J Rheumatol Suppl [JOURNAL]
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200 papers
The efficacy and safety of treatments for acute gout: results from a series of systematic literature reviews including Cochrane reviews on intraarticular glucocorticoids, colchicine, nonsteroidal antiinflammatory drugs, and interleukin-1 inhibitors.
Wechalekar MD, Vinik O, Moi JH … +10 more , Sivera F, van Echteld IA, van Durme C, Falzon L, Bombardier C, Carmona L, Aletaha D, Landewé RB, van der Heijde DM, Buchbinder R
J Rheumatol Suppl · 2014 Sep · PMID 25180124 · Publisher ↗
OBJECTIVE: To determine the efficacy and safety of glucocorticoids (GC), colchicine, nonsteroidal antiinflammatory drugs (NSAID), interleukin-1 (IL-1) inhibitors, and paracetamol to treat acute gout. METHODS: We searched...
OBJECTIVE: To determine the efficacy and safety of glucocorticoids (GC), colchicine, nonsteroidal antiinflammatory drugs (NSAID), interleukin-1 (IL-1) inhibitors, and paracetamol to treat acute gout. METHODS: We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials to September 2011. Randomized controlled trials (RCT) or quasi-RCT in adults with acute gout that compared GC, colchicine, NSAID, IL-1 inhibitors, and paracetamol to no treatment, placebo, another intervention, or combination therapy were included. Two authors independently extracted data and assessed risk of bias. Primary endpoints were pain and adverse events. Data were pooled where appropriate. RESULTS: Twenty-six trials evaluating GC (N = 5), NSAID (N = 21), colchicine (N = 2), and canakinumab (N = 1) were included. No RCT assessed paracetamol or intraarticular (IA) GC. No RCT compared systemic GC with placebo. Moderate quality evidence (3 trials) concluded that systemic GC were as effective as NSAID but safer. Low quality evidence (1 trial) showed that both high- and low-dose colchicine were more effective than placebo, and low-dose colchicine was no different to placebo with respect to safety but safer than high-dose colchicine. Low quality evidence (1 trial) showed no difference between NSAID and placebo with regard to pain or inflammation. No NSAID was superior to another. Moderate quality evidence (1 trial) found that 150 mg canakinumab was more effective than a single dose of intramuscular GC (40 mg triamcinolone) and equally safe. CONCLUSION: GC, NSAID, low-dose colchicine, and canakinumab all effectively treat acute gout. There was insufficient evidence to rank them. Systemic GC appeared safer than NSAID and lower-dose colchicine was safer than higher-dose colchicine.
Cardiovascular risk factors and comorbidities in patients with hyperuricemia and/or gout: a systematic review of the literature.
van Durme C, van Echteld IA, Falzon L … +3 more , Aletaha D, van der Heijde DM, Landewé RB
J Rheumatol Suppl · 2014 Sep · PMID 25180123 · Publisher ↗
OBJECTIVE: To review the available literature on the likelihood of having cardiovascular (CV) risk factors and on developing CV comorbidities in patients with gout and/or asymptomatic hyperuricemia as an evidence base fo...
OBJECTIVE: To review the available literature on the likelihood of having cardiovascular (CV) risk factors and on developing CV comorbidities in patients with gout and/or asymptomatic hyperuricemia as an evidence base for generating multinational clinical practice recommendations in the 3e (Evidence, Expertise, Exchange) Initiative in Rheumatology. METHODS: A systematic literature search was carried out using MEDLINE, EMBASE, and The Cochrane Library, and abstracts presented at the 2010/2011 meetings of the American College of Rheumatology (ACR) and the European League Against Rheumatism, searching for CV risk factors and new CV comorbidities in patients with asymptomatic hyperuricemia and/or a diagnosis of gout. Trials that fulfilled predefined inclusion criteria were systematically reviewed. RESULTS: A total of 66 out of 8918 identified publications were included in this review. After assessment of the risk of bias, 32 articles with a high risk of bias were excluded. Data could not be pooled because of clinical and statistical heterogeneity. In general, both for asymptomatic hyperuricemia and for gout the hazard ratios for CV comorbidities were only modestly increased (1.5 to 2.0) as were the hazard ratios for CV risk factors, ranging from 1.4 to 2.0 for hypertension and from 1.0 to 2.4 for diabetes. CONCLUSION: Unlike the common opinion that patients with gout or hyperuricemia are at higher risk of developing CV disease, the actual risk to develop CV disease is either rather weak (for hyperuricemia) or poorly investigated (for gout).
