Treatment of chronic gout in patients with renal function impairment: an open, randomized, actively controlled study.

Treatment of gout and hyperuricemia can be difficult in patients with chronic renal failure. At present, there is no study available comparing the efficacy of the most widely used agent, allopurinol, and the uricosuric benzbromarone for the control of hyperuricemia in patients with renal insufficiency. We describe an open, randomized, actively controlled, comparative trial in patients with clearance of creatinine from 20 to 80 mL/ min/1.73 m(2). Patients were randomized to take benzbromarone (100-200 mg/day) or allopurinol (100-300 mg/day). Outcome variables were the following: reduction of serum urate (Sur), Sur & tl; 6 mg/dL (357 micromol/L), reduction of gouty bouts and reduction of tophi. During 9-24 months of follow-up 36 patients were studied.The reduction of Sur was higher with benzbromarone, and only 1 of 17 patients taking benzbromarone did not achieve Sur < 6 mg/dL versus 7 of 19 taking allopurinol. Patients who did not reach optimal Sur levels with allopurinol were more frequently taking diuretics and showed lower fractional excretion of urate and higher initial Sur levels than patients with proper control of Sur. Seven patients with suboptimal control of serum urate were changed to benzbromarone 100 mg/day, which showed efficacy similar in those who were initially randomized to benzbromarone. A reduction of gouty bouts and size of tophi was observed after proper control of Sur. Allopurinol is effective in controlling hyperuricemia, but patients with higher initial Sur levels or taking concomitant diuretic therapy are less prone to reach therapeutic goals.Benzbromarone is useful for the control of hyperuricemia in patients with renal insufficiency even with concomitant diuretic administration; patients benefited include those who previously had no improvement by taking allopurinol.

Efficacy of allopurinol and benzbromarone for the control of hyperuricaemia. A pathogenic approach to the treatment of primary chronic gout.

OBJECTIVES: To study the efficacy of allopurinol and benzbromarone to reduce serum urate concentrations in patients with primary chronic gout. METHODS: Prospective, parallel, open study of 86 consecutive male patients with primary chronic gout. Forty nine patients (26 normal excretors and 23 under excretors) were given allopurinol 300 mg/day and 37 under excretors benzbromarone 100 mg/day. After achieving steady plasma urate concentrations with such doses, treatment was then adjusted to obtain optimal plasmatic urate concentrations (under 6 mg/dl). RESULTS: Patients receiving allopurinol 300 mg/day showed a mean reduction of plasmatic urate of 2.75 mg/dl (from 8.60 to 5.85 mg/dl) and 3.34 mg/dl (from 9.10 to 5.76 mg/dl) in normal excretors and under excretors respectively. Patients receiving benzbromarone 100 mg/day achieved a reduction of plasmatic urate of 5.04 mg/dl (from 8.58 to 3.54 mg/dl). Fifty three per cent of patients receiving allopurinol and 100% receiving benzbromarone achieved optimal plasma urate concentrations at such doses. The patients with poor results with allopurinol 300 mg/day achieved a proper plasma urate concentration with allopurinol 450 to 600 mg/day, the mean final dose being 372 mg/day. Renal function improved and no case of renal lithiasis was observed among benzbromarone treated patients, whose mean final dose was 76 mg/day. CONCLUSION: Benzbromarone is very effective to control plasma urate concentrations at doses ranging from 50 to 100 mg/day. Uricosuric treatment is a suitable approach to the treatment of patients with gout who show underexcretion of urate.

Efficacy of radiosynovectomy of the knee in rheumatoid arthritis: evaluation with magnetic resonance imaging.

