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Rheumatology - Disease Topic Overview

Rheumatology is the medical specialty that focuses on the diagnosis and treatment of diseases of the musculoskeletal system (bones, joints, muscles, tendons, and ligaments).¹

The specialty of rheumatology encompasses more than 150 diseases such as; rheumatoid arthritis (RA), osteoarthritis, osteoporosis, scleroderma, ankylosing spondylitis, systemic lupus erythematosus, Sjogren's disease and vasculitis.¹

Rheumatic diseases, degenerative or inflammatory, are the most common sources of chronic pain and physical disabilities. They are more common in the elderly and often cause pain, joint deformity and decreased mobility.¹ The pain can also lead to poor sleep quality, resulting in a decreased quality of life, increased morbidity and mortality, and an even greater perception of pain.² Rheumatic diseases are the leading cause of disability and early retirement, their social and economic impact is considerable.¹

RA is a progressive inflammatory disease characterised by inflammation of the joints, causing pain, deformities and often joint destruction.³ The exact etiology of RA is still unknown.⁴ However, it appears to result from a complex interaction between genetic factors and some environmental agents, which are still poorly defined.⁴ RA does not just affect the musculoskeletal system; extra-articular manifestations usually appear late and may affect the skin, the eyes or the heart.⁴ RA is the most common type of arthritis and affects approximately 1% of the population.⁴ It has a worldwide distribution and the incidence is twice as high in women compared with their male counterparts.4 RA can also occur in children and is then called juvenile rheumatoid arthritis.³

In recent years, significant progress has been made in the field of rheumatology. There is a greater scientific understanding of the changes of bone and cartilage at the genetic and molecular level, but much remains to be discovered in order to improve the prevention and treatment of these diseases.¹

1. Pereira da Silva J.A. et al. Rheumatology in Practice. Springer. 1st Edition. 2010 : 1.1-1.3.
2. Taylor-Gjevre R.M. et al. Components of Sleep Quality and Sleep Fragmentation in Rheumatoid Arthritis and Osteoarthritis. Musculoskeletal Care. June 2011 ; available online.
3. Beers M.H. et al. The Merck manual of medical information. Merck research laboratories. Second home edition. 2003, 370-377.
4. Cush J.J. et al. Rheumatoid Arthritis : Early Diagnosis and Treatment. Professional Communications Inc. Third edition. 2010 : 368 pages.

Osteoarthritis Perspectives
Osteoarthritis (OA) is a debilitating rheumatological disease that causes significant morbidity; it affects 45% of women over 65 and is a major cause of disability¹. OA is characterised by the degeneration of articular cartilage in synovial joints causing bone hypertrophy. Although this is a disease with no cure, many treatments for OA symptoms are available. Many people with OA have co-morbidities which affect which treatments are appropriate.

A satellite symposium symposium entitled Clinical Choices in Osteoarthritis Pain Management – Evidence Versus Practice: An Interactive Case-Based Assessment which was held at the EULAR Congress 2011 in London, UK, discussed the the treatment regimens available for the treatment of OA.

This interactive webcast contains three multimedia presentations delivered by Michael Doherty MA MD FRCP FHEA, Marc C. Hochberg MD MPH and Francis Berenbaum MD PhD.The first presentation, presented by Michael Doherty, explains how evidence-based guidelines provide the tools for effective, individualised treatment for patients with OA. Marc C. Hochberg discusses the importance of identifying patients with gastrointestinal risk (GI) factors and specific treatments available for these people. Francis Berenbaum completes the webcast with a presentation on treatment of patients with both cardiovascular and GI risk factors.

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References

1. Chasm R.M. et al. Pediatric Orthopedic Emergencies. Emergency Medical Clinics of North America. November 2010 ; 28 (4) : 907-926

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The EULAR (European League Against Rheumatism) 2011 satellite symposium was held in London in May 2011. The symposium entitled Clinical Choices in Osteoarthritis Pain Management – Evidence Versus Practice: An Interactive Case-Based Assessment discussed the treatment regimens available for the treatment of OA.

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Arthritis
Arthritis is a complex disorder that comprises more than 100 distinct musculoskeletal conditions and can affect people at any stage of life. Arthritis causes joint pain, loss of movement, and inflammation. Common forms of arthritis include osteoarthritis (OA) and rheumatoid arthritis. Both OA and RA are chronic and incurable but respond well to intervention.

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Arthritis is a complex disorder that comprises more than 100 distinct musculoskeletal conditions and can affect people at any stage of life. Arthritis causes joint pain, loss of movement, and inflammation.

Common forms of arthritis include osteoarthritis (OA) and rheumatoid arthritis. Both OA and RA are chronic and incurable but respond well to intervention.Osteoarthritis is the most common type of arthritis.

