<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_455"
                     title="Low Vitamin D Linked to Hip OA (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/Rheumatology/Arthritis/tb/18379?impressionId=1265804157513"
                     
      &lt;p&gt;Elderly men with low serum levels of vitamin D are at increased risk for developing hip osteoarthritis, a prospective cohort study found.&lt;/p&gt;
&lt;p&gt;Men whose levels of 25-hydroxyvitamin (OH)D were between 15.1 to 30 ng/mL had twice the likelihood of prevalent radiographic hip osteoarthritis than those whose levels were normal (OR 2.19, 95% CI 1.21 to 3.97), according to R. Krishna Chaganti, MD, of the University of California at San Francisco, and colleagues.&lt;/p&gt;
&lt;p&gt;Conversely, after adjusting for age, season at blood draw, and clinic site, higher vitamin D levels were associated with a lower prevalence of hip osteoarthritis (OR 1.39 per 1 SD decrease in 25(OH)D level, 95% CI 1.11 to 1.74), the researchers reported in the February issue of &lt;em&gt;Arthritis &amp;amp; Rheumatism&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Because the role vitamin D may play in the pathogenesis and progression of osteoarthritis is unclear, Chaganti and colleagues analyzed data from the Osteoporotic Fractures in Men Study, which enrolled a large cohort of elderly men between 2000 and 2002 from six centers across the U.S.&lt;/p&gt;
&lt;p&gt;A total of 1,104 men whose mean age was 77.2 years had baseline measurements of serum vitamin D, and about 4.5 years later pelvic radiographs were obtained.&lt;/p&gt;
&lt;p&gt;Radiographs were scored to reflect joint space narrowing, osteophyte formation, cysts, subchondral sclerosis, and femoral head deformity.&lt;/p&gt;
&lt;p&gt;Vitamin D levels were categorized as deficiency (&amp;#8804;15 ng/mL), insufficiency (15.1 to 30 ng/mL), and sufficiency (&amp;gt;30 ng/mL).&lt;/p&gt;
&lt;p&gt;Mean vitamin D level was 23.38 ng/mL in men who had radiographic hip osteoarthritis, compared with 26.04 ng/mL in men without radiographic abnormalities (&lt;em&gt;P&lt;/em&gt;=0.0002).&lt;/p&gt;
&lt;p&gt;Men with hip osteoarthritis had a higher prevalence of both vitamin D insufficiency (77% versus 65%, &lt;em&gt;P&lt;/em&gt;=0.002) and deficiency (10.2% versus 7.5%, &lt;em&gt;P&lt;/em&gt;=0.012).&lt;/p&gt;
&lt;p&gt;Moreover, they had slower six-meter walking speed (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001) and reported more hip pain (&lt;em&gt;P&lt;/em&gt;=0.0001).&lt;/p&gt;
&lt;p&gt;Men who were vitamin D deficient also tended to have an increased likelihood of hip osteoarthritis (OR 1.99, 95% CI 0.83 to 4.74), but after adjustment in multivariate models, statistical significance was lost with this level of the vitamin.&lt;/p&gt;
&lt;p&gt;&quot;The association of low 25(OH)D levels with prevalent radiographic hip [osteoarthritis] underscores the potentially important role of vitamin D in the pathogenesis of [osteoarthritis]. Vitamin D metabolites have been found to be associated with the regulation of the Wnt pathway, products of which play important roles in the development and maintenance of bone and cartilage,&quot; the investigators explained.&lt;/p&gt;
&lt;p&gt;Furthermore, in vitro studies have suggested that serum levels of 25-hydroxyvitamin D&lt;sub&gt;3&lt;/sub&gt; can affect the ratio of RANKL to osteoprotegerin and thereby influence bone deterioration and repair.&lt;/p&gt;
&lt;p&gt;Previous investigations have yielded conflicting results. One study found that low levels of vitamin D were not associated with worsening of knee osteoarthritis, as reflected in loss of articular cartilage on MRI.&lt;/p&gt;
&lt;p&gt;Another study, however, linked knee osteoarthritis with low vitamin D levels, particularly in patients who also had decreased bone mineral density in the lumbar spine.&lt;/p&gt;
&lt;p&gt;&quot;Vitamin D influences the mineralization of bone matrix, and low serum levels of vitamin D may result in poorly mineralized bone that might alter forces across the joint and reduce joint deterioration,&quot; the authors suggested.&lt;/p&gt;
