ACR Annual Meeting 2013

SAN DIEGO – Patients with osteoarthritis of the knee who wore a patellofemoral brace for 6 weeks experienced a significant reduction in pain and in bone marrow lesion volumes in the patellofemoral region, compared with those who did not wear the brace, a multicenter trial showed.

"There’s a pressing need for nonsurgical intervention for knee osteoarthritis," Dr. David T. Felson said in a press briefing at the annual meeting of the American College of Rheumatology.

"There are no currently approved structure-modifying treatments. This has been a focus of studies that have been testing modifying treatments on hyaline cartilage, which changes slowly, necessitating expensive, long-term, large trials. Even so, mechanopathology such as that caused by malalignment or meniscal tears may make it impossible to protect cartilage in existing OA," he noted.

Dr. Felson, director of the Research in Osteoarthritis in Manchester group at the University of Manchester (England) and professor of medicine at Boston University, went on to note that bone marrow lesions (BMLs) "have been well shown to predict later cartilage loss in that location and correlate with pain and its severity. Recently, we showed that BMLs fluctuate in volume in as little as 6 weeks. Further, one small trial has suggested that zoledronic acid may shrink BMLs and reduce knee pain. That leads us to suggest that BMLs may be a viable treatment target in OA."

The patellofemoral joint "is a major source of knee pain in OA, and there has been little study of the efficacy of PF braces," he continued. "In a body mechanics study, PF bracing has been shown to increase the contact area of the PF joint. It may thereby lower the contact stress and shrink BMLs."

He and his associates set out to determine whether bracing would improve pain and lessen the volume of BMLs in patients with knee OA. They enrolled 126 patients with a mean age of 55 years whose knee pain had been present daily for the previous 3 months. Half of the patients wore a soft neoprene PF brace for a mean of 7.3 hours per day, while the other half did not.

All study participants "had to have at least a score of 40 on a 0-100 mm visual analogue scale (VAS) for nominated aggravating activity likely to originate in the PF joint," Dr. Felson said. "They had to have pain with activities such as stair climbing, kneeling, prolonged sitting or squatting, [and] they also had to have a radiographic KL [Kellgren-Lawrence] score of grade 2 or 3 in the PF joint. That score had to be greater than the KL score for the tibiofemoral compartments. They also had to undergo a clinical exam by a trained physiotherapist to confirm PF joint tenderness."

The researchers performed contrast-enhanced knee MRIs at baseline and at 6 weeks. The primary symptom outcome measure was VAS pain during the patients’ nominated aggravating activity, while the primary structural outcome measure was BML volume in the PF joint as assessed on sagittal precontrast view.

At 6 weeks, Dr. Felson reported that patients in the no-brace group had a mean reduction in their VAS pain of 1.3, compared with a reduction of 18.2 in the braced group, a mean between-group difference of 16.9 that reached statistical significance (P less than .001).

As for PF BML volume, patients in the no-brace group showed a slight increase in volume (mean, 102.7 mm³), while the braced group showed a significant decrease in PF BML volume (mean, –554.9 mm³), for a mean between-group difference of 657.6 mm³ that reached statistical significance (P = .02). "That represents about a 25% decrease in volume," Dr. Felson said.

No differences were observed between the two groups in terms of tibiofemoral BML volume or in synovitis volume.

Dr. Felson acknowledged certain limitations of the study, including its 6-week design. "OA is a long-term chronic disease," he said. "We don’t know what relevance our findings have for longer-term structure changes of the knee."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Patients with osteoarthritis of the knee who wore a patellofemoral brace for 6 weeks experienced a significant reduction in pain and in bone marrow lesion volumes in the patellofemoral region, compared with those who did not wear the brace, a multicenter trial showed.

"There’s a pressing need for nonsurgical intervention for knee osteoarthritis," Dr. David T. Felson said in a press briefing at the annual meeting of the American College of Rheumatology.

"There are no currently approved structure-modifying treatments. This has been a focus of studies that have been testing modifying treatments on hyaline cartilage, which changes slowly, necessitating expensive, long-term, large trials. Even so, mechanopathology such as that caused by malalignment or meniscal tears may make it impossible to protect cartilage in existing OA," he noted.

Dr. Felson, director of the Research in Osteoarthritis in Manchester group at the University of Manchester (England) and professor of medicine at Boston University, went on to note that bone marrow lesions (BMLs) "have been well shown to predict later cartilage loss in that location and correlate with pain and its severity. Recently, we showed that BMLs fluctuate in volume in as little as 6 weeks. Further, one small trial has suggested that zoledronic acid may shrink BMLs and reduce knee pain. That leads us to suggest that BMLs may be a viable treatment target in OA."

The patellofemoral joint "is a major source of knee pain in OA, and there has been little study of the efficacy of PF braces," he continued. "In a body mechanics study, PF bracing has been shown to increase the contact area of the PF joint. It may thereby lower the contact stress and shrink BMLs."

He and his associates set out to determine whether bracing would improve pain and lessen the volume of BMLs in patients with knee OA. They enrolled 126 patients with a mean age of 55 years whose knee pain had been present daily for the previous 3 months. Half of the patients wore a soft neoprene PF brace for a mean of 7.3 hours per day, while the other half did not.

All study participants "had to have at least a score of 40 on a 0-100 mm visual analogue scale (VAS) for nominated aggravating activity likely to originate in the PF joint," Dr. Felson said. "They had to have pain with activities such as stair climbing, kneeling, prolonged sitting or squatting, [and] they also had to have a radiographic KL [Kellgren-Lawrence] score of grade 2 or 3 in the PF joint. That score had to be greater than the KL score for the tibiofemoral compartments. They also had to undergo a clinical exam by a trained physiotherapist to confirm PF joint tenderness."

The researchers performed contrast-enhanced knee MRIs at baseline and at 6 weeks. The primary symptom outcome measure was VAS pain during the patients’ nominated aggravating activity, while the primary structural outcome measure was BML volume in the PF joint as assessed on sagittal precontrast view.

At 6 weeks, Dr. Felson reported that patients in the no-brace group had a mean reduction in their VAS pain of 1.3, compared with a reduction of 18.2 in the braced group, a mean between-group difference of 16.9 that reached statistical significance (P less than .001).

As for PF BML volume, patients in the no-brace group showed a slight increase in volume (mean, 102.7 mm³), while the braced group showed a significant decrease in PF BML volume (mean, –554.9 mm³), for a mean between-group difference of 657.6 mm³ that reached statistical significance (P = .02). "That represents about a 25% decrease in volume," Dr. Felson said.

No differences were observed between the two groups in terms of tibiofemoral BML volume or in synovitis volume.

Dr. Felson acknowledged certain limitations of the study, including its 6-week design. "OA is a long-term chronic disease," he said. "We don’t know what relevance our findings have for longer-term structure changes of the knee."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Patients with osteoarthritis of the knee who wore a patellofemoral brace for 6 weeks experienced a significant reduction in pain and in bone marrow lesion volumes in the patellofemoral region, compared with those who did not wear the brace, a multicenter trial showed.

"There’s a pressing need for nonsurgical intervention for knee osteoarthritis," Dr. David T. Felson said in a press briefing at the annual meeting of the American College of Rheumatology.

"There are no currently approved structure-modifying treatments. This has been a focus of studies that have been testing modifying treatments on hyaline cartilage, which changes slowly, necessitating expensive, long-term, large trials. Even so, mechanopathology such as that caused by malalignment or meniscal tears may make it impossible to protect cartilage in existing OA," he noted.

Dr. Felson, director of the Research in Osteoarthritis in Manchester group at the University of Manchester (England) and professor of medicine at Boston University, went on to note that bone marrow lesions (BMLs) "have been well shown to predict later cartilage loss in that location and correlate with pain and its severity. Recently, we showed that BMLs fluctuate in volume in as little as 6 weeks. Further, one small trial has suggested that zoledronic acid may shrink BMLs and reduce knee pain. That leads us to suggest that BMLs may be a viable treatment target in OA."

The patellofemoral joint "is a major source of knee pain in OA, and there has been little study of the efficacy of PF braces," he continued. "In a body mechanics study, PF bracing has been shown to increase the contact area of the PF joint. It may thereby lower the contact stress and shrink BMLs."

He and his associates set out to determine whether bracing would improve pain and lessen the volume of BMLs in patients with knee OA. They enrolled 126 patients with a mean age of 55 years whose knee pain had been present daily for the previous 3 months. Half of the patients wore a soft neoprene PF brace for a mean of 7.3 hours per day, while the other half did not.

All study participants "had to have at least a score of 40 on a 0-100 mm visual analogue scale (VAS) for nominated aggravating activity likely to originate in the PF joint," Dr. Felson said. "They had to have pain with activities such as stair climbing, kneeling, prolonged sitting or squatting, [and] they also had to have a radiographic KL [Kellgren-Lawrence] score of grade 2 or 3 in the PF joint. That score had to be greater than the KL score for the tibiofemoral compartments. They also had to undergo a clinical exam by a trained physiotherapist to confirm PF joint tenderness."

