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.
Initiation of urate lowering therapies have been associated with an increased risk of gout flares. Hence, prophylaxis with either colchicine or naproxen has become routine in order to ameliorate this risk. Groups may vary on how long prophylaxis should be given but 6 months is generally recommended. Aside from prophylaxis, slow reduction of serum urate levels have also been advised as a means of minimizing flares (which is another reason why many groups still prefer allopurinol as first line therapy since following dosing guides result in a more gradual reduction of SUA compared to agents like febuxostat).
Some patients may be concerned with the number of pills they have to take when undergoing treatment for gout. So here is where arhalofenate may be an option. Arhalofenate is a novel uricosuric that blocks URAT1 mediated reabsorption of urate in the proximal tubules of the kidney. Similar to benzbromarone and lenisurad, it can be given as a single daily dose and does not share the need for frequent dosing seen with older uricosurics like probenecid and sulfinpyrazone. In mouse models, it has also been shown to inhibit activity of IL-1B – a key inducer of gout attacks – and also blocks neutrophil influx at the site of inflammation. In short, arhalofenate is a novel ULT with anti-inflammatory properties.
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.
Anti-phospholipid antibody syndrome (APAS) is an autoimmune non-inflammatory condition characterized by vascular thrombosis and pregnancy morbidity in the background of anti-phospholipid (aPL) antibodies. Up to one-third of lupus patients may have concomitant APAS which further complicates management. Evidence suggests that presence of lupus anti-coagulants correlate with risks for developing poor pregnancy outcomes and vascular events and these risks are multiplied by the presence of additional aPLs. While a variety of options are available to treat APAS related vascular events, there are limited options to treat pregnancy morbidity.
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.
Ang RHEUMATOID ARTHRITIS ay isang uri ng chronic or matagalang arthritis kung saan ang mga panlaban ng katawan sa mikrobyo at impeksyon ay linalabanan ang ibang pang bahagi ng katawan na nakatuon sa mga kasu-kasuhan. At di tulad ng ibang rayuma at arthritis kung saan mabagal ang mga pagbabago, kapag pinabayaan, ang rheumatoid arthritis ay magdudulot ng mabilisang pagkasira ng mga kasu-kasuhan na maaaring maging sanhi ng maagang pagkakabalda. Liban sa kasu-kasuhan, maaari ring maapektuhan ang iba pang bahagi ng katawan tulad ng balat, daluyan ng dugo (blood vessels), baga at puso.
Ang tamang pag inom ng gamot para sa gout ay malaki ang maitutulong upang maiwasan ang pabalik-balik na pag-atake ng arthritis at ang pagkakaroon ng mga komplikasyon tulad ng tophi at kidney stones. Sa mga pasyenteng meron na ng mga nabanggit na komplikasyon, kinakailangan pa rin ang tamang gamutan dahil may posibilidad na mapaliit o matunaw ang mga ito. Para sa naunang post tungkol sa mga uri ng gamot na ginagamit sa gout, maaaring magtungo rito.
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?