Atherogenic lipid profiles in rheumatoid arthritis

AIMS

Rheumatoid arthritis is associated with an excess mortality from cardiovascular disease, and this may be related to an atherogenic lipid profile. We set out to identify whether there was a correlation between disease activity and levels of different lipid fractions in a stable population of patients with rheumatoid arthritis on disease-modifying therapy.

METHODS

Patients with rheumatoid arthritis were selected from our database and requested to have inflammatory markers and a fasting lipid profile taken at their next visit for monitoring of their disease modifying therapy.

RESULTS

204 patients were recruited for the study. A statistically significant relationship exists between reduced HDL and elevated CRP (p=0.01) and ESR (p=0.041). Elevated ESR, but not elevated CRP, was associated with raised LDL cholesterol (p=0.014). Fourteen patients (6.8%) were receiving statin therapy and 71 (34.8%) were taking prednisone. Use of prednisone, independent of dose, was associated with elevated triglyceride levels (p=0.041).

CONCLUSIONS

This study supports previous work showing that rheumatoid arthritis is associated with an adverse lipid profile. While good disease control is clearly important, we should not neglect management of traditional cardiovascular risk factors.

Inadequate calcium, folic acid, vitamin E, zinc, and selenium intake in rheumatoid arthritis patients: results of a dietary survey

OBJECTIVES

To determine the adequacy of calcium, folic acid, vitamin E, zinc, and selenium intake in patients with rheumatoid arthritis (RA).

METHODS

We conducted an observational study on 48 patients (13 men, 35 women; mean age, 64.5 years) with RA attending a specialty clinic in New Zealand comparing their dietary intake as measured by a 5-day dietary survey with recommended dietary intake (RDI) guidelines. Information on disease activity, functional ability, and drug therapy also was obtained.

RESULTS

The percentage of patients who achieved the RDI was 23% for calcium, 46% for folic acid, 29% for vitamin E, 10% for zinc, and only 6% for selenium. Patients on methotrexate had a significantly reduced intake of folic acid as a percentage of RDI (P < .05) compared with those on other therapies. In contrast, dietary intake of iron and protein was largely adequate and unrelated to anemia.

CONCLUSIONS

Patients with RA should receive dietary education or supplementation to bring their intake of calcium, folic acid, vitamin E, zinc, and selenium up to the RDI.

Structured approach to the investigation of anaemia in patients with rheumatoid arthritis

A group of 28 patients with rheumatoid arthritis who were severely anaemic were investigated for iron deficiency. On the basis of bone marrow studies, the patients were divided into two groups, those with and those without signs of stainable iron in the marrow. This grouping did not distinguish between the severity of their rheumatoid arthritis measured by clinical parameters. Measurement of the red cell count and biochemical parameters in the peripheral blood showed a statistical difference in red cell size, haemoglobin content, and iron binding capacity between the two groups. The statistical variation of these parameters, however, did not allow these measurements to predict bone marrow iron deficiency in any subject. Investigation of the upper gastrointestinal tract by endoscopy showed that acute macroscopic lesions were infrequently associated with anaemia. It was concluded that anaemia in association with rheumatoid arthritis may mimic iron deficiency anaemia, and that simple investigations of the peripheral blood do not accurately show the iron status of the reticuloendothelial system in the presence of a chronic inflammatory disease. For the investigation of severe anaemia in rheumatoid arthritis, bone marrow assessment of iron status should be performed as the initial investigation. In addition, iron deficient patients require investigation of the lower and the upper gastrointestinal tract.

Effect of misoprostol on concentrations of prostaglandins in synovial fluid

The effect of misoprostol, a synthetic analogue of prostaglandin E, on prostaglandin concentrations in synovial fluids was investigated in a randomised placebo controlled, double blind study. The synovial fluid concentrations of prostaglandin E1, 6-keto-prostaglandin F1 alpha, and thromboxane B2 were measured at the beginning and end of a 24 hour period in 25 patients with effusions of the knee joint. During this period the patients were treated with diclofenac (50 mg every eight hours) and either misoprostol (400 micrograms) or placebo every 12 hours. The concentrations of prostaglandin E and 6-keto-prostaglandin F1 alpha were not significantly altered during treatment. There was an unexpected significant reduction in thromboxane B2 concentrations in the group treated with misoprostol (within group analysis). Although the mean concentration with misoprostol was about half the mean concentration with placebo, this difference was not statistically significant in the between group analysis. These results indicate that misoprostol is unlikely to exert a proinflammatory effect or to interfere with the prostaglandin mediated effects of non-steroidal anti-inflammatory drugs. The significant decrease in thromboxane B2 concentrations in the misoprostol treated group suggests that misoprostol may exert an anti-inflammatory effect.

