Psoriasis: Masson C

Pham T, Fautrel B, Dernis E, Goupille P, Guillemin F, Le Loët X, Ravaud P, Claudepierre P, Miceli-Richard C, de Bandt M, Breban M, Maillefert JF, Masson C, Saraux A, Schaeverbeke T, Wendling D, Mariette X, Combe B, Anonymous00063. · Rheumatology Department, la Conception Teaching Hospital, 147 boulevard Baille, 13005 Marseille, France. · Joint Bone Spine. · Pubmed #18065252 No free full text.

Abstract: OBJECTIVE: To update French Society for Rheumatology guidelines regarding the use of tumor necrosis factor alpha (TNFalpha) antagonists for treating patients with ankylosing spondylitis (AS) or psoriatic arthritis (PsA). METHODS: We used the method recommended by Shekelle et al. to update the original recommendations: a limited group of experts selected the items that required updating, the relevant literature was critically appraised, and the experts developed new wording for the recommendations, which was then subjected to internal and external validation. As with the original recommendations, three topics were addressed, namely, indications of TNFalpha antagonist therapy, treatment initiation, and treatment adjustment and follow-up. RESULTS: Four criteria should be used to evaluate the indication of TNFalpha antagonist therapy. First, the patient must have a definitive diagnosis of AS or PsA. Thus, patients with AS must meet modified New York criteria or exhibit characteristic involvement of the sacroiliac joints, spine, or peripheral sites documented by radiographs or computed tomography (structural damage) or by magnetic resonance imaging (inflammation). Patients with PsA must meet validated criteria such as the Moll and Wright or CASPAR criteria. The second criterion is active disease for more than 1month, with a BASDAI >or=4 in patients with predominantly axial disease or a tender/swollen joint count >or=3, and with a physician assessment of disease activity of >or=4/10. The third criterion is failure of at least three non-steroidal anti-inflammatory drugs in patients with axial disease or of disease-modifying antirheumatic drug (DMARD) therapy (methotrexate, salazopyrine, or leflunomide) in patients with peripheral disease. Fourth, the patient must be free of contraindications to TNFalpha antagonist therapy. Four recommendations pertain to the initiation of TNFalpha antagonist therapy: a workup should be performed prior to treatment initiation; there is no evidence that one TNFalpha antagonist is more effective than the others, so decisions about drug selection should be shared with the patient and guided by available safety data and the patient's profile; there is no proof that greater effectiveness can be achieved by routinely combining a conventional DMARD; and patients should receive regular standardized follow-up. The last four recommendations deal with adjusting TNFalpha antagonist therapy: the treatment objective is a 2-point or greater improvement in the BASDAI in patients with axial disease and a 30% or greater improvement in the tender/swollen joint counts in patients with peripheral disease; there is no evidence to support the introduction of DMARD therapy in non-responders, who can be switched to another TNFalpha antagonist or, when on infliximab, given higher dosages or more closely spaced injections; patients who fail to tolerate one TNFalpha antagonist can be switched to another TNFalpha antagonist if allowed by the nature of the adverse event; and when a remission is achieved, reduction or discontinuation of concomitant anti-inflammatory therapy should be considered, followed in the event of a prolonged remission by a reduction in the dosage of the TNFalpha antagonist.

Pham T, Guillemin F, Claudepierre P, Luc M, Miceli-Richard C, Fautrel B, de Bandt M, Breban M, Goupille P, Maillefert JF, Masson C, Saraux A, Schaeverbeke T, Wendling D, Mariette X, Combe B, Anonymous00190, Anonymous00191. · Service de Rhumatologie, CHU de la Conception, 147, bd Baille, 13005 Marseille, France. · Joint Bone Spine. · Pubmed #16843030 No free full text.