&lt;p&gt;On the other hand, low levels may interfere with chondrocyte metabolism and thereby increase degeneration.&lt;/p&gt;
&lt;p&gt;Further studies will be needed to more fully clarify the effects of the vitamin on the development and progression of osteoarthritis, the investigators cautioned.&lt;/p&gt;
&lt;p&gt;Strengths of the study include the large cohort of participants, careful classification of radiographic osteoarthritis, and reliance on the gold standard of vitamin D measurement, the 25(OH)D level.&lt;/p&gt;
&lt;p&gt;Limitations include the cross-sectional design, precluding the inference of causality, and the gap in time between measurement of serum vitamin D and radiography.&lt;/p&gt;
&lt;p&gt;The authors concluded that therapeutic interventions to increase vitamin D serum levels in the elderly &quot;are warranted,&quot; with the goal of improving skeletal health in this vulnerable age group.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute on Aging, the National Center for Research Resources, and the NIH Roadmap for Medical Research.&lt;/p&gt;&lt;p&gt;The lead author was supported by a grant from the American College of Rheumatology Research and Education Foundation.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_404"
                     title="Tailor Etanercept to Symptoms in Psoriasis and Psoriatic Arthritis (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/Rheumatology/Arthritis/tb/18309?impressionId=1265804157513"
                     
      &lt;p&gt;The decision to use once-weekly or twice-weekly etanercept (Enbrel) in patients with both psoriasis and psoriatic arthritis should be determined by the cutaneous and joint symptoms of the patient, researchers said.&lt;/p&gt;
&lt;p&gt;In a blinded, multicenter study, 46% of patients who received the drug twice a week had cleared or almost cleared their skin manifestations of psoriasis at week 12, compared with 32% of those who received the drug only once each week (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), according to Wolfram Sterry, MD, of Charite University Medicine in Berlin, and colleagues.&lt;/p&gt;
&lt;p&gt;In contrast, there were no differences in response for arthritis symptoms, with 77% of those in the twice-weekly group and 76% of those in the once-weekly group meeting predetermined psoriatic arthritis response criteria at week 12, the researchers reported online in the &lt;em&gt;BMJ&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;An estimated 30% of patients with psoriasis have an arthritic component to their disease, manifesting as chronic inflammation of the joints and entheses.&lt;/p&gt;
&lt;p&gt;&quot;The challenge of treating patients with both active psoriasis and active psoriatic arthritis is to optimize the treatment of both disease manifestations to give the best overall outcome,&quot; the investigators wrote.&lt;/p&gt;
&lt;p&gt;Etanercept, a fully human tumor necrosis factor (TNF) inhibitor, is approved for use in both conditions based on findings showing that TNF and other cytokines are upregulated in both inflamed joint and skin tissues.&lt;/p&gt;
&lt;p&gt;To determine the efficacy of two different treatment regimens in patients who had not previously received a TNF inhibitor but had moderate-to-severe skin symptoms and active arthritis, Sterry and colleagues recruited 752 patients from 98 centers for PRESTA (Psoriasis Randomized Etanercept STudy in subjects with psoriatic Arthritis).&lt;/p&gt;
&lt;p&gt;They paired rheumatologists and dermatologists to cooperatively assess effects of the drug.&lt;/p&gt;
&lt;p&gt;Patients were randomized to receive subcutaneous etanercept, 50 mg once or twice weekly for 12 weeks, and for an additional 12 weeks both groups received 50 mg once weekly.&lt;/p&gt;
&lt;p&gt;To maintain blinding, the once-weekly group also received a placebo injection during the first 12 weeks.&lt;/p&gt;
