Practice advisory on the appropriate use of NSAIDs in primary care

Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks

An adolescent with both Wegener's Granulomatosis and chronic blastomycosis

We report a case of Wegener's Granulomatosis (WG) associated with blastomycosis. This appears to be the first case report of WG co-existing with a tissue proven blastomycosis infection. The temporal correlation of the two conditions suggests that blastomycosis infection (and therefore possibly other fungal infections), may trigger the systemic granulomatous vasculitis in a predisposed individual; a provocative supposition warranting further study

Associations of Lifestyle Factors, Disease History and Awareness with Health-Related Quality of Life in a Thai Population

10.1371/journal.pone.0049921PLoS ONE711

Advances in rheumatology: new targeted therapeutics

Treatment of inflammatory arthritides - including rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis - has seen much progress in recent years, partially due to increased understanding of the pathogenesis of these diseases at the cellular and molecular levels. These conditions share some common mechanisms. Biologic therapies have provided a clear advance in the treatment of rheumatological conditions. Currently available TNF-targeting biologic agents that are licensed for at east one of the above-named diseases are etanercept, infliximab, adalimumab, golimumab, and certolizumab. Biologic agents with a different mechanism of action have also been approved in rheumatoid arthritis (rituximab, abatacept, and tocilizumab). Although these biologic agents are highly effective, there is a need for improved management strategies. There is also a need for education of family physicians and other healthcare professionals in the identification of early symptoms of inflammatory arthritides and the importance of early referral to rheumatologists for diagnosis and treatment. Also, researchers are developing molecules - for example, the Janus kinase inhibitor CP-690550 (tofacitinib) and the spleen tyrosine kinase inhibitor R788 (fostamatinib) - to target other aspects of the inflammatory cascade. Initial trial results with new agents are promising, and, in time, head-to-head trials will establish the best treatment options for patients. The key challenge is identifying how best to integrate these new, advanced therapies into daily practice

Serum levels of leptin and adiponectin and clinical parameters in women with fibromyalgia and overweight/obesity

ABSTRACT Objectives The objectives of this study were to evaluate the serum levels of adipokines in women with fibromyalgia with and without overweight/obesity, and to correlate the adipokines levels with clinical parameters associated with fibromyalgia and adipose tissue mass (body fat). Subjects and methods The study included 100 women divided into four groups: (a) fibromyalgia and overweight/obesity; (b) fibromyalgia and normal weight; (c) controls and overweight/obesity; and (d) controls and normal weight. Patients and controls were evaluated for clinical, anthropometric, and fibromyalgia-related parameters. Assessments included serum levels of leptin, adiponectin, monocyte chemoattractant protein-1 (MCP-1), and C-reactive protein (CRP). Levels of adipokines were further adjusted for fat mass. Results Fibromyalgia patients with overweight/obesity or normal weight had no differences in clinical parameters. Unadjusted leptin levels were lower in fibromyalgia patients than controls, a finding that was more remarkable in fibromyalgia patients with overweight/obesity. Leptin levels had no correlation with clinical parameters of fibromyalgia or inflammation markers (MCP-1 and CRP), and adiponectin levels showed no difference between groups. Conclusions No correlation was observed between adjusted leptin levels and clinical parameters of fibromyalgia. Patients with fibromyalgia and overweight/obesity presented lower levels of leptin than controls with overweight/obesity

Antineutrophil cytoplasmic antibody vasculitis associated with mycobacterium avium intracellulare infection

