Year in Review, Part 2

VBCR - February 2013, Volume 2, No 1 - Rheumatology Update

By Wayne Kuznar

Washington, DC—In the previous issue of Value-Based Care in Rheumatology, clinical publications of impact from the peer-reviewed literature from late 2011 and 2012 were selected for review by David A. Isenberg, MD, FRCP, FAMS, Arthritis Research Campaign’s Diamond Jubilee Professor of Rheumatology, University College London, and presented at the 2012 meeting of the American College of Rheumatology.

This second article focuses on Dr Isenberg’s selections in translational medicine, as well as a category he called “quirky reports.”

Translational Medicine

In a study of 55 serologically active, clinically quiescent patients with systemic lupus erythematous (SLE) and 110 SLE controls matched for age, sex, disease duration, and damage score, patients with prolonged, serologically active, clinically quiescent SLE accrued less damage over a decade than the SLE controls (Steiman AJ, et al. Arthritis Care Res [Hoboken]. 2012;64: 511-518.)

Therefore, management by active surveillance without the use of steroids or immunosuppressive agents is optimal. “In other words, treat the patient, don’t treat the result,” said Dr Isenberg.

Muro and colleagues (Rheumatology [Oxford]. 2012;51:800-804) studied antibodies against the melanoma differentiation-associated gene 5 (MDA5), which is a marker for dermatomyositis. These antibodies are especially associated with progressive interstitial lung disease. The researchers established enzyme-linked immunosorbent assay to measure anti-MDA5 in 11 patients who were followed for 3 months to 16 years. At the stage of clinical remission, the anti-MDA5 antibodies disappeared in 9 of the patients, which suggests that anti-MDA5 antibodies may be useful for monitoring disease activity in interstitial lung disease that is complicated by amyopathic dermatomyositis.

In a study known as ESPOIR, patients who had at least 2 swollen joints for >6 weeks but <6 months had the serum levels of various cytokines measured (Gottenberg JE, et al. Ann Rheum Dis. 2012;71:1243-1248). At the 1-year follow-up, 578 of the patients had developed rheumatoid arthritis (RA), and 132 were deemed to have undifferentiated arthritis. On univariate analysis, only interleukin (IL)-6 and IL-21 distinguished RA. On multivariate analysis, IL-6 and anticyclic citrullinated protein were linked to radiographic erosions.

Nielsen and colleagues (BMJ. 2012; 345:e5244) assessed the levels of rheumatoid factor in 9712 individuals who were part of the Copenhagen City Heart Study and followed them for up to 28 years. Using multivariate adjusted hazard ratios for RA development, they found that the highest absolute risk of RA (32%) was observed in women aged 50 to 69 years who smoked and had a rheumatoid factor >100 IU/mL.

Mammen and colleagues suggested in a recent study that there may be a mechanistic link between statin exposure, increased anti–hydroxy­methylglutaryl-­coenzyme A reductase (anti-HMGCR) expression, and the possible presentation of HMGCR-derived peptides by DRB1*11:01 (Mammen AL, et al. Arthritis Care Res [Hoboken]. 2012; 64:1233-1237). Human leukocyte antigen (HLA) links to statin myopathy were assessed in 20 Caucasian patients and 487 Caucasian controls, and 8 black patients and 167 black controls. In the Caucasian patients, HLA and DR11, DQA5, and DQB7 were strongly associated. In blacks, only DR11 was linked to HLA. High-resolution mapping helped to establish that the best overall link with anti-HMGCR myopathy was to DRB1*11:01.

Quirky Reports

In a Finnish town in which tap water was contaminated with feces in November 2007, gastrointestinal symptoms, especially diarrhea and blood in the feces, predicted joint complaints (Laine J, et al. Rheumatology [Oxford]. 2012;51:513-518). Joint symptoms occurred in 13.9% of the respondents living in the area with fecal-contaminated tap water and in 4.3% of the respondents living in areas with uncontaminated water.

Milman and Smith (Arthritis Care Res [Hoboken]. 2011;63:1195-1202) described 8 patients with cocaine-related cutaneous vasculopathy. Three patients stopped using cocaine and their skin problems improved, but problems were chronic and persistent in the 4 patients who continued to use it, 2 of whom died.

The ability of tumor necrosis factor (TNF)-alpha inhibitors to prevent the development of diabetes mellitus in 1587 patients with RA was explored in a retrospective study (Antohe JL, et al. Arthritis Care Res [Hoboken]. 2012;64:215-221). Only 3% of the patients who received TNF-alpha inhibitors developed diabetes compared with 7% of the patients who had not received TNF-alpha inhibitors, indicating that the use of TNF-alpha inhibitors may offer the additional benefit of reducing the risk of diabetes in patients with RA.

Testicular function is normal overall in primary antiphospholipid syndrome (PAPS) despite morphofunctional penile abnormalities, as was found in a cross-sectional study (Rabelo-Júnior CN, et al. Lupus. 2012;21: 251-256) of 12 male patients with PAPS and 20 controls who were assessed with testicular ultrasound and other urologic studies.

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