Rheumatoid Arthritis medicines use during pregnancy linked to adverse outcomes in new study

In a groundbreaking investigation, researchers have
delved into the medication utilization patterns during pregnancy among women
grappling with rheumatoid arthritis (RA). The study concludes that appropriate medication adjustment is quite
necessary when planning for pregnancy among women with RA.


The study
results were published in the journal Rheumatic & Musculoskeletal Diseases.

Also Read: Long-Term Exercise Therapy Improves Functional Outcomes among Rheumatoid Arthritis patients: BMJ

Patients
diagnosed with rheumatoid arthritis (RA) often face challenges when it comes to
achieving favorable pregnancy outcomes, as compared to individuals in the
general population. This disparity underscores the need for careful
consideration and specialized management for female patients with RA who are
planning for pregnancy and lactation, as they encounter limited treatment
options.

By drawing on data from the Korean
national health insurance database spanning a decade from 2010 to 2020, sheds
light on critical factors influencing pregnancy outcomes for this vulnerable
population.

Led by a team of esteemed scientists, the study focused
on female patients aged 20 to 50 years diagnosed with RA. Pregnancy episodes
were meticulously analyzed and categorized into two distinct groups: those
resulting in successful delivery and those culminating in adverse pregnancy
outcomes (APOs), encompassing instances of abortion and stillbirth.


Findings:

  • The findings, published in a reputable medical
    journal, unveiled crucial insights into medication utilization trends and their
    implications for maternal and fetal health.

  • Among the 5728 pregnancy episodes scrutinized, a
    stark contrast emerged between the delivery group, comprising 4576 episodes,
    and the APO group, encompassing 1152 episodes.


  • Remarkably, the study revealed hydroxychloroquine
    as the predominant conventional synthetic disease-modifying antirheumatic drug
    (DMARD) prescribed both prior to conception and throughout pregnancy in both
    cohorts.

  • However, a noteworthy decline in the prescription
    rates of all DMARDs was observed as pregnancies progressed, signaling cautious
    medication management during gestation.


  • Of paramount significance were the revelations from
    the multivariable logistic regression analysis, which pinpointed two specific
    medications—methotrexate and leflunomide—as posing heightened risks for APOs.

  • The use of these drugs within three months
    preceding conception was associated with significantly increased odds ratios of
    2.14 and 2.68, respectively, underscoring the imperative for judicious
    medication adjustments when planning pregnancy among women with RA.

Also Read: Rheumatoid arthritis patients more prone to depression, claims JAMA study


Moving forward, efforts to enhance awareness and
facilitate informed decision-making among patients and healthcare providers
alike are paramount. By fostering a collaborative approach grounded in
evidence-based practices and patient-centered care, we can empower women with
RA to navigate pregnancy with confidence and mitigate the risks posed by
medication exposures.


Further reading: Song YJ, Cho SK, Jung YS, et al. Medication utilisation trends during pregnancy and factors influencing adverse pregnancy outcomes in patients with rheumatoid arthritis. RMD Open. 2024;10(1):e003739. Published 2024 Mar 22. doi:10.1136/rmdopen-2023-003739. 

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Exercise-associated secondary amenorrhea in physically active women linked to cardiovascular disease: JAHA

Canada: A recent systematic review and meta-analysis has shed light on the impact of secondary amenorrhea on cardiovascular disease (CVD) risk in physically active women. The findings were published online in the Journal of the American Heart Association.  