Abstract: OBJECTIVES: To develop recommendations for TNFalpha antagonist therapy in patients with spondyloarthropathies. METHODS: The Delphi consensus procedure was used to select questions, to which evidence-based answers were sought in the literature. Expert opinion was used when needed to estimate the risks and benefits of TNFalpha antagonists. TNFalpha antagonists exert potent antiinflammatory effects but fail to provide a definitive cure. RESULTS: Recommendations were developed for patients with ankylosing spondylitis (AS) or psoriatic arthritis (PsA). The following criteria for TNFalpha antagonist therapy were selected: definitive diagnosis of AS or PsA, active disease for at least 4 consecutive weeks documented during two physician visits, overall physician's assessment of disease activity>/=4/10 and BASDAI>/=4/10 in axial disease or at least three tender and swollen joints in peripheral disease, failure to respond adequately to at least three nonsteroidal antiinflammatory drugs given in optimal dosages for at least 3 months in axial disease or at least one disease-modifying antirheumatic drug (methotrexate, leflunomide, sulfasalazine) for at least 4 months, with local glucocorticoid injections if appropriate, in peripheral disease. Effectiveness and safety should be evaluated by a rheumatologist. The frequency of monitoring depends on the drug. Lack of effectiveness should be defined as inadequate improvement after 6-12 weeks, with a less than two-point decrease in the BASDAI in axial disease or a less than 30% decrease in the tender and swollen joint counts in peripheral disease. CONCLUSION: These clinical practice recommendations should help rheumatologists in their everyday decisions regarding the use of TNFalpha antagonist therapy in patients with AS or PsA.

Sellam J, Bouvard B, Masson C, Rousière M, Villoutreix C, Lacombe K, Khanine V, Chennebault JM, Leclech C, Audran M, Berenbaum F. · Rheumatology Department, Saint-Antoine Teaching Hospital, AP-HP, Paris, France. <> · Joint Bone Spine. · Pubmed #17321777 No free full text.

Abstract: Psoriatic arthritis in HIV-positive patients is not only severe, but also raises specific treatment challenges, as immunosuppressant and immunomodulating agents may adversely affect both the course of the HIV infection and the risk of opportunistic infections. TNFalpha antagonists have not been evaluated in patients with HIV infection, which is therefore considered to contraindicate their use. Two HIV-positive patients with psoriatic arthritis unresponsive to methotrexate alone were treated with infliximab (5 and 2 mg/kg, respectively), methotrexate, and antiretroviral drugs. Dramatic improvements in the skin and joint manifestations occurred in both patients. Tolerance was good, after follow-ups of 24 and 50 months, respectively. No opportunistic infections occurred. Viral load remained well controlled and CD4+T-cell counts stable, although both patients required adjustments in their antiretroviral regimens based on close monitoring of these two parameters. HIV infection classically contraindicates the use of TNFalpha antagonists to treat refractory inflammatory joint disease. However, exceptions to this rule can be made in carefully selected patients who have exhausted all other treatment options for their joint disease and who respond well to antiretroviral therapy. Potential long-term effects such as opportunistic infections, malignancies, and loss of HIV control need to be evaluated.

Saraux A, Guillemin F, Guggenbuhl P, Roux CH, Fardellone P, Le Bihan E, Cantagrel A, Chary-Valckenaere I, Euller-Ziegler L, Flipo RM, Juvin R, Behier JM, Fautrel B, Masson C, Coste J. · Rheumatology Unit, University Hospital, Brest-Cedex, France. · Ann Rheum Dis. · Pubmed #15817661 links to  free full text

Abstract: OBJECTIVE: To estimate the prevalence of spondyloarthropathies (SpAs) in France in a multiregional representative sample in the year 2001. METHODS: A two stage random sample was constituted in seven areas from the national telephone directory and the next birthday method in each household. Interviewers were patient-members of self help groups trained to administer telephone surveys using a validated questionnaire for detecting inflammatory joint disease. Quality of data collection was controlled periodically. SpA was confirmed by the patient's rheumatologist or by clinical examination. Prevalence estimates after probability sampling correction were standardised for age and sex (1999 national census). RESULTS: Among the 15 219 anonymous telephone numbers selected, 3.6% were places of work or secondary residences and were excluded. The phone interview participation rate ranged across regions from 55.1 to 69.9%. 3554 men and 5841 women were included in the study. Twenty nine cases of SpA were confirmed. All but one fulfilled ESSG criteria. Mean age was 47 years (range 21-78). The overall prevalence standardised for age and sex was 0.30% (95% confidence interval (CI) 0.17 to 0.46). Prevalence was similar in women (0.29% (95% CI 0.14 to 0.49)) and men (0.31 % (95% CI 0.12 to 0.60)). Geographical analysis by department clustering found no significant differences. The prevalence of SpA was as high as that of rheumatoid arthritis. CONCLUSION: Prevalence of SpA in France was 0.30% in 2001, with no difference between women and men. Ankylosing spondylitis and psoriatic arthritis were the most common SpA subsets.