The intra-articular injection of a radiopharmaceutical agent (radiosynovectomy) produces a reduction of the synovial inflammatory process. The inflammed synovial membrane can be identified with magnetic resonance imaging after the intravenous administration of gadolinium (MRI-Gd). A 6-month prospective study was carried out in 10 patients with rheumatoid arthritis after radiosynovectomy of the knee. The efficacy was evaluated with clinical parameters and MRI-Gd. A progressive amelioration of synovial effusion, pain, articular range of mobility, total leucocytes count in synovial fluid and synovial membrane thickness through MRI-Gd was observed. The global efficacy was considered to be good in six patients, fair in three and bad in one. The study shows for the first time that MRI-Gd allows the evaluation of the response of the synovial membrane to radiosynovectomy.

Comparative study of the efficacy and safety of aceclofenac and tenoxicam in rheumatoid arthritis.

To compare the efficacy and safety of aceclofenac (AC) and tenoxicam (TX) in the treatment of rheumatoid arthritis (RA), a multicentric parallel, randomized, double-blind trial of three months duration was performed in 292 patients: 145 were randomized to the AC treatment group and 147 to the TX treatment group. The trial was completed by 237 (81.1%) patients. Both treatment groups showed amelioration of clinical parameters monitored at 15 days, and this improvement continued until the end of the trial, no statistically significant differences being observed between AC and TX. Twenty-four patients (8.2%, 12 AC and 12 TX) did not complete the trial because of inefficacy, and 15 because of side effects (5.1%, 6 AC and 9 TX), in 7 of them due to gastrointestinal intolerance (2,4%, 1 AC, 6 TX, p = 0.052). These data demonstrate that AC shows similar efficacy to TX in the treatment of rheumatoid arthritis and better safety profile than TX, mainly regarding gastrointestinal tolerability.

High prevalence of undetected carpal tunnel syndrome in patients with fibromyalgia syndrome.

OBJECTIVE: To assess the prevalence of carpal tunnel syndrome (CTS) in patients with fibromyalgia syndrome (FM). METHODS: A series of 206 consecutive patients with FM was evaluated for CTS in an unblinded, uncontrolled study. Sixty patients with dermatomal paresthesia in the fingers enervated by the median nerve were evaluated with electromyogram and nerve conduction velocity studies (EMG/NCV). RESULTS: Thirty-three patients showed EMG/NCV findings diagnostic for CTS (16% of the 206 cases, 55% of the 60 EMG studies). Only 2 of the 33 patients with CTS had been diagnosed before rheumatologic evaluation. We compared our results with those reported for women in the general population. The overall prevalence of CTS in women was higher (16 vs 10.2%), but not statistically different. However, in our series, there was a clear difference in the higher rate of undetected CTS in women with FM compared to that of the general population (14.1 vs 6.7%) (p < 0.01). CONCLUSION: (1) CTS is at least as common in patients with FM as in the general population, contrary to that reported in retrospective studies; (2) the rate of underdiagnosed CTS in women with FM is much higher than the rate reported in the general population; (3) NCV studies may be necessary to evaluate underdiagnosed CTS in patients with FM and dermatomal paresthesia in their hands.

Toxic oil syndrome. A long-term follow-up of a cohort of 332 patients.

Toxic oil syndrome is a multisystemic, epidemic disease that appeared in Spain in 1981, related to the intake of rapeseed cooking oil sold in bulk. It affected 19,748 people, of whom 457 died. The toxic substance was never identified. We report the 8-year follow-up of a cohort of 332 patients. The disease was usually severe and disabling during the first 2 years, but the clinical condition of most of the patients improved thereafter. The acute phase lasted 2 months, and was characterized by pulmonary edema, rash, eosinophilia, and myalgia. During the intermediate phase (second to fourth months), severe myalgia, skin tenderness, subcutaneous edema, altered liver function, and pulmonary hypertension developed. Later on, an early chronic phase developed, from the fourth month to the end of the second year. It was marked by scleroderma, sicca syndrome, polyneuropathy, joint contractures, weight loss, and functional limitations. The clinical manifestations improved during the late chronic phase. Its most prominent clinical features were muscle cramps, chronic musculoskeletal pain, chronic lung disease, Raynaud phenomenon, carpal tunnel syndrome, and psychologic disturbances. Only 9% of the patients achieved remission after the acute phase, the rest developing late clinical manifestations of the disease. The severity of the chronic manifestations was rather variable. At the end of the 8-year follow-up, there were 10 TOS-related deaths (3%), 47% of the patients had some kind of complaint, albeit subtle in most cases, and 16% showed organic involvement related to TOS. The most important pathologic features of TOS were widespread interstitial infiltrates, non-necrotizing angiitis, endothelial proliferation, and tissue fibrosis. Toxic oil syndrome is a dramatic example of an induced scleroderma-like syndrome, similar to the eosinophilia-myalgia syndrome. Patients with EMS may develop some of the late clinical features of TOS in the years to come.

