Category Archives: Biologics

These drugs are used extensively to induce remission in conditions such as rheumatoid arthritis

Rheumatoid arthritis drugs… which ones are friendly to the heart and which ones aren’t!

Rheumatoid arthritis (RA) is a chronic, autoimmune systemic disease which affects approximately two million Americans. While the symptoms that bring the patient to the doctor are the joint swelling and pain, the area of most concern may not be the joints.  It is well established that cardiovascular risk is markedly increased in RA and in fact it is this complication that shortens lifespan by between ten to fifteen years.

A number of clinical studies have retrospectively examined the relationship between certain medications and the risk of cardiovascular events.  The report card has provided some real surprises.heart-attack_0

For example, methotrexate, the workhorse disease modifying anti-rheumatic drug (DMARD) of choice reduces cardiovascular mortality by almost 70 per cent. The mechanism is felt to be due to a reduction of atherosclerotic plaque formation as well as increased clearance of foam cells (Solomon DH, et al. Circulation 2003; 11: 1303-1307).

The other major player in the treatment of RA is the TNF inhibitor group.  These are used in more than 50 per cent of RA patients in the US. These drugs apparently reduce the risk of cardiovascular events by almost 50 per cent (Gonzalaz A, et al. Ann Rheum Dis. 2008; 67: 64-69). Why this occurs is still not clearly understood.

Steroids have been used to treat RA since the early 1950’s.  Steroids have been shown to worsen cardiovascular risk because of their effects on both blood pressure as well as blood glucose.  Steroid use in RA has been associated with increased carotid plaque formation as well as increased arterial stiffness.  So what dose is a safe dose?  The answer is still unknown.

Non-steroidal anti-inflammatory drugs (NSAIDS) raise blood pressure.  Randomized clinical trials have shown that cardiovascular risk is associated with COX-2 inhibitors but also with non-selective COX drugs also.  The upshot? All NSAIDS regardless of class, are associated with increased cardiovascular risk.

Hydroxychloroquine, a drug often used to treat mild RA, is associated with a decrease in diabetes and may also improve lipid status.  Actemra increases lipid profile but the long term effects are still unknown.  Leflunomide (Arava) increases blood pressure.  The eventual effects are still a subject of conjecture.

So what about aspirin?  This medication is used for cardiovascular prophylaxis.  In higher doses it also has anti-inflammatory effects although these are limited by the potential gastrointestinal side effects known to be caused by high dose aspirin. It is well known that other NSAIDS should not be used in patients taking aspirin for cardiovascular prophylaxis since they blunt that effect.

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Are you at risk for the complications due to ankylosing spondylitis? Discover what they are…

Ankylosing spondylitis (AS) is an inflammatory form of arthritis that preferentially attacks the spine.  Many people are under the impression it’s one of the less serious forms of arthritis. Uh-uh.  Unfortunately, it has a number of potential complications associated with it.  These include:

  1. Acute eye inflammation, termed “uveitis”, in one-third of patients.  Symptoms include pain, redness, blurred vision, light sensitivity, and if left untreated, blindness.
  2. Osteoporosis occurring in a significant number of patients.  This is a condition where the bones become brittle and more likely to fracture.
  3. Approximately 10-15% of patients have inflammatory bowel disease such as Crohn’s or ulcerative colitis.
  4. Skin involvement occurs in as many as a quarter of patients.  The most common skin condition is psoriasis.
  5. AS can lead to conduction abnormalities in the heart as well as inflammation of the aorta.
  6. Fibrosis of the lungs can cause restrictive lung disease.
  7. Neurologic complications are due to compression of the spinal cord and can be life-threatening.
  8. Long term ankylosing spondylitis can cause a condition called amyloidosis of the kidneys leading to kidney failure.

Comment: Not such a benign condition is it?

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Conventional Medication Combo May Be As Effective As Anti-TNF Agents In RA

Nancy Walsh writing in Medpage Today reported, “Among patients with established rheumatoid arthritis, a combination of conventional disease-modifying drugs was as effective as early use of anti-tumor necrosis factor (TNF) agents,” according to a study presented at the annual meeting of the British Society for Rheumatology. Investigators found that individuals “who received disease-modifying anti-rheumatic drugs (DMARDs) had a change over 12 months on the Health Assessment Questionnaire (HAQ) of 0.45 points compared with 0.30 points for those given anti-TNF therapy.

I disagree with the findings of this study.  Conventional combination DMARDS are touted as being as effective as anti-TNFs by a few rheumatologists.  Personally, I don’t think they work as well and have their own share of potential side effects.

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TNF Inhibitors and the Placenta… Which Should You Worry About During Pregnancy?

