New Options for Hepatitis C, Osteoporosis. One Less for Pain

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

Hepatitis C

Editorial: HCV Treatment - No More Room for Interferonologists?N Engl J Med, May 16, 2013 .Full text $15

Sofosbuvir for Hepatitis C Genotype 2 or 3 in Patients without Treatment Options. The POSITRON and FUSION trials. N Engl J Med, May 16, 2013. Full text $15

Sofosbuvir for Previously Untreated Chronic Hepatitis C Infection. The FISSION and NEUTRINO trials. N Engl J Med, May 16, 2013. Full text $15

A new treatment for hepatitis C virus (HCV) can be used in patients with autoimmune disease. This offers a new option for patients with disorders such as lupus, rheumatoid arthritis, and sarcoidosis in whom the interferon in the standard regimen for HCV is contraindicated. Two papers report that sofosbuvir plus ribavirin is as effective as peginterferon plus ribavirin, with activity over all genotypes of HCV plus a better adverse-effect profile. An editorial notes that 19% of patients in the POSITRON trial had autoimmune disorders for which interferon, but not sofosbuvir, would be contraindicated.


Osteoporosis

Teriparatide and denosumab, alone or combined, in women with postmenopausal osteoporosis: the DATA study randomised trialThe Lancet. Online first, May 15, 2013. Full text $31.50

Comment: Is it time to combine osteoporosis therapies?The Lancet, Online first, May 15, 2013. Full text $31.50

Teriparatide and denosumab combined increased bone density more than either drug separately. In a 12-month study of 100 postmenopausal women randomized into three groups, bone mineral density (BMD at the lumbar spine, the primary end point, increased 6.2% with teriparatide, 5.5% with denosumab, and 9.1% with both combined -- greater than reported for any approved therapy. The articles reveal the underlying biology that explains why these two are a better combination than teriparatide plus a bisphosphonate. The comment calls the improvement in total-hip BMD of 4.9% over 12 months “particularly impressive”, but wonders whether the combination remains effective after 12 months. Cost-effectiveness is another issue.


Psoriasis

Do TNF Inhibitors Reduce the Risk of Myocardial Infarction in Psoriasis Patients?JAMA, May 15, 2013. Full text $30

A retrospective cohort study reported in Arch Dermatol last year found that the use of tumor necrosis factor (TNF) inhibitors for psoriasis was associated with a significant reduction in myocardial infarction risk, compared to treatment with topical agents. Another study found no reduction. A third study found varying effects using different outcomes. This commentary discusses the reasons for the discrepancies. Lacking a randomized controlled trial, uncertainty will remain


Musculoskeletal Pain

Point-of-Care Prognosis for Common Musculoskeletal Pain in Older AdultsJAMA Intern Med., online first, May 13, 2013. Full text $30

Commentary: Tailoring Chronic Pain Care by Brief Assessment of Impact and PrognosisJAMA Intern Med., online first, May 13, 2013. Full text $30

Models for predicting the prognosis for chronic musculoskeletal pain at specific anatomical locations have not been useful for primary care physicians. Using three common prognostic indicators across anatomical sites improved the physician’s ability to predict outcome after six months:
•   When was the last time you were free of pain for a month or more?
•   In the last month, how much has this pain interfered with your daily activities?
•   Have you had pain anywhere else in the last month?

Two questions – about intensity of pain and depression – were not as useful:
•   How would you rate your pain on a 0- to 10-point scale?
•   During the past month, have you often been bothered by (1) feeling down, depressed or hopeless, or (2) little interest in pleasure or doing things?

The improvement was due to correcting the physician’s tendency to be over-optimistic.
Prescription Opioids for Back Pain and Use of Medications for Erectile DysfunctionSpine, May 15, 2013. Full text $64.24

In analysis of electronic records of 11,327 men with back pain enrolled in the Kaiser Permanente health plan, men withlong-term prescriptions for opioids were more likely also to have prescriptions for erectile dysfunction medications or testosterone (n=909, odds ratio 1.45). The most significant factors correlating factor  was age, followed by comorbidity, depression, and use of sedative-hypnotics.


Spinal Injection Therapy for Low Back Pain,JAMA, online first May 16, 2013. Free full text.

Current scientific evidence is insufficient to support injection therapy for patients with low back pain or sciatica, whether using corticosteroids, local anesthetics, or other drugs, says this viewpoint from three PhD analysts at Radboud University in the Netherlands. Neither physicians nor expert bodies should recommend them, it concludes.


Rheumatologist-Patient Relationship

Partnering with patientsBMJ, May 15, 2013.  Free full text

Personal View: Doctors’ understanding of rheumatoid disease does not align with patients’ experiencesBMJ, May 14, 2013.  Free full text

Rheumatology patients are beginning to demand partnership on an equal footing with their rheumatologists, who often can't resolve their problems. These articles focus on the experiences of Kelly Young, who started her blog rawarrior.com, and then founded the Rheumatoid Patient Foundation, as she decided to take ownership of her condition because her doctors admitted they were stumped. In the process, she found many people who shared her atypical presentation. “I am a physician with RA," wrote one doctor on her blog. "I have been so let down by my profession.” The BMJ plans a conference and a theme issue on participatory care.