Radiosynoviorthesis in people with haemophilia.

Abstract

In the last three decades radiosynovectomy (RSV) has been partially accepted as an alternative to surgical synovectomy in cases of haemophilic arthropathy. This issue of the journal contains an interesting article1 on the use of RSV in haemophiliacs by a Spanish group with experience in this technique2. RSV was first used by Fellinger et al. in 1952 in patients with rheumatoid arthritis3 and the technique has now been exploited for more than 50 years to treat resistant synovitis in patients with this form of arthritis. It is well known that about 90% of people with severe haemophilia experience chronic degenerative joint changes by the second or third decades of their lives. Such degenerative changes are mainly due to spontaneous recurrent intra-articular bleeding in patients undergoing on-demand treatment and a critical point for avoiding haemophilic arthropathy is the prevention of articular haemorrhages by means of prophylactic treatment. However, despite regular infusions of antihaemophilic concentrate at an early age (primary or secondary prophylactic treatment), recurrent haemarthrosis and chronic arthropathy still persist in adult patients treated on-demand as well as in a small proportion of patients on prophylaxis even in the absence of clinical evidence of bleeding4. Synoviorthesis with radioisotopes has some advantages over the same technique using chemical agents. These advantages are mainly related to the reduced number of injections, usually only one, although in some cases up to three as described in the paper published in this issue1, compared to five to ten, which are the norm with chemicals, as reported by Radossi et al5. The paper by De la Corte-Rodriguez et al.1 describes the possibility that further improvements can be achieved by using more than one radioisotope injection and that the results, in terms of relief of pain, increased range of movements and decreased haemarthrosis, are obtained by the cumulative administrations which seem to work “independently”. This approach needs optimal safety precautions. Indeed, although much has been learnt from thousands of administrations in patients with rheumatoid arthritis, RSV is not widely used in the management of haemophilic arthropathy as it is considered to be potentially dangerous because of the isotopes. Furthermore, some logistic difficulties may be encountered in relation to, for example, drug supplies and inadequate space for the procedure to be carried out in designated protected areas. Further caution is required in haemophiliacs because of the young age of the patients and there are also concerns about the risk of chromosomal damage. Even though long-term monitoring has not detected this adverse event in any haemophiliac who has undergone RSV, these concerns probably explain why there is only limited experience of RSV in Europe and in North America as opposed to Latin America and developing countries. Radossi et al. have demonstrated the successful treatment of end-stage arthropathy using chemical synoviorthesis even in advanced age. Although the average age of the cohort described by the Spanish group in this issue of the journal was 18 years1, the patients’ ages ranged from 18 to 51 years old and the cohort probably included a proportion of patients with advanced stage arthropathy: the overall results of the study would, therefore, support the use of RSV in this subset of patients. The current, ideal treatment of haemophilic arthropathy is primary prophylaxis but unfortunately, only 15–20% of the world’s population has access to this, meaning that 80–85% of haemophiliacs in the world are presently treated on-demand or even untreated. RSV is a relatively simple, virtually painless and inexpensive technique for the treatment of chronic haemophilic synovitis, even in patients with inhibitors. In conclusion, we strongly support the spread of use of RSV and we invite doctors dealing with haemophilia to address frequent logistic difficulties (e.g. legal restrictions, poor appeal) in order to adopt this technique, especially in the current climate of cost-saving and resource limitation, as underlined in the paper by De La Corte-Rodriguez et al1.