Observational studies linked secondary amenorrhea to several cardiovascular (CV) risk factors in physically active women.
“Estrogen deficiency resulting from exercise-associated secondary amenorrhea in physically active women may affect CV physiology and certain CVD risk factors,” the researchers wrote. However, they noted that research in the area is observational, and findings should be interpreted cautiously.
They add, “As exercise-associated amenorrhea is reversible and primary prevention of cardiovascular disease is important for public health, it may be important to treat secondary amenorrhea and restore estrogen levels.
Exercise-associated secondary amenorrhea leads to estrogen deficiency, which may result in dysfunction in estrogen’s normal cardioprotective pathways. Estrogen may be essential in a woman’s endothelial adaptations to exercise. Nicole L. Tegg, Faculty of Nursing University of Alberta Edmonton Alberta Canada, and colleagues aimed to assess the association between secondary amenorrhea in physically active women and CVD risk.
For this purpose, the researchers performed a literature search in January 2023 and updated in August 2023 of the online databases from inception to present with no date or language limitations. Citation chaining was done to screen for additional studies. Eight sources were searched for gray literature.
The review included studies that compared physically active women with amenorrhea to physically active women with eumenorrhea aged 18 to 35 years with evidence of cardiovascular disease, alterations to cardiovascular physiology, or CVD risks. Eighteen observational studies from three countries were included. The quality of evidence was good overall.
“Physically active women with secondary amenorrhea had significantly lower estradiol, resting heart rate, flow-mediated dilation, systolic blood pressure, and diastolic blood pressure and higher total cholesterol, high-density lipoprotein, triglycerides, and low-density lipoprotein cholesterol,” the researchers reported.
In conclusion, the systematic review and meta-analysis found that functional hypothalamic amenorrhea may obviate CV benefits of exercise and may adversely impact CV physiology and certain CVD risk factors, including, endothelial function and lipid profiles.
The findings highlight a need to further investigate the long-term CV consequences of hypoestrogenemia. Given the hormonal profiles of athletes with amenorrhea (AAs) and the evidence suggesting AAs may demonstrate increased CVD risk factors, determining the causative factor of amenorrhea is important so that appropriate interventions may be explored to restore menses and thereby, estrogen levels.
.Finally, increasing awareness of the CV health consequences linked with energy deficiency is of paramount importance.
“There is a need for high-quality, large‐scale longitudinal studies to investigate the underlying relationships between secondary amenorrhea and the development of cardiovascular diseases and to increase the understanding of the clinical relevance of findings in this area,” the researchers wrote.
Reference:
Tegg NL, Myburgh C, O’Donnell E, Kennedy M, Norris CM. Impact of Secondary Amenorrhea on Cardiovascular Disease Risk in Physically Active Women: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2024 Mar 18:e033154. doi: 10.1161/JAHA.123.033154. Epub ahead of print. PMID: 38497482.

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Higher dietary inflammatory index score tied to increased mortality in individuals with hyperuricemia: JAMA

China: Findings from the National Health and Nutritional Examination Surveys (2001-2018) revealed that a higher dietary inflammatory index (DII) increases the mortality rate of adults With hyperuricemia. The findings were published online in Arthritis Care & Research on March 31, 2024.

The researchers suggest that controlling the intake of pro-inflammatory food might be a potential strategy to reduce all-cause and cardiovascular disease (CVD) mortality.

Hyperuricemia is a metabolic disorder resulting from prolonged dysfunction in purine metabolism, impaired elimination of uric acid, or excessive purine intake.

Dietary management is a crucial component of non-pharmacological treatment for hyperuricemia. Clinicians highly recommend a low-purine diet as it is suggested to improve hyperuricemia and prevent gout attacks. Furthermore, studies have found that probiotics, anthocyanins, and other bioactive compounds hold the potential to reduce hyperuricemia. Although these dietary components are believed to have anti-inflammatory effects, there is no knowledge of the overall inflammatory potential of the diet and its relationship with the physical health of hyperuricemia patients.

To fill this knowledge gap, Jiuliang Zhao, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China, and colleagues conducted the study to assess the association between Dietary Inflammatory Index score and mortality among adults with hyperuricemia.

For this purpose, the researchers collected data from the 2001-2018 NHANES cohorts. They obtained mortality information based on death certificate records from the National Death Index (NDI) through 31 December 2019. Cox proportional hazards regression models were used to investigate the associations between DII score and all-cause, CVD, and cancer mortality. 7786 participants with hyperuricemia were enrolled in the study.

Based on the findings, the researchers reported the following findings:

  • The DII score ranged from −4.42 to 4.61. Higher DII score was significantly associated with higher levels of BMI, glycohemoglobin, glucose, LDL-cholesterol, and CRP.
  • During 67851 person-years of follow-up, 1456 participants were identified with death including 532 CVD deaths and 246 cancer deaths.
  • After adjusting for potential variables, a significantly higher risk of all-cause (HR:1.18) and CVD (HR:1.30) mortality was observed for individuals with higher DII scores.
  • Considering the DII score as a continuous variable, the risk of all-cause and CVD mortality increases by 5% (HR:1.05) and 8% (HR:1.08) with each one-unit increment in DII, respectively.
  • Subgroup analysis indicated that the association between DII and all-cause mortality among hyperuricemia participants was more significant in males.