Diagnostic value of clinical, laboratory, and imaging findings in patients with a clinical suspicion of gout: a systematic literature review.
Sivera F, Andrès M, Falzon L … +2 more , van der Heijde DM, Carmona L
J Rheumatol Suppl · 2014 Sep · PMID 25180122 · Publisher ↗
OBJECTIVE: To analyze the diagnostic utility of clinical, laboratory, and imaging items for gout. METHODS: A systematic literature search was performed in MEDLINE, EMBASE, and The Cochrane Library; and a manual search of...
OBJECTIVE: To analyze the diagnostic utility of clinical, laboratory, and imaging items for gout. METHODS: A systematic literature search was performed in MEDLINE, EMBASE, and The Cochrane Library; and a manual search of abstracts from the 2010/2011 meetings of the American College of Rheumatology (ACR) and the European League Against Rheumatism, as well as the reference lists of retrieved papers. Studies were included if they evaluated the diagnostic utility of clinical, laboratory, or imaging features or criteria for the diagnosis or classification of gout in adult patients. Two independent reviewers selected papers, extracted the data, and assessed the risk of bias. RESULTS: Nineteen studies were included in the review; 4 used the identification of monosodium urate (MSU) crystals as the reference standard (RS) and the rest used expert opinion or the ACR preliminary criteria. Most features were evaluated in a single study. Evidence for diagnostic utility, using MSU crystals as RS, of over 50 individual clinical, laboratory, and radiographic features was retrieved. Most items showed a positive likelihood ratio (LR+) < 3, except for the following: response of arthritis to colchicine (LR+ 4.3); presence of tophi on physical examination (LR+ 15.6-30.9); identification of the double-contour sign in ultrasound (US) (LR+ 13.6); and detection of urate deposits by dual-energy computed tomography (DECT) (LR+ 9.5). CONCLUSION: Individual clinical features show low diagnostic utility, with the exception of tophi and response to colchicine. Some US and DECT findings show better performance than most clinical features.
Introduction: diagnosis and management of gout. Systematic literature reviews of the 3e Initiative 2011-2012.
van der Heijde D, Buchbinder R
J Rheumatol Suppl · 2014 Sep · PMID 25180121 · Publisher ↗
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Cost for tuberculosis care in developed countries: which data for an economic evaluation?
Trieste L, Turchetti G
J Rheumatol Suppl · 2014 May · PMID 24789005 · Publisher ↗
Tuberculosis (TB) seems to be eradicated in developed countries. However, current migration flows and increasing use of immunosuppressive and biologic drugs for rheumatic diseases are increasing the risk of latent TB and...
Tuberculosis (TB) seems to be eradicated in developed countries. However, current migration flows and increasing use of immunosuppressive and biologic drugs for rheumatic diseases are increasing the risk of latent TB and TB onset for citizens of developed countries. Because little is known about the economic burden of TB in developed countries, we set out to describe the order and dimension of the costs of TB care in developed countries. A review of the literature indicated that the cost for anti-TB therapy is about $2000 US per patient. Costs of drugs associated with standard therapy for active TB [2HRZE/4HR, i.e., 2 months of isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E), followed by 4 months of HR] are about $600. Standard therapy for latent TB care costs about $80 for 9H and $256 for 4R, respectively. However, these data are very limited because of the horizon of analysis and because data are strongly localized. It can be concluded that in developed countries, available data on TB care costs are insufficient for detailed analysis of the economic burden of TB.
Restarting biologics and management of patients with flares of inflammatory rheumatic disorders or psoriasis during active tuberculosis treatment.
Cantini F, Prignano F, Goletti D
J Rheumatol Suppl · 2014 May · PMID 24789004 · Publisher ↗
Our aim was to review the evidence concerning optimal timing for restarting biologics in patients with active tuberculosis (TB), and the management of relapsing rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankyl...
