Timothy F. Kirn

RENO, NEV. — Glyburide may successfully control gestational diabetes in all but about 20% of patients, and a failed trial of glyburide appears to cause no long-term harm, Meredith Rochon, M.D., of the department of obstetrics, gynecology, and reproductive science at Mount Sinai School of Medicine, New York, and colleagues reported.

Glyburide treatment has been shown to be effective and safe for gestational diabetes.

The investigators reviewed the records of all patients with class A2 gestational diabetes treated with glyburide at a diabetes clinic over a period of 2 years to ensure that there were no adverse effects when the treatment failed.

The study found no reason to avoid using glyburide instead of insulin as first-line therapy, the researchers wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Of 83 patients identified, 18 (22%) were patients who underwent a trial of glyburide but failed to reach the target of fasting and postprandial-glucose levels of 60-90 mg/dL and 120 mg/dL, respectively, even when treated with a dose of 20 mg daily. Consequently, those patients were switched to insulin.

Despite their initial lack of blood glucose control, the pregnancy outcomes in the patients who failed treatment—including birth weight, mode of delivery, and incidence of macrosomia—were no different from those who were successfully managed on glyburide.

The sole difference in outcome was in the patients successfully treated with glyburide. Those patients had more neonates who required admission to the neonatal intensive care unit (NICU) than did the women who had been switched to insulin (35% vs. 11%). The most common reason for the admission was hypoglycemia (10 of 23 admissions).

In an interview, Dr. Rochon said the finding was a surprise and something of a mystery, since glyburide does not cross the placenta, and previous studies have not noted this potential association.

The hypoglycemia was not considered by the investigators to be a serious adverse effect because it was transient in all cases.

However, if it proves to be true that glyburide treatment does produce a higher rate of hypoglycemic neonates who need NICU admission, it may have significant cost implications, Dr. Rochon said.

Source: Dr. Daneshpazhooh

RENO, NEV. — Glyburide may successfully control gestational diabetes in all but about 20% of patients, and a failed trial of glyburide appears to cause no long-term harm, Meredith Rochon, M.D., of the department of obstetrics, gynecology, and reproductive science at Mount Sinai School of Medicine, New York, and colleagues reported.

Glyburide treatment has been shown to be effective and safe for gestational diabetes.

The investigators reviewed the records of all patients with class A2 gestational diabetes treated with glyburide at a diabetes clinic over a period of 2 years to ensure that there were no adverse effects when the treatment failed.

The study found no reason to avoid using glyburide instead of insulin as first-line therapy, the researchers wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Of 83 patients identified, 18 (22%) were patients who underwent a trial of glyburide but failed to reach the target of fasting and postprandial-glucose levels of 60-90 mg/dL and 120 mg/dL, respectively, even when treated with a dose of 20 mg daily. Consequently, those patients were switched to insulin.

Despite their initial lack of blood glucose control, the pregnancy outcomes in the patients who failed treatment—including birth weight, mode of delivery, and incidence of macrosomia—were no different from those who were successfully managed on glyburide.

The sole difference in outcome was in the patients successfully treated with glyburide. Those patients had more neonates who required admission to the neonatal intensive care unit (NICU) than did the women who had been switched to insulin (35% vs. 11%). The most common reason for the admission was hypoglycemia (10 of 23 admissions).

In an interview, Dr. Rochon said the finding was a surprise and something of a mystery, since glyburide does not cross the placenta, and previous studies have not noted this potential association.

The hypoglycemia was not considered by the investigators to be a serious adverse effect because it was transient in all cases.

However, if it proves to be true that glyburide treatment does produce a higher rate of hypoglycemic neonates who need NICU admission, it may have significant cost implications, Dr. Rochon said.

Source: Dr. Daneshpazhooh

RENO, NEV. — Glyburide may successfully control gestational diabetes in all but about 20% of patients, and a failed trial of glyburide appears to cause no long-term harm, Meredith Rochon, M.D., of the department of obstetrics, gynecology, and reproductive science at Mount Sinai School of Medicine, New York, and colleagues reported.

Glyburide treatment has been shown to be effective and safe for gestational diabetes.

The investigators reviewed the records of all patients with class A2 gestational diabetes treated with glyburide at a diabetes clinic over a period of 2 years to ensure that there were no adverse effects when the treatment failed.

The study found no reason to avoid using glyburide instead of insulin as first-line therapy, the researchers wrote in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Of 83 patients identified, 18 (22%) were patients who underwent a trial of glyburide but failed to reach the target of fasting and postprandial-glucose levels of 60-90 mg/dL and 120 mg/dL, respectively, even when treated with a dose of 20 mg daily. Consequently, those patients were switched to insulin.

Despite their initial lack of blood glucose control, the pregnancy outcomes in the patients who failed treatment—including birth weight, mode of delivery, and incidence of macrosomia—were no different from those who were successfully managed on glyburide.

The sole difference in outcome was in the patients successfully treated with glyburide. Those patients had more neonates who required admission to the neonatal intensive care unit (NICU) than did the women who had been switched to insulin (35% vs. 11%). The most common reason for the admission was hypoglycemia (10 of 23 admissions).

In an interview, Dr. Rochon said the finding was a surprise and something of a mystery, since glyburide does not cross the placenta, and previous studies have not noted this potential association.

The hypoglycemia was not considered by the investigators to be a serious adverse effect because it was transient in all cases.

However, if it proves to be true that glyburide treatment does produce a higher rate of hypoglycemic neonates who need NICU admission, it may have significant cost implications, Dr. Rochon said.

Source: Dr. Daneshpazhooh

RENO, NEV. — Preterm twins conceived through assisted reproductive techniques are more likely than twins conceived naturally to have respiratory distress syndrome and patent ductus arteriosus at delivery, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Nils Stenman, M.D., of the University of Pennsylvania, Philadelphia, and his colleagues compared neonatal outcomes of 238 preterm twins conceived using assisted reproductive techniques (ART) with those of 718 preterm twins that were naturally conceived. All twins were born at 24-35 weeks' gestation at one hospital over a 5-year period.

Mean birth weight and mean gestational age at delivery were the same for both groups of twins, as were rates of sepsis, necrotizing enterocolitis, intraventricular hemorrhage rates, and neonatal mortality.

However, the ART-conceived twins had a higher incidence of respiratory distress syndrome (70% versus 45%) and patent ductus arteriosus (63% versus 38%).

Mothers of the ART-conceived twins were more likely to be older, nulliparous, and white. However, there is no explanation for why the ART-conceived neonates would have a higher incidence of respiratory distress syndrome or patent ductus arteriosus, the researchers said.

A recent metaanalysis of studies of neonatal outcome in ART concluded that while singleton neonates conceived with ART tend to be born earlier and with lower birth weight and have worse outcomes, the same is not true for twins (BMJ [online] 2004;328:261). The studies in the analysis tended not to look as specifically at different neonatal outcomes in preterm twins as did the current study, or they looked at different outcomes, Dr. Stenman and colleagues said.

The neonatal mortality in the current study was 2% for both groups of twins.

