News updates
News of advances in the treatment of rheumatoid arthritis
There are some new products devised by the biotechnology industry for the treatment of rheumatoid arthritis that appear to have ushered in a new era of scientifically based therapy for arthritis.
Anti-TNF drugs
In people with rheumatoid arthritis a protein called TNF is present in the blood and joints in excessive amounts where it increases inflammation. Anti-TNF drugs block the action of TNF and so can reduce inflammation. Three new anti-TNF drugs have been introduced Etanercept (Enbrel), Adalimumab (Humira) and Infliximab (Remicade). These are available locally now for some patients with very active disease who have not responded to existing medication. These drugs are used in combination with methotrexate, or other commonly used disease modifying drugs.
Whilst these drugs are associated with improvement in the signs and symptoms of rheumatoid arthritis and with a lower risk of joint damage, there is no reason to believe that agents that inhibit TNF, and any other currently available treatment used in rheumatoid arthritis, cure the disease. Disease activity is suppressed only during treatment, and therefore relapses are inevitable if treatment is discontinued, regardless of the duration of treatment.
New era in rheumatoid arthritis treatment?
An article in the Lancet highlights the importance of three drugs; rituximab, abatercept and tociluzumab for patients with severe rheumatoid arthritis, whose symptoms are not controlled by anti-TNF therapy.
Professor Alan Silman, medical director of the Arthritis Research Campaign, said: "While the advent of these new drugs is exciting, the real revolution in new treatment for rheumatoid arthritis started several years earlier with the discovery of anti-TNF therapy. That research, much of it performed by Arthritis Research Campaign scientists, identified the complex process of what caused inflammation in rheumatoid arthritis.
"The three drugs highlighted in The Lancet result from that increased knowledge and more new therapies will follow in the next few years as pharmaceutical companies continue to exploit these research findings.
"Rituximab, abatercept and tocilizumab will all be used in patients who fail on anti-TNF therapy (about 30 per cent of patients) so offer more potential choice for patients with severe disease, for whom at present there are no real alternatives. The results for these three drugs in such treatment-resistant patients are useful though not staggering, and they may play a more useful role if given early in disease as an alternative to anti-TNF therapy. However more research is needed both about their effectiveness and, equally important about their safety in long term large scale studies,” added Professor Silman.
Of the three drugs, rituximab (brand name Mabthera) is licensed in Europe and has been approved by NICE and has just started to be used locally. Abatercept (Orencia) gained its license within the past couple of weeks, while tociluzumab (Actemra) is in phase III trials and both are still not available yet.
The work surrounding Rituximab focuses on the role of B-cells, white blood cells that defend the body against viruses and bacteria, by making antibodies. Rogue B-cells also attack healthy tissues, and trigger the production of copies of themselves. This results in the joints being attacked.
Rituximab works by destroying the body’s B-cells and the body then makes new B-cells, which only have a small chance of triggering the rheumatoid arthritis again. The drug is given in two infusions, a fortnight apart. Patients are also given methotrexate. At present Rituximab is sometimes used if the patient has not responded to anti-TNF treatment.
Rituximab is not a cure for RA. Not everyone responds to the treatment, and although the results of the latest trial are very positive, we do not have any long-term evidence of its effectiveness at present.
Combination therapies more effective in treating rheumatoid arthritis
Using a combination of traditional and newer biologic drugs is an effective way to reduce joint swelling and tenderness in patients with rheumatoid arthritis, a new report suggests.
A team compared the benefits and harms of disease-modifying anti-rheumatic drugs (DMARDs) including drugs like hydroxychloroquine, leflunomide, methotrexate and sulfasalazine, biologics including abatacept, adalimumab, anakinra, etanercept, infliximab and rituximab and corticosteroids, such as prednisolone.
The results show that combining methotrexate with one of the biologics was more effective than using methotrexate or a biologic alone. It was also discovered that methotrexate works as effectively as adalimumab and etanercept for patients who have early RA.
Elsewhere, the research found that there were no meaningful differences in the effectiveness of methotrexate, leflunomide or sulphasalazine.
An Arthritis Research Campaign spokesman said drugs used in combination rather than singly were often more effective in treating RA, and the new study confirmed this.
Non-steroidal anti-inflammatory drugs
As their name implies, non-steroidal anti-inflammatory drugs (or NSAIDs) are medicines that block the body’s inflammation process without the use of cortisone or other steroid drugs. They are useful in rheumatoid arthritis and similar conditions and some types of osteoarthritis. The most commonly used NSAIDs in Dorset are ibuprofen and diclofenac but there are many others available.