Our aim was to review the evidence concerning optimal timing for restarting biologics in patients with active tuberculosis (TB), and the management of relapsing rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), and psoriasis during treatment for TB. Few or no indications are available for 2 important challenges for clinicians: the timing for restarting biologics in patients with TB reactivation and the management of the underlying disorder. In the absence of clear evidence, guidelines and experts suggest restarting anti-tumor necrosis factor-α (TNF-α) agents after completion of an active TB therapy course, but no indications are available on the appropriate management of patients with flares of underlying rheumatic disease or psoriasis. Among anti-TNF-α agents, etanercept is associated with the lowest risk of TB reactivation, and non-anti-TNF-α biologics and several nonbiologic drugs are associated with low/no risk of TB reactivation. Therefore, for patients with relapsing RA, PsA, AS, or psoriasis during TB treatment we propose a therapeutic schedule modulated by disease activity and individual single drug-related TB risk.
Current treatment options for latent tuberculosis infection.
Bocchino M, Matarese A, Sanduzzi A
J Rheumatol Suppl · 2014 May · PMID 24789003 · Publisher ↗
Treatment of latent tuberculosis infection (LTBI) is a key component in TB control strategies worldwide. However, as people with LTBI are neither symptomatic nor contagious, any screening decision should be weighed caref...
Treatment of latent tuberculosis infection (LTBI) is a key component in TB control strategies worldwide. However, as people with LTBI are neither symptomatic nor contagious, any screening decision should be weighed carefully against the potential benefit of preventing active disease in those who are known to be at higher risk and are willing to accept therapy for LTBI. This means that a targeted approach is desirable to maximize cost effectiveness and to guarantee patient adherence. We focus on LTBI treatment strategies in patient populations at increased risk of developing active TB, including candidates for treatment with tumor necrosis factor-α blockers. In the last 40 years, isoniazid (INH) has represented the keystone of LTBI therapy across the world. Although INH remains the first therapeutic option, alternative treatments that are effective and associated with increased adherence and economic savings are available. Current recommendations, toxicity, compliance, and cost issues are discussed in detail in this review. A balanced relationship between the patient and healthcare provider could increase adherence, while cost-saving treatment strategies with higher effectiveness, fewer side effects, and of shorter duration should be offered as preferred.
Tuberculosis reactivation risk in dermatology.
Pescitelli L, Ricceri F, Prignano F
J Rheumatol Suppl · 2014 May · PMID 24789002 · Publisher ↗
The treatment of some dermatological diseases, especially psoriasis, has been revolutionized by the advent of biologic therapies that target various immune cells or cytokines. However, biologic therapies may affect the r...
The treatment of some dermatological diseases, especially psoriasis, has been revolutionized by the advent of biologic therapies that target various immune cells or cytokines. However, biologic therapies may affect the risk of active tuberculosis (TB). We review the published safety data about TB risk reactivation for biologic agents used in dermatology. According to recent findings, psoriasis itself could represent an independent risk factor for TB; a high prevalence of TB was found in patients with psoriasis (18.0%), even after adjusting for age, work, and other characteristics. Latent TB infection was more common in patients with psoriasis (50%) than in those with inflammatory bowel disease (24.2%). Risk of TB reactivation was also influenced by the type of agent used. Several structural and functional differences among biologic drugs could account for differences in risk of granulomatous infection. Different kinetics of currently available tumor necrosis factor (TNF) antagonists, leading to different TNF bioavailability in granulomatous tissue, may explain differences in TB reactivation among patients treated with biologics. One could argue that etanercept should be the first choice of anti-TNF agent in populations at high risk of TB. Risk of TB reactivation during treatment with other biologics is not yet well defined.
Tuberculosis risk in patients treated with non-anti-tumor necrosis factor-α (TNF-α) targeted biologics and recently licensed TNF-α inhibitors: data from clinical trials and national registries.
Cantini F, Niccoli L, Goletti D
J Rheumatol Suppl · 2014 May · PMID 24789001 · Publisher ↗
This review aimed to evaluate the risk of active tuberculosis (TB) occurrence in patients with rheumatic disorders receiving non-anti-tumor necrosis factor (TNF) targeted biologics anakinra (ANK), tocilizumab (TCZ), ritu...
