Drug treatment of rheumatoid arthritis. A systematic approach

Statin or nonsteroidal anti-inflammatory drug use is associated with lower erythrocyte sedimentation rate in patients with giant cell arteritis

BACKGROUND

Previous studies have found that nonsteroidal anti-inflammatory drugs (NSAIDs) and statins may impact erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels in patients. The current study was performed to determine if NSAID or statin use is associated with lower ESR and CRP in patients with biopsy-proven giant cell arteritis (GCA).

METHODS

A retrospective cross-sectional study was conducted that included 161 patients via chart review. Charts of patients with GCA seen at the University of Iowa Hospitals and Clinics from 1960 to 2008 were reviewed. Inclusion criteria were adequate medication records, serum ESR and/or CRP on record, no prior corticosteroid use, and biopsy-positive GCA. Exclusion criteria were the presence of diseases known to elevate ESR or CRP. Main outcome measures included ESR and CRP values measured while evaluating patients for GCA but prior to receiving treatment.

RESULTS

Statin nonusers had an ESR of 85.0 mm per hour (interquartile range [IQR] = 60-110 mm per hour) and a CRP of 8.7 mg/dL (IQR = 2.7-16.2 mg/dL). Statin users had an ESR of 57.5 mm per hour (IQR = 35-85) and a CRP of 2.4 mg/dL (IQR = 0.8-15.9 mg/dL). Statin use was associated with a lower ESR (P = 0.005), while there was no significant association with a lower CRP (P = 0.127). NSAID nonusers had an ESR of 98.0 mm per hour (IQR = 64-116) and a CRP of 8.7 mg/dL (IQR = 2.1-16.2 mg/dL). NSAID users had an ESR of 75.0 mm per hour (IQR = 46-98.5 mm per hour) and CRP of 8.0 mg/dL (IQR. = 1.5-16.2 mg/dL). NSAID use was associated with a lower ESR (P = 0.004), but there was no significant association with a lower CRP (P = 0.522).

CONCLUSION

Statin use and NSAID use were associated with a lower ESR; however, they were not associated with lower CRP values. Clinicians should be aware that statin or NSAID use is associated with lower ESR in patients with GCA, and this test may therefore have lower sensitivity and specificity for recognizing patients with GCA, and CRP may be a superior test to evaluate patients for GCA.

Long-term treatment of rheumatoid arthritis with sulphasalazine, gold, or penicillamine: a comparison using life-table methods

Life-table analysis was applied to the records of 317 patients with rheumatoid arthritis (RA) treated with sulphasalazine (SAS), 201 treated with sodium aurothiomalate (gold), and 163 with penicillamine. They comprised all those treated in our department with these drugs between January 1973 and July 1984. Risks of treatment termination for all reasons were similar for each drug at five years (gold 92%, penicillamine 83%, SAS 81%). The risk of treatment termination due to inefficacy was less for gold (29.5%) than for penicillamine (38.1%) or sulphasalazine (41.2%). Adverse effects, however, led to withdrawal of gold in 57%, penicillamine in 41.2%, and SAS in 37%; the most effective drugs appeared most toxic. Serious adverse effects were much more common in association with gold (17.4%) and penicillamine (12.3%) than with SAS (1.6%). Sulphasalazine appears as well tolerated over long periods in RA as gold or penicillamine and is associated with fewer serious adverse effects; of these drugs, it might therefore be considered the agent of first choice.

Benefit-risk assessment of investigational drugs: current methodology, limitations, and alternative approaches

Development of investigational drugs is a process integrated traditionally into four overlapping phases. The goal is to introduce new therapies to clinical medicine by assessing benefits and risks associated with administering the new drug. Benefit assessment is performed with respect to the disease for which the drug may comprise an effective treatment. In contrast, safety assessment is relatively standardized across many pharmacologic classes of agents. For purposes of benefit-risk assessment, investigational drugs are developed to provide benefit in three major disease categories: acute, episodic, and chronic. Benefit assessment is the major focus of conventional methodologies. Inherent limitations of risk assessment produced by conventional approaches are illustrated by the historical inability to detect toxicities of various drugs until large patient populations have been treated, typically after the drug is marketed. Alternative approaches to overcome these limitations include assessment of safety in studies specifically designed to optimize such evaluation and more extensive safety testing of investigational drugs in patient subgroups at higher risk. Such approaches serve the interest of patients, physicians, and developers by facilitating the development of new therapies by providing a more complete benefit-risk assessment prior to initial marketing of the drug.

C-reactive protein levels in patients with rheumatoid arthritis: the impact of therapy

C-reactive protein levels were measured in sera of 111 patients with rheumatoid arthritis and were compared with erythrocyte sedimentation rate. The patients were divided into six groups according to drug therapy. Comparison between the groups suggests that CRP correlates best with ESR in patients treated with penicillamine and in patients in clinical remission. Patients treated with gold, NSAID or methotrexate have a weaker correlation between the two parameters, while steroid therapy yields the poorest correlation which is not statistically significant. Our data suggest that although CRP is a sensitive index of disease activity, the specific drug taken by the patient must be considered before interpreting the results.

