PRD 2014

LAS VEGAS – When methotrexate doesn’t work in rheumatoid arthritis and patients are still suffering after their first tumor necrosis factor inhibitor, it’s worthwhile to try a second TNF inhibitor, according to Dr. Daniel Furst, the Carl M Pearson Professor in Rheumatology at University of California, Los Angeles.

Even just side effects from the first TNF inhibitor indicate that the second one might work, he said at the conference held by Global Academy for Medical Education.

Dr. Furst also explains in the video how to safely use steroids in RA patients, and when to move them to non–TNF inhibitor biologics.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – When methotrexate doesn’t work in rheumatoid arthritis and patients are still suffering after their first tumor necrosis factor inhibitor, it’s worthwhile to try a second TNF inhibitor, according to Dr. Daniel Furst, the Carl M Pearson Professor in Rheumatology at University of California, Los Angeles.

Even just side effects from the first TNF inhibitor indicate that the second one might work, he said at the conference held by Global Academy for Medical Education.

Dr. Furst also explains in the video how to safely use steroids in RA patients, and when to move them to non–TNF inhibitor biologics.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – When methotrexate doesn’t work in rheumatoid arthritis and patients are still suffering after their first tumor necrosis factor inhibitor, it’s worthwhile to try a second TNF inhibitor, according to Dr. Daniel Furst, the Carl M Pearson Professor in Rheumatology at University of California, Los Angeles.

Even just side effects from the first TNF inhibitor indicate that the second one might work, he said at the conference held by Global Academy for Medical Education.

Dr. Furst also explains in the video how to safely use steroids in RA patients, and when to move them to non–TNF inhibitor biologics.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS– With the help of newer equipment, ophthalmologists are catching hydroxychloroquine-associated retina changes earlier than ever before, but it’s not clear if early changes signal trouble and a need to discontinue the drug, a linchpin of lupus therapy, according to Dr. Susan Manzi.

Hydroxychloroquine (Plaquenil) causes eye damage in an estimated 1% of users after about 5-7 years of use. Bilateral “bull’s-eye” retinal pigment-change lesions are the traditional telltale signs; by the time they appear, patients already have some permanent vision loss.

The hope is to catch problems earlier. Newer ophthalmologic techniques – optical coherence tomography, fundus autofluorescence screening, and others – detect far more subtle retina changes earlier in the course of treatment, but the importance of those early changes is not clear. This uncertainty makes it hard for patients and rheumatologists to know what to do when they hear about such findings, especially when hydroxychloroquine is working, Dr. Manzi said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

“Before, they used to look in the eye for pigment changes. Now, [we are] getting calls from ophthalmologists with concerns about” retinal edema and other less obvious problems, which are sometimes described as “early maculopathy, so we have to stop the drug” even if there are no vision problems. “We really don’t know what to make of it when [maybe] there’s just a little edema. It reminds me of the era when we started doing MRIs. We weren’t sure if all the things we found were relevant; I think we are going to be hearing more from ophthalmologists about some of these changes” and how much to worry about them, said Dr. Manzi, chair of the Allegheny Health Network department of medicine and director of the Lupus Center of Excellence, both in Pittsburgh.

In the meantime, “I can count the times I’ve stopped” hydroxychloroquine for eye issues, “and mostly it was because of [concomitant] macular degeneration or diabetic retinopathy,” not hydroxychloroquine-induced damage, she said.

In 2011, the American Academy of Ophthalmology recommended baseline screening with the newer technologies, and follow-up screening after 5 years. When “possible” toxicity is found, the group recommends screening every 3-6 months.

“There is no firm definition of ‘early’ toxicity, so that subtle changes (especially if parafoveal) – in visual field sensitivity, macular pigmentation, or any of the objective screening tests … should be taken seriously. If such changes occur, the tests should be repeated for verification or verified with other procedures. However, mild and nonspecific changes can appear in all tests for reasons other than toxicity (including cataract, early macular degeneration, and testing variation of the visual field …), and a relationship to [hydroxychloroquine] is difficult to confirm without evidence of paracentral functional or structural loss,” the group said (Ophthalmology 2011;118:415-22).

