Wednesday, February 17, 2010

Sometimes reading can be a positive...Methotrexate, Mortality & Pain

Three of the latest articles I'm can find the links to all the articles I am reading at the side of the blog in: Articles I'm Reading
Click on the title of the article to read it in it's entirety. I'm pulling out pieces of note to me, but they are not the full article.
Kids in Remission May Be Able to Stop Meds Sooner
Deaths Due to Childhood Arthritis Drop
The Importance of Pain Management

Kids in Remission May Be Able to Stop Meds Sooner
Doctors have long known that even when children with juvenile rheumatoid arthritis, or JRA, achieve remission, they have a high risk of relapse when taken off their medication.
So it has been standard practice for most kids to stay on their methotrexate for at least one year after their symptoms disappear.
But a new study, presented at the 2009 annual meeting of the American College of Rheumatology in Philadelphia, has concluded that the extra year on medication doesn’t really affect the risk of relapse – a finding that may allow more JRA patients to come off methotrexate as soon as their disease subsides.
For this study, Dirk Foell, MD, of the Department of Pediatrics at the University of Muenster in Germany, and his team set out to determine if the length of treatment after reaching inactive disease status influenced the risk of future recurrences and whether patients at risk for flares can be identified by molecular biomarkers.

Scientists studied 365 JRA patients whose disease had been inactive for at least three months. Patients were split into two groups. One stopped methotrexate after six months, the other after 12. When participants were taken off the medication, myeloid-related proteins 8 and 14 – which are markers for inflammation – were analyzed.
Of the 297 patients who completed the study, roughly half in each group saw their arthritis flare again – 54.3 percent of the group continuing on methotrexate for six months and 43.7 percent of those taking it for a year saw the disease return.
“Longer treatment with methotrexate in remission does not prevent flares after withdrawing therapy in juvenile idiopathic arthritis,” Dr. Foell says. “We say that children should be taken off medication earlier when they are in remission, and that novel biomarkers may be used to help with this decision.”
Study authors found that traditional blood tests, C-reactive protein or CRP, and ESR, or “sed rate”, couldn’t accurately tell them who was at risk of relapse. “All of our patients had normal CRP, although clearly the outcome with regard to disease flare differed. Hence, CRP is not able to detect subclinical, minimal inflammation and cannot be used to further differentiate between patients at risk for flares and those who stay in remission,” Dr. Foell explains.
But scientists did find that measuring myeloid-related proteins 8 and 14, or MRP 8/14, which are markers of inflammation, could accurately predict which children would relapse, and which could safely come off their meds. These proteins were significantly higher in those patients who subsequently relapsed compared to patients with stable remission.
“MRP 8/14 is the first biomarker reflecting subclinical inflammation in remission,” Dr. Foell says. ”Novel molecular markers of inflammation may at least give more certainty about the fact that there are no signs of ongoing inflammation, and that will help with decision making.”
Unfortunately, the blood test for these proteins is still experimental and is not yet available for clinical use.
“We do notice with methotrexate in particular, that a good percentage of patients flare up again. There have never been any studies about what we should do. So this shows us what we’ve all found – that sometimes a lot of patients can’t come off the methotrexate. They need to continue on it.”
“If a patient is doing well, you don’t have to wait to take away the methotrexate. That’s sort of good news for some patients. This study shows there’s no added reason to continue the medication for an additional year.”

Deaths Due to Childhood Arthritis Drop
- Mortality rates for pediatric rheumatology patients found to be lower than previously reported and no worse or greater than the general population.

02/05/10 - In the February issue of Arthritis and Rheumatology, a Cleveland Clinic research team reports that the overall mortality rate in the U.S. for all pediatric patients with rheumatic diseases wasn’t worse or greater than the general population, even in conditions associated with increased mortality.
“We were most surprised by systemic JRA that was not significantly greater than the general population, and the improved prognosis of kids with pain syndromes compared to the general population with most of their deaths occurring from non-natural causes like motor vehicle accidents, suicide and homicide.”
Dr. Hashkes says he hopes his study results will be encouraging to patients and families with the diseases and he hopes it gives doctors more accurate information to pass on about the prognosis of these diseases in children. He also hopes there will be more research using the registry.
“I think this cohort should be followed for mortality trends in the next decade, to monitor especially for the long-term effects of our medications, excess malignancies for example, and to search for cardiovascular deaths similar to that found in adult diseases like rheumatoid arthritis and SLE.”

The Importance of Pain Management - Children with arthritis shouldn’t have to accept pain.
Pain’s throb, stab and ache can become a serious problem for a child with a chronic disease like juvenile arthritis (JA) and can affect many facets of a child’s life. But do kids with arthritis have to be saddled with pain? “What I see clinically is that a lot of kids and their families assume that because they have arthritis they need to live with pain and nothing can be done, and that’s not true,” says Lonnie Zeltzer, MD, director of the Pediatric Pain Program at Mattel Children’s Hospital at UCLA in California.
Another reality is that pediatric rheumatologists don’t always think of targeting the pain directly; instead focusing on disease control with the belief that decreased inflammation will be all that is needed to ease discomfort.
“A fairly new finding is that pain can lead to more inflammation, so by treating pain in somebody with arthritis, you can reduce some of the inflammation,” says Dr. Zeltzer.

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