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07/19/2010 11:01 PM


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New Guidance for Methotrexate in RA

By Nancy Walsh, Staff Writer, MedPage Today

Published: July 18, 2010

Reviewed by

Adam J. Carinci, MD; Instructor, Harvard Medical School and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

■Explain to interested patients that methotrexate remains an important drug in the treatment of rheumatoid arthritis, despite the availability of many newer biologic agents.

■Advise patients that methotrexate can be taken safely with many other drugs -- an exception being the combination antibiotic trimethoprim-sulfamethoxazole.

New Canadian recommendations on the use of methotrexate in rheumatoid arthritis focus on routine clinical practice concerns -- ranging from drug interactions to clinical response and patient participation in therapeutic decision-making.

Despite the availability of newer, more effective biologic agents, methotrexate remains an anchor drug for the treatment of rheumatoid arthritis, Wanruchada Katchamart, MD, of the University of Toronto, and colleagues wrote online in the Journal of Rheumatology.

There is considerable variation in the use of the drug among rheumatologists, however, so a multinational initiative was undertaken to formulate evidence-based recommendations to help address practical problems associated with methotrexate use.

The recommendations were formulated by an expert committee consisting of 26 rheumatologists and were derived from a systematic review that included 93 articles from the literature, including meta-analyses, randomized trials, case-control studies, and case reports.

First, the authors stated, the majority of drugs, including nonsteroidal anti-inflammatory drugs, can be used safely in combination with methotrexate, despite reports of cytopenia and liver enzyme elevations. (Grade C Recommendation)

An exception was trimethoprim-sulfamethoxazole, which should be avoided because of the possibility of bone marrow suppression.

In determining an overall treatment strategy for patients with rheumatoid arthritis, clinicians should take into account patient characteristics associated with poor response to methotrexate, the researchers observed. (Grade B Recommendation)

These clinical predictors include:

•Female sex

•Prior use of disease-modifying anti-rheumatic drugs

•High disease activity at baseline as measured by the Disease Activity Score or Simplified Disease Activity Index

•High tender joint count

In addition, important predictors of poor radiographic outcome and joint damage that should be considered were elevated baseline erythrocyte sedimentation rate and other markers of persistent inflammation such as C-reactive protein.

With regard to the management of nonserious gastrointestinal side effects associated with methotrexate, consideration can be given to switching from oral to parenteral administration of the drug. (Grade D Recommendation)

This recommendation was based on two cohort studies that found the intramuscular formulation of the drug was more easily tolerated.

In another survey, almost half of patients (P<0.001) who had tolerated the drug when given parenterally were unable to continue with oral use because of nausea when intramuscular methotrexate became unavailable.

Another strategy that could be used to minimize side effects is splitting the dose -- a recommendation based entirely on expert opinion.

For assessment of clinical response, the researchers recommended the use of validated outcome measures to reach a target of low disease activity or remission. (Grade A Recommendation)

In addition, assessment of response should include joint counts, which "is the most important parameter reflecting disease activity," and other parameters including physician and patient global assessments and inflammatory markers. (Grade B Recommendation)

Finally, they stressed that patients need to be educated about their disease and treatment options, and should be involved in the decision-making process. (Grade D Recommendation)

This last recommendation was not based on evidence in the literature, but the experts "agreed that shared decision-making should incorporate patient's preference, research evidence, and knowledge of the patient's clinical state."

They also noted that at least temporary beneficial effects have been seen for patient education programs on pain, functional impairment, tender joint counts, patient overall assessments, and psychological status.

The authors also explained that because they relied primarily on expert opinion in formulating these recommendations, grading the levels of evidence was low, and further research is needed in "these clinically important areas."

This work was supported by an unrestricted educational grant from Abbott.

No other financial disclosures were reported.

Primary source: Journal of Rheumatology

Source reference:

Katchamart W, et al "Canadian recommendations for use of methotrexate in patients with rheumatoid arthritis" J Rheumatol 2010; DOI:10.3899/jrheum.090978.


