First Report®

American College of Rheumatology/Association of Rheumatology Health Professionals (ACR/ARHP) 2012 Annual Meeting

November 9-14, 2012, Washington, DC

Allopurinol May Not Sufficiently Achieve Target Serum Uric Acid Levels in Patients With Gout

Inflammation and severe pain are common symptoms of gout in older adults, but over time deposits of uric acid crystals may cause joint deformity, resulting in severe disability. In nursing home residents, many of whom have renal insufficiency, serum uric acid (SUA) levels and activities of daily living (ADLs) require evaluation and resident care management. During a poster session at the ACR/ARHP meeting, Joy Higa, Takeda Pharmaceuticals, and colleagues reported the findings of a study that compared patients’ characteristics, SUA levels, and ADLs while taking allopurinol. 

Between October 2010 and March 2011, the researchers conducted on-site chart reviews of 14 Hawaii-based nursing homes. The charts included patients’ serum creatinine levels, SUA levels, characteristics from the Minimum Data Set (MDS), and medication records. Patients were considered eligible for the study if they were above the age of 65 years, had been a nursing home resident for more than 30 days, and had recent SUA and ADL assessments. Residents with gout taking allopurinol (identified by the term “cases”; n=202) were compared with a control group of patients without gout who were identified by simple random sampling from the same time frame (two controls per case, n=404). A global ADL score was calculated from the most recent MDS per the Carpenter study (BMC Geriatr. 2006;6:7). 

The team found that of the nursing home residents with gout, 69% had SUA levels ≥6 mg/dL despite allopurinol treatment. Age was found to be a related factor. When compared with the control group, residents with SUA levels ≥6 mg/dL were more likely to be younger than 85 years (39% vs 53%; P<.001) and more likely to be of Hawaiian ancestry (odds ratio [OR]=7.3; P<.001). Cases in this study were more likely to have coronary artery disease (OR=4.0; P<.001), diabetes (OR=3.6; P<.001), previous myocardial infarction (OR=7.3; P<.001), and charted renal failure (OR=4.9; P<.001). Body mass index was also 2.3 points higher for cases of gout versus the control group (P<.001). Gout was independently associated with a 7.26-point higher Carpenter ADL score (P<.001). Cases were also more likely to receive an opiate than the control arm (adjusted OR=8.7; P<.001). 

Higa and colleagues concluded that gout is independently associated with worsened ADL scores and they should be factored into pre-admission evaluation upon entering a nursing home. Furthermore, they noted, allopurinol may not be sufficient to achieve target SUA levels, even when given at maximum renally-adjusted doses.—Kerri Fitzgerald

CAPRA-2 Trial Finds Prednisone May Improve Rheumatoid Arthritis–Associated Fatigue

For patients with rheumatoid arthritis (RA), disease-related pain and inflammation can cause fatigue and negatively impact overall quality of life. Recent studies have shown that glucocorticoid treatment and chronotherapy with delayed-release prednisone may improve patient-reported fatigue. During a poster session at the ACR/ARHP meeting, Rieke Alten, Schlosspark-Klinik, University Medicine, Germany, and colleagues analyzed the results of the CAPRA-2 trial (Circadian Administration of Prednisone in Rheumatoid Arthritis-2) and found that delayed-release prednisone may  significantly reduce fatigue in RA patients.

During a 12-week, double-blind, placebo-controlled study, 350 patients with RA were randomized to receive either 5 mg delayed-release prednisone (n=231) or placebo (n=119) taken once daily at bedtime in addition to standard treatment with a disease-modifying antirheumatic drug. At the 12-week follow-up, the primary end point of the study was the proportion of patients achieving a 20% improvement in tender or swollen joints, as defined by the American College of Rheumatology criteria (ACR20). One of the secondary objectives was to observe improvement in fatigue symptoms, measured by change from baseline status on the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. The FACIT-F is a 13-item questionnaire that assesses the effect of fatigue on daily activity and function on a 5-point scale with a total score range of 0 to 52. 

The results of their analysis showed mean baseline scores on the FACIT-F were comparable between the prednisone group and the placebo group (28.81 vs 28.73). By week 12, the difference in FACIT-F score between these two groups reached clinical significance. At week 12, the least square mean (LSM) change from baseline was significantly greater for 5 mg delayed-release prednisone than for placebo (LSM difference=2.24; 95% confidence interval, 0.76, 3.72; P=.0032). The findings were consistent with improvement in ACR20 score.