They work by blocking cyclo-oxygenases (COXs), enzymes that stimulate a family of chemicals called prostaglandins. Some prostaglandins cause inflammation so NSAIDs reduce pain and stiffness. Other prostaglandins protect the stomach lining from acid, help kidney function and are important in regulating clotting of the blood. Therefore, NSAIDs may have side effects including stomach ulcers, kidney problems and an increased risk of heart attacks and strokes.
In 1998 a new class of NSAIDs was produced that have little effect on the prostaglandins that protect the stomach. These COX II selective drugs are safer on the stomach lining but still have potential side effects on the kidneys and heart. There has been a lot of controversy about COX II selective drugs and rofecoxib (Vioxx) was withdrawn because of these potential adverse effects.
The current position is not very clear but it is probably best to consider that all NSAIDs have potential side effects on the stomach, heart and kidneys. The choice of an NSAID will, therefore, depend on an assessment of the risks and benefits for an individual and we cannot make general recommendations that would suit everyone. We suggest that you discuss the relative merits of NSAID treatment with your doctor or rheumatology practitioner.
Dr Paul Thompson, Consultant Rheumatologist
Ultrasound available as routine diagnostic tool in arthritis
The use of ultrasound as a routine diagnostic tool by rheumatologists is now available. Ultrasound imaging is based on the same principles involved in the sonar used by bats, ships at sea and anglers with fish detectors. As a controlled sound bounces against objects, its echoing waves can be used to identify how far away the object is, its shape, how large it is, and its internal consistency (fluid, solid or mixed).
An ultrasound image is a useful way of examining the musculoskeletal system of the body to detect problems with muscles, tendons, ligaments, joints and soft tissue. Ultrasound images are captured in real time, so they can often show movement, function and anatomy, as well as enable radiologists and rheumatologists to diagnose a variety of conditions and assess damage after an injury or illness.
Up until now, the imaging technique has only been used in some major rheumatology centres such as Leeds, Glasgow, Newcastle, London, Bath and Belfast. The rheumatology department at Poole Hospital has chosen to save for an ultrasound imager as part of the Poole Hospital Wish List scheme and it has now been purchased.
The Wish List is Poole Hospital's fundraising charity. It has been launched to provide support for all wards and departments in the provision of key pieces of equipment. The hospital is indebted to organisations and individuals whose continuing generosity helps us to finance a variety of initiatives that can make all the difference to a patient’s care.
Diet and Arthritis – Food facts and fallacies
People with arthritis desperately want to help themselves by finding a diet that suits them but there is simply no quick-fix, miracle diet that will cure arthritis. Eating a healthy diet with plenty of fresh fruit and vegetables and at least two portions of oily fish a week is beneficial. But the common-sense advice is that people should expect minor improvements rather than a miracle.
A lot of excessive claims are made in the media and in magazines and books about the latest wonder food or fad but there is very little real evidence to back them up.
Lots of people believe a particular diet, or cutting out certain foods – such as red wine, sugar and chocolate – has helped their arthritis. The problem is that what works for one person doesn’t work for someone else. And the power of the placebo – mind over matter, needs to be taken into account.
Facts
- Losing weight if you are overweight by changing your eating and lifestyle habits should help relieve pain, particularly in osteoarthritis of the knee. It's estimated that a quarter of all cases of osteoarthritis of the knee could be prevented by eliminating obesity. Losing weight may also mean you can reduce the number of painkillers you take.
- Eating oily fish such as herring, sardines, kippers, mackerel, pilchards and tuna twice a week or taking cod liver oil daily should help reduce arthritic pain. Oily fish and cod-liver oil contain Omega 3 essential fatty acids, which has been proven to have a mild anti-inflammatory effect on osteoarthritis.
- Cutting out certain foods as part of a rigorously observed elimination diet under strict medical supervision can help relieve symptoms in some people with rheumatoid arthritis but NOT osteoarthritis.
- Eating oily fish, liver and kidneys is likely to exacerbate gout.
Fallacies
- Acidic food such as citrus fruits can cause arthritis. There is no evidence for this.
- Tomatoes, aubergines and red peppers can cause arthritis. There is no evidence of this. Tomatoes can contain beneficial antioxidants such as Vitamin C.
- Green-lipped mussels, cider vinegar, selenium ACE, molasses, CMO and seaweed can significantly affect people with arthritis. There is no evidence to prove that they work, although they appear to help some people due to placebo effect (mind over matter).
- You can test for possible food allergies through methods such as applied kinesiology, dowsing, vega testing or cytoxic testing. None of these methods are reliable.
Red meat linked to rheumatoid arthritis
Eating a large amount of red meat has been linked to an increased risk of developing rheumatoid arthritis, according to an Arthritis Research Campaign-funded study.
