Safety of glucocorticoids: clinical trials

Clinical trials published over the last 5 years support the main conclusion of a comprehensive review on glucocorticoid safety published in 2006: there is little if any solid evidence to support the fear that low-dose glucocorticoids are associated with significant toxicity when used appropriately in inflammatory rheumatic diseases. In fact, most of the recent randomised-controlled research underlines the influence of the underlying inflammatory process in the occurrence of 'adverse events' such as osteoporosis, fractures, hypertension and glucose intolerance. This 'confounding by indication' is inherent to the field and questions the validity of the observational data, that seems to drive currently common concepts about low-dose glucocorticoid toxicity. Decisive conclusions cannot, in any case, be achieved at this stage because the clinical trials available are of limited duration and dimension and have not been designed specifically to address toxicity. Toxicity with low-dose glucocorticoids needs to be kept under careful clinical surveillance while we expect such trials to be produced. Meanwhile, the risks of stopping these medications, even on longstanding well controlled disease, need also to be considered, as underlined by withdrawal trials recently published

Safety of low- to medium-dose glucocorticoid treatment in rheumatoid arthritis: myths and reality over the years

Low- to medium-dose glucocorticoids have been shown to have not only anti-inflammatory but also disease-modifying properties in rheumatoid arthritis. The evidence for the benefit of its early use in combination with disease-modifying antirheumatic drugs underlines the need for a close evaluation of their risk-benefit ratio. Over time, numerous myths and fears about glucocorticoid toxicity in rheumatoid arthritis have arisen from observational studies, and many concerns have been unduly extrapolated from observations with higher-dose treatment. Furthermore, we cannot exclude the possibility of a powerful effect of bias by indication in these studies. Low- to medium-dose glucocorticoid regimens continued to be evaluated in randomized clinical trials, particularly in early disease, but these studies also have relevant methodological limitations in assessing safety, particularly due to small size and/or short duration. At present, the evidence on which to support clear recommendations about glucocorticoid toxicity remains remarkably weak. A large prospective pragmatic trial dedicated to the toxicity of low-dose glucocorticoids is dearly needed. Meanwhile, adherence to recommendations on standardized methodologies for registration and report of glucocorticoid adverse events is essential for improving our knowledge and competence in the best management of these important medications

Competencies in rheumatology: a European framework

The aims, structure, methods and educational experiences employed in the training of rheumatologists vary from one national programme to another, according to traditions, rules and resources. Mutual recognition of titles, the free movement of labour and the striving towards for high-quality standards in medical care in Europe demand that efforts and progress are made to ensure that similar competencies are achieved by different programmes. The European Rheumatology Curriculum Framework, developed by the European Board of Rheumatology, is meant to be a step towards the harmonization of rheumatology specialist training within the European Union, by providing a reference framework to the development and benchmarking of national curricula for the specialist training of rheumatologists. The European Rheumatology Curriculum Framework has now been endorsed by scientific and educational bodies in 17 member countries. It has been provided with a contextualized review of good practice in curriculum planning and development - the European Board of Rheumatology Educational Guide

Selecting men for bone densitometry: performance of osteoporosis risk assessment tools in Portuguese men

Clinicians need tools to identify patients most likely to benefit from bone mineral density (BMD) testing, for which cost-effectiveness does not allow generalized screening. This study supports the utility of osteoporosis risk assessment tools in selecting men for BMD testing. Different cutoff values may be appropriate for different countries and/or ethnic origins. INTRODUCTION: Our aim was to evaluate the utility of three osteoporosis (OP) risk assessment tools in a large group of Portuguese men aged 50 or more and to determine the best cutoff value to be used for selecting men for bone densitometry. METHODS: We assessed the performance of three simple tools in 202 randomly selected men: body weight criterion (BWC), osteoporosis self-assessment tool for Asians (OSTA), and a modified version of the OSTA equation (OST). Previously published cutoff values (validated in postmenopausal women) and three additional cutoff values were tested. Sensitivity (SE), specificity (SP), predictive values, and area under the receiver operating characteristic (AUROC) curve for correctly selecting men with OP (defined by BMD testing) were determined. RESULTS: Mean age of the cohort was 63.8 years. According to the World Health Organization diagnostic categories, 16.8% had osteoporosis. The best performing cutoffs for correctly selecting men with OP for BMD testing were OST < 3 (SE = 75.5%, SP = 50.0%, AUROC = 0.632), OSTA < 3 (SE = 73.5%, SP = 58.3%, AUROC = 0.659), and BWC < 75 kg (SE = 73.5%, SP = 61.3%, AUROC = 0.674). CONCLUSIONS: OP risk assessment tools seem to be useful in men aged 50 or more. Best cutoff values are different from those recommended for postmenopausal women. Different cutoff values may be appropriate for different countries and/or ethnic origins

Arthropathy of genetic hemochromatosis: a major and distinctive manifestation of the disease

Genetic hemochromatosis is not a rare disease and represents a frequently underestimated cause of arthropathy. Joint involvement is one of the most frequent manifestations of the disease and presents typical clinical and radiological features that strongly suggest the diagnosis. Joint complaints are often the first clinical manifestation of GH. Their identification may be crucial to establish the diagnosis in the pre-cirrhotic phase and to institute appropriate therapy to prevent organ damage and associated mortality. Recent identification of the genetic defect responsible for the disease is leading to new insights into the pathogenesis of GH and the associated arthropathy

Psychological factors associated with response to treatment in rheumatoid arthritis

This paper presents a comprehensive review of research relating psychological domains with response to therapy in patients with rheumatoid arthritis. A holistic approach to the disease was adopted by incorporating not only disease activity but also dimensions of the impact of disease on patients' lives. Psychological distress, including depression and anxiety, is common among patients with rheumatoid arthritis and has a significant negative impact on response to therapy and on patients' abilities to cope with chronic illness. Evidence regarding the influence of positive psychological dimensions such as acceptance, optimism, and adaptive coping strategies is scarce. The mechanisms involved in these interactions are incompletely understood, although changes in neuro-endocrine-immune pathways, which are common to depression and rheumatoid arthritis, seem to play a central role. Indirect psychological influences on therapeutic efficacy and long-term effectiveness include a myriad of factors such as adherence, placebo effects, cognition, coping strategies, and family and social support. Data suggest that recognition and appropriate management of psychological distress may improve response to treatment and significantly reduce disease burden

Performance of decision algorithms for the identification of low bone mineral density in portuguese postmenopausal women

OBJECTIVES: Although several algorithms have been proposed to select postmenopausal women PMW for dual-energy x-ray absorptiometry DEXA measurements information on their utility in clinical practice is scarce. Our aim was to assess the utility and the economic repercussion of the use of five of these algorithms in Portuguese postmenopausal women. METHODS: We included 588 PMW and selected five simple algorithms ORAI ABONE Body Weight Criterion OSTA and a modified version of OSTA (OST). Sensitivities specificities predictive values areas under the receiver operating characteristic curve (AUROC) and economic estimates were computed. RESULTS: Sensitivities ranged between 71.2%-80.8% and AUROC between 0.611-0.674. In PMW aged > or = 65 years (Y) the use of any of the algorithms would cause extra costs or a residual saving. In PMW aged > or = 55 and or = 40 and or = 65Y: perform DEXA irrespective of other risk factors. 2) Aged < 65Y: perform DEXA if body weight < 70Kg