Efficacy and safety of etoricoxib 30 mg and celecoxib 200 mg in the treatment of osteoarthritis in two identically designed, randomized, placebo-controlled, non-inferiority studies.

OBJECTIVE: To compare the efficacy of etoricoxib 30 mg with the generally maximum recommended dose of celecoxib, 200 mg, in the treatment of osteoarthritis (OA) in two identically designed studies. METHODS: Two multi-centre, 26-week, double-blind, placebo-controlled, non-inferiority studies were conducted, enrolling patients who were prior non-steroidal anti-inflammatory drug (NSAID) or acetaminophen users. There were 599 patients in study 1 and 608 patients in study 2 randomized 4:4:1:1 to etoricoxib 30 mg qd, celecoxib 200 mg qd or one of two placebo groups for 12 weeks. After 12 weeks, placebo patients were evenly distributed to etoricoxib or celecoxib based on their initial enrollment randomization schedule. The primary hypothesis was that etoricoxib 30 mg would be at least as effective as celecoxib 200 mg for the time-weighted average change from baseline over 12 weeks for Western Ontario and McMaster (WOMAC) Pain Subscale, WOMAC Physical Function Subscale and Patient Global Assessment of Disease Status. Active treatments were also assessed over the full 26 weeks. Adverse experiences were collected for safety assessment. RESULTS: In both studies, etoricoxib was non-inferior to celecoxib for all three efficacy outcomes over 12 and 26 weeks; both were superior to placebo (P < 0.001) for all three outcomes in each study over 12 weeks. The safety and tolerability of etoricoxib 30 mg qd and celecoxib 200 mg qd were similar over 12 and 26 weeks. CONCLUSIONS: Etoricoxib 30 mg qd was at least as effective as celecoxib 200 mg qd and had similar safety in the treatment of knee and hip OA; both were superior to placebo. ClinicalTrials.gov Identifiers: NCT00092768; NCT00092791.

Oral polymeric N-acetyl-D-glucosamine and osteoarthritis.

Many patients with arthritis are using alternative modes of therapy, including nutritional supplements, to treat their arthritis. Most patients never tell their doctors that they are taking alternative medications, and few doctors even ask about such activities. Over-the-counter supplements are expensive and consume large amounts of patients' healthcare dollars. Glucosamine has been widely touted as being an effective arthritis treatment. The authors designed and undertook a study to test the efficacy of a polymer of N-acetyl-D-glucosamine (NAG), or POLY-Nag, in a double-blind, placebo-controlled study in patients with osteoarthritis. Results indicate that POLY-Nag may be useful in treating patients with osteoarthritis.

Osteoarthritis.

Arthritis is a common, disabling condition that affects an increasing percentage of the population. This article includes discussion of new theories of risk factors and treatment paradigms.

Gastropathy induced by nonsteroidal anti-inflammatory drugs: prescribing patterns among geriatric practitioners.

The objective of this study was to determine patterns among geriatric practitioners in prescribing agents that protect the gastrointestinal tract when nonsteroidal anti-inflammatory drug (NSAID) treatment is started for elderly patients. A questionnaire describing five scenarios of elderly patients requiring NSAID therapy asked respondents to choose gastrointestinal-protective agents for each scenario. Respondents were then asked to what extent four established risk factors for NSAID gastropathy (age, previous peptic ulcer, previous gastrointestinal bleeding, and heart disease) affected their choices. The choice of gastrointestinal-protective agent was compared with the training and experience of the respondents. This self-administered survey was provided to 821 randomly selected physicians from the membership of the American Geriatrics Society throughout the United States and Puerto Rico. Statistical Package for the Social Sciences (SPSS), version 6.1.4, was used to obtain frequencies. Of 821 surveys, 229 (28%) were returned. It was found that well elderly patients and nursing home residents were not treated with any gastrointestinal-protective agent by 64% (well elderly patients) and 32% (nursing home residents) of respondents. Among respondents who would prescribe, about half would choose misoprostol for a well elderly patient or a nursing home resident, whereas half or more preferred histamine H2-receptor antagonists. Twenty-three percent would not prescribe misoprostol when NSAID therapy was resumed after an active ulcer had healed, and 68% preferred H2 antagonists in that setting. The difference in response attributable to training/experience was less than 9%. Factors that did not affect prescribing patterns included the patient's age (15% to 62%) and heart disease (44% to 50%). The study concluded that age and heart disease are risk factors to which physicians give less consideration when choosing gastrointestinal-protective agents. Although misoprostol is the only agent approved by the Food and Drug Administration for prophylaxis against NSAID gastropathy, 23% of respondents chose not to prescribe misoprostol when NSAID therapy was resumed after an active ulcer had healed. Histamine H2-receptor antagonists were preferred over misoprostol for well elderly patients and nursing home residents. Training and experience were not responsible for differences among respondents' prescribing patterns.