07/20/2010 10:12 PM
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Varicella Vaccine Safe for Rheumatic Patients

By Nancy Walsh, Staff Writer, MedPage Today

Published: July 19, 2010

Reviewed by

Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

&#9632;Explain to interested patients that immunosuppression, whether from disease or drug treatment, can result in severe infection with varicella if exposure occurs.

&#9632;Also tell them that two doses of the vaccine are likely to be needed for full protection.

Varicella vaccine appears to be safe and relatively immunogenic for use in children with rheumatic diseases being treated with immunosuppressive drugs, a small prospective study has found.

Positive varicella-zoster virus IgG titers were detected in 10 of 20 previously seronegative patients with juvenile idiopathic arthritis, dermatomyositis, scleroderma, or vasculitis and in 13 of 18 healthy matched controls (P=0.2) four to six weeks after immunization, according to Gecilmara Salviato Pileggi, MD, of the University of São Paulo in Brazil.

During the three months following receipt of the vaccine, no overt varicella episodes or severe adverse reactions were seen among children who seroconverted, the researchers reported in the July Arthritis Care & Research.

Children with altered immune systems, such as can occur with the use of antirheumatic drugs, are at increased risk of severe disease should they be exposed to varicella, and there have been case reports of affected patients having serious and even fatal infections.

But evidence has been lacking on the safety of live vaccines in children with rheumatic diseases receiving immunosuppressive therapy, so Pileggi and colleagues conducted an open-label study that included 25 patients whose median age was 7.2 years. All patients received a single dose of varicella vaccine.

All participants were receiving methotrexate, at a mean dosage of 16.4 mg/m2/week, and 13 also were receiving prednisone in doses of 0.1 to 0.7 mg/kg/day.

Among the total cohort of 25 patients, five had equivocal pre-immunization virus titers and were excluded from the vaccine response analysis.

Low-grade fever lasting a single day was seen in one patient and one control, and three patients had mild varicella-like rashes during the first two weeks.

During a median follow-up period of 32 months, 16 patients reported exposure to wild varicella zoster virus, with eight of the exposures involving a household or classmate contact.

Two of those eight, both of whom were nonresponders to the vaccine, developed chickenpox, with one having a severe case complicated by pneumonia and probable macrophage activation syndrome.

That patient was receiving anti-tumor necrosis factor therapy at the time of the exposure, the investigators noted.

Vaccination was not associated with worsening of the underlying disease, and, in fact, among the subgroup of 17 patients with juvenile idiopathic arthritis, a significant improvement was seen in the number of joints with active arthritis in the three months following vaccination, decreasing from a mean of 3.2 (95% CI 1.4 to 5) to 1.8 (95% CI 0.8 to 2.8, P=0.009).

The investigators noted that the overall seroconversion rate to the vaccine was lower in this study than was seen in an earlier large study, where response rates exceeded 90%.

However, a more recent study found rates of seroconversion of 76% after one dose of the vaccine, and the Advisory Committee on Immunization Practices recommends the use of two doses in healthy children.

An editorial accompanying the study concurred.

"Based on the results of the current study, if a decision was made to immunize children with rheumatic diseases against varicella, a two-dose regimen would be preferable," wrote Robert W. Frenck, MD, of Cincinnati Children's Hospital and Jane F. Seward, MBBS, of the Centers for Disease Control and Prevention in Atlanta.

"Of note, in countries using varicella vaccine (one- or two-dose policy) in their universal childhood immunization program, most children will receive varicella vaccine before developing juvenile rheumatic diseases," the editorialists pointed out.

A limitation of the study was the small number of patients from a single center, and multicenter studies with larger numbers of patients are clearly needed to more fully estimate responsiveness to the vaccine in children with rheumatic diseases, Pileggi and colleagues noted.

