Spotlight: ClinEpi Team Highlights

Recent publication in the news

By Anne M PlunkettNovember 9th, 2018

A recent paper, published in October in JAMA Internal Medicine, detailed research in a large observational study exploring the risk of CKD among patients prescribed allopurinol for gout. The research was cited in Internal Medicine News and in the Highlights section of JAMA Network.

Vargas-Santos  AB, Peloquin  CE, Zhang  Y, Neogi  T.  Association of chronic kidney disease with allopurinol use in gout treatment [published online October 8, 2018].  JAMA Intern Med. doi:10.1001/jamainternmed.2018.4463Google Scholar

Recent publication in Arthritis & Rheumatology cited in ScienceDaily and EurekAlert

By Anne M PlunkettNovember 9th, 2018

A paper on persistent pain and OA published in Arthritis & Rheumatology in October was referenced in ScienceDaily and EurekAlert

Carlesso LC, Segal NA, Frey-Law L, Zhang Y, Lu N, Nevitt M, Lewis CE, Neogi T. Pain susceptibility phenotypes in those free of knee pain with or at risk of knee osteoarthritis: The Multicenter Osteoarthritis Study. Arthritis Rheumatol. 2018. Epub 2018/10/12. doi: 10.1002/art.40752. PubMed PMID: 30307131.

Tuhina Neogi featured in two podcasts on gout on The Curbsiders

By Anne M PlunkettNovember 9th, 2018

https://thecurbsiders.com/podcast/113-gout-uric-acid-targets-urate-therapy

https://thecurbsiders.com/podcast/112-gout-flares-bathtubs-and-firefighting

About The Curbsiders

The Curbsiders is an Internal Medicine Podcast featuring three board-certified Internists as they interview (“curbside”) the experts to provide listeners with clinical pearls and  practice-changing knowledge. Join Dr. Matthew Watto, Dr. Stuart Brigham, and Dr. Paul Williams as they serve up some triple-distilled knowledge (and maybe a little humor) for your continuing medical education. No boring lectures here, just the stuff you wish they’d taught in medical school and residency. For more information, visit www.thecurbsiders.com.

The Curbsiders are board-certified Internists practicing in San Antonio, TX. The opinions expressed on this show are those of The Curbsiders and do not necessarily represent the views and opinions of their places of employment. The opinions expressed on this podcast are meant for entertainment and education and should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.

Publication highlighting the differential MI risk of various NSAIDs in spondyloarthritis and osteoarthritis

By Anne M PlunkettJune 21st, 2018
NSAIDs and risk of myocardial infarction in patients with #spondyloarthritis #osteoarthritis: highest risk with current diclofenac use, with risk of event highest in SpA patients ow.ly/imj230kduZj
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the rheumatologist
Diclofenac May Boost MI Risk in Patients with Spondyloarthritis

May 7, 2018 • By Marilynn Larkin

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NEW YORK (Reuters Health)—Risk of myocardial infarction (MI) is increased in patients with spondyloarthritis (SpA) who use the nonsteroidal anti-inflammatory drug (NSAID) diclofenac, but not in those who take naproxen, researchers say.

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Maureen Dubreuil, MD, MSc, of Boston University School of Medicine, and colleagues analyzed 20 years of medical records from the U.K.’s Health Improvement Network for adults ages 18–89 with incident ankylosing spondylitis (AS) or psoriatic arthritis (PsA), two forms of SpA. Controls had incident osteoarthritis (OA).

Within each cohort, the team then matched each MI case to four controls without MI.

NSAID use was categorized as a) current (prescription within 180 days prior to index date); b) recent (181-365 days); or c) remote (>365 days).

The daily dosage of diclofenac was 100 mg or more in 92% of individuals with OA, 95% of those with AS and 92% of those with PsA. The most common daily dosage of naproxen was 1,000 mg (55%); the dose was 1,000 mg or more in 56% of patients with OA, 63% of those with AS and 72% of those with PsA.

Among those whose most recent prescription was an NSAID other than diclofenac or naproxen, the most common drugs were ibuprofen (55%), celecoxib (11%), meloxicam (10%), rofecoxib (7%), etoricoxib (5%), indomethacin (3%) and etodolac (3%). All other NSAIDs accounted for 2% or less of prescriptions.

Within the SpA cohort of 8,140 and the OA cohort of 244,339, there were 115 and 6,287 cases of MI, respectively.

As reported online April 19 in Annals of Rheumatic Diseases, current diclofenac use was associated with an adjusted OR of 3.32 for MI in SpA patients. The risk was also increased in those with OA (aOR, 1.26).1

A similar pattern was seen with current use of other NSAIDs (aOR, 1.17), but not with current naproxen use (aOR 0.98).

Because current diclofenac was associated with increased MI risk, the authors also assessed whether recent use (18–365 days from prescription date) conferred risk. The unadjusted OR for recent use in SpA was 1.45, and in OA, 0.94. By contrast, recent naproxen was not associated with an increased or decreased risk in either SpA or OA.

Overall, the authors state, “Current use of diclofenac in SpA was associated with a twofold to threefold risk of MI relative to remote use of any NSAID.”

“[Although] this finding warrants some concern,” Dr. Dubreuil tells Reuters Health, “similar studies should be conducted in other data sets and other populations to help determine if a change in clinical practice is warranted.”

