Beyond the Plenary Sessions and scientific abstract presentations, there were many exciting events in which to participate and presentations to attend throughout the Vascular Annual Meeting, including sessions especially planned for residents and students. These photos capture some of the action:

©Martin Allred

©Martin Allred

©Martin Allred

©Martin Allred

Beyond the Plenary Sessions and scientific abstract presentations, there were many exciting events in which to participate and presentations to attend throughout the Vascular Annual Meeting, including sessions especially planned for residents and students. These photos capture some of the action:

©Martin Allred

©Martin Allred

©Martin Allred

©Martin Allred

Beyond the Plenary Sessions and scientific abstract presentations, there were many exciting events in which to participate and presentations to attend throughout the Vascular Annual Meeting, including sessions especially planned for residents and students. These photos capture some of the action:

©Martin Allred

©Martin Allred

©Martin Allred

©Martin Allred

LONDON – Tobacco use and excess weight can make it harder to achieve sustained remission in the treatment of early rheumatoid arthritis, according to findings from more than 1,000 patients in the Canadian Early Arthritis Cohort (CATCH) multicenter, prospective study.

Aggressive treatment that starts soon after diagnosis of rheumatoid arthritis (RA) is important for the absence of disease activity, which is the hallmark of sustained remission. But the reality is a success rate of less than 50% in the first 3 years with physical deterioration continuing thereafter. “Excess weight and smoking are two risk factors for developing RA. We were interested in seeing if they might also affect how well people responded to treatment,” said Susan Bartlett, Ph.D., a clinical psychologist at McGill University in Montreal.

At the annual European Congress of Rheumatology, Dr. Bartlett and colleagues reported on a cohort of 1,008 early RA patients who were enrolled in the Canadian Early Arthritis Cohort (CATCH) multicenter, prospective study and followed from around the time of diagnosis through the first 3 years of treatment to estimate the time it took until they achieved sustained remission, defined as having a 28-joint Disease Activity Score less than 2.6 for two consecutive visits.

Mean age of the patients (72% female, 81% white) was early 50s. Overall, 30% of females and 47% of males were overweight, one-third of both genders were obese, and 15%-20% smoked. Treatment at entry included methotrexate in mono- or combination therapy in about three-quarters of the patients, with steroids used in about half and biologics used sparingly.

The proportion of patients in sustained remission was 38% at 3 years, with a median time to remission of 11.3 months. “That finding wasn’t surprising because that is generally what is found in most studies of early RA. However, when we looked more closely at who was and wasn’t achieving remission, we found that people who smoked and those who were overweight or obese were much less likely than their nonsmoking, normal-weight peers to be in sustained remission,” Dr. Bartlett said in a pre-congress interview.

After adjustment for factors that could affect response to treatment – including age, race, disability status, pain, and early medications used – smoking (P = .046) and excess weight (P = .003) were associated with a poorer likelihood of achieving sustained remission. While more men than women were overweight or obese, the effects of weight and smoking appeared to be more problematic for women (P = .02).

An average nonsmoking male with a healthy body mass index (BMI; 25 kg/m² or less) had about a 41% probability of achieving sustained remission within 3 years, compared with 15% for an obese male smoker. A nonsmoking female with a healthy BMI had a 27% probability of achieving sustained remission within 3 years, compared with 10% for an obese female smoker. Probabilities of sustained remission were also lower for overweight men and women, Dr. Bartlett reported.

Smoking and obesity have already been linked with an increased likelihood of developing RA, which in turn increases the risk of cardiovascular disease and premature death. The latest data suggest that both smoking and extra weight – including overweight and obese as defined by BMI – may also independently influence the success of treatment. “Our data suggest that if you have RA, it’s important to take the medications that your doctor has prescribed. If you smoke, you need to stop. And if you’re carrying extra weight, not only is that placing a greater demand on already vulnerable joints, it may also be making your RA treatment less effective,” Dr. Bartlett said.

These lifestyle modifications can be challenging for some people with RA, she said in the interview. Clinicians can help by considering lifestyle behaviors that lead to chronic diseases and poorer outcomes in addition to their more traditional view of diagnosis and treatment, she said, adding that patients and clinicians should know that even a small amount of weight loss can improve health and may improve response to therapy.

Well controlled clinical trials will be needed to better understand the benefits of weight control and smoking cessation on response to RA treatment. Also, why women who smoke and are overweight are at more of a disadvantage than their male counterparts is unknown. “As we begin putting these pieces together, we may learn valuable information that helps us to better control and ultimately cure RA,” said Dr. Bartlett.

The researchers had no conflicts of interest to declare.

LONDON – Tobacco use and excess weight can make it harder to achieve sustained remission in the treatment of early rheumatoid arthritis, according to findings from more than 1,000 patients in the Canadian Early Arthritis Cohort (CATCH) multicenter, prospective study.

Aggressive treatment that starts soon after diagnosis of rheumatoid arthritis (RA) is important for the absence of disease activity, which is the hallmark of sustained remission. But the reality is a success rate of less than 50% in the first 3 years with physical deterioration continuing thereafter. “Excess weight and smoking are two risk factors for developing RA. We were interested in seeing if they might also affect how well people responded to treatment,” said Susan Bartlett, Ph.D., a clinical psychologist at McGill University in Montreal.

At the annual European Congress of Rheumatology, Dr. Bartlett and colleagues reported on a cohort of 1,008 early RA patients who were enrolled in the Canadian Early Arthritis Cohort (CATCH) multicenter, prospective study and followed from around the time of diagnosis through the first 3 years of treatment to estimate the time it took until they achieved sustained remission, defined as having a 28-joint Disease Activity Score less than 2.6 for two consecutive visits.

Mean age of the patients (72% female, 81% white) was early 50s. Overall, 30% of females and 47% of males were overweight, one-third of both genders were obese, and 15%-20% smoked. Treatment at entry included methotrexate in mono- or combination therapy in about three-quarters of the patients, with steroids used in about half and biologics used sparingly.

The proportion of patients in sustained remission was 38% at 3 years, with a median time to remission of 11.3 months. “That finding wasn’t surprising because that is generally what is found in most studies of early RA. However, when we looked more closely at who was and wasn’t achieving remission, we found that people who smoked and those who were overweight or obese were much less likely than their nonsmoking, normal-weight peers to be in sustained remission,” Dr. Bartlett said in a pre-congress interview.

After adjustment for factors that could affect response to treatment – including age, race, disability status, pain, and early medications used – smoking (P = .046) and excess weight (P = .003) were associated with a poorer likelihood of achieving sustained remission. While more men than women were overweight or obese, the effects of weight and smoking appeared to be more problematic for women (P = .02).

An average nonsmoking male with a healthy body mass index (BMI; 25 kg/m² or less) had about a 41% probability of achieving sustained remission within 3 years, compared with 15% for an obese male smoker. A nonsmoking female with a healthy BMI had a 27% probability of achieving sustained remission within 3 years, compared with 10% for an obese female smoker. Probabilities of sustained remission were also lower for overweight men and women, Dr. Bartlett reported.

Smoking and obesity have already been linked with an increased likelihood of developing RA, which in turn increases the risk of cardiovascular disease and premature death. The latest data suggest that both smoking and extra weight – including overweight and obese as defined by BMI – may also independently influence the success of treatment. “Our data suggest that if you have RA, it’s important to take the medications that your doctor has prescribed. If you smoke, you need to stop. And if you’re carrying extra weight, not only is that placing a greater demand on already vulnerable joints, it may also be making your RA treatment less effective,” Dr. Bartlett said.

These lifestyle modifications can be challenging for some people with RA, she said in the interview. Clinicians can help by considering lifestyle behaviors that lead to chronic diseases and poorer outcomes in addition to their more traditional view of diagnosis and treatment, she said, adding that patients and clinicians should know that even a small amount of weight loss can improve health and may improve response to therapy.

Well controlled clinical trials will be needed to better understand the benefits of weight control and smoking cessation on response to RA treatment. Also, why women who smoke and are overweight are at more of a disadvantage than their male counterparts is unknown. “As we begin putting these pieces together, we may learn valuable information that helps us to better control and ultimately cure RA,” said Dr. Bartlett.

The researchers had no conflicts of interest to declare.

LONDON – Tobacco use and excess weight can make it harder to achieve sustained remission in the treatment of early rheumatoid arthritis, according to findings from more than 1,000 patients in the Canadian Early Arthritis Cohort (CATCH) multicenter, prospective study.

