Musculoskeletal Disorders

How safe and effective is combination therapy for rheumatoid arthritis?

For the past 7 years, a 32-year-old African-American man had multiple nonpruritic scalp abscesses. He also reported intermittent fever and joint pain. The abscesses had been drained on many occasions, and he had received several antibiotics, although no organisms had been isolated. Collagen vascular disease, SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), discoid lupus, and cutaneous sarcoid had been ruled out. During the past 7 years, he had been treated with prednisone, methotrexate, and hydroxychloroquine without any response.

A 56-year-old woman seen during physician’s hospice visit. Stormy course from lupus nephritis, dialysisdependency, repeated episodes of dialysis-catheter–related peritonitis, each treated and followed by Clostridium difficile–associated disease.

The use of bisphosphonates, which are commonly taken to prevent and treat osteoporosis, may lower the risk of breast cancer, according to the results of a recent study led by Polly A. Newcomb, PhD, MPH, a researcher at the Fred Hutchinson Cancer Research Center in Seattle.

To save time and minimize pain and tissue trauma when injecting a joint or soft tissue with a corticosteroid, use a single needle and 2 screw-on syringes. Fill the first syringe with lidocaine and the second with the corticosteroid, then lightly but securely attach the first syringe to the needle. After inserting the needle and achieving local analgesia in the desired location, simply leave the needle in place and, while holding it firmly, switch the syringes; then inject the corticosteroid.

A 38-year-old man had fever and fatigue for the past 6 days and tenderness in the left upper abdominal quadrant for the past 3 days. He also had a facial butterfly rash that had been present for 10 years and a 1-year history of lupus nephritis, treated with prednisone and mycophenolate. He denied respiratory complaints or recent weight loss.

To ensure accurate joint injections, mark the site by firmly pressing the end of a closed ballpoint pen against the patient's skin.

Case studies of athletes with isolated axillary neuropathy provide an overview of this injury's anatomy and function, which are key to definitive diagnosis and appropriate treatment.

As the number of biologic agents for rheumatoid arthritis (RA)-and rheumatologists’ use of these agents for RA and other rheumatological diseases-grows, getting coverage for RA treatment is taking an increasing investment of physicians’ staff time. However, the majority of respondents to a recent survey say it is an investment in patient care that is worth making.

An estimated 5 million US adults, or about 2% of the adult population, have fibromyalgia (FM), according to 2005 data collected by the National Arthritis Data Workgroup (Figure 1). FM is a chronic condition of unknown etiology characterized by widespread muscle pain, sleep disturbance, fatigue, and often psychological distress and is considered a form of arthritis. The workgroup also reported that the only study on the prevalence of primary FM in the United States-which included 3006 adults 18 years and older-showed that prevalence was significantly higher among women than among men (3.4% vs 0.5%; approximately a 7:1 ratio). In women, prevalence of the condition rose sharply in middle age, to 7.4% among those aged 70 to 79 years, and then declined. Prevalence of FM in men similarly peaked between 70 and 79 years but was only slightly more than 1% among men in this age-group. The CDC notes that the condition can also develop in children.

THE CASE: A 7-year-old boy has had left ankle pain for 2 days. Neither he nor his mother can recall any recent trauma to the joint. He is usually very active, but he has been unable to bear weight on the left foot and has been resting in bed. His mother reports that he had some tactile fevers, which were transiently relieved with ibuprofen, and that he has been eating and drinking normally. Despite the application of ice and elevation, the ankle has become red and swollen.

This rash erupted on the upper body of a 58-year-old woman in late August. It was mildly pruritic and nontender. The patient had not started any new medications and was not taking photosensitizing drugs. She had Sjögren syndrome; the rest of her history was noncontributory. Subacute cutaneous lupus erythematosus (SCLE) was diagnosed. SCLE typically affects white women aged 30 to 40 years.1 It presents as nonindurated, nonscarring, erythematous plaques with or without a fine scale that may progress into a diffuse, widespread, papulosquamous or annular lesion with central hypopigmentation or telangiectasia.

These joint deformities occurred in a 61-year-old man with chronic tophaceous gout. The patient had had joint pain and swelling since he was 40 years old; the symptoms began in 2 fingers and were initially mild. He did not seek medical attention. Within 5 to 10 years, joint abnormalities had developed in the fingers and then in the left elbow and right ankle. The toes were not affected. He had no family history of joint pain or swelling. Serum uric acid level was 9.7 mg/dL.

For several months, a 45-year-old woman had ocular irritation, tearing, blurred vision, and swelling of the eyelids in both eyes. During that time, she had been treated for allergic conjunctivitis and blepharitis by several physicians, including an ophthalmologist. Her medical history included lupus and seasonal allergies, for which she was taking hydroxychloroquine and loratadine.