The researchers performed contrast-enhanced knee MRIs at baseline and at 6 weeks. The primary symptom outcome measure was VAS pain during the patients’ nominated aggravating activity, while the primary structural outcome measure was BML volume in the PF joint as assessed on sagittal precontrast view.

At 6 weeks, Dr. Felson reported that patients in the no-brace group had a mean reduction in their VAS pain of 1.3, compared with a reduction of 18.2 in the braced group, a mean between-group difference of 16.9 that reached statistical significance (P less than .001).

As for PF BML volume, patients in the no-brace group showed a slight increase in volume (mean, 102.7 mm³), while the braced group showed a significant decrease in PF BML volume (mean, –554.9 mm³), for a mean between-group difference of 657.6 mm³ that reached statistical significance (P = .02). "That represents about a 25% decrease in volume," Dr. Felson said.

No differences were observed between the two groups in terms of tibiofemoral BML volume or in synovitis volume.

Dr. Felson acknowledged certain limitations of the study, including its 6-week design. "OA is a long-term chronic disease," he said. "We don’t know what relevance our findings have for longer-term structure changes of the knee."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Viscosupplementation using hyaluronic acid injections delayed total knee replacement for patients with knee osteoarthritis by up to a median 2.6 years in a retrospective observational study.

The study, involving analysis of a large commercial health insurance claims database (Truven MarketScan), included all 16,529 patients with knee osteoarthritis (OA) who made their first visit to a specialist for the condition in 2008-2011 and who eventually went on to total knee replacement surgery.

Among this group were 4,178 knee OA patients who underwent one or more courses of treatment with any of the Food and Drug Administration–approved injectable hyaluronic acid products. A total of 3,647 of these patients were successfully matched to controls with knee OA who had total knee replacement surgery without any prior hyaluronic acid injections, Dr. Roy D. Altman explained at the annual meeting of the American College of Rheumatology.

The matching process relied upon propensity scores based on age, sex, physician specialty, diagnosis at the first specialist visit, and year. Therein lays a significant study limitation: These variables provide only limited ability to adjust for any differences in baseline knee OA severity that might have existed between patients who did or didn’t receive hyaluronic acid injections. Nor can an observational study establish causality, observed Dr. Altman, professor emeritus of medicine at the University of California, Los Angeles.

That being said, the study demonstrated a strong dose-dependent relationship between viscosupplementation and time from first specialist visit to knee replacement surgery, he noted.

Seventy-nine percent of patients who got hyaluronic acid injections received a single course consisting of either one injection or a series of injections, depending upon the specific product. Those patients experienced a median 233-day increase in the time to surgery, compared with matched controls who didn’t get hyaluronic acid injections.

Moreover, the 16% of viscosupplementation recipients who underwent a second round of treatment further delayed their median time from first specialist visit to total knee replacement by an additional 7 months. And that pattern continued in the relatively small numbers of patients who underwent three or more courses of viscosupplementation: Each round of hyaluronic acid injections brought a roughly 7-month further delay in time to surgery, out to a total of 2.6 years.

The study was sponsored by Johnson & Johnson. Dr. Altman reported having no financial conflicts.

[email protected]

SAN DIEGO – Viscosupplementation using hyaluronic acid injections delayed total knee replacement for patients with knee osteoarthritis by up to a median 2.6 years in a retrospective observational study.

The study, involving analysis of a large commercial health insurance claims database (Truven MarketScan), included all 16,529 patients with knee osteoarthritis (OA) who made their first visit to a specialist for the condition in 2008-2011 and who eventually went on to total knee replacement surgery.

Among this group were 4,178 knee OA patients who underwent one or more courses of treatment with any of the Food and Drug Administration–approved injectable hyaluronic acid products. A total of 3,647 of these patients were successfully matched to controls with knee OA who had total knee replacement surgery without any prior hyaluronic acid injections, Dr. Roy D. Altman explained at the annual meeting of the American College of Rheumatology.

The matching process relied upon propensity scores based on age, sex, physician specialty, diagnosis at the first specialist visit, and year. Therein lays a significant study limitation: These variables provide only limited ability to adjust for any differences in baseline knee OA severity that might have existed between patients who did or didn’t receive hyaluronic acid injections. Nor can an observational study establish causality, observed Dr. Altman, professor emeritus of medicine at the University of California, Los Angeles.

That being said, the study demonstrated a strong dose-dependent relationship between viscosupplementation and time from first specialist visit to knee replacement surgery, he noted.

Seventy-nine percent of patients who got hyaluronic acid injections received a single course consisting of either one injection or a series of injections, depending upon the specific product. Those patients experienced a median 233-day increase in the time to surgery, compared with matched controls who didn’t get hyaluronic acid injections.

Moreover, the 16% of viscosupplementation recipients who underwent a second round of treatment further delayed their median time from first specialist visit to total knee replacement by an additional 7 months. And that pattern continued in the relatively small numbers of patients who underwent three or more courses of viscosupplementation: Each round of hyaluronic acid injections brought a roughly 7-month further delay in time to surgery, out to a total of 2.6 years.

The study was sponsored by Johnson & Johnson. Dr. Altman reported having no financial conflicts.

[email protected]

SAN DIEGO – Viscosupplementation using hyaluronic acid injections delayed total knee replacement for patients with knee osteoarthritis by up to a median 2.6 years in a retrospective observational study.

The study, involving analysis of a large commercial health insurance claims database (Truven MarketScan), included all 16,529 patients with knee osteoarthritis (OA) who made their first visit to a specialist for the condition in 2008-2011 and who eventually went on to total knee replacement surgery.

Among this group were 4,178 knee OA patients who underwent one or more courses of treatment with any of the Food and Drug Administration–approved injectable hyaluronic acid products. A total of 3,647 of these patients were successfully matched to controls with knee OA who had total knee replacement surgery without any prior hyaluronic acid injections, Dr. Roy D. Altman explained at the annual meeting of the American College of Rheumatology.

The matching process relied upon propensity scores based on age, sex, physician specialty, diagnosis at the first specialist visit, and year. Therein lays a significant study limitation: These variables provide only limited ability to adjust for any differences in baseline knee OA severity that might have existed between patients who did or didn’t receive hyaluronic acid injections. Nor can an observational study establish causality, observed Dr. Altman, professor emeritus of medicine at the University of California, Los Angeles.

That being said, the study demonstrated a strong dose-dependent relationship between viscosupplementation and time from first specialist visit to knee replacement surgery, he noted.

Seventy-nine percent of patients who got hyaluronic acid injections received a single course consisting of either one injection or a series of injections, depending upon the specific product. Those patients experienced a median 233-day increase in the time to surgery, compared with matched controls who didn’t get hyaluronic acid injections.

Moreover, the 16% of viscosupplementation recipients who underwent a second round of treatment further delayed their median time from first specialist visit to total knee replacement by an additional 7 months. And that pattern continued in the relatively small numbers of patients who underwent three or more courses of viscosupplementation: Each round of hyaluronic acid injections brought a roughly 7-month further delay in time to surgery, out to a total of 2.6 years.

The study was sponsored by Johnson & Johnson. Dr. Altman reported having no financial conflicts.

[email protected]

SAN DIEGO – Knee osteoarthritis is too frequently underdiagnosed and undertreated by primary care physicians and bariatric surgeons in obese patients considering weight loss surgery.

That’s the conclusion Dr. Janice Lin and her coinvestigators at New York University reached based upon their prospective study in which 408 consecutive patients scheduled for bariatric surgery at NYU Langone Medical Center and Bellevue Hospital were screened for this common form of arthritis.

The researchers found that 54% of the obese patients reported significant knee pain. Of these 221 patients, 26 weren’t interested in further evaluation, but 115 were deemed likely to have knee osteoarthritis (OA) on the basis of a brief screen indicating they had knee pain on more than 15 days per month for longer than 1 month, had a visual analog scale (VAS) pain score of at least 30 out of 100, and didn’t have lupus, bilateral knee replacement, crystal disease, psoriasis, or an inflammatory arthritis. These 115 patients formed the study population for this ongoing prospective investigation.

The primary care physicians of only 47% of these 115 patients had evaluated their knee pain. Bariatric surgeons had similarly not addressed the knee pain in about half of cases. Indeed, fewer than one-third of these obese patients with knee pain had been assessed via knee x-rays in accord with guideline-recommended practice.

"In the bariatric population, knee pain is often attributed to mechanical load from obesity without proper evaluation or treatment. Patients are rarely referred to rheumatologists or other appropriate specialists, though they may benefit from such evaluation and management," according to Dr. Lin.

In fact, only 3% of these patients with significant knee pain had been referred to a rheumatologist and 15% to an orthopedic surgeon.