RENO, NEV. — Preterm twins conceived through assisted reproductive techniques are more likely than twins conceived naturally to have respiratory distress syndrome and patent ductus arteriosus at delivery, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Nils Stenman, M.D., of the University of Pennsylvania, Philadelphia, and his colleagues compared neonatal outcomes of 238 preterm twins conceived using assisted reproductive techniques (ART) with those of 718 preterm twins that were naturally conceived. All twins were born at 24-35 weeks' gestation at one hospital over a 5-year period.

Mean birth weight and mean gestational age at delivery were the same for both groups of twins, as were rates of sepsis, necrotizing enterocolitis, intraventricular hemorrhage rates, and neonatal mortality.

However, the ART-conceived twins had a higher incidence of respiratory distress syndrome (70% versus 45%) and patent ductus arteriosus (63% versus 38%).

Mothers of the ART-conceived twins were more likely to be older, nulliparous, and white. However, there is no explanation for why the ART-conceived neonates would have a higher incidence of respiratory distress syndrome or patent ductus arteriosus, the researchers said.

A recent metaanalysis of studies of neonatal outcome in ART concluded that while singleton neonates conceived with ART tend to be born earlier and with lower birth weight and have worse outcomes, the same is not true for twins (BMJ [online] 2004;328:261). The studies in the analysis tended not to look as specifically at different neonatal outcomes in preterm twins as did the current study, or they looked at different outcomes, Dr. Stenman and colleagues said.

The neonatal mortality in the current study was 2% for both groups of twins.

RENO, NEV. — Preterm twins conceived through assisted reproductive techniques are more likely than twins conceived naturally to have respiratory distress syndrome and patent ductus arteriosus at delivery, investigators reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Nils Stenman, M.D., of the University of Pennsylvania, Philadelphia, and his colleagues compared neonatal outcomes of 238 preterm twins conceived using assisted reproductive techniques (ART) with those of 718 preterm twins that were naturally conceived. All twins were born at 24-35 weeks' gestation at one hospital over a 5-year period.

Mean birth weight and mean gestational age at delivery were the same for both groups of twins, as were rates of sepsis, necrotizing enterocolitis, intraventricular hemorrhage rates, and neonatal mortality.

However, the ART-conceived twins had a higher incidence of respiratory distress syndrome (70% versus 45%) and patent ductus arteriosus (63% versus 38%).

Mothers of the ART-conceived twins were more likely to be older, nulliparous, and white. However, there is no explanation for why the ART-conceived neonates would have a higher incidence of respiratory distress syndrome or patent ductus arteriosus, the researchers said.

A recent metaanalysis of studies of neonatal outcome in ART concluded that while singleton neonates conceived with ART tend to be born earlier and with lower birth weight and have worse outcomes, the same is not true for twins (BMJ [online] 2004;328:261). The studies in the analysis tended not to look as specifically at different neonatal outcomes in preterm twins as did the current study, or they looked at different outcomes, Dr. Stenman and colleagues said.

The neonatal mortality in the current study was 2% for both groups of twins.

RENO, NEV. — An increased nuchal translucency thickness can predict congenital heart disease in a euploid fetus and indicate pregnancies that should be referred for fetal echocardiography, according to data from the large First and Second Trimester Evaluation of Risk for Aneuploidy study.

When nuchal translucency thickness found on ultrasound in the first trimester is at least 2 multiples of the appropriate gestational median (MoM), the risk of a major congenital heart defect is 14 times higher than normal, Lynn L. Simpson, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Moreover, as the MoM increased, so did the likelihood of having such a defect: When the MoM was at least 3, the risk was 51 times higher than normal.

Overall, the sensitivity of nuchal translucency screening for major congenital heart defects is low (less than 20%) and therefore is not a good screening test on its own, said Dr. Simpson of the department of obstetrics and gynecology at Columbia University, New York.

However, when nuchal translucency screening is added to the standard first trimester evaluation, it can pick up cases of major congenital heart defects that otherwise would have been missed.

With the cutoff of a nuchal thickness that is at least 2 MoM, about 1% of all infants would end up possibly being referred for fetal echocardiography, Dr. Simpson said.

The First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) study had 33,968 patients enrolled whose records could be reviewed for cardiac outcome. Among those, there were 195 cases of congenital heart disease (an incidence of 5.7/1,000), of which 43 were defined by the authors as major defects. Major defects were those associated with a poor perinatal outcome or ductal dependency after birth.

The majority of cases of major cardiac defect occurred in fetuses with a nuchal translucency thickness less than the 2 MoM cutoff (81%), hence the low sensitivity of the test. But because the specificity of the test is very high in the absence of aneuploidy, the negative predictive value of the test at the 2 MoM cutoff is greater than 99%, Dr. Simpson said.

RENO, NEV. — An increased nuchal translucency thickness can predict congenital heart disease in a euploid fetus and indicate pregnancies that should be referred for fetal echocardiography, according to data from the large First and Second Trimester Evaluation of Risk for Aneuploidy study.

When nuchal translucency thickness found on ultrasound in the first trimester is at least 2 multiples of the appropriate gestational median (MoM), the risk of a major congenital heart defect is 14 times higher than normal, Lynn L. Simpson, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Moreover, as the MoM increased, so did the likelihood of having such a defect: When the MoM was at least 3, the risk was 51 times higher than normal.

Overall, the sensitivity of nuchal translucency screening for major congenital heart defects is low (less than 20%) and therefore is not a good screening test on its own, said Dr. Simpson of the department of obstetrics and gynecology at Columbia University, New York.

However, when nuchal translucency screening is added to the standard first trimester evaluation, it can pick up cases of major congenital heart defects that otherwise would have been missed.

With the cutoff of a nuchal thickness that is at least 2 MoM, about 1% of all infants would end up possibly being referred for fetal echocardiography, Dr. Simpson said.

The First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) study had 33,968 patients enrolled whose records could be reviewed for cardiac outcome. Among those, there were 195 cases of congenital heart disease (an incidence of 5.7/1,000), of which 43 were defined by the authors as major defects. Major defects were those associated with a poor perinatal outcome or ductal dependency after birth.

The majority of cases of major cardiac defect occurred in fetuses with a nuchal translucency thickness less than the 2 MoM cutoff (81%), hence the low sensitivity of the test. But because the specificity of the test is very high in the absence of aneuploidy, the negative predictive value of the test at the 2 MoM cutoff is greater than 99%, Dr. Simpson said.

RENO, NEV. — An increased nuchal translucency thickness can predict congenital heart disease in a euploid fetus and indicate pregnancies that should be referred for fetal echocardiography, according to data from the large First and Second Trimester Evaluation of Risk for Aneuploidy study.

When nuchal translucency thickness found on ultrasound in the first trimester is at least 2 multiples of the appropriate gestational median (MoM), the risk of a major congenital heart defect is 14 times higher than normal, Lynn L. Simpson, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Moreover, as the MoM increased, so did the likelihood of having such a defect: When the MoM was at least 3, the risk was 51 times higher than normal.

Overall, the sensitivity of nuchal translucency screening for major congenital heart defects is low (less than 20%) and therefore is not a good screening test on its own, said Dr. Simpson of the department of obstetrics and gynecology at Columbia University, New York.