This review aimed to evaluate the risk of active tuberculosis (TB) occurrence in patients with rheumatic disorders receiving non-anti-tumor necrosis factor (TNF) targeted biologics anakinra (ANK), tocilizumab (TCZ), rituximab (RTX), abatacept (ABA), and recently approved anti-TNF golimumab (GOL), and certolizumab pegol (CTP). In recent findings, no cases of active TB were recorded in patients with rheumatoid arthritis (RA) and other rheumatic conditions treated with anti-CD20+ RTX and anti-CD28 ABA. No patient receiving anti-interleukin 1 (IL-1) ANK developed active TB, and an increased risk was excluded in a Canadian database. In contrast, 8 active TB cases were observed in 21 trials of patients with RA receiving anti-IL-6 TCZ, while no increased TB risk resulted from Japanese postmarketing surveillance. Among GOL-treated and CTP-treated patients, 8 and 10 active TB cases occurred, respectively, while no data are available from registries. However, all but 1 TB case recorded in patients treated with TCZ, GOL, and CTP occurred in TB-endemic countries. No TB risk resulted for ANK, RTX, and ABA, suggesting pretreatment screening procedures for latent TB infection detection are unnecessary. Because all TB cases occurred in countries at high risk for TB, where TB exposure could have occurred during treatment, no definitive conclusions can be drawn for TCZ, GOL, and CTP.
Adalimumab, etanercept, infliximab, and the risk of tuberculosis: data from clinical trials, national registries, and postmarketing surveillance.
Cantini F, Niccoli L, Goletti D
J Rheumatol Suppl · 2014 May · PMID 24789000 · Publisher ↗
This review evaluates the risk of tuberculosis (TB), adherence with recommendations for TB prevention, and host-related risk in patients with rheumatoid arthritis (RA), psoriatic arthritis, and ankylosing spondylitis rec...
This review evaluates the risk of tuberculosis (TB), adherence with recommendations for TB prevention, and host-related risk in patients with rheumatoid arthritis (RA), psoriatic arthritis, and ankylosing spondylitis receiving infliximab (IFX), adalimumab (ADA), and etanercept (ETN) through an analysis of phase III randomized controlled trials (RCT), postmarketing surveillance, and national registries. Ten (0.21%) TB cases occurred among 4590 patients in 16 RCT of IFX, 9 (0.12%) among 7009 patients in 21 RCT of ADA, and 4 (0.05%) among 7741 patients in 26 RCT of ETN. Overall, 19/23 (83%) TB cases occurred in patients with RA. Data from national registries and postmarketing surveillance showed an increased risk of TB in patients receiving any of the 3 anti-tumor necrosis factor (TNF) drugs, with a 3-4 times higher risk associated with IFX and ADA than with ETN. Deviations from recommended TB prevention procedures were observed in up to 80% of patients, and most registries did not include data on host-related risk factors for TB. TB occurrence was reduced in recent RCT but not in real-life practice. TB risk was lower for ETN than for monoclonal antibody anti-TNF agents. More complete data collection, including host-related TB risk factors, is advisable to avoid biased results.
Diagnosis of latent tuberculosis and prevention of reactivation in rheumatic patients receiving biologic therapy: international recommendations.
Iannone F, Cantini F, Lapadula G
J Rheumatol Suppl · 2014 May · PMID 24788999 · Publisher ↗
OBJECTIVE: To review the official international recommendations on the management of latent tuberculosis infection (LTBI) in patients with rheumatic diseases undergoing biologic therapy. METHODS: A systematic search of a...