In conclusion, the dietary inflammatory index score positively correlates with all-cause and CVD mortality in adults with hyperuricemia. Controlling the intake of pro-inflammatory food might be a potential strategy to reduce mortality.

Reference:

Zhou, M., Cai, B., Xiao, Q., Zou, H., Zeng, X., Zhao, J., & Zhu, X. Higher Dietary Inflammatory Index Increases Mortality Rate of Adults With Hyperuricemia: Findings From the National Health and Nutritional Examination Surveys (2001-2018). Arthritis Care & Research. https://doi.org/10.1002/acr.25336

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PIVCs secured with integrated securement dressings and tissue adhesive significantly reduce PIVC failure for children: JAMA

Australia: Peripheral intravenous catheters (PIVCs) secured with integrated securement dressings and tissue adhesive compared to traditional bordered polyurethane dressings significantly reduce PIVC failure in children admitted to the hospital via the emergency department (ED), says a new study.

“The randomized clinical trial comprising 383 children revealed that PIVC failure was highest with traditional bordered polyurethane dressings (34%) and lowest with integrated securement dressing and tissue adhesive (12%),” the researchers reported in JAMA Pediatrics.

Peripheral intravenous catheter insertion is a common procedure in an ED, impacting around 70% of hospitalized patients. Despite their widespread use, the failure of these essential devices is frequent and there is a need for new securement strategies that may reduce failure and improve patient outcomes. Therefore, Brooke Charters, Logan Hospital, Brisbane, Queensland, Australia, and colleagues aimed to evaluate the clinical effectiveness of novel PIVC securement technologies for children to reduce catheter failure.

For this purpose, the researchers conducted a 3-arm, parallel-group, superiority randomized clinical trial at 2 regional Australian hospitals from 2020 to 2022. Children aged 6 months to 8 years who were anticipated to require admission with a PIVC for at least 24 hours of in-hospital treatment were eligible.

383 patients (51% female; median age 36 months) were randomly allocated in a 1:1:1 ratio to standard care (n=134), bordered polyurethane (n=118) (Tegaderm [3M]), integrated securement dressing (SorbaView SHIELD [Medline]), and integrated securement dressing (ISD) with tissue adhesive (TA) (n=131). One catheter was studied per patient.

The study’s primary outcome was PIVC failure, defined as premature cessation of PIVC function for any reason before the completion of planned treatment. Secondary outcomes included PIVC longevity, PIVC complications (any time dislodgement, infiltration, occlusion, partial dislodgement, device leaking, extravasation, phlebitis, pain), pain on removal (caregivers and participants; 0-10 scale relevant to age), intervention acceptability (participants, clinicians, caregivers; 0-10 scale), PIVC longevity, health care costs, and adverse costs.

The study led to the following findings:

  • PIVC failure was lowest in integrated securement dressing with tissue adhesive (12%; adjusted hazard ratio [aHR], 0.47) compared with integrated securement dressing (21%; aHR, 0.78) and standard care (34%).
  • Direct costs were significantly lower for integrated securement dressing with tissue adhesive (median, Australian dollars [A$], 312 [A$1 is equal to $0.65 US dollars]; IQR, A$302-A$380) and integrated securement dressing (median, A$303; IQR, A$294-A$465) compared with standard care (median, A$341; IQR, A$297-A$592) when considering the economic burden related to failure of devices.
  • PIVC longevity and intervention acceptability were similar across all groups.

“These findings support the preferential use of ISD and TA to secure PIVCs to reduce costs and improve patient outcomes,” the researchers wrote.

“Further research should focus on implementation in inpatient units where prolonged dwell and reliable intravenous access is most required,” they concluded.

Reference:

Charters B, Foster K, Lawton B, et al. Novel Peripheral Intravenous Catheter Securement for Children and Catheter Failure Reduction: A Randomized Clinical Trial. JAMA Pediatr. Published online April 01, 2024. doi:10.1001/jamapediatrics.2024.0167

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Lotilaner Ophthalmic Solution Promising Treatment for Demodex Blepharitis: Study

Demodex blepharitis, caused by an infestation of Demodex mites, poses a significant burden on affected individuals, impacting their quality of life. Traditional management options have been associated with adverse effects, prompting the search for novel therapeutic alternatives. A recent systematic review and meta-analysis assessed the safety and efficacy of lotilaner ophthalmic solution (0.25%) as a treatment for Demodex blepharitis. The study was published in the American Journal Of Ophthalmology. The study was conducted by Talha M. and colleagues.