However, when nuchal translucency screening is added to the standard first trimester evaluation, it can pick up cases of major congenital heart defects that otherwise would have been missed.

With the cutoff of a nuchal thickness that is at least 2 MoM, about 1% of all infants would end up possibly being referred for fetal echocardiography, Dr. Simpson said.

The First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) study had 33,968 patients enrolled whose records could be reviewed for cardiac outcome. Among those, there were 195 cases of congenital heart disease (an incidence of 5.7/1,000), of which 43 were defined by the authors as major defects. Major defects were those associated with a poor perinatal outcome or ductal dependency after birth.

The majority of cases of major cardiac defect occurred in fetuses with a nuchal translucency thickness less than the 2 MoM cutoff (81%), hence the low sensitivity of the test. But because the specificity of the test is very high in the absence of aneuploidy, the negative predictive value of the test at the 2 MoM cutoff is greater than 99%, Dr. Simpson said.

RENO, NEV. — Saline amnioinfusion for labors with thickly meconium-stained amniotic fluid does not prevent meconium aspiration syndrome, William D. Fraser, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

In an international, randomized, prospective trial of laboring women with thickly stained fluid, there was a 4% rate of moderate or severe meconium aspiration syndrome or death in 985 neonates born after amnioinfusion, compared with a 3% rate in 988 neonates born to women who did not undergo the procedure, said Dr. Fraser of the University of Montreal.

“Our evidence does not support amnioinfusion,” Dr. Fraser said.

The findings of the current study run counter to those of some previous studies, including a recent metaanalysis of 12 trials, which concluded that the practice reduces by two-thirds the rate of meconium aspiration syndrome.

The metaanalysis, however, was dominated by a single study conducted in Zimbabwe, where modern labor and delivery practices usually aren't implemented, Dr. Fraser said, adding that the other studies that showed a positive benefit from amnioinfusion were much smaller than his.

His study was conducted in 56 different centers in 13 countries, including South Africa, Canada, and the United States, with the majority of patients enrolled in South Africa. There was no significant difference in results obtained from the various countries, Dr. Fraser said.

The study participants were at greater than 36 weeks' gestation and were stratified for randomization to one of two groups: one group with fetal heart-rate decelerations and one without decelerations. There was no significant difference in results between these two groups.

The investigators also saw a slight trend toward cesarean delivery in the group that received amnioinfusion (32% versus 29%), Dr. Fraser noted.

RENO, NEV. — Saline amnioinfusion for labors with thickly meconium-stained amniotic fluid does not prevent meconium aspiration syndrome, William D. Fraser, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

In an international, randomized, prospective trial of laboring women with thickly stained fluid, there was a 4% rate of moderate or severe meconium aspiration syndrome or death in 985 neonates born after amnioinfusion, compared with a 3% rate in 988 neonates born to women who did not undergo the procedure, said Dr. Fraser of the University of Montreal.

“Our evidence does not support amnioinfusion,” Dr. Fraser said.

The findings of the current study run counter to those of some previous studies, including a recent metaanalysis of 12 trials, which concluded that the practice reduces by two-thirds the rate of meconium aspiration syndrome.

The metaanalysis, however, was dominated by a single study conducted in Zimbabwe, where modern labor and delivery practices usually aren't implemented, Dr. Fraser said, adding that the other studies that showed a positive benefit from amnioinfusion were much smaller than his.

His study was conducted in 56 different centers in 13 countries, including South Africa, Canada, and the United States, with the majority of patients enrolled in South Africa. There was no significant difference in results obtained from the various countries, Dr. Fraser said.

The study participants were at greater than 36 weeks' gestation and were stratified for randomization to one of two groups: one group with fetal heart-rate decelerations and one without decelerations. There was no significant difference in results between these two groups.

The investigators also saw a slight trend toward cesarean delivery in the group that received amnioinfusion (32% versus 29%), Dr. Fraser noted.

RENO, NEV. — Saline amnioinfusion for labors with thickly meconium-stained amniotic fluid does not prevent meconium aspiration syndrome, William D. Fraser, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

In an international, randomized, prospective trial of laboring women with thickly stained fluid, there was a 4% rate of moderate or severe meconium aspiration syndrome or death in 985 neonates born after amnioinfusion, compared with a 3% rate in 988 neonates born to women who did not undergo the procedure, said Dr. Fraser of the University of Montreal.

“Our evidence does not support amnioinfusion,” Dr. Fraser said.

The findings of the current study run counter to those of some previous studies, including a recent metaanalysis of 12 trials, which concluded that the practice reduces by two-thirds the rate of meconium aspiration syndrome.

The metaanalysis, however, was dominated by a single study conducted in Zimbabwe, where modern labor and delivery practices usually aren't implemented, Dr. Fraser said, adding that the other studies that showed a positive benefit from amnioinfusion were much smaller than his.

His study was conducted in 56 different centers in 13 countries, including South Africa, Canada, and the United States, with the majority of patients enrolled in South Africa. There was no significant difference in results obtained from the various countries, Dr. Fraser said.

The study participants were at greater than 36 weeks' gestation and were stratified for randomization to one of two groups: one group with fetal heart-rate decelerations and one without decelerations. There was no significant difference in results between these two groups.

The investigators also saw a slight trend toward cesarean delivery in the group that received amnioinfusion (32% versus 29%), Dr. Fraser noted.

RENO, NEV. — Metformin controlled blood glucose levels as well as insulin in patients with class A2 gestational diabetes, and was not associated with any adverse maternal or neonatal outcomes, according to a randomized trial with 63 patients.

“We found that metformin appears to be an acceptable way to achieve glucose homeostasis in the A2 diabetes patient,” Christian Briery, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

The study enrolled pregnant patients who were at greater than 11 weeks' gestation but less than 35 weeks' gestation. The women received a starting dose of insulin of 0.7 U/kg daily, in three doses (31 patients) or 500 mg metformin twice daily (32 patients). The patients were then monitored weekly to see that they achieved a postprandial blood glucose level of less than 120 mg/dL and a fasting glucose level of 60–90 mg/dL, said Dr. Briery of the University of Mississippi Medical Center, Jackson.

In blood glucose measurements taken by the patients at home, the mean fasting glucose level was 96.8 mg/dL in the insulin-treated patients and 92.6 mg/dL in the metformin group.

Similarly, the mean postprandial glucose levels ranged in the insulin group from 104.4 mg/dL 2 hours after breakfast to 112.5 mg/dL 2 hours after lunch, while they ranged in the metformin group from 104.6 mg/dL 2 hours after breakfast to 108.1 mg/dL 2 hours after dinner.

The maternal and delivery measures considered included abdominal delivery, gestational age at delivery, shoulder dystocia, and postpartum hemorrhage. There was no difference in those measures between the groups. There was one intrauterine fetal death in the metformin group from a “cord problem” that was determined not to be related to treatment because the mother's glucose levels were consistently normal, Dr. Briery said.

Neonatal outcomes that were considered include birth weight, 5-minute Apgar score, respiratory distress syndrome, neonatal hypoglycemia, and neonatal ICU admission. Again, there was no difference in the groups.