"More research in this field is necessary for the development of specific immunization guidelines for patients with rheumatic and other autoimmune diseases receiving treatment with immunosuppressive agents who are still susceptible to preventable infectious disease," they concluded.

The lead author's work was supported by the University of São Paulo, and another author was supported by the Conselho Nacional de Desenvolvimento Científico e Technológico.

Editorialist Frenck has received consultant and speaking fees from the Data Safety Monitoring Boards of Novartis Vaccines.

Primary source: Arthritis Care & Research

Source reference:

Pileggi G, et al "Safety and immunogenicity of varicella vaccine in patients with juvenile rheumatic diseases receiving methotrexate and corticosteroids" Arthritis Care Res 2010; 62: 1034-1039.

Additional source: Arthritis Care & Research

Source reference:

Frenck R, Seward J "Varicella vaccine safety and immunogenicity in patients with juvenile rheumatic diseases receiving methotrexate and corticosteroids" Arthritis Care Res 2010; 62: 903-906.

08/05/2010 11:36 PM
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Anti-TNF Therapy for RA Raises Infection Risk

By Nancy Walsh, Staff Writer, MedPage Today

Published: August 04, 2010

Reviewed by

Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

&#9632;Explain to interested patients that a large British registry showed that rheumatoid arthritis sufferers treated with anti-TNF drugs had a higher rate of serious infections in the first six months of treatment compared with those on disease-modifying agents.

&#9632;Note that further analysis showed that while hospitalization rates were higher, 30-day mortality was not different between the groups.

Patients with rheumatoid arthritis being treated with tumor necrosis factor (TNF) blocking agents have a small but significant risk of developing serious infections, according to an update from the prospective British Society for Rheumatology Biologics Register.

Compared with patients being treated with conventional disease-modifying anti-rheumatic drugs, those on anti-TNF biologics had an adjusted hazard ratio of 1.2 (95% CI 1.1 to 1.5) for serious infection, James B. Galloway, MBBS, and colleagues from the University of Manchester, reported online in Rheumatology.

Researchers from the British register previously reported a nonsignificant 20% increase in the rate of serious infections, particularly with intracellular bacterial species such as Listeria and Salmonella, as well as Mycobacterium tuberculosis.

With longer follow-up, the increased risk remains at 20%, but has now become statistically significant, they noted.

The register includes 11,798 patients receiving anti-TNF therapy, whose mean age on enrollment was 56 years and whose mean disease duration was 11 years.

Baseline disease activity among these patients was high, at 6.6 on the 28-joint Disease Activity Scale, and 44% were on steroids at the time of enrollment.

A parallel cohort of patients taking conventional agents has also been recruited and includes 3,598 patients whose mean age at enrollment was 60 years and whose mean disease duration was six years.

Disease activity score in this second cohort was 5.1, and 23% were on steroids at baseline.

A total of 1,512 patients in the anti-TNF-treated cohort experienced at least one serious infection -- defined as an event requiring intravenous antibiotics or hospitalization or that resulted in death -- as did 296 in the comparator group.

The unadjusted rate of serious infection was higher in the anti-TNF cohort, at 42 versus 32 per 1,000 patient-years of follow-up.

Crude serious infection rates were higher in patients receiving infliximab (Remicade) than in those given etanercept (Enbrel) or adalimumab (Humira), but in adjusted analysis there was no difference between the three drugs.

The adjusted hazard ratio in the anti-TNF group was highest in the first six months of therapy,

at 1.8 (95% CI 1.3 to 2.6), decreasing over time to

0.9 (95% CI 0.6 to 1.3) between 24 and 36 months.

Crude rates of infection increased with advancing age in both cohorts, but adjusted hazard ratios were similar across all age groups.

Duration of hospitalization did not differ between the groups, but the 30-day mortality rate was much lower in the anti-TNF group, at 7% compared with 16% (P<0.001), for an adjusted odds ratio of 0.5 (95% CI 0.3 to 0.8).

