Management Of Rheumatic Diseases Research Articles

‘Full-house’ rheumatic heart disease

We report the case and cardiac imaging of a 27 year old African female with every clinical feature of advanced rheumatic heart disease. The case illustrates the continuing life-threatening impact of rheumatic heart disease in young adults. Appropriate diagnosis and management of rheumatic heart disease in the UK remains relevant with increased immigration of at-risk populations.

Patientenschulung in der Rheumatologie: Ein Weg zum besseren Krankheitsmanagement durch Kompetenzsteigerung bei den Betroffenen

Patients' empowerment has become a main issue in modern treatment of chronic rheumatic diseases. Within this concept patient education is an important instrument. Specific standardized programs, developed by multicenter groups under the leadership of the DGRh (German Society for Rheumatology) have become widely used all over Germany. The DGRh takes care of the program quality and of the trainers and heads of courses. Based on modern educational theories for adults and using a modular concept, which must be adapted to the individual situation of the patients, the curricula are put into practice by trainees of the different professions concerned. Controlled studies have not only shown the progress of patients' knowledge, compliance and coping, but also showed striking socioeconomic advantages in long-term follow-up. Patient education leads to a better and cost-effective management of rheumatic diseases.

A practical guide for the use of biologic agents in the treatment of rheumatoid arthritis*

A practical guide for the use of biologic agents in the treatment of rheumatoid arthritis*

Anti‐tumor necrosis factor therapy: the Australian experience

AbstractAnti‐tumor necrosis factor (TNF) therapy for the management of rheumatic diseases has been reimbursed in Australia progressively per agent and disease indication since 2003. Initial projections of uptake were grossly overestimated. In this article the anti‐TNF experience in Australia is reviewed, including results of an eligibility study, Australian Rheumatology Association guidelines, anti‐TNF registry, and a report of adverse effects. These observations may assist APLAR countries currently coming to terms with anti‐TNF drug registration and funding.

Management of adherence and chronic rheumatic disease in children and adolescents

Medical treatment regimens for pediatric rheumatic diseases are complex, have delayed beneficial effects, and require consistent adherence over a long period of time. All of these factors place patients at risk for non-adherence that can compromise the benefits of treatment and the long-term health and quality of life for patients. This chapter provides a definition of adherence and reviews the prevalence of non-adherence to regimens for pediatric rheumatic diseases. It also describes various methods for assessing adherence, including assays, observation, electronic monitoring, pill counts, and provider or patient ratings of adherence. Studies which identify risk factors for non-adherence are also reviewed, with suggestions on how these risk factors might be addressed. The final section reviews the few studies that have reported on efforts to improve adherence to regimens for pediatric rheumatic diseases and offers strategies for providers to promote adherence with their patients.

Management of Rheumatic Diseases in Pregnant and Nursing Women

Management of Rheumatic Diseases in Pregnant and Nursing Women

A Primary Care Approach to the Use and Interpretation of Common Rheumatologic Tests

The results of common rheumatologic laboratory tests play an important part in the diagnosis and management of rheumatic diseases. Rheumatologic test results can often be ambiguous and can sometimes be misleading, particularly in primary care settings. Because the diagnosis of most rheumatic conditions depends on information derived from sources other than serum tests, these laboratory values are usually supportive rather than diagnostic [1]. Few serum test results are pathognomonic for a specific rheumatic disease and alone are insufficient to determine a diagnosis [2]. Test results should be interpreted in a clinical context, which includes information derived from the history and physical examination, basic laboratory tests, radiographic and other imaging studies, and synovial fluid analysis. Serum rheumatologic tests are most useful for confirming a clinically suspected diagnosis. Because there is a high incidence of false-positive results in the general population, these tests have little clinical utility when there is a low pretest probability. Furthermore, the predictive value of serum rheumatologic tests is limited when performed in settings in which the prevalence of rheumatic conditions is low. Studies suggest that primary care physicians overuse common rheumatologic tests [3]. The practice of routinely ordering a battery of rheumatologic laboratory tests to ‘‘rule out’’ rheumatologic disease is not uncommon [1]. This approach rarely leads to a definitive diagnosis and

Ultrasound in rheumatology

Over the last decade, several studies have highlighted the value of ultrasonography for both clinical and research purposes in rheumatology. Ultrasonography is a non-invasive, inexpensive and free-of-radiation-hazards imaging technique providing quick and useful information for the management of rheumatic diseases. Considerable evidence supporting the role of ultrasonography in rheumatological clinical practice has led many rheumatologists to want to become experienced with this imaging technique. The main indications of ultrasonography in rheumatology include the evaluation of patients with regional pain syndromes and chronic arthritis, short-term therapy monitoring and guidance for invasive procedures. Ultrasonography's long learning curve is the main obstacle that hinders its widespread use in rheumatology. Many technical aspects may affect the scanning process and a correct interpretation of sonographic images depends on several elements such as a deep knowledge of ultrasonography anatomy and pathology.