&lt;p&gt;Participants&apos; mean age was 46.5 years. Mean duration of psoriasis was 18.9 years, and mean duration of arthritis was seven years. Most were white men.&lt;/p&gt;
&lt;p&gt;For the joint symptoms, the proportions of patients who achieved American College of Rheumatology (ACR) responses were similar at weeks 12 and 24 in the two groups.&lt;/p&gt;
&lt;p&gt;At week 12, 66.4% and 60.8% of patients in the twice- and once-weekly groups, respectively, had achieved ACR20 responses (representing a 20% improvement). At week 24, the corresponding proportions were 69% and 71.7%.&lt;/p&gt;
&lt;p&gt;At week 12, the percentage reductions in physician&apos;s global assessment of arthritis were 60% and 62% for the twice- and once-weekly groups (&lt;em&gt;P&lt;/em&gt;=0.823), and at week 24 the corresponding percentages were 73% and 74% (&lt;em&gt;P&lt;/em&gt;=0.760).&lt;/p&gt;
&lt;p&gt;At baseline, enthesitis was found in 287 patients and dactylitis in 318. These two symptoms decreased comparatively in both groups at weeks 12 and 24.&lt;/p&gt;
&lt;p&gt;Skin findings included the following for the twice-weekly and once-weekly groups, respectively: &lt;ul&gt; &lt;li&gt;Improvement in physician&apos;s global assessment at week 12, 52% versus 45%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001&lt;/li&gt; &lt;li&gt;At week 24, 57% versus 55%, &lt;em&gt;P&lt;/em&gt;=0.420&lt;/li&gt; &lt;li&gt;Improvement in psoriasis area and severity index at week 12, 71% versus 62%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001&lt;/li&gt; &lt;li&gt;At week 24, 78% versus 74%, &lt;em&gt;P&lt;/em&gt;=0.110&lt;/li&gt; &lt;li&gt;75% improvement in psoriasis area and severity index at week 12, 55% versus 36%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001&lt;/li&gt; &lt;li&gt;At week 24, 70% versus 62%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.026&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Clearly there were differences in the optimal dosages for the skin lesions at week 12, but when the dosage was decreased to once weekly for the two groups, improvements in both joint and skin symptoms continued to improve, and at week 24 the responses were similar in the two groups, the investigators observed.&lt;/p&gt;
&lt;p&gt;&quot;We found that initial treatment of the psoriasis with etanercept 50 mg twice weekly may allow for more rapid clearance of skin lesions than a 50 mg weekly regimen,&quot; they wrote, noting that the higher dose therefore may be preferable for patients with more severe cutaneous involvement.&lt;/p&gt;
&lt;p&gt;In contrast, at no time was the twice-weekly regimen more effective in treating the articular symptoms, so 50 mg once weekly is a sufficient dose for the treatment of joint symptoms alone, they concluded.&lt;/p&gt;
&lt;p&gt;There were no differences in safety between the regimens.&lt;/p&gt;
&lt;p&gt;It is not clear why the higher dose cleared the skin symptoms more rapidly than the low dose but did not have an additional benefit for the joint symptoms.&lt;/p&gt;
&lt;p&gt;&quot;These two different organ systems may have dissimilar autoimmune inflammatory environments, allowing for differences in local concentrations of tumor necrosis factor or in disease burdens or a subtle difference in tissue penetration of drug, although little information is available to support any particular mechanism,&quot; the researchers noted.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Wyeth Research, which was acquired by Pfizer in October 2009, sponsored the trial.&lt;/p&gt;&lt;p&gt;Authors and sponsor were involved in study design, interpretation of data, manuscript preparation, and decision to publish.&lt;/p&gt;&lt;p&gt;Statistical analyses were done by the biostatistics department of Wyeth Research.&lt;/p&gt;&lt;p&gt;Several co-authors are employees of Pfizer, and others have received fees from multiple pharmaceutical companies including Wyeth.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_375"
