Assessment of health locus of control in the use of nonconventional remedies by patients with rheumatic diseases.

OBJECTIVE: To assess the prevalence and characteristics of the use of nonconventional remedies (NCR) and to determine the type of health locus of control that the users of NCR may have. METHODS: We conducted a cross sectional survey of 200 patients with rheumatic diseases at 3 outpatient rheumatic clinics in Edmonton, Canada. A face-to-face structured interview was administered by a trained assistant to evaluate the prevalence of use, and patient beliefs, perceptions, and expectations in relation to NCR. To assess locus of control the Multidimensional Health Locus of Control (MHLC) instrument was applied. RESULTS: One-hundred nineteen patients (60%) had used a total of 530 NCR (range 1-25) in the previous 12 months; 94 (79%) of these patients used 309 NCR (mean of 3, range 1-15 remedies). Forty-seven percent had received at least one NCR before the first rheumatology consultation, but an additional 8% initiated NCR after their initial contact with a rheumatologist at our clinics. Only 22 (18%) of the patients using NCR notified their rheumatologist about their use. The mean reported expenditures for the users of NCR in the past 12 months were $260.00 CDN per patient (range 0 to $3,520), and the mean reported expenditures for the ever users of NCR were $730.00 CDN (range 0 to $9,720). Patients who used NCR in the past 12 months were younger (52 +/- 14 vs 58 +/- 15 yrs; p = 0.003), slightly more disabled (1.26 vs 1.11, modified Health Assessment Questionnaire; p = 0.006), and in the middle income class (p < 0.001). Possible associations between MHLC and the use of NCR were assessed in different ways in the logistic regression models, including the entry of MHLC subscales as means or class intervals, and NCR as users versus no users, or as higher users (> 4 NCR) versus no users of NCR. The use of NCR, ever or in the past 12 months, did not have statistical association with any of the subscales of the MHLC. CONCLUSION: In this survey over one-half of patients used NCR for treatment of their rheumatic disease. NCR were costly and the MHLC scales scores alone did not explain all the variance in health behaviors. Other contributing factors such as perceived severity of the disease, health motivation, or previous behavior should be addressed in further research.

Use of second line drugs for the treatment of rheumatoid arthritis in Edmonton, Alberta. Patterns of prescription and longterm effectiveness.

OBJECTIVE: Our purpose was to compare the patterns of prescription of 2nd line drugs for the treatment of rheumatoid arthritis (RA) among rheumatologists in Edmonton, Alberta, and to examine the longterm effectiveness of these drugs. METHODS: A 1985 inception cohort of 128 patients with RA was assessed between 1991 and 1992, using measures of disease activity, radiological scores and physical functional status. Use of different therapies was retrieved from the medical charts. RESULTS: All patients had seen a rheumatologist at any time between January, 1985 and December, 1991, 88% within the first 3 years of disease. Most (85%) had received at least one 2nd line drug, the majority within the first 2 years. Overall, gold salts were the most frequently prescribed drugs. Patterns of prescription varied among different rheumatologists; some drugs were never prescribed by some and very often by others (e.g., auranofin). Terminations because of toxicity and lack of efficacy were high. Methotrexate (MTX) had the lowest termination rate and sulfasalazine the highest, mostly due to lack of efficacy. CONCLUSION: In this cohort, patients were treated early in the course of RA. Patterns of prescription of 2nd line drugs varied among rheumatologists. Termination rates were highest for sulfasalazine and lowest for MTX.

Comparative efficacy and toxicity of 10-ethyl-10-deazaaminopterin and methotrexate in a mycobacterial rat arthritis model.

OBJECTIVE: To compare the efficacy and toxicity of the newer antifolate 10-ethyl-10-deazaaminopterin (10-EDAM) with methotrexate (MTX) in an animal model of inflammatory arthritis. METHODS: Groups of 8 or 9 female Lewis rats received intraperitoneal (ip) Mycobacterium butyricum to induce arthritis, and then one of the antifolates at either 1.0 mg/kg/day by oral gavage or 0.2 mg/kg/2 days ip until 25 days post-induction. Treatment groups were compared with control arthritic and non-arthritic animals. Efficacy was assessed by changes in weight, paw volume, and paw diameter, as well as maximum arthritis index, plasma albumin and plasma iron levels. Toxicity was documented for all groups. RESULTS: 10-EDAM was as effective as MTX at identical doses in preventing arthritis. 10-EDAM produced less toxicity than MTX at the higher dose used but similar toxicity at the lower dose. CONCLUSIONS: 10-EDAM may provide an alternative antifolate therapy in the clinical management of inflammatory arthritis, and appears to be less toxic than MTX.

Stereoselective disposition of etodolac enantiomers in synovial fluid.

The synovial fluid (SF) uptake of the chiral nonsteroidal anti-inflammatory drug, etodolac, was studied in six arthritic patients, 2 hours (n = 1) or 12 hours (n = 5) after a single 200 mg dose of racemate. Marked stereoselectivity was seen in both SF and plasma; concentrations of pharmacologically inactive R-etodolac were up to 10-fold greater than active S-etodolac. Concentrations of S-etodolac were greater in SF than in plasma (SF:plasma ratio = 1.98 +/- 0.8): No such difference was seen for R-etodolac (SF:plasma = 0.91 +/- 0.3). Considerable concentrations of conjugated enantiomers were present in SF. In vitro equilibrium dialysis studies in drug-spiked samples showed that the unbound fraction of both enantiomers in SF was greater than in plasma; both fluids bound R more extensively than S etodolac. Therapeutically active S-etodolac has greater concentrations in synovial fluid than plasma during the post-distributive phase, which may be of possible clinical relevance.

Pharmacokinetics of ketoprofen enantiomers in young and elderly arthritic patients following single and multiple doses.

Ketoprofen (KT), a chiral nonsteroidal anti-inflammatory drug (NSAID), is marketed and used as a racemic mixture. In healthy volunteers, negligible differences have been reported between the plasma time courses of KT enantiomers. Using a stereospecific high-performance liquid chromatographic (HPLC) assay measuring (R)- and (S)-KT in plasma and urine, pharmacokinetics of the enantiomers following single (50 mg) and then multiple (50 mg every 6 h for 3 d) doses were delineated in nine young and nine elderly arthritic patients. There were no significant differences between pharmacokinetic indices calculated after single and multiple doses, or between the two groups. In plasma, there were no significant differences between intact enantiomers in either patient group. However, significantly more conjugated (S)-KT was found in elderly patient plasma. Similar to findings in healthy volunteers, elimination of conjugated KT in both patient groups was more extensive for the (S)-, as compared with the (R)-isomer. It is suggested that age-dependent impaired elimination of conjugated (S)-KT, along with preferential biliary excretion of conjugated (R)-KT, is responsible for these observations.

Low-dose methotrexate kinetics in arthritis.

Twelve patients with either rheumatoid or psoriatic arthritis were injected with a 10-mg bolus dose of methotrexate (MTX) either intramuscularly (n = 6) or intravenously (n = 6) and the MTX concentration in their sera was determined by radioimmunoassay. MTX concentration--time data fitted triexponential equations. Doses injected intramuscularly were rapidly and completely absorbed. There were no significant intergroup differences in drug mean t 1/2, volume of distribution, and total body clearance. In nine patients serum MTX concentrations remained above the suggested critical level of 0.01 mumol throughout the 24-hr study irrespective of the route of administration, but MTX did not cumulate in the serum. We conclude that the behavior of low doses of MTX in patients with arthritis closely resembles the pattern in patients receiving intermediate and high doses for the treatment of neoplasia.