Aggressive treatment that starts soon after diagnosis of rheumatoid arthritis (RA) is important for the absence of disease activity, which is the hallmark of sustained remission. But the reality is a success rate of less than 50% in the first 3 years with physical deterioration continuing thereafter. “Excess weight and smoking are two risk factors for developing RA. We were interested in seeing if they might also affect how well people responded to treatment,” said Susan Bartlett, Ph.D., a clinical psychologist at McGill University in Montreal.

At the annual European Congress of Rheumatology, Dr. Bartlett and colleagues reported on a cohort of 1,008 early RA patients who were enrolled in the Canadian Early Arthritis Cohort (CATCH) multicenter, prospective study and followed from around the time of diagnosis through the first 3 years of treatment to estimate the time it took until they achieved sustained remission, defined as having a 28-joint Disease Activity Score less than 2.6 for two consecutive visits.

Mean age of the patients (72% female, 81% white) was early 50s. Overall, 30% of females and 47% of males were overweight, one-third of both genders were obese, and 15%-20% smoked. Treatment at entry included methotrexate in mono- or combination therapy in about three-quarters of the patients, with steroids used in about half and biologics used sparingly.

The proportion of patients in sustained remission was 38% at 3 years, with a median time to remission of 11.3 months. “That finding wasn’t surprising because that is generally what is found in most studies of early RA. However, when we looked more closely at who was and wasn’t achieving remission, we found that people who smoked and those who were overweight or obese were much less likely than their nonsmoking, normal-weight peers to be in sustained remission,” Dr. Bartlett said in a pre-congress interview.

After adjustment for factors that could affect response to treatment – including age, race, disability status, pain, and early medications used – smoking (P = .046) and excess weight (P = .003) were associated with a poorer likelihood of achieving sustained remission. While more men than women were overweight or obese, the effects of weight and smoking appeared to be more problematic for women (P = .02).

An average nonsmoking male with a healthy body mass index (BMI; 25 kg/m² or less) had about a 41% probability of achieving sustained remission within 3 years, compared with 15% for an obese male smoker. A nonsmoking female with a healthy BMI had a 27% probability of achieving sustained remission within 3 years, compared with 10% for an obese female smoker. Probabilities of sustained remission were also lower for overweight men and women, Dr. Bartlett reported.

Smoking and obesity have already been linked with an increased likelihood of developing RA, which in turn increases the risk of cardiovascular disease and premature death. The latest data suggest that both smoking and extra weight – including overweight and obese as defined by BMI – may also independently influence the success of treatment. “Our data suggest that if you have RA, it’s important to take the medications that your doctor has prescribed. If you smoke, you need to stop. And if you’re carrying extra weight, not only is that placing a greater demand on already vulnerable joints, it may also be making your RA treatment less effective,” Dr. Bartlett said.

These lifestyle modifications can be challenging for some people with RA, she said in the interview. Clinicians can help by considering lifestyle behaviors that lead to chronic diseases and poorer outcomes in addition to their more traditional view of diagnosis and treatment, she said, adding that patients and clinicians should know that even a small amount of weight loss can improve health and may improve response to therapy.

Well controlled clinical trials will be needed to better understand the benefits of weight control and smoking cessation on response to RA treatment. Also, why women who smoke and are overweight are at more of a disadvantage than their male counterparts is unknown. “As we begin putting these pieces together, we may learn valuable information that helps us to better control and ultimately cure RA,” said Dr. Bartlett.

The researchers had no conflicts of interest to declare.

NATIONAL HARBOR, MD. – The approved once-daily oral immunomodulator teriflunomide is effective in reducing relapse, and worsening of relapsing forms, of multiple sclerosis (RMS) in patients with faster-advancing disease.

The findings from a post hoc pooled subgroup analysis of patients in the TEMSO and TOWER randomized, double-blind, placebo-controlled phase III trials presented as a poster at the annual meeting of the Consortium of Multiple Sclerosis Centers expand the efficacy of teriflunomide to a broad spectrum of patients with RMS.

The pooled analysis examined the outcomes of treatment with two doses of teriflunomide in all patients (n = 2,257) and in a subgroup of patients with faster-advancing MS (n = 1,184) according to disease severity using a baseline Multiple Sclerosis Severity Score (MSSS) of 5 as a cutoff. The group with faster-advancing disease included 405 who received placebo, 396 treated with teriflunomide 7 mg, and 383 treated with teriflunomide 14 mg.

The 1,184 patients with faster-advancing MS were comparable to the other 1,073 patients in terms of age, sex, MS subtype, and number of relapses in the prior year. Baseline characteristics of the faster-advancing MS patients treated with placebo and both teriflunomide doses were comparable.

Relative to the placebo group, the annualized relapse rate in patients with faster-advancing MS was significantly reduced by both doses of teriflunomide, with a relative risk reduction of 30.3% for the 7-mg dose (P = .0002) and 37.5% for the 14-mg dose (P less than .0001). Time to first relapse was also reduced by teriflunomide 14 mg and 7 mg, with reductions in relapse risk of 43.2% (P less than .0001) and 28.8% (P = .0014), respectively, compared with placebo.

The higher dose of teriflunomide was effective in reducing the worsening of disability at greater than or equal to 12 weeks and 24 weeks, with reductions, compared with placebo, of 40.3% (P = .0076) and 46.1% (P = .0110), respectively.

The results were consistent with data reported in the individual TEMSO and TOWER trials, and prior analyses of the pooled data.

“These results indicate that teriflunomide is not only effective for MS patients with relatively mild disease, but also with rather more aggressive disease. Teriflunomide, a well-tolerated and convenient once-daily tablet, is a very reasonable option for this population,” said the presenter, Dr. Aaron E. Miller of the Icahn School of Medicine at Mount Sinai, New York.

Teriflunomide is approved for relapsing-remitting MS in many countries, including the United States and the European Union. The TEMSO and TOWER trials were pivotal in securing approval. The trials had a similar design, except for the absence of magnetic resonance imaging evaluation in TOWER.

The study was funded by Sanofi Genzyme. Dr. Miller disclosed consulting fees from Accordant Health Services, Acorda Therapeutics, Alkermes, Biogen, EMD Serono, Genentech, Genzyme, GlaxoSmithKline, Mallinckrodt Paharmaceuticals/Questor, Novartis, Roche, and Teva, and grant/research support from Biogen, Genentech, Novartis, Questor, Roche, and Sanofi.

NATIONAL HARBOR, MD. – The approved once-daily oral immunomodulator teriflunomide is effective in reducing relapse, and worsening of relapsing forms, of multiple sclerosis (RMS) in patients with faster-advancing disease.

The findings from a post hoc pooled subgroup analysis of patients in the TEMSO and TOWER randomized, double-blind, placebo-controlled phase III trials presented as a poster at the annual meeting of the Consortium of Multiple Sclerosis Centers expand the efficacy of teriflunomide to a broad spectrum of patients with RMS.

The pooled analysis examined the outcomes of treatment with two doses of teriflunomide in all patients (n = 2,257) and in a subgroup of patients with faster-advancing MS (n = 1,184) according to disease severity using a baseline Multiple Sclerosis Severity Score (MSSS) of 5 as a cutoff. The group with faster-advancing disease included 405 who received placebo, 396 treated with teriflunomide 7 mg, and 383 treated with teriflunomide 14 mg.

The 1,184 patients with faster-advancing MS were comparable to the other 1,073 patients in terms of age, sex, MS subtype, and number of relapses in the prior year. Baseline characteristics of the faster-advancing MS patients treated with placebo and both teriflunomide doses were comparable.

Relative to the placebo group, the annualized relapse rate in patients with faster-advancing MS was significantly reduced by both doses of teriflunomide, with a relative risk reduction of 30.3% for the 7-mg dose (P = .0002) and 37.5% for the 14-mg dose (P less than .0001). Time to first relapse was also reduced by teriflunomide 14 mg and 7 mg, with reductions in relapse risk of 43.2% (P less than .0001) and 28.8% (P = .0014), respectively, compared with placebo.

The higher dose of teriflunomide was effective in reducing the worsening of disability at greater than or equal to 12 weeks and 24 weeks, with reductions, compared with placebo, of 40.3% (P = .0076) and 46.1% (P = .0110), respectively.

The results were consistent with data reported in the individual TEMSO and TOWER trials, and prior analyses of the pooled data.

“These results indicate that teriflunomide is not only effective for MS patients with relatively mild disease, but also with rather more aggressive disease. Teriflunomide, a well-tolerated and convenient once-daily tablet, is a very reasonable option for this population,” said the presenter, Dr. Aaron E. Miller of the Icahn School of Medicine at Mount Sinai, New York.

