One of the more confounding dilemmas that clinicians face is when patients present with undifferentiated arthritis (UA). While these patients reportedly comprise the majority of those who come into rheumatology practices with recently developed arthritis, UA defies a more defined classification criteria and the lack of a more specific diagnosis leads to less clarity when it comes to treating the disease.

Clinicians are subsequently torn between initiating treatment with methotrexate, in order to address symptoms and help inhibit progression of the disease, or foregoing treatment as reportedly upward of 50 percent of patients with UA have spontaneous remission.

However, a recent study may shed a little light in this area. As reported in a recent issue of Arthritis and Rheumatism, researchers say clinicians may be able to predict the risk of rheumatoid arthritis development in patients with UA by using a prediction rule that incorporates nine clinical variables.

Eric Gall, MD, says this type of study is important in that it might facilitate more timely treatment and appropriate referrals from primary care clinicians.

“Most practicing rheumatologists do not see (UA) cases early on. These patients initially present to the primary care clinicians who send them on only after they cannot figure things out,” points out Dr. Gall, a Professor and Chairman of the Department of Medicine at the Chicago Medical School at Rosalind Franklin University of Medicine and Science. “This is often months or longer (after the initial patient presentation) and by that time, many cases declare themselves.”

Here is a view of rheumatoid arthritis (RA) in the hands. A new study suggests a new prediction rule can help clinicians detect RA risk in patients with undifferentiated arthritis (UA).

Ara Dikranian, MD, says the prediction rule may not only allow more timely treatment for UA patients at risk of developing RA but could prevent over-treatment of those patients who do not have an elevated RA risk.

“In my experience, I encounter UA daily and nearly a third of (UA patients) go on to develop RA based on the American College of Rheumatology (ACR) criteria. Accordingly, I have been fairly aggressive in treating with DMARDs early, even before a formal diagnosis of RA,” concedes Dr. Dikranian, a San Diego-based rheumatologist.

“(The prediction rule) will make it much easier to validate our clinical suspicions with good certainty on which of our UA patients should be treated. Those scoring low on this prediction model can be spared exposure to potentially toxic medications.”

According to the study, the nine clinical variables to consider with the prediction rule include: sex, age, localization of symptoms, morning stiffness, tender joint count, swollen joint count, C-reactive protein level, rheumatoid factor positivity and the presence of anti-cyclic citrullinated peptide antibodies.

“The current study validates what we have known informally,” claims Dr. Dikranian. “The patients who will likely progress into RA cases are the ones who will happen to have various features of inflammation, either clinically or serologically.”

Still, Drs. Dikranian and Gall both cite the need for further research on the prediction rule. While some studies suggest “a high percentage” of UA patients who develop RA, Dr. Gall says these are prospective studies. Dr. Dikranian also notes it is difficult to identify how many UA patients resolve with no treatment as they often do not return for follow-up visits.

Researchers Assess Costs Of Treating JIA
While juvenile idiopathic arthritis (JIA) is one of the most common rheumatic diseases affecting children, there are few reports in the literature that have studied the health care costs associated with treating the disease.

When it comes to treating juvenile idiopathic arthritis (JIA), a study found that a higher active joint count was associated with greater direct medical costs.

Accordingly, researchers recently studied the costs of treating children with JIA in two tertiary referral pediatric centers in Canada. In the study, which was recently published in Arthritis and Rheumatism, the authors found that the annual average direct medical costs for children with JIA was $3,002, nearly $1,700 higher than the annual average direct medical costs for outpatients without JIA.

Medication cost was the most significant factor that accounted for the higher medical costs in treating JIA in comparison to study controls, according to Sasha Bernatsky, MD, PhD, the lead investigator of the study. Dr. Bernatsky says the difference in average annual costs for medications was $1,219.02. She also points out that the JIA group had higher costs when it came to visits to specialists and allied health care professionals. There were also higher costs in regard to diagnostic testing for the JIA group. Dr. Bernatsky suggested that much of these costs may be related to monitoring for adverse effects from medications.

One of the important findings in the study was the correlation between good disease control and lower costs.

“Our study did suggest the importance of good disease control in limiting the economic burden in JIA,” notes Dr. Bernatsky, an Assistant Professor in the Divisions of Rheumatology and Clinical Epidemiology at the McGill University Health Centre in Montreal, Quebec, Canada. “We showed that higher active joint count was independently associated with greater total direct medical costs. The JIA type at onset was also a predictor with higher costs for patients with polyarthritis or systemic JIA.”

While the study did not delve into cost-to-benefit comparisons, Dr. Bernatsky believes the study can be helpful for clinicians when it comes to resource allocation and doing what it takes to bringing the disease under good control.

— A.B.

Study Finds Long-Term Benefits Of Etanercept For AS

Recent findings from an ongoing, open-label phase 4 study reveal sustained improvement with etanercept in treating the signs and symptoms of ankylosing spondylitis (AS).