ABSTRACT. A variety of possible associations between infection and antineutrophil cytoplasmic antibody (ANCA) associated vasculitis have been reported. We describe a 75-year-old woman who presented with chronic nonproductive cough, migratory polyarthralgias, and microscopic hematuria. She had an elevated perinuclear ANCA and antimyeloperoxidase antibody. She had a positive PPD test and a cavitary lesion in the right upper lung lobe; biopsy of the lung lesion showed granulomatous vasculitis, but the culture grew Mycobacterium avium intracellulare (MAI According to the Chapel Hill international consensus definitions, which use the vessel size as the determinant for classification of vasculitides, Wegener's granulomatosis (WG), microscopic polyangiitis, and Churg-Strauss syndrome are described as small-vessel vasculitides and are commonly associated with antineutrophil cytoplasmic antibodies (ANCA). They are acknowledged as ANCA associated vasculitis syndromes 1 . The association of infections and ANCA vasculitis has been noted by various authors, especially in WG 2 . Recently we encountered a patient with ANCA associated vasculitis and pulmonary Mycobacterium avium intracellulare (MAI) infection, suggesting a possible association between ANCA associated vasculitis and MAI infections. We emphasize the clinical similarities between ANCA associated vasculitis and MAI infection, since treatment of vasculitis with immunosuppressive agents could be devastating in patients with MAI infection. CASE REPORT A 75-year-old woman was referred by her primary physician for evaluation of chronic nonproductive cough, migratory polyarthralgias, and microscopic hematuria. She had these symptoms intermittently for 5 years, but they had worsened in the past 2-3 months. Her history included hypertension and chronic kidney disease with a baseline serum creatinine of 1.4 mg/dl. Pertinent data included an elevated erythrocyte sedimentation rate (ESR; 110 mm/h), perinuclear ANCA (pANCA) 1:640 (normal < 1:20), and antimyeloperoxidase antibody (MPO) 29 (normal < 6). She also had a positive PPD test (20 mm erythema and induration) and a cavitary lesion in the right upper lung field. She underwent a right thoracoscopic wedge resection. The histology revealed granulomatous vasculitis with focally abundant eosinophils Two months after discontinuation of MAI treatment, she had episodes of hemoptysis, dyspnea, migratory polyarthritis, and new purpuric skin lesions at the second, third and fourth finger pulps and the left calf. She had worsening renal function (creatinine 2.1 mg/dl). A radiograph showed chronic fibrotic changes in both lower lung fields. A computer tomographic scan of the chest showed diffuse airspace disease in the right lower lung field with bronchiectatic change in the right upper lung field. pANCA and MPO were elevated (1:320 and 29, respectively). Cytoplasmic ANCA (cANCA) and antiproteinase 3 antibody were negative. A urinalysis revealed 1+ proteinuria and 194 red blood cells per high power field; no cast was noted. A skin biopsy from the left calf showed necrotizing vasculitis of medium and small arteries with occasional eosinophil

Risks versus benefits of cyclooxygenase-2-selective nonsteroidal antiinflammatory drugs

PURPOSE: A summary of the basic science underlying the current controversies regarding cyclooxygenase-2 (COX-2)-selective nonsteroidal antiinflammatory drugs (NSAIDs), including data on their cardiovascular safety, their gastrointestinal (GI) benefits, cost-effectiveness, physician-prescribing trends, and recommendations for prescribing these agents is presented. SUMMARY: A number of randomized controlled trials (RCTs) have reported that COX-2-selective NSAIDs increase cardiovascular events, although there appear to be gradations of risks among the COX-2-selective NSAIDs. In addition, traditional NSAIDs may increase the risk for cardiovascular events, complicating the interpretation of RCTs that use traditional NSAIDs as comparators. Selective inhibitors of COX-2-selective NSAIDs are effective antiinflammatory and analgesic drugs with improved upper-GI safety compared to traditional NSAIDs. Data on the cost-effectiveness of COX-2-selective NSAIDs indicate that they should be limited to patients at high risk for upper-GI adverse effects. However, they had been increasingly used in patients with lower GI risks until recent events reversed that trend. Circumstances under which COX-2-selective NSAIDs may be appropriate are in patients at high GI risk and in patients who did not respond to multiple traditional NSAIDs. The national spotlight in the United States on NSAID-related adverse events and recent lawsuits against health care providers prescribing COX-2-selective NSAIDs further highlights the need for provider-patient communication and risk disclosure. The relative cardiovascular risks of NSAIDs are similar in magnitude to other currently prescribed therapies. CONCLUSION: Health care providers must consider the efficacy, GI and cardiovascular risks, concomitant medications, and costs when determining the appropriateness of COX-2-selective NSAID therapy