                     title="Rituximab Safe Long-Term in RA (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Rheumatology/Arthritis/tb/18267?impressionId=1265804157513"
                     
      &lt;p&gt;Multiple courses of rituximab (Rituxan) were safe for patients with advanced rheumatoid arthritis, with no increase in serious adverse events or serious infections, an analysis of data from an international follow-up program demonstrated.&lt;/p&gt;
&lt;p&gt;The rate of serious adverse events was 17.85 per 100 patient-years (95% CI 16.72 to 19.06), remaining stable following each course of treatment for up to five years, according to Ronald F. van Vollenhoven, MD, of Karolinska University Hospital in Stockholm, and colleagues.&lt;/p&gt;
&lt;p&gt;Serious infections such as pneumonia, cellulitis, and urinary tract infections were reported in 170 patients (7%), for an overall serious infection rate of 4.31 per 100 patient-years (95% CI 3.77 to 4.92), the investigators reported online in &lt;em&gt;The Journal of Rheumatology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Time and experience have made clear that the immunomodulatory nature of biologic therapies in patients with rheumatoid arthritis requires careful safety vigilance.&lt;/p&gt;
&lt;p&gt;In addition to treatment-related risks, patients with rheumatoid arthritis already are at increased risk of infections, malignancies, and cardiovascular disease.&lt;/p&gt;
&lt;p&gt;Rituximab acts by binding to the CD20 antigen, resulting in depletion of CD20-positive B cells. It is licensed in the U.S. for use in combination with methotrexate in rheumatoid arthritis patients who have had an inadequate response to one or more tumor necrosis factor inhibitors.&lt;/p&gt;
&lt;p&gt;To identify adverse events possibly attributable to B-cell depletion, and of particular concern for RA patients, van Vollenhoven and colleagues analyzed long-term follow-up from patients who had been treated in nine clinical trials and two open-label extension studies.&lt;/p&gt;
&lt;p&gt;&quot;This analysis involves a larger number of rituximab-treated patients than previously reported, followed for multiple courses,&quot; they observed.&lt;/p&gt;
&lt;p&gt;A single course of treatment consisted of infusions of 2 X 500 mg or 2 X 1,000 mg, given two weeks apart.&lt;/p&gt;
&lt;p&gt;In the overall cohort there were patients who had undergone up to 10 courses of rituximab. This analysis, however, only included patients with up to five courses, because the numbers of patients having more than five were small and the confidence intervals of point estimates were wide.&lt;/p&gt;
&lt;p&gt;A total of 2,578 patients were included, with 5,013.5 patient-years of observation.&lt;/p&gt;
&lt;p&gt;Most study participants were women, mean age was 53 years, and disease duration averaged 10 years.&lt;/p&gt;
&lt;p&gt;They had received a mean of three previous biologic or disease-modifying drugs (other than methotrexate), and more than half had previously been treated with a tumor necrosis factor inhibitor.&lt;/p&gt;
&lt;p&gt;A total of 123 patients (5%) withdrew from the study because of adverse events.&lt;/p&gt;
&lt;p&gt;The overall rate of adverse events was 359.6 per 100 patient-years, being highest for the first course, declining with the second course, and remaining stable thereafter.&lt;/p&gt;
&lt;p&gt;The most common adverse events were infusion-related reactions, observed in 25% of patients during the first course, typically manifesting as mild-to-moderate headache, pruritus, hypertension, and rash.&lt;/p&gt;
&lt;p&gt;Some 9% of patients required slowing or stopping the infusion because of these reactions during the first course.&lt;/p&gt;
&lt;p&gt;By the fifth course, all patients were tolerating the infusion. &quot;This pattern is consistent with the hypothesis that cytokine release syndrome is less likely with additional courses because of a lower B-cell load,&quot; the investigators wrote.&lt;/p&gt;