Adherence with drug therapy in the rheumatic diseases Part one: A review of adherence rates

Drug therapy plays a major role in the management of many rheumatic diseases and is particularly important in rheumatoid arthritis (RA) because of the significant rates of morbidity and mortality (Pincus, 1995). Understanding of the pathogenesis of RA has led to the development of new and more effective drugs (Emery et al., 1999), but the ultimate efficacy of any drug therapy depends upon the patient's decision to take it. There is widespread agreement that many people with rheumatic disease do not adhere to their medication regimens (Deyo et al., 1981; Belcon et al., 1984; Pullar et al., 1988; Hill et al., 2001). Research has demonstrated that 50% of women taking hormone replacement therapy for the prevention of osteoporosis discontinue treatment after a year (Fordham, 2000) and similar rates of discontinuation are found in other chronic diseases (Haynes et al., 1996, 2000). This is bewildering as, in asymptomatic illnesses such as hypertension and diabetes, the expectation is that levels of adherence would be lower than in diseases where pain and stiffness are present. The picture becomes even more confusing when we consider the findings from a recent multi-country study of RA, which found no association between adherence and disease severity, nor with the treatment prescribed (Viller et al., 1999). In chronic disease poor adherence is commonplace. The World Health Organization (WHO) recognizes this and has recently stated that 'poor adherence to treatment of chronic diseases is a worldwide problem of striking magnitude' and cites adherence to long-term therapy for chronic illnesses in developed countries averaging just 50% (WHO, 2003). The first part of this two part review focuses on adherence with drug therapy, and the second part discusses different methods of measuring it.

Doppler sonography in rheumatology

The importance of ultrasonography in rheumatology has increased dramatically within the last few years both with regard to clinical practice and to research. High-resolution colour Doppler ultrasound equipment is, to date, widely available. Colour and power Doppler studies of intra-articular and peritendinous blood flow allow an estimation of the inflammatory activity and aid in distinguishing anatomical structures. Contrast agent increases the ability of ultrasonography to detect even minor perfusion. These findings have a practical clinical impact on the management of inflammatory rheumatic diseases. The resolution of ultrasonography is superior to that of magnetic resonance imaging (MRI) and computed tomography (CT) with regard to superficial anatomical structures. Furthermore, ultrasonography can depict the artery wall in contrast to angiography. In temporal arteritis and Takayasu's arteritis, ultrasonography depicts characteristic, homogenous wall thickening, stenoses and acute occlusions. These pathologies resolve quickly with treatment in the temporal arteries and much more slowly in larger arteries.

The Expanding Role of Tumor Necrosis Factor-α Inhibitors in the Management of Rheumatic Diseases

He development of biological agents has provided rheumatologists with a variety of new and effective treatment options. The success of these agents in the treatment of rheumatoid arthritis, has spurred research into novel targets for the management of other rheumatic diseases. In addition to rheumatoid arthritis, TNF-α inhibitors (infliximab and / or etanercept) have been approved for the use in patients suffering from Crohns disease, ankylosing spondylitis and psoriatic arthritis. Also the treatment of persistent monoarticular and oligoarticular arthritis, resistant to disease modifying antirheumatic drugs and steroid therapies, with intra-articular anti-TNF therapy appears promising. Most importantly, such therapies have improved the quality of life and clinical outcomes in this group of patients. This article reviews the recent clinical studies published and ongoing research on the treatment of rheumatic diseases, other than rheumatoid arthritis, using these biological agents.

Pregnancy in patients with rheumatic diseases: psychological implication of a chronic disease and neuropsychological evaluation of the children.

As a consequence of the general improvement in the diagnosis and management of rheumatic diseases, patients achieve a better quality of life, with the possibility of a normal family life including one or more pregnancies. It is important, therefore, to consider the psychological aspects of these mothers' life and the influence of their chronic disease on their children is development. Several papers have reported the impact of systemic lupus erythematosus (SLE) on the quality of life. They found higher incidence of anxiety (from 15 to 45%) and depression (from 25 to 47%) compared to the general population. We have investigated the psychological influence of SLE on family planning, and we observed that it can interfere with physiological phenomena such as parenthood and the upbringing of children. The children of lupus mothers have a normal intelligence level for their age. What is emerging, however, is an increased incidence of learning disabilities compared to the general population. This observation suggests the importance of an early neuropsychological examination, in order to identify the children needing particular care. Therefore, psychological support seems to be an important help in the counseling of patients with rheumatic disease and in the future life of their children.

