VIENNA, Austria-European rheumatologists released three new sets of recommendations on the management of early arthritis,1 ankylosing spondylitis,2 and gout3 at the Annual European Congress of Rheumatology of the European League Against Rheumatism (EULAR) here. Taken together, the three sets of recommendations do not offer many specifics, but do chart at least an initial treatment algorithm for patients.

EULAR has previously issued recommendations for knee and hip osteoarthritis (OA) and is working on similar recommendations for fibromyalgia and systemic lupus erythematosus. All recommendations are based on research-based evidence and expert consensus.

 

Hit RA early and hard

Based on both evidence and, at times, eminence, the new early arthritis recommendations call for hitting arthritis early and hard-with methotrexate (MTX) as the first-line drug of choice

"Patients at risk of persistent erosive arthritis should be started with DMARDs even if they don't fulfill all the criteria," says Bernard Combe, MD, PhD, rheumatologist at the University of Montpelier in France. "MTX is the anchor drug and should be first-line."

If remission is not achieved, therapy needs to be stepped up to biologics, the recommendations state. They also call for regular monitoring of disease activity according to joint assessment, C-reactive protein, and erythrocyte sedimentation rate. Structural damage should be assessed by x-ray every 6 to 12 months.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as adjunct therapy (after gastrointestinal, renal, and cardiovascular [CV] status is assessed), as can intraarticular steroids. Nonpharmacologic therapies, including hydrotherapy and exercise, can also be part of the treatment plan in early arthritis.

"Based on the data, it's recommended to start RA patients very early with MTX and, if they don't achieve the goal of remission in 3 months, then consider a biologic," Maxime Dougados, MD, professor of rheumatology at René Descartes University in Paris, France, and department of rheumatology chief at Cochin Hospital, also in Paris, tells CIAOMed. "If you see early signs, start a DMARD and monitor patients every 2 weeks to see if they achieve remission in 3 months. If not, then switch to a biologic," he states. "The most important thing is that any patient suffering from synovitis be referred to a rheumatologist by 6 weeks," he emphasizes. "We know there is a window of opportunity, but we need to improve access to care."

According to the recommendations, patients with more than one swollen joint should be referred to and seen by a rheumatologist within 6 weeks.

 

Ankylosing spondylitis

"Treatment of AS should be tailored to the current manifestation of the disease, including level of current symptoms, clinical findings and prognostic indices, general health status of patients, and patients' wishes and expectations," says Jorgen Braun, MD, PhD, rheumatologist at the Rheumazentrum Ruhrgebiet and Ruhr Universitat in Bochum, Germany, who presented the new recommendations.

Optimally, AS treatment should include both pharmacologic and nonpharmacologic treatment modalities. NSAIDs are first-line treatment, although the new recommendations are not specific as to dosages or whether they are better taken on-demand or continuously. Last week, CIAOMed reported findings from a study showing that continuous NSAID use over a 2-year time period decreased radiographic progression without substantially increasing toxicity.2 However, "there is no final decision on that," Dr. Braun cautions.

If pain is not adequately controlled with NSAIDs, paracetamol (acetaminophen) and opioids may be tried, as well as corticosteroids injected directly into the site of inflammation. The use of systemic steroids for axial disease, however, is not supported by the evidence. Anti-TNF drugs should be tried for AS patients with persistently high disease activity who have failed other therapies. "There is no evidence to support the obligatory use of DMARDs prior to use of anti-TNF drugs," Dr. Braun observes.

Although evidence is not strong, total hip replacement surgery should be considered in patients with refractory pain or disability and radiographic evidence of structural damage. Spinal surgery may be useful in a select group of patients, but this is not strongly supported by data. "If damage is strong and cannot be controlled by conservative means, surgery needs to be considered," Dr. Braun notes.

 

Gout

The new EULAR recommendations state that low doses of colchicine (0.5 mg 3 times a day) may sufficiently control acute gout; higher doses are effective, but toxic. Additionally, intraarticular steroids can be used in acute attacks. Prophylaxis against acute attacks can be achieved with low-doses of colchine or NSAIDs (with gastroprotection if indicated). Again, the committee did not speak to specific recommendations regarding use of NSAIDs during a gout attack.

Patients with persistent hyperuricemia and acute attacks may benefit from uric acid lowering drugs including allpurinol initiated at 100 mg a day-especially in patients with renal impairment. This dosage can be increased in 100 mg increments every 2 to 4 weeks until the level of serum uric acid is maintained within the lower half of normal. As an alternative to allpurinol, uricosuric agents, including probenecid and sulfinpyrazone, can be tried. Moreover, losartan and fenofibrate tend to have moderate uricosuric effects, which can benefit patients unresponsive to or intolerant of allpurinol (ie, with hypertension or other evidence of the metabolic syndrome).

Optimal gout treatment should include pharmacologic and nonpharmacologic modalities. These include combinations of ice-pack therapy, colchichine, and NSAIDs on acute gout and/or diet modifications and uric acid lowering drugs in chronic gout.

Gout is frequently part of the metabolic syndrome and cofactors leading to increased CV risk should be treated, according to the new recommendations.

References:

1. Combe B, Landewe R, Lukas C, et al. Evidence-based recommendations for the management of early rheumatoid arthritis. Presented at: Annual European Congress of Rheumatology of EULAR; June 8-11, 2005; Vienna, Austria. Abstract THU0339.
2. Wanders AJ, van der Heijde DM, Landewe RB, et al. Nonsteroidal anti-inflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis: a randomized clinical trial. Arthritis Rheum. 2005;52:1756-1765.
3. Doherty M, Pascual-Gómez E, Bardin T, et al. EULAR evidence based recommendations for the diagnosis and management of gout. Presented at: Annual European Congress of Rheumatology of EULAR; June 8-11, 2005; Vienna, Austria. Abstract SAT0291.