&lt;p&gt;For serious adverse events, the most frequently reported were: &lt;ul&gt; &lt;li&gt;Pneumonia, 1%&lt;/li&gt; &lt;li&gt;Falls, 1%&lt;/li&gt; &lt;li&gt;Myocardial infarction, 0.9%&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The rate of myocardial infarction was an expected 0.56 per 100 patient-years, generally occurring in patients with risk factors. This was consistent with rates reported for other rheumatoid arthritis populations, according to the authors.&lt;/p&gt;
&lt;p&gt;A total of 65% of patients experienced some type of infection  --  most commonly nasopharyngitis and upper respiratory tract infection  --  with a rate of 97.7 per 100 patient-years.&lt;/p&gt;
&lt;p&gt;There were no cases of serious opportunistic infections during the analysis period.&lt;/p&gt;
&lt;p&gt;Overall serum immunoglobulin levels decreased during follow-up, with 5% of patients having levels of IgG below the lower limit of normal on at least one occasion.&lt;/p&gt;
&lt;p&gt;&quot;Classical observations have shown that IgG is the most important among serum immunoglobulins for protective immunity and that patients with low levels of IgG are at increased risk of serious infections,&quot; the investigators said.&lt;/p&gt;
&lt;p&gt;In this patient cohort, the rates of serious infections did not significantly increase when low IgG levels were detected.&lt;/p&gt;
&lt;p&gt;Older age and the concomitant use of steroids can contribute to decreases in IgG, and because corticosteroids were permitted in the clinical trials, it&apos;s unclear to what degree rituximab caused the fall in immunoglobulins.&lt;/p&gt;
&lt;p&gt;&quot;Irrespective of the underlying mechanisms for patients who had low IgG levels, this subset of patients may be at higher risk for infections and should be monitored closely,&quot; they cautioned.&lt;/p&gt;
&lt;p&gt;The overall incidence of malignancies other than nonmelanoma skin cancer was 0.84 per 100 patient-years, and the adjusted standardized incidence ratio compared with the general U.S. population was 1.05 (95% CI 0.76 to 1.42).&lt;/p&gt;
&lt;p&gt;Thirty deaths occurred, and the adjusted standardized mortality rate compared with the overall U.S. population was 0.83 (95% CI 0.56 to 1.18).&lt;/p&gt;
&lt;p&gt;The study had limitations, the authors&lt;strong&gt; &lt;/strong&gt;acknowledged, such as pooling of information from trials in which number of treatment courses, disease status, and doses of rituximab differed.&lt;/p&gt;
&lt;p&gt;The data were also constrained by the inclusion and exclusion criteria of the clinical trials.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Several co-authors are employees of Biogen Idec, Genentech, or Roche.&lt;/p&gt;&lt;p&gt;Writing assistance was provided and supported by Genentech, Biogen Idec, and F. Hoffmann La Roche.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_350"
                     title="Leflunomide Equal to Methotrexate in Anti-TNF Combo for RA Treatment (CME/CE)"
                     score="0.008"
                     href="http://www.medpagetoday.com/Rheumatology/Arthritis/tb/18231?impressionId=1265804157513"
                     
      &lt;p&gt;Treatments combining leflunomide (Arava) with an antitumor necrosis factor (TNF) agent were as effective in rheumatoid arthritis as regimens combining methotrexate with the biologics, a randomized Italian study found.&lt;/p&gt;
&lt;p&gt;After 24 weeks of therapy, patients receiving a methotrexate-based regimen achieved a mean Disease Activity Score (DAS)28 of 3.3, while those receiving leflunomide-based treatment had a mean DAS28 of 3.5, according to Renato De Stefano, MD, and colleagues from the Siena (Italy) University Hospital.&lt;/p&gt;
&lt;p&gt;Remission was achieved by 21.6% of patients in the methotrexate group and 16.6% of those in the leflunomide group. Neither of these differences was statistically significant, the investigators reported online in &lt;em&gt;Clinical Rheumatology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Multiple clinical trials have now demonstrated the efficacy of TNF blocking agents in combination with methotrexate for rheumatoid arthritis, but some patients can&apos;t tolerate or don&apos;t respond to methotrexate.&lt;/p&gt;