[Selective deficiency of IgA in autoimmune diseases]. / Deficiencia selectiva de IgA en enfermedades autoinmunes.

A selective IgA deficiency (SD IgA) appears in a 0.15% of the population, being more frequent in autoimmune diseases. We present here eight patients presenting this association who were diagnosed at the Rheumatology Department during a period of eight years. Five patients suffered Juvenile Chronic Arthritis (JCA), two patients Rheumatoid Arthritis (RA) and one Systemic Lupus Erythematous (SLE). There were to cases of familiar deficiency. There was not a relationship between SD IgA and treatments used. There is an important association between SD IgA and JCA (4.27% prevalence). In the other two conditions, however, the association could be casual.

[Fibromyalgia syndrome (fibrositis): as frequent as it is unknown]. / Síndrome de fibromialgia (fibrositis): tan frecuente como desconocido.

Fibromyalgia syndrome is characterized by generalized musculoskeletal pain and abnormal sensitivity to palpation of characteristic myofascial areas. We evaluated its prevalence in the 673 patients seen as first consultations in a hospital rheumatological outpatient clinic during one year, and we made an automatized review of the Spanish literature about this condition in the last 17 years. We found 70 cases (10.4%) of fibromyalgia syndrome, none of which had been referred to the hospital with this diagnosis. We report their clinical features. In our bibliographical search we found only one article describing this condition. We conclude that it is a common clinical syndrome, unknown in nonspecialized milieus. Generally, the patients are inadequately diagnosed and treated, and/or referred to hospital.

[Cutaneous panarteritis nodosa with destructive arthritis]. / Panarteritis nudosa cutánea con artritis destructiva.

The existence of arthritis in cutaneous panarteritis nodosa (CPAN) is controversial. We report a 52-year-old male with chronic destructive arthritis of both knees and palpable purpura in the feet, where the underlying histological finding was necrotizing arteritis. Systemic involvement was not demonstrated. AntiHBc and antiHBs antibodies were positive. Four of the 11 cases of CPAN with arthritis that we have found reported in the literature were well documented, and only one developed erosions of the joints. Our patient is the first reported case of CPAN with destructive arthritis and evidence of previous hepatitis B virus infection.

Toxic oil syndrome: a syndrome with features overlapping those of various forms of scleroderma.

Thirty-two toxic oil syndrome (TOS) patients were selected because they presented with scleroderma-like changes and were observed during the first 36 months of evolution of the disease. Initially, these patients presented with a noncardiogenic pulmonary edema, eosinophilia, arthralgia/arthritis, peripheral edema, and myositis. Histologic investigations showed a widespread chronic interstitial infiltrate with lymphocytic vasculitis. They subsequently developed peripheral neuropathy, joint contractures, scleroderma-like changes, Raynaud phenomenon, pulmonary hypertension, sicca syndrome, and liver disease. Biopsy studies during this stage showed fibrosis and obliterating arteriopathy. Late features of TOS are musculoskeletal pain, cramps, livedo reticularis, carpal tunnel syndrome, and digital tuft changes. TOS is a new chemically induced scleroderma-like syndrome with features overlapping those of eosinophilic fasciitis, systemic sclerosis, and forms of localized scleroderma.