some of these patients. Young patients who present with axial arthropathy may be candidates for a gastrointestinal evaluation, said Dr. Roth, who is also director of the center for esophageal disorders at UCLA.

The treatment regimen for AS includes physiotherapy, 5-aminosalicylic acid (5-ASA) or immunomodulatory therapy with agents such as 6-mercaptopurine or azathioprine (6MP/AZA), or methotrexate. Fallback treatments are short courses of steroids. If these are insufficient, biologic anti-TNF antibodies may be effective.

One large study showed that infliximab was efficacious in 61% of a group of IBD patients with peripheral arthritis (Am. J. Gastroenterol. 2002;97:2688-90). Infliximab has been shown to be effective in 53% of patients with AS, regardless of the presence of concurrent IBD (Lancet 2002;359:1187-93). Findings from randomized controlled trials of patients who had both AS and IBD and were treated with infliximab show a significant drop in BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) scores but not CDAI (Crohn's Disease Activity Index) scores (Ann. Rheum. Dis. 2004;63:1664-9).

Peripheral arthropathy is divided into types 1 and 2 for classification purposes. Type 1 peripheral arthropathy can involve the large joints, specifically ankles, knees, hips, elbows, and shoulders, in a pauciarticular pattern.

When it comes to the treatment of type 1, Dr. Roth said that as the IBD goes, “so goes the arthritis.” In other words, because the joint inflammation corresponds to the activity of the disease in the gut, there is likely to be a concomitant joint response once the bowel disease is placed into remission. Standard approaches to treating the IBD are employed, including anti-inflammatory agents such as 5-ASA and steroids with the additional use of immunosuppressants 6MP/AZA, or anti-TNF agents as needed.

Other options include a local steroid injection when possible and the use of simple analgesics. However, NSAIDs (with the possible exception of celecoxib) should be avoided.

Type 2 peripheral arthropathy involves the small joints of the hands, is persistent and polyarticular, and follows a course that is independent of the IBD course.

Treatment consists of physical therapy, simple analgesics, short courses of steroids with progression to immunosuppressive agents, and/or biologics as needed.

Disclosures: Dr. Roth reported that he has no financial disclosures that are relevant to the topic of his presentation. Skin Disease Education Foundation and

SANTA MONICA, CALIF. — There is only one cause of joint inflammation in childhood that the child will typically outgrow: true oligoarthritis. Even though the inflammation will eventually pass, affected children still need treatment to prevent limb-length discrepancy or blindness resulting from uveitis, according to Dr. Thomas J.A. Lehman.

Because of the shortage of pediatric rheumatologists, adult rheumatologists often end up treating children with new-onset joint symptoms, he noted at the meeting sponsored by

Without genetic markers, it is difficult to separate all the types of arthritis—which are not limited to just the eight subtypes listed in the official diagnostic criteria—that occur in children. “There may be anywhere from 30 to 50 subtypes” of arthritis in children. This matters, because they will not all respond to the same treatment or have the same disease course, said Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York.

Oligoarthritis is not a systemic disease, which makes it harder to diagnose early. The onset of joint swelling and pain should be limited to four or fewer large joints during the first 6 months, and most often only a single joint is affected. Because the stiffness and pain are worse upon awakening and tend to ease as the day progresses, parents often let it continue awhile and often cannot pinpoint when the symptoms started. Also, onset usually occurs at age 1-5 years (and typical oligoarthritis never begins after age 9 years), which means that the children are too young to describe their symptoms. A limp in the morning and a swollen knee may be the only sign that something is wrong; sometimes a visiting grandmother notices what the parents have overlooked.

Laboratory findings—or lack thereof—can help confirm the diagnosis. Because this is not a systemic disease, the hemoglobin level is never less than 11.0 g/dL and the erythrocyte sedimentation rate is never greater than 40 mm/h, according to Dr. Lehman. There is never fever, rash, or elevated white blood cell count. Oligoarthritis affects more girls than boys. The children are often positive for antinuclear antibodies and often have eye disease, usually uveitis.

It is important to make the diagnosis of true oligoarthritis as early as possible, according to Dr. Lehman. Too many children are allowed to continue limping without a diagnosis because some criteria require joint pain for at least 6 weeks and others say 3 months. That doesn't mean children can't be treated before a definitive diagnosis of oligoarthritis is made, he said. Continued pain produces muscle loss and joint damage. In addition, it hinders a child's emotional development when they can't keep up with their friends and participate in normal activities.