&lt;p&gt;Some data suggested leflunomide as an alternative to methotrexate, particularly if the TNF blocker is not begun for at least 12 weeks after the initiation of leflunomide.&lt;/p&gt;
&lt;p&gt;The mechanism of action of leflunomide is not fully understood, but it may be related to its ability to inhibit de novo pyrimidine biosynthesis through the inhibition of the enzyme dihydroorotate dehydrogenase, researchers say. Laboratory studies have demonstrated that it also affects stimulated T cells.&lt;/p&gt;
&lt;p&gt;So De Stefano and colleagues undertook a prospective trial that included 120 patients whose disease activity was high (DAS28 &amp;gt;5.1) despite treatment with methotrexate at 15 mg/week or leflunomide at 20 mg/day.&lt;/p&gt;
&lt;p&gt;These two groups of 60 patients each were then divided into three subgroups, with patients being randomized to receive etanercept (Enbrel), 25 mg twice weekly, adalimumab (Humira), 40 mg every two weeks, or infliximab (Remicade) at 5 mg/kg/week at baseline, weeks two and six, and every six to eight weeks thereafter.&lt;/p&gt;
&lt;p&gt;Treatment was discontinued in patients whose DAS28 score did not change more than 1.2 points or if they had an insufficient ACR20 response (20% improvement on American College of Rheumatology criteria) by 12 weeks.&lt;/p&gt;
&lt;p&gt;Most patients were women, with an average age of 52.&lt;/p&gt;
&lt;p&gt;In the methotrexate group, therapy was discontinued prematurely in 30%. The reasons were lack of efficacy in 18.3% and serious adverse effects in 11.6%.&lt;/p&gt;
&lt;p&gt;Serious adverse effects associated with methotrexate use included vasculitis in a patient receiving etanercept, elevated liver enzymes in one patient receiving etanercept and another receiving infliximab, and a diffuse rash in one patient on etanercept and in another on adalimumab.&lt;/p&gt;
&lt;p&gt;In the leflunomide group, therapy was discontinued in 30%, in 15% because of lack of efficacy and in 15% because of adverse effects.&lt;/p&gt;
&lt;p&gt;Serious adverse events in the leflunomide patients included one case each of thrombocytopenia and leukopenia in patients receiving etanercept, and diffuse rash in one patient on infliximab and in another on adalimumab.&lt;/p&gt;
&lt;p&gt;Mild adverse events, such as nausea and arthromyalgia, occurred much more frequently in the methotrexate group (43.3% versus 20%, &lt;em&gt;P&lt;/em&gt;=0.032), the investigators reported.&lt;/p&gt;
&lt;p&gt;By week 24, antinuclear antibodies had appeared in titers exceeding 1:160 in seven patients undergoing methotrexate treatment and in five taking leflunomide.&lt;/p&gt;
&lt;p&gt;In one patient taking leflunomide in combination with etanercept, anticardiolipid and anti-SS-A antibodies also appeared, but no patients developed clinical signs of connective tissue disease.&lt;/p&gt;
&lt;p&gt;Efficacy was similar among all groups. At week 24, methotrexate patients in the three coordinated-drug subgroups had these DAS28 scores: &lt;ul&gt; &lt;li&gt;Etanercept, 2.93&lt;/li&gt; &lt;li&gt;Adalimumab, 3.2&lt;/li&gt; &lt;li&gt;Infliximab, 3.7&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Leflunomide patients had these scores: &lt;ul&gt; &lt;li&gt;Adalimumab, 3.3&lt;/li&gt; &lt;li&gt;Infliximab, 3.6&lt;/li&gt; &lt;li&gt;Etanercept, 3.7&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;There were no significant differences in DAS28 scores between the leflunomide and methotrexate groups or in the six subgroups.&lt;/p&gt;
&lt;p&gt;At week 24, the ACR responses in the methotrexate group were: &lt;ul&gt; &lt;li&gt; ACR20, 63.3%&lt;/li&gt; &lt;li&gt;ACR50, 51.2%&lt;/li&gt; &lt;li&gt;ACR70, 32.1%&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Corresponding responses in the leflunomide group were &lt;ul&gt; &lt;li&gt;ACR20, 66.6%&lt;/li&gt; &lt;li&gt;ACR50, 47.4%&lt;/li&gt; &lt;li&gt;ACR70, 26.3%&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Differences in ACR scores were not significant between the leflunomide and methotrexate groups, or in the six subgroups.&lt;/p&gt;
