Treating Rheumatoid Arthritis Early May Cut Damaging Effects

Study suggests that delaying treatment leads to more joint inflammation, disability down the road

By Robert Preidt

HealthDay Reporter

SATURDAY, Oct. 26 (HealthDay News) -- Immediate and effective treatment for rheumatoid arthritis reduces the risk that patients will have joint damage and disability within a few years, a new study suggests.

The findings show the need for doctors to discourage patients from delaying treatment, according to the researchers at the Hospital for Special Surgery in New York City.

"We need to educate people diagnosed with rheumatoid arthritis about this. Some want to delay treatment because they are afraid. They haven't wrapped their heads around the fact that they have this disease, or they are reluctant to start taking medication. Some resort to non-medicinal approaches, many of which have limited effect," study lead investigator and rheumatologist Dr. Vivian Bykerk said in a hospital news release.

"Unfortunately, I have seen too many people delay effective treatment approaches and they come back a year later very disappointed, often with joint damage that could have been prevented. The longer you have inflammation in the joints, the more likely you are to have joint damage, and it is going to impact how you function down the road," she added.

The study included 833 patients with early rheumatoid arthritis -- defined as having symptoms for a year or less. Six months into the study, the patients were classified as having achieved low disease activity or not. Low disease activity means that joint pain, swelling and other signs of inflammation are significantly reduced.

The 56 percent of patients who achieved low disease activity at six months were much less likely to have joint damage and disability at two years, according to the findings to be presented Monday at the annual meeting of the American College of Rheumatology/Association of Rheumatology Health Professionals in San Diego.

"We believe there is a window in which people have a much better chance of getting rheumatoid arthritis under good control, often with less intense therapy, and the window is within the first three months of developing joint inflammation," Bykerk said.

These findings show the need for doctors to warn patients about the hazards of delaying therapy and to follow patients more often in the early stages of treatment, she added.

Research presented at medical meetings is considered preliminary until published in a peer-reviewed journal.

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RA Strategy: Treat Early, but With What Medicines?

Oct. 30, 2013 (San Diego) -- Most experts agree it’s best to treat rheumatoid arthritis early -- and some say aggressively -- as soon as the diagnosis is made.

But debate continues about what medications are best to use first, and in what combinations. Some experts think patients should use three medications, known as triple DMARDs (disease-modifying antirheumatic drugs), from the start. Others favor starting with a single medication.

The old mantra ''start low, go slow" is out the door, says Kam Nola, PharmD. She is an associate professor of pharmacy at Lipscomb University's College of Pharmacy in Nashville.

About 1.3 million Americans have RA, a chronic and potentially disabling disease that causes pain, stiffness, and swelling, and limits how joints work. The American College of Rheumatology recommends starting with methotrexate (Rheumatrex, Trexall) alone for most patients, then switching or adding other drugs if necessary. These include other DMARDs, as well as the more expensive injected biologics.

At a news conference Tuesday at the annual meeting of the American College of Rheumatology, several researchers shared study findings that looked at specific treatment strategies.

Here is what they found:

Using three traditional DMARD medications works better than a single drug, says Pascal de Jong, PhD. He is a researcher at Erasmus Medical Center in the Netherlands. He looked at 281 patients who had had symptoms less than 6 months.The patients received one of four treatments:

 Triple therapy included methotrexate, sulfasalazine and hydroxychloroquine, with corticosteroids either by pills or a muscle injection. Single therapy was methotrexate alone with either corticosteroid treatment.

''We saw that if you started the combination of DMARDs, you achieved low disease activity after 3 months," de Jong says. "It's very important to have disease control very early." The results lasted for a year.

Another plus of the triple regimen, he says: "If you start with the combination of DMARDS, you can more often taper the medications [as symptoms improve]."

The DMARD triple treatment was also more cost-effective, de Jong says. Those on it stayed more productive at work, he also found.

The triple DMARD treatment gives results similar to biologic drugs known as anti-TNFs (anti-tumor necrosis factor agents). This was true whether patients used the drugs in combination with methotrexate from the beginning, or if they added them 6 months later as a next step.

A benefit of the triple therapy: It’s less expensive, says researcher Kaleb Michaud, PhD, an assistant professor at the University of Nebraska Medical Center. Michaud looked at how cost-effective the treatments were. He also at looked at the patients’ quality of life. While all strategies worked equally well, the triple strategies were most cost-effective over the long term. The biologics cost nearly twice as much, Michaud says. In the future, this information could help doctors and their patients choose treatment options when cost is an issue.  

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Blood Test for Pancreatic Cancer Shows Promise in Early Trial

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New Drug Shows Early Promise in Treating Parkinson's Psychosis

Pimavanserin may have fewer side effects than current therapy, study suggests

By Steven Reinberg

HealthDay Reporter

THURSDAY, Oct. 31 (HealthDay News) -- Many people living with Parkinson's disease suffer from hallucinations and delusions, but an experimental drug might offer some relief without debilitating side effects.