Teriflunomide is approved for relapsing-remitting MS in many countries, including the United States and the European Union. The TEMSO and TOWER trials were pivotal in securing approval. The trials had a similar design, except for the absence of magnetic resonance imaging evaluation in TOWER.

The study was funded by Sanofi Genzyme. Dr. Miller disclosed consulting fees from Accordant Health Services, Acorda Therapeutics, Alkermes, Biogen, EMD Serono, Genentech, Genzyme, GlaxoSmithKline, Mallinckrodt Paharmaceuticals/Questor, Novartis, Roche, and Teva, and grant/research support from Biogen, Genentech, Novartis, Questor, Roche, and Sanofi.

NATIONAL HARBOR, MD. – The approved once-daily oral immunomodulator teriflunomide is effective in reducing relapse, and worsening of relapsing forms, of multiple sclerosis (RMS) in patients with faster-advancing disease.

The findings from a post hoc pooled subgroup analysis of patients in the TEMSO and TOWER randomized, double-blind, placebo-controlled phase III trials presented as a poster at the annual meeting of the Consortium of Multiple Sclerosis Centers expand the efficacy of teriflunomide to a broad spectrum of patients with RMS.

The pooled analysis examined the outcomes of treatment with two doses of teriflunomide in all patients (n = 2,257) and in a subgroup of patients with faster-advancing MS (n = 1,184) according to disease severity using a baseline Multiple Sclerosis Severity Score (MSSS) of 5 as a cutoff. The group with faster-advancing disease included 405 who received placebo, 396 treated with teriflunomide 7 mg, and 383 treated with teriflunomide 14 mg.

The 1,184 patients with faster-advancing MS were comparable to the other 1,073 patients in terms of age, sex, MS subtype, and number of relapses in the prior year. Baseline characteristics of the faster-advancing MS patients treated with placebo and both teriflunomide doses were comparable.

Relative to the placebo group, the annualized relapse rate in patients with faster-advancing MS was significantly reduced by both doses of teriflunomide, with a relative risk reduction of 30.3% for the 7-mg dose (P = .0002) and 37.5% for the 14-mg dose (P less than .0001). Time to first relapse was also reduced by teriflunomide 14 mg and 7 mg, with reductions in relapse risk of 43.2% (P less than .0001) and 28.8% (P = .0014), respectively, compared with placebo.

The higher dose of teriflunomide was effective in reducing the worsening of disability at greater than or equal to 12 weeks and 24 weeks, with reductions, compared with placebo, of 40.3% (P = .0076) and 46.1% (P = .0110), respectively.

The results were consistent with data reported in the individual TEMSO and TOWER trials, and prior analyses of the pooled data.

“These results indicate that teriflunomide is not only effective for MS patients with relatively mild disease, but also with rather more aggressive disease. Teriflunomide, a well-tolerated and convenient once-daily tablet, is a very reasonable option for this population,” said the presenter, Dr. Aaron E. Miller of the Icahn School of Medicine at Mount Sinai, New York.

Teriflunomide is approved for relapsing-remitting MS in many countries, including the United States and the European Union. The TEMSO and TOWER trials were pivotal in securing approval. The trials had a similar design, except for the absence of magnetic resonance imaging evaluation in TOWER.

The study was funded by Sanofi Genzyme. Dr. Miller disclosed consulting fees from Accordant Health Services, Acorda Therapeutics, Alkermes, Biogen, EMD Serono, Genentech, Genzyme, GlaxoSmithKline, Mallinckrodt Paharmaceuticals/Questor, Novartis, Roche, and Teva, and grant/research support from Biogen, Genentech, Novartis, Questor, Roche, and Sanofi.

LONDON – The prevalence of gout is increasing and to prevent an epidemic, rheumatologists and other physicians need to diagnose and treat cases promptly and better explain the treatment process to their patients, according to a Swedish expert on the disease.

“It’s a disease for which we understand the mechanisms, we know how to diagnose it, and we have had good treatments for the last 50 years,” said Dr. Lennart Jacobsson, professor of rheumatology at the University of Gothenburg in Sweden. “Despite that, we don’t treat it properly. It’s difficult to understand why that is the case, why there is such a lack of knowledge and such a lack of willingness to pursue treatment.”

Gout is the most common nondegenerative inflammatory joint disease, exemplified by a prevalence of 0.9%-2.5% in Europe and 3.9% in the United States. The incidence is increasing along with factors such as the aging population, as well as lifestyle changes such as rising body mass index and physical inactivity, Dr. Jacobsson said at the European Congress of Rheumatology.

“It’s the same story everywhere,” he said. “Gout is underdiagnosed, it’s diagnosed late, and once it’s diagnosed people don’t get treated with urate-lowering therapy, which aims at the heart of the disease. If they are treated, treatment often is discontinued, which we think is largely due to lack of education and information to patients.”

Urate crystals can build up over as much as a decade before a person experiences a first gout attack, Dr. Jacobsson said. “It can take 3-5 years of effective treatment to get rid of those masses within the body. Over that time, especially at the beginning, patients may still have gout attacks, which they often interpret as side effects of the medication or a misinterpretation that it doesn’t work because they’re not properly informed that medication needs to be a long-term treatment.”

Close to 10% of men aged 70-80 years have gout, he said, but it’s still unclear how many of those have mild, moderate, or severe disease. It’s also not well studied how gout itself can affect health-related quality of life and costs to society. “You can easily imagine that the costs are pretty large, however, and they will increase,” he said.

Gout is interrelated with several metabolic syndrome disorders such as obesity, hypertension, and diabetes, Dr. Jacobsson said: “If you have renal disease, you have higher uric acid levels and can more easily get gout, but from having high uric acid levels you may also get decreased renal function, so it’s sort of circular. The same is true of gout and hypertension.”

Once considered a disease of the wealthy, Dr. Jacobsson said, gout has recently been shown to be associated with lower income and socioeconomic class, as is the case for many other chronic diseases. There are still large opportunities for improvements regarding early detection and the initiation of urate-lowering therapy, he said, as well as counseling patients on lifestyle improvements.

“We know what to do, we have the tools, and we should start using them more effectively,” he said. “It’s really very simple, but that message has to get through. It’s an increasing problem, and it’s bad not just for the joints but also for quality of life and comorbidities.”

Dr. Jacobsson reported no relevant financial disclosures.

LONDON – The prevalence of gout is increasing and to prevent an epidemic, rheumatologists and other physicians need to diagnose and treat cases promptly and better explain the treatment process to their patients, according to a Swedish expert on the disease.

“It’s a disease for which we understand the mechanisms, we know how to diagnose it, and we have had good treatments for the last 50 years,” said Dr. Lennart Jacobsson, professor of rheumatology at the University of Gothenburg in Sweden. “Despite that, we don’t treat it properly. It’s difficult to understand why that is the case, why there is such a lack of knowledge and such a lack of willingness to pursue treatment.”

Gout is the most common nondegenerative inflammatory joint disease, exemplified by a prevalence of 0.9%-2.5% in Europe and 3.9% in the United States. The incidence is increasing along with factors such as the aging population, as well as lifestyle changes such as rising body mass index and physical inactivity, Dr. Jacobsson said at the European Congress of Rheumatology.

“It’s the same story everywhere,” he said. “Gout is underdiagnosed, it’s diagnosed late, and once it’s diagnosed people don’t get treated with urate-lowering therapy, which aims at the heart of the disease. If they are treated, treatment often is discontinued, which we think is largely due to lack of education and information to patients.”

Urate crystals can build up over as much as a decade before a person experiences a first gout attack, Dr. Jacobsson said. “It can take 3-5 years of effective treatment to get rid of those masses within the body. Over that time, especially at the beginning, patients may still have gout attacks, which they often interpret as side effects of the medication or a misinterpretation that it doesn’t work because they’re not properly informed that medication needs to be a long-term treatment.”

Close to 10% of men aged 70-80 years have gout, he said, but it’s still unclear how many of those have mild, moderate, or severe disease. It’s also not well studied how gout itself can affect health-related quality of life and costs to society. “You can easily imagine that the costs are pretty large, however, and they will increase,” he said.

Gout is interrelated with several metabolic syndrome disorders such as obesity, hypertension, and diabetes, Dr. Jacobsson said: “If you have renal disease, you have higher uric acid levels and can more easily get gout, but from having high uric acid levels you may also get decreased renal function, so it’s sort of circular. The same is true of gout and hypertension.”

Once considered a disease of the wealthy, Dr. Jacobsson said, gout has recently been shown to be associated with lower income and socioeconomic class, as is the case for many other chronic diseases. There are still large opportunities for improvements regarding early detection and the initiation of urate-lowering therapy, he said, as well as counseling patients on lifestyle improvements.