A previous study of metformin use in pregnancy looked specifically at patients with polycystic ovary syndrome, who conceived while on the drug, and it likewise found no indication of any adverse effects that might be associated with the agent.

RENO, NEV. — Metformin controlled blood glucose levels as well as insulin in patients with class A2 gestational diabetes, and was not associated with any adverse maternal or neonatal outcomes, according to a randomized trial with 63 patients.

“We found that metformin appears to be an acceptable way to achieve glucose homeostasis in the A2 diabetes patient,” Christian Briery, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

The study enrolled pregnant patients who were at greater than 11 weeks' gestation but less than 35 weeks' gestation. The women received a starting dose of insulin of 0.7 U/kg daily, in three doses (31 patients) or 500 mg metformin twice daily (32 patients). The patients were then monitored weekly to see that they achieved a postprandial blood glucose level of less than 120 mg/dL and a fasting glucose level of 60–90 mg/dL, said Dr. Briery of the University of Mississippi Medical Center, Jackson.

In blood glucose measurements taken by the patients at home, the mean fasting glucose level was 96.8 mg/dL in the insulin-treated patients and 92.6 mg/dL in the metformin group.

Similarly, the mean postprandial glucose levels ranged in the insulin group from 104.4 mg/dL 2 hours after breakfast to 112.5 mg/dL 2 hours after lunch, while they ranged in the metformin group from 104.6 mg/dL 2 hours after breakfast to 108.1 mg/dL 2 hours after dinner.

The maternal and delivery measures considered included abdominal delivery, gestational age at delivery, shoulder dystocia, and postpartum hemorrhage. There was no difference in those measures between the groups. There was one intrauterine fetal death in the metformin group from a “cord problem” that was determined not to be related to treatment because the mother's glucose levels were consistently normal, Dr. Briery said.

Neonatal outcomes that were considered include birth weight, 5-minute Apgar score, respiratory distress syndrome, neonatal hypoglycemia, and neonatal ICU admission. Again, there was no difference in the groups.

A previous study of metformin use in pregnancy looked specifically at patients with polycystic ovary syndrome, who conceived while on the drug, and it likewise found no indication of any adverse effects that might be associated with the agent.

RENO, NEV. — Metformin controlled blood glucose levels as well as insulin in patients with class A2 gestational diabetes, and was not associated with any adverse maternal or neonatal outcomes, according to a randomized trial with 63 patients.

“We found that metformin appears to be an acceptable way to achieve glucose homeostasis in the A2 diabetes patient,” Christian Briery, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

The study enrolled pregnant patients who were at greater than 11 weeks' gestation but less than 35 weeks' gestation. The women received a starting dose of insulin of 0.7 U/kg daily, in three doses (31 patients) or 500 mg metformin twice daily (32 patients). The patients were then monitored weekly to see that they achieved a postprandial blood glucose level of less than 120 mg/dL and a fasting glucose level of 60–90 mg/dL, said Dr. Briery of the University of Mississippi Medical Center, Jackson.

In blood glucose measurements taken by the patients at home, the mean fasting glucose level was 96.8 mg/dL in the insulin-treated patients and 92.6 mg/dL in the metformin group.

Similarly, the mean postprandial glucose levels ranged in the insulin group from 104.4 mg/dL 2 hours after breakfast to 112.5 mg/dL 2 hours after lunch, while they ranged in the metformin group from 104.6 mg/dL 2 hours after breakfast to 108.1 mg/dL 2 hours after dinner.

The maternal and delivery measures considered included abdominal delivery, gestational age at delivery, shoulder dystocia, and postpartum hemorrhage. There was no difference in those measures between the groups. There was one intrauterine fetal death in the metformin group from a “cord problem” that was determined not to be related to treatment because the mother's glucose levels were consistently normal, Dr. Briery said.

Neonatal outcomes that were considered include birth weight, 5-minute Apgar score, respiratory distress syndrome, neonatal hypoglycemia, and neonatal ICU admission. Again, there was no difference in the groups.

A previous study of metformin use in pregnancy looked specifically at patients with polycystic ovary syndrome, who conceived while on the drug, and it likewise found no indication of any adverse effects that might be associated with the agent.

SNOWMASS, COLO. — A gonadotropin-releasing hormone agonist can prevent ovarian failure in lupus patients on cyclophosphamide, according to a small, case-control study conducted at the University of Michigan.

Evidence suggests that by the time a patient with lupus has taken a total 30 g of cyclophosphamide (equivalent to about a year of treatment at 100 mg a day) the rate of ovarian failure is about 70%, W. Joseph McCune, M.D., said at a symposium sponsored by the American College of Rheumatology.

The regimen can also result in cervical dysplasia, which is why patients started on cyclophosphamide should have a Pap smear early in the course of their treatment, advised Dr. McCune, a lupus expert and the codirector of the nephrology/rheumatology vasculitis clinic at the University of Michigan, Ann Arbor.

In their prospective study, Dr. McCune and his colleagues enrolled 40 patients with lupus nephritis or severe systemic lupus erythematosus (SLE), whose average age was 23 years. Their regimen was sequential, with monthly intravenous cyclophosphamide for 6 months followed by a switch to azathioprine and then mycophenolate mofetil. If the disease did not respond after 6 months of cyclophosphamide, patients were treated with 4 more months of cyclophosphamide.

Among the 20 patients treated with leuprolide acetate in depot suspension (Lupron, 3.75 mg a month), only 1 developed ovarian failure at the end of 3 years, compared with 6 of 20 matched women who did not receive GnRH.

Treatment-group patients received their first monthly injection of depot leuprolide acetate after receiving their first dose of cyclophosphamide, and the hormone agonist therapy was readministered after each course of cyclophosphamide—including when the patients had a flare after initial treatment and had to go back on the alkylating agent.

Patients who developed menopausal symptoms from the GnRH agonist were given an estrogen patch, together with depot medroxyprogesterone acetate (Depo Provera) to prevent a pregnancy.

The average cumulative dose of cyclophosphamide received by the patients and controls during the study was 12.9 g.

“These patients were relatively young, their cumulative dose was relatively low, and yet they still appeared to benefit from” leuprolide treatment, Dr. McCune said. “A randomized controlled trial obviously would be more convincing, and we are going to try to do that. But, this study suggests that this approach benefits patients, particularly if they are going to have relapses and if they are young.”

Dr. McCune noted that his study did not address those patients who are on oral cyclophosphamide, but he predicted that leuprolide treatment would be of greater merit in those patients because they generally are exposed to higher cumulative doses.

Dr. McCune added that the increased risk of cervical dysplasia associated with cyclophosphamide use has been documented at his own institution. In that report, 61 patients with SLE were given cervical smears at baseline and then followed annually or as practice indicated for 7 years (J. Rheumatol. 2004;31:1763-7).

At enrollment, patients were excluded from the study if they had an abnormal smear or a history of cervical dysplasia. The study also did not enroll any patients on daily oral cyclophosphamide. However, use of monthly intravenous cyclophosphamide was permitted.