Management Strategies for Osteoarthritis, Ankylosing Spondylitis, and Gouty Arthritis

Rheumatic diseases are among the most frequent causes of pain and disability. Effective management of rheumatic diseases including osteoarthritis (OA), ankylosing spondylitis (AS), and gouty arthritis requires an understanding of the underlying disease mechanisms.Symptoms of OA result from both mechanical factors and elements of inflammation. Current management strategies target both of these factors and generally consist of nonpharmacologic and pharmacologic interventions, including use of nonspecific nonsteroidal antiinflammatory drugs (NSAIDs) and cyclooxygenase-2-specific inhibitors (coxibs), which have analgesic and antiinflammatory properties. Other approaches include intraarticular hyaluronate and the use of alternative therapies under investigation such as acupuncture or glucosamine.Disease mechanisms in AS involve enthesitis, an inflammation at the site of insertion of ligaments, tendons, or joint capsules to bone. Posture and exercise are important nonpharmacologic strategies that may be made easier with the use of NSAIDs or coxibs. Recently developed therapies, including tumor necrosis factor inhibitors, target the underlying disease mechanisms and have demonstrated dramatic symptomatic effects. Disease-modifying effects still need to be established.In gout, hyperuricemia leads to crystal-induced inflammation in some patients. Etoricoxib, one of the newer coxibs, has shown promise in treating acute gout, with efficacy similar to indomethacin, the current standard NSAID often used in these patients. Oral or intraarticular steroids can also be considered. For chronic care uricosurics can be beneficial if renal function is normal and excretion is not excessive, but allopurinol is used most often. Nonpharmacologic modalities, such as rest and cold applications, are useful for acute episodes, and lifestyle modification in the form of diet can also play a role in chronic disease management.

From clinical pharmacology to clinical rheumatology: bench to bedside

The mainstay of management of rheumatic diseases is based on drug therapy. A number of drugs, from gold salts of yesteryear to methotrexate, leflunomide and the biologicals of today, are in vogue. These are used both singly and in permutations and combinations. Patient response varies enormously, from impressive results to abysmal failure. Why this great variability of response? The following factors would determine patient response: the choice of drug (factors in the drug and factors in the patient), the dosage forms, the dose, the pharmacokinetics, the pharmacodynamics, the drug interactions (synergism, additive effects, and antagonism), the adverse reactions, the pharmacoeconomics, and the patient education. This presentation highlights nuances in drug therapy that will minimise failure rate, enhancing the success rate in the realm of rheumatology.

Uveitis associated with childhood rheumatic diseases

Optimal management of childhood rheumatic diseases requires an appreciation of their multisystem nature. The eye represents an important site of involvement, and inflammation of the uveal tract is a particularly frequent and potentially debilitating extra-articular feature of some childhood rheumatic diseases. Anterior uveitis associated with oligoarticular juvenile idiopathic arthritis is an especially distinctive entity. Other disorders in children, however, can be associated with posterior and intermediate uveal tract inflammation. The potentially debilitating consequences of uveitis associated with childhood rheumatic diseases, the inadequacies of existing therapies, and the immunopathogenic basis for particular forms of uveitis have prompted the use of immunomodulatory therapy, including new biologic agents, to treat childhood uveitis. This review summarizes recent contributions to the literature that help to clarify the spectrum of conditions associated with uveitis in children, consider evidence for immunopathogenic processes associated with uveitis, and address new approaches to therapy.

Aceclofenac: a reappraisal of its use in the management of pain and rheumatic disease.