Demodex blepharitis affects millions of individuals worldwide, leading to various ocular manifestations. Prior management strategies, including topical tea tree oil and antibiotics, were associated with adverse effects. Lotilaner, an antiparasitic compound, offers a targeted approach for Demodex eradication.

The systematic review included data from four randomized controlled trials and two single-arm studies, comprising a total of 328 neonates. Studies were selected based on eligibility criteria, including treatment with lotilaner ophthalmic solution and assessment of Demodex mite eradication and collarette score.

The key findings of the study were:

  • Effectiveness of Lotilaner:

Lotilaner ophthalmic solution demonstrated efficacy in eradicating Demodex mites compared to the control group (RR, 3.55; 95% CI, 2.87 – 4.40; P < .00001).

The intervention cohort showed a significantly improved clinically meaningful collarette score compared to the control cohort (RR, 3.15; 95% CI, 2.56 – 3.89; P < .00001).

  • Safety Profile:

Rare adverse effects, including mild burning, redness, and blurriness, were reported with lotilaner treatment, reaffirming its favourable safety profile.

Lotilaner ophthalmic solution (0.25%) emerges as a promising treatment option for Demodex blepharitis, offering efficacy in mite eradication and improvement in collarette scores. The findings underscore its potential as a specific and well-tolerated therapy, enhancing the management of this common ocular condition.

The approval of lotilaner by the FDA signifies a significant advancement in the management of Demodex blepharitis. Its targeted mechanism of action and favourable safety profile position it as a valuable addition to existing treatment strategies, benefiting patients and healthcare providers alike.

Reference:

Talha M, Haris Ali M, Fatima E, Nadeem A, Ahmed A, Nashwan AJ. Efficacy and Safety of Lotilaner Ophthalmic Solution (0.25%) for the Treatment of Demodex Blepharitis: A GRADE Assessed Systematic Review and Meta-Analysis of Observational & Experimental Studies. Am J Ophthalmol. Published online March 19, 2024. doi:10.1016/j.ajo.2024.03.019

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People with essential tremor may have increased risk of dementia, reveals study

Dementia may be three times more common among people with essential tremor, a movement disorder that causes involuntary shaking, than the general population, according to research released on March 6, 2024. The study will be presented at the American Academy of Neurology’s 76th Annual Meeting taking place April 13-18, 2024, in person in Denver and online.

Essential tremor is the most common tremor disorder, more common than Parkinson’s disease. In addition to arm and hand tremors, people may also develop involuntary shaking of the head, jaw and voice.

“While many people living with essential tremor experience mild tremor, in some individuals, the tremor can be quite severe,” said study author Elan D. Louis, MD, MSc, at University of Texas Southwestern Medical Center in Dallas and a Fellow of the American Academy of Neurology. “Not only do tremors affect a person’s ability to complete daily tasks such writing and eating, our study suggests that people with essential tremor also have an increased risk of developing dementia.”

The study involved 222 people with essential tremor who had an average age of 79 at the start of the study. They took thinking and memory tests to determine whether they had normal cognitive skills, mild cognitive impairment or dementia at the start of the study.

Participants then had follow-up exams every 1.5 years for an average of five years.

Of this group, 168 people had normal cognitive skills, 35 had mild cognitive impairment and 19 had dementia at the start of the study.

During the study, 59 developed mild cognitive impairment and 41 developed dementia.

Researchers then compared the rate at which people developed mild cognitive impairment and dementia, as well as the prevalence of these conditions, to the rates and prevalence for the general population. They also compared participants to the rates and prevalence for people with Parkinson’s disease.

Researchers found 19% of participants had or developed dementia during the study, and each year an average of 12% of people diagnosed with mild cognitive impairment went on to develop dementia. These rates were three times higher than the rates in the general population. However, the rates were lower than those seen in people with Parkinson’s disease, a population for which dementia is more prevalent.

Researchers also found that 27% of participants had or developed mild cognitive impairment during the study, a rate almost double that of the rate of 14.5% for the general population, but less than the rate of 40% for people with Parkinson’s disease.

“While the majority of people with essential tremor will not develop dementia, our findings provide the basis for physicians to educate people with essential tremor and their families about the heightened risk, and any potential life changes likely to accompany this diagnosis,” Louis said.