OBJECTIVE: To review the official international recommendations on the management of latent tuberculosis infection (LTBI) in patients with rheumatic diseases undergoing biologic therapy. METHODS: A systematic search of all clinical practice recommendations on the diagnosis and treatment of LTBI in rheumatic patients eligible for starting biologic drugs published between January 2002 and March 2013. RESULTS: For the diagnosis of LTBI, based on positivity of tuberculin skin test (TST), interferon-γ release assay (IGRA) is also available. Most recommendations advise using both TST and IGRA, especially in case of Bacillus Calmette-Guérin vaccination, to screen patients before commencing biologic drugs. There is a general consensus that evaluation of the global risk of TB infection is a crucial point and that patients with LTBI must receive chemoprophylaxis prior to biologic therapy. However, recommendations on the need for rescreening for activation of LTBI or new TB infection while patients are being treated are inadequate. Nevertheless, the main concern is poor compliance with TB recommendations of rheumatologists in clinical practice, which seems to be the main cause of the occurrence of active TB in rheumatic patients receiving biologic therapy. CONCLUSION: Notwithstanding some differences, mainly related to regional TB incidence, international recommendations strongly suggest careful screening for LTBI before starting biologic therapy. However, the critical point is implementing dissemination and awareness of the recommendations among rheumatologists to improve adherence in real life.
Diagnostic accuracy of chest radiography for the diagnosis of tuberculosis (TB) and its role in the detection of latent TB infection: a systematic review.
Piccazzo R, Paparo F, Garlaschi G
J Rheumatol Suppl · 2014 May · PMID 24788998 · Publisher ↗
In this systematic review we evaluate the role of chest radiography (CXR) in the diagnostic flow chart for tuberculosis (TB) infection, focusing on latent TB infection (LTBI) in patients requiring medical treatment with...
In this systematic review we evaluate the role of chest radiography (CXR) in the diagnostic flow chart for tuberculosis (TB) infection, focusing on latent TB infection (LTBI) in patients requiring medical treatment with biological drugs. In recent findings, patients scheduled for immunomodulatory therapy with biologic drugs are a group at risk of TB reactivation and, in such patients, detection of LTBI is of great importance. CXR for diagnosis of pulmonary TB has good sensitivity, but poor specificity. Radiographic diagnosis of active disease can only be reliably made on the basis of temporal evolution of pulmonary lesions. In vivo tuberculin skin test and ex vivo interferon-γ release assays are designed to identify development of an adaptive immune response, but not necessarily LTBI. Computed tomography (CT) is able to distinguish active from inactive disease. CT is considered a complementary imaging modality to CXR in the screening procedure to detect past and LTBI infection in specific subgroups of patients who have increased risk for TB reactivation, including those scheduled for medical treatment with biological drugs.
Performance of the tuberculin skin test and interferon-γ release assays: an update on the accuracy, cutoff stratification, and new potential immune-based approaches.
Goletti D, Sanduzzi A, Delogu G
J Rheumatol Suppl · 2014 May · PMID 24788997 · Publisher ↗
An association between biologic agents and reactivation of active disease from latent tuberculosis infection (LTBI) has been established. Screening for LTBI is, therefore, now recommended for candidates for biologic drug...
An association between biologic agents and reactivation of active disease from latent tuberculosis infection (LTBI) has been established. Screening for LTBI is, therefore, now recommended for candidates for biologic drugs. The tuberculin skin test (TST) and interferon-γ release assays (IGRA) are the available commercial tests for detecting LTBI. We discuss their accuracy in immune-competent subjects and patients with autoimmune diseases, as well as potential new approaches to immune diagnosis. IGRA seem to be more accurate than TST in bacillus Calmette-Guerin vaccinated subjects and patients with autoimmune diseases. However, longitudinal studies are needed to estimate the risk of progression to TB after IGRA-based and/or TST-based diagnosis of LTBI in these vulnerable patients. New tests are needed to identify those patients with LTBI who will develop active TB and need prophylaxis.
Cellular and humoral immune responses during tuberculosis infection: useful knowledge in the era of biological agents.
Matucci A, Maggi E, Vultaggio A
J Rheumatol Suppl · 2014 May · PMID 24788996 · Publisher ↗
In this review, recent insights into innate and adaptive cellular and humoral immune response to Mycobacterium tuberculosis (Mtb) are discussed and the role of specific cytokines such as tumor necrosis factor-α (TNF-α) i...