The prevalence increases with age, and most people over 60 years will have some radiological evidence of it. Osteoarthritis is the result of active, sometimes inflammatory but potentially reparative processes rather than the inevitable result of trauma and ageing.Rheumatoid arthritis is a chronic symmetrical polyarthritis of unexplained cause.

It is a systematic disorder characterized by chronic inflammatory synovitis of mainly peripheral joints. Its course is extremely variable and it is associated with nonarticular features.

To diagnose arthritis, there are a number of guidelines which outline the classification criteria, as well as tools to assess the patients pain.

There are a variety of treatment options available to help manage the pain and inflammation of osteo and rheumatoid arthritis, both pharmacological and non-pharmacological. It is important to balance the potential benefit against the potential side-effects.

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Opioids and Pain
Opioid analgesics are used to relieve moderate to severe pain. They can be used in the acute setting and are also appropriate for the treatment of certain cases of persistent non-cancer pain.

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The Pain in Europe survey¹ revealed the truly shocking nature, prevalence and impact of chronic pain in Europe and its devastating human, economic and social impact.

Types of chronic pain include both cancer and non-cancer pain. Pain is the single most common reason for consultation with a general practitioner and is the most frequent symptom in hospital practice.² Pain is also an individual experience and can be measured in a number of ways.

In Europe, the main activities affected by pain are exercising, sleeping, lifting, walking, carrying out chores, having sexual relations and working outside the home.¹

Chronic pain management can be managed through opioid therapy. However, before initiating opioid therapy, it is important that all patients undergo a thorough physical, psychological and functional examination, to ensure the management regimen is appropriate.

It is important to maintain frequent interaction between the doctor, healthcare team and patient on an ongoing basis to effectively monitor the dosage, side effects and funtional outcomes.

Other drugs that are widely used to control pain include paracetamol and NSAID's.

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References

1. Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006; 10:287-333.
2. MIMS Handbook of pain management. London: Haymarket Medical Imprint; 2006.

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Rheumatology Drug Data - A-Z English

Drug Updates

Enbrel 25 mg powder and solvent for solution for injection

Rheumatoid arthritis Enbrel in combination with methotrexate is indicated for the treatment of moderate to severe active rheumatoid arthritis in adults when the response to disease-modifying antirheumatic drugs, including methotrexate (unless contraindicated), has been inadequate.

Napratec OP

Napratec combination pack is indicated for patients who require Naproxen 500mg twice daily and Cytotec 200mcg twice daily.

Naproxen Tablets 500mg

Naproxen is indicated for the treatment of: 1) Rheumatoid arthritis.

Latest Drug News

FDA to review tofacitinib(Pfizer) for Rheumatoid Arthritis in August 2012 - 22-12-2011

The FDA has accepted for review the oral JAK inhibitor tofacitinib (CP-690,550) from Pfizer as a treatment for adults with moderately to severely active Rheumatoid Arthritis.The review is expected to take place in August 2012. The drug also is under review by the European Medicines Agency for the same indication. The submissions are based on the results of the ORAL Sync study.

European decentralised approval concluded for Steovess (Takeda) for Osteoporosis - 20-12-2011

Takeda Pharmaceuticals International GmbH announced that the European decentralised procedure was positively concluded for Steovess (formerly known as EX101), a once-a-week 70mg buffered effervescent alendronate for the treatment of Post-menopausal Osteoporosis. The Company submitted its application for marketing authorization in multiple countries through the DCP on 17 September 2010, with the United Kingdom (MHRA) serving as its Reference Member State (RMS). Following its evaluation, the RMS and all Concerned Member States (CMS) reached consensus that Steovess is approvable. The regulatory process will enter now into the national phase in which each of the member states shall adopt a national decision and grant national marketing authorizations. Pending those decisions, Takeda anticipates first launches in the second half of 2012. European approval will be used as the basis for submissions in key emerging markets. Takeda holds exclusive rights from EffRx Pharma, to develop, manufacture and commercialise the effervescent formulation of alendronate for the treatment of osteoporosis in all territories in the world except USA, Canada, and Japan

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Latest Clinical Trials

Study of MAGE-A3 and NY-ESO-1 Immunotherapy in Combo With DTPACE Chemo and Auto Transplantation in Multiple Myeloma

The hope is that the peptide vaccines will stimulate the immune system to attack and kill the myeloma cells. The purpose is to generate anti-myeloma T-cells which will kill myeloma cells and nothing else.

GDC-0449 in Treating Patients With High-Risk First Remission or Relapsed Multiple Myeloma Who Received an Autologous Stem Cell

This phase I trial is studying how well GDC-0449 works in treating patients with high-risk first remission or relapsed multiple myeloma who received an autologous stem cell transplant.