ACR treatment guidelines were for the most part not being followed. Although roughly three-quarters of patients were taking NSAIDs and/or acetaminophen, only 31% of the group had been referred for physical therapy, 14% had received a steroid injection, 11% used a topical NSAID, and 1% had undergone viscosupplementation, recommended as a second-line therapy.

All 115 study participants got a baseline posterior-anterior standing bilateral knee x-ray scored for Kellgren-Lawrence grade. Based on the findings, 19% of patients were determined to not have knee OA, 21% had mild Kellgren-Lawrence grade 1 disease, and the rest had more advanced knee OA.

The group’s mean baseline VAS pain score was 64.5. Their Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) mean pain, stiffness, and function scores were 268, 102, and 938, respectively.

This ongoing study builds upon an earlier retrospective study by Dr. Lin’s coinvestigators at New York University, who reported that 51% of 192 patients who underwent bariatric laparoscopic banding surgery had complete improvement in knee OA pain 19 months later.In the ongoing prospective study, participants will repeat the WOMAC and other validated measures of knee OA pain and function 1, 3, and 6 months after laparascopic banding, sleeve gastrectomy, or gastric bypass. They will also have follow-up knee x-rays. Dr. Lin and her coworkers will be eager to see if any of the three types of bariatric surgery is advantageous in terms of its impact on knee pain, she said.

She reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Knee osteoarthritis is too frequently underdiagnosed and undertreated by primary care physicians and bariatric surgeons in obese patients considering weight loss surgery.

That’s the conclusion Dr. Janice Lin and her coinvestigators at New York University reached based upon their prospective study in which 408 consecutive patients scheduled for bariatric surgery at NYU Langone Medical Center and Bellevue Hospital were screened for this common form of arthritis.

The researchers found that 54% of the obese patients reported significant knee pain. Of these 221 patients, 26 weren’t interested in further evaluation, but 115 were deemed likely to have knee osteoarthritis (OA) on the basis of a brief screen indicating they had knee pain on more than 15 days per month for longer than 1 month, had a visual analog scale (VAS) pain score of at least 30 out of 100, and didn’t have lupus, bilateral knee replacement, crystal disease, psoriasis, or an inflammatory arthritis. These 115 patients formed the study population for this ongoing prospective investigation.

The primary care physicians of only 47% of these 115 patients had evaluated their knee pain. Bariatric surgeons had similarly not addressed the knee pain in about half of cases. Indeed, fewer than one-third of these obese patients with knee pain had been assessed via knee x-rays in accord with guideline-recommended practice.

"In the bariatric population, knee pain is often attributed to mechanical load from obesity without proper evaluation or treatment. Patients are rarely referred to rheumatologists or other appropriate specialists, though they may benefit from such evaluation and management," according to Dr. Lin.

In fact, only 3% of these patients with significant knee pain had been referred to a rheumatologist and 15% to an orthopedic surgeon.

ACR treatment guidelines were for the most part not being followed. Although roughly three-quarters of patients were taking NSAIDs and/or acetaminophen, only 31% of the group had been referred for physical therapy, 14% had received a steroid injection, 11% used a topical NSAID, and 1% had undergone viscosupplementation, recommended as a second-line therapy.

All 115 study participants got a baseline posterior-anterior standing bilateral knee x-ray scored for Kellgren-Lawrence grade. Based on the findings, 19% of patients were determined to not have knee OA, 21% had mild Kellgren-Lawrence grade 1 disease, and the rest had more advanced knee OA.

The group’s mean baseline VAS pain score was 64.5. Their Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) mean pain, stiffness, and function scores were 268, 102, and 938, respectively.

This ongoing study builds upon an earlier retrospective study by Dr. Lin’s coinvestigators at New York University, who reported that 51% of 192 patients who underwent bariatric laparoscopic banding surgery had complete improvement in knee OA pain 19 months later.In the ongoing prospective study, participants will repeat the WOMAC and other validated measures of knee OA pain and function 1, 3, and 6 months after laparascopic banding, sleeve gastrectomy, or gastric bypass. They will also have follow-up knee x-rays. Dr. Lin and her coworkers will be eager to see if any of the three types of bariatric surgery is advantageous in terms of its impact on knee pain, she said.

She reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Knee osteoarthritis is too frequently underdiagnosed and undertreated by primary care physicians and bariatric surgeons in obese patients considering weight loss surgery.

That’s the conclusion Dr. Janice Lin and her coinvestigators at New York University reached based upon their prospective study in which 408 consecutive patients scheduled for bariatric surgery at NYU Langone Medical Center and Bellevue Hospital were screened for this common form of arthritis.

The researchers found that 54% of the obese patients reported significant knee pain. Of these 221 patients, 26 weren’t interested in further evaluation, but 115 were deemed likely to have knee osteoarthritis (OA) on the basis of a brief screen indicating they had knee pain on more than 15 days per month for longer than 1 month, had a visual analog scale (VAS) pain score of at least 30 out of 100, and didn’t have lupus, bilateral knee replacement, crystal disease, psoriasis, or an inflammatory arthritis. These 115 patients formed the study population for this ongoing prospective investigation.

The primary care physicians of only 47% of these 115 patients had evaluated their knee pain. Bariatric surgeons had similarly not addressed the knee pain in about half of cases. Indeed, fewer than one-third of these obese patients with knee pain had been assessed via knee x-rays in accord with guideline-recommended practice.

"In the bariatric population, knee pain is often attributed to mechanical load from obesity without proper evaluation or treatment. Patients are rarely referred to rheumatologists or other appropriate specialists, though they may benefit from such evaluation and management," according to Dr. Lin.

In fact, only 3% of these patients with significant knee pain had been referred to a rheumatologist and 15% to an orthopedic surgeon.

ACR treatment guidelines were for the most part not being followed. Although roughly three-quarters of patients were taking NSAIDs and/or acetaminophen, only 31% of the group had been referred for physical therapy, 14% had received a steroid injection, 11% used a topical NSAID, and 1% had undergone viscosupplementation, recommended as a second-line therapy.

All 115 study participants got a baseline posterior-anterior standing bilateral knee x-ray scored for Kellgren-Lawrence grade. Based on the findings, 19% of patients were determined to not have knee OA, 21% had mild Kellgren-Lawrence grade 1 disease, and the rest had more advanced knee OA.

The group’s mean baseline VAS pain score was 64.5. Their Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) mean pain, stiffness, and function scores were 268, 102, and 938, respectively.

This ongoing study builds upon an earlier retrospective study by Dr. Lin’s coinvestigators at New York University, who reported that 51% of 192 patients who underwent bariatric laparoscopic banding surgery had complete improvement in knee OA pain 19 months later.In the ongoing prospective study, participants will repeat the WOMAC and other validated measures of knee OA pain and function 1, 3, and 6 months after laparascopic banding, sleeve gastrectomy, or gastric bypass. They will also have follow-up knee x-rays. Dr. Lin and her coworkers will be eager to see if any of the three types of bariatric surgery is advantageous in terms of its impact on knee pain, she said.

She reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Knee osteoarthritis is too frequently underdiagnosed and undertreated by primary care physicians and bariatric surgeons in obese patients considering weight loss surgery.

That’s the conclusion Dr. Janice Lin and her coinvestigators at New York University reached based upon their prospective study in which 408 consecutive patients scheduled for bariatric surgery at NYU Langone Medical Center and Bellevue Hospital were screened for this common form of arthritis.

The researchers found that 54% of the obese patients reported significant knee pain. Of these 221 patients, 26 weren’t interested in further evaluation, but 115 were deemed likely to have knee osteoarthritis (OA) on the basis of a brief screen indicating they had knee pain on more than 15 days per month for longer than 1 month, had a visual analog scale (VAS) pain score of at least 30 out of 100, and didn’t have lupus, bilateral knee replacement, crystal disease, psoriasis, or an inflammatory arthritis. These 115 patients formed the study population for this ongoing prospective investigation.

The primary care physicians of only 47% of these 115 patients had evaluated their knee pain. Bariatric surgeons had similarly not addressed the knee pain in about half of cases. Indeed, fewer than one-third of these obese patients with knee pain had been assessed via knee x-rays in accord with guideline-recommended practice.

"In the bariatric population, knee pain is often attributed to mechanical load from obesity without proper evaluation or treatment. Patients are rarely referred to rheumatologists or other appropriate specialists, though they may benefit from such evaluation and management," according to Dr. Lin.

In fact, only 3% of these patients with significant knee pain had been referred to a rheumatologist and 15% to an orthopedic surgeon.

ACR treatment guidelines were for the most part not being followed. Although roughly three-quarters of patients were taking NSAIDs and/or acetaminophen, only 31% of the group had been referred for physical therapy, 14% had received a steroid injection, 11% used a topical NSAID, and 1% had undergone viscosupplementation, recommended as a second-line therapy.