“We know what to do, we have the tools, and we should start using them more effectively,” he said. “It’s really very simple, but that message has to get through. It’s an increasing problem, and it’s bad not just for the joints but also for quality of life and comorbidities.”

Dr. Jacobsson reported no relevant financial disclosures.

LONDON – The prevalence of gout is increasing and to prevent an epidemic, rheumatologists and other physicians need to diagnose and treat cases promptly and better explain the treatment process to their patients, according to a Swedish expert on the disease.

“It’s a disease for which we understand the mechanisms, we know how to diagnose it, and we have had good treatments for the last 50 years,” said Dr. Lennart Jacobsson, professor of rheumatology at the University of Gothenburg in Sweden. “Despite that, we don’t treat it properly. It’s difficult to understand why that is the case, why there is such a lack of knowledge and such a lack of willingness to pursue treatment.”

Gout is the most common nondegenerative inflammatory joint disease, exemplified by a prevalence of 0.9%-2.5% in Europe and 3.9% in the United States. The incidence is increasing along with factors such as the aging population, as well as lifestyle changes such as rising body mass index and physical inactivity, Dr. Jacobsson said at the European Congress of Rheumatology.

“It’s the same story everywhere,” he said. “Gout is underdiagnosed, it’s diagnosed late, and once it’s diagnosed people don’t get treated with urate-lowering therapy, which aims at the heart of the disease. If they are treated, treatment often is discontinued, which we think is largely due to lack of education and information to patients.”

Urate crystals can build up over as much as a decade before a person experiences a first gout attack, Dr. Jacobsson said. “It can take 3-5 years of effective treatment to get rid of those masses within the body. Over that time, especially at the beginning, patients may still have gout attacks, which they often interpret as side effects of the medication or a misinterpretation that it doesn’t work because they’re not properly informed that medication needs to be a long-term treatment.”

Close to 10% of men aged 70-80 years have gout, he said, but it’s still unclear how many of those have mild, moderate, or severe disease. It’s also not well studied how gout itself can affect health-related quality of life and costs to society. “You can easily imagine that the costs are pretty large, however, and they will increase,” he said.

Gout is interrelated with several metabolic syndrome disorders such as obesity, hypertension, and diabetes, Dr. Jacobsson said: “If you have renal disease, you have higher uric acid levels and can more easily get gout, but from having high uric acid levels you may also get decreased renal function, so it’s sort of circular. The same is true of gout and hypertension.”

Once considered a disease of the wealthy, Dr. Jacobsson said, gout has recently been shown to be associated with lower income and socioeconomic class, as is the case for many other chronic diseases. There are still large opportunities for improvements regarding early detection and the initiation of urate-lowering therapy, he said, as well as counseling patients on lifestyle improvements.

“We know what to do, we have the tools, and we should start using them more effectively,” he said. “It’s really very simple, but that message has to get through. It’s an increasing problem, and it’s bad not just for the joints but also for quality of life and comorbidities.”

Dr. Jacobsson reported no relevant financial disclosures.

SAN FRANCISCO – Adding left atrial appendage excision to pulmonary vein isolation does not reduce the rate of recurrence in persistent atrial fibrillation, according to a Russian investigation.

Eighty-eight patients with persistent atrial fibrillation (AF) were randomized to thoracoscopic pulmonary vein isolation (PVI) with bilateral epicardial ganglia ablation and box lesion set of the posterior left atrial wall; 88 others were randomized to that approach plus left atrial appendage (LAA) amputation. After 18 months, 64 out of 87 patients in the LAA-excision group (73.6%) and 61 out of 86 patients (70.9%) in the control group were free from recurrent AF, meaning no episodes greater than 30 seconds (P = .73). Freedom from any atrial arrhythmia after a single procedure with or without follow-up antiarrhythmic drugs (AADs) was also similar, with 70.9% in the control and 74.7% in the treatment groups. “Both approaches had excellent” results with no differences in complication rates, but there “was no reduction in AF recurrence when LAA excision was performed,” said investigator Dr. Alexander Romanov of the State Research Institute of Circulation Pathology, Novosibirsk, Russia.

The results are a bit surprising because some previous studies have suggested that electrical isolation of the LAA improves AF ablation success, and surgical excision might be expected to have a similar effect. In many places in the United States, LAA excisions are routine in open heart surgery when patients have AF, to prevent stroke. Guidelines for AF management from the American Heart Association, American College of Cardiology, and Heart Rhythm Society published in 2014 give a class IIb recommendation, saying “surgical excision of the left atrial appendage may be considered in patients undergoing cardiac surgery,” with an evidence level of C, meaning there are no data to support the recommendation, only expert consensus (J Am Coll Cardiol. 2014;64[21]:2246-80).

There were no significant differences between the groups; patients were about 60 years old, on average, and more than 80% in both groups had baseline CHADS₂ scores of 0 or 1. All patients had persistent AF for more than a week but no longer than a year; longer-standing cases were excluded, as were patients with prior heart surgeries or catheter ablations. There were no statistically significant differences in operative times or complications. A few patients in each arm needed sternotomies for hemostasis, and one in each arm had a stroke during follow-up. Patients were followed at regular intervals by ECG and Holter monitoring.

AADs were allowed during the blanking period; patients could continue them afterwards for AF recurrence or have endocardial redo ablations; 10 patients in the control group (12%) and 13 in the LAA group (15%) had repeat procedures (P = .55). Most were for right atrial flutter and a few for left atrial flutter. “Only one redo case was for true AF recurrence,” Dr. Romanov said.

The team did not test for exertion intolerance and other potential LAA excision problems.

Dr. Romanov is a speaker for Medtronic, Biosense Webster, and Boston Scientific.

[email protected]

SAN FRANCISCO – Adding left atrial appendage excision to pulmonary vein isolation does not reduce the rate of recurrence in persistent atrial fibrillation, according to a Russian investigation.

Eighty-eight patients with persistent atrial fibrillation (AF) were randomized to thoracoscopic pulmonary vein isolation (PVI) with bilateral epicardial ganglia ablation and box lesion set of the posterior left atrial wall; 88 others were randomized to that approach plus left atrial appendage (LAA) amputation. After 18 months, 64 out of 87 patients in the LAA-excision group (73.6%) and 61 out of 86 patients (70.9%) in the control group were free from recurrent AF, meaning no episodes greater than 30 seconds (P = .73). Freedom from any atrial arrhythmia after a single procedure with or without follow-up antiarrhythmic drugs (AADs) was also similar, with 70.9% in the control and 74.7% in the treatment groups. “Both approaches had excellent” results with no differences in complication rates, but there “was no reduction in AF recurrence when LAA excision was performed,” said investigator Dr. Alexander Romanov of the State Research Institute of Circulation Pathology, Novosibirsk, Russia.

The results are a bit surprising because some previous studies have suggested that electrical isolation of the LAA improves AF ablation success, and surgical excision might be expected to have a similar effect. In many places in the United States, LAA excisions are routine in open heart surgery when patients have AF, to prevent stroke. Guidelines for AF management from the American Heart Association, American College of Cardiology, and Heart Rhythm Society published in 2014 give a class IIb recommendation, saying “surgical excision of the left atrial appendage may be considered in patients undergoing cardiac surgery,” with an evidence level of C, meaning there are no data to support the recommendation, only expert consensus (J Am Coll Cardiol. 2014;64[21]:2246-80).

There were no significant differences between the groups; patients were about 60 years old, on average, and more than 80% in both groups had baseline CHADS₂ scores of 0 or 1. All patients had persistent AF for more than a week but no longer than a year; longer-standing cases were excluded, as were patients with prior heart surgeries or catheter ablations. There were no statistically significant differences in operative times or complications. A few patients in each arm needed sternotomies for hemostasis, and one in each arm had a stroke during follow-up. Patients were followed at regular intervals by ECG and Holter monitoring.

AADs were allowed during the blanking period; patients could continue them afterwards for AF recurrence or have endocardial redo ablations; 10 patients in the control group (12%) and 13 in the LAA group (15%) had repeat procedures (P = .55). Most were for right atrial flutter and a few for left atrial flutter. “Only one redo case was for true AF recurrence,” Dr. Romanov said.

The team did not test for exertion intolerance and other potential LAA excision problems.

Dr. Romanov is a speaker for Medtronic, Biosense Webster, and Boston Scientific.

[email protected]

SAN FRANCISCO – Adding left atrial appendage excision to pulmonary vein isolation does not reduce the rate of recurrence in persistent atrial fibrillation, according to a Russian investigation.

