Annals Reviews Best Rheumatology Evidence of 2013

April 15, 2014
Norman Bauman

The best news for rheumatologists from last year, in this review, involved osteoarthritis, psoriatic arthritis, and rheumatoid arthritis -- including a good way to assess cardiovascular risk in RA.

Solow EB, Kazi S, and Makris UE. Update in Rheumatology: Evidence Published in 2013. Ann Intern Med. (2014) 10 April doi:10.7326/M14-0287

The theme underlying this annual review is the best evidence for delivering high-value, cost conscious care to rheumatology patients. The findings in brief:

Osteoarthritis:   Surgery for meniscal tears was not superior to sham procedures or nonoperative management in two randomized controlled trials.

Rheumatoid arthritis:  Triple therapy is not inferior to biologics for active rheumatoid arthritis (RA), judging from a randomized double-blind trial that compared methotrexate (MTX), sulfasalazine, and hydroxychloroquine to etanercept plus MTX in 353 patients who had active RA despite taking MTX. The primary outcome was Disease Activity Score 28. Of note: a higher percentage in the etanercept plus MTX group achieved 70% improvement at 24 weeks, but the significance of this is uncertain.

Patients with early RA who took fish oil along with triple therapy had a significantly higher rate of first remission and a lower therapy failure rate, in a controlled trial of 140 patients who were randomized to a high dose or low dose of fish oil.

A 10-year observational study of 741 patients with RA found that risk factors for cardiovascular disease varied by age:

≥65

Glucorticoid

Increased

≥65

Methotrexate
C-reactive protein decreased
Erythrocyte sedimentation rate decreased

Decreased

<65

Rheumatoid factor
Anti-citrullinated peptide antibody
C-reactive protein
Erythrocyte sedimentation rate

Increased

Psoriatic arthritis:  Ustekinumab is effective in psoriatic arthritis. In a randomized controlled trial, 615 patients were randomized to ustekinumab 90 mg, ustekinumab 45 mg, or placebo. At week 24, almost half the ustekinumab recipients achieved the primary endpoint of American College of Rheumatology 20 (ACR20), and this was maintained at week 52.

Health care delivery:  European patients randomly assigned to a clinical nurse specialist with 10 years' experience in rheumatology were significantly more satisfied than those randomly assigned to a physician. Physicians had lower scores in “access to care” and “provision of information.”

Strategies promoting early diagnosis, referral, and management of inflammatory arthritis identified in a literature review: Primary care education programs and patient questionnaires helped identify patients with arthritis and promoted referrals. To shorten the time from referral to assessment: Triage, referral forms, early arthritis clinics and rapid- access services.

The review also cited the "Choosing Wisely" list of five top tests rheumatologists should avoid, chosen by the American College of Rheumatology with a consensus process. The list is available online at http://www.choosingwisely.org/doctor-patient-lists/american-college-of-rheumatology/.