In discussing their findings, Galloway and colleagues observed that presenting a single estimate for the risk of infection can be misleading, because the risk does not remain constant over time.

Several factors may contribute to the variation in risk over time:

•When patients at higher risk develop an infection, they are likely to stop the drug, resulting in a depletion of susceptible patients (healthy user effect).

•There may be time-dependent change in drug effects, with persistent blockade of TNF leading to an upregulation of other immune-signaling compensatory pathways.

•As patients become established on anti-TNF therapy they may be able to reduce their steroid dose and become more active, and disease-driven abnormalities in natural immunity may be reduced.

The authors acknowledged that physicians might have had a lower threshold for hospitalizing patients on anti-TNF agents who had infection, which might have affected the serious infection rate reported.

The investigators also noted that the 50% reduction in 30-day mortality was "intriguing," explaining that in animal models of sepsis, pretreatment with TNF inhibitors was beneficial, presumably because of suppression of the inflammatory response.

And although human studies found no benefit to adding TNF inhibitors to the regimen when sepsis has already developed, patients on these drugs could be considered as having had pretreatment against sepsis.

However, the study did not provide proof of causality for this, and further research is warranted in this area, they said.

The British Society for Rheumatology receives restricted income from Abbott Laboratories, Amgen, Schering-Plough, and Wyeth Pharmaceuticals.

The authors have declared no conflicts of interest.

Primary source: Rheumatology

Source reference:

Galloway J, et al "Anti-TNF therapy is associated with an increased risk of serious infections in patients with rheumatoid arthritis especially in the first 6 months of treatment: Updated results from the British Society for Rheumatology Biologics Register with special emphasis on risks in the elderly"

Rheumatology 2010; DOI: 10.1093/rheumatology/keq242.

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08/19/2010 02:52 AM
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Sham Acupuncture Matches the Real Thing in Knee OA

By Michael Smith, North American Correspondent, MedPage Today

Published: August 17, 2010

Reviewed by

Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

&#9632;Explain to interested patients that an optimistic presentation by the provider of both traditional and sham acupuncture treatments improved the outcome for knee osteoarthritis.

&#9632;Note that both acupuncture and sham treatments improved outcomes compared with controls but did not differ in any category from each other.

Traditional Chinese acupuncture was no more effective than sham acupuncture in relieving pain in patients with osteoarthritis of the knee, researchers said.

On the other hand, both procedures were better at pain relief than no therapy, according to Maria Suarez-Almazor, MD, PhD, of MD Anderson Cancer Center in Houston, and colleagues.

And treatment style -- neutral or positive -- also affected outcomes, with patients reporting better results if the acupuncturist was highly positive, regardless of whether what was actually delivered was traditional or sham acupuncture, the researchers reported online in Arthritis Care & Research.

"We found a small but significant effect on pain and satisfaction with treatment, demonstrating a placebo effect related to the clinician's communications style," Suarez-Almazor said in a statement, suggesting that the benefits of acupuncture may be "partially mediated through placebo effects related to the behavior of the acupuncturist."

In traditional Chinese medicine, the researchers noted, health is thought to arise through the flow of vital energy -- Qi -- through body paths called meridians, while disease is caused by blockages of the flow.

In Chinese acupuncture, needles are inserted at points along meridians to clear the obstructions.

Evidence is conflicting, they wrote, about the value of the procedure in knee osteoarthritis, which affects some 27 million Americans 25 and older, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

To help clarify the issue, Suarez-Almazor and colleagues conducted a nested randomized controlled trial, in which participants were first assigned either to a waiting list (to act as controls) or to an acupuncturist trained to deliver care in either a positive or a neutral manner.

In the "high expectations" group, the clinician said things like "I've had a lot of success with treating knee pain," while in the neutral group, patients were told the treatment "may or not may work" and "it depends on the patient."

Within the acupuncture groups, participants were further randomized to get traditional treatment -- with needles placed on meridians -- or a sham treatment, with needles placed outside the relevant meridians and inserted more shallowly, the researchers reported.

