Intravenous pamidronate for treatment of reflex sympathetic dystrophy during breast feeding.

A 39-year-old woman presented in the first month of pregnancy with reflex sympathetic dystrophy involving both lower legs. Symptoms became so severe that she could not walk unassisted, and the pain worsened after delivery. Radiographs showed patchy reduction in apparent density in the tarsal bones and around the ankles and knees. Uptake was increased in these areas on technetium methylene diphosphonate bone scan. Bone density (dual-energy X-ray absorptiometry) was reduced in the spine, hip, and radius. Biochemical tests were normal except for an increase in urinary excretion of the N-telopeptide cross-linking region of type I collagen (NTx). Because the patient wanted to continue breast-feeding, intravenous pamidronate was administered at monthly intervals. Breast milk was collected for 48 h after the infusion. The pain began to decrease soon after drug administration was initiated, and it was virtually gone by 6 months. NTx excretion fell by 78% and bone density increased by as much as 18.9% over the 6-month treatment interval. The baby was healthy and grew normally. Milk expressed after the first treatment was assayed for pamidronate content by high-performance liquid chromatography with fluorescence detection. None was detected (limit of quantitation, 0.4 micromol/liter). This case shows that pamidronate may be considered for treatment of lactating women.

Consequences of delayed therapy with second-line agents in rheumatoid arthritis: a 3 year followup on the hydroxychloroquine in early rheumatoid arthritis (HERA) study.

OBJECTIVE: To assess the longterm effect of delaying therapy with second-line agents in patients with early rheumatoid arthritis (RA). METHODS: One hundred nineteen patients who participated in a 9 month placebo controlled randomized trial of hydroxychloroquine sulfate (HCQ) were followed prospectively for an additional 3 years. Those randomized to HCQ are referred to as the early treatment group and those randomized to placebo as the delayed treatment group. Participants were assessed annually for pain [Arthritis Impact Measurement Scales (AIMS) and Stanford Health Assessment Questionnaire (HAQ)], physical disability (AIMS and HAQ), and the RA global well being scale (AIMS). Conversion of results into standard deviation (SD) units permitted defining a substantial difference as per Felson as > 0.30 SD units and a clinically indistinguishable difference as < or = 0.06 SD units. RESULTS: One hundred fifteen patients (97%) participated and complete data were available on 104 (87%). Compared to the early treatment group, the delayed group remained worse for both the pain and the physical disability outcomes over the additional 3 year followup. The difference in the RA global well being score became clinically indistinguishable for the early and delayed groups only after the 2 year post-trial assessment. The between-group differences were not explained by post-trial therapy with corticosteroids, other second-line agents, or nonsteroidal antiinflammatory drugs and analgesic preparations. CONCLUSION: These findings show that a delay in instituting therapy with second-line agents, even a 9 month delay in instituting a moderately powerful second-line agent such as HCQ, has significant effects on longterm patient outcome, and provides strong evidence in support of early therapy in RA.

A comparison of flurbiprofen and naproxen in the treatment of rheumatoid arthritis: a Canadian multi-centre study.

A 6-week double-blind, parallel controlled, randomized study was carried out to compare the efficacy and tolerability of 100 mg flurbiprofen twice daily with 375 mg naproxen twice daily in patients with rheumatoid arthritis. One hundred and six patients from five centres were evaluable; 52 from the flurbiprofen group and 54 from the naproxen group. Evaluation of the primary efficacy parameters demonstrated no difference in efficacy between the treatment groups. In general, the results of evaluation of the secondary efficacy parameters also supported similar improvement for both treatment groups. The overall incidence of adverse clinical/laboratory experiences was similar between the treatment groups. Five patients, 3 flurbiprofen and 2 naproxen-treated, discontinued the study, all because of gastro-intestinal intolerance.

Rapid reversal of ergotamine-induced vasospasm.

Peripheral ischemia, secondary to ergotamine tartrate and caffeine suppositories is reported in a 48-year-old female. Lower extremity pre-gangrenous changes were unresponsive to surgical sympathectomy, calcium channel blockade, intra-arterial vasodilators and systemic anticoagulation. A dramatic clinical and radiological reversal of the vasospasm was obtained with intravenous sodium nitroprusside when surgical amputation appeared inevitable.

Arthritis, hilar adenopathy, erythema nodosum complex.

Sarcoidosis may be associated with an arthritis primarily of the legs, usually accompanied by hilar adenopathy and marked systemic symptoms. We retrospectively reviewed 16 Caucasian patients referred because of rheumatologic complaints with an associated asymptomatic hilar adenopathy in 8 (50%) and the presence of erythema nodosum in 12 (75%). Investigations, including pulmonary function tests and angiotensin converting enzyme, were normal. Clinical course was generally benign and self-limited with median duration of 3 months for the hilar adenopathy and arthritis. HLA typing revealed a significant increased prevalence of HLA A1 B8 haplotype.