Applying science in practice: the optimization of biological therapy in rheumatoid arthritis

Most authorities recommend starting biological agents upon failure of at least one disease-modifying agent in patients with rheumatoid arthritis. However, owing to the absence of head-to-head studies, there is little guidance about which biological to select. Still, the practicing clinician has to decide. This review explores the application of published evidence to practice, discussing the goals of treatment, the (in) ability to predict individual responses to therapy, and the potential value of indirect comparisons. We suggest that cycling of biological agents, until remission is achieved or until the most effective agent for that individual patient is determined, deserves consideration in the current stage of knowledge

Transdermal fentanyl for the treatment of pain caused by osteoarthritis of the knee or hip: an open, multicentre study

BACKGROUND: This study was designed to evaluate the utility of transdermal fentanyl (TDF, Durogesic(®)) for the treatment of pain due to osteoarthritis (OA) of the knee or hip, which was not adequately controlled by non-opioid analgesics or weak opioids. The second part of the trial, investigating TDF in patients with rheumatoid arthritis (RA) is reported separately. METHODS: Current analgesia was optimised during a 1-week run-in. Patients then received 28 days treatment with TDF starting at 25 μg/hr, with the option to increase the dose until adequate pain control was achieved. Metoclopramide was taken during the first week and then as needed. RESULTS: Of the 159 patients recruited, 75 with OA knee and 44 with OA hip completed the treatment phase, 30 knee and 18 hip patients entered the one-week taper-off phase. The most frequently used maximum dose of TDF was 25 μg/hr. The number of patients with adequate pain control increased during the run-in period from 4% to 27%, and further increased during TDF treatment to 88% on day 28. From baseline to endpoint, there were significant reductions in pain (p < 0.001) and improvements in functioning (p < 0.001) and physical (p < 0.001) and mental (p < 0.05) health. Scores for 'pain right now' decreased significantly within 24 hours of starting TDF treatment. TDF was assessed favourably and 84% of patients would recommend it for OA-related pain. Nausea and vomiting were the most common adverse events (reported by 32% and 26% of patients respectively), despite prophylaxis with metoclopramide, which showed limited efficacy in this setting. CONCLUSION: TDF significantly increased pain control, and improved functioning and quality of life. Metoclopramide appeared to be of limited value in preventing nausea and vomiting; more effective anti-emetic treatment may enable more people to benefit from strong opioids such as TDF. This study suggests that four weeks is a reasonable period to test the benefit of adding TDF to improve pain control in OA patients and that discontinuing therapy in cases of limited benefit creates no major obstacles

Old law meets new medicine: revisiting involuntary psychotropic medication of the criminal defendant

Summary: ... The government initially argued that Weston could adequately control his delusions in order to stand trial. ... Besides avoiding the ultimate constitutional question, the Court also expressly declined to specify under what circumstances involuntary psychotropic medication of a pretrial defendant could occur - that is, what substantive standard the government would have to meet in order to justify involuntary medication. ... Mental health conditions rendering one imminently dangerous justify emergency involuntary psychotropic medication, notwithstanding one\u27s status as a pretrial criminal defendant, but general standards for medication for the purpose of restoring competence to stand trial cannot be based solely upon emergency or dangerousness requirements. ... Restoring or maintaining a criminal defendant\u27s competence to stand trial, through involuntary psychotropic medication, may be a compelling government interest. ... Restoring or maintaining a criminal defendant\u27s competence to stand trial - through involuntary psychotropic medication - may implicate specific trial-related rights, which must be independently protected anytime involuntary medication is undertaken. ... Maintaining or restoring the defendant\u27s competence to stand trial cannot alone justify involuntary psychotropic medication without a searching inquiry that medications are medically appropriate, that there is no less intrusive alternative to achieve competence, and that the defendant\u27s trial-related rights are protected. ..