At 3 years, there were no cases of biopsy-proven cervical intraepithelial neoplasia in those who had taken only prednisone (23 patients) or prednisone and azathioprine (four patients). But there were two cases among eight patients treated with intravenous cyclophosphamide alone, and four cases among the 26 patients treated with intravenous cyclophosphamide together with azathioprine and/or prednisone.

In 3-7 years of follow-up, fewer cases of dysplasia occurred. Three of the 45 patients who remained in the study developed cervical intraepithelial neoplasia, and none of these cases occurred among patients who had received prednisone alone.

Overall, most patients with abnormal smears had resolution of their cervical dysplasia, but three patients required surgery and one continued to have persistently abnormal smears throughout the 7-year follow-up period.

SNOWMASS, COLO. — A gonadotropin-releasing hormone agonist can prevent ovarian failure in lupus patients on cyclophosphamide, according to a small, case-control study conducted at the University of Michigan.

Evidence suggests that by the time a patient with lupus has taken a total 30 g of cyclophosphamide (equivalent to about a year of treatment at 100 mg a day) the rate of ovarian failure is about 70%, W. Joseph McCune, M.D., said at a symposium sponsored by the American College of Rheumatology.

The regimen can also result in cervical dysplasia, which is why patients started on cyclophosphamide should have a Pap smear early in the course of their treatment, advised Dr. McCune, a lupus expert and the codirector of the nephrology/rheumatology vasculitis clinic at the University of Michigan, Ann Arbor.

In their prospective study, Dr. McCune and his colleagues enrolled 40 patients with lupus nephritis or severe systemic lupus erythematosus (SLE), whose average age was 23 years. Their regimen was sequential, with monthly intravenous cyclophosphamide for 6 months followed by a switch to azathioprine and then mycophenolate mofetil. If the disease did not respond after 6 months of cyclophosphamide, patients were treated with 4 more months of cyclophosphamide.

Among the 20 patients treated with leuprolide acetate in depot suspension (Lupron, 3.75 mg a month), only 1 developed ovarian failure at the end of 3 years, compared with 6 of 20 matched women who did not receive GnRH.

Treatment-group patients received their first monthly injection of depot leuprolide acetate after receiving their first dose of cyclophosphamide, and the hormone agonist therapy was readministered after each course of cyclophosphamide—including when the patients had a flare after initial treatment and had to go back on the alkylating agent.

Patients who developed menopausal symptoms from the GnRH agonist were given an estrogen patch, together with depot medroxyprogesterone acetate (Depo Provera) to prevent a pregnancy.

The average cumulative dose of cyclophosphamide received by the patients and controls during the study was 12.9 g.

“These patients were relatively young, their cumulative dose was relatively low, and yet they still appeared to benefit from” leuprolide treatment, Dr. McCune said. “A randomized controlled trial obviously would be more convincing, and we are going to try to do that. But, this study suggests that this approach benefits patients, particularly if they are going to have relapses and if they are young.”

Dr. McCune noted that his study did not address those patients who are on oral cyclophosphamide, but he predicted that leuprolide treatment would be of greater merit in those patients because they generally are exposed to higher cumulative doses.

Dr. McCune added that the increased risk of cervical dysplasia associated with cyclophosphamide use has been documented at his own institution. In that report, 61 patients with SLE were given cervical smears at baseline and then followed annually or as practice indicated for 7 years (J. Rheumatol. 2004;31:1763-7).

At enrollment, patients were excluded from the study if they had an abnormal smear or a history of cervical dysplasia. The study also did not enroll any patients on daily oral cyclophosphamide. However, use of monthly intravenous cyclophosphamide was permitted.

At 3 years, there were no cases of biopsy-proven cervical intraepithelial neoplasia in those who had taken only prednisone (23 patients) or prednisone and azathioprine (four patients). But there were two cases among eight patients treated with intravenous cyclophosphamide alone, and four cases among the 26 patients treated with intravenous cyclophosphamide together with azathioprine and/or prednisone.

In 3-7 years of follow-up, fewer cases of dysplasia occurred. Three of the 45 patients who remained in the study developed cervical intraepithelial neoplasia, and none of these cases occurred among patients who had received prednisone alone.

Overall, most patients with abnormal smears had resolution of their cervical dysplasia, but three patients required surgery and one continued to have persistently abnormal smears throughout the 7-year follow-up period.

SNOWMASS, COLO. — A gonadotropin-releasing hormone agonist can prevent ovarian failure in lupus patients on cyclophosphamide, according to a small, case-control study conducted at the University of Michigan.

Evidence suggests that by the time a patient with lupus has taken a total 30 g of cyclophosphamide (equivalent to about a year of treatment at 100 mg a day) the rate of ovarian failure is about 70%, W. Joseph McCune, M.D., said at a symposium sponsored by the American College of Rheumatology.

The regimen can also result in cervical dysplasia, which is why patients started on cyclophosphamide should have a Pap smear early in the course of their treatment, advised Dr. McCune, a lupus expert and the codirector of the nephrology/rheumatology vasculitis clinic at the University of Michigan, Ann Arbor.

In their prospective study, Dr. McCune and his colleagues enrolled 40 patients with lupus nephritis or severe systemic lupus erythematosus (SLE), whose average age was 23 years. Their regimen was sequential, with monthly intravenous cyclophosphamide for 6 months followed by a switch to azathioprine and then mycophenolate mofetil. If the disease did not respond after 6 months of cyclophosphamide, patients were treated with 4 more months of cyclophosphamide.

Among the 20 patients treated with leuprolide acetate in depot suspension (Lupron, 3.75 mg a month), only 1 developed ovarian failure at the end of 3 years, compared with 6 of 20 matched women who did not receive GnRH.

Treatment-group patients received their first monthly injection of depot leuprolide acetate after receiving their first dose of cyclophosphamide, and the hormone agonist therapy was readministered after each course of cyclophosphamide—including when the patients had a flare after initial treatment and had to go back on the alkylating agent.

Patients who developed menopausal symptoms from the GnRH agonist were given an estrogen patch, together with depot medroxyprogesterone acetate (Depo Provera) to prevent a pregnancy.

The average cumulative dose of cyclophosphamide received by the patients and controls during the study was 12.9 g.

“These patients were relatively young, their cumulative dose was relatively low, and yet they still appeared to benefit from” leuprolide treatment, Dr. McCune said. “A randomized controlled trial obviously would be more convincing, and we are going to try to do that. But, this study suggests that this approach benefits patients, particularly if they are going to have relapses and if they are young.”

Dr. McCune noted that his study did not address those patients who are on oral cyclophosphamide, but he predicted that leuprolide treatment would be of greater merit in those patients because they generally are exposed to higher cumulative doses.

Dr. McCune added that the increased risk of cervical dysplasia associated with cyclophosphamide use has been documented at his own institution. In that report, 61 patients with SLE were given cervical smears at baseline and then followed annually or as practice indicated for 7 years (J. Rheumatol. 2004;31:1763-7).

At enrollment, patients were excluded from the study if they had an abnormal smear or a history of cervical dysplasia. The study also did not enroll any patients on daily oral cyclophosphamide. However, use of monthly intravenous cyclophosphamide was permitted.