Eighty-eight patients with persistent atrial fibrillation (AF) were randomized to thoracoscopic pulmonary vein isolation (PVI) with bilateral epicardial ganglia ablation and box lesion set of the posterior left atrial wall; 88 others were randomized to that approach plus left atrial appendage (LAA) amputation. After 18 months, 64 out of 87 patients in the LAA-excision group (73.6%) and 61 out of 86 patients (70.9%) in the control group were free from recurrent AF, meaning no episodes greater than 30 seconds (P = .73). Freedom from any atrial arrhythmia after a single procedure with or without follow-up antiarrhythmic drugs (AADs) was also similar, with 70.9% in the control and 74.7% in the treatment groups. “Both approaches had excellent” results with no differences in complication rates, but there “was no reduction in AF recurrence when LAA excision was performed,” said investigator Dr. Alexander Romanov of the State Research Institute of Circulation Pathology, Novosibirsk, Russia.

The results are a bit surprising because some previous studies have suggested that electrical isolation of the LAA improves AF ablation success, and surgical excision might be expected to have a similar effect. In many places in the United States, LAA excisions are routine in open heart surgery when patients have AF, to prevent stroke. Guidelines for AF management from the American Heart Association, American College of Cardiology, and Heart Rhythm Society published in 2014 give a class IIb recommendation, saying “surgical excision of the left atrial appendage may be considered in patients undergoing cardiac surgery,” with an evidence level of C, meaning there are no data to support the recommendation, only expert consensus (J Am Coll Cardiol. 2014;64[21]:2246-80).

There were no significant differences between the groups; patients were about 60 years old, on average, and more than 80% in both groups had baseline CHADS₂ scores of 0 or 1. All patients had persistent AF for more than a week but no longer than a year; longer-standing cases were excluded, as were patients with prior heart surgeries or catheter ablations. There were no statistically significant differences in operative times or complications. A few patients in each arm needed sternotomies for hemostasis, and one in each arm had a stroke during follow-up. Patients were followed at regular intervals by ECG and Holter monitoring.

AADs were allowed during the blanking period; patients could continue them afterwards for AF recurrence or have endocardial redo ablations; 10 patients in the control group (12%) and 13 in the LAA group (15%) had repeat procedures (P = .55). Most were for right atrial flutter and a few for left atrial flutter. “Only one redo case was for true AF recurrence,” Dr. Romanov said.

The team did not test for exertion intolerance and other potential LAA excision problems.

Dr. Romanov is a speaker for Medtronic, Biosense Webster, and Boston Scientific.

[email protected]

CHICAGO – Adding the monoclonal anti-CD52 antibody alemtuzumab to CHOP (A-CHOP) increased response rates in elderly patients with peripheral T-cell lymphomas but did not improve their survival, based on the final results from 116 patients treated in the international ACT-2 phase III trial.

Complete responses were seen in 43% of 58 patients given CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and in 60% of 58 patients given A-CHOP in the trial. However, trial participants did not significantly differ in event-free survival and progression-free survival at 3 years.

Further, overall survival at 3 years was 38% for the patients given A-CHOP and 56% for the patients given CHOP. The poorer overall survival was mainly the result of treatment-related toxicity, Dr. Lorenz H. Trümper reported at the annual meeting of the American Society of Clinical Oncology.

The estimated 3-year disease-free survival is 25% for elderly patients with peripheral T-cell lymphomas. Previous phase II trials had indicated that alemtuzumab was active in primary and relapsed T-cell lymphoma, prompting the study of adjuvant alemtuzumab in combination with dose-dense CHOP-14 in patients with previously untreated peripheral T-cell lymphoma, he said.

Although the treatment protocol demanded stringent monitoring for cytomegalovirus and Epstein-Barr virus and anti-infective prophylaxis, there were more grade 3 or higher infections in the A-CHOP group (40%) than the CHOP group (21%). The higher infection rates were attributed to higher rates of grade 3/4 hematotoxicity in patients given A-CHOP. Grade 4 leukocytopenia was seen in 70% with A-CHOP and 54% with CHOP; grade 3/4 thrombocytopenia was seen in 19% given A-CHOP and 13% given CHOP, according to Dr. Trümper of the University of Göttingen, Germany.

For the study, 116 patients from 52 centers were randomized to receive either six cycles of CHOP or A-CHOP given at 14-day intervals with granulocyte-colony stimulating factor (G-CSF) support. Initially, patients received a total of 360 mg of alemtuzumab (90 mg given at each of the first four cycles of CHOP). After patient 39 was enrolled, the dose was reduced to 120 mg (30 mg given at each of the first four cycles of CHOP). Median patient age was 69 years, and 58% of the trial participants were men.

Treatment was completed as planned in 79% of the CHOP patients and in 57% of the A-CHOP patients.

The study was sponsored by the University of Göttingen. Dr. Trümper is a consultant or adviser to Hexal and Janssen-Ortho, and receives research funding from Genzyme, the maker of alemtuzumab (Lemtrada), as well as other drug companies.

Abstract 7500

[email protected]

On Twitter @maryjodales

CHICAGO – Adding the monoclonal anti-CD52 antibody alemtuzumab to CHOP (A-CHOP) increased response rates in elderly patients with peripheral T-cell lymphomas but did not improve their survival, based on the final results from 116 patients treated in the international ACT-2 phase III trial.

Complete responses were seen in 43% of 58 patients given CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and in 60% of 58 patients given A-CHOP in the trial. However, trial participants did not significantly differ in event-free survival and progression-free survival at 3 years.

Further, overall survival at 3 years was 38% for the patients given A-CHOP and 56% for the patients given CHOP. The poorer overall survival was mainly the result of treatment-related toxicity, Dr. Lorenz H. Trümper reported at the annual meeting of the American Society of Clinical Oncology.

The estimated 3-year disease-free survival is 25% for elderly patients with peripheral T-cell lymphomas. Previous phase II trials had indicated that alemtuzumab was active in primary and relapsed T-cell lymphoma, prompting the study of adjuvant alemtuzumab in combination with dose-dense CHOP-14 in patients with previously untreated peripheral T-cell lymphoma, he said.

Although the treatment protocol demanded stringent monitoring for cytomegalovirus and Epstein-Barr virus and anti-infective prophylaxis, there were more grade 3 or higher infections in the A-CHOP group (40%) than the CHOP group (21%). The higher infection rates were attributed to higher rates of grade 3/4 hematotoxicity in patients given A-CHOP. Grade 4 leukocytopenia was seen in 70% with A-CHOP and 54% with CHOP; grade 3/4 thrombocytopenia was seen in 19% given A-CHOP and 13% given CHOP, according to Dr. Trümper of the University of Göttingen, Germany.

For the study, 116 patients from 52 centers were randomized to receive either six cycles of CHOP or A-CHOP given at 14-day intervals with granulocyte-colony stimulating factor (G-CSF) support. Initially, patients received a total of 360 mg of alemtuzumab (90 mg given at each of the first four cycles of CHOP). After patient 39 was enrolled, the dose was reduced to 120 mg (30 mg given at each of the first four cycles of CHOP). Median patient age was 69 years, and 58% of the trial participants were men.

Treatment was completed as planned in 79% of the CHOP patients and in 57% of the A-CHOP patients.

The study was sponsored by the University of Göttingen. Dr. Trümper is a consultant or adviser to Hexal and Janssen-Ortho, and receives research funding from Genzyme, the maker of alemtuzumab (Lemtrada), as well as other drug companies.

Abstract 7500

[email protected]

On Twitter @maryjodales

CHICAGO – Adding the monoclonal anti-CD52 antibody alemtuzumab to CHOP (A-CHOP) increased response rates in elderly patients with peripheral T-cell lymphomas but did not improve their survival, based on the final results from 116 patients treated in the international ACT-2 phase III trial.

Complete responses were seen in 43% of 58 patients given CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and in 60% of 58 patients given A-CHOP in the trial. However, trial participants did not significantly differ in event-free survival and progression-free survival at 3 years.

Further, overall survival at 3 years was 38% for the patients given A-CHOP and 56% for the patients given CHOP. The poorer overall survival was mainly the result of treatment-related toxicity, Dr. Lorenz H. Trümper reported at the annual meeting of the American Society of Clinical Oncology.

The estimated 3-year disease-free survival is 25% for elderly patients with peripheral T-cell lymphomas. Previous phase II trials had indicated that alemtuzumab was active in primary and relapsed T-cell lymphoma, prompting the study of adjuvant alemtuzumab in combination with dose-dense CHOP-14 in patients with previously untreated peripheral T-cell lymphoma, he said.