&lt;p&gt;Improvements in health assessment questionnaire scores, reflecting levels of disability, were seen throughout the study for both groups, and by week 24 (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001) were most pronounced for the methotrexate-etanercept subgroup (median 0.11) and for the leflunomide-etanercept subgroup (median 0.3).&lt;/p&gt;
&lt;p&gt;The results of the study seem to confirm that TNF-blocker combination therapy with leflunomide is associated with a similar likelihood of achieving significant clinical response as with methotrexate, and without a significantly greater risk of adverse effects.&lt;/p&gt;
&lt;p&gt;In fact, treatment with leflunomide was more readily tolerated, lacking the minor dyspeptic and arthromyalgic side effects associated with methotrexate.&lt;/p&gt;
&lt;p&gt;That tolerability, and the fact that the drug can be administered orally, &quot;undoubtedly represent points in its favor as far as patients are concerned,&quot; the investigators noted.&lt;/p&gt;
&lt;p&gt;However, leflunomide is much more expensive than methotrexate, they pointed out.&lt;/p&gt;
&lt;p&gt;They called for further research on the use of leflunomide in this context, with greater numbers of patients and longer duration to better assess the persistence of efficacy, potential safety concerns with long-term use, and effects on structural joint damage.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors disclosed no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_337"
                     title="RA Patients Maintain Computer Skills (CME/CE)"
                     score="0.006"
                     href="http://www.medpagetoday.com/Rheumatology/Arthritis/tb/18215?impressionId=1265804157513"
                     
      &lt;p&gt;The hand impairment experienced by many patients with rheumatoid arthritis did not significantly interfere with their computer use, researchers found.&lt;/p&gt;
&lt;p&gt;On average, a group of patients with longstanding rheumatoid arthritis had only mild impairments on the Keitel Hand Function Index, which assesses active range of motion, according to Nancy A. Baker, ScD, and Joan C. Rogers, PhD, from the University of Pittsburgh.&lt;/p&gt;
&lt;p&gt;Participants&apos; mean score was 21.8 on this index, which includes scores ranging from 4 to 52, with higher scores indicating greater impairment, the investigators reported in the Feb. 15 issue of&lt;em&gt; Arthritis Care &amp;amp; Research.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Many patients with rheumatoid arthritis experience impairments in hand strength and range of motion because of joint synovitis and report difficulties using computer peripherals.&lt;/p&gt;
&lt;p&gt;But to remain competitive in today&apos;s marketplace, workers must maintain computer skills, including typing and use of the mouse, both of which require coordinated hand actions.&lt;/p&gt;
&lt;p&gt;Because there&apos;s little objective data on possible loss of productivity because of hand involvement in rheumatoid arthritis, Baker and Rogers recruited 45 computer users with the disease from their university&apos;s Arthritis Network Research Registry.&lt;/p&gt;
&lt;p&gt;Their study sought to discover which variables  --  impairments in range of motion, impairments in hand function, general activity limitations, or task-specific training (training in touch typing)  --  explain the most variance in keyboard and mouse speeds in computer users with rheumatoid arthritis.&lt;/p&gt;
&lt;p&gt;Participants&apos; mean age was 56.2, and duration of disease was 16.7 years. Most were women and white and 73% had been trained in touch typing.&lt;/p&gt;
&lt;p&gt;About half were employed, and most of those reported that computer use was very important to their work.&lt;/p&gt;