All 115 study participants got a baseline posterior-anterior standing bilateral knee x-ray scored for Kellgren-Lawrence grade. Based on the findings, 19% of patients were determined to not have knee OA, 21% had mild Kellgren-Lawrence grade 1 disease, and the rest had more advanced knee OA.

The group’s mean baseline VAS pain score was 64.5. Their Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) mean pain, stiffness, and function scores were 268, 102, and 938, respectively.

This ongoing study builds upon an earlier retrospective study by Dr. Lin’s coinvestigators at New York University, who reported that 51% of 192 patients who underwent bariatric laparoscopic banding surgery had complete improvement in knee OA pain 19 months later.In the ongoing prospective study, participants will repeat the WOMAC and other validated measures of knee OA pain and function 1, 3, and 6 months after laparascopic banding, sleeve gastrectomy, or gastric bypass. They will also have follow-up knee x-rays. Dr. Lin and her coworkers will be eager to see if any of the three types of bariatric surgery is advantageous in terms of its impact on knee pain, she said.

She reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Knee osteoarthritis is too frequently underdiagnosed and undertreated by primary care physicians and bariatric surgeons in obese patients considering weight loss surgery.

That’s the conclusion Dr. Janice Lin and her coinvestigators at New York University reached based upon their prospective study in which 408 consecutive patients scheduled for bariatric surgery at NYU Langone Medical Center and Bellevue Hospital were screened for this common form of arthritis.

The researchers found that 54% of the obese patients reported significant knee pain. Of these 221 patients, 26 weren’t interested in further evaluation, but 115 were deemed likely to have knee osteoarthritis (OA) on the basis of a brief screen indicating they had knee pain on more than 15 days per month for longer than 1 month, had a visual analog scale (VAS) pain score of at least 30 out of 100, and didn’t have lupus, bilateral knee replacement, crystal disease, psoriasis, or an inflammatory arthritis. These 115 patients formed the study population for this ongoing prospective investigation.

The primary care physicians of only 47% of these 115 patients had evaluated their knee pain. Bariatric surgeons had similarly not addressed the knee pain in about half of cases. Indeed, fewer than one-third of these obese patients with knee pain had been assessed via knee x-rays in accord with guideline-recommended practice.

"In the bariatric population, knee pain is often attributed to mechanical load from obesity without proper evaluation or treatment. Patients are rarely referred to rheumatologists or other appropriate specialists, though they may benefit from such evaluation and management," according to Dr. Lin.

In fact, only 3% of these patients with significant knee pain had been referred to a rheumatologist and 15% to an orthopedic surgeon.

ACR treatment guidelines were for the most part not being followed. Although roughly three-quarters of patients were taking NSAIDs and/or acetaminophen, only 31% of the group had been referred for physical therapy, 14% had received a steroid injection, 11% used a topical NSAID, and 1% had undergone viscosupplementation, recommended as a second-line therapy.

All 115 study participants got a baseline posterior-anterior standing bilateral knee x-ray scored for Kellgren-Lawrence grade. Based on the findings, 19% of patients were determined to not have knee OA, 21% had mild Kellgren-Lawrence grade 1 disease, and the rest had more advanced knee OA.

The group’s mean baseline VAS pain score was 64.5. Their Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) mean pain, stiffness, and function scores were 268, 102, and 938, respectively.

This ongoing study builds upon an earlier retrospective study by Dr. Lin’s coinvestigators at New York University, who reported that 51% of 192 patients who underwent bariatric laparoscopic banding surgery had complete improvement in knee OA pain 19 months later.In the ongoing prospective study, participants will repeat the WOMAC and other validated measures of knee OA pain and function 1, 3, and 6 months after laparascopic banding, sleeve gastrectomy, or gastric bypass. They will also have follow-up knee x-rays. Dr. Lin and her coworkers will be eager to see if any of the three types of bariatric surgery is advantageous in terms of its impact on knee pain, she said.

She reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Knee osteoarthritis is too frequently underdiagnosed and undertreated by primary care physicians and bariatric surgeons in obese patients considering weight loss surgery.

That’s the conclusion Dr. Janice Lin and her coinvestigators at New York University reached based upon their prospective study in which 408 consecutive patients scheduled for bariatric surgery at NYU Langone Medical Center and Bellevue Hospital were screened for this common form of arthritis.

The researchers found that 54% of the obese patients reported significant knee pain. Of these 221 patients, 26 weren’t interested in further evaluation, but 115 were deemed likely to have knee osteoarthritis (OA) on the basis of a brief screen indicating they had knee pain on more than 15 days per month for longer than 1 month, had a visual analog scale (VAS) pain score of at least 30 out of 100, and didn’t have lupus, bilateral knee replacement, crystal disease, psoriasis, or an inflammatory arthritis. These 115 patients formed the study population for this ongoing prospective investigation.

The primary care physicians of only 47% of these 115 patients had evaluated their knee pain. Bariatric surgeons had similarly not addressed the knee pain in about half of cases. Indeed, fewer than one-third of these obese patients with knee pain had been assessed via knee x-rays in accord with guideline-recommended practice.

"In the bariatric population, knee pain is often attributed to mechanical load from obesity without proper evaluation or treatment. Patients are rarely referred to rheumatologists or other appropriate specialists, though they may benefit from such evaluation and management," according to Dr. Lin.

In fact, only 3% of these patients with significant knee pain had been referred to a rheumatologist and 15% to an orthopedic surgeon.

ACR treatment guidelines were for the most part not being followed. Although roughly three-quarters of patients were taking NSAIDs and/or acetaminophen, only 31% of the group had been referred for physical therapy, 14% had received a steroid injection, 11% used a topical NSAID, and 1% had undergone viscosupplementation, recommended as a second-line therapy.

All 115 study participants got a baseline posterior-anterior standing bilateral knee x-ray scored for Kellgren-Lawrence grade. Based on the findings, 19% of patients were determined to not have knee OA, 21% had mild Kellgren-Lawrence grade 1 disease, and the rest had more advanced knee OA.

The group’s mean baseline VAS pain score was 64.5. Their Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) mean pain, stiffness, and function scores were 268, 102, and 938, respectively.

This ongoing study builds upon an earlier retrospective study by Dr. Lin’s coinvestigators at New York University, who reported that 51% of 192 patients who underwent bariatric laparoscopic banding surgery had complete improvement in knee OA pain 19 months later.In the ongoing prospective study, participants will repeat the WOMAC and other validated measures of knee OA pain and function 1, 3, and 6 months after laparascopic banding, sleeve gastrectomy, or gastric bypass. They will also have follow-up knee x-rays. Dr. Lin and her coworkers will be eager to see if any of the three types of bariatric surgery is advantageous in terms of its impact on knee pain, she said.

She reported having no relevant financial conflicts.

[email protected]

SAN DIEGO – Osteoarthritis patients who meet federal guidelines for exercise have more days of perfect health per year than do their sedentary counterparts, results from a novel study suggest.

"Our findings support interventions that help older adults to increase their physical activity level, even if guidelines are not fully met," Dr. Kai Sun said during a press briefing at the annual meeting of the American College of Rheumatology. "Increased physical activity could essentially translate into better quality of life and increased time spent in good health. We expect that this benefit would translate into lower overall health care costs."

Osteoarthritis is "a major cause of disability, and its prevalence is on the rise due to the aging population and the obesity epidemic. Inactivity is also a major problem in the United States. This is a significant economic burden as well because of the disability and the many health issues associated with inactivity as well as lost productivity and diminished quality of life," noted Dr. Sun, a medical resident and research trainee at Northwestern Feinberg School of Medicine, Chicago.

Doug Brunk/IMNG Medical Media

The study involved analysis of data from the National Institutes of Health–funded Osteoarthritis Initiative (OAI) to gather information on the physical activity levels of more than 4,700 adults, most of whom were aged older than 65 years and more than 40% of whom had a body mass index over 30 kg/m², with or at risk for knee osteoarthritis.

The researchers set out to determine whether meeting the 2008 physical activity guidelines from the Department of Health and Human Services would translate into better overall quality of life and whether interventions to improve physical activity level correlate to better quality-adjusted life years (QALYs).The HHS guidelines recommend 150 minutes of moderate to vigorous activity per week performed in sessions lasting at least 10 minutes each. "An example of moderate activity would be walking briskly as if you were late to an appointment," Dr. Sun said.

The researchers used accelerometers to measure the physical activity level in 1,794 OAI study participants over the course of 1 week and placed them into one of three groups: 235 who met the HHS exercise guidelines of 150 minutes of moderate to vigorous activity, 763 who were "insufficiently active" (engaging in some but fewer than 150 minutes of moderate to vigorous exercise per week), and 796 who were inactive (engaging in no moderate to vigorous exercise per week). Health-related utility scores used to calculate QALYs were measured at the beginning of the study and 2 years later.