Although the treatment protocol demanded stringent monitoring for cytomegalovirus and Epstein-Barr virus and anti-infective prophylaxis, there were more grade 3 or higher infections in the A-CHOP group (40%) than the CHOP group (21%). The higher infection rates were attributed to higher rates of grade 3/4 hematotoxicity in patients given A-CHOP. Grade 4 leukocytopenia was seen in 70% with A-CHOP and 54% with CHOP; grade 3/4 thrombocytopenia was seen in 19% given A-CHOP and 13% given CHOP, according to Dr. Trümper of the University of Göttingen, Germany.

For the study, 116 patients from 52 centers were randomized to receive either six cycles of CHOP or A-CHOP given at 14-day intervals with granulocyte-colony stimulating factor (G-CSF) support. Initially, patients received a total of 360 mg of alemtuzumab (90 mg given at each of the first four cycles of CHOP). After patient 39 was enrolled, the dose was reduced to 120 mg (30 mg given at each of the first four cycles of CHOP). Median patient age was 69 years, and 58% of the trial participants were men.

Treatment was completed as planned in 79% of the CHOP patients and in 57% of the A-CHOP patients.

The study was sponsored by the University of Göttingen. Dr. Trümper is a consultant or adviser to Hexal and Janssen-Ortho, and receives research funding from Genzyme, the maker of alemtuzumab (Lemtrada), as well as other drug companies.

Abstract 7500

[email protected]

On Twitter @maryjodales

LONDON – U.S. rheumatoid arthritis patients had a significantly reduced incidence of type 2 diabetes when on treatment with either hydroxychloroquine or abatacept in an analysis of more than 13,000 patients enrolled in a U.S. national registry during 2000-2015.

The same analysis also showed statistically significant increases in the risk for new-onset type 2 diabetes in rheumatoid arthritis (RA) patients treated with a glucocorticoid or a statin, Kaleb Michaud, Ph.D., reported in a poster at the European Congress of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

“Our findings can inform clinicians about determining appropriate treatment decisions in rheumatoid arthritis patients at increased risk for developing type 2 diabetes,” said Dr. Michaud, an epidemiologist at the University of Nebraska in Omaha and also codirector of the National Data Bank for Rheumatic Diseases in Wichita, Kan., the source of the data used in his study.

Hydroxychloroquine, a relatively inexpensive drug that’s often used in RA patients in combination with other drugs, might be a good agent to consider adding to the therapeutic mix of RA patients at risk for developing type 2 diabetes, he said in an interview. Although the implications of this finding for the use of abatacept (Orencia) are less clear, it is a signal of a novel benefit from the drug that merits further study, Dr. Michaud said.

The findings also suggest that, when rheumatoid arthritis patients receive statin treatment, they are candidates for more intensive monitoring of diabetes onset, he added.

His analysis focused on the 13,669 RA patients who participated in the National Data Bank for Rheumatic Diseases for at least a year during 2000-2015 and had not been diagnosed as having diabetes of any type at the time they entered the registry. During a median 4.6 years of follow-up, 1,139 patients either self-reported receiving a new diagnosis of type 2 diabetes or began treatment with a hypoglycemic medication. Patients averaged about 59 years old at the time they entered the registry, and about 80% were women.

Dr. Michaud and his associates assessed the incidence rate of type 2 diabetes according to six categories of RA treatment: methotrexate monotherapy, which they used as the reference group; any treatment with abatacept with or without methotrexate; any treatment with hydroxychloroquine; any treatment with a glucocorticoid; treatment with any other disease-modifying antirheumatic drug (DMARD) with methotrexate; and treatment with any other DMARD without methotrexate or no DMARD treatment. A seventh treatment category was treatment with a statin.

A series of time-varying Cox proportional hazard models that adjusted for sociodemographic variables, comorbidities, body mass index, and measures of RA severity showed that, when compared with methotrexate monotherapy, patients treated with abatacept had a statistically significant 48% reduced rate of developing diabetes, and those treated with hydroxychloroquine had a statistically significant 33% reduced diabetes incidence, they reported.

In contrast, compared with methotrexate monotherapy, treatment with a glucocorticoid linked with a statistically significant 31% increased rate of type 2 diabetes, and treatment with a statin linked with a statistically significant 56% increased rate of diabetes. Other forms of DMARD treatment, including tumor necrosis factor inhibitors and other biologic DMARDs, had no statistically significant link with diabetes development.

Dr. Michaud also reported additional analyses that further defined the associations between hydroxychloroquine treatment and reduced diabetes incidence: The reduction in diabetes incidence became statistically significant in patients only when they had received the drug for at least 2 years. The link with reduced diabetes incidence seemed dose dependent, with a stronger protective effect in patients who received at least 400 mg/day. Also, the strength of the protection waned in patients who had discontinued hydroxychloroquine for at least 6 months, and the protective effect completely disappeared once patients were off hydroxychloroquine for at least 1 year. Finally, the link between hydroxychloroquine use and reduced diabetes incidence also was statistically significant in patients who concurrently received a glucocorticoid, but a significant protective association disappeared in patients who received a statin as well as hydroxychloroquine.

Dr. Michaud had no disclosures. The study received no commercial support.

[email protected]

On Twitter @mitchelzoler

LONDON – U.S. rheumatoid arthritis patients had a significantly reduced incidence of type 2 diabetes when on treatment with either hydroxychloroquine or abatacept in an analysis of more than 13,000 patients enrolled in a U.S. national registry during 2000-2015.

The same analysis also showed statistically significant increases in the risk for new-onset type 2 diabetes in rheumatoid arthritis (RA) patients treated with a glucocorticoid or a statin, Kaleb Michaud, Ph.D., reported in a poster at the European Congress of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

“Our findings can inform clinicians about determining appropriate treatment decisions in rheumatoid arthritis patients at increased risk for developing type 2 diabetes,” said Dr. Michaud, an epidemiologist at the University of Nebraska in Omaha and also codirector of the National Data Bank for Rheumatic Diseases in Wichita, Kan., the source of the data used in his study.

Hydroxychloroquine, a relatively inexpensive drug that’s often used in RA patients in combination with other drugs, might be a good agent to consider adding to the therapeutic mix of RA patients at risk for developing type 2 diabetes, he said in an interview. Although the implications of this finding for the use of abatacept (Orencia) are less clear, it is a signal of a novel benefit from the drug that merits further study, Dr. Michaud said.

The findings also suggest that, when rheumatoid arthritis patients receive statin treatment, they are candidates for more intensive monitoring of diabetes onset, he added.

His analysis focused on the 13,669 RA patients who participated in the National Data Bank for Rheumatic Diseases for at least a year during 2000-2015 and had not been diagnosed as having diabetes of any type at the time they entered the registry. During a median 4.6 years of follow-up, 1,139 patients either self-reported receiving a new diagnosis of type 2 diabetes or began treatment with a hypoglycemic medication. Patients averaged about 59 years old at the time they entered the registry, and about 80% were women.

Dr. Michaud and his associates assessed the incidence rate of type 2 diabetes according to six categories of RA treatment: methotrexate monotherapy, which they used as the reference group; any treatment with abatacept with or without methotrexate; any treatment with hydroxychloroquine; any treatment with a glucocorticoid; treatment with any other disease-modifying antirheumatic drug (DMARD) with methotrexate; and treatment with any other DMARD without methotrexate or no DMARD treatment. A seventh treatment category was treatment with a statin.

A series of time-varying Cox proportional hazard models that adjusted for sociodemographic variables, comorbidities, body mass index, and measures of RA severity showed that, when compared with methotrexate monotherapy, patients treated with abatacept had a statistically significant 48% reduced rate of developing diabetes, and those treated with hydroxychloroquine had a statistically significant 33% reduced diabetes incidence, they reported.

In contrast, compared with methotrexate monotherapy, treatment with a glucocorticoid linked with a statistically significant 31% increased rate of type 2 diabetes, and treatment with a statin linked with a statistically significant 56% increased rate of diabetes. Other forms of DMARD treatment, including tumor necrosis factor inhibitors and other biologic DMARDs, had no statistically significant link with diabetes development.

Dr. Michaud also reported additional analyses that further defined the associations between hydroxychloroquine treatment and reduced diabetes incidence: The reduction in diabetes incidence became statistically significant in patients only when they had received the drug for at least 2 years. The link with reduced diabetes incidence seemed dose dependent, with a stronger protective effect in patients who received at least 400 mg/day. Also, the strength of the protection waned in patients who had discontinued hydroxychloroquine for at least 6 months, and the protective effect completely disappeared once patients were off hydroxychloroquine for at least 1 year. Finally, the link between hydroxychloroquine use and reduced diabetes incidence also was statistically significant in patients who concurrently received a glucocorticoid, but a significant protective association disappeared in patients who received a statin as well as hydroxychloroquine.