In this review, recent insights into innate and adaptive cellular and humoral immune response to Mycobacterium tuberculosis (Mtb) are discussed and the role of specific cytokines such as tumor necrosis factor-α (TNF-α) is highlighted. According to recent findings, the immune system plays a key role in avoiding mycobacteria dissemination. The importance of different cell types (macrophages, dendritic cells, interferon-γ-producing T cells) as well as the production of proinflammatory cytokines such as interleukin 6 (IL-6), IL-12, and IL-23/IL-17 have been demonstrated. Alveolar macrophages are considered the first cells infected by Mtb during respiratory infection. Mtb proliferates within alveolar macrophages and dendritic cells and induces the release of cytokines such as TNF-α, IL-1, IL-6, and IL-12. Toll-like receptors-stimulated dendritic cells link innate and adaptive immunity by promoting polarization of effector T cells. The efficient induction of Th1 immunity is decisive in defense against Mtb. In fact, host effector immune response against Mtb is related to the presence of a Th1 response. The definition of the cellular and molecular mechanisms involved in the immune response to Mtb can be helpful in developing new preventive strategies to avoid infection relapse, particularly in patients treated with biological agents.
The spectrum of tuberculosis infection: new perspectives in the era of biologics.
Delogu G, Goletti D
J Rheumatol Suppl · 2014 May · PMID 24788995 · Publisher ↗
The risk of developing active tuberculosis (TB) is higher in patients taking immunosuppressive drugs, either as a result of reactivation of a latent TB infection (LTBI) or following a new infection with Mycobacterium tub...
The risk of developing active tuberculosis (TB) is higher in patients taking immunosuppressive drugs, either as a result of reactivation of a latent TB infection (LTBI) or following a new infection with Mycobacterium tuberculosis (Mtb). We discuss the pathogenesis and spectrum of Mtb infection in light of its implication for the management of patients following biologic regimens. Among recent findings, during LTBI, Mtb can persist in the host for decades, localizing in many tissues and assuming different metabolic states that protect the bacilli from the harsh host immune defenses. Despite the strong host T cell response against Mtb, the bacilli may also replicate and multiply in vivo, and any event impairing immune function may lead to active and uncontrolled bacteria replication and active disease. The classic dichotomy between active and latent disease is being reconsidered in favor of a continuous and dynamic spectrum extending from infection to disease that can coexist in the same individual. This TB spectrum results from the dynamic interaction between the host immune system and the bacilli and can be maintained in equilibrium for decades, although treatments affecting the host immune cells may result in disease reactivation.
Update on the epidemiology of tuberculosis in Italy.
Conversano M
J Rheumatol Suppl · 2014 May · PMID 24788994 · Publisher ↗
As in many countries in Western Europe, in Italy tuberculosis (TB) is a relatively rare disease. In the last decade its incidence has remained constant at under 10 cases/100,000 inhabitants, the threshold considered to d...
As in many countries in Western Europe, in Italy tuberculosis (TB) is a relatively rare disease. In the last decade its incidence has remained constant at under 10 cases/100,000 inhabitants, the threshold considered to define a country as low prevalence. The epidemiological picture, however, is very different in the countries of Eastern Europe and in Africa, Asia, and Latin America, where the incidence of TB continues to increase and in some cases is accompanied by the emergence and spread of multidrug-resistant TB. The present review describes the epidemiology of TB in Italy. In 2008, the incidence rate was 3.8 cases per 100,000 for people born in Italy, and 50-60 cases per 100,000 for those born abroad. There was an increase in cases from Eastern Europe. The crude mortality rate for TB in 2006 was 0.7 deaths per 100,000 residents. Although TB is a low-prevalence disease in Italy, its epidemiology is changing. Since 1955, more than 160,000 people in Italy have died from this potentially preventable and curable disease.
Biologics and tuberculosis risk: the rise and fall of an old disease and its new resurgence.
Cantini F, Goletti D
J Rheumatol Suppl · 2014 May · PMID 24788993 · Publisher ↗
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Proceedings of the Second Update on Psoriatic Disease, University Federico II Congress Center, July 6–7, 2011, Naples, Italy.
J Rheumatol Suppl · 2012 Jul · PMID 23072005
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Pain pharmacotherapy in patients with inflammatory arthritis and concurrent cardiovascular or renal disease: a Cochrane systematic review.
