The Latest News in Rheumatology
7/5/2002
Predictors of the Progression of Functional Disability in
Patients with Ankylosing Spondylitis
Do Dietary Supplements in Topical Ointments Really
Work for Arthritis Pain?
Why Some People With Arthritis Swear by Leeches
FDA Approves a New COX-2 Medication
HMO's Dealt Blow by U.S. Supreme Court
Case of a Pharmacy Jeopardizing Patient Privacy
In the July 2002 Journal of Rheumatology, Michael M. Ward published
findings of his study, which sought to identify patient characteristics to
predict the short term rate of progression of functional disability in AS.
Ward defines functional ability as a major component of health related
quality of life and an important health outcome for people with AS.
Accordingly, functional disability can predict future work loss and is the main
determinant of medical costs in AS. With hopes of learning how to improve
functional ability, Ward designed a study to identify which patients are at
greater risk for functional disability and to understand the mechanisms by which
disability develops.
Results: 241 patients from the Stanford University Medical Center and
the VA Palo Alto Health Care System were enrolled in the five-year study. Ward
found that four factors predicted the rate of progression of functional
disability: older age, smoking, social support, and back exercise. Older age and
current smoking were associated with more rapid rates of progression, whereas
more frequent back exercise and better perceived social support were associated
with improvement in functional disability over time.
The findings indicate that age has an important influence on functional
disability, apart from its association with disease duration. Essentially,
functional disability in AS patients accelerates with age.
Smoking may directly influence functional ability in AS patients by worsening
lung function (which may already be a problem for those who have a rigid thorax
and restrictive ventilatory deficits), causing cardiovascular disease, and by
contributing to osteoporotic fractures. These conditions could further wreak
havoc on a person's functional ability by leading to decreased exercise capacity
and greater deconditioning.
Consistent with studies on other rheumatic diseases, Ward found that better
social support is associated with lower prevalence of functional disability and
slower relates of progression of functional disability in people with AS. Those
who are in contact with people or have resources to discuss their disease and
related problems seem to function better than the patients who do not have or
seek a social support system.
Lastly, doctors have long been prescribing back exercise for AS, primarily to
reduce symptoms and maintain good posture. Ward's findings suggest that more
frequent back exercise (performed by patients in a supervised or unsupervised
setting) is also associated with slower rate of progression of functional
disability over a period of several years.
According to an article by Jennifer L. Huget in The Washington Post
(June 25, 2002), some manufacturers are boasting popular dietary supplements--
glucosamine and chondroitin--in their topical arthritis creams to treat
osteoarthritis, yet it is questionable whether these supplements actually work
as a topical cream.
There is absolutely no evidence to suggest these supplements aid in easing
arthritis pain if applied topically. Daniel Clegg, a lead investigator of the
University of Utah, said "Glucosamine and especially chondroitin are both
large molecules, and it is difficult to believe that they would be absorbed
through the skin."
That is not stopping companies (such as Joint-Ritis, JointFlex, and
MaxxiRubboldly) from marketing topical ointments to highlight the two
ingredients in question. JointFlex settled a case by the Federal Trade
Commission for advertising that the supplements could contribute to pain relief,
although they could not back up the statement with any sort of evidence.
JointFlex remains on the market, but currently lists glucosamine and chondroitin
as "moisturizing agents", a claim that appears to have more
legitimacy. Joint-Ritis now does the same. This puts the creams in the more
regulatory relaxed world of cosmetics.
But this causes a confusing situation for consumers because the ointments are
sharing shelf space with both dietary supplements containing glucosamine and
chondroitin, and with topical analgesics that do not contain those ingredients.
"How are consumers going to know that some of the products on the shelves
have had to support their claims and others haven't?" asks David Schardt, a
senior nutritionist at the Center for Science in the Public Interest.
Stockholm, Sweden (Reuters)--A team of Russian researchers announced results
of their study at the recent European Congress of Rheumatology in which they
successfully administered Hirido Medicinalis (aka leeches) to rheumatoid
arthritis and
osteoarthritis patients.
The first recorded clinical use of the blood-sucking
creatures occurred approximately 2500 years ago, and some doctors continued to
use leeches throughout the years to treat a variety of ailments before modern
medicine was available. Now as the cost of health care and medical procedures continue
to rise and billions of dollars are spent on more conventional drug therapies
each year, leeches may prove an attractive possibility for some people.
Leeches remove blood through a tiny incision in their teeth. Their saliva contains analgesic and anesthetic compounds, in addition to
an anti-blood clotting agent.
The Russian researchers recently evaluated leech
therapy in 105 patients with symptoms of rheumatoid arthritis and osteoarthritis.