The sham treatment was referred to as "nontraditional acupuncture" in the patient consent form.

In accordance with current clinical practice, the researchers used electro-acupuncture; the electrical stimulation was continued for 20 minutes in the traditional arm, but stopped immediately after patients were able to feel it in the sham arm.

All told, 455 patients received got either traditional or sham acupuncture, and results were compared with 72 healthy controls on three scales --

the Joint-Specific Multidimensional Assessment of Pain (J-MAP), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, and the Satisfaction with Knee Procedure (SKIP) scale.

The researchers found:

•No significant differences between treatment groups on the J-MAP scale at any time point, but a significant difference (at P=0.0003) for both compared with patients on the waiting list.

•No significant differences between treatment groups on the WOMAC scale at any time point, but a significant difference (at P=0.0002) for both compared with patients on the waiting list.

•No significant differences between treatment groups on the SKIP scale at any time point. The SKIP questionnaire was not given to the patients on the waiting list.

On the other hand, when the acupuncture groups were compared by treatment style, they found that those in the high expectations group had significantly better scores on the J-MAP scale and the SKIP scale than those in the neutral group, at P=0.006 and P=0.004, respectively.

Differences on the WOMAC scale were not significant.

The researchers cautioned that, although verbal interactions between clinicians and patients were taped and reviewed, nonverbal communication, which was not measured, may also play a role in the effect.

Also, they wrote, there might have been some activity related to shallow insertion of needles into nonmeridian points, making it impossible to know what would have happened with the use of a less-invasive placebo.

Finally, they cautioned, it remains possible that some patients were able to tell what treatment they were getting, despite efforts to ensure blinding.

The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Agency for Healthcare Research and Quality. No disclosures were reported.

Primary source: Arthritis Care & Research

Source reference:

Suarez-Almazor ME, et al "A randomized controlled trial of acupuncture for osteoarthritis of the knee: Effects of patient-provider communication" Arth Care Research 2010.

© 2004-2010 MedPage Today, LLC. All Rights Reserved

12/31/2010 12:39 PM
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03/18/2011 09:27 PM
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TNF Blockers Improve Cardiac Risk in RA

By Nancy Walsh, Staff Writer, MedPage Today

Published: March 16, 2011

Reviewed by

Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Rheumatoid arthritis patients treated with tumor necrosis factor (TNF) inhibitors not only achieved significant improvements in symptoms and functioning, but also had a lower risk of cardiovascular disease, researchers found.

A study of more than 10,000 RA patients found that TNF inhibitor treatment was associated with a reduced risk of any cardiovascular event (HR 0.39, 95% CI 0.19 to 0.82) compared with nonbiological disease-modifying anti-rheumatic drugs (DMARDs) other than methotrexate, according to Jeffrey D. Greenberg, MD, of the NYU Hospital for Joint Diseases in New York City, and colleagues.

Methotrexate -- long the cornerstone of RA treatment -- did not decrease cardiovascular risk (HR 0.94, 95% CI 0.49 to 1.80), Greenberg and co-authors reported in the April Annals of the Rheumatic Diseases.

Action Points

&#9632;Explain that this study found that rheumatoid arthritis patients treated with tumor necrosis factor inhibitors not only experienced significant improvements in their symptoms and functioning but may also have a lowered risk of cardiovascular disease.

&#9632;Note that methotrexate -- a long-time cornerstone of RA treatment -- did not decrease cardiovascular risk in this study.

&#9632;Further note the limitations of this study included potential confounding by indication and selection bias, as well as the small number of cardiovascular events that limited the study's statistical power for secondary outcomes.

"Tumor necrosis factor antagonists have been a major advance in the treatment of RA, with randomized controlled trials demonstrating significant reductions in pain and improvement in function," the researchers wrote.

TNF inhibitors have anti-inflammatory effects, but it has been unclear if these effects extended to cardioprotection since previous studies have yielded conflicting results.