Dr. Manzi follows this screening advice. She also requests repeat testing if ophthalmologists find a problem on somewhat subjective measures, such as peripheral vision. Repeat testing sometimes alleviates worries.

Her practice also mirrors the academy’s dosing guidelines, which aim to minimize eye and other toxicities. For most lupus patients, that means 200 mg twice a day, or 400 mg once daily. “Most people do fine with that,” although 200 mg a day is a better call in small women and adolescents, she said.

Dr. Manzi is an adviser or consultant for Genentech, Eli Lilly, Bristol-Myers Squibb, GlaxoSmithKline, and other companies. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS– With the help of newer equipment, ophthalmologists are catching hydroxychloroquine-associated retina changes earlier than ever before, but it’s not clear if early changes signal trouble and a need to discontinue the drug, a linchpin of lupus therapy, according to Dr. Susan Manzi.

Hydroxychloroquine (Plaquenil) causes eye damage in an estimated 1% of users after about 5-7 years of use. Bilateral “bull’s-eye” retinal pigment-change lesions are the traditional telltale signs; by the time they appear, patients already have some permanent vision loss.

The hope is to catch problems earlier. Newer ophthalmologic techniques – optical coherence tomography, fundus autofluorescence screening, and others – detect far more subtle retina changes earlier in the course of treatment, but the importance of those early changes is not clear. This uncertainty makes it hard for patients and rheumatologists to know what to do when they hear about such findings, especially when hydroxychloroquine is working, Dr. Manzi said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

“Before, they used to look in the eye for pigment changes. Now, [we are] getting calls from ophthalmologists with concerns about” retinal edema and other less obvious problems, which are sometimes described as “early maculopathy, so we have to stop the drug” even if there are no vision problems. “We really don’t know what to make of it when [maybe] there’s just a little edema. It reminds me of the era when we started doing MRIs. We weren’t sure if all the things we found were relevant; I think we are going to be hearing more from ophthalmologists about some of these changes” and how much to worry about them, said Dr. Manzi, chair of the Allegheny Health Network department of medicine and director of the Lupus Center of Excellence, both in Pittsburgh.

In the meantime, “I can count the times I’ve stopped” hydroxychloroquine for eye issues, “and mostly it was because of [concomitant] macular degeneration or diabetic retinopathy,” not hydroxychloroquine-induced damage, she said.

In 2011, the American Academy of Ophthalmology recommended baseline screening with the newer technologies, and follow-up screening after 5 years. When “possible” toxicity is found, the group recommends screening every 3-6 months.

“There is no firm definition of ‘early’ toxicity, so that subtle changes (especially if parafoveal) – in visual field sensitivity, macular pigmentation, or any of the objective screening tests … should be taken seriously. If such changes occur, the tests should be repeated for verification or verified with other procedures. However, mild and nonspecific changes can appear in all tests for reasons other than toxicity (including cataract, early macular degeneration, and testing variation of the visual field …), and a relationship to [hydroxychloroquine] is difficult to confirm without evidence of paracentral functional or structural loss,” the group said (Ophthalmology 2011;118:415-22).

Dr. Manzi follows this screening advice. She also requests repeat testing if ophthalmologists find a problem on somewhat subjective measures, such as peripheral vision. Repeat testing sometimes alleviates worries.

Her practice also mirrors the academy’s dosing guidelines, which aim to minimize eye and other toxicities. For most lupus patients, that means 200 mg twice a day, or 400 mg once daily. “Most people do fine with that,” although 200 mg a day is a better call in small women and adolescents, she said.

Dr. Manzi is an adviser or consultant for Genentech, Eli Lilly, Bristol-Myers Squibb, GlaxoSmithKline, and other companies. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS– With the help of newer equipment, ophthalmologists are catching hydroxychloroquine-associated retina changes earlier than ever before, but it’s not clear if early changes signal trouble and a need to discontinue the drug, a linchpin of lupus therapy, according to Dr. Susan Manzi.

Hydroxychloroquine (Plaquenil) causes eye damage in an estimated 1% of users after about 5-7 years of use. Bilateral “bull’s-eye” retinal pigment-change lesions are the traditional telltale signs; by the time they appear, patients already have some permanent vision loss.