Dr. Michaud had no disclosures. The study received no commercial support.

[email protected]

On Twitter @mitchelzoler

LONDON – U.S. rheumatoid arthritis patients had a significantly reduced incidence of type 2 diabetes when on treatment with either hydroxychloroquine or abatacept in an analysis of more than 13,000 patients enrolled in a U.S. national registry during 2000-2015.

The same analysis also showed statistically significant increases in the risk for new-onset type 2 diabetes in rheumatoid arthritis (RA) patients treated with a glucocorticoid or a statin, Kaleb Michaud, Ph.D., reported in a poster at the European Congress of Rheumatology.

Mitchel L. Zoler/Frontline Medical News

“Our findings can inform clinicians about determining appropriate treatment decisions in rheumatoid arthritis patients at increased risk for developing type 2 diabetes,” said Dr. Michaud, an epidemiologist at the University of Nebraska in Omaha and also codirector of the National Data Bank for Rheumatic Diseases in Wichita, Kan., the source of the data used in his study.

Hydroxychloroquine, a relatively inexpensive drug that’s often used in RA patients in combination with other drugs, might be a good agent to consider adding to the therapeutic mix of RA patients at risk for developing type 2 diabetes, he said in an interview. Although the implications of this finding for the use of abatacept (Orencia) are less clear, it is a signal of a novel benefit from the drug that merits further study, Dr. Michaud said.

The findings also suggest that, when rheumatoid arthritis patients receive statin treatment, they are candidates for more intensive monitoring of diabetes onset, he added.

His analysis focused on the 13,669 RA patients who participated in the National Data Bank for Rheumatic Diseases for at least a year during 2000-2015 and had not been diagnosed as having diabetes of any type at the time they entered the registry. During a median 4.6 years of follow-up, 1,139 patients either self-reported receiving a new diagnosis of type 2 diabetes or began treatment with a hypoglycemic medication. Patients averaged about 59 years old at the time they entered the registry, and about 80% were women.

Dr. Michaud and his associates assessed the incidence rate of type 2 diabetes according to six categories of RA treatment: methotrexate monotherapy, which they used as the reference group; any treatment with abatacept with or without methotrexate; any treatment with hydroxychloroquine; any treatment with a glucocorticoid; treatment with any other disease-modifying antirheumatic drug (DMARD) with methotrexate; and treatment with any other DMARD without methotrexate or no DMARD treatment. A seventh treatment category was treatment with a statin.

A series of time-varying Cox proportional hazard models that adjusted for sociodemographic variables, comorbidities, body mass index, and measures of RA severity showed that, when compared with methotrexate monotherapy, patients treated with abatacept had a statistically significant 48% reduced rate of developing diabetes, and those treated with hydroxychloroquine had a statistically significant 33% reduced diabetes incidence, they reported.

In contrast, compared with methotrexate monotherapy, treatment with a glucocorticoid linked with a statistically significant 31% increased rate of type 2 diabetes, and treatment with a statin linked with a statistically significant 56% increased rate of diabetes. Other forms of DMARD treatment, including tumor necrosis factor inhibitors and other biologic DMARDs, had no statistically significant link with diabetes development.

Dr. Michaud also reported additional analyses that further defined the associations between hydroxychloroquine treatment and reduced diabetes incidence: The reduction in diabetes incidence became statistically significant in patients only when they had received the drug for at least 2 years. The link with reduced diabetes incidence seemed dose dependent, with a stronger protective effect in patients who received at least 400 mg/day. Also, the strength of the protection waned in patients who had discontinued hydroxychloroquine for at least 6 months, and the protective effect completely disappeared once patients were off hydroxychloroquine for at least 1 year. Finally, the link between hydroxychloroquine use and reduced diabetes incidence also was statistically significant in patients who concurrently received a glucocorticoid, but a significant protective association disappeared in patients who received a statin as well as hydroxychloroquine.

Dr. Michaud had no disclosures. The study received no commercial support.

[email protected]

On Twitter @mitchelzoler

CHICAGO – Adding concomitant and adjuvant temozolomide to a shorter course of radiotherapy (RT) for elderly patients with glioblastoma improves progression-free survival, according to a phase III study presented at the annual meeting of the American Society of Clinical Oncology.

Both patients with and without MGMT methylated promoters in their tumors benefited, with the greatest benefit accruing to patients with promoter methylation, reported Dr. James Perry, head of the division of neurology at Sunnybrook Health Sciences Centre, Toronto.

The age of peak incidence of glioblastoma is 64 years, and the incidence is increasing. Best practice has been surgical resection and 6 weeks of radiation combined with oral temozolomide. A pivotal trial just over 10 years ago was restricted to patients younger than age 70 years and included few patients older than 65 years. It showed decreasing benefit of temozolomide with increasing age. Furthermore, trials in the elderly have compared only head-to-head radiation schedules or radiation alone with temozolomide alone. There has been no evidence on which to base practice for combining radiotherapy with temozolomide, Dr. Perry said.

To address this deficiency, Dr. Perry and his colleagues randomly assigned patients 65 years or older with newly diagnosed glioblastoma either to a short course of RT, consisting of 40 Gy in 15 fractions over 3 weeks or to the same radiotherapy plus 3 weeks of concomitant temozolomide and then adjuvant temozolomide for 12 months or until progression.

Patients (n = 562; 281 in each arm) averaged 73 years (range, 65-90 years), 77% had Eastern Cooperative Oncology Group performance score (PS) 0/1 and the rest PS 2, and 58% had had tumor resection.

Median overall survival was 9.3 months with the combined therapy and 7.6 months with radiation alone. Median progression-free survival was 5.3 vs. 3.9 months, respectively, with a hazard ratio of 0.50 (P less than .0001).

MGMT promoter methylation is a predictive marker for benefit from chemotherapy and a prognostic factor for survival. Forty-six percent of the tumors had this promoter methylation.

Temozolomide use added relatively more benefit if promoters were methylated. Patients with methylated promoters had an overall survival of 7.7 months with radiation alone and 13.5 months with combined radiation and temozolomide (HR, 0.53; P = .0001). For unmethylated promoters, overall survival with radiation alone was 7.9 months and was 10.0 months when temozolomide was added (HR, 0.75; P = .055), suggesting some benefit from temozolomide, although not as great as with tumors with methylated promoters.

“The advantage of this combined treatment with chemoradiation was achieved with minimal side effects,” Dr. Perry reported. Mild nausea and vomiting occurred mostly in the first weeks of therapy, and a slight increase in grade 3/4 hematologic toxicity was seen but occurred in less than 5% of patients. No differences in quality of life were reported between the treatment arms.

Most patients could easily complete the treatment plan, with 97% adherence to the 3 weeks of chemoradiation. “This is quite important because the elderly often have difficulties with mobility, distance from treatment centers, and sometimes don’t have caregivers [who] are able to bring them back and forth for treatment,” Dr. Perry said. He suggested that the shorter course of radiotherapy may have been one factor in the high adherence rate.

Based on these results of higher efficacy using concomitant and adjuvant temozolomide with manageable toxicities and no sacrifice in quality of life, “oncologists now have evidence to consider radiation with chemotherapy in all newly diagnosed elderly patients with glioblastoma,” he said.

Dr. Julie Vose, president of the American Society of Clinical Oncology, said the study was important because it compared the treatments in the appropriate patient population, that is, in the elderly who have the highest incidence of glioblastoma.

CHICAGO – Adding concomitant and adjuvant temozolomide to a shorter course of radiotherapy (RT) for elderly patients with glioblastoma improves progression-free survival, according to a phase III study presented at the annual meeting of the American Society of Clinical Oncology.

Both patients with and without MGMT methylated promoters in their tumors benefited, with the greatest benefit accruing to patients with promoter methylation, reported Dr. James Perry, head of the division of neurology at Sunnybrook Health Sciences Centre, Toronto.

The age of peak incidence of glioblastoma is 64 years, and the incidence is increasing. Best practice has been surgical resection and 6 weeks of radiation combined with oral temozolomide. A pivotal trial just over 10 years ago was restricted to patients younger than age 70 years and included few patients older than 65 years. It showed decreasing benefit of temozolomide with increasing age. Furthermore, trials in the elderly have compared only head-to-head radiation schedules or radiation alone with temozolomide alone. There has been no evidence on which to base practice for combining radiotherapy with temozolomide, Dr. Perry said.

To address this deficiency, Dr. Perry and his colleagues randomly assigned patients 65 years or older with newly diagnosed glioblastoma either to a short course of RT, consisting of 40 Gy in 15 fractions over 3 weeks or to the same radiotherapy plus 3 weeks of concomitant temozolomide and then adjuvant temozolomide for 12 months or until progression.