Mary Ann Moon writing in Rheumatology News reported on the conclusions of two studies. One concern rheumatologists have had is what to do about pregnant patients who are on TNF inhibitors.  Two observational studies (one from University California San Francisco and the other from Erasmus Medical Center, pregnant-womanRotterdam) provide some information.

The upshot is that stopping Remicade and Humira at the end of the second trimester reduces the amount of antibody transferred to the infant and shortens the time for the infant to clear the antibody. Cimzia doesn’t need to be stopped since it doesn’t cross the placenta.

Comment: This is important since it reduces the likelihood of opportunistic infection in the infant.

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Long-Term Humira Use … Few Adverse Events

Nancy Walsh writing in MedPage Today reported, “Long-term immunosuppressive treatment with Humira,  a TNF inhibitor drug used in humiradiseases such as rheumatoid arthritis and psoriatic arthritis,  is associated with low rates of adverse events such as serious infections and malignancies, with differences being seen according to the underlying disease,” according to  a study published in the Annals of the Rheumatic Diseases.

Investigators found that “the most frequently reported serious adverse events across indications were infections.” The study indicated that “the most common infections among patients with rheumatoid arthritis were cellulitis – occurring at a rate of 0.3 per 100 patient-years – and pneumonia, seen at a rate of 0.7 per 100.”

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TB Hides In Bone Marrow

Michelle Fay Cortez writing in Bloomberg News reported on a study in “Science Translational Medicine.  Researchers said they have uncovered the first evidence of tuberculosis hiding in mesenchymal stem cells in the bone marrow of people treated for the disease.”

tb-bacteriaAccording to the article, “the bacteria’s hideout in the self-renewing cells, where they capitalize on protection from the body’s own immune system, may explain how the germs survive.”

This is disturbing news since these sequestered tuberculosis bacteria can be protected from drugs used to eradicate them.

This has important  implications for patients intending to go on biologic therapy for rheumatoid arthritis and other diseases.

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Apremilast (Celgene) Effective in Psoriatic Arthritis

From the American College of Rheumatology…

Apremilast (Celgene), an investigational oral small-molecule inhibitor of phosphodiesterase 4 (PDE4), led to significant improvement in the signs and symptoms of psoriatic arthritis in patients who failed to respond to recommended drugs, including DMARDs and biologics, in the phase 3 PALACE-1 trial.

psoriasisLead investigator Arthur Kavanaugh, from University of California, San Diego, who reported the results, said the drug was “well tolerated and has a good side-effect profile.”

Psoriatic arthritis is a very common type of arthritis and unlike what many physicians think, is not the same as rheumatoid arthritis and must be treated differently.

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Some RA Patients May Be Able to Taper Biologics

Slide 1.From the American College of Rheumatology meeting 2012

Tapering or even stopping tumor necrosis factor (TNF)-inhibitor therapy is feasible for a sizable number of patients with RA who are stabilized and in remission, according to a randomized trial. “This study is relevant for the burden of treatment for RA patients and the economic burden to society. These drugs are expensive. If we can taper the intervals and use less drug, we can reduce the cost and possibly reduce the risk of infection and lymphoma,” said study leader Bruno Fautrel, MD, PhD, from University of Paris Medical Center in France.

This is good news since these drugs cost approximately $2,000 a month.

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Are anti-TNF drugs worth the cost?

No question… anti-TNF drugs, the new biologics that are used to treat diseases like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, are expensive. Are they worth the cost?anti-tnf-drugs

A new study says they are…

Susan London writing in Rheumatology News reported that a study presented at the Canadian Rheumatology Association from the Alberta Biologics Pharmacosurveillance Program, showed that “patients achieving remission were significantly less likely to have had a recent hospitalization, had lower monthly costs for over-the-counter drugs, and were less likely to have been unable to do usual activities in the past month, to have needed help from others with activities of daily living in the past month, and to have had to reduce their work hours in the past six months because of poor health, compared to other patients with high disease activity.”

In essence, then what is the price you place on quality of life?

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Anti-TNF drugs increase risk of shingles in arthritis patients

A report filed in MedWire by Ingrid Grasmo highlighted the dangers of anti-TNF therapy.  She wrote about a study presented at the Annual European Congress of Rheumatology.  The investigators showed that patients with inflammatory forms of arthritis who are treated with anti-tumor necrosis factor medications are significantly more likely to experience herpes zoster infections –shingles- than shinglesthose treated with traditional disease-modifying anti-rheumatic drugs (DMARDs).

“Shingles” is a painful, blistering skin rash due to the same virus that causes chickenpox. While the infection can be treated with anti-viral medication, patients are often left with residual pain, called post-herpetic neuralgia.  This pain can be debilitating.

For more information on rheumatoid arthritis treatments and other arthritis problems go to:

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And don’t forget to sign up for  free weekly arthritis tips and a free copy of our special report “The Consumer’s Guide to Arthritis”

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