Marks JL, van der Heijde DM, Colebatch AN … +2 more , Buchbinder R, Edwards CJ
J Rheumatol Suppl · 2012 Sep · PMID 22942334 · Publisher ↗
BACKGROUND: Pain in inflammatory arthritis (IA) is common and often multifactorial, and many different pharmacotherapeutic agents are routinely used for pain management. There are concerns that some current pain pharmaco...
BACKGROUND: Pain in inflammatory arthritis (IA) is common and often multifactorial, and many different pharmacotherapeutic agents are routinely used for pain management. There are concerns that some current pain pharmacotherapies may increase the risk of adverse events in patients with concurrent cardiovascular (CV) or renal disease. METHODS: A systematic literature review was performed searching Medline, Embase, Cochrane Central Register of Controlled Trials, DARE, and Cochrane Database of Systematic Reviews. We also hand-searched conference proceedings for the American College of Rheumatology and the European League Against Rheumatism for 2008-2009. RESULTS: Our search identified 4782 studies, of which 190 were included for detailed review, but none met the inclusion criteria for our review. We identified 1 study of etoricoxib and diclofenac in non-IA populations [osteoarthritis (OA) or mixed OA and rheumatoid arthritis]. In that study, the presence of CV disease increased the likelihood of a further CV event 3-fold. Patients with 2 or more CV risk factors showed a 2-fold increased likelihood of adverse CV events. CONCLUSION: Our review has highlighted a lack of specific evidence to guide clinicians in the management of pain in patients with IA and coexistent CV or renal disease. In the absence of this evidence, we suggest clinicians use nonsteroidal antiinflammatory drugs (NSAID) with caution in patients with preexisting CV disease or ≥ 2 CV risk factors. There is currently no evidence to advise clinicians considering other pain pharmacotherapies in the context of CV comorbidities. Current guidelines regarding the use of NSAID and opioids in moderate to severe renal impairment should also be applied to the IA population.
How do gastrointestinal or liver comorbidities influence the choice of pain treatment in inflammatory arthritis? A Cochrane systematic review.
Radner H, Ramiro S, van der Heijde DM … +3 more , Landewé R, Buchbinder R, Aletaha D
J Rheumatol Suppl · 2012 Sep · PMID 22942333 · Publisher ↗
OBJECTIVE: To assess efficacy and safety of pharmacological pain treatment in patients with inflammatory arthritis (IA) and gastrointestinal (GI) or liver comorbidities. METHODS: A systematic literature search was perfor...
OBJECTIVE: To assess efficacy and safety of pharmacological pain treatment in patients with inflammatory arthritis (IA) and gastrointestinal (GI) or liver comorbidities. METHODS: A systematic literature search was performed using Medline, Embase, and Cochrane Controlled Trial Register up to June 2010, as well as American College of Rheumatology and European League Against Rheumatism meeting abstracts (2007-2010). The population investigated was defined as patients with IA and existing or prior reported GI or liver disease treated with nonsteroidal antiinflammatory drugs (NSAID), opioids or opioid-like drugs, paracetamol, antidepressants, neuromodulators, or muscle relaxants. Outcomes of interest were defined as efficacy evaluated by common pain measures and safety evaluated by withdrawals due to adverse events, worsening of comorbidity, and mortality. RESULTS: Out of 2869 identified studies only a single open-arm trial fulfilled inclusion criteria assessing the safety and efficacy of naproxen in 58 patients with active rheumatoid arthritis and GI comorbidities. The presence of fecal occult blood was reported in 1/58 participants tested between Weeks 1 to 26 and 2/32 participants tested between Weeks 27 to 52. Over the course of the study, 7 participants (12.1%) withdrew due to adverse events; no serious adverse events were reported. Among the 14 studies excluded due to inclusion of a mixed population (osteoarthritis or other rheumatic conditions) or an intervention that was already withdrawn, 5 trials reported a higher risk of developing GI events in patients with prior GI events when treated with NSAID. CONCLUSION: Very little evidence regarding safety and efficacy of pain treatment in patients with IA and GI or hepatic comorbidities was found. In patients with a history of GI events, extrapolating from other studies, NSAID should be used cautiously since there is evidence that these patients are at a higher risk of developing adverse events.
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