“If confirmed,” she says by email, “it is possible that subsequent treatment guidelines would recommend for or against a specific NSAID as first-line treatment in spondyloarthritis.”

Daniel Solomon, MD, MPH, chief, Section of Clinical Sciences, Divisions of Rheumatology and Pharmacoepidemiology at Brigham and Women’s Hospital in Boston comments to Reuters Health by email, “We know that all NSAIDs confer cardiovascular [CV] risk. However, most patients with normal CV risk who use these agents intermittently will not experience harm. Chronic use of NSAIDs in patients with certain risk factors is associated with substantial potential for CV and other adverse events.”

“The best data we have on these issues comes from large randomized controlled trials, such as PRECISION which tested different NSAIDs across patients with osteoarthritis (OA) or rheumatoid arthritis (RA),” says Dr. Solomon, who was a coauthor on PRECISION.2

“No important differences were found in relative risks across different NSAIDs by disease,” he notes. “In other words, patients with OA and RA experienced the same relative risks by NSAID. However, the CV risk was higher in RA so absolute risks were higher for the RA patients.”

The authors of the current study “specifically examined patients with spondyloarthritis and with OA and found that use of current diclofenac conferred an increased relative risk for CV events compared to past use among both patient groups, but the relative risk was increased for SpA compared with OA,” he says.

“This is interesting and there are biologic reasons why this is plausible,” he says, “but by no means are these results practice-changing. NSAID observational studies are very tricky because of confounding by indication as well as over the counter NSAID use. These results should generate new hypotheses that might be tested in prospective cohorts.”

Patients should not be told to steer clear of diclofenac, he adds. “All NSAIDs, including celecoxib, confer CV, gastrointestinal and renal risk. Patients should not use these agents chronically if they have known CV or renal disease.”

Reference

  1. Dubreuil M, Louie-Gao Q, Peloquin CE, et al. Risk of myocardial infarction with use of selected non-steroidal anti-inflammatory drugs in patients with spondyloarthritis and osteoarthritis. Ann Rheum Dis. 2018 Apr 19. pii: annrheumdis-2018-213089. [Epub ahead of print]
  2. Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen or ibuprofen for arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. Epub 2016 Nov 13.

 

Tuhina Neogi — ACR Gout Treatment Guidelines

By Anne M PlunkettJune 21st, 2018

Tuhina Neogi has been named as a co-PI for the American College of Rheumatology (ACR) Gout Treatment Guidelines Update.

Please join us in congratulating Tuhina on her participation in this important contribution to the treatment of gout!

Congratulations to Dr. Maureen Dubreuil, MD, MSc

By Anne M PlunkettJune 21st, 2018

for being selected as a recipient of the 2018 SAA/Bruckel Early Career Investigator in #AxSpA Award #spotspondy

June 18, 2018

MD award 2018BU researcher recognized for outstanding contributions in the field of spondyloarthritis

Boston University School of Medicine

(Boston)–Maureen Dubreuil, MD, MSc, assistant professor of Clinical Epidemiology Research & Training at Boston University School of Medicine (BUSM), is one of two recipients of the 2018 Spondylitis Association of America (SAA) Bruckel Early Career Investigator in Axial Spondyloarthritis Award.

Spondyloarthritis is a type of arthritis that attacks the spine and, in some people, the joints of the arms and legs. Dubreuil’s research focuses on comorbidities and pharmacoepidemiology of spondyloarthritis. She is currently studying patient preferences and the cost-effectiveness of treatment modalities for this disease. The $20,000 award will help this ongoing research.

The award was created to recognize outstanding “contributions to the care and understanding of patients with spondyloarthritis.” It was named in honor of the SAA’s co-founder Jane Bruckel and is given annually to the early career investigator who shows the most promise to contribute to the understanding or therapy of axial spondyloarthritis.

One theme of Dubreuil’s work is heart disease in spondyloarthritis. She led a study that examined the risk of heart attacks with non-steroidal anti-inflammatory drugs (NSAIDs) in spondyloarthritis patients, using a large database from the United Kingdom. The study found that specific NSAIDs may increase risk of heart attacks to a greater degree in people with spondyloarthritis than those with osteoarthritis. She is studying this same topic in other populations, including a large database in the United States. Dubreuil also collaborated on a study of the effects of statin (cholesterol medication) use in ankylosing spondylitis, finding that statins appear to have a more protective effect in people with ankylosing spondylitis than in the general population.

“A second theme of my work is understanding patients’ preferences for treatments in spondyloarthritis,” she explained. In 2016 she began work on a National Institutes of Health-funded project to assess factors that influence spondyloarthritis patients’ preferences for medications. “In the coming year, I will begin work on a cost-effectiveness study, comparing different approaches to spondyloarthritis treatment, such as starting with an NSAID versus starting with a biologic medication.”

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Dubreuil is a member of the Spondyloarthritis Research and Treatment Network (SPARTAN), and of the Assessment of Spondyloarthritis International Society (ASAS), and serves on the Early Career Investigator Subcommittee of the American College of Rheumatology. In 2013, she was awarded the Arthritis Foundation Clinical to Research Transition Award and 2016, she began work on a K23-funded project to study patient preferences, and the cost-effectiveness of treatment modalities for spondyloarthritis, to inform both clinical care and policy decisions.