So Greenberg and colleagues analyzed data from 10,156 RA patients enrolled in the Consortium of Rheumatology Researchers of North America RA Registry (CORRONA) between October 2001 and December 2006.

Three-quarters of the patients were women, most were white, with a mean age of 59.

Median duration of disease was about seven years.

During a median follow-up of 22.9 months, there were 11,438 individual periods of drug exposure, with some patients switching from one treatment to another.

This included 4,684 exposures to TNF inhibitors, 4,969 exposures to methotrexate, and 1,785 exposures to other nonbiologic DMARDs, such as azathioprine.

In addition, there were 3,141 exposures to prednisone, at doses of 1 to 7 mg/day, and 1,090 exposures at daily doses of 7.5 mg/day or higher.

The primary outcome was a composite endpoint of myocardial infarction, stroke, transient ischemic attack (TIAs), and cardiovascular death.

During the study period there were 88 events, including 45 strokes or TIAs, 26 MIs, and 17 deaths.

Risks for cardiovascular events were adjusted for multiple possible confounders, including age, sex, smoking, concomitant disease such as diabetes and hypertension, as well as previous MI or stroke.

The incidence rates for the composite endpoint per 1,000 person-years were:

•Non-biologic DMARDs, 7.51 (95% CI 3.95 to 11.07)

•Methotrexate, 6.73 (95% CI 4.83 to 8.63)

•TNF inhibitors, 2.93 (95% CI 1.74 to 4.13)

"These data indicate that TNF antagonists may represent a therapeutic strategy to attenuate the heightened cardiovascular risk experienced by RA patients," Greenberg and colleagues observed.

At the same time, prednisone use was associated with an increased risk for cardiovascular events, with hazard ratios of 1.78 (95% CI 1.06 to 2.96) for daily doses up to 7 mg and 2.62 (95% CI 1.29 to 2.96) for higher doses (P=0.04 for trend).

This finding confirmed earlier observations linking prednisone use with cardiovascular risk in RA patients, they noted.

Precisely how TNF inhibitors may lower cardiovascular risk in RA is uncertain, but some research has suggested that the drugs may help prevent plaque rupture and improve endothelial function.

Strengths of the study, according to the investigators, include the size of the cohort and the availability of detailed data on drug exposure and potential confounders.

But, as with all observational studies, there were limitations such as potential confounding by indication and selection bias, as well as the small number of cardiovascular events that limited the study's statistical power for secondary outcomes.

The researchers cited as an additional limitation the study's definition for drug exposures as being based on current drug use -- which may have introduced bias from left censored data.

The study was funded by the Arthritis Foundation.

CORRONA has received support from Abbott, Amgen, BMS, Centocor, Genentech, Lilly, and Roche.

The lead investigator reported receiving salary support from research grants from the National Institutes of Health, the Arthritis Foundation, and Bristol-Myers Squibb. He also has served on advisory boards for BMS, Centocor, Genentech, Roche, and UCB.

Co-investigators reported receiving support from various foundations and companies including Amgen, Abbott, Roche, and Centocor.

Primary source: Annals of the Rheumatic Diseases

Source reference:

Greenberg J, et al "Tumor necrosis factor antagonist use and associated risk reduction of cardiovascular events among patients with rheumatoid arthritis" Ann Rheum Dis 2011; 70: 576-582. utm_content=&utm_medium=email&utm_campaign=DailyHeadlines& utm_source=WC&em=

© 2011 Everyday Health, Inc. All rights reserved

03/18/2011 10:31 PM
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Doctors Need to Improve Guidance on Arthritis: Study

Only one of three goals set a decade ago to help patients manage the disease has been met, CDC finds

URL of this page: fullstory_109826.html(*this news item will not be available after 06/13/2011)

Tuesday, March 15, 2011

MONDAY, March 14 (HealthDay News) --

Doctors today are more likely to advise obese arthritis patients to lose weight than 10 years ago, but they still fall short on counseling patients to exercise or learn about pain-management techniques, a new study finds.