Although gout has been recognized since ancient times, its management remains challenging. In a previous article (CONSULTANT, December 2008, page 1010), I focused on diagnosis; here I discuss how the treatment approaches for an acute flare and for chronic gout differ, and I compare the safety and efficacy of available therapies.

Acute gouty arthritis is frequently misdiagnosed or diagnosed late in its clinical course, and therapy is often suboptimal. Because the treatment of gout as a chronic, progressive disease has not been standardized, optimal disease management remains a challenge.

Because the medical literature and direct-to-consumer advertising have focused mainly on the burden of osteoporosis in postmenopausal women, recent screening guidelines for this disease in men may catch some by surprise.

Now that baby boomers have reached the age of Medicare eligibility, joint replacements are on the rise. Because patients who undergo hip or knee arthroplasty require anticoagulation, primary care physicians have a key role in the care of these persons- before as well as after surgery.

I often inject patients’ knees with a mixture of a corticosteroid and an anesthetic agent to alleviate arthritis pain. However, some patients with knee pain have difficulty in climbing onto the examination table.

Despite the availability of good clinical tools for identifying patients at risk for fracture, osteoporosis is underdiagnosed in clinical practice. This is the case even in patients who have already sustained a fragility fracture and are at very high risk for future fracture.

The numerous symptom domains of fibromyalgia syndrome (FMS) include pain, fatigue, sleep disturbance, mood disturbance, function impairment, irritable bowel syndrome, tension and migraine headache, and cognitive dysfunction. Its pathophysiology is rooted in neural dysregulation in the spinal cord and brain.

Systemic lupus erythematosus (SLE) is an unpredictable multisystem disease that affects more than 1.5 million Americans and at least 5 million persons worldwide, according to the Lupus Foundation of America (LFA).

The number of Americans with arthritis or another rheumatological disorder is expected to climb to 67 million-a 44% increase-by the year 2030, according to a new study released by the CDC for the National Arthritis Data Workgroup (NADW).

An 84-year-old woman with progressive stenosis of the cervical spinal canal, type 2 diabetes mellitus, hyperlipidemia, gastroesophageal reflux disease, hypertension, and stable angina presents to her primary care physician after an appointment with the orthopedist who is monitoring her chronic degenerative joint disease.

NSAIDs help control the pain and inflammation of rheumatoid arthritis (RA) but do not affect disease progression; they are recommended for patients with newly diagnosed RA only as an adjunct to disease-modifying antirheumatic drug (DMARD) therapy.

An estimated 46.4 million US adults, or approximately 21% of the adult population, self-reported a physician-diagnosed form of arthritis, which is the leading cause of disability in the United States, according to 2005 data collected by the National Arthritis Data Work group. The work group estimates that by 2030, the number of US adults aged 18 years and older with arthritis or other rheumatic conditions will jump to nearly 67 million (25% of the adult population)-an increase of about 40% (Figure 1).

Specialty medications constitute the fastest-growing segment of drug spending under the pharmacy benefit. This study evaluated the impact of a specialty pharmacy prior authorization (PA) program on prescription drug costs for biologic response modifiers (BRMs) used in the treatment of persons with rheumatoid arthritis, juvenile rheumatoid arthritis, Crohn disease, ankylosing spondylitis, psoriatic arthritis, psoriasis, and other spondyloarthropathies. A retrospective, case-control, one-to-one matching approach based on patient age, sex, and client characteristics was used. Case clients were enrolled in the specialty pharmacy PA program from January 1 through December 31, 2005. The control group consisted of clients who were not enrolled in the program during this time. The average costs per eligible member per month (PMPM), for the total, plan, and member were $1.32, $1.29, and $0.03, respectively, in the case group, and $1.44, $1.41, and $0.03, respectively, in the control group. Clients who implemented the specialty pharmacy PA program for BRMs saved an estimated total cost of $0.12 PMPM. Implementing a specialty pharmacy PA program reduced BRM costs. (Drug Benefit Trends. 2008;20:26-31)

A 50-year-old woman had a 6-month history of severe generalized itchiness and fatigability. There was no associated fever, abdominal pain, or joint pain. A cholecystectomy had been performed 20 years earlier. She had no family history of hypercholesterolemia or liver disease.

Worsening painful ulcers on both legs prompted a 62-year-old woman to seek medical attention. She had a history of rheumatoid arthritis (RA), demonstrated by the markedly deformed interphalangeal joints in her thumbs (A), and scleroderma-polymyositis overlap syndrome.

ATLANTA -- On the eve of World Arthritis Day 2007, the CDC has released a snapshot, taken in 2003, of the burden of arthritis in the working world.