Many children with true oligoarthritis will respond to NSAIDs, but physicians should not be afraid to use all the medication necessary to control the disease. Corticosteroid injections may be helpful if there is a single “stubborn” joint.

This arthritis never involves the fingers or hips and never more than four joints. “True oligoarthritis affects only the knees,” said Dr. Lehman, who stressed that these diagnostic criteria are his own and are not accepted by any accrediting body. Some children with a swollen and painful ankle, wrist, or elbow may have oligoarthritis, but children with these joints involved are much less likely to “grow out of it.”

Children who present after age 9 years or who have involvement of four or fewer joints that expand to more than four joints do not have true oligoarthritis. Theirs is likely to be a debilitating arthritis, and they will not outgrow it, he stressed. “You need to be very aggressive and careful” in their management.

SDEF and this news organization are owned by Elsevier. Dr. Lehman has financial relationships with Celgene Corp., BioMarin Pharmaceutical Inc., Genentech Inc., Bristol-Meyers Squibb Co., Abbott Laboratories, Wyeth (now owned by Pfizer Inc.), and Amgen Inc.

SANTA MONICA, CALIF. — There is only one cause of joint inflammation in childhood that the child will typically outgrow: true oligoarthritis. Even though the inflammation will eventually pass, affected children still need treatment to prevent limb-length discrepancy or blindness resulting from uveitis, according to Dr. Thomas J.A. Lehman.

Because of the shortage of pediatric rheumatologists, adult rheumatologists often end up treating children with new-onset joint symptoms, he noted at the meeting sponsored by

Without genetic markers, it is difficult to separate all the types of arthritis—which are not limited to just the eight subtypes listed in the official diagnostic criteria—that occur in children. “There may be anywhere from 30 to 50 subtypes” of arthritis in children. This matters, because they will not all respond to the same treatment or have the same disease course, said Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York.

Oligoarthritis is not a systemic disease, which makes it harder to diagnose early. The onset of joint swelling and pain should be limited to four or fewer large joints during the first 6 months, and most often only a single joint is affected. Because the stiffness and pain are worse upon awakening and tend to ease as the day progresses, parents often let it continue awhile and often cannot pinpoint when the symptoms started. Also, onset usually occurs at age 1-5 years (and typical oligoarthritis never begins after age 9 years), which means that the children are too young to describe their symptoms. A limp in the morning and a swollen knee may be the only sign that something is wrong; sometimes a visiting grandmother notices what the parents have overlooked.

Laboratory findings—or lack thereof—can help confirm the diagnosis. Because this is not a systemic disease, the hemoglobin level is never less than 11.0 g/dL and the erythrocyte sedimentation rate is never greater than 40 mm/h, according to Dr. Lehman. There is never fever, rash, or elevated white blood cell count. Oligoarthritis affects more girls than boys. The children are often positive for antinuclear antibodies and often have eye disease, usually uveitis.

It is important to make the diagnosis of true oligoarthritis as early as possible, according to Dr. Lehman. Too many children are allowed to continue limping without a diagnosis because some criteria require joint pain for at least 6 weeks and others say 3 months. That doesn't mean children can't be treated before a definitive diagnosis of oligoarthritis is made, he said. Continued pain produces muscle loss and joint damage. In addition, it hinders a child's emotional development when they can't keep up with their friends and participate in normal activities.

Many children with true oligoarthritis will respond to NSAIDs, but physicians should not be afraid to use all the medication necessary to control the disease. Corticosteroid injections may be helpful if there is a single “stubborn” joint.

This arthritis never involves the fingers or hips and never more than four joints. “True oligoarthritis affects only the knees,” said Dr. Lehman, who stressed that these diagnostic criteria are his own and are not accepted by any accrediting body. Some children with a swollen and painful ankle, wrist, or elbow may have oligoarthritis, but children with these joints involved are much less likely to “grow out of it.”

Children who present after age 9 years or who have involvement of four or fewer joints that expand to more than four joints do not have true oligoarthritis. Theirs is likely to be a debilitating arthritis, and they will not outgrow it, he stressed. “You need to be very aggressive and careful” in their management.