The drug -- pimavanserin -- appears to significantly relieve these troubling symptoms, according to the results of a phase 3 trial to test its effectiveness.

Such symptoms affect as many as half of the estimated 7 million to 10 million Parkinson's patients around the world, according to study background information.

Currently, patients are treated with antipsychotic drugs such as clozapine and quetiapine, which worsen Parkinson's motor symptoms, hasten mental decline, increase the risk of stroke and can be life-threatening, authors of the new study said.

Their study was published in the Nov. 1 online issue of The Lancet and funded by Acadia Pharmaceuticals, the makers of pimavanserin.

"There are no first-line approved treatments for psychosis in people with Parkinson's disease," said lead researcher Dr. Clive Ballard, a professor of age-related diseases at King's College, London.

"Existing antipsychotics are either ineffective or not tolerated. Pimavanserin is not yet licensed, but could potentially offer a change in the treatment of these distressing and impactful symptoms," he said.

An expert not involved with the study talked about the need for a medication alternative.

"The Parkinson's disease community has been waiting for a potentially new approach for the treatment of psychosis and hallucinations," said Dr. Michael Okun, national medical director of the National Parkinson Foundation.

"Pimavanserin may offer a relatively safe and reasonably efficacious choice for many patients in the situation where the current therapies are not adequate," Okun added.

The new drug works differently from other antipsychotics, study author Ballard said.

Pimavanserin blocks certain receptors -- called serotonin 5-HT2A receptors -- in the neocortex of the brain. This part of the brain is responsible for sensory perceptions, conscious thought and language, and is associated with hallucinations and delusions, Ballard explained.

For the trial, Ballard's team randomly assigned 199 Parkinson's patients suffering from disease-associated psychosis to daily doses either of pimavanserin or an inactive placebo pill.

After 43 days, patients taking pimavanserin showed a significant improvement on a scale of psychotic symptoms compared to those given a placebo -- 37 percent versus 14 percent.

However, this early study only provided short-term results, another expert pointed out.

Frances Weaver, director of the Center for Management of Complex Chronic Care at Hines VA Hospital, in Illinois, said although the trial was promising, more needs to be known about the long-term picture for this drug.

"The follow-up was only 43 days," she said. "It will be important to examine the long-term effects of this medication as psychosis is an ongoing problem which will likely require the patient to remain on medications for the rest of his life. Questions about long-term tolerability and effectiveness still need to be answered."

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Early HIV Treatment a Win-Win, Researchers Report

A cost-effective way to help patients stay healthy and prevent virus transmission, study finds

By Robert Preidt

HealthDay Reporter

WEDNESDAY, Oct. 30 (HealthDay News) -- Providing early antiretroviral drug treatment for recently infected HIV patients and their uninfected sexual partners is a cost-effective way to help patients stay healthy and prevent transmission of HIV, a new study finds.

The study, published Oct. 31 in the New England Journal of Medicine, looked at HIV patients in India and South Africa. Some of the patients received early antiretroviral therapy while the start of treatment was delayed for other patients. HIV is the virus that causes AIDS.

During the first five years of the study, 93 percent of those who received early antiretroviral therapy survived, compared with 83 percent of those whose treatment was delayed. Life expectancy was nearly 16 years for those in the early treatment group, compared with nearly 14 years for those in the delayed treatment group.

During the first five years, the potential costs of infections -- particularly tuberculosis -- prevented by early treatment of HIV patients in South Africa outweighed the costs of antiretroviral therapy drugs, suggesting that the early treatment strategy would reduce overall costs.

This was not the case in India, where the costs of treating HIV-related infections are less. Even so, early antiretroviral therapy in India was projected to be cost-effective according to established standards, the researchers said.

They also found that across patients' lifetimes, early antiretroviral therapy was very cost-effective in both countries. While most of the benefits of early treatment were seen in the HIV-infected patients -- fewer illnesses and deaths -- there were also added health care and economic cost savings from reducing HIV transmission, according to the study.

"By demonstrating that early HIV therapy not only has long-term clinical benefits to individuals but also provides excellent economic value in both low- and middle-income countries, this study provides a critical answer to an urgent policy question," study corresponding author Dr. Rochelle Walensky, of the Massachusetts General Hospital Division of Infectious Disease, said in a hospital news release.

"HIV-infected patients live healthier lives, their partners are protected from HIV, and the investment is superb," she added.

Walensky, a professor of Medicine at Harvard Medical School, said the findings point to a need to "redouble international efforts" to provide early antiretroviral therapy to any HIV-infected person who can benefit from it.

Her colleague, Dr. Kenneth Freedberg, director of the Medical Practice Evaluation Center at Massachusetts General, agreed.

"Some people have questioned whether providing early [antiretroviral therapy] to all who need it would be feasible in resource-limited countries," he said in the news release. "We've shown that in countries like South Africa, where it actually saves money in the short-term, the answer is 'yes.' We believe that continued international public and private partnerships can make this true in other countries as well."

Freedberg said such an investment could bring about dramatic decreases in infections and illness that could save millions of lives over the next decade.

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