Even before you can properly assess any complaint of joint pain, paresthesias, tingling, numbness or ngalay, the typical Filipino patient already has an expectation that he’ll be prescribed vitamin B. And if you do decide NOT to give it, the Pinoys will make sure to ask you about it. Some physicians give in, thinking there’s no harm to it. Others take the time to explain why they didn’t include it. But what is the state of evidence surrounding the use of vitamin B in various painful conditions?
I had the chance to review it during the 12th Post Graduate Course of the East Avenue Medical Center Department of Internal Medicine. Here were my slides for that presentation last 16 September 2016.
There’s this expectation that guidelines put perspective into the scheme of things as new evidence is obtained on the use of both novel and established agents. Personally, a well made algorithm is the core of guidelines as it organizes the tools available to a physician after weighing in concerns such as efficacy, safety, tolerability and, hopefully, costs (biologics and targeted synthetic DMARDs are far from being cheap!).
The following are my opinions on parts of the ACR 2015 Guidelines on Rheumatoid arthritis that I feel more time should have been devoted to in clarifying issues. Others may call these missed opportunities (see the editorial by van Vollenhoven R. Nature Rev Rheum 2016; 12. doi: 10.1038/nrrheum.2015.181). I’d refer to them as conflicts as these added more confusion rather than organization to how we manage the disease. Feel free to discuss them with me as I’d appreciate more ideas on these matters.
Sessions on rheumatoid arthritis are guaranteed crowd-drawers in any rheumatology conference. Speakers discussing guidelines draw attention because it is a challenge keeping up with the evidence and guidelines, hopefully, put things in perspective. You can just imagine how exciting a session on RA guidelines would be. I remember attending several where the ACR 2015 guidelines (get them here) were featured even before it could see print. Overviews of the algorithms made everyone excited.
But after finally going through the final print, i can say that I’m divided on what to feel. Some items affirmed what we have been doing all along. But many parts were confusing and, at times, seem to go against reason.
Let’s take a break from the medical posts and discuss something related to practice!
I’ve heard of stories on how the pharmas have influenced the doctor-patient relationship. I recall one story shared by Dr. Tony Dans (circa 2003?) of how prescriptions for a drug changed in relation to an out-of-town launch (on a cruise, if I’m not mistaken). Peaks in prescriptions were observed when the news came out, when invitations were sent, the days leading to the launch and for several days afterwards. Amused as I was, I didn’t pay much attention then as that story happened abroad. I recall commenting also that probably what happened was an exception rather than a common occurrence.
I am amused that in a country recognized internationally for its high prevalence of gout (yes, I’m referring to the Philippines!), there has only been ONE gout guideline. But other nations and groups have produced several iterations of recommendations. Case in point, EULAR released last month its second version of gout guidelines – this time employing the GRADE approach in evaluating the evidence. But how does it compare to the Philippine Guidelines in 2008 (which also used GRADE) and the 2012 ACR Recommendations?
The 2016 EULAR consists of three overarching principles and 11 final recommendations. If you’re after specifics it would be best to read the full article here.
Physical activity is advised for patients with chronic inflammatory arthritis as this helps relieve some symptoms such as stiffness and pain. While the inflammatory process takes it’s toll on the patient’s body (patients also complain of malaise, anorexia and fatigue), we still encounter obese patients suffering from these conditions. Should this be a reason for worry?
PREGABALIN is an effective drug used in treating painful neuropathic conditions, anxiety disorders and is also adjunct therapy for partial seizure disorders. It’s safety in pregnancy is under FDA Category C – which means that animal studies suggest adverse fetal outcomes but no controlled human studies have been done. As such, when considering its use during pregnancy, the physician should weigh maternal benefit against fetal risk.
But recently, a multicenter observational cohort suggests that pregabalin exposure (particularly during the first trimester) was associated with a three-fold increased risk for major birth defects – with risks being higher for central nervous system malformations.
I recently attended the Lupus Special Interest Forum held last 30 May at the CME Auditorium, UST Hospital. One of the topics I was looking forward to was the one given by Prof. Guillermo Luis-Irastorza (Cruces University Hospital, Spain) during the recent Lupus Academy on using low doses of glucocorticoids in managing SLE.
He started by reviewing how steroids take effect and differentiated genomic vs. non-genomic mechanisms of action. When steroids are given in usual (oral) doses, we observe its genomic effects – which is also responsible for many of the adverse events we see. However, when pulse steroids are given, doctors are usually after the much faster non-genomic effects in reducing inflammation. Several studies were shown on how cumulative high doses of steroids were ultimately responsible for many of the organ damage observed in SLE patients. However, he also pointed out that pulse GCs minimally contribute to damage. He then proceeded to mention that the main reason why we have such patterns of steroid use in SLE is because it’s been the way things have been over the last 60 years. No head on trials have shown that lower doses of steroids work better compared to what we usually give. (What surprised me during this part is his avoidance of protocol to present steroid dose in relation to body weight i.e. mg/kg/day).
Early this year, many colleagues were surprised by headlines concerning paracetamol in osteoarthritis. Many started to ask, “Does paracetamol really not work in osteoarthritis?”
The network meta analysis by da Costa et al (Lancet 2016) focused on the comparative efficacy of paracetamol and NSAIDs for osteoarthritis. Similar to the study by Bannuru et al (Ann Int Med 2015), the review again used effect size to compare the impact of interventions on pain and function. However, the population was expanded to include patients with hip osteoarthritis and separated effect size depending on drug dose. It also included only large scale studies (i.e. only trials with at least 100 patients per treatment group) to minimize bias resulting from small samples sizes. The paper included some drugs which had been pulled out of the market (rofecoxib, lumiracoxib) so this will not be discussed in this post.
The Philippine Rheumatology Association warns the public against the use of UA Block, an unregistered herbal supplement for arthritis. The Philippine Food and Drug Administration (Ph FDA), through advisory no. 2015-035, has declared this drug to be potentially dangerous to health. Rheumatologists have observed serious medical complications which may be associated with this product among some patients.
Selling of this product is in direct violation of the Food and Drug Administration Act on 2009 (Republic Act No. 9711). To ensure public safety, we call on everyone to remain vigilant and report establishments selling these products to firstname.lastname@example.org or (02) 807-8275.
Link to Philippine FDA Advisory No 2015-035 here.