Patients (n = 562; 281 in each arm) averaged 73 years (range, 65-90 years), 77% had Eastern Cooperative Oncology Group performance score (PS) 0/1 and the rest PS 2, and 58% had had tumor resection.

Median overall survival was 9.3 months with the combined therapy and 7.6 months with radiation alone. Median progression-free survival was 5.3 vs. 3.9 months, respectively, with a hazard ratio of 0.50 (P less than .0001).

MGMT promoter methylation is a predictive marker for benefit from chemotherapy and a prognostic factor for survival. Forty-six percent of the tumors had this promoter methylation.

Temozolomide use added relatively more benefit if promoters were methylated. Patients with methylated promoters had an overall survival of 7.7 months with radiation alone and 13.5 months with combined radiation and temozolomide (HR, 0.53; P = .0001). For unmethylated promoters, overall survival with radiation alone was 7.9 months and was 10.0 months when temozolomide was added (HR, 0.75; P = .055), suggesting some benefit from temozolomide, although not as great as with tumors with methylated promoters.

“The advantage of this combined treatment with chemoradiation was achieved with minimal side effects,” Dr. Perry reported. Mild nausea and vomiting occurred mostly in the first weeks of therapy, and a slight increase in grade 3/4 hematologic toxicity was seen but occurred in less than 5% of patients. No differences in quality of life were reported between the treatment arms.

Most patients could easily complete the treatment plan, with 97% adherence to the 3 weeks of chemoradiation. “This is quite important because the elderly often have difficulties with mobility, distance from treatment centers, and sometimes don’t have caregivers [who] are able to bring them back and forth for treatment,” Dr. Perry said. He suggested that the shorter course of radiotherapy may have been one factor in the high adherence rate.

Based on these results of higher efficacy using concomitant and adjuvant temozolomide with manageable toxicities and no sacrifice in quality of life, “oncologists now have evidence to consider radiation with chemotherapy in all newly diagnosed elderly patients with glioblastoma,” he said.

Dr. Julie Vose, president of the American Society of Clinical Oncology, said the study was important because it compared the treatments in the appropriate patient population, that is, in the elderly who have the highest incidence of glioblastoma.

CHICAGO – Adding concomitant and adjuvant temozolomide to a shorter course of radiotherapy (RT) for elderly patients with glioblastoma improves progression-free survival, according to a phase III study presented at the annual meeting of the American Society of Clinical Oncology.

Both patients with and without MGMT methylated promoters in their tumors benefited, with the greatest benefit accruing to patients with promoter methylation, reported Dr. James Perry, head of the division of neurology at Sunnybrook Health Sciences Centre, Toronto.

The age of peak incidence of glioblastoma is 64 years, and the incidence is increasing. Best practice has been surgical resection and 6 weeks of radiation combined with oral temozolomide. A pivotal trial just over 10 years ago was restricted to patients younger than age 70 years and included few patients older than 65 years. It showed decreasing benefit of temozolomide with increasing age. Furthermore, trials in the elderly have compared only head-to-head radiation schedules or radiation alone with temozolomide alone. There has been no evidence on which to base practice for combining radiotherapy with temozolomide, Dr. Perry said.

To address this deficiency, Dr. Perry and his colleagues randomly assigned patients 65 years or older with newly diagnosed glioblastoma either to a short course of RT, consisting of 40 Gy in 15 fractions over 3 weeks or to the same radiotherapy plus 3 weeks of concomitant temozolomide and then adjuvant temozolomide for 12 months or until progression.

Patients (n = 562; 281 in each arm) averaged 73 years (range, 65-90 years), 77% had Eastern Cooperative Oncology Group performance score (PS) 0/1 and the rest PS 2, and 58% had had tumor resection.

Median overall survival was 9.3 months with the combined therapy and 7.6 months with radiation alone. Median progression-free survival was 5.3 vs. 3.9 months, respectively, with a hazard ratio of 0.50 (P less than .0001).

MGMT promoter methylation is a predictive marker for benefit from chemotherapy and a prognostic factor for survival. Forty-six percent of the tumors had this promoter methylation.

Temozolomide use added relatively more benefit if promoters were methylated. Patients with methylated promoters had an overall survival of 7.7 months with radiation alone and 13.5 months with combined radiation and temozolomide (HR, 0.53; P = .0001). For unmethylated promoters, overall survival with radiation alone was 7.9 months and was 10.0 months when temozolomide was added (HR, 0.75; P = .055), suggesting some benefit from temozolomide, although not as great as with tumors with methylated promoters.

“The advantage of this combined treatment with chemoradiation was achieved with minimal side effects,” Dr. Perry reported. Mild nausea and vomiting occurred mostly in the first weeks of therapy, and a slight increase in grade 3/4 hematologic toxicity was seen but occurred in less than 5% of patients. No differences in quality of life were reported between the treatment arms.

Most patients could easily complete the treatment plan, with 97% adherence to the 3 weeks of chemoradiation. “This is quite important because the elderly often have difficulties with mobility, distance from treatment centers, and sometimes don’t have caregivers [who] are able to bring them back and forth for treatment,” Dr. Perry said. He suggested that the shorter course of radiotherapy may have been one factor in the high adherence rate.

Based on these results of higher efficacy using concomitant and adjuvant temozolomide with manageable toxicities and no sacrifice in quality of life, “oncologists now have evidence to consider radiation with chemotherapy in all newly diagnosed elderly patients with glioblastoma,” he said.

Dr. Julie Vose, president of the American Society of Clinical Oncology, said the study was important because it compared the treatments in the appropriate patient population, that is, in the elderly who have the highest incidence of glioblastoma.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: Are patients with obstructive sleep apnea (OSA) and preoperative hypercapnia more likely to experience postoperative complications than those without?

Background: Obesity hypoventilation syndrome (OHS) is known to increase medical morbidity in patients with OSA, but its impact on postoperative outcome is unknown.

Study design: Retrospective cohort study.

Setting: Single tertiary-care center.

Synopsis: The study examined 1,800 patients with body mass index (BMI) ≥30 who underwent polysomnography, elective non-cardiac surgery (NCS), and had a blood gas performed. Of those, 194 patients were identified as having OSA with hypercapnia, and 325 were identified as having only OSA. Investigators found that the presence of hypercapnia in patients with OSA, whether from OHS, COPD, or another cause, was associated with worse postoperative outcomes. They found a statistically significant increase in postoperative respiratory failure (21% versus 2%), heart failure (8% versus 0%), tracheostomy (2% versus 1%), and ICU transfer (21% versus 6%). Mortality data did not reach significance.

The major limitation to the study is that hypercapnia is underrecognized in this patient population, and as a result, only patients who had a blood gas were included; many hypercapnic patients may have had elective NCS without receiving a blood gas and were thus excluded.

Bottom line: Consider performing a preoperative blood gas in patients with OSA undergoing elective NCS to help with postoperative complication risk assessment.

Citation: Kaw R, Bhateja P, Paz y Mar H, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149(1):84-91 doi:10.1378/chest.14-3216.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.

Clinical question: How useful are rapid immunoassays (RIs) compared to other tests for heparin-induced thrombocytopenia (HIT)?

Background: HIT is a clinicopathologic diagnosis, which traditionally requires clinical criteria and laboratory confirmation through initial testing with enzyme-linked immunosorbent assay (ELISA) and “gold standard” testing with washed platelet functional assays when available. There are an increasing number of RIs available, which have lab turnaround times of less than one hour. Their clinical utility is not well understood.

Study design: Meta-analysis.

Setting: Twenty-three studies.

Synopsis: The authors found 23 articles to include for review. These studies included 5,637 unique patients and included heterogeneous (medical, surgical, non-ICU) populations. These articles examined six different rapid immunoassays, which have been developed in recent years. All RIs examined had excellent negative predictive values (NPVs) ranging from 0.99 to 1.00, though positive predictive values (PPVs) had much wider variation (0.42–0.71). The greatest limitation in this meta-analysis is that 17 of the studies were marked as “high risk of bias” because they did not compare the RIs to the “gold standard” assay.

Bottom line: RIs for the diagnosis of HIT have very high NPVs and may be usefully incorporated into the diagnostic algorithm for HIT, but they cannot take the place of “gold standard” washed platelet functional assays.

Citation: Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accuracy of rapid immunoassays for heparin-induced thrombocytopenia: a systematic review and meta-analysis [published online ahead of print January 14, 2016]. Thromb Haemost. doi:10.1160/TH15-06-0523.