As reported at the recent American College of Rheumatology (ACR) conference, researchers found that 78 percent of AS patients who were treated with etanercept (Enbrel, Amgen/Wyeth) for up to 160 weeks had a 20 percent improvement in the Assessment on Ankylosing Spondylitis Response Criteria (ASAS 20).

This study does not surprise Don Flinn, PA, who has used different biologics to treat AS patients and has seen the improvements.

“We have noted that the range of motion has increased, stiffness has decreased and the patient’s activities of daily living have increased with the addition of biologics to their treatment regimen,” says Flinn, who has been in practice for 25 years at the McBride Clinic Orthopedics and Arthritis in Oklahoma City.
Flinn says TNF-a blockers are the biologics of choice when treating AS. Flinn believes that TNF-a may be a significant trigger in causing inflammation in AS and that blocking TNF is beneficial for most of his patients with AS.

“I believe that etanercept will benefit the patients with AS by halting the progression of the disease and giving the patients a chance at a normal life even with a very aggressive deforming disease,” notes Flinn.

— A.B.

Osteoporosis Study Assesses Patient Compliance
While one might assume that a medication with less frequent dosing would facilitate improved patient compliance, a recent study comparing risedronate and ibandronate for osteoporosis found that is not necessarily true.

The study compared patient adherence to weekly dosing of risedronate (Actonel, Procter and Gamble/Sanofi-Aventis) with patient adherence to monthly dosing of ibandronate (Boniva, Roche) over a six-month period. In the study of 22,718 patients taking risedronate and 3,309 patients taking ibandronate, researchers found that the mean persistence for the risedronate group was 103.52 days whereas the mean persistence for the ibandronate group was 92.08 days.

According to the study, researchers considered patients compliant until there was a gap of more than 90 days between the end of one prescription and the refilling of that prescription.
Deborah T. Gold, MD, the lead investigator of the study, noted the overall poor rate of compliance in the study population.

“Clinicians cannot afford to assume that patients are compliant with their medication,” notes Dr. Gold, an Associate Professor of Medical Sociology at the Duke University Medical Center in Durham, N.C. She encourages clinicians to discuss potential obstacles to compliance with their patients.

Given the ibandronate was fairly new at the time of the study, Dr. Gold says there should be studies with similarly sized patient groups in the future to see if the results from this study hold up.

— A.B.

Expert Insights On Osteoporosis Treatment
Approximately 10 million Americans suffer from osteoporosis. For this growing population, osteoporotic fractures are an everyday fear. Accordingly, clinicians at the Beth Israel Deaconess Medical Center in Boston answered the following questions on treating the disease.

Q: What are the key elements of fall prevention for people who are at risk for osteoporotic fractures?

A: “Optimizing environmental safety and muscular strength, endurance and flexibility are key factors in reducing the risk of falls,” says Colleen Kennedy, PT. “Patients with osteoporosis need to perform a home safety evaluation to eliminate hazards and be encouraged to wear closed, supportive, rubber soled shoes for all daily activity.”

Kennedy notes that practitioners should encourage these patients to exercise. She says patients should stay away from exercises such as sit-ups, which include “forceful, flexed” motion, and can lead to fracture. Kennedy says proper stretching of the flexor groups in the legs is a low impact exercise, which can allow for improved posturing and balance.

Q: Since the 2004 publication of Bone Health and Osteoporosis: A Report of The Surgeon General, what are the key treatment guidelines that have emerged from this report and will there be significant changes in treatment options in the near future?

A: Deborah Brown, APRN, BC, MSN, says the 2004 recommendations use a “pyramid approach” to treatment. She notes this includes addressing lifestyle changes such as nutrition and physical activity; secondary factors such as drugs and diseases; and pharmacotherapy, whether it is antiresorptive therapy or the use of anabolic medications.

Brown adds that researchers are currently studying a variety of emerging options — such as denosumab, androgens, growth factors, statins, strontium ralenate, folate and B12 and Vitamin K — for the possible treatment of post-menopausal osteoporosis.

Q: When a post-menopausal woman presents with a new wrist fracture, what are your recommendations for obtaining a bone density exam and/or further metabolic workup?

A: Tamara Rozental, MD, recommends obtaining a thorough patient history. If the patient has not been evaluated previously for osteoporosis, Dr. Rozental recommends a bone density test. Once the results are available, Dr. Rozental, an orthopedic surgeon, will work with the patient’s primary care physician (PCP) to determine treatment.

Dr. Rozental says there is no clear consensus on treating these patients. Since many post-menopausal women who present with a fragility fracture of the distal radius are osteopenic, Dr. Rozental says metabolic bone specialists recommend treating these patients, especially those with other risk factors for osteoporosis, with anti-resorptive therapy.

She notes, however, that some PCPs prefer to follow patients with bone density tests and only treat them if the bone quality continues to deteriorate and the patients become osteoporotic.

— A.B.