Reference:

People with essential tremor may have increased risk of dementia, American Academy of Neurology, Meeting: 2024 American Academy of Neurology’s 76th Annual Meeting.

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Azithromycin associated with higher remission rate among patients with chronic Asthma: Study

Azithromycin is associated with a higher remission rate among patients with chronic Asthma suggests a study published in the Chest.

This secondary analysis used data from the AMAZES clinical trial – a double-blind placebo-controlled trial that evaluated the safety and efficacy of azithromycin on asthma exacerbations. The primary remission definition (referred to as clinical remission) was zero exacerbations and zero oral corticosteroids (OCS) during the previous six months evaluated at 12 months and Asthma Control Questionnaire (ACQ-5) ≤1 at 12 months. Secondary remission definitions included clinical remission plus lung function criteria (post-bronchodilator FEV1≥80% or post-bronchodilator FEV1≤5% decline from baseline) and complete remission (sputum eosinophils<3% plus the above criteria). Sensitivity analyses explored the robustness of primary and secondary remission definitions. The predictors of clinical remission were identified. Results: 335 participants (41.5% male; median [Q1, Q3] age 61.01 [51.03, 68.73] years) who completed the 12-month treatment period were included in the analysis. Twelve months of treatment with azithromycin induced asthma remission in a subgroup of patients, and a significantly higher proportion in the azithromycin arm achieved both clinical remission (50.6% vs 38.9%; p=0.032) and clinical remission plus lung function criteria (50.8% vs 37.1%; p=0.029) compared with placebo. In addition, a higher proportion of the azithromycin group achieved complete remission (23% vs 13.7%; p=0.058). Sensitivity analyses supported these findings. Baseline factors such as better asthma-related quality of life and absence of OCS burst in the previous year predicted the odds of achieving clinical remission—azithromycin-induced remission in both eosinophilic and noneosinophilic asthma. Adults with persistent symptomatic asthma achieved a higher remission rate when treated with azithromycin. Remission on treatment may be an achievable target in moderate/severe asthma, and future studies should consider remission as an outcome measure.

Reference:

Dennis Thomas, Vanessa M. McDonald, Sean Stevens, Melissa Baraket, Sandra Hodge, Alan James, Christine Jenkins, Guy B. Marks, Matthew Peters, Paul Reynolds, John W. Upham, Ian A. Yang, Peter G. Gibson. Azithromycin induced asthma remission in adults with persistent uncontrolled asthma: a secondary analysis of a randomised, double-blind, placebo-controlled trial, CHEST, 2024, ISSN 0012-3692 https://doi.org/10.1016/j.chest.2024.02.048.

(https://www.sciencedirect.com/science/article/pii/S0012369224002848)

Keywords:

Azithromycin, higher remission rate, patients, chronic Asthma, Chest, Dennis Thomas, Vanessa M. McDonald, Sean Stevens, Melissa Baraket, Sandra Hodge, Alan James, Christine Jenkins, Guy B. Marks, Matthew Peters, Paul Reynolds, John W. Upham, Ian A. Yang, Peter G. Gibson, Asthma; azithromycin; remission

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Woman experiences an acute ischemic stroke five weeks after tooth extraction: Case study

USA: A case report published in the Journal of the American Dental Association has highlighted the rare association between a dental procedure, infective endocarditis, and an acute ischemic stroke.

Zachary M. Wilseck, University of Michigan-Michigan Medicine, Ann Arbor, MI, and colleagues revealed that the risk of developing stroke and infective endocarditis is low among low-risk patients, but it is not nonexistent.

In the case described, the patient was initially deemed to be at low risk and, therefore, not given prophylactic antibiotics before tooth extraction, and, therefore, the development of infective endocarditis led to the detection of valvular abnormalities.

“Proper identification, prompt management, and close interdisciplinary collaborations are important to improve outcomes in these patients,” the researchers wrote.

The case concerns a 54-year-old woman who experienced an acute ischemic stroke five weeks following a tooth extraction. The initial symptoms of this patient included right facial drop and mild to moderate word-finding difficulty. Computed tomographic angiography showed a left M1 segment middle cerebral artery occlusion (thrombolysis in cerebral infarction scale, 0) with reconstitution of the distal middle cerebral branches through arterial collaterals.

Following the initial administration of tissue plasminogen activator, endovascular thrombectomy was performed successfully with thrombolysis in cerebral infarction scale 3 (complete) recanalization.

