Intermittent Rituximab Suggested Best for ANCA-Associated Vasculitis


Results from the RAVE trial show rituximab noninferior to and safer than cyclophosphamide and azathioprine for severe AAV. Also in the nonspecialty journals: On mistreating patients with back pain, and more.

Last week's articles on rheumatology topics in the major non-rheumatology journals

Efficacy of Remission-Induction Regimens for ANCA-Associated VasculitisN Engl J Med, August 1, 2013

Intermittent rituximab may be more effective than daily cyclophosphamide and azathioprine for severe antineutorphil cytoplasmic antibody (ANCA)-associated vasculitis, In an 18-month noninferiority trial, four doses of rituximab over one month was as effective as daily therapy with cyclophosphamide (CYC) followed by azathioprine (AZA) for the induction and maintenance of remissionsAmong patients n the rituximab group, 64% had complete remission by six months, compared to 53% in the CYC/AZA group. Thirty-nine and 33%, respectively, maintained their remission by 18 months, which met the criteria for noninferiority. For the subgroup of patients who entered the trial with relapsing disease, rituximab was superior at six and 12 months. The CYC/AZA group had more cases of leucopenia and pneumonia. The study is a long-term continuation of the Rituximab in Associated Vasculitis (RAVE) trial.

ALSO NEW THIS WEEK:Worsening Trends in the Management and Treatment of Back PainJAMA Intern Med, July 29, 2013

Comment: Why Don’t Physicians (and Patients) Consistently Follow Clinical Practice Guidelines?JAMA Intern Med, July 29, 2013

New evidence-based guidelines were published for treatment of back and neck pain between 1999 and 2010, but physicians moved in the opposite direction. In a representative U.S. sample of 23,918 patient visits:

•  use of nonsteroidal anti-inflammatory drug or acetaminophen use decreased, but narcotic use increased
•  referrals for physical therapy remained constant, but referrals to specialists increased
•  use of radiographs remained constant, but use of CTs and MRIs increased.

A commentary discusses research into why physicians don’t adopt evidence-based guidelines, and offers suggestions for improvement. (In defense of physicians: The first rigorous guidelines on back pain were published only in 2007.)

Global Health: Measuring the Global Burden of DiseaseN Engl J Med, August 1, 2013

In the United States, low back pain, which affects 10% of the population, was one of the three musculoskeletal disorders (along with neck pain and "other" musculoskeletal disorders) among the top ten causes of burden of disease as assessed by disability-adjusted life-years (DALYs), the measure used to compare death and disability worldwide in the Global Burden of Disease Study. Globally, the burden of disease has been shifting from premature death to disability. About a quarter of low back pain is occupation-related and preventable, says this report.


Images in Clinical Medicine: Heerfordt's Syndrome, or Uveoparotid FeverN Engl J Med, August 1, 2013

Heerfort’s syndrome is a rare form of sarcoidosis in which the compression of the facial nerve results in palsy. In this case study, a 32-year-old woman presented with a swelling of both parotid glands, palsy due to compression of the facial nerves, dry eyes, and dry mouth, but no fever and no uveitis. After 19 days of prednisone, the swelling resolved.

Clinical Problem-Solving: Weak in the KneesN Engl J Med, August 1, 2013

Weak in the KneesNow@NEJM, August 2, 2013

Lambert-Eaton myasthenic syndrome is caused by autoantibodies to the presynaptic membrane of the neuromuscular junction, in contrast, myasthenia gravis is caused by autoantibodies to the postsynaptic acetycholine receptors. In myasthenia gravis, exercise causes muscle fatigue; in Lambert-Eaton myasthenic syndrome, muscles become strengthened with exercise. Electromyography and nerve-conduction studies can localize the weakness. Autoantibody tests confirm the diagnosis. Over half of patients with Lambert-Eaton myasthenic syndrome have an associated cancer (usually small-cell lung cancer), of which the muscle syndrome is often the presenting symptom. 

OsteopoikilosisLancet, August 2, 2013

Osteopoikilosis is a rare, benign, autosomal dominant disorder usually found incidentally and characterized by sclerotic, ovoid bone lesions, commonly on hands, feet, pelvis, and ends of long bones. The symmetric distribution, lack of bone destruction, and location distinguishes it from metastatic disease, which is more often seen in ribs, vertebral bodies, and the diaphysis of long bones.

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