The hope is to catch problems earlier. Newer ophthalmologic techniques – optical coherence tomography, fundus autofluorescence screening, and others – detect far more subtle retina changes earlier in the course of treatment, but the importance of those early changes is not clear. This uncertainty makes it hard for patients and rheumatologists to know what to do when they hear about such findings, especially when hydroxychloroquine is working, Dr. Manzi said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

“Before, they used to look in the eye for pigment changes. Now, [we are] getting calls from ophthalmologists with concerns about” retinal edema and other less obvious problems, which are sometimes described as “early maculopathy, so we have to stop the drug” even if there are no vision problems. “We really don’t know what to make of it when [maybe] there’s just a little edema. It reminds me of the era when we started doing MRIs. We weren’t sure if all the things we found were relevant; I think we are going to be hearing more from ophthalmologists about some of these changes” and how much to worry about them, said Dr. Manzi, chair of the Allegheny Health Network department of medicine and director of the Lupus Center of Excellence, both in Pittsburgh.

In the meantime, “I can count the times I’ve stopped” hydroxychloroquine for eye issues, “and mostly it was because of [concomitant] macular degeneration or diabetic retinopathy,” not hydroxychloroquine-induced damage, she said.

In 2011, the American Academy of Ophthalmology recommended baseline screening with the newer technologies, and follow-up screening after 5 years. When “possible” toxicity is found, the group recommends screening every 3-6 months.

“There is no firm definition of ‘early’ toxicity, so that subtle changes (especially if parafoveal) – in visual field sensitivity, macular pigmentation, or any of the objective screening tests … should be taken seriously. If such changes occur, the tests should be repeated for verification or verified with other procedures. However, mild and nonspecific changes can appear in all tests for reasons other than toxicity (including cataract, early macular degeneration, and testing variation of the visual field …), and a relationship to [hydroxychloroquine] is difficult to confirm without evidence of paracentral functional or structural loss,” the group said (Ophthalmology 2011;118:415-22).

Dr. Manzi follows this screening advice. She also requests repeat testing if ophthalmologists find a problem on somewhat subjective measures, such as peripheral vision. Repeat testing sometimes alleviates worries.

Her practice also mirrors the academy’s dosing guidelines, which aim to minimize eye and other toxicities. For most lupus patients, that means 200 mg twice a day, or 400 mg once daily. “Most people do fine with that,” although 200 mg a day is a better call in small women and adolescents, she said.

Dr. Manzi is an adviser or consultant for Genentech, Eli Lilly, Bristol-Myers Squibb, GlaxoSmithKline, and other companies. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion.

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion.

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion.

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – If patients don’t respond to an antidepressant within 2 weeks, it’s probably time to switch them to another antidepressant or think about add-on therapy. If symptoms have gotten worse, however, it’s time to stop the antidepressant altogether, according to Dr. Charles Raison, professor of psychiatry at the University of Arizona in Tucson.

It doesn’t take 6-8 weeks for antidepressants to work; that commonly held notion is “100% wrong,” he said.

Imaging studies show brain activity changes within 2 hours of a single dose, and in trials where antidepressants separate from placebo, they do so in a week or 2 (Arch. Gen. Psychiatry 2006;63:1217-23). “Most of the action is early on,” Dr. Raison said at the annual Perspectives in Rheumatic Diseases conference held by the Global Academy for Medical Education.

“Monitoring response in the first 2 weeks is essential, because it’s going to tell you whether you’ve got the right” treatment. With any given antidepressant, about 75% of patients will respond, but about 25% will get “much, much worse. If a patient gets worse, stop. You should take that extremely seriously,” he said (Arch. Gen. Psychiatry 2011;68:1227-37).

In general, anxious people and suicidal people don’t do as well on antidepressants. Also, people with a history of childhood neglect, abuse, or trauma respond better to psychotherapy, so it’s worth asking about such issues. It’s also worth asking patients what they want to do, be it pharmaceuticals, psychotherapy, or both. Success is more likely if patients get what they want, Dr. Raison said.

