The following represent additions to UpToDate since the last version that were considered by the authors and editors to be of particular interest. The new material described below represents a small subset of the updating that has been performed, since approximately 40 percent of the topic reviews are updated during each four-month cycle.
DRUG SAFETY
Leflunomide and pregnancy — Exposure to leflunomide (LEF), which is known to be embryotoxic and teratogenic, must be avoided during pregnancy. In women with rheumatoid arthritis who become pregnant while taking LEF, however, reassuring data from a large pregnancy database suggest that healthy pregnancy outcomes usually occur, if the drug is discontinued upon learning of the pregnancy, and immediate attention is given to use of a procedure for enhanced drug elimination [1]. (See "Use of antiinflammatory and immunosuppressive drugs in rheumatic diseases during pregnancy and lactation", section on 'Leflunomide'.)
FIBROMYALGIA
Preliminary diagnostic criteria — Classification criteria developed in 1990 for fibromyalgia (FM), while useful for clinical trials, have been less helpful in the diagnosis of fibromyalgia in routine clinical practice. The 2010 American College of Rheumatology (ACR) preliminary diagnostic criteria for FM provide an alternative approach to diagnosis, which does not require a tender point examination, but does provide a scale for measurement of the severity of symptoms that are characteristic of FM [2]. (See "Clinical manifestations and diagnosis of fibromyalgia in adults", section on 'Preliminary diagnostic criteria'.)
GOUT
Lower dose colchicine — A lower dose regimen of colchicine may have similar efficacy and fewer side effects than a traditional, higher dose regimen for patients with acute gouty arthritis. This was supported by the results of a randomized, placebo-controlled trial that compared colchicine given as 1.2 mg followed by one additional dose of 0.6 mg an hour later (total dose 1.8 mg), versus 1.2 mg followed by 0.6 mg every hour for up to six hours (total dose 4.8 mg) [3]. (See "Treatment of acute gout", section on 'Colchicine'.)
MUSCLE AND SOFT TISSUE DISORDERS
Nocturnal leg cramps — A systematic review of prospective trials identified limited data to support the use of several agents, including calcium channel blockers and vitamin B complex, in the treatment of nocturnal leg cramps [4]. Quinine has been the best-studied drug, but is no longer routinely recommended due to the potential for serious side effects, important drug interactions, and evidence for only modest benefit. (See "Nocturnal leg cramps, night starts, and nocturnal myoclonus", section on 'Pharmacotherapy'.)
ORTHOPEDICS AND SPINE DISEASE
Lumbar spinal stenosis — A review of a Medicare claims database demonstrated that over the 2002 to 2007 time period, the incidence of major complications and 30-day mortality associated with lumbar spine surgery increased in association with an increased frequency of complex fusion procedures [5]. (See "Lumbar spinal stenosis: Treatment and prognosis", section on Surgical therapy.)
Low back pain — In a systematic review that included two randomized trials, post-treatment exercises were more effective than no intervention for reducing the rate of low back pain recurrence at one year [6]. The most promising approaches involve back flexibility and strengthening exercises. (See "Exercise-based therapy for low back pain".)
Compartment syndrome — A study using fresh cadavers found that palpation of leg compartments was neither sensitive nor specific for detecting substantial elevations in compartment pressures [7]. This study reemphasizes the importance of measuring compartment pressures whenever the diagnosis of acute compartment syndrome is suspected. (See "Acute compartment syndrome", section on 'Clinical features'.)
OSTEOPOROSIS
Denosumab — The US Food and Drug Administration (FDA) and the European Commission (EC) approved denosumab for the treatment of postmenopausal women with osteoporosis at high risk for fracture (history of osteoporotic fracture, multiple risk factors for fracture) or patients who have failed or are intolerant of other available osteoporosis therapies [8,9]. Denosumab inhibits the formation, function, and survival of osteoclasts. It decreases bone resorption, increases bone mineral density (BMD), and reduces the risk of fracture. (See "Denosumab for osteoporosis".)
Vitamin D — A randomized trial of high-dose vitamin D (500,000 units) administered once yearly versus placebo in women age 70 years and older found an increase in the risk of falls and fracture in the vitamin D group [10]. (See "Calcium and vitamin D supplementation in osteoporosis", section on 'Calcium versus vitamin D'.)
Teriparatide
- In a randomized trial of teriparatide versus placebo in 102 postmenopausal women with distal radial fractures, teriparatide did not significantly accelerate fracture healing [11]. (See "Parathyroid hormone therapy for osteoporosis", section on 'Fracture healing'.)
