Indices of inflammatory activity. Relationship between isotope studies and clinical methods

A Double Blind Cross over Study of Ibuprofen, Metiazinic Acid, Aspirin and a Placebo in Rheumatoid Arthritis

In a double-blind cross-over study the analgesic and anti-inflammatory action of ibuprofen 1600 mg/day in cases of rheumatoid arthritis has been compared with aspirin 4 g/day, metiazinic acid 1 .5 g/day and a placebo, lactose.

Each compound was administered in identical capsules and in a totally randomised order to all patients studied. Assessment of the articular index, grip strength, knee score, erythrocyte sedimentation rate and subjective improvement was made before and after one week's treatment with each drug.

In the doses used in this trial, the analgesic and anti-inflammatory activity of metiazinic acid in rheumatoid arthritis, was found to be approximately equipotent to that of aspirin, while ibuprofen seemed to be slightly more potent and to cause fewer side-effects.

Outcome measures, pooled index and quality of life instruments in rheumatoid arthritis

BACKGROUND AND OBJECTIVE

A variety of outcome measures are used in evaluating disease activity and therapeutic efficacy in rheumatoid arthritis (RA) studies, and this makes comparisons of drug efficacy difficult. Some of the endpoints used are not standardized and/or are insensitive to change. The purpose of this report is to present a critical appraisal of outcome measures and quality of life assessments in RA studies.

METHOD

An overview of the literature was undertaken to determine the extent to which there is consensus among experts in this area of research.

RESULTS

The data suggest that the core set of endpoints in RA clinical studies should include tender joint count swollen joint count, patients' assessment of pain, patients' and physicians' global assessments, patients' assessment of physical function and acute phase reactant level. When trials of disease-modifying antirheumatic drugs (DMARD) last for more than a year, radiography may be useful. A 'pooled index' may be valuable, and its construction is discussed. Quality of life (QoL) instruments facilitate a fuller examination of the effects of health care interventions and these should be used to complement the more traditional clinical endpoints in the core set. The instruments most commonly used in RA research are identified.

CONCLUSIONS

We conclude that randomized clinical trials of treatments in RA should now ideally use the core set of clinical endpoints and validated QoL instruments for assessing safety and efficacy.

Sensitivity of effect variables in rheumatoid arthritis: a meta-analysis of 130 placebo controlled NSAID trials

In a meta-analysis of placebo controlled NSAID trials, the sensitivity of the effect variables was calculated as the correlation coefficient and as the difference between drug and placebo, divided by the placebo group standard deviation. The patient's global evaluation was the most sensitive variable overall. Pain was more sensitive than Ritchie's index. Several variables may be omitted from clinical trials, especially if two active drugs are being compared. For example, the best maximum estimate for the difference in ESR between NSAIDs and placebo was 1.0 mm/hr (95% confidence interval -1.5 to 3.4 mm/hr), and for joint size 0.44% (-1.0 to 1.9%), corresponding to a quarter of a millimeter for each of the 10 joints usually measured. It is suggested to record only the patient's global evaluation, pain, and morning stiffness.

A double-blind crossover trial of diflunisal and naproxen in osteoarthritis

Fifty patients with osteoarthritis were studied in a double-blind, crossover trial of diflunisal (1000 mg daily) and naproxen (750 mg daily). In the 45 patients who completed the study, no significant difference was noted between the drugs in most of the parameters studied, including evening pain intensity and effectiveness rating by patient and investigator. There was a trend towards greater patient preference for diflunisal, although this trend did not reach statistical significance. Naproxen produced significantly fewer side-effects, although side-effects with both drugs were mild.

Double-blind dose-response study of indomethacin in rheumatoid arthritis

Indomethacin 0, 15, 25 and 35 mg t.i.d. was given in randomized order for two weeks to eight outpatients with rheumatoid arthritis in a double-blind study. At the end of each treatment period the clinical response was evaluated by subjective and objective methods and the plasma indomethacin concentration was measured by GLC-mass fragmentography. Compared with non-treatment periods, indomethacin had a statistically significant therapeutic effect as judged by global assessment, duration of morning stiffness, use of escape analgesia, articular index and pain score, but there was no relation between the clinical effect and the size of the dose or the plasma concentration of the drug. Technetium uptake over the affected joints did not change during indomethacin therapy, which might reflect a lack of effect on the local activity of the disease. Lower doses than those currently prescribed are probably sufficient to alleviate symptoms in this disease.

Kinetics of 99MTc-pertechnetate uptake in healthy and arthritic knees

99mPertechnetate (99TcO-4) was injected intravenously in 7 healthy subjects and 30 patients with rheumatoid arthritis (RA). The uptake of isotope (99Tc) in both knee joint regions was traced continuously for 30 min from the time of injection. The isotope showed more rapid accumulation with increasing arthritic involvement of the knee, and the rate of uptake of 99TcO-4 in the knee region tallied with the clinical findings before and after treatment (14 RA patients). The findings indicate that the rate of 99TcO-4 uptake could serve as a useful complement to the more commonly used quantitative uptake of isotope. The two measures may possibly reflect different features of synovial inflammation.

A short-term comparative trial of salsalate and indomethacin in rheumatoid arthritis

A short-term, double-blind, placebo-controlled crossover study was completed in 15 patients with classical or definite rheumatoid arthritis to compare the antirheumatic activity of salsalate (3 g/day) with placebo and indomethacin (75 mg/day). Subjective and objective assessments showed that both salsalate and indomethacin were significantly superior to placebo. Grip strength was not improved by either of the drugs. Patient preference was in favour of indomethacin, but the difference between it and salsalate was insignificant.

Clinical evaluation of two daily doses of naproxen and indomethacin: result of a double-blind crossover trail

A double-blind crossover clinical trial is reported on the effects of naproxen in two doses, 500 mg. and 750 mg. daily, and 100 mg. indomethacin daily in 23 patients with classical rheumatoid arthritis, each drug being given for 1 week. The results show that there was little to choose between the drugs and that there was clinical equivalence between the two doses of naproxen. Radioactive pertechnetate (99mTc) joint uptakes were depressed by both naproxen and indomethacin, indicating anti-inflammatory effect.

Method for assessing therapeutic potential of anti-inflammatory antirheumatic drugs in rheumatoid arthritis

A 14-day, single-blind trial of prednisone, aspirin, and placebo was carried out in 128 patients suffering from rheumatoid arthritis, using subjective criteria only (severity of pain daily on a pain chart and assessment of the drug for effectiveness). The average treated pain rating, mean patient satisfaction rating, and mean number of days withdrawn from each drug all showed significant differences between prednisone, aspirin, and placebo. Of various pretreatment observations, only the initial pain score and articular index of joint tenderness were significantly related to the average treated pain rating.The trial method is simple and allows many patients to participate without being time consuming for patient or physician. The method seems to have potential in comparing the comparative effectiveness of anti-inflammatory analgesics used in the treatment of patients with rheumatoid arthritis.