At 3 years, there were no cases of biopsy-proven cervical intraepithelial neoplasia in those who had taken only prednisone (23 patients) or prednisone and azathioprine (four patients). But there were two cases among eight patients treated with intravenous cyclophosphamide alone, and four cases among the 26 patients treated with intravenous cyclophosphamide together with azathioprine and/or prednisone.

In 3-7 years of follow-up, fewer cases of dysplasia occurred. Three of the 45 patients who remained in the study developed cervical intraepithelial neoplasia, and none of these cases occurred among patients who had received prednisone alone.

Overall, most patients with abnormal smears had resolution of their cervical dysplasia, but three patients required surgery and one continued to have persistently abnormal smears throughout the 7-year follow-up period.

RENO, NEV. — Obstetricians are delivering more sets of twins early—a trend that is improving neonatal mortality, Cande V. Ananth, Ph.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Black twins, however, are not benefiting equally by this more aggressive practice. According to federal statistics, 44% of white and 53% of black twin births occurred before 37 weeks' gestation in 1989. In 2000, those percentages rose to 57% for whites and 61% for blacks.

These increases largely reflected obstetricians' decisions to deliver twin infants early—but more so among whites, said Dr. Ananth of the department of obstetrics and gynecology at the University of Medicine and Dentistry of New Jersey, New Brunswick.

Medically indicated preterm delivery among white twins rose 51% for the 11-year period, and 33% among black twins.

Among the whites, this medically indicated early delivery significantly affected perinatal mortality, defined as stillbirth after 22 weeks' gestation or neonatal mortality within 28 days of birth.

Perinatal mortality decreased by 41% during the period overall. It fell by 31% among the medically indicated deliveries, and, because of the large increase in medically indicated preterm births among whites, that 37% reduction accounted for 10% of the overall decline.

Among the black twins, perinatal mortality declined 37% overall and 34% among medically indicated preterm births. However, largely because the increase in medically indicated preterm deliveries was less in blacks, that decline accounted for only 5% of the overall drop.

A reduction in mortality tied to births following premature rupture of membranes was more important among blacks.

The study also found that preterm birth following spontaneous onset of labor rose 3% among white twins and fell 1% among black twins. Preterm birth following premature rupture of membranes fell 3% among whites and 7% among blacks.

RENO, NEV. — Obstetricians are delivering more sets of twins early—a trend that is improving neonatal mortality, Cande V. Ananth, Ph.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Black twins, however, are not benefiting equally by this more aggressive practice. According to federal statistics, 44% of white and 53% of black twin births occurred before 37 weeks' gestation in 1989. In 2000, those percentages rose to 57% for whites and 61% for blacks.

These increases largely reflected obstetricians' decisions to deliver twin infants early—but more so among whites, said Dr. Ananth of the department of obstetrics and gynecology at the University of Medicine and Dentistry of New Jersey, New Brunswick.

Medically indicated preterm delivery among white twins rose 51% for the 11-year period, and 33% among black twins.

Among the whites, this medically indicated early delivery significantly affected perinatal mortality, defined as stillbirth after 22 weeks' gestation or neonatal mortality within 28 days of birth.

Perinatal mortality decreased by 41% during the period overall. It fell by 31% among the medically indicated deliveries, and, because of the large increase in medically indicated preterm births among whites, that 37% reduction accounted for 10% of the overall decline.

Among the black twins, perinatal mortality declined 37% overall and 34% among medically indicated preterm births. However, largely because the increase in medically indicated preterm deliveries was less in blacks, that decline accounted for only 5% of the overall drop.

A reduction in mortality tied to births following premature rupture of membranes was more important among blacks.

The study also found that preterm birth following spontaneous onset of labor rose 3% among white twins and fell 1% among black twins. Preterm birth following premature rupture of membranes fell 3% among whites and 7% among blacks.

RENO, NEV. — Obstetricians are delivering more sets of twins early—a trend that is improving neonatal mortality, Cande V. Ananth, Ph.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Black twins, however, are not benefiting equally by this more aggressive practice. According to federal statistics, 44% of white and 53% of black twin births occurred before 37 weeks' gestation in 1989. In 2000, those percentages rose to 57% for whites and 61% for blacks.

These increases largely reflected obstetricians' decisions to deliver twin infants early—but more so among whites, said Dr. Ananth of the department of obstetrics and gynecology at the University of Medicine and Dentistry of New Jersey, New Brunswick.

Medically indicated preterm delivery among white twins rose 51% for the 11-year period, and 33% among black twins.

Among the whites, this medically indicated early delivery significantly affected perinatal mortality, defined as stillbirth after 22 weeks' gestation or neonatal mortality within 28 days of birth.

Perinatal mortality decreased by 41% during the period overall. It fell by 31% among the medically indicated deliveries, and, because of the large increase in medically indicated preterm births among whites, that 37% reduction accounted for 10% of the overall decline.

Among the black twins, perinatal mortality declined 37% overall and 34% among medically indicated preterm births. However, largely because the increase in medically indicated preterm deliveries was less in blacks, that decline accounted for only 5% of the overall drop.

A reduction in mortality tied to births following premature rupture of membranes was more important among blacks.

The study also found that preterm birth following spontaneous onset of labor rose 3% among white twins and fell 1% among black twins. Preterm birth following premature rupture of membranes fell 3% among whites and 7% among blacks.

SNOWMASS, COLO. — Elevated WBC count is the best indication that a pediatric patient presenting with joint pain has juvenile idiopathic arthritis rather than leukemia, but there are some subtle clinical differences, Patience White, M.D., said at a symposium sponsored by the American College of Rheumatology.

Joint pain in leukemia is usually much more severe than in JIA, and the patient with leukemia may also have bone pain and night pain, said Dr. White, chief of pediatric rheumatology at Children's National Medical Center, Washington.

In the child with JIA, fever will often be high and spiking; fever associated with leukemia tends to be low-grade.

In addition, 90% of patients with systemic onset JIA will have an associated rash, compared with 10% of leukemia patients.

Still, the two can look clinically similar, and it's common for patients with leukemia to end up on a potentially harmful trial course of corticosteroids. In questionable cases, the white blood cell count is most revealing.

Dr. White noted the case of an 8-year-old boy referred to her for possible diagnosis of systemic onset JIA.

The patient had painful arthritis and a maculopapular rash over the trunk, wrist, and ankle and had been experiencing daily fevers for 4 weeks. He had lost 5% of his body weight.

Testing for infection, including blood and urine cultures and a Lyme disease assay, had been negative.

A course of treatment with an NSAID had been unsuccessful and, most importantly, the white blood cell count, at 9,000 cells/μL, was too low to be consistent with a diagnosis of JIA, Dr. White said.

If the patient had JIA, the WBC should have been at least 30,000 cells/μL.

She ordered a bone marrow biopsy rather than initiate a trial of corticosteroid therapy, and the diagnosis of leukemia was confirmed.

SNOWMASS, COLO. — Elevated WBC count is the best indication that a pediatric patient presenting with joint pain has juvenile idiopathic arthritis rather than leukemia, but there are some subtle clinical differences, Patience White, M.D., said at a symposium sponsored by the American College of Rheumatology.