After the procedure, there was an improvement in the patient’s language and neurologic deficits. Imaging showed bilateral, multifocal, cortical, and deep brain hemorrhages. Blood cultures grew Streptococcus mitis, ultimately leading to endocarditis diagnosis. Echocardiographic imaging revealed moderate to severe aortic insufficiency, mitral valve vegetation, and mild mitral valve regurgitation.

The cardiothoracic surgery team evaluated the patient after which she was discharged with intravenous antibiotics and short-term outpatient follow-up with the cardiothoracic surgery team.

The case highlights an association between a dental procedure, infective endocarditis, and acute ischemic strokes resulting from large-vessel occlusion or embolus.

In conclusion, dental procedures are generally safe, however, can introduce oral bacteria into the bloodstream, resulting in bacterial seeding of cardiac valves and subsequent infective endocarditis.

The researchers suggest the importance of recognizing infective endocarditis after a dental procedure, including tooth extraction, as a potential cause of an acute ischemic stroke so that prompt treatment can be initiated.

“Dental procedures can be a potential source of bacteremia, leading to the development of infective endocarditis and subsequent complications such as hemorrhagic or ischemic stroke,” the researchers wrote.

“Vigilance is important in recognizing the signs and symptoms of infective endocarditis, specifically in patients who have undergone dental interventions and have underlying cardiac conditions or are immunocompromised, they concluded.

Reference:

Bah, M. G., Wilseck, Z. M., Lin, L. Y., Peterson, A. J., Chaudhary, N., & Gemmete, J. J. (2024). The interplay among a dental procedure, infective endocarditis, and an acute ischemic stroke. The Journal of the American Dental Association, 155(3), 244-250. https://doi.org/10.1016/j.adaj.2023.11.009

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EULAR releases updated recommendations clarifying treatment sequence for psoriatic arthritis

France: The European Alliance of Associations for Rheumatology (EULAR) has released an updated recommendation document for managing psoriatic arthritis (PsA) with pharmacological therapies.

New modes of action and more data on the safety and efficacy of existing drugs in psoriatic arthritis needed an update of the EULAR 2019 recommendations for the pharmacological treatment of PsA. Following EULAR standardized operating procedures, the process of recommendations development included a systematic literature review and a consensus meeting of 36 international experts in April 2023.

The updated recommendations, published in the BMJ journal Annals of the Rheumatic Diseases, comprise 7 overarching principles and 11 recommendations and provide a treatment strategy for pharmacological therapies. The new guideline covers the full range of the available disease-modifying anti-rheumatic drugs (DMARDs) — including conventional, biologic, and targeted oral agents. It comes with an easy-to-follow algorithm, in words and with a graphical flow diagram, for which drugs to start or add and under what circumstances.

The recommendations are described below:

  1. Treatment should be aimed at reaching the target of remission or low disease activity, by regular disease activity assessment and appropriate adjustment of therapy.
  2. Non-steroidal anti-inflammatory drugs may be used to relieve musculoskeletal signs and symptoms; local injections of glucocorticoids may be considered adjunctive therapy.
  3. In patients with polyarthritis or those with monoarthritis/oligoarthritis and poor prognostic factors (eg, structural damage, elevated acute phase reactants, dactylitis, or nail involvement), a csDMARD should be initiated rapidly, with methotrexate preferred in those with clinically relevant skin involvement.
  4. In patients with peripheral arthritis and an inadequate response to at least one csDMARD, therapy with a bDMARD should be commenced.
  5. In patients with peripheral arthritis and an inadequate response to at least one bDMARD, or when a bDMARD is not appropriate, a JAKi may be considered, taking safety considerations into account.
  6. In patients with mild disease and an inadequate response to at least one csDMARD, in whom neither a bDMARD nor a JAKi is appropriate, a PDE4 inhibitor may be considered.
  7. In patients with unequivocal enthesitis and an insufficient response to NSAIDs (non-steroidal anti-inflammatory drugs) or local glucocorticoid injections, therapy with a bDMARD should be considered.
  8. In patients with a clinically relevant axial disease with an insufficient response to NSAIDs, therapy with an IL-17Ai, a TNFi, an IL-17 A/Fi, or a JAKi should be considered.
  9. The choice of the mode of action should reflect non-musculoskeletal manifestations related to PsA; with clinically relevant skin involvement, preference should be given to an IL-17A or IL-17A/F or IL-23 or IL-12/23 inhibitor; with uveitis to an anti-TNF monoclonal antibody; and with IBD to an anti-TNF monoclonal antibody or an IL-23 inhibitor or IL-12/23 inhibitor or a JAKi.
  10. In patients with an inadequate response or intolerance to a bDMARD or a JAKi, switching to another bDMARD or JAKi should be considered, including one switch within a class.
  11. In patients in sustained remission, tapering of DMARDs may be considered.