SDEF and this news organization are owned by Elsevier. Dr. Lehman has financial relationships with Celgene Corp., BioMarin Pharmaceutical Inc., Genentech Inc., Bristol-Meyers Squibb Co., Abbott Laboratories, Wyeth (now owned by Pfizer Inc.), and Amgen Inc.

SANTA MONICA, CALIF. — There is only one cause of joint inflammation in childhood that the child will typically outgrow: true oligoarthritis. Even though the inflammation will eventually pass, affected children still need treatment to prevent limb-length discrepancy or blindness resulting from uveitis, according to Dr. Thomas J.A. Lehman.

Because of the shortage of pediatric rheumatologists, adult rheumatologists often end up treating children with new-onset joint symptoms, he noted at the meeting sponsored by

Without genetic markers, it is difficult to separate all the types of arthritis—which are not limited to just the eight subtypes listed in the official diagnostic criteria—that occur in children. “There may be anywhere from 30 to 50 subtypes” of arthritis in children. This matters, because they will not all respond to the same treatment or have the same disease course, said Dr. Lehman, chief of the division of pediatric rheumatology at the Hospital for Special Surgery in New York.

Oligoarthritis is not a systemic disease, which makes it harder to diagnose early. The onset of joint swelling and pain should be limited to four or fewer large joints during the first 6 months, and most often only a single joint is affected. Because the stiffness and pain are worse upon awakening and tend to ease as the day progresses, parents often let it continue awhile and often cannot pinpoint when the symptoms started. Also, onset usually occurs at age 1-5 years (and typical oligoarthritis never begins after age 9 years), which means that the children are too young to describe their symptoms. A limp in the morning and a swollen knee may be the only sign that something is wrong; sometimes a visiting grandmother notices what the parents have overlooked.

Laboratory findings—or lack thereof—can help confirm the diagnosis. Because this is not a systemic disease, the hemoglobin level is never less than 11.0 g/dL and the erythrocyte sedimentation rate is never greater than 40 mm/h, according to Dr. Lehman. There is never fever, rash, or elevated white blood cell count. Oligoarthritis affects more girls than boys. The children are often positive for antinuclear antibodies and often have eye disease, usually uveitis.

It is important to make the diagnosis of true oligoarthritis as early as possible, according to Dr. Lehman. Too many children are allowed to continue limping without a diagnosis because some criteria require joint pain for at least 6 weeks and others say 3 months. That doesn't mean children can't be treated before a definitive diagnosis of oligoarthritis is made, he said. Continued pain produces muscle loss and joint damage. In addition, it hinders a child's emotional development when they can't keep up with their friends and participate in normal activities.

Many children with true oligoarthritis will respond to NSAIDs, but physicians should not be afraid to use all the medication necessary to control the disease. Corticosteroid injections may be helpful if there is a single “stubborn” joint.

This arthritis never involves the fingers or hips and never more than four joints. “True oligoarthritis affects only the knees,” said Dr. Lehman, who stressed that these diagnostic criteria are his own and are not accepted by any accrediting body. Some children with a swollen and painful ankle, wrist, or elbow may have oligoarthritis, but children with these joints involved are much less likely to “grow out of it.”

Children who present after age 9 years or who have involvement of four or fewer joints that expand to more than four joints do not have true oligoarthritis. Theirs is likely to be a debilitating arthritis, and they will not outgrow it, he stressed. “You need to be very aggressive and careful” in their management.

SDEF and this news organization are owned by Elsevier. Dr. Lehman has financial relationships with Celgene Corp., BioMarin Pharmaceutical Inc., Genentech Inc., Bristol-Meyers Squibb Co., Abbott Laboratories, Wyeth (now owned by Pfizer Inc.), and Amgen Inc.

SANTA MONICA, CALIF. — Effective treatments exist for fibromyalgia syndrome, but many physicians still do a poor job of treating affected patients, according to Dr. Chad S. Boomershine.

Could it be that these physicians don't consider fibromyalgia to be a “real” disease, that they perceive affected patients as being too time consuming and unlikely to get better? asked Dr. Boomershine, a rheumatologist at Vanderbilt University in Nashville, Tenn., where he specializes in treating fibromyalgia in collaboration with the Vanderbilt Center for Integrative Health and the Vanderbilt Dayani Center.

About 2%-4% of the U.S. population meet the fibromyalgia classification criteria issued in 1990 by the American College of Rheumatology. The true prevalence is estimated to be about twice as high.

