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Does this evidence from recent research overturn some generally accepted principles about gout, rheumatoid arthritis, reactive arthritis, and osteoarthritis? Most of these studies were undertaken in order to test ideas that were described as common wisdom in rheumatology.
Assumption #1. Gout does not occur in patients with rheumatoid arthritis.
In another one of those large longitudinal studies from the Mayo Clinic, during nearly 10,000 patient-years of followup among people with rheumatoid arthritis (RA), the 25-year cumulative incidence of gout diagnosed by clinical criteria was 5.3%, arising most commonly in the great toe. Monosodium urate crystals were documented in nearly half of these patients, all of whom were diagnosed with RA before gout developed. This is a lower rate of gout occurrence than in the general population, although the risk factors are similar: male gender, obesity, and older age.
Assumption #2. An adequate dose of colchicine taken at the first signs of a gout attack can prevent a flare.
In a survey of patients who reported having one gout attack within the previous year, backed up by medical records review, colchicine protected against gout attacks only if it had been taken consistently over the preceding 14 days. Intermittent and inconsistent use of colchicine, or NSAIDs however consistently used, were ineffective in preventing gout attacks. (However, this community-based study cannot exclude the possibility that certain formulations and/or doses of NSAIDs, used consistently, may be effective.)
Assumption #3. Rheumatologists and primary care physicians can achieve flare-free status for most patients with chronic gout by appropriately prescribing xanthane oxidase inhibitors.
One-third of gout patients considered "adequately controlled" by their physicians experienced two or more gout flares per year, according to a national survey of 125 US rheumatologists and 124 primary care physicians by Dinesh Khanna and Puja Khanna of the University of Michigan. Only 26% of the patients were free of flares during the year under study, and fewer than half achieved serum urate levels below 6 mg/dL. (Are current treatment standards and options inadequate to control gout, as the researchers conclude, or are many physicians insufficiently vigilant?)
Assumption #4. Osteoarthritis (OA) of the knee almost always progresses over time.
Evidence from a three-year study of 1,447 participants in the Osteoarthritis Initiative who had radiographically evident and symptomatic OA showed that half reported less knee pain at 48 months than at 12 months. About a third of patients reported having no pain at one or more followup visits, and only 36% reported a higher pain score at 48 months. Symptoms worsened progressively for only 12.6% of subjects.
Assumption #5. Antibiotic treatment is indicated for reactive arthritis.
A systematic review of randomized trials carried out by researchers at the Universities of British Columbia, Calgary, and Toronto reveals no significant effects of antibiotics on swollen joint counts, tender joint counts, pain, or patient global scores among patients with reactive arthritis. However, antibiotics were associated with a 97% increase in gastrointestinal adverse events.
Assumption #6. Degeneration of one or more lumbar discs is the most common cause of low back pain and associated leg pain.
Among 840 newly enrolled participants in the Johnson Count (NC) Osteoarthritis Project who had low back pain plus radiographically documented evidence of disc space narrowing, vertebral osteophytes, or facet joint OA, only modest associations were found between disc space narrowing and low back pain. No significant associations were found between low back pain and associated leg pain, which "may have an etiology other than disc degeneration," write the authors. "Plain film radiographs may have limited clinical utility for this subgroup," they add.
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