“Pain is a powerful predictor of not doing well,” especially with SSRIs, so “unfortunately, [rheumatologists] deal with populations that are less likely to have a robust response.” Even so, “if you can help people with their pain, you’ll probably help” relieve their depression and help their antidepressant work, he said.

When patients don’t respond after a few weeks, “the first thing most of us do is increase the dose; for SSRIs, the data” indicate it doesn’t work. In one study, for instance, people did just as well on a lower dose as on a higher one, he said (Br. J. Psychiatry 2006;189:309-16).

Up to a quarter of patients, however, will do better if switched to another antidepressant. Some studies suggest staying in the same class of drugs; others suggest trying a different class. For now, which one to pick “depends [mostly] on side effects. There isn’t a best antidepressant; the best one is the one that works in any given patient,” Dr. Raison said (Eur. Neuropsychopharmacol. 2012;22:453-68).

Augmentation is another option, with atypical antipsychotics currently the most popular choice. There’s convincing evidence that they help, but they also have well-known and serious side effects, including extrapyramidal syndromes, metabolic derangements, and weight gain.

There’s also strong evidence for psychotherapy as an adjunct, and good data for lithium and a range of other agents. Whole-body hyperthermia is emerging as a possible depression treatment, as well.

Dr. Raison recommended actively treating nausea, jitteriness, diarrhea, and other short-term SSRI side effects; it makes it more likely that patients will stay on their treatment. Also, anxious patients and those with somatic complaints are more likely to tolerate antidepressants if they are started on subtherapeutic doses, then are titrated slowly up to a recommended dose.

Of all the SSRIs, paroxetine (Paxil) “is the one I most highly recommend you do not use. There’s no evidence it’s better than any of the others,” and it’s the one most likely to cause weight gain, sexual dysfunction, and cardiac issues, he said.

“We don’t know how long you should treat” with antidepressants; “probably at least 6-9 months,” he noted.

Dr. Raison is a consultant for Pamlab, Lilly, and Lundbeck. He is on the speakers bureaus of Pamlab and Sunovion. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – Up to 30% of patients diagnosed with polymyalgia rheumatica actually have a different disease, according to Dr. Eric L. Matteson.

The proximal pain and stiffness syndrome, which is a commonly accepted phenotype of polymyalgia rheumatica (PMR), also occurs in many other rheumatologic and inflammatory illnesses, Dr. Matteson said at the annual Perspectives in Rheumatic Diseases. Laboratory tests are nonspecific, and there is significant overlap – in terms of pathobiology – with other forms of inflammatory diseases associated with synovitis and vasculitis. Further, multiple conditions can coexist – including osteoarthritis, rotator cuff lesions, secondary capsulitis, and other periarticular lesions – and several conditions can mimic PMR.

Dr. Matteson of the Mayo Clinic College of Medicine, Rochester, Minn., described one 73-year-old patient with “discitis” who was initially thought to have PMR. She was admitted to the hospital with acute stiffness in the shoulder and acute onset backache. In keeping with a PMR diagnosis, her C-reactive protein (CRP) level was 113 mg/L, and she responded to 20 mg of prednisolone.

Another case involved a 63-year-old man with metastatic cancer. He presented with typical symptoms of PMR, a CRP level of 150 mg/L, and an alkaline phosphatase level of 1.5 times the upper limit of normal. He did not respond to 15 mg/day of prednisolone but felt better on 30 mg/day, with alkaline phosphatase rising to three times the upper limit of normal.

A third case involved a patient with antineutrophil cytoplasmic autoantibody vasculitis who was initially thought to have PMR. The patient presented with constitutional symptoms and was started on 15 mg/day of oral prednisone. Hemoptysis occurred 4 weeks later.

In an effort to improve diagnosis, the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) developed consensus candidate classification criteria. An expert panel that included Dr. Matteson had recognized that opinions differ as to the definition of PMR and its treatment, and that classification criteria are needed. In pursuit of this goal, the panel identified seven core criteria that 70% of survey respondents agreed upon, including age of 50 years or older, duration of at least 2 weeks, bilateral shoulder and/or pelvic girdle aching, morning stiffness duration of more than 45 minutes, elevated erythrocyte sedimentation rate (ESR), elevated CRP level, and rapid corticosteroid response with greater than 75% global response within 1 week to 15-20 mg of prednisolone or prednisone daily.