The ACR classification criteria for fibromyalgia include widespread pain for at least 3 months' duration, and pain at a minimum of 11 of 18 specified tender points when enough pressure to just blanch the examiner's thumbnail is applied. The reported 9:1 ratio of women to men with the condition is incorrect, he said, as women have more tender points and men are more likely to self-medicate rather than to seek medical care.

Fibromyalgia typically involves symptoms other than pain, which Dr. Boomershine teaches using the FIBRO mnemonic (F for fatigue and 'fibrofog' [cognitive dysfunction], I for insomnia [nonrestorative sleep], B for blues [depression and anxiety], R for rigidity [muscle and joint stiffness], and O for Ow! [pain and work disability]). Nevertheless, pharmacologic management should start by treating pain because it is the one symptom common to all fibromyalgia patients, he said. When choosing among the three indicated medications, individualize therapy based on the associated symptom that is most disabling for the patient, Dr. Boomershine said at a meeting sponsored by

Pain associated with insomnia is best treated with pregabalin (Lyrica), he said. The label states that pregabalin should be given in two divided doses daily beginning with a total of 150 mg/day and increasing to as much as 450 mg/day if needed. In an effort to avoid the typical side effects of dizziness, somnolence, fatigue, and cognitive dysfunction, however, Dr. Boomershine recommends beginning with 25-75 mg once daily at bedtime and titrating up to 150-225 mg at night before adding a morning dose.

Pain with depression and/or anxiety is best managed with duloxetine (Cymbalta) every morning, he said. The label states that the recommended dosage for fibromyalgia is 60 mg/day, but Dr. Boomershine recommends starting with 20-30 mg and increasing to 60 mg only if necessary. Trial data indicate that many patients do well on lower doses, he noted, and higher doses are associated with increased risk for side effects.

For pain associated with fatigue, the treatment of choice is milnacipran (Savella), he said. The label for this agent recommends starting at a dose of 12.5 mg once daily and gradually working up to 50 mg twice daily after 1 week and a maximum dosage of 100 mg twice daily. But Dr. Boomershine recommends titrating the dosage up more gradually.

Dr. Boomershine is an investigator for Pfizer Inc. and the National Institutes of Health, and is a consultant for Pfizer, Eli Lilly & Co., Forest Pharmaceuticals Inc., and Takeda Pharmaceutical Co.

SDEF and this news organization are owned by Elsevier.

Management should start by treating pain because it is the one symptom common to all patients.

Source DR. BOOMERSHINE

Advise Patients To Get Moving

Although effective medications are available, it takes more than drug therapy to manage fibromyalgia, according to Dr. Chad S. Boomershine.

“I recommend patients perform stretches every morning and, on alternating days, engage in aerobic and resistance exercise a total of 6 days per week,” he said.

“The combination of aerobic and resistance exercise is particularly effective in improving symptoms. Since many patients don't live near an exercise facility, I provide patients with instructional handouts and [professional elastic resistance bands] for resistance exercise on their initial visit so they can exercise at home,” the rheumatologist from Vanderbilt University added.

Dr. Boomershine said he refers his patients to the exercise guide on the National Institute on Aging Web site (

www.nia.nih.gov/Health Information/Publications/Exercise Guide

He also recommends the National Center on Physical Activity and Disability Web site for access to an exercise fact sheet that's helpful for younger patients (

www.ncpad.org/exercise/fact_sheet.php?sheet=259

Additionally, he recommends that patients learn more about fibromyalgia and find support groups in their area.

“Due to the severity of their symptoms, patients are often afraid they have a terminal illness,” he noted. “Understanding that fibromyalgia is not progressive and realizing they can manage their symptoms by learning self-help techniques is empowering and necessary if patients are to have lasting symptom improvement.”

The Web sites

www.knowfibro.com

www.fmaware.org

SANTA MONICA, CALIF. — Effective treatments exist for fibromyalgia syndrome, but many physicians still do a poor job of treating affected patients, according to Dr. Chad S. Boomershine.

Could it be that these physicians don't consider fibromyalgia to be a “real” disease, that they perceive affected patients as being too time consuming and unlikely to get better? asked Dr. Boomershine, a rheumatologist at Vanderbilt University in Nashville, Tenn., where he specializes in treating fibromyalgia in collaboration with the Vanderbilt Center for Integrative Health and the Vanderbilt Dayani Center.

