Liver Injuries Documented From TNF-α Inhibitors

May 7, 2013

New in the non-rheumatology journals: Adverse effects of TNF-α inhibitors, a comment on meniscectomy vs. physical therapy, and the latest on adolescent scoliosis.

Last week's articles on rheumatology topics in the major nonspecialty journals

Medication Adverse Events

Liver Injury From Tumor Necrosis Factor-α Antagonists: Analysis of Thirty-four CasesClinical Gastroenterology and Hepatology, May 2013 (Free full text)

Using the U.S. Drug-Induced Liver Injury Network database and PubMed, researchers found 34 cases of liver injury probably caused by tumor necrosis factor-α (TNF-α) inhibitors. Infliximab, whose experience has been best documented because of its earlier approval and widespread use, was responsible for 26 cases. Etanercept and adalimumab were each responsible for four cases. Median latency before symptoms appear was 13 weeks, but seven cases had latency longer than 24 weeks. The most common presentation is an autoimmune phenotype with marked hepatocellular injury, but a mixed or cholesatic pattern also occurs. All subjects improved after discontinuation, except for one who previously had cirrhosis and required liver transplantation. The underlying diseases were psoriasis and/or psoriatic arthritis (13 cases) inflammatory bowel disease (12 cases), rheumatoid arthritis (6 cases), and ankylosing spondylitis (3 cases). After resolution, patients treated with an alternative TNF-α inhibitor seemed to tolerate it.


Osteoarthritis

Meniscal tear: Operate or PT?
NOW@NEJM, May 1, 2013,. Free full text

What should you do for a patient with knee pain and loss of mobility who has MRI evidence of a meniscal tear and osteoarthritis?  Accompanying the print publication of the previously reported study showing no benefit for meniscectomy over physical therapy, a blog post by Rachel Wolfson now asserts the clinical significance of the finding: It is safe to try physical therapy first for osteoarthritis knee pain. Patients who don't respond can get surgery later.


Adolescent Idiopathic Scoliosis

Clinical Review: Adolescent idiopathic scoliosisBMJ, April 30, 2013. Full text $30

Previous long-term studies of scoliosis combined adolescent idiopathic scoliosis (AIS), neuromuscular scoliosis and congenital scoliosis, thus encouraging the misconception that AIS leads to respiratory failure, cardiovascular risk, and increased mortality. Recent studies of its 50-year natural course found no such evidence. Thoracic curvatures of <30° did not progress. Most adolescents with scoliosis do not require surgery, which is reccommended only for curvatures >45-50°. It is not clear that surgery eliminates back pain. Adolescents with curvatures of <25° require observation only, after underlying pathology is excluded. On the other hand, during the adolescent growth spurt scoliosis with a high risk of progression should be detected and treated as early as possible. Monitoring the growth spurt for scoliosis by measuring height is inaccurate; Risser stages are more accurate, and analyzing radiographs of the hand is even better. The evidence for bracing is also reviewed.