Overall, QALYs were significantly better with increasing level of physical activity, Dr. Sun reported. "This was a graded relationship, meaning that [people] in the middle group who had some [level of exercise] but not enough to meet guidelines had significantly better overall quality of life compared with the inactive group," she said. Specifically, after adjustment for socioeconomic and health factors over the 2-year period, people who met the HHS exercise guidelines had QALYs that were 0.11 higher compared with those who were inactive. At the same time, those in the insufficiently active group had QALYs that were 0.058 higher compared with those who were inactive.

"The most active group experienced the most benefit," Dr. Sun said. "The improvement was meaningful and translated into roughly an additional 10-20 days of perfect health in a year. We estimate that if an intervention could move someone out of the inactive group and cost less than $1,450 per person per year, that intervention would be considered cost-effective."

The researchers had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Osteoarthritis patients who meet federal guidelines for exercise have more days of perfect health per year than do their sedentary counterparts, results from a novel study suggest.

"Our findings support interventions that help older adults to increase their physical activity level, even if guidelines are not fully met," Dr. Kai Sun said during a press briefing at the annual meeting of the American College of Rheumatology. "Increased physical activity could essentially translate into better quality of life and increased time spent in good health. We expect that this benefit would translate into lower overall health care costs."

Osteoarthritis is "a major cause of disability, and its prevalence is on the rise due to the aging population and the obesity epidemic. Inactivity is also a major problem in the United States. This is a significant economic burden as well because of the disability and the many health issues associated with inactivity as well as lost productivity and diminished quality of life," noted Dr. Sun, a medical resident and research trainee at Northwestern Feinberg School of Medicine, Chicago.

Doug Brunk/IMNG Medical Media

The study involved analysis of data from the National Institutes of Health–funded Osteoarthritis Initiative (OAI) to gather information on the physical activity levels of more than 4,700 adults, most of whom were aged older than 65 years and more than 40% of whom had a body mass index over 30 kg/m², with or at risk for knee osteoarthritis.

The researchers set out to determine whether meeting the 2008 physical activity guidelines from the Department of Health and Human Services would translate into better overall quality of life and whether interventions to improve physical activity level correlate to better quality-adjusted life years (QALYs).The HHS guidelines recommend 150 minutes of moderate to vigorous activity per week performed in sessions lasting at least 10 minutes each. "An example of moderate activity would be walking briskly as if you were late to an appointment," Dr. Sun said.

The researchers used accelerometers to measure the physical activity level in 1,794 OAI study participants over the course of 1 week and placed them into one of three groups: 235 who met the HHS exercise guidelines of 150 minutes of moderate to vigorous activity, 763 who were "insufficiently active" (engaging in some but fewer than 150 minutes of moderate to vigorous exercise per week), and 796 who were inactive (engaging in no moderate to vigorous exercise per week). Health-related utility scores used to calculate QALYs were measured at the beginning of the study and 2 years later.

Overall, QALYs were significantly better with increasing level of physical activity, Dr. Sun reported. "This was a graded relationship, meaning that [people] in the middle group who had some [level of exercise] but not enough to meet guidelines had significantly better overall quality of life compared with the inactive group," she said. Specifically, after adjustment for socioeconomic and health factors over the 2-year period, people who met the HHS exercise guidelines had QALYs that were 0.11 higher compared with those who were inactive. At the same time, those in the insufficiently active group had QALYs that were 0.058 higher compared with those who were inactive.

"The most active group experienced the most benefit," Dr. Sun said. "The improvement was meaningful and translated into roughly an additional 10-20 days of perfect health in a year. We estimate that if an intervention could move someone out of the inactive group and cost less than $1,450 per person per year, that intervention would be considered cost-effective."

The researchers had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Osteoarthritis patients who meet federal guidelines for exercise have more days of perfect health per year than do their sedentary counterparts, results from a novel study suggest.

"Our findings support interventions that help older adults to increase their physical activity level, even if guidelines are not fully met," Dr. Kai Sun said during a press briefing at the annual meeting of the American College of Rheumatology. "Increased physical activity could essentially translate into better quality of life and increased time spent in good health. We expect that this benefit would translate into lower overall health care costs."

Osteoarthritis is "a major cause of disability, and its prevalence is on the rise due to the aging population and the obesity epidemic. Inactivity is also a major problem in the United States. This is a significant economic burden as well because of the disability and the many health issues associated with inactivity as well as lost productivity and diminished quality of life," noted Dr. Sun, a medical resident and research trainee at Northwestern Feinberg School of Medicine, Chicago.

Doug Brunk/IMNG Medical Media

The study involved analysis of data from the National Institutes of Health–funded Osteoarthritis Initiative (OAI) to gather information on the physical activity levels of more than 4,700 adults, most of whom were aged older than 65 years and more than 40% of whom had a body mass index over 30 kg/m², with or at risk for knee osteoarthritis.

The researchers set out to determine whether meeting the 2008 physical activity guidelines from the Department of Health and Human Services would translate into better overall quality of life and whether interventions to improve physical activity level correlate to better quality-adjusted life years (QALYs).The HHS guidelines recommend 150 minutes of moderate to vigorous activity per week performed in sessions lasting at least 10 minutes each. "An example of moderate activity would be walking briskly as if you were late to an appointment," Dr. Sun said.

The researchers used accelerometers to measure the physical activity level in 1,794 OAI study participants over the course of 1 week and placed them into one of three groups: 235 who met the HHS exercise guidelines of 150 minutes of moderate to vigorous activity, 763 who were "insufficiently active" (engaging in some but fewer than 150 minutes of moderate to vigorous exercise per week), and 796 who were inactive (engaging in no moderate to vigorous exercise per week). Health-related utility scores used to calculate QALYs were measured at the beginning of the study and 2 years later.

Overall, QALYs were significantly better with increasing level of physical activity, Dr. Sun reported. "This was a graded relationship, meaning that [people] in the middle group who had some [level of exercise] but not enough to meet guidelines had significantly better overall quality of life compared with the inactive group," she said. Specifically, after adjustment for socioeconomic and health factors over the 2-year period, people who met the HHS exercise guidelines had QALYs that were 0.11 higher compared with those who were inactive. At the same time, those in the insufficiently active group had QALYs that were 0.058 higher compared with those who were inactive.

"The most active group experienced the most benefit," Dr. Sun said. "The improvement was meaningful and translated into roughly an additional 10-20 days of perfect health in a year. We estimate that if an intervention could move someone out of the inactive group and cost less than $1,450 per person per year, that intervention would be considered cost-effective."

The researchers had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Women who regularly drink one or more sugar-sweetened soft drinks per day are at heightened risk of developing seropositive rheumatoid arthritis, according to a massive analysis of combined data from the prospective-cohort Nurses’ Health Study and Nurses’ Health Study II.

During 1.9 million person-years of prospective follow-up in the Nurses' Health Study (NHS) and 1.5 million person-years in NHS II, there were 563 confirmed cases of new-onset seropositive rheumatoid arthritis and 320 cases of seronegative rheumatoid arthritis. The two studies collectively enrolled 238,131 U.S. female registered nurses who periodically filled out validated food frequency questionnaires.

In a multivariate analysis adjusted for numerous potential confounding variables, women who reported drinking an average of one or more non-diet sodas per day had a 71% greater risk of developing seropositive rheumatoid arthritis during follow-up than did those who drank none or less than one per month (P = .005), Yang Hu reported at the annual meeting of the American College of Rheumatology.

It’s noteworthy that the increased risk was present at a cut point of one daily serving, a level of consumption many Americans wouldn’t view as excessive.

The mechanism for the observed association between frequent soft drink consumption and seropositive rheumatoid arthritis remains unclear. The investigators decided to look at sugar-containing soda consumption because it has been shown to be associated with overweight and obesity, type 2 diabetes, and cardiovascular disease. And since obesity has previously been shown to be associated with increased risk of rheumatoid arthritis, the thinking was that obesity might mediate the link between soda consumption and rheumatoid arthritis. Daily soda consumption, however, was independently associated with a 71% increase in risk even after controlling for body mass index in the multivariate analysis, noted Mr. Hu of Brigham and Women’s Hospital, Boston.

Other potential confounders that were adjusted for in the analysis included age, smoking, alcohol consumption, physical activity, reproductive factors, multivitamin use, income level, and diet quality.

The NHS and NHS II studies are funded by the National Institutes of Health. Mr. Hu reported having no financial conflicts of interest, but one of his associates disclosed relationships with several pharmaceutical companies.

[email protected]

*Correction, 11/15/2013: An earlier version of the article misstated the number of nurses involved in the analysis.

SAN DIEGO – Women who regularly drink one or more sugar-sweetened soft drinks per day are at heightened risk of developing seropositive rheumatoid arthritis, according to a massive analysis of combined data from the prospective-cohort Nurses’ Health Study and Nurses’ Health Study II.

During 1.9 million person-years of prospective follow-up in the Nurses' Health Study (NHS) and 1.5 million person-years in NHS II, there were 563 confirmed cases of new-onset seropositive rheumatoid arthritis and 320 cases of seronegative rheumatoid arthritis. The two studies collectively enrolled 238,131 U.S. female registered nurses who periodically filled out validated food frequency questionnaires.