&lt;p&gt;Specific keyboard tasks measured included typing the alphabet from memory, typing a series of words that contain all letters of the alphabet, and repeating key strikes.&lt;/p&gt;
&lt;p&gt;Specific mouse tasks included pointing and clicking, dragging an icon, and moving a rectangle to a target.&lt;/p&gt;
&lt;p&gt;Moderate impairments were seen on the Arthritis Hand Function Test, which measures pure and applied strength and dexterity, with a mean score of 35.5 (range 14 to 56, with higher scores representing less impairment).&lt;/p&gt;
&lt;p&gt;General activity limitations, as measured by the Health Assessment Questionnaire (HAQ), were mild, with a mean score of 1 (range 0 to 3, with higher scores indicating worse functioning).&lt;/p&gt;
&lt;p&gt;The investigators then performed regression analyses for each of the individual keyboard and mouse tasks, with predictor variables for keyboard tasks being age, training in touch typing, and the three arthritis scores. Mouse regression analyses omitted the touch-typing variable.&lt;/p&gt;
&lt;p&gt;All regression analyses of skills in keyboarding were significant and explained 27% to 45% of the variance in typing speed, the investigators found.&lt;/p&gt;
&lt;p&gt;The strongest predictor of typing speed was training in touch typing, as was shown by the large effect sizes for this association (r&lt;sup&gt;2&lt;/sup&gt;=0.40 to 0.56).&lt;/p&gt;
&lt;p&gt;&quot;Motor skill, such as the ability to tap fingers quickly, is not consistently associated with speed in touch typing because speed in touch typing is most strongly associated with the ability to look ahead in the text, a perceptual ability rather than a motor skill,&quot; they explained.&lt;/p&gt;
&lt;p&gt;Younger age also had moderate to large significant associations with faster typing (r&lt;sup&gt;2&lt;/sup&gt;=0.32 to 0.51).&lt;/p&gt;
&lt;p&gt;Several regression analyses of skill in use of the mouse also were significant and explained from 26% to 43% of the variance in mouse speed.&lt;/p&gt;
&lt;p&gt;Younger age once again had significant and large associations with faster mouse speed (r&lt;sup&gt;2&lt;/sup&gt;=0.43 to 0.54).&lt;/p&gt;
&lt;p&gt;In general, there were few significant associations between speed and impairments in hand function.&lt;/p&gt;
&lt;p&gt;Rather, the researchers found that general activity limitation and decreased context-specific activity ability, as measured by the HAQ disability index, was the most significant arthritis-related variable.&lt;/p&gt;
&lt;p&gt;The skills of the patients in the rheumatoid arthritis group also were compared with those of historical controls (30 who were unimpaired and 24 with various upper extremity impairments).&lt;/p&gt;
&lt;p&gt;Keyboarding speeds were found to be comparable with unimpaired workers, suggesting that most of the arthritis patients could be competitive in the job market.&lt;/p&gt;
&lt;p&gt;Mouse speed, however, was greater in the controls. Moreover, some of the arthritis patients were considerably slower than both unimpaired and impaired controls.&lt;/p&gt;
&lt;p&gt;The findings of this study suggest that if people with motor impairments can learn touch typing, it might increase their productivity.&lt;/p&gt;
&lt;p&gt;&quot;Clinicians may want to consider informing computer users with [rheumatoid arthritis] to take touch-typing training to improve performance,&quot; the investigators wrote.&lt;/p&gt;
&lt;p&gt;They acknowledged that the study was exploratory and had certain limitations, including small sample size, low response rate, and use of historical controls.&lt;/p&gt;
&lt;p&gt;They recommended that the study be replicated including participants both with and without rheumatoid arthritis to more closely examine personal factors such as age.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the American College of Rheumatology Research and Education Foundation.&lt;/p&gt;&lt;p&gt;No financial disclosures were provided.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
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