- A phase 2 clinical trial compared transdermal teriparatide to a placebo patch or teriparatide injection in 165 postmenopausal women with osteoporosis [12]. After six months, the mean change in lumbar spine BMD was similar in the teriparatide groups and significantly greater than placebo. (See "Parathyroid hormone therapy for osteoporosis", section on 'Transdermal administration'.)
PEDIATRIC RHEUMATOLOGY
Classification of childhood vasculitis — Classification criteria for Henoch-Schönlein purpura, Takayasu arteritis, polyarteritis nodosa, and Wegener's granulomatosis have been formally validated and finalized by an international consortium of rheumatologic societies [13]. These represent minor changes from previously proposed criteria in 2005. (See "Classification and incidence of childhood vasculitis".)
RHEUMATOID ARTHRITIS
Anti-CCP antibody testing — Testing for anti-citrullinated peptide/protein antibodies (ACPA) has become common in the evaluation of patients for rheumatoid arthritis (RA). The best data regarding test performance characteristics of different ACPA come from a 2010 systematic review and meta-analyses which found that second generation anti-cyclic citrullinated peptide (anti-CCP) antibodies had the highest utility, with higher specificity and similar sensitivity to rheumatoid factor (RF) [14]. Both RF and anti-CCP testing should be performed in patients suspected of having RA. (See "Clinically useful biologic markers in the diagnosis and assessment of outcome in rheumatoid arthritis", section on 'Anti-CCP antibodies' and "Diagnosis and differential diagnosis of rheumatoid arthritis", section on 'Laboratory features'.)
Anti-MCV antibodies — Anti-mutated citrullinated vimentin (MCV) antibodies recognize a naturally occurring isoform of citrullinated vimentin, which can be found in patients with RA. The diagnostic and prognostic value of anti-MCV antibodies in RA was analyzed in a systematic review of 14 studies, most of which used a commercially available assay, finding similar performance to anti-CCP antibody testing [15]. Assays for anti-CCP antibodies are presently more widely available than anti-MCV antibody tests in many countries, including the United States. (See "Clinically useful biologic markers in the diagnosis and assessment of outcome in rheumatoid arthritis", section on 'Anti-MCV antibodies'.)
Golimumab — Golimumab, a neutralizing human anti-tumor necrosis factor alpha monoclonal antibody, is administered subcutaneously once monthly for the treatment of rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. A 48-week phase III trial involving over 600 patients demonstrated that it may also be beneficial, in combination with continued weekly methotrexate, in patients with active rheumatoid arthritis, when given by intravenous infusion every 12 weeks [16]. Further study is required, and this route and schedule of drug administration are not presently approved by the US Food and Drug Administration. (See "Randomized clinical trials of tumor necrosis factor inhibitors in rheumatoid arthritis", section on 'Golimumab'.)
Rituximab — In patients with rheumatoid arthritis (RA) who do not respond to an initial course of rituximab, there has been some uncertainty as to whether a second infusion is warranted. A study found that a second set of infusions, administered to nonresponders six months after the initial treatment, resulted in greater B cell depletion than initially achieved and a substantial rate of clinical improvement [17]. (See "Rituximab and other B cell targeted therapies for rheumatoid arthritis", section on 'Retreatment'.)
Treatment to target — New drug development, along with evolving strategies for patient management, including rapid achievement of tight control with use of disease-modifying antirheumatic drugs, have substantially improved patient outcomes. An international task force has developed a set of recommendations, based upon a systematic review of the evidence and expert opinion, to help optimize achievement of these treatment goals [18,19]. (See "General principles of management of rheumatoid arthritis", section on 'Importance of tight control'.)
SJOGREN'S SYNDROME
Rituximab for primary Sjogren's syndrome — Rituximab, which is used for the treatment of B cell lymphomas, rheumatoid arthritis, and other autoimmune and lymphoproliferative disorders, is a chimeric monoclonal antibody directed against the B cell antigen CD20. Several case series and one small randomized trial [20] have previously suggested that rituximab may be of potential benefit in Sjogren's syndrome (SS). In the largest randomized trial to date, involving 30 patients with primary SS, one course of treatment resulted in significant improvement, compared with placebo, in stimulated whole saliva flow rate, as well as fatigue, vitality and sicca symptoms [21]. Additional and larger trials are required. (See "Treatment of Sjögren's syndrome", section on 'Rituximab'.)