“These updated recommendations integrate all currently available drugs in a practical and progressive approach, which will be helpful in the pharmacological management of PsA,” Laure Gossec, MD, PhD, of INSERM and Sorbonne Université in Paris, and colleagues wrote.

Reference:

Gossec L, Kerschbaumer A, Ferreira RJO, et alEULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2023 updateAnnals of the Rheumatic Diseases Published Online First: 18 March 2024. doi: 10.1136/ard-2024-225531

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High BMI risk factor for adverse outcomes after autologous breast reconstruction: Study

USA: A recent study has shown a great potential of preoperative weight loss to alleviate surgical risk in obese and overweight patients pursuing autologous breast reconstruction. 

The results, published in Plastic and Reconstructive Surgery, quantify the risk reduction based on a patient’s preoperative body mass index (BMI). 

For women undergoing autologous breast reconstruction-reconstruction using the patient’s own tissues, rather than implants – the risks of overall and specific complications are increased at higher BMI levels, the study stated. 

“Our study clarifies the impact of high BMI as a risk factor for adverse outcomes of autologous breast reconstruction,” comments senior author Merisa Piper, MD, of University of California, San Francisco. “It also suggests that, among patients with obesity, losing weight before surgery might lower the risk of complications.”

How does BMI affect autologous breast reconstruction outcomes?

Autologous breast reconstruction, typically using a flap of tissue from the abdomen, is an alternative for reconstruction after mastectomy for breast cancer. Autologous reconstruction offers advantages including stable breast reconstruction with fewer surgical procedures, in less time, and at lower cost, compared to implant-based reconstruction.

However, not all patients are optimal candidates for this procedure: risk factors for adverse outcomes include smoking, uncontrolled diabetes, and high BMI. Despite previous studies, the impact of high BMI on outcomes of autologous breast reconstruction remain unclear.

Dr. Piper and colleagues analyzed the impact of BMI on outcomes of autologous reconstruction in 365 patients (545 breasts) between 2004 and 2021. All patients underwent microvascular breast reconstruction using an abdominal-based flap. Complications were assessed for patients in different BMI categories, ranging from normal weight (less than 25 kg/m2), to overweight (25 to 29.9 kg/m2), to obese (30 kg/m2 or higher).

Complication risks affected at different BMI cutoffs

Several types of complications increased at distinct levels of BMI, especially in the obese range. The risk of any complication increased at a BMI of 30 kg/m2 or higher. More severe obesity-BMI 35 kg/m2 or higher-was associated with increased rates of unplanned repeat surgery, including wound breakdown requiring reoperation.

Risk of infection requiring oral antibiotics increased at BMI 25 kg/m2 or higher, while infections requiring intravenous antibiotics increased at BMI 30 kg/m2 or higher. Higher BMI levels were also associated with increased rates of complications related to the abdominal donor flap, including infection and wound-healing problems.

Further analyses suggested optimal BMI cutoff point of 32.7 kg/m2 to minimize the occurrence of any breast complication and 30.0 kg/m2 for any abdominal complication. With a BMI of 32.7 kg/m2, the risk of breast complications was similar to that associated with current smoking.

The study demonstrates “a robust trend” whereby higher BMI levels are associated with increased complication rates for women undergoing autologous breast reconstruction. The findings suggest that targeting specific levels of weight loss before surgery might help to avoid postoperative complications.

“By quantifying the change in risk profile associated with a given change in BMI, our results can be used clinically to set evidence-based preoperative weight-loss goals for patients,” Dr. Piper and coauthors conclude. They emphasize that further studies would be needed to specifically evaluate the effects of weight loss before surgery.

Reference:

Barnes LL, Lem M, Patterson A, Segal R, Holland MC, Lentz R, Sbitany H, Piper M. Relationship between Body Mass Index and Outcomes in Microvascular Abdominally Based Autologous Breast Reconstruction. Plast Reconstr Surg. 2024 Mar 1;153(3):553-566. doi: 10.1097/PRS.0000000000010621. 

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