Rheumatoid Arthritis: Zerkak D

Zerkak D, Dougados M. · Rheumatology B Department, Cochin Hospital, René Descartes University, Paris, France. · Clin Exp Rheumatol. · Pubmed #15552518 No free full text.

Abstract: It is now accepted that rheumatoid arthritis is not a benign disease, and has considerable morbidity and increased mortality rates. Monotherapy with disease modifying anti-rheumatic drugs (DMARDs) is often ineffective, and rarely leads to sustained clinical remission. Many clinical trials suggest the effectiveness of using combination therapies, and also the benefit of aggressive management early in the course of the disease. However, recent publications studying a variety of combination therapies in rheumatoid arthritis have shown diverse results. Drug combinations at an early stage of rheumatoid arthritis which slow radiographic progression appear to be the most convincing. These data suggest that practitioners should begin with intensive therapy in early disease, and not reserve combination therapy for those who fail monotherapy. The therapeutic strategy should be positioned according to the severity of the disease: in RA with markers indicating severity, combination should be initiated at the start of therapy while it should be instituted in a rapid step-up fashion in mild RA if insufficient efficacy is seen for monotherapy. In general, combinations appear safe and well-tolerated, but continued caution with appropriate monitoring of long-term results and possible toxicities is required.

Soubrier M, Zerkak D, Dougados M. · Service de Rhumatologie, Hôpital G. Montpied, Clermont-Ferrand, France. · J Rheumatol. · Pubmed #16845709 No free full text.

Abstract: OBJECTIVE: To evaluate the prevalence of patients with rheumatoid arthritis (RA) in whom lowering low density lipoprotein cholesterol (LDL-C) should be considered in accord with the ATPIII guidelines. The treatment goals are based on the number of risk factors (RF) other than LDL-C. The goal for 0-1 RF is < 160 mg/l, for multiple RF < 130 mg/l, and < 100 mg/l for coronary heart disease (CHD) or CHD risk equivalent (other clinical atherosclerotic diseases and diabetes mellitus). METHODS: A cross-sectional study was conducted in 145 patients with RA. We recorded the patients' characteristics, the potential risk factors for CHD, and results of lipid profile tests [total cholesterol (TC), high density lipoprotein cholesterol, and LDL-C]. RESULTS: Of the 145 patients recruited, 23 had LDL-C lowering therapy. Of the remaining 122 patients (mean age 54 +/- 15 years), of whom 101 (83%) were women, 109 were taking a disease modifying antirheumatic drug. At the time of the study, disease duration was 12 +/- 10 years. Twenty-seven (22%) of the 122 patients needed lowering of LDL-C. If RA was considered as an additional risk factor or a major risk factor, like diabetes mellitus, 35 patients (29%) and 86 (70%) patients, respectively, needed lowering therapy. CONCLUSION: Our study shows the high percentage of patients with RA for whom LDL-C intervention should be considered. As cardiovascular morbidity and mortality is increased in patients with RA, it would be useful to determine whether RA should be considered as an independent cardiovascular risk factor or as a major risk factor like diabetes that warrants more aggressive cardiac prevention measures.

Mayoux-Benhamou A, Giraudet-Le Quintrec JS, Ravaud P, Champion K, Dernis E, Zerkak D, Roy C, Kahan A, Revel M, Dougados M. · Department of Rehabilitation, Cochin Hospital, 27 Rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France. · J Rheumatol. · Pubmed #18085742 No free full text.

Abstract: OBJECTIVE: To determine the effect of education on the exercise habits of patients with rheumatoid arthritis (RA) after 6 and 12 months. METHODS: We studied 208 outpatients recruited between June 2001 and December 2002. This was a prospective controlled randomized trial. The active group received a multidisciplinary education program, including training in home-based exercises and guidelines for leisure physical activity (PA). The control group received a booklet added to usual medical care. Compliance with home-based exercises was defined as a practice rate >or= 30% of the prescribed training. Compliance with leisure PA was defined as >or= 20% increase in Baecke questionnaire score. Additional assessments involved possible predictors of compliance and changes with regard to the compliance. RESULTS: At 6-month followup, home-based exercise and leisure PA compliance were significantly higher [13.5% vs 1%, respectively (p = 0.001); and 28.2% vs 13.8% (p = 0.02)], but were not at 12 months. Predictors of leisure PA compliance at 6 months included participating in the active group (odds ratio 2.74, 95% CI 1.17 to 6.38) and previous low leisure PA (OR 6.01, 95% CI 2.47 to 14.61), with decreased fatigue (FACIT-F mean -2.94 +/- 8.04 vs -0.1 +/- 7.25 for noncompliant subjects; p = 0.04) and improved psychological status (Arthritis Impact Measurement Scale mean -1.25 +/- 3.12 vs 0.11 +/- 3.39; p = 0.03). CONCLUSION: Education of patients with RA may increase compliance especially with leisure PA, particularly when it is poor at baseline, but these effects are limited and short-term.

Giraudet-Le Quintrec JS, Mayoux-Benhamou A, Ravaud P, Champion K, Dernis E, Zerkak D, Ouslimani A, Courpied JP, Revel M, Kahan A, Dougados M. · AP-HP, Hôpital Cochin, Université René-Descartes, Faculté de Médecine, Paris, France. · J Rheumatol. · Pubmed #17610321 No free full text.