People who eat a large amount of red meat such as beef or lamb are at double the risk of developing RA than those who eat little red meat, according to a study published in the December edition of the journal Arthritis and Rheumatism.
Researchers suggest that something in meat, possibly collagen, could trigger an immune system response.
The team also found that people who developed RA were more likely to be former smokers and who ate less food containing Vitamin C; two risk factors for RA already established by the epidemiology unit.
A spokeswoman for the Arthritis Research Campaign said: ‘This provides further evidence that environmental factors can help to trigger rheumatoid arthritis.’
In the light of this new evidence we would suggest that as part of a healthy lifestyle, people should cut down the amount of red meat (beef and lamb) they eat.
Cod liver oil research latest
Researchers in Cardiff have discovered that cod liver oil is effective in treating joint pain and can slow, even reverse, the destruction of joint cartilage.
Preliminary data from a small clinical study of 25 patients awaiting joint replacement surgery showed that 86 per cent of patients with arthritis who took capsules daily, containing 1000mg cod liver oil, had absent or significantly reduced levels of one of the enzymes that cause cartilage damage compared to 26 per cent of those given a placebo oil capsule. In addition, the result showed a marked reduction in some of the enzymes that cause joint pain in those patients taking the cod liver oil.
Research published by the Cardiff team last year showed that cod liver oil appeared to be effective in reducing cartilage destruction in laboratory experiments, but this is the first time its efficacy has been demonstrated on patients. The data suggests that cod liver oil has a dual mode of action, potentially slowing down the cartilage degeneration inherent in osteoarthritis and also reducing factors that cause pain and inflammation.
These new findings bring hope to sufferers of the more prevalent osteoarthritic joint disease, particularly to those who are unable, because of adverse side effects, to take the non-steroidal anti-inflammatory drugs (NSAIDs) commonly prescribed for the condition.
Helping people with arthritis to help themselves
The Expert Patients Programme
Self-management is one of the big buzzwords doing the rounds in healthcare circles. Empowerment is another; enabling patients with chronic conditions such as arthritis to take back some control over their lives - lives that have been taken over and dominated by the disease for many years.
Drugs only offer a partial solution – particularly for patients whose conditions through medication can be largely ineffective – severe osteoarthritis, for example, fibromyalgia; many other chronic pain syndromes.
Self-management means relying on yourself, being pro-active rather than passive, and finding solutions to everyday problems. Easier said than done when you're feeling ill, vulnerable and lacking in confidence.
But if you're in a small group of people who are in similar situations with other chronic long-term conditions, it can be much easier. Sharing problems and solutions, finding solace and encouragement from others who are probably worse off than you can be of help.
That's the general concept behind the Expert Patients Programme, which has been running in pilot form in towns and cities around the UK for the past three years.
The EPP is run by the NHS, and offers free, six-weekly courses of two-and-a-half hour sessions for people with chronic conditions. The courses are led by a combination of professional trainers and volunteer tutors - who themselves have chronic conditions and have been on the course. The trainers and tutors follow a fairly rigid format and make sure that participants set and achieve sensible goals. EPP is not counselling, and the course covers different topics each week – how to deal with GPs, for example, how to make yourself heard, how to relax.
To find out if there is an Expert Patients Programme in your area ask for further information, when you visit the RFU clinic. Or you can contact your GP for details, ring the national information line on 0845 606 6040 or go to www.expertpatients.nhs.uk
What you can learn from the Expert Patients Programme
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Researchers identify gene behind rheumatoid arthritis
Researchers in Manchester have identified a genetic variant in a region on chromosome 6 that is associated with rheumatoid arthritis (RA), the most common inflammatory arthritis affecting 387,000 people in the UK.
Professor Jane Worthington and her team at the Arthritis Research Campaign (arc) Epidemiology Unit at the University of Manchester investigated nine genetic regions identified earlier this year as potentially harbouring DNA variants determining susceptibility to rheumatoid arthritis. Association to one of the variants on chromosome 6 was unequivocally confirmed, reports this week's Nature Genetics (4 November 2007). Although this variant is not located in a gene, Professor Worthington suggests that it may influence the behaviour of a nearby gene: tumour necrosis factor associated protein (TNFAIP3) as this is a gene that is known to be involved in inflammatory processes.
Professor Worthington and her team, who are funded by the Arthritis Research Campaign, made their findings as part of the largest ever study of the genetics behind common diseases, the £9M Wellcome Trust Case Control Consortium (WTCCC). The WTCCC study has given a major boost to the understanding of the genetics of seven common diseases, including RA. As well as providing insights into what leads some people to develop the diseases and offering new avenues for treatments, the success of the approach heralds exciting advances in the study of the genetics of disease.