In a multivariate analysis adjusted for numerous potential confounding variables, women who reported drinking an average of one or more non-diet sodas per day had a 71% greater risk of developing seropositive rheumatoid arthritis during follow-up than did those who drank none or less than one per month (P = .005), Yang Hu reported at the annual meeting of the American College of Rheumatology.

It’s noteworthy that the increased risk was present at a cut point of one daily serving, a level of consumption many Americans wouldn’t view as excessive.

The mechanism for the observed association between frequent soft drink consumption and seropositive rheumatoid arthritis remains unclear. The investigators decided to look at sugar-containing soda consumption because it has been shown to be associated with overweight and obesity, type 2 diabetes, and cardiovascular disease. And since obesity has previously been shown to be associated with increased risk of rheumatoid arthritis, the thinking was that obesity might mediate the link between soda consumption and rheumatoid arthritis. Daily soda consumption, however, was independently associated with a 71% increase in risk even after controlling for body mass index in the multivariate analysis, noted Mr. Hu of Brigham and Women’s Hospital, Boston.

Other potential confounders that were adjusted for in the analysis included age, smoking, alcohol consumption, physical activity, reproductive factors, multivitamin use, income level, and diet quality.

The NHS and NHS II studies are funded by the National Institutes of Health. Mr. Hu reported having no financial conflicts of interest, but one of his associates disclosed relationships with several pharmaceutical companies.

[email protected]

*Correction, 11/15/2013: An earlier version of the article misstated the number of nurses involved in the analysis.

SAN DIEGO – Women who regularly drink one or more sugar-sweetened soft drinks per day are at heightened risk of developing seropositive rheumatoid arthritis, according to a massive analysis of combined data from the prospective-cohort Nurses’ Health Study and Nurses’ Health Study II.

During 1.9 million person-years of prospective follow-up in the Nurses' Health Study (NHS) and 1.5 million person-years in NHS II, there were 563 confirmed cases of new-onset seropositive rheumatoid arthritis and 320 cases of seronegative rheumatoid arthritis. The two studies collectively enrolled 238,131 U.S. female registered nurses who periodically filled out validated food frequency questionnaires.

In a multivariate analysis adjusted for numerous potential confounding variables, women who reported drinking an average of one or more non-diet sodas per day had a 71% greater risk of developing seropositive rheumatoid arthritis during follow-up than did those who drank none or less than one per month (P = .005), Yang Hu reported at the annual meeting of the American College of Rheumatology.

It’s noteworthy that the increased risk was present at a cut point of one daily serving, a level of consumption many Americans wouldn’t view as excessive.

The mechanism for the observed association between frequent soft drink consumption and seropositive rheumatoid arthritis remains unclear. The investigators decided to look at sugar-containing soda consumption because it has been shown to be associated with overweight and obesity, type 2 diabetes, and cardiovascular disease. And since obesity has previously been shown to be associated with increased risk of rheumatoid arthritis, the thinking was that obesity might mediate the link between soda consumption and rheumatoid arthritis. Daily soda consumption, however, was independently associated with a 71% increase in risk even after controlling for body mass index in the multivariate analysis, noted Mr. Hu of Brigham and Women’s Hospital, Boston.

Other potential confounders that were adjusted for in the analysis included age, smoking, alcohol consumption, physical activity, reproductive factors, multivitamin use, income level, and diet quality.

The NHS and NHS II studies are funded by the National Institutes of Health. Mr. Hu reported having no financial conflicts of interest, but one of his associates disclosed relationships with several pharmaceutical companies.

[email protected]

*Correction, 11/15/2013: An earlier version of the article misstated the number of nurses involved in the analysis.

SAN DIEGO – Women who regularly drink one or more sugar-sweetened soft drinks per day are at heightened risk of developing seropositive rheumatoid arthritis, according to a massive analysis of combined data from the prospective-cohort Nurses’ Health Study and Nurses’ Health Study II.

During 1.9 million person-years of prospective follow-up in the Nurses' Health Study (NHS) and 1.5 million person-years in NHS II, there were 563 confirmed cases of new-onset seropositive rheumatoid arthritis and 320 cases of seronegative rheumatoid arthritis. The two studies collectively enrolled 238,131 U.S. female registered nurses who periodically filled out validated food frequency questionnaires.

In a multivariate analysis adjusted for numerous potential confounding variables, women who reported drinking an average of one or more non-diet sodas per day had a 71% greater risk of developing seropositive rheumatoid arthritis during follow-up than did those who drank none or less than one per month (P = .005), Yang Hu reported at the annual meeting of the American College of Rheumatology.

It’s noteworthy that the increased risk was present at a cut point of one daily serving, a level of consumption many Americans wouldn’t view as excessive.

The mechanism for the observed association between frequent soft drink consumption and seropositive rheumatoid arthritis remains unclear. The investigators decided to look at sugar-containing soda consumption because it has been shown to be associated with overweight and obesity, type 2 diabetes, and cardiovascular disease. And since obesity has previously been shown to be associated with increased risk of rheumatoid arthritis, the thinking was that obesity might mediate the link between soda consumption and rheumatoid arthritis. Daily soda consumption, however, was independently associated with a 71% increase in risk even after controlling for body mass index in the multivariate analysis, noted Mr. Hu of Brigham and Women’s Hospital, Boston.

Other potential confounders that were adjusted for in the analysis included age, smoking, alcohol consumption, physical activity, reproductive factors, multivitamin use, income level, and diet quality.

The NHS and NHS II studies are funded by the National Institutes of Health. Mr. Hu reported having no financial conflicts of interest, but one of his associates disclosed relationships with several pharmaceutical companies.

[email protected]

*Correction, 11/15/2013: An earlier version of the article misstated the number of nurses involved in the analysis.

SAN DIEGO – Women who regularly drink one or more sugar-sweetened soft drinks per day are at heightened risk of developing seropositive rheumatoid arthritis, according to a massive analysis of combined data from the prospective-cohort Nurses’ Health Study and Nurses’ Health Study II.

During 1.9 million person-years of prospective follow-up in the Nurses' Health Study (NHS) and 1.5 million person-years in NHS II, there were 563 confirmed cases of new-onset seropositive rheumatoid arthritis and 320 cases of seronegative rheumatoid arthritis. The two studies collectively enrolled 238,131 U.S. female registered nurses who periodically filled out validated food frequency questionnaires.

In a multivariate analysis adjusted for numerous potential confounding variables, women who reported drinking an average of one or more non-diet sodas per day had a 71% greater risk of developing seropositive rheumatoid arthritis during follow-up than did those who drank none or less than one per month (P = .005), Yang Hu reported at the annual meeting of the American College of Rheumatology.

It’s noteworthy that the increased risk was present at a cut point of one daily serving, a level of consumption many Americans wouldn’t view as excessive.

The mechanism for the observed association between frequent soft drink consumption and seropositive rheumatoid arthritis remains unclear. The investigators decided to look at sugar-containing soda consumption because it has been shown to be associated with overweight and obesity, type 2 diabetes, and cardiovascular disease. And since obesity has previously been shown to be associated with increased risk of rheumatoid arthritis, the thinking was that obesity might mediate the link between soda consumption and rheumatoid arthritis. Daily soda consumption, however, was independently associated with a 71% increase in risk even after controlling for body mass index in the multivariate analysis, noted Mr. Hu of Brigham and Women’s Hospital, Boston.

Other potential confounders that were adjusted for in the analysis included age, smoking, alcohol consumption, physical activity, reproductive factors, multivitamin use, income level, and diet quality.

The NHS and NHS II studies are funded by the National Institutes of Health. Mr. Hu reported having no financial conflicts of interest, but one of his associates disclosed relationships with several pharmaceutical companies.

[email protected]

*Correction, 11/15/2013: An earlier version of the article misstated the number of nurses involved in the analysis.

SAN DIEGO – Women who regularly drink one or more sugar-sweetened soft drinks per day are at heightened risk of developing seropositive rheumatoid arthritis, according to a massive analysis of combined data from the prospective-cohort Nurses’ Health Study and Nurses’ Health Study II.

During 1.9 million person-years of prospective follow-up in the Nurses' Health Study (NHS) and 1.5 million person-years in NHS II, there were 563 confirmed cases of new-onset seropositive rheumatoid arthritis and 320 cases of seronegative rheumatoid arthritis. The two studies collectively enrolled 238,131 U.S. female registered nurses who periodically filled out validated food frequency questionnaires.

In a multivariate analysis adjusted for numerous potential confounding variables, women who reported drinking an average of one or more non-diet sodas per day had a 71% greater risk of developing seropositive rheumatoid arthritis during follow-up than did those who drank none or less than one per month (P = .005), Yang Hu reported at the annual meeting of the American College of Rheumatology.