Researchers at the U.S. Centers for Disease Control and Prevention looked at how well the health care system met arthritis-management goals set by the federal government in 2000 as part of a program called Healthy People 2010.

Noting that only one of the three key objectives was achieved -- recommending weight loss -- the study authors said physicians are missing important opportunities to help arthritis patients manage their pain and disability.

"Doctors are pressed for time and may be focused on medications rather than behaviors," said lead author Dr. Charles Helmick, a medical epidemiologist at the Arthritis Program of the CDC's National Center for Chronic Disease Prevention and Health Promotion.

"They may not know how to connect people with the right sort of education or exercise programs."

About 46 million U.S. adults suffer from arthritis, making it one of the most common chronic conditions in the United States, according to background information in the study.

Osteoarthritis, the most common form of the disease, results from wear and tear as people age.

Rheumatoid arthritis, an autoimmune disease, can occur at any age, and is believed to have a genetic basis. Symptoms for both include inflammation and stiffness of the joints, and pain.

Weight loss, arthritis education and exercise are known to improve pain and quality of life for arthritis patients, according to the study, published in the March/April issue of Annals of Family Medicine.

The U.S. government goals were developed with input from many professional organizations, said Hemlick. "Our purpose was to try to achieve higher levels of these objectives," he added.

Using data compiled from two national surveys involving more than 100,000 U.S. adults with doctor-diagnosed arthritis, the study found no change in the percentage of patients who took an arthritis self-management class (11 percent) or were told to engage in physical activity (52 percent) between 2002 and 2006.

(The targets for 2010 were 13 percent and 67 percent, respectively.)

But the number of obese arthritis patients whose doctors advised weight loss for pain relief increased significantly -- from 35 percent in 2002 to 41 percent in 2006, putting the 2010 target of 46 percent within reach.

Doctors were less likely to advise patients who were merely overweight, rather than obese, to shed pounds, the study found.

About 66 percent of arthritis patients are overweight or obese, which increases stress on the joints, contributing to chronic pain.

Losing just 13 pounds can significantly reduce disability from knee osteoarthritis, according to the study.

Also, arthritis education programs can "improve the health of an adult ... by 15 to 30 percent more than medication alone," the study said, and physical activity helps "reduce pain and disability and to increase function."

The Arthritis Foundation offers educational programs for people with the disease in community settings such as the YMCA.

"There is good evidence that being physically active reduces pain in the long run, so it's just a matter of getting over the initial hump," said Hemlick, referring to patients' concerns about pain from exercising.

Recommended activities include low-impact exercise, such as walking, swimming, tai chi or aquatic exercise.

One expert cautioned that the study findings are subject to bias because the subjects were interviewed by telephone, and their recall might be faulty.

"Surveys by phone are great for gathering a lot of data so it eliminates the statistical problems when you have too few patients," said Dr. James Barber, an orthopedic surgeon at Coffee Regional Medical Center in Douglas, Ga.

"But it's not as scientific as if patients were studied in a more prospective manner."

However, he said the findings do reflect communication gaps in current practice.

Doctors hesitate to tell patients something obvious, such as the need to lose weight, and like patients, they feel uncomfortable discussing the subject, said Barber.

"It's safe to say that the things this study measured -- education, weight loss, exercise -- we know they help patients. But how do we get doctors to talk freely and easily with patients?" he asked.


Charles Helmick, M.D., epidemiologist, Arthritis Program, U.S. National Center for Chronic Disease Prevention and Health Promotion, U.S. Centers for Disease Control and Prevention, Atlanta;

James Barber, M.D., board-certified orthopedic surgeon, Coffee Regional Medical Center, Douglas, Ga.;

March/April 2011 Annals of Family Medicine

HealthDay fullstory_109826.html

Copyright (c) 2011 HealthDay. All rights reserved.


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