The Manchester team is currently investigating several genomic regions which may be important in the development of RA but the locus near TNFAIP3 is the first to be fully validated. Until recently, only two other genes were known to explain 50% of genetically determined susceptibility. Now the Manchester researchers are working to understand how the variation within the chromosome 6q region influences the development of RA, the course of the disease and the response to treatment.
Dr Anne Barton, a clinician on the team, said: "RA is a complex, heterogeneous disease with some people suffering inflammation of the hands and feet which comes and goes whilst others develop a progressive form which can quite rapidly result in marked disability. We believe the genetic marker we have found may determine who develops RA or how severe the disease becomes."
Risk of cardiovascular disease in rheumatoid arthritis patients
Greater awareness should be focused on the cardiovascular risk of patients with rheumatoid arthritis, says a leading arthritis charity, so that patients can then take steps to minimise that risk.
People with rheumatoid arthritis are more likely to suffer a heart attack or stroke than the general population, but many patients are unaware of this, according to the Arthritis Research Campaign.
Now the charity is taking steps to warn people about the risks so that they can make the necessary lifestyle changes such as stopping smoking, losing weight, eating more healthily, and taking drugs such as aspirin or statins to lower their blood pressure or cholesterol.
At Poole Hospital rheumatology department patients with RA are being told about the Trace RA Study.
Trace RA Study at Poole Hospital
We are inviting patients who are 50 years or older, or who have had rheumatoid arthritis for 10 years or more, to take part in a study that aims to find out if a drug called Atorvastatin can reduce the risk of a heart attack or stroke in patients with RA.
Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis affecting about 1% of the adult UK population. Research has shown that people with RA are more likely to suffer from diseases of the heart and blood vessels (mainly heart attack and stroke). This may be because the high levels of inflammation in RA cause damage to blood vessels.
Statins are drugs that can help prevent diseases of the heart and blood vessels. This is done by reducing cholesterol and possibly inflammation.
This study will determine whether the statin called Atorvastatin can reduce the occurrence of conditions such as heart attacks and strokes in people with RA. We are only including RA patients who are not otherwise considered to be eligible for statin treatment. The TRACE RA study involves more than 65 NHS hospitals throughout the UK and aims to enrol 3808 participants in total.
Ask your rheumatologist or rheumatology practitioner about this when you next have a clinic appointment. The doctor and research nurse will have a look at your medical history to assess if you are eligible for the trial. If you are, your doctor will then discuss the trial and the benefits and disadvantages of it with you, then ask you to read a patient information leaflet and think about whether you want to take part.
If you still want to take part, you will be seen again to have a clinical assessment, and medical history taken. You will then be provided with the trial medication or placebo (your doctor will be able to explain these terms to you) to take every evening.
You will also be seen three months after you first take your medication to check that you have no problem with it.
After that, you will be seen once every year for up to seven years and will have to continue to take your trial medication throughout this time. At these annual visits, a nurse will check if you have experienced any cardiac related events in the previous 12 months and ask how your general health is.
If at any stage your health gets worse, you will be treated in the standard way. You will not miss out on any normal treatment because you are in this trial.
Delays in visiting the doctor mean patients missing out on treatment
An Arthritis Research Campaign-funded study has shown that many patients with rheumatoid arthritis are missing out on early diagnosis and treatment because they are not seeking medical advice when their symptoms first develop.
The study of 169 patients in Birmingham showed that there was an average delay of nearly six months between the initial onset of symptoms and patients being assessed by a rheumatologist in hospital.
The researchers found that the majority of delays occurred because sufferers failed to seek medical advice at an early stage. On average patients waited three months from the onset of symptoms before visiting their GP. In the majority of cases this accounted for more than half the delay in getting an assessment from a rheumatologist.
Dr Karim Raza from the University of Birmingham who led the research team commented: “Rheumatoid arthritis is relatively common, affecting one per cent of the population. Research over the last ten years has led to major advances in our ability to treat this condition effectively. However, current treatments are much more effective if commenced early in the course of disease.
An early diagnosis is thus extremely important. Our research showed that although there can be delays in referring patients to a specialist the biggest problem is in encouraging patients to make an initial appointment with their doctor. This may be because patients don’t realise the potential seriousness of painful, stiff, swollen joints and the possible long term complications if effective treatment is not started early.
It is important that patients are able to take advantage of the great advances in treatment by seeking help early.”
Some of the information used in these news items has come from the Arthritis Research Campaign website, republished with kind permission from the ARC. Visit their website at www.arc.org.uk.
Contact us
If you have any further questions or need advice about your treatment phone the Rheumatology Advice line on 01202 442849.