Winter 2008 News4You
Hot topics in Research & Treatment
The only way to improve our ability to prevent, diagnose, and treat osteoarthritis and rheumatoid arthritis (RA) is with clinical studies. Here, we update you on three recent studies. The first, published in the medical journal Lancet, provides valuable information on the benefits of early treatment with a combination of two drugs for rheumatoid arthritis compared with the traditional, single-treatment drug. The other two studies were presented at the American Academy of Rheumatology’s annual meeting in October. The first provides information about one way your diet could keep your osteoarthritis from getting worse; the other details a new test that could help doctors improve their ability to diagnose RA. Enbrel® and Methotrexate Combination More Effective than Methotrexate Alone
A study published in the journal Lancet this summer found that half of patients with early, moderate-to-severe rheumatoid arthritis who took a combination of methotrexate and the biologic drug Enbrel® (etanercept) for one year achieved remission compared with just 28 percent of those taking methotrexate alone.
The findings may change the traditional treatment for early-stage RA, which national guidelines recommend should involve disease-modifying anti-rheumatic drugs (DMARDs) and begin within three months of diagnosis. [i]
This initial treatment typically starts with methotrexate, a drug also used to treat certain types of cancer that suppresses the immune system. If methotrexate alone isn’t sufficient on its own, other drugs are added, including newer biologic medications that target proteins and cells involved in inflammation and joint destruction. These medications can be very effective but they also may carry a risk of serious side effects.[ii]
This study compared the effects of methotrexate alone or in combination with the biologic Enbrel® (etanercept). Like methotrexate, Enbrel suppresses the immune system. But it works in a more targeted manner by blocking a substance called tumor necrosis factor. This substance contributes to inflammation, a hallmark of RA.
The randomized study, funded by Enbrel manufacturer Wyeth Pharmaceuticals, involved 542 people who had been diagnosed for 24 months or less.
Half received methotrexate and half both drugs. After one year, those treated with both drugs showed far less disease progression than those treated with methotrexate. In addition, of the 487 patients with severe disease, 80 percent of those taking both drugs achieved “radiograph non-progression,” meaning that x-rays showed no sign of further joint damage, compared with just 21 percent of those who took methotrexate alone.
The combination group also had an improved quality of life, with 61 percent improving in their daily functions compared with 44 percent of those taking methotrexate alone, and nearly three times as many able to keep working.[iii] Both groups had similar rates of serious side effects. The study is continuing for another year.
What does it mean to me?doctor about starting you on a combination of methotrexate and Enbrel rather than methotrexate alone. This study suggests that the combination may be more effective at slowing or even halting disease progression, as well as improving your quality of life, than methotrexate alone.
Vitamin C and Osteoarthritis
High Vitamin C Levels May Slow Osteoarthritis Progression
An underlying cause of osteoarthritis is the damaging effects of free radicals on joint tissue. Free radicals are rogue molecules that cells create when they burn energy, much like the exhaust your car creates when it burns gasoline. These free radicals can damage healthy cells. However, substances called antioxidants that are produced by your own body and found in various foods can prevent free radical damage by destroying these dangerous substances.
One potent source of antioxidants is vitamin C. Studies find that high levels of vitamin C (as well as vitamins E and beta-carotene, which are also powerful antioxidants) can slow the progression of arthritis.[iv]
In a study presented at the 2008 annual meeting of the American Academy of Rheumatology, researchers used x-rays to evaluate the progression of arthritis in 156 patients’ knees and compared the risk for progression with blood levels of vitamin C. They found that people who had the lowest amount of vitamin C (an indication of the amount of the vitamin they got in their diet or through supplements) were twice as likely to have their arthritis get worse as those with high levels.[v] However, high levels of vitamin C did not reduce the risk of developing the disease in the first place.
What does it mean to me? If you have osteoarthritis, consider increasing the amount of vitamin C in your diet. Good sources include all citrus fruits and fruit juices, strawberries, bell peppers, broccoli, and spinach. Aim to get your vitamins through diet; studies with antioxidant supplements rarely show the same benefits.
Will You Develop Rheumatoid Arthritis?
New Test May Predict Rheumatoid Arthritis Development
Rheumatoid arthritis is a difficult disease to diagnose. Yet early diagnosis is critical because studies show that the earlier treatment begins, the less joint damage and disability results.
A study presented at the 2008 annual meeting of the American College of Rheumatology suggests that evaluating nine items in patients and assigning each a score could help doctors predict whether patients who have arthritic symptoms will develop rheumatoid arthritis. About a third of people with this condition, called “undifferentiated arthritis,” are diagnosed with rheumatoid arthritis.
The nine variables are gender, age, location of symptoms, level of morning stiffness and tenderness and swelling of the joints, and levels of three inflammatory blood markers associated with RA. Each variable receives a point value, with a total score between 0 and 14. Researchers evaluated the rule in 288 people with new onset of undifferentiated arthritis, finding scores of six or below strongly predicted the person did not have RA; while scores of eight and higher strongly predicted patients did have RA.[vi]
What it means for you: If your doctor is not sure if you have rheumatoid arthritis, ask about using this rule to further assess your condition. It is available from researchers at Leiden University Medical Center in the Netherland (http://www.leidenuniv.nl).
[i] American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis Rheum. 2002;46:328-346.
[ii] Majithia V, Geraci SA. Rheumatoid arthritis: diagnosis and management. Am J Med. 2007 Nov;120(11):936-9. Review.
[iii] Emery P, Breedveld FC, Hall S, et al. Comparison of methotrexate monotherapy with a combination of methotrexate and etanercept in active, early, moderate to severe rheumatoid arthritis (COMET): a randomized, double-blind, parallel treatment trial. Lancet. 2008 Aug 2;372(9636):375-82. Epub 2008 Jul 16.
[iv] McAlindon TE, Jacques P, Zhang Y, et al. Do antioxidant micronutrients protect against the development and progression of knee osteoarthritis? Arthritis Rheum 1996, 39:648-656.
[v] Chaganti RK, Tolstykh I, Javaid MK et al. Osteoarthritis. Association of Baseline Vitamin C with Incident and Progressive Radiographic Knee OA. The MOST Study 3. Presented at: American College of Rheumatology annual meeting. San Francisco, CA: 2008.
[vi]Van der Helm AH, Detert J, le Cessie S, et al. Towards Personalized Medicine In Rheumatology - A Prediction Rule For The Development Of Rheumatoid Arthritis In Patients With Undifferentiated Arthritis. Presented at: American College of Rheumatology annual meeting. San Francisco, CA: 2008.