Use of simple analgesics in rheumatoid arthritis

The usefulness of anti-inflammatory drugs in rheumatoid arthritis (RA) is beyond dispute. The role of simple analgesics is less clear and has been disputed. A survey of 21 rheumatologists indicated that a majority sometimes supplemented anti-inflammatory treatment of RA with simple analgesics. A random sample of 120 RA patients treated by the same doctors revealed that 47% ranked pain relief as the most desirable objective of their treatment and 54% were taking analgesics regularly. Of those receiving analgesics as well as non-steroidal anti-inflammatory drugs 48% considered the former to be the more effective preparations. Almost half the patients on analgesics were taking drugs without the knowledge of the rheumatologists, who may have underestimated their patients' desire for pain relief.

Diflunisal ('Dolobid') once-a-day in the treatment of rheumatoid arthritis

A 4-week, double-blind, controlled multi-centre study was carried out in 235 patients with active rheumatoid arthritis to compare the efficacy and tolerance of 500 mg or 1000 mg diflunisal per day administered once daily, in the evening, or in divided, twice daily dosage. The results showed that diflunisal given once daily was at least as effective as diflunisal given twice daily. Day pain, morning stiffness, average grip strength and erythrocyte sedimentation rate improved similarly in both groups. Significant differences favouring the once-daily regimen were observed for improvement in night pain, Ritchie index and overall assessments by patient and investigator. Adverse experiences were slightly more common in patients taking diflunisal once daily (24% vs 19%) but this difference was not significant. It is concluded, therefore, that diflunisal once-a-day is an alternative regimen for the treatment of rheumatoid arthritis. It is at least as effective as the twice-daily regimen and may provide additional convenience to the patient and potential enhancement of compliance.

Outcome of attempts to treat rheumatoid arthritis with gold, penicillamine, sulphasalazine, or dapsone

The outcome of attempts to continue treatment indefinitely with either gold, penicillamine, sulphasalazine, or dapsone was studied in 240 patients with rheumatoid arthritis (RA). The usual reason for discontinuing treatment was the occurrence of an adverse effect. This led to 53% of patients stopping gold, 33% sulphasalazine, 32% penicillamine, and 17% dapsone. The next most frequent reason was that the drug was ineffective, leading to discontinuation in 37% of patients having dapsone, 24% sulphasalazine, 19% penicillamine, and 16% gold. Other reasons for stopping treatment were infrequent. The high discontinuation rate of these drugs over 2 years in part accounts for the conflict of opinion on whether they can alter the course of RA; their efficacy must to a large extent be governed by their acceptability.

A solid-phase enzyme immunoassay for C-reactive protein: clinical value and the effect of rheumatoid factor

Measurement of serum C-reactive protein (CRP) concentration is useful in monitoring the progress of chronic inflammatory diseases. Rheumatoid factor, by its interaction with the Fc portion of IgG, has the potential to interfere with solid-phase immunoassays for CRP and other serum proteins. To determine the effect of RF on a solid-phase enzyme immunoassay for CRP we compared assays employing whole antisera or F(ab')2 fragments. In 92 sera with RF latex titres ranging from 1/80 to 1/81,920, no correlation was found between RF concentrations and CRP measurements. CRP concentrations measured by use of whole antisera (mean +/- standard error of the mean, 59.7 +/- 5.7 mg/l, n = 92) were lower than those measured with F(ab')2 fragments (62.5 +/- 5 mg/l), indicating that exaggeration of CRP measurements did not occur in RF containing sera under the conditions of the assay. Our results show that in the CRP-ELISA, interference from RF was precluded by the high serum dilutions employed. At lower serum dilutions RF binding was detected. Consequently, in solid-phase enzyme immunoassays at lower serum dilutions the presence of RF may lead to false positive results and exaggerated measurements.

The effect of drugs in established rabbit monoarticular arthritis

Established antigen-induced arthritis was produced in 264 out of 339 sensitized Old English rabbits 4-6 weeks after a single intra-articular injection of ovalbumin into one knee joint. Positive arthritis was diagnosed when the joint swelling at this time was greater than or equal to 2 mm. A positive correlation between established joint swelling and delayed hypersensitivity to ovalbumin injected intradermally 24 h prior to joint challenge was demonstrated. Groups of 5-10 arthritic rabbits were dosed orally with increasing or fixed doses of a range of drugs for a period of 3-7 weeks. Drug activity was measured on joint swelling intermittently during the test and on joint macroscopy, cell content of the synovial fluid and joint histopathology at the end of the experiment. Prednisolone sodium phosphate and ketoprofen were the most active compounds tested. Chloroquine diphosphate, cyclo phosphamide, indomethacin, naproxen, SKF 36914 and sudoxicam had some activity, while aspirin, levamisole, oxisuran and D(-)penicillamine had little or no activity.