Latest Journal Publications

European Journal of Medical Genetics

A common purpose of microarray experiments is to study the variation in gene expression across the categories of an experimental factor such as tissue types and drug treatments. However, it is not uncommon that the studied experimental factor is a quantitative variable rather than categorical variable. Loss of information would occur by comparing gene-expression levels between groups that are factitiously defined according to the quantitative threshold values of an experimental factor. Additionally, lack of control for some sensitive clinical factors may bring serious false positive or negative findings. In the present study, we described a bootstrap-based regression method for analyzing gene-expression data from the non-categorical microarray experiments. To illustrate the utility of this method, we applied it to our recent gene-expression study of circulating monocytes in subjects with a wide range of variations in bone mineral density (BMD). This method allows a comprehensive discovery of gene expressions associated with osteoporosis-related traits while controlling other common confounding factors such as height, weight and age. Several genes identified in our study are involved in osteoblast and osteoclast functions and bone remodeling and/or menopause-associated estrogen-dependent pathways, which provide important clues to understand the etiology of osteoporosis.

Clinical and Developmental Immunology

In this paper we focus our attention on the role of two families of receptors, Toll-like receptors (TLR) and decoy receptors (DcR) involved in the generation of systemic lupus erythematosus (SLE) and lupus-like syndromes in human and mouse models. To date, these molecules were described in several autoimmune disorders such as rheumatoid arthritis, antiphospholipids syndrome, bowel inflammation, and SLE. Here, we summarize the findings of recent investigations on TLR and DcR and their role in the immunopathogenesis of the SLE.

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Related News

ACZ 885 positive in Phase III Juvenile Idiopathic Arthritis trial Rheumatology Page

ACZ 885 (canakinumab) from Novartis results are reported of a Phase III trial in patients with systemic juvenile idiopathic arthritis (SJIA), a rare and serious childhood auto-inflammatory disease. The results, presented at the 2011 European Pediatric Rheumatology Congress in Bruges, Belgium, showed all primary and secondary endpoints of the study were met. Most ACZ885 patients (83.7%) experienced at least a 30% improvement in symptoms vs. 9.8% for placebo (p<0.0001) and a third of ACZ 885 patients (32.6%) achieved a 100% improvement vs. 0% for placebo (p=0.0001). ACZ 885 is an investigational, fully human monoclonal antibody that neutralizes interleukin-1 beta (IL-1 beta), which is a key driver of inflammation in SJIA. see Ruperto N, Brunner H, Horneff G, et al. Efficacy and safety of canakinumab, a long acting fully human anti-interleukin-1 beta antibody, in systemic juvenile idiopathic arthritis with active systemic features: results from a phase III study. At: The 18th European Pediatric Rheumatology Congress; September 14-18, 2011, Bruges, Belgium. 2011. Worldwide regulatory submissions for ACZ 885 in SJIA are planned for 2012.

Protelos risk benefit profile in PMO questioned Rheumatology Page

The transparency committee at the French health authority, HASe has been investigating pharmacoviligence data on Protelos( strontium ranelate) from Servier to see if its risk benefit profile needs to change. The drug has been associated with hyperesenitivity reactions such as rash, eosinophilia , systemic syndromes (DRESS)(16 cases) and Stevens Johnson Syndrome. EMA was critical of the Servier pharmacovigilence system and Servier implemented an action plan. EMA now considers the risk benefit profile of Protelos as positive. HASe has decided that Protelos offers no medical benefit over other medications for post-menopausal osteoporosis considering that the drug has safety risks including VTE (50 cases) between 2009-2011. Its investigations are continuing. Servier is also facing investigations and court proceedings into its promotion in France of Mediator, a Type 2 Diabetes drug that was used off label for weight loss. The drug was banned in 2009.

SHOTZ study shows Forteo more effective than Zometa in bone remodelling Rheumatology Page

Data from the SHOTZ study were compared showing the mechanisms of action of Forteo (teriparatide [rDNA origin] injection) from Eli Lilly and zoledronic acid (Zometa) from Novartis that evaluated histomorphometric measurements of bone remodeling in transiliac crest bone biopsies from postmenopausal women with osteoporosis. These data were presented in an oral presentation at the 2011 Annual Meeting of the American Society for Bone and Mineral Research (ASBMR) in San Diego, Calif. Dynamic indices of bone formation, including mineralizing surface/bone surface (MS/BS) and bone formation rate (BFR), were significantly higher in women treated with Forteo than in women treated with zoledronic acid at six months.see Dempster, D., et al. "Skeletal Histomorphometry in Patients On Teriparatide or Zoledronic Acid Therapy (SHOTZ) Study: 6—Month Results of a Randomized Clinical Trial." Abstract presented at the ASBMR 2011 Annual Meeting, Sept. 19, 2011, 3:45 PM.