It’s noteworthy that the increased risk was present at a cut point of one daily serving, a level of consumption many Americans wouldn’t view as excessive.

The mechanism for the observed association between frequent soft drink consumption and seropositive rheumatoid arthritis remains unclear. The investigators decided to look at sugar-containing soda consumption because it has been shown to be associated with overweight and obesity, type 2 diabetes, and cardiovascular disease. And since obesity has previously been shown to be associated with increased risk of rheumatoid arthritis, the thinking was that obesity might mediate the link between soda consumption and rheumatoid arthritis. Daily soda consumption, however, was independently associated with a 71% increase in risk even after controlling for body mass index in the multivariate analysis, noted Mr. Hu of Brigham and Women’s Hospital, Boston.

Other potential confounders that were adjusted for in the analysis included age, smoking, alcohol consumption, physical activity, reproductive factors, multivitamin use, income level, and diet quality.

The NHS and NHS II studies are funded by the National Institutes of Health. Mr. Hu reported having no financial conflicts of interest, but one of his associates disclosed relationships with several pharmaceutical companies.

[email protected]

*Correction, 11/15/2013: An earlier version of the article misstated the number of nurses involved in the analysis.

SAN DIEGO – Alteration in the balance of placentally secreted angiogenic factors early in pregnancy provides a potent new predictor of subsequent preeclampsia and other poor outcomes in pregnant women with systemic lupus erythematosus and/or antiphospholipid antibody syndrome.

Patients with systemic lupus erythematosus (SLE) and/or antiphospholipid antibody syndrome (APS) who had an elevated ratio of a splice variant of vascular endothelial growth factor R1 called sFLT1 to placental growth factor (PlGF) when measured at 16-19 weeks’ gestation were at 13.8-fold increased relative risk of preeclampsia before 34 weeks, compared with patients with an sFLT1/PlGF ratio below that cut-point in the large, multicenter, observational PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and SLE) study, Dr. Jane E. Salmon reported at the annual meeting of the American College of Rheumatology.

"Nearly half of the patients with an SFLT1/PlGF ratio greater than 3.45 when measured at 16-19 weeks’ gestation will develop early preeclampsia. On the other hand, a low ratio, as well as low levels of sFLT1 or high levels of PlGF, can reassure physicians and patients that preterm preeclampsia is unlikely: a 3% chance," said Dr. Salmon, professor of medicine and of ob.gyn. at Cornell University and a rheumatologist at the Hospital for Special Surgery, both in New York.

Pregnancy in patients with lupus is associated with obstetric complications placing both mother and fetus at great risk. Yet, until now it hasn’t been possible to predict which patients will have poor outcomes.

The key to identifying those at high risk lies in a recognition that preeclampsia and other poor outcomes are dramatic manifestations of placental insufficiency, which actually begins, initially silently, early in pregnancy. The maternal hypertension, proteinuria, thrombocytopenia, and other end-organ manifestations of preeclampsia are caused by maternal endothelial dysfunction mediated by placental secretion of antiangiogenic factors. Angiogenic growth factors, such as PIGF and vascular endothelial growth factor (VEGF), are essential to a healthy endothelium. But placentally secreted sFLT1 binds to these two angiogenic growth factors, rendering them unavailable to the endothelium, she explained.

Overexpression of sFLT1 in multiple animal models results in hypertension and proteinuria, the hallmarks of preeclampsia. Moreover, cancer patients treated with VEGF inhibitors often develop these two conditions. Based in part on these observations, Dr. Salmon and her coinvestigators turned to the PROMISSE study to test their hypothesis that elevated levels of antiangiogenic factors early in pregnancy predict poor outcomes in patients with SLE and/or APS. The prospective study involved 503 pregnant women with SLE and/or APS and 204 healthy controls, all with monthly blood draws starting before 12 weeks’ gestation.

The composite outcome of preeclampsia, small for gestational age, indicated preterm delivery, and other adverse events occurred in 37% of SLE patients who also had APS. The rate was 16% in patients with SLE alone, 26% in those with APS alone, and 3% in controls.

Subjects with SLE and/or APS who developed preeclampsia and other pregnancy complications displayed significantly higher levels of sFLT1 beginning at 12 weeks and sustained through 31 weeks’ gestation, compared with those with normal pregnancies. Moreover, PlGF levels were significantly lower during weeks 16-31 in the patients with pregnancy complications. The investigators determined that the best predictor of pregnancy complications was the ratio of antiangiogenic sFLT1 to angiogenic PlGF. And the optimal cut-point was 3.45.

Audience members said that while a predictive test for preeclampsia is most welcome, the fact remains that physicians don’t have a lot to offer in terms of prevention or treatment of this feared pregnancy complication. Dr. Salmon responded that the SFLT1/PlGF ratio can be used to risk-stratify pregnant lupus patients for future interventional trials with new drugs looking at new pathways. Already, for example, other investigators have reported some success using a strategy targeting sFLT1 itself. In a small study, they found that women with severe preeclampsia who had their blood run through a heparin column that binds and removes sFLT1 were able to maintain their pregnancies for up to 2 weeks.

"It’s a tiny, open-label trial involving a device, but I think that will move forward," she predicted.

The PROMISSE study was funded by the National Institutes of Health, the Alliance for Lupus Research, and the Mary Kirkland Center for Lupus Research at the Hospital for Special Surgery. Dr. Salmon reported having received research grants from and/or serving as a consultant to Alexion, Novartis, and Roche.

[email protected]

SAN DIEGO – Alteration in the balance of placentally secreted angiogenic factors early in pregnancy provides a potent new predictor of subsequent preeclampsia and other poor outcomes in pregnant women with systemic lupus erythematosus and/or antiphospholipid antibody syndrome.

Patients with systemic lupus erythematosus (SLE) and/or antiphospholipid antibody syndrome (APS) who had an elevated ratio of a splice variant of vascular endothelial growth factor R1 called sFLT1 to placental growth factor (PlGF) when measured at 16-19 weeks’ gestation were at 13.8-fold increased relative risk of preeclampsia before 34 weeks, compared with patients with an sFLT1/PlGF ratio below that cut-point in the large, multicenter, observational PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and SLE) study, Dr. Jane E. Salmon reported at the annual meeting of the American College of Rheumatology.

"Nearly half of the patients with an SFLT1/PlGF ratio greater than 3.45 when measured at 16-19 weeks’ gestation will develop early preeclampsia. On the other hand, a low ratio, as well as low levels of sFLT1 or high levels of PlGF, can reassure physicians and patients that preterm preeclampsia is unlikely: a 3% chance," said Dr. Salmon, professor of medicine and of ob.gyn. at Cornell University and a rheumatologist at the Hospital for Special Surgery, both in New York.

Pregnancy in patients with lupus is associated with obstetric complications placing both mother and fetus at great risk. Yet, until now it hasn’t been possible to predict which patients will have poor outcomes.

The key to identifying those at high risk lies in a recognition that preeclampsia and other poor outcomes are dramatic manifestations of placental insufficiency, which actually begins, initially silently, early in pregnancy. The maternal hypertension, proteinuria, thrombocytopenia, and other end-organ manifestations of preeclampsia are caused by maternal endothelial dysfunction mediated by placental secretion of antiangiogenic factors. Angiogenic growth factors, such as PIGF and vascular endothelial growth factor (VEGF), are essential to a healthy endothelium. But placentally secreted sFLT1 binds to these two angiogenic growth factors, rendering them unavailable to the endothelium, she explained.

Overexpression of sFLT1 in multiple animal models results in hypertension and proteinuria, the hallmarks of preeclampsia. Moreover, cancer patients treated with VEGF inhibitors often develop these two conditions. Based in part on these observations, Dr. Salmon and her coinvestigators turned to the PROMISSE study to test their hypothesis that elevated levels of antiangiogenic factors early in pregnancy predict poor outcomes in patients with SLE and/or APS. The prospective study involved 503 pregnant women with SLE and/or APS and 204 healthy controls, all with monthly blood draws starting before 12 weeks’ gestation.

The composite outcome of preeclampsia, small for gestational age, indicated preterm delivery, and other adverse events occurred in 37% of SLE patients who also had APS. The rate was 16% in patients with SLE alone, 26% in those with APS alone, and 3% in controls.

Subjects with SLE and/or APS who developed preeclampsia and other pregnancy complications displayed significantly higher levels of sFLT1 beginning at 12 weeks and sustained through 31 weeks’ gestation, compared with those with normal pregnancies. Moreover, PlGF levels were significantly lower during weeks 16-31 in the patients with pregnancy complications. The investigators determined that the best predictor of pregnancy complications was the ratio of antiangiogenic sFLT1 to angiogenic PlGF. And the optimal cut-point was 3.45.