Specific cyclooxygenase-2 (COX-2) inhibitors.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are currently among the most widely prescribed drugs worldwide. Their therapeutic benefits and their side effects in the gastrointestinal tract and kidney, as well as in hemostasis, are of great importance in modern medicine. Within the past decade, new insights into how NSAIDs produce both their therapeutic benefits and their serious side effects have been discovered. It is now known that there are two froms of the cyclooxygenase (COX) enzyme that metabolize arachidonic acid into prostaglandins. Drugs that specifically inhibit the COX-2 enzyme were formulated and put into clinical trials during the past 5 years. These drugs are now available to treat patients in the United States. Specific COX-2 inhibitors offer the benefit of being able to treat the pain and inflammation of arthritis with potentially little risk of serious gastrointestinal injury.

Juvenile rheumatoid arthritis.

Musculoskeletal problems account for the majority of initial complaints attended to by primary care physicians. It is likely that a child who eventually has juvenile rheumatoid arthritis diagnosed will initially be evaluated by a family physician or a pediatrician. Primary care physicians will play an increasingly important role in management of juvenile rheumatoid arthritis, as the availability of specialists in many communities is limited, and access to them may be further limited by managed care initiatives. This article offers a brief review of the definition and classification of juvenile rheumatoid arthritis and introduces a diagnostic algorithm to provide a simplified approach toward evaluating children with arthritis. Treatment and outcomes are summarized in text and graphic formats.

Biochemical characterization of ADP-ribose polymer metabolism in SLE.

The metabolism of poly(ADP-ribose) in peripheral blood mononuclear (PBM) cells was studied in 13 patients with systemic lupus erythematosus (SLE) and in 12 age and sex matched controls. Poly(ADP-ribose) polymerase activity was measured as the net accumulation of ADP-ribose polymers during the conversion of 32P-NAD to poly(ADP-ribose) in PBM cells in vitro. The control population showed a mean activity of 418 +/- 91(s.d.)pmol ADP-ribose/10 min/10(6) cells. The SLE population was more heterogeneous and showed a lower mean of 225 +/- 147(s.d.)pmol ADP-ribose/10 min/10(6) cells. The mechanism of decreased ADP-ribose polymer accumulation was investigated. Measurements of turnover of the ADP-ribose polymers and its substrate, NAD+, showed that diminished ADP-ribose polymer accumulation in SLE subjects resulted from decreased poly(ADP-ribose) synthesis and not from altered rates of polymer turnover or NAD utilization. Western blot analyses of enzyme protein levels, kinetic studies of poly(ADP-ribose) polymerase activity and analyses of polymer size distribution suggested that the mechanisms of poly(ADP-ribose) synthesis in SLE cells is not altered but that the number of active poly(ADP-ribose) polymerase molecules is reduced.

Understanding antinuclear antibodies.

The American College of Rheumatology (formerly the American Rheumatism Association) diagnostic criteria for connective tissue disorders frequently include positive antinuclear antibody (ANA) assays. Proper interpretation of these tests requires an understanding of the principles governing ANA assays. Assay results are reported in two ways: as titers and as descriptions of fluorescent patterns. A titer is a quantitative measure of ANAs in serum. Different patterns of immunofluorescence are associated with different subsets of collagen vascular disease. Positive results can occur in the absence of connective tissue disease. Accurate diagnosis of connective tissue disorders requires judicious use of ANA assays as well as skillful interpretation of the results.

Pain management in the older adult with rheumatoid arthritis or osteoarthritis.

The study's major purpose was to explore the pain management of the older adult with rheumatic disease. Medication, rest, heat, distraction, exercise, and talking with others were methods most often used by older adults (n = 31). Methods identified by them as most helpful included medication, rest, and heat. When the pain management techniques of those adults 65 and over were compared with those of younger adults (n = 51), several differences were noted. The combined number of methods used by the younger group was significantly greater, and they rated relaxation techniques as being significantly more helpful. Increasing the elderly arthritis patient's repertoire of pain management modalities and measuring the ongoing individual effectiveness of the individual and combined methods used are identified as needs to be addressed in improving pain management.

Acute visual loss in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) often presents as a multisystem disease that can be difficult to diagnose. Although ocular symptoms are infrequent, actual acute visual loss has been reported. A review of four cases of acute visual loss from a lupus clinic revealed that two patients had visual loss as a presenting sign of SLE. One had bilateral occipital lobe infarctions, the other multiple cotton wool spots and an attenuated retinal vascular system. Of the two patients with documented SLE prior to the onset of visual problems, one presented with a coincidental retinal tear and the other with retinal phlebitis.

Increased carbonyl content of proteins in synovial fluid from patients with rheumatoid arthritis.

The carbonyl content of proteins in the synovial fluid (SF) of patients with rheumatoid arthritis was significantly (p less than or equal to 0.10) elevated over levels in the SF of patients with osteoarthritis (OA). Other indicators of oxidative damage including catalse, ceruloplasmin, ferritin and superoxide dismutase also showed statistically significant differences (p less than or equal to 0.05) compared to patients with OA.

The redox state in lymphocytes from patients with rheumatoid arthritis.

Our study was designed to quantitate levels of NAD+, NADH, NADP(H), and ATP in peripheral blood lymphocytes with and without mitogenic stimulation from patients with rheumatoid arthritis (RA). No differences were found in patients with RA and healthy controls. Our data suggest the ability of the redox system of circulating peripheral lymphocytes to respond to mitogenic stimulation in patients with RA is not markedly impaired.