Symptomatic manubriosternal joint involvement in rheumatoid arthritis

The manubriosternal joint is commonly involved in rheumatoid arthritis but rarely gives rise to symptoms. A patient is reported with seropositive, erosive rheumatoid arthritis, who developed symptoms resembling pleuritic pain, arising from synovitis of the manubriosternal joint. Treatment with intra-articular steroid injection resolved these symptoms rapidly.

Influence of non-steroidal anti-inflammatory drugs and disease activity on serum alkaline phosphatase concentrations in rheumatoid arthritis, osteoarthritis, and polymyalgia rheumatica

The influence of non-steroidal anti-inflammatory drugs (NSAIDs) and of disease activity on the serum alkaline phosphatase concentration was examined in patients with rheumatoid arthritis, osteoarthritis, and polymyalgia rheumatica. Concentrations of serum alkaline phosphatase were similar both in patients with rheumatoid arthritis taking NSAIDs and in those not taking NSAIDs. In patients with osteoarthritis NSAID use was not associated with a significant increase in serum alkaline phosphatase. In rheumatoid arthritis no correlation was found between clinical indices of disease activity and serum alkaline phosphatase concentrations. There was significant correlation with plasma viscosity in rheumatoid arthritis, both in those taking and not taking NSAIDs, and in polymyalgia rheumatica. Serum alkaline phosphatase concentrations are not influenced by NSAIDs. Concentrations correlate with laboratory parameters, but not clinical indices of disease activity.

Anaemia in patients with arthritis: are simple investigations helpful?

The level of haemoglobin, serum iron, total iron binding capacity and ferritin were measured in patients with rheumatological conditions who were anaemic at the time of upper gastrointestinal endoscopy. These parameters were similar in patients with or without lesions of their upper gastrointestinal tract, and in patients with a positive or negative faecal occult blood result. Lesions of the upper gastrointestinal tract were not more frequent in patients with a microcytic anaemia when compared to those with a normocytic anaemia, nor were they found more frequently in patients with a positive faecal occult blood test. Lesions visible at upper gastrointestinal endoscopy are not an important cause of microcytic anaemia in patients with arthritis. The finding that patients with normocytic anaemia are more likely to proceed to lower bowel examination than patients with microcytic anaemia is a reflection of the difficulty in interpretation of these simple haematological tests and showed they were unhelpful in determining which patients warrant investigation of the lower bowel. The frequency of further investigation of the lower bowel was significantly reduced by a positive endoscopy report, irrespective of the nature of the lesion, but was not significantly increased by finding faecal occult blood. We suggest that patients with arthritis selected for investigation of possible gastrointestinal blood loss should follow an organized plan of investigation that includes examination of both upper and lower bowel, and which should proceed uninfluenced by pro tem results. Unfortunately the selection of patients for such further investigation is hampered by a lack of simple discriminatory tests.

Bacterial endocarditis presenting as acute monoarthritis

The presentation of a pig farmer with acute arthritis of the shoulder, cardiac murmurs, and Streptococcus suis growing on blood cultures highlights one of the rheumatological presentations of bacterial endocarditis. The need for a thorough general medical examination together with synovial fluid and blood culture in patients with acute monarthritis is emphasised. The suggestion that acute arthritis related to endocarditis is in nature truly septic, rather than mediated by circulating immune complexes, is supported.

Nonsteroidal anti-inflammatory drug-induced dyspepsia--is Campylobacter pyloridis implicated?

An endoscopic study of 34 patients with rheumatic diseases taking nonsteroidal anti-inflammatory drugs (NSAIDs) was undertaken to evaluate whether dyspepsia was associated with Campylobacter pyloridis. Twenty-two patients had an indication for upper gastrointestinal endoscopy and 12 patients were asymptomatic volunteers. Dyspepsia did not correlate with the macroscopic findings at endoscopy, the presence of histological gastritis or the presence of C. pyloridis. However, this study did demonstrate that macroscopic mucosal changes, histological gastritis and the presence of C. pyloridis have an equal prevalence in asymptomatic volunteers and symptomatic patients.

Bicipital swelling in adult-onset Still's disease

A patient with typical features of adult-onset Still's disease is described in whom bicipital swellings were a feature. Arthrography of shoulders and elbow joints failed to demonstrate communication with the cyst, suggesting the swelling was due to inflammation in a bursa overlying biceps muscle.