The study concluded that patients treated with 5 mg delayed-release prednisone demonstrated significant improvements in their FACIT-F scores when compared with patients receiving placebo, which indicates a reduction in fatigue and, therefore, a major improvement to quality of life for RA patients. The authors concluded, “chronotherapy with a [delayed-release] prednisone formulation improves ACR scores and provides a potential new treatment option for patients with RA that can also improve symptoms of fatigue.”—Kerri Fitzgerald

Researchers Analyze Relationships Between Morning Stiffness Severity and Duration in Patients With Rheumatoid Arthritis

Morning stiffness (MS), which is commonly reported by patients with rheumatoid arthritis (RA), is predictive of functional disability and escalated RA care in older adults; however, clinicians are still unsure of the best way to evaluate MS in RA patients. A recent study, presented in a poster session at the ACR/ARHP meeting, reported that morning pain, MS severity, and MS duration are the key patient-reported outcomes in RA treatment response and disease progression. In this study, Frank Buttgereit, MD, Charite University Medicine, Berlin, and colleagues examined data taken from CAPRA-2 (Circadian Administration of Prednisone in Rheumatoid Arthritis-2), a study in which RA patients were randomized to receive either 5 mg delayed-release prednisone (n=231) or placebo (n=119) in addition to standard treatment with an antirheumatic disease-modifying drug. The primary end point at the 12 week-follow-up was the proportion of patients achieving a response according to the American College of Rheumatology criteria (ACR20). A secondary objective was a reduction in patients’ self-reported MS. The team used these data to evaluate MS duration, MS severity, and pain intensity (PI) in patients upon waking, with other RA measures representing disease progression and response, to determine if one is more clearly related to the disease activity. The extent of these relationships were assessed using patient response criteria from the ACR20, the Disease Activity Score 28 Calculator (DAS28), and the Health Assessment Questionnaire for Rheumatoid Arthritis (HAQ-DI).

Changes from baseline in MS duration, MS severity, and PI were assessed using Pearson Correlations. In addition, a Wilcoxon rank sum analysis was completed between responders and nonresponders based on MS duration, ACR20, DAS28, and HAQ-DI. The results of the study indicated significant correlations among MS duration, MS severity, and PI with the DAS28 and HAQ-DI in all group analyses (P<.0001). There were stronger absolute correlations seen with MS severity and PI when compared with MS duration. A moderately strong correlation was seen between DAS28 and MS severity and PI in both the treatment and placebo groups. Overall, MS severity and PI were strongly correlated. 

The authors noted that the findings in this study were consistent with previous studies showing that joint impairment is moderately correlated with disability, as measured by self-report questionnaires. The researchers found that responders had a greater relative reduction in MS duration than non-responders, especially in the RA patients treated with delayed-release prednisone. 

The authors concluded, “Patients who met ACR20, DAS28, and HAQ-DI response criteria had a significantly greater reduction in MS than nonresponders.”—Kerri Fitzgerald

Study Examines Effect of TNF Inhibitors on MRSA Carriage in Patients With Rheumatologic Disease

Methicillin-resistant Staphylococcus aureus (MRSA) presents great risk for patients and healthcare providers, representing a significant source of financial burden and morbidity and mortality. While numerous studies of MRSA have assessed the relationship between colonization and drugs with immunosuppressive properties, they tend to be limited to transplant patients, cancer patients, and those with human immunodeficiency virus. In a poster session at the ACR/ARHP meeting, Daniel E. Kreutz, MD, and colleagues, Scott & White Healthcare/Texas A&M University, presented the findings of their study, which sought to identify the influence of tumor necrosis factor (TNF) inhibitor drugs on MRSA carrier states in patients with psoriasis (PS), psoriatic arthritis (PsA), rheumatoid arthritis (RA), or ankylosing spondylitis (AS). 

Medical records of patients admitted to two large referral hospitals between January 1, 2007, and March 31, 2010, were reviewed for this study. Eligible patients were adults aged 18 years or older with PS, PsA, RA, or AS admitted during this time period (N=1001). Using a retrospective chart review, 436 patients were screened for nasal MRSA, which is the most common colonization site.

Of this group with nasal MRSA, 10 patients (2.3%) had PsA, 15 (3.4%) had AS, 72 (16.5%) had PS, and 341 (78.2%) had RA. Approximately 12% of patients (n=53) were noted to have MRSA colonization, compared with the overall rate of 6.7% in adults. Additionally, 12.4% (n=54) of patients had a TNF inhibitor in their medication regimen, 11.1% of whom were MRSA-positive. 

The study found patients with MRSA tended to have a longer length of hospital stay (P=.0529) and were more likely to have come from a nursing home (27.5%). The presence of MRSA was strongly associated with nursing home residence, the authors noted (P=.0003).

The researchers concluded that patients with PS and rheumatologic diseases had a higher rate of MRSA colonization than the general patient population who participated in the study. Patients treated with TNF inhibitors were no more likely than those being treated with traditional immune modulating agents to have a MRSA-positive screen, they noted. Additionally, patients transferred from a nursing facility to the hospital were more likely to have a MRSA-positive screen.—Kerri Fitzgerald