Aceclofenac is an orally administered phenylacetic acid derivative with effects on a variety of inflammatory mediators. Through its analgesic and anti-inflammatory properties, aceclofenac provides symptomatic relief in a variety of painful conditions. In patients with osteoarthritis of the knee, the drug decreases pain, reduces disease severity and improves the functional capacity of the knee to a similar extent to diclofenac, piroxicam and naproxen. Aceclofenac reduces joint inflammation, pain intensity and the duration of morning stiffness in patients with rheumatoid arthritis, and is similar in efficacy to ketoprofen, diclofenac, indomethacin and tenoxicam in these patients. The duration of morning stiffness and pain intensity are reduced, and spinal mobility improved, by aceclofenac in patients with ankylosing spondylitis, with improvements being similar to those observed with indomethacin, naproxen or tenoxicam. Aceclofenac is also effective in other painful conditions (e.g. dental and gynaecological). In contrast to some other NSAIDs, aceclofenac has shown stimulatory effects on cartilage matrix synthesis. Aceclofenac is well tolerated, with most adverse events being minor and reversible, and affecting mainly the GI system. Although the incidence of GI adverse events with aceclofenac was similar to those of comparator NSAIDs in individual clinical trials, withdrawal rates due to these events were significantly lower with aceclofenac than with ketoprofen and tenoxicam. Superior overall and/or GI tolerability of the drug relative to other NSAIDs has been indicated by a nonrandomised comparison with sustained release diclofenac in 10,142 patients, a meta-analysis of 13 comparisons with diclofenac, naproxen, piroxicam, indomethacin, tenoxicam or ketoprofen in 3574 patients, and preliminary details of a comparison with 10 other NSAIDs in 142,776 patients. Further analysis of the above meta-analytical data has indicated that costs incurred as a result of adverse event management are lower with aceclofenac than with a range of comparator NSAIDs. Trials of 2 to 6 months' duration have shown aceclofenac to be an effective agent in the management of pain and rheumatic disease. Data from in vitro studies indicate properties of particular interest with respect to cartilage matrix effects and selectivity for cyclo-oxygenase-2. Aceclofenac is well tolerated, with encouraging reports of improved general and GI tolerability relative to other NSAIDs from a meta-analysis of double-blind trials and from large nonblind studies.

Problems faced in the surgical management of rheumatic heart disease in Nepal

Rheumatic heart disease (RHD) is a very common cardiac disease in Nepal. The public awareness among Nepalese population is negligible, therefore it is seen in very early age and in severe form. The majority of the patients are of low socio-economical condition, who cannot afford expensive valve replacement surgery. All these facts create a daunting problem in the surgical management of the disease for the newly established open heart surgery unit. The first regular open heart surgery in Nepal was started on 20 February 1997 in Tribhuvan University teaching Hospital (TUTH), Kathmandu. Closed heart surgery was the only procedure available for isolated mitral stenosis in the past. Since 1997 in three years, a total of 285 cases of RHD were referred for surgery. Male to female ratio was 1.1:1.0. The youngest patient was 3 years and oldest 58 years with a mean age of 30 years. There were 32 patients (11%) under the age of 16 years. The isolated mitral valve disease was found in 195 cases (68%), aortic valve disease in 28 cases (10%) and double valve disease in 62 cases (22%). In the mitral valve disease, severe subvalvular fusion and calcification were found in 101 (52%) and 76 patients (39%) respectively, whereas closed mitral commissurotomy (CMC) was possible in only 69 patients (35%). In 3 years, 104 cases of valve surgeries were performed at TUTH. CMC was perfomed in 55 cases whereas open heart surgery in 49 cases of RHD patients. Here we present our difficulties in beginning regular open heart surgery in Nepal and the problems faced by our patients.

APHERESIS

The removal of pathologic humors by various methods is an ancient medical remedy used in the management of diseases whose pathophysiology is poorly understood and whose effective treatment modalities are lacking. The contemporary means for such an approach involves apheresis, which is now possible due to advances in blood banking technologies. Apheresis has been used in most of the major rheumatic diseases, in particular systemic lupus erythematosus and rheumatoid arthritis. Although numerous case reports describe clinical benefits of apheresis in rheumatologic disorders, data from clinical trials are discouraging and suggest a limited role for apheresis in rheumatic disease management.

Pharmacologic Management of Rheumatic Diseases

Pharmacologic Management of Rheumatic Diseases

Drug Interactions Affecting the Efficacy of Corticosteroid Therapy A Brief Review with An Illustrative Case

A drug interaction that seemed to contribute to sudden worsening of corticosteroid-stabilized vasculitis stimulated this review. A large number of drugs share with corticosteroids critical phase I metabolic steps mediated by hepatic cytochrome P450 (CYP) enzymes, particularly the individual enzyme CYP3A4. In their metabolic interaction with CYP3A4 as substrates, a growing number of these drugs have the potential to induce (upregulate) hepatic CYP3A4 levels, resulting in accelerated clearance (and reduced efficacy) of concomitantly administered glucocorticoids, which are also CYP3A4 substrates. Many other drugs can have the opposite effect, that is, they can inhibit CYP3A4 function by tight binding to its active site. This can result in reduced clearance (and augmented efficacy) of concurrently administered glucocorticoids. Current knowledge of this type of drug interaction, the drugs to watch out for, and multiple clinical reports of altered corticosteroid efficacy, are reviewed after presentation of the case illustrating potential relevance to the management of rheumatic diseases.