About 2%-4% of the U.S. population meet the fibromyalgia classification criteria issued in 1990 by the American College of Rheumatology. The true prevalence is estimated to be about twice as high.

The ACR classification criteria for fibromyalgia include widespread pain for at least 3 months' duration, and pain at a minimum of 11 of 18 specified tender points when enough pressure to just blanch the examiner's thumbnail is applied. The reported 9:1 ratio of women to men with the condition is incorrect, he said, as women have more tender points and men are more likely to self-medicate rather than to seek medical care.

Fibromyalgia typically involves symptoms other than pain, which Dr. Boomershine teaches using the FIBRO mnemonic (F for fatigue and 'fibrofog' [cognitive dysfunction], I for insomnia [nonrestorative sleep], B for blues [depression and anxiety], R for rigidity [muscle and joint stiffness], and O for Ow! [pain and work disability]). Nevertheless, pharmacologic management should start by treating pain because it is the one symptom common to all fibromyalgia patients, he said. When choosing among the three indicated medications, individualize therapy based on the associated symptom that is most disabling for the patient, Dr. Boomershine said at a meeting sponsored by

Pain associated with insomnia is best treated with pregabalin (Lyrica), he said. The label states that pregabalin should be given in two divided doses daily beginning with a total of 150 mg/day and increasing to as much as 450 mg/day if needed. In an effort to avoid the typical side effects of dizziness, somnolence, fatigue, and cognitive dysfunction, however, Dr. Boomershine recommends beginning with 25-75 mg once daily at bedtime and titrating up to 150-225 mg at night before adding a morning dose.

Pain with depression and/or anxiety is best managed with duloxetine (Cymbalta) every morning, he said. The label states that the recommended dosage for fibromyalgia is 60 mg/day, but Dr. Boomershine recommends starting with 20-30 mg and increasing to 60 mg only if necessary. Trial data indicate that many patients do well on lower doses, he noted, and higher doses are associated with increased risk for side effects.

For pain associated with fatigue, the treatment of choice is milnacipran (Savella), he said. The label for this agent recommends starting at a dose of 12.5 mg once daily and gradually working up to 50 mg twice daily after 1 week and a maximum dosage of 100 mg twice daily. But Dr. Boomershine recommends titrating the dosage up more gradually.

Dr. Boomershine is an investigator for Pfizer Inc. and the National Institutes of Health, and is a consultant for Pfizer, Eli Lilly & Co., Forest Pharmaceuticals Inc., and Takeda Pharmaceutical Co.

SDEF and this news organization are owned by Elsevier.

Management should start by treating pain because it is the one symptom common to all patients.

Source DR. BOOMERSHINE

Advise Patients To Get Moving

Although effective medications are available, it takes more than drug therapy to manage fibromyalgia, according to Dr. Chad S. Boomershine.

“I recommend patients perform stretches every morning and, on alternating days, engage in aerobic and resistance exercise a total of 6 days per week,” he said.

“The combination of aerobic and resistance exercise is particularly effective in improving symptoms. Since many patients don't live near an exercise facility, I provide patients with instructional handouts and [professional elastic resistance bands] for resistance exercise on their initial visit so they can exercise at home,” the rheumatologist from Vanderbilt University added.

Dr. Boomershine said he refers his patients to the exercise guide on the National Institute on Aging Web site (

www.nia.nih.gov/Health Information/Publications/Exercise Guide

He also recommends the National Center on Physical Activity and Disability Web site for access to an exercise fact sheet that's helpful for younger patients (

www.ncpad.org/exercise/fact_sheet.php?sheet=259

Additionally, he recommends that patients learn more about fibromyalgia and find support groups in their area.

“Due to the severity of their symptoms, patients are often afraid they have a terminal illness,” he noted. “Understanding that fibromyalgia is not progressive and realizing they can manage their symptoms by learning self-help techniques is empowering and necessary if patients are to have lasting symptom improvement.”

The Web sites

www.knowfibro.com

www.fmaware.org

SANTA MONICA, CALIF. — Effective treatments exist for fibromyalgia syndrome, but many physicians still do a poor job of treating affected patients, according to Dr. Chad S. Boomershine.