SPONDYLOARTHROPATHY
Chronic reactive arthritis with evidence of prior Chlamydial infection — Results are mixed in studies of long-term antibiotic therapy for chronic reactive arthritis, particularly following apparent Chlamydial infection. Significant benefit for long-term (six-month) treatment with either of two combination antibiotic regimens was found in a trial comparing active treatment with placebo in patients with persistent Chlamydial species in blood or synovial tissue as evidenced by polymerase chain reaction testing [22]. These findings need further confirmation before the use of long-term antibiotics can be routinely adopted for the treatment of established reactive arthritis. (See "Reactive arthritis (formerly Reiter syndrome)", section on 'Chronic arthritis with no evidence of active infection'.)
REFERENCES
- Chambers, CD, Johnson, DL, Robinson, LK, et al. Birth outcomes in women who have taken leflunomide during pregnancy. Arthritis Rheum 2010; 62:1494.
- Wolfe, F, Clauw, DJ, Fitzcharles, MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010; 62:600.
- Terkeltaub, RA, Furst, DE, Bennett, K, et al. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum 2010; 62:1060.
- Katzberg, HD, Khan, AH, So, YT. Assessment: Symptomatic treatment for muscle cramps (an evidence-based review): Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2010; 74:691.
- Deyo, RA, Mirza, SK, Martin, BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010; 303:1259.
- Choi, BK, Verbeek, JH, Tam, WW, Jiang, JY. Exercises for prevention of recurrences of low-back pain. Cochrane Database Syst Rev 2010; :CD006555.
- Shuler, FD, Dietz, MJ. Physicians' ability to manually detect isolated elevations in leg intracompartmental pressure. J Bone Joint Surg Am 2010; 92:361.
- www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails (accessed June 17, 2010).
- ec.europa.eu/health/documents/community-register/html/h618.htm#EndOfPage (accessed June 17, 2010).
- Sanders, KM, Stuart, AL, Williamson, EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA 2010; 303:1815.
- Aspenberg, P, Genant, HK, Johansson, T, et al. Teriparatide for acceleration of fracture repair in humans: A prospective, randomized, double-blind study of 102 postmenopausal women with distal radial fractures. J Bone Miner Res 2010; 25:404.
- Cosman, F, Lane, NE, Bolognese, MA, et al. Effect of transdermal teriparatide administration on bone mineral density in postmenopausal women. J Clin Endocrinol Metab 2010; 95:151.
- Ozen, S, Pistorio, A, Iusan, SM, et al. EULAR/PRINTO/PRES criteria for Henoch-Schonlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis 2010; 69:798.
- Whiting, PF, Smidt, N, Sterne, JA, et al. Systematic review: accuracy of anti-citrullinated Peptide antibodies for diagnosing rheumatoid arthritis. Ann Intern Med 2010; 152:456.
- Luime, JJ, Colin, EM, Hazes, JM, Lubberts, E. Does anti-mutated citrullinated vimentin have additional value as a serological marker in the diagnostic and prognostic investigation of patients with rheumatoid arthritis? A systematic review. Ann Rheum Dis 2010; 69:337.
- Kremer, J, Ritchlin, C, Mendelsohn, A, et al. Golimumab, a new human anti-tumor necrosis factor alpha antibody, administered intravenously in patients with active rheumatoid arthritis: Forty-eight-week efficacy and safety results of a phase III randomized, double-blind, placebo-controlled study. Arthritis Rheum 2010; 62:917.
- Vital, EM, Dass, S, Rawstron, AC, et al. Management of nonresponse to rituximab in rheumatoid arthritis: predictors and outcome of re-treatment. Arthritis Rheum 2010; 62:1273.
- Smolen, JS, Aletaha, D, Bijlsma, JW, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010; 69:631.
- Schoels, M, Knevel, R, Aletaha, D, et al. Evidence for treating rheumatoid arthritis to target: results of a systematic literature search. Ann Rheum Dis 2010; 69:638.
- Dass, S, Bowman, SJ, Vital, EM, et al. Reduction of fatigue in Sjogren syndrome with rituximab: results of a randomised, double-blind, placebo-controlled pilot study. Ann Rheum Dis 2008; 67:1541.
- Meijer, JM, Meiners, PM, Vissink, A, et al. Effectiveness of rituximab treatment in primary Sjogren's syndrome: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2010; 62:960.
- Carter, JD, Espinoza, LR, Inman, RD, et al. Combination antibiotics as a treatment for chronic Chlamydia-induced reactive arthritis: a double-blind, placebo-controlled, prospective trial. Arthritis Rheum 2010; 62:1298.