Joint pain in leukemia is usually much more severe than in JIA, and the patient with leukemia may also have bone pain and night pain, said Dr. White, chief of pediatric rheumatology at Children's National Medical Center, Washington.

In the child with JIA, fever will often be high and spiking; fever associated with leukemia tends to be low-grade.

In addition, 90% of patients with systemic onset JIA will have an associated rash, compared with 10% of leukemia patients.

Still, the two can look clinically similar, and it's common for patients with leukemia to end up on a potentially harmful trial course of corticosteroids. In questionable cases, the white blood cell count is most revealing.

Dr. White noted the case of an 8-year-old boy referred to her for possible diagnosis of systemic onset JIA.

The patient had painful arthritis and a maculopapular rash over the trunk, wrist, and ankle and had been experiencing daily fevers for 4 weeks. He had lost 5% of his body weight.

Testing for infection, including blood and urine cultures and a Lyme disease assay, had been negative.

A course of treatment with an NSAID had been unsuccessful and, most importantly, the white blood cell count, at 9,000 cells/μL, was too low to be consistent with a diagnosis of JIA, Dr. White said.

If the patient had JIA, the WBC should have been at least 30,000 cells/μL.

She ordered a bone marrow biopsy rather than initiate a trial of corticosteroid therapy, and the diagnosis of leukemia was confirmed.

SNOWMASS, COLO. — Elevated WBC count is the best indication that a pediatric patient presenting with joint pain has juvenile idiopathic arthritis rather than leukemia, but there are some subtle clinical differences, Patience White, M.D., said at a symposium sponsored by the American College of Rheumatology.

Joint pain in leukemia is usually much more severe than in JIA, and the patient with leukemia may also have bone pain and night pain, said Dr. White, chief of pediatric rheumatology at Children's National Medical Center, Washington.

In the child with JIA, fever will often be high and spiking; fever associated with leukemia tends to be low-grade.

In addition, 90% of patients with systemic onset JIA will have an associated rash, compared with 10% of leukemia patients.

Still, the two can look clinically similar, and it's common for patients with leukemia to end up on a potentially harmful trial course of corticosteroids. In questionable cases, the white blood cell count is most revealing.

Dr. White noted the case of an 8-year-old boy referred to her for possible diagnosis of systemic onset JIA.

The patient had painful arthritis and a maculopapular rash over the trunk, wrist, and ankle and had been experiencing daily fevers for 4 weeks. He had lost 5% of his body weight.

Testing for infection, including blood and urine cultures and a Lyme disease assay, had been negative.

A course of treatment with an NSAID had been unsuccessful and, most importantly, the white blood cell count, at 9,000 cells/μL, was too low to be consistent with a diagnosis of JIA, Dr. White said.

If the patient had JIA, the WBC should have been at least 30,000 cells/μL.

She ordered a bone marrow biopsy rather than initiate a trial of corticosteroid therapy, and the diagnosis of leukemia was confirmed.

SNOWMASS, COLO. — Prescribing patterns for sulfasalazine and methotrexate in patients with juvenile idiopathic arthritis need fine tuning, Patience White, M.D., said at a symposium sponsored by the American College of Rheumatology.

The doctor's concerns: Sulfasalazine needs to be prescribed more cautiously, and methotrexate dosages are often too high.

Although sulfasalazine is commonly prescribed for juvenile idiopathic arthritis (JIA), there are significant risks to weigh against the benefits in this population, said Dr. White, chair of pediatric rheumatology at Children's National Medical Center, Washington.

Reports have suggested that in late-onset pauciarticular juvenile arthritis, sulfasalazine decreases symptoms by 50% or more. But “I would urge you to use caution here,” Dr. White said. It may not be as effective in other subtypes of juvenile arthritis, and findings from double-blind trials have been mixed on the issue of whether it really is better than placebo.

Most important, 30% of patients with systemic onset JIA can have a febrile, serum-sickness-like reaction while taking sulfasalazine. This is a risk that deserves serious consideration before the drug is started, Dr. White stressed.

Methotrexate is an established second-line agent, yet the dosages used are often too high.

In a recent investigation comparing the safety and efficacy of parenteral methotrexate 15 mg/m2 per week with higher dosages for patients with polyarticular-course JIA, researchers found that efficacy plateaued with the lower dose.

All participants had failed to improve while receiving standard dosages of methotrexate (8-12.5 mg/m2 per week (Arthritis Rheum. 2004;50:2191-201).

Dr. White said she considers 10 mg/m2 per week the most effective and appropriate dose; when patients do not respond, she tends to try etanercept rather than increase the dose of methotrexate.

Etanercept clearly has a place in treatment, she said. About 74% of polyarticular JIA patients respond to etanercept, and it can reduce the need for prednisone and methotrexate. The biologic has been shown to have no more toxicity in patients as young as 3 years old than it does in adults.

Various combination treatments have been tried in JIA with some success. However, these reports are based on small groups of patients, so combination therapy is not really evidence based, Dr. White said.

She added that sometimes when a JIA patient stops responding to a particular regimen that once was effective, it is not a failure of therapy. It may be that the patient has simply outgrown his or her dosage.

Children can be more susceptible than adults to certain types of toxicity, and these effects can be subtle. NSAIDs, for example, can make some children hyperactive. Naproxen can cause pseudoporphyria.

Because of their effects on growth, systemic corticosteroids should be avoided unless the diagnosis is absolutely certain, she said.

Intraarticular corticosteroid injections, on the other hand, work well in children. Several studies have demonstrated that triamcinolone is the agent of choice, Dr. White added.

SNOWMASS, COLO. — Prescribing patterns for sulfasalazine and methotrexate in patients with juvenile idiopathic arthritis need fine tuning, Patience White, M.D., said at a symposium sponsored by the American College of Rheumatology.

The doctor's concerns: Sulfasalazine needs to be prescribed more cautiously, and methotrexate dosages are often too high.

Although sulfasalazine is commonly prescribed for juvenile idiopathic arthritis (JIA), there are significant risks to weigh against the benefits in this population, said Dr. White, chair of pediatric rheumatology at Children's National Medical Center, Washington.

Reports have suggested that in late-onset pauciarticular juvenile arthritis, sulfasalazine decreases symptoms by 50% or more. But “I would urge you to use caution here,” Dr. White said. It may not be as effective in other subtypes of juvenile arthritis, and findings from double-blind trials have been mixed on the issue of whether it really is better than placebo.

Most important, 30% of patients with systemic onset JIA can have a febrile, serum-sickness-like reaction while taking sulfasalazine. This is a risk that deserves serious consideration before the drug is started, Dr. White stressed.

Methotrexate is an established second-line agent, yet the dosages used are often too high.

In a recent investigation comparing the safety and efficacy of parenteral methotrexate 15 mg/m2 per week with higher dosages for patients with polyarticular-course JIA, researchers found that efficacy plateaued with the lower dose.

All participants had failed to improve while receiving standard dosages of methotrexate (8-12.5 mg/m2 per week (Arthritis Rheum. 2004;50:2191-201).

Dr. White said she considers 10 mg/m2 per week the most effective and appropriate dose; when patients do not respond, she tends to try etanercept rather than increase the dose of methotrexate.