Abstract: OBJECTIVE: To evaluate the effect on health and functional status of an 8-week group-education program for rheumatoid arthritis (RA) in addition to usual medical care. METHODS: All consecutive inpatients and outpatients with RA (ACR criteria) were asked to participate in this randomized, prospective, controlled trial. The educational intervention consisted of 8 weekly ambulatory sessions, each lasting 6 hours. Followup was undertaken after 1 year. The primary criterion for judging effectiveness was the Health Assessment Questionnaire (HAQ) score; secondary criteria consisted of coping, medical knowledge, patient global satisfaction, and quality of life scores before the intervention and after 1 year. RESULTS: We asked 1242 inpatients and outpatients to participate in the study: 208 (16.75%) agreed (104 in each group). At baseline, there was no statistically significant difference between the 2 groups. After 1 year, no statistically significant difference was observed between the 2 groups in change in HAQ score: -0.04 +/- 0.46 (education group) vs -0.06 +/- 0.47 (control group) (p = 0.79). Statistically significant differences were found in 3 domains: patient coping (-1.22 +/- 5.55 vs -0.22 +/- 3.81; p = 0.03), knowledge (3.42 +/- 4.73 vs 0.73 +/- 3.78; p < 0.0001), and satisfaction (10.07 +/- 11.70 vs 5.72 +/- 13.77; p = 0.02), all of which were better for the group attending the education sessions. CONCLUSION: Despite improvements in patient coping, knowledge, and satisfaction, the education program was not found to be effective at 1 year. There may have been methodological problems relating to the sensitivity of questionnaires and patient selection, and tailored educational interventions should be considered.

Soubrier M, Zerkak D, Gossec L, Ayral X, Roux C, Dougados M. · Service de Rhumatologie, Hôpital G. Montpied, Clermont-Ferrand, France. · J Rheumatol. · Pubmed #16622906 No free full text.

Abstract: OBJECTIVE:To determine in clinical practice which clinical status variables for rheumatoid arthritis (RA) are most closely associated with a change in disease modifying antirheumatic drug (DMARD) therapy. METHODS: A prospective monocenter study was conducted in 204 consecutive patients with RA. Rheumatologists recorded patient characteristics, treatments, and disease activity data [tender and swollen joint count (28), morning stiffness, visual analog scale (VAS) for pain (0-100 mm), patient global assessment and physician global assessment, Westergren erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)]. The rheumatologists decided whether or not to initiate or change treatment but were not informed that their decisions were part of the investigation. Logistic regression analysis was performed to evaluate which study variables best predict change in therapy. ROC analysis was used to obtain the cutoff value of the different composite indices (DAS28(ESR), DAS28(CRP), SDAI) for treatment change, as well as sensitivity and specificity. RESULTS: The variables that were predictive for a change in treatment were (in descending order): swollen joint count, morning stiffness, CRP, tender joint count, and patient global assessment. Composite index values associated with a decision to modify DMARD therapy were: DAS28(ESR) 4.2 (sensitivity 87%, specificity 70%); DAS28(CRP) 3.6 (sensitivity 86%, specificity 78%); and SDAI 15 (sensitivity 90%, specificity 86%). The discriminative ability of SDAI was better than that of DAS28(CRP) or DAS28(ESR). CONCLUSION: In our study, swollen joint count was the variable with the greatest weight, which explains the observed better performance of SDAI.

Falgarone G, Zerkak D, Bauer C, Messow M, Dougados M. · Paris Nord University, Avicenne Hospital AP-HP, Rheumatology Department UPRES EA-3408, Bobigny, France. · Clin Exp Rheumatol. · Pubmed #15895896 No free full text.

Abstract: OBJECTIVES: Pain is frequently the primary variable in symptomatic clinical trials for the evaluation of rheumatological disorders. The protocol of such trials mention a minimum level of pain as an entry criterion [e.g. a level above the Patient Acceptable Symptoms State (PASS)] and the changes in pain as the primary variable. Usually, the results are expressed at a group level as the mean changes in pain. However, the presentation at an individual level and, in particular, the percentage of patients with a Low Disease Activity State at the end of the study seems more clinically relevant. Pain is usually evaluated using a continuous variable such as a 0-100 visual analogue scale. The cut-offs permitting one to define both the entry criterion and the LDAS are not well established. The objective of this study was to evaluate such cut-offs using a patient-derived perspective. METHODS: Study design: cross-sectional study. Patients: consecutive out patients suffering from chronic rheumatic diseases familiar with the use of a VAS to evaluate their level of pain. Data collected: two questions were asked the patients at the end of the visit: "Based on the experience you have because of your chronic rheumatic disorder, could you please specify the level of pain below which you consider your disease as inactive ? Moreover, could you please also specify the level of pain above which you consider taking a pain killer?" Before answering the second question, it was explained to the patient that their answer to the second question could be similar to their response to the first one. For the two questions, the cumulative percentage of patients (disease inactive and pain killer intake) were calculated for each level of pain. RESULTS: The underlying disease of the 137 evaluated patients (mean age: 57+/-16 and female sex: 76%) was rheumatoid arthritis (n = 59), ankylosing spondylitis (n = 19), SLE (n = 2), back pain (n = 20), or peripheral osteoarthritis (n = 37). The mean disease duration was 12+/-10 years. At the time of the study, the current level of pain evaluated on a 0-100 VAS was 33+/-22. The LDAS was 49, 36 and 25 for our patient population at the 25th, 50th and 75th percentiles, respectively. The pain killer intake level was 32, 48, 64 at the 25th, 50th, 75th percentile respectively. CONCLUSION: This study suggests that LDAS and PASS may be distinct concepts. The methodological approach adopted here could be of interest for specifying the minimum level of symptoms at entry in a symptomatic trial (PASS) and also to present results in terms of the percentage of patients in good condition (LDAS) at the end of a trial.