Psoriatic arthritis: new treatment guidelines ACR

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According to the results of a U.S. case-control study published in The Journal of Rheumatology, the addition of methotrexate (MTX) to glucocorticoid (GC) therapy could reduce the risk of relapse in patients with giant cell arteritis (GCA) by half compared to those treated with glucocorticoids alone. If confirmed, these findings expand the treatment options for such patients, enabling a reduction in glucocorticoid dosage and, consequently, a potential decrease in adverse events. Why Consider Methotrexate for Giant Cell Arteritis? Giant cell arteritis (GCA) is the most common primary systemic vasculitis in individuals over 50 years old, predominantly affecting the aorta and its major branches. Due to the severe ischemic complications associated with the disease (e.g., vision loss, stroke, and aortic aneurysm/dissection), both early diagnosis and prompt treatment initiation are crucial. The cornerstone of GCA therapy involves glucocorticoids, initially at high doses and then gradually tapered. However, 40% to 75% of patients experience at least one relapse during follow-up. Analyses have shown that patients with disease relapse are generally those who undergo longer treatment durations or higher cumulative exposure to glucocorticoids. Unfortunately, long-term GC treatment in the age group affected by GCA is associated with a higher frequency of adverse events, reported by nearly all treated patients (86%-100%). Methotrexate (MTX) is a cost-effective and well-established drug in rheumatology. However, data on its use in GCA have so far yielded conflicting results. A recent meta-analysis at the patient level showed a modest reduction in cumulative GC use and absolute relapse risk, though it did not demonstrate a reduction in GC-associated adverse events. The New Study This case-control study aimed to describe MTX use in a large cohort of patients with relapsing GCA and compare these findings to a cohort treated with GCs alone. Study Design The study included 166 patients diagnosed with GCA between 1998 and 2013, confirmed by temporal artery biopsy and/or radiographic evidence of large-vessel vasculitis. Data from GCA patients treated with MTX (“cases”) were matched with those from patients treated with GCs alone (“controls”). Researchers calculated the rate ratio (RR) of relapses between the two groups to assess the potential benefits of adding MTX to GC therapy. Key Results The median time from GCA diagnosis to MTX initiation was 39 weeks (IQR: 13–80), with a median dose of 13.5 mg/week (IQR: 10–15). Disease relapse rates decreased significantly in both groups: MTX group: RR = 0.32 (95% CI: 0.24–0.41) GC-only group: RR = 0.60 (95% CI: 0.43–0.86) The reduction in relapse rates was significantly greater in the MTX group (p=0.004). No significant differences were observed between the groups in GC use or discontinuation. Implications and Limitations These findings suggest that MTX could offer an alternative, cost-effective treatment option for GCA, potentially reducing GC doses and related adverse events. However, caution is warranted due to methodological limitations: The retrospective observational design limits data to medical records, which may lack completeness. MTX initiation and dosing were not standardized, relying on the treating physician's discretion, which may affect the generalizability of results. The study could not account for potential confounding factors influencing physicians’ decisions to prescribe MTX. The absence of a defined GC tapering protocol prevented an in-depth evaluation of MTX's GC-sparing effects. While these preliminary results are promising, randomized, controlled trials are needed to confirm the findings and establish standardized guidelines for managing relapsing GCA.

Pregabalin outperforms duloxetine in controlling hand osteoarthritis pain.

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A study published in the Journal of Pain Research highlighted that treatment with pregabalin, but not duloxetine, improves pain and functional scores in patients with hand osteoarthritis (OA). Osteoarthritis is the most common form of arthritis worldwide, characterized by chronic pain and impaired physical function. When it affects the hands, pain predominates, along with reduced functionality, creating significant challenges for affected individuals. Pain and functional limitations impose a substantial burden on patients and healthcare systems. Although various pharmacological agents are available for managing OA pain, such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids, many patients continue to suffer from chronic pain despite these treatments. Recent studies have raised concerns about current therapies, suggesting that acetaminophen has limited efficacy in controlling this type of pain. The Need for New Approaches As the study authors emphasized, there is a pressing need to explore alternative approaches to address this significant public health issue. Ideal analgesics for OA should provide sustained, dose-dependent pain relief with minimal side effects. Centrally acting agents such as pregabalin and duloxetine may meet these criteria but have not been extensively studied for OA management. Pregabalin and Duloxetine: Mechanisms and Evidence Duloxetine, a serotonin and norepinephrine reuptake inhibitor (SNRI), has shown efficacy in relieving knee pain in patients with OA. However, no previous studies have evaluated its use in hand OA. In contrast, interest in gabapentinoids for OA treatment has grown, as gabapentin inhibits pain sensitization. Studies suggest that pain from OA can be improved with NSAIDs and pregabalin. For example, previous research by Ohtori et al. found that pregabalin combined with meloxicam was more effective for knee OA pain than monotherapy. Similarly, Arendt-Nielsen’s study demonstrated that NSAIDs could improve pain and sensitization in knee OA. These findings highlight the potential for centrally acting analgesics to alleviate OA-related pain. Conclusion The study provides new insights into pain management for hand OA, suggesting that pregabalin may offer a viable alternative to traditional treatments, particularly for patients unresponsive to standard therapies. Further research is needed to explore its long-term efficacy, safety, and potential for integration into current treatment protocols.
il dolore artrosico. Hanno, quindi, condotto uno studio proof of concept, randomizzato, controllato con placebo in cui sono state confrontate la duloxetina e il pregabalin al placebo per il controllo del dolore alla mano in pazienti con OA. Sono stati utilizzati endpoint primari convalidati per il dolore, endpoint secondari per la sensibilizzazione del dolore con QST, e punteggi relativi a depressione e ansia. In questo studio prospettico, 65 pazienti (da 40 a 75 anni) con osteoartrosi della mano e con un punteggio sulla scala numerica di valutazione superiore a 5 hanno ricevuto, random, la terapia con duloxetina, pregabalin o placebo per 13 settimane. Il dolore è stato valutato sulla scala di valutazione numerica e attraverso l’indice del dolore AUSCAN (Australian and Canadian Hand Osteoarthritis Index) che valuta anche rigidità e funzione. I punteggi del dolore sono stati significativamente diversi tra i 3 gruppi dopo 13 settimane (p=0.008). Nei campioni delle analisi intention-to-treat, il pregabalin ha migliorato il dolore misurato con la scala di valutazione numerica e con la scala del dolore AUSCAN (p=0.02 e p=0.008 rispettivamente). Pregabalin ha inoltre migliorato i punteggi delle funzioni come indicato dal punteggio AUSCAN (p=0.009). Nessun miglioramento è stato osservato nel gruppo duloxetina rispetto al placebo nell’analisi intention-to-treat (p>0.05), ma un miglioramento significativo è stato osservato nell’analisi per protocol per duloxetina rispetto al placebo (p=0.03). In conclusione, come evidenziato dagli autori: “Quando i pazienti continuano ad avere dolori a causa dell’osteoartrosi della mano, nonostante siano in trattamento con analgesici convenzionali come il paracetamolo o farmaci antinfiammatori non steroidei, pregabalin può fornire un’alternativa realistica per il controllo di tale dolore”.

Sofat N. et al. The effect of pregabalin or duloxetine on arthritis pain: a clinical and mechanistic study in peoplewith hand osteoarthritis. J Pain Res. 2017 Oct 10;10:2437-2449. doi: 10.2147/JPR.S147640. eCollection 2017.