Etanercept clearly has a place in treatment, she said. About 74% of polyarticular JIA patients respond to etanercept, and it can reduce the need for prednisone and methotrexate. The biologic has been shown to have no more toxicity in patients as young as 3 years old than it does in adults.

Various combination treatments have been tried in JIA with some success. However, these reports are based on small groups of patients, so combination therapy is not really evidence based, Dr. White said.

She added that sometimes when a JIA patient stops responding to a particular regimen that once was effective, it is not a failure of therapy. It may be that the patient has simply outgrown his or her dosage.

Children can be more susceptible than adults to certain types of toxicity, and these effects can be subtle. NSAIDs, for example, can make some children hyperactive. Naproxen can cause pseudoporphyria.

Because of their effects on growth, systemic corticosteroids should be avoided unless the diagnosis is absolutely certain, she said.

Intraarticular corticosteroid injections, on the other hand, work well in children. Several studies have demonstrated that triamcinolone is the agent of choice, Dr. White added.

SNOWMASS, COLO. — Prescribing patterns for sulfasalazine and methotrexate in patients with juvenile idiopathic arthritis need fine tuning, Patience White, M.D., said at a symposium sponsored by the American College of Rheumatology.

The doctor's concerns: Sulfasalazine needs to be prescribed more cautiously, and methotrexate dosages are often too high.

Although sulfasalazine is commonly prescribed for juvenile idiopathic arthritis (JIA), there are significant risks to weigh against the benefits in this population, said Dr. White, chair of pediatric rheumatology at Children's National Medical Center, Washington.

Reports have suggested that in late-onset pauciarticular juvenile arthritis, sulfasalazine decreases symptoms by 50% or more. But “I would urge you to use caution here,” Dr. White said. It may not be as effective in other subtypes of juvenile arthritis, and findings from double-blind trials have been mixed on the issue of whether it really is better than placebo.

Most important, 30% of patients with systemic onset JIA can have a febrile, serum-sickness-like reaction while taking sulfasalazine. This is a risk that deserves serious consideration before the drug is started, Dr. White stressed.

Methotrexate is an established second-line agent, yet the dosages used are often too high.

In a recent investigation comparing the safety and efficacy of parenteral methotrexate 15 mg/m2 per week with higher dosages for patients with polyarticular-course JIA, researchers found that efficacy plateaued with the lower dose.

All participants had failed to improve while receiving standard dosages of methotrexate (8-12.5 mg/m2 per week (Arthritis Rheum. 2004;50:2191-201).

Dr. White said she considers 10 mg/m2 per week the most effective and appropriate dose; when patients do not respond, she tends to try etanercept rather than increase the dose of methotrexate.

Etanercept clearly has a place in treatment, she said. About 74% of polyarticular JIA patients respond to etanercept, and it can reduce the need for prednisone and methotrexate. The biologic has been shown to have no more toxicity in patients as young as 3 years old than it does in adults.

Various combination treatments have been tried in JIA with some success. However, these reports are based on small groups of patients, so combination therapy is not really evidence based, Dr. White said.

She added that sometimes when a JIA patient stops responding to a particular regimen that once was effective, it is not a failure of therapy. It may be that the patient has simply outgrown his or her dosage.

Children can be more susceptible than adults to certain types of toxicity, and these effects can be subtle. NSAIDs, for example, can make some children hyperactive. Naproxen can cause pseudoporphyria.

Because of their effects on growth, systemic corticosteroids should be avoided unless the diagnosis is absolutely certain, she said.

Intraarticular corticosteroid injections, on the other hand, work well in children. Several studies have demonstrated that triamcinolone is the agent of choice, Dr. White added.

SNOWMASS, COLO. — Lyme disease patients without erythema migrans were thought to be rare—until they showed up more frequently than expected in a large trial of the Lyme disease vaccine, Linda K. Bockenstedt, M.D., said at a symposium sponsored by the American College of Rheumatology.

In that trial, 269 cases of Lyme disease were detected by serum assay, of which 42, or about 16%, involved patients without erythema migrans. However, those patients did have flulike symptoms, such as malaise, fever, myalgia, migratory arthralgias, occipital headache, and neck stiffness. They did not have any upper respiratory symptoms, such as cough.

Additionally, Dr. Bockenstedt of the rheumatology section at Yale University (New Haven) noted that there may soon be a way to monitor Lyme disease treatment.

A new enzyme-linked immunoabsorbent assay for Lyme disease, the C6 ELISA (Immunetics Inc.), tests for a single small peptide expressed by the Borrelia burgdorferi spirochete during active infection, instead of the whole organism.

Research has shown that antibody titers to this antigen drop fourfold when an infected individual has been successfully treated. Dr. Bockenstedt added that forthcoming study results will confirm the ability of the assay to adequately detect a drop in the antigen level.

SNOWMASS, COLO. — Lyme disease patients without erythema migrans were thought to be rare—until they showed up more frequently than expected in a large trial of the Lyme disease vaccine, Linda K. Bockenstedt, M.D., said at a symposium sponsored by the American College of Rheumatology.

In that trial, 269 cases of Lyme disease were detected by serum assay, of which 42, or about 16%, involved patients without erythema migrans. However, those patients did have flulike symptoms, such as malaise, fever, myalgia, migratory arthralgias, occipital headache, and neck stiffness. They did not have any upper respiratory symptoms, such as cough.

Additionally, Dr. Bockenstedt of the rheumatology section at Yale University (New Haven) noted that there may soon be a way to monitor Lyme disease treatment.

A new enzyme-linked immunoabsorbent assay for Lyme disease, the C6 ELISA (Immunetics Inc.), tests for a single small peptide expressed by the Borrelia burgdorferi spirochete during active infection, instead of the whole organism.

Research has shown that antibody titers to this antigen drop fourfold when an infected individual has been successfully treated. Dr. Bockenstedt added that forthcoming study results will confirm the ability of the assay to adequately detect a drop in the antigen level.

SNOWMASS, COLO. — Lyme disease patients without erythema migrans were thought to be rare—until they showed up more frequently than expected in a large trial of the Lyme disease vaccine, Linda K. Bockenstedt, M.D., said at a symposium sponsored by the American College of Rheumatology.

In that trial, 269 cases of Lyme disease were detected by serum assay, of which 42, or about 16%, involved patients without erythema migrans. However, those patients did have flulike symptoms, such as malaise, fever, myalgia, migratory arthralgias, occipital headache, and neck stiffness. They did not have any upper respiratory symptoms, such as cough.

Additionally, Dr. Bockenstedt of the rheumatology section at Yale University (New Haven) noted that there may soon be a way to monitor Lyme disease treatment.

A new enzyme-linked immunoabsorbent assay for Lyme disease, the C6 ELISA (Immunetics Inc.), tests for a single small peptide expressed by the Borrelia burgdorferi spirochete during active infection, instead of the whole organism.

Research has shown that antibody titers to this antigen drop fourfold when an infected individual has been successfully treated. Dr. Bockenstedt added that forthcoming study results will confirm the ability of the assay to adequately detect a drop in the antigen level.