For each patient, they placed leeches on "pain zones" in the muscles
surrounding the joints, anywhere from one to five times per area. "We found
in all patients clinical improvement after leech therapy," said I.G.
Salikhov and colleagues at Kazan State Medical University, Kazan.
Improvements
included decrease or disappearance of muscle pain, less morning stiffness, and
an increase in the range of joint movements. Laboratory tests showed blood
changes, including reduction of an inflammation-related compound known as
C-reactive protein, and a change in blood-clotting factors, including a longer
coagulation time.
There were no significant side effects after the leech treatment, so the scientists
conclude the use of leeches was both effective and safe. There was no
information regarding use in people with AS.
Valdecoxib (Bextra--Pharmacia, Pfizer) is a new, once-daily COX-2 inhibitor
approved by the FDA for use in treating osteoarthritis, adult rheumatoid
arthritis, and menstrual pain and cramping. It joins the COX-2 family of
medications, which currently include celecoxib (Celebrex--Pharmacia, Pfizer) and
rofecoxib (Vioxx--Merck). Valdecoxib gives patients another treatment option
since not everyone responds well to each medication.
In clinical trials, valdecoxib demonstrated efficacy comparable with that of
conventional NSAIDS (specifically naproxen, ibuprofen, and diclofenac), but it
offered improved gastrointestinal safety and tolerability when compared with the
NSAIDS. As with other COX-2 inhibitors, valdecoxib can cause serious GI
toxicity, including bleeding, ulceration, and perforation of the stomach with or
without warning symptoms, although they are less likely to occur when using
COX-2's instead of traditional NSAIDS.
The most common adverse effects during clinical trials were dyspepsia, headache,
abdominal pain, nausea, and diarrhea. It is not advised for patients who have
experienced asthma or allergic reactions after taking aspirin or conventional
NSAIDS. The agent should be used with caution in patients with fluid retention,
heart failure, or hypertension.
Washington (CNN News)--The Supreme Court ruled that state laws designed to
help patients fight decisions of their HMO's
are constitutional. This will likely pave the way for patients to obtain second
opinions from doctors, and for independent boards to review HMO decisions.
Most states have some type of law intended to assist HMO patients. But
proposals for a "national patient bill of rights" have been victims of
partisan debate, as the Congress has not yet passed a federal law concerning
this issue. Talks at the Capitol stalled after the September 11 attacks, putting
on hold plans for a nationwide system for independent evaluations.
The Supreme Court's decision took place at a hearing of an Illinois woman who
underwent surgery after receiving a second opinion from a specialist
unaffiliated with her HMO. Her HMO, "Rush Prudential", refused to pay
for the $95,000 procedure to correct her nerve condition, so the woman sued and
won. The court rejected the HMO's appeal, which claimed a federal law on
employment benefits pre-empts the Illinois HMO Act that provides patients with a
right to an independent review of denial of medical benefits.
After being treated for psoriasis, Paul Dansereau thought the information he
had been sharing with his doctor and pharmacist was confidential. Once he
began receiving mailings about other psoriasis treatments, "It seemed
pretty clear to me that either the physician or the pharmacy had released my
name." Unbeknownst to many in the public, some pharmaceutical companies are
paying pharmacies for direct access to the patient, causing patients to feel
that their privacy has been violated.
According to Craig Fuller of the National Association of Chain Drug Stores,
"In order to provide educational information to patients, someone has to
pay for it. There definitely is a business relationship between the
pharmaceutical manufacturer and the pharmacy."
Pharmaceutical companies today are feeling the impact of more competition
from generic drug makers, and fewer blockbuster drugs in the pipeline. In some
cases, pharmacies sell lists of patients who take certain drugs to
pharmaceutical manufacturers, and the pharmacies can receive about $1 for every
patient who gets a follow-up letter about treatments or medications, and up to
$3 for each phone call to a patient.
In April 2003, new medical privacy rules will require health care providers
to tell patients exactly how their private medical information could be used,
bought, or sold. It will allow patients to accept or reject the parameters,
along with the ability to say "I will choose to seek my services
elsewhere."
But opponents of the new rule say that is not good enough because when it
comes to privacy, the patient's word should be the last. Dr. Paul Appelbaum of
the American Psychiatric Association commented, "Traditionally, medical
information was never released unless patients gave their consent for it and
that's the rule we think should be carried forward." Appelbaum said it will
be tough for patients who do not agree with their providers' practice of passing
on medical information because they will have to either try to find a new health
care provider or pay out of pocket.
Like Appelbaum, Dansereau expresses great concern: "I'm self-employed
and my wife and I have individual health insurance. We're not part of a big
plan. So if we're dropped, we'd be scrambling."