Could it be that these physicians don't consider fibromyalgia to be a “real” disease, that they perceive affected patients as being too time consuming and unlikely to get better? asked Dr. Boomershine, a rheumatologist at Vanderbilt University in Nashville, Tenn., where he specializes in treating fibromyalgia in collaboration with the Vanderbilt Center for Integrative Health and the Vanderbilt Dayani Center.

About 2%-4% of the U.S. population meet the fibromyalgia classification criteria issued in 1990 by the American College of Rheumatology. The true prevalence is estimated to be about twice as high.

The ACR classification criteria for fibromyalgia include widespread pain for at least 3 months' duration, and pain at a minimum of 11 of 18 specified tender points when enough pressure to just blanch the examiner's thumbnail is applied. The reported 9:1 ratio of women to men with the condition is incorrect, he said, as women have more tender points and men are more likely to self-medicate rather than to seek medical care.

Fibromyalgia typically involves symptoms other than pain, which Dr. Boomershine teaches using the FIBRO mnemonic (F for fatigue and 'fibrofog' [cognitive dysfunction], I for insomnia [nonrestorative sleep], B for blues [depression and anxiety], R for rigidity [muscle and joint stiffness], and O for Ow! [pain and work disability]). Nevertheless, pharmacologic management should start by treating pain because it is the one symptom common to all fibromyalgia patients, he said. When choosing among the three indicated medications, individualize therapy based on the associated symptom that is most disabling for the patient, Dr. Boomershine said at a meeting sponsored by

Pain associated with insomnia is best treated with pregabalin (Lyrica), he said. The label states that pregabalin should be given in two divided doses daily beginning with a total of 150 mg/day and increasing to as much as 450 mg/day if needed. In an effort to avoid the typical side effects of dizziness, somnolence, fatigue, and cognitive dysfunction, however, Dr. Boomershine recommends beginning with 25-75 mg once daily at bedtime and titrating up to 150-225 mg at night before adding a morning dose.

Pain with depression and/or anxiety is best managed with duloxetine (Cymbalta) every morning, he said. The label states that the recommended dosage for fibromyalgia is 60 mg/day, but Dr. Boomershine recommends starting with 20-30 mg and increasing to 60 mg only if necessary. Trial data indicate that many patients do well on lower doses, he noted, and higher doses are associated with increased risk for side effects.

For pain associated with fatigue, the treatment of choice is milnacipran (Savella), he said. The label for this agent recommends starting at a dose of 12.5 mg once daily and gradually working up to 50 mg twice daily after 1 week and a maximum dosage of 100 mg twice daily. But Dr. Boomershine recommends titrating the dosage up more gradually.

Dr. Boomershine is an investigator for Pfizer Inc. and the National Institutes of Health, and is a consultant for Pfizer, Eli Lilly & Co., Forest Pharmaceuticals Inc., and Takeda Pharmaceutical Co.

SDEF and this news organization are owned by Elsevier.

Management should start by treating pain because it is the one symptom common to all patients.

Source DR. BOOMERSHINE

Advise Patients To Get Moving

Although effective medications are available, it takes more than drug therapy to manage fibromyalgia, according to Dr. Chad S. Boomershine.

“I recommend patients perform stretches every morning and, on alternating days, engage in aerobic and resistance exercise a total of 6 days per week,” he said.

“The combination of aerobic and resistance exercise is particularly effective in improving symptoms. Since many patients don't live near an exercise facility, I provide patients with instructional handouts and [professional elastic resistance bands] for resistance exercise on their initial visit so they can exercise at home,” the rheumatologist from Vanderbilt University added.

Dr. Boomershine said he refers his patients to the exercise guide on the National Institute on Aging Web site (

www.nia.nih.gov/Health Information/Publications/Exercise Guide

He also recommends the National Center on Physical Activity and Disability Web site for access to an exercise fact sheet that's helpful for younger patients (

www.ncpad.org/exercise/fact_sheet.php?sheet=259

Additionally, he recommends that patients learn more about fibromyalgia and find support groups in their area.

“Due to the severity of their symptoms, patients are often afraid they have a terminal illness,” he noted. “Understanding that fibromyalgia is not progressive and realizing they can manage their symptoms by learning self-help techniques is empowering and necessary if patients are to have lasting symptom improvement.”

The Web sites

www.knowfibro.com

www.fmaware.org