Audience members said that while a predictive test for preeclampsia is most welcome, the fact remains that physicians don’t have a lot to offer in terms of prevention or treatment of this feared pregnancy complication. Dr. Salmon responded that the SFLT1/PlGF ratio can be used to risk-stratify pregnant lupus patients for future interventional trials with new drugs looking at new pathways. Already, for example, other investigators have reported some success using a strategy targeting sFLT1 itself. In a small study, they found that women with severe preeclampsia who had their blood run through a heparin column that binds and removes sFLT1 were able to maintain their pregnancies for up to 2 weeks.

"It’s a tiny, open-label trial involving a device, but I think that will move forward," she predicted.

The PROMISSE study was funded by the National Institutes of Health, the Alliance for Lupus Research, and the Mary Kirkland Center for Lupus Research at the Hospital for Special Surgery. Dr. Salmon reported having received research grants from and/or serving as a consultant to Alexion, Novartis, and Roche.

[email protected]

SAN DIEGO – Alteration in the balance of placentally secreted angiogenic factors early in pregnancy provides a potent new predictor of subsequent preeclampsia and other poor outcomes in pregnant women with systemic lupus erythematosus and/or antiphospholipid antibody syndrome.

Patients with systemic lupus erythematosus (SLE) and/or antiphospholipid antibody syndrome (APS) who had an elevated ratio of a splice variant of vascular endothelial growth factor R1 called sFLT1 to placental growth factor (PlGF) when measured at 16-19 weeks’ gestation were at 13.8-fold increased relative risk of preeclampsia before 34 weeks, compared with patients with an sFLT1/PlGF ratio below that cut-point in the large, multicenter, observational PROMISSE (Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and SLE) study, Dr. Jane E. Salmon reported at the annual meeting of the American College of Rheumatology.

"Nearly half of the patients with an SFLT1/PlGF ratio greater than 3.45 when measured at 16-19 weeks’ gestation will develop early preeclampsia. On the other hand, a low ratio, as well as low levels of sFLT1 or high levels of PlGF, can reassure physicians and patients that preterm preeclampsia is unlikely: a 3% chance," said Dr. Salmon, professor of medicine and of ob.gyn. at Cornell University and a rheumatologist at the Hospital for Special Surgery, both in New York.

Pregnancy in patients with lupus is associated with obstetric complications placing both mother and fetus at great risk. Yet, until now it hasn’t been possible to predict which patients will have poor outcomes.

The key to identifying those at high risk lies in a recognition that preeclampsia and other poor outcomes are dramatic manifestations of placental insufficiency, which actually begins, initially silently, early in pregnancy. The maternal hypertension, proteinuria, thrombocytopenia, and other end-organ manifestations of preeclampsia are caused by maternal endothelial dysfunction mediated by placental secretion of antiangiogenic factors. Angiogenic growth factors, such as PIGF and vascular endothelial growth factor (VEGF), are essential to a healthy endothelium. But placentally secreted sFLT1 binds to these two angiogenic growth factors, rendering them unavailable to the endothelium, she explained.

Overexpression of sFLT1 in multiple animal models results in hypertension and proteinuria, the hallmarks of preeclampsia. Moreover, cancer patients treated with VEGF inhibitors often develop these two conditions. Based in part on these observations, Dr. Salmon and her coinvestigators turned to the PROMISSE study to test their hypothesis that elevated levels of antiangiogenic factors early in pregnancy predict poor outcomes in patients with SLE and/or APS. The prospective study involved 503 pregnant women with SLE and/or APS and 204 healthy controls, all with monthly blood draws starting before 12 weeks’ gestation.

The composite outcome of preeclampsia, small for gestational age, indicated preterm delivery, and other adverse events occurred in 37% of SLE patients who also had APS. The rate was 16% in patients with SLE alone, 26% in those with APS alone, and 3% in controls.

Subjects with SLE and/or APS who developed preeclampsia and other pregnancy complications displayed significantly higher levels of sFLT1 beginning at 12 weeks and sustained through 31 weeks’ gestation, compared with those with normal pregnancies. Moreover, PlGF levels were significantly lower during weeks 16-31 in the patients with pregnancy complications. The investigators determined that the best predictor of pregnancy complications was the ratio of antiangiogenic sFLT1 to angiogenic PlGF. And the optimal cut-point was 3.45.

Audience members said that while a predictive test for preeclampsia is most welcome, the fact remains that physicians don’t have a lot to offer in terms of prevention or treatment of this feared pregnancy complication. Dr. Salmon responded that the SFLT1/PlGF ratio can be used to risk-stratify pregnant lupus patients for future interventional trials with new drugs looking at new pathways. Already, for example, other investigators have reported some success using a strategy targeting sFLT1 itself. In a small study, they found that women with severe preeclampsia who had their blood run through a heparin column that binds and removes sFLT1 were able to maintain their pregnancies for up to 2 weeks.

"It’s a tiny, open-label trial involving a device, but I think that will move forward," she predicted.

The PROMISSE study was funded by the National Institutes of Health, the Alliance for Lupus Research, and the Mary Kirkland Center for Lupus Research at the Hospital for Special Surgery. Dr. Salmon reported having received research grants from and/or serving as a consultant to Alexion, Novartis, and Roche.

[email protected]

SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.

"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.

Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.

Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).

After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.

The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).

Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."

He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."

The researchers have yet to perform a cost analysis comparing the two treatment groups.

The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.

[email protected]

*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage. 

SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.

"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.

Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.

Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).

After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.

The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).

Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."

He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."

The researchers have yet to perform a cost analysis comparing the two treatment groups.

The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.

[email protected]

*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage. 

SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.

"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.

Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.

Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).

After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.

The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).

Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."

He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."

The researchers have yet to perform a cost analysis comparing the two treatment groups.

The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.

[email protected]

*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage. 

SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.

"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.

Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.

Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).

After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.

The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).

Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."

He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."

The researchers have yet to perform a cost analysis comparing the two treatment groups.

The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.

[email protected]

*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage. 

SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.

"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.

Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.

Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).

After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.

The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).

Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."

He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."

The researchers have yet to perform a cost analysis comparing the two treatment groups.

The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.

[email protected]

*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage. 

SAN DIEGO – Compared with standard care, intensive management of psoriatic arthritis using a treat-to-target approach significantly improved joint and skin outcomes for patients newly diagnosed with the disease, results from a multicenter, randomized controlled trial showed.

"Treating to target works in this disease, and it’s going to result in better long-term outcomes," lead investigator Dr. Philip Helliwell said during a press briefing at the annual meeting of the American College of Rheumatology.

Dr. Helliwell and his associates at eight centers in the United Kingdom randomized 206 patients with early psoriatic arthritis to standard care or intensive management, and followed them for 48 weeks. Patients in the standard care group were treated by a rheumatologist with no set protocol and no limitations, while those in the intensive management group followed a strict treatment protocol with escalation of therapy if minimal disease activity criteria were not met.

Patients in the intensive management group were started on methotrexate with rapid escalation to a dose of *25 mg/week after 6 weeks if they tolerated the drug. If they did not meet minimal disease criteria after 12 weeks, they received a more powerful combination of disease-modifying antirheumatic drugs (DMARDs).

After another 12 weeks, patients in the intensive management group were given anti–tumor necrosis factor therapy if they had three or more tender joints. If they had fewer than three tender or swollen joints but did not meet the minimal disease activity criteria, they were given methotrexate and an alternative DMARD. Patients in the standard care group were treated with DMARDs, but with no set time limits for drug therapy escalation or measurements to reach.

The primary outcome measures were the proportion of patients in both groups who achieved ACR20, ACR50, and ACR70 criteria for disease activity, which represent disease improvement of 20%, 50%, and 70%, respectively. Dr. Helliwell reported that compared with the standard care group, a higher proportion of patients in the intensive management group achieved ACR20 (62% vs. 45%, respectively), ACR50 (51% vs. 25%), and ACR70 (38% vs. 17%). A higher proportion of patients in the intensive management group also achieved a Psoriasis Area and Severity Index 75 compared with their counterparts in the standard care group (59% vs. 33%).

Research in psoriatic arthritis has "lagged behind that of rheumatoid arthritis for years in terms of pathogenesis and treatment paradigms," noted Dr. Helliwell, a senior lecturer in rheumatology at the Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds (England). "I think the study we’ve reported brings psoriatic arthritis right up to date alongside RA."

He said that up to one-third of people with psoriasis will develop psoriatic arthritis, "so it’s not an insignificant arthritis. It’s often not recognized. One survey we did of people with psoriasis in the community in the U.K. found that up to half of the people with psoriatic arthritis didn’t know they had it. They’d seen their doctor for various reasons and had been told they’d had another form of arthritis, or they were fobbed off with other diagnoses."

The researchers have yet to perform a cost analysis comparing the two treatment groups.

The study was funded by Arthritis Research UK and Pfizer. Dr. Helliwell disclosed that he has received consulting fees from Pfizer.

[email protected]

*Correction 11/11/13: A previous version of this story misstated the methotrexate dosage used in the study. This version has been updated to reflect the correct dosage.