In addition, more than 70% of survey respondents agreed on the importance of assessing shoulder pain and limitation and/or hip motion. Agreement was low for peripheral signs such as carpal tunnel syndrome, tenosynovitis, and peripheral arthritis (J. Rheumatol. 2008;35:270-7).

Dr. Matteson suggested a stepwise approach to diagnosis, which includes evaluating for inclusion criteria, evaluating for exclusion criteria, prescribing steroids and evaluating patient response, and confirming the diagnosis at follow-up.

Inclusion criteria include age of 50 years or older, bilateral shoulder or pelvic girdle aching, morning stiffness for at least 45 minutes, symptom duration of at least 2 weeks, and acute phase response with an ESR greater than 30 mm/hr or a CRP level greater than 10 mg/L. All of these features must be present, he said at the conference held by Global Academy for Medical Education.

The panel also found that typical findings of synovitis in the shoulder and hip regions can assist in the classification of PMR.

Core exclusion criteria include active infection, neoplasia, and giant cell arteritis. Other criteria that reduce the likelihood that PMR is present include rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and inflammatory myopathy.

Drug-induced myalgia, pain syndromes, endocrine disorders, and Parkinson’s disease are mimics of PMR and must be excluded.

Corticosteroid response should be carefully assessed in those thought to have PMR, and the response should be rapid, complete, and sustained. Especially high doses increase the probability of diagnostic error, and nonresponse is an indication for reevaluation of the diagnosis and reassessment of the disease, Dr. Matteson said.

A scoring algorithm that incorporates ultrasound findings is also useful in the evaluation of a patient with suspected PMR. In patients aged 50 years or older with bilateral shoulder aching and abnormal ESR/CRP levels, points are awarded as follows: 2 points for morning stiffness for more than 45 minutes, 1 point for hip pain or limited range of motion, 2 points for normal rheumatoid factor or anticitrullinated peptide antibodies (ACPAs), 1 point for the absence of other joint pain. Further, 1 point is awarded if ultrasound identifies subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis in at least one shoulder. Also, 1 point is awarded if ultrasound shows subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis in both shoulders.

A score of 5 using this algorithm has 71% sensitivity and 70% specificity for discriminating all comparison subjects from PMR. The specificity is higher (85%) for discriminating shoulder conditions from PMR, and lower (65%) for discriminating rheumatoid arthritis from PMR, Dr. Matteson noted.

Clues that a patient does not have PMR include younger age, chronic onset, male gender, severe constitutional symptoms, lack of shoulder involvement, peripheral arthritis, rheumatoid factor­–positive/ACPA status, normal acute phase reactants (CRP, ESR) levels, peripheral arthritis, foot and ankle involvement, and poor response to low-dose corticosteroids. Also, keep in mind that the closest mimic of PMR is late-onset spondyloarthropathy, he said.

The severity of PMR is based on the intensity of pain, stiffness, and disability. Comorbidities should also be assessed, as these may affect the choice of corticosteroid dose. The corticosteroid dose, as well as other therapy, should be individualized based on the severity and comorbidities, and on the patient’s preference.

Patients diagnosed with PMR should be educated about the disease, its treatment and the potential related complications, and about precautions and monitoring requirements, Dr. Matteson said. Range-of-motion exercises for the shoulder and pelvic girdle muscles should be encouraged, and referral to physiotherapy should be made if necessary.

Patients should be monitored for relapse; in a recent study, relapse-free survival at 1 year and 2 years among patients with PMR was 68.8% and 42.4%, respectively, he noted.

Dr. Matteson reported serving as an advisory board member for Janssen; providing editorial services for UpToDate and inPractice; receiving research grants from the ACR, EULAR, Celgene, Biogen Idec, Centocor/Janssen, Genentech, Novartis, Roche, Ardea Biosciences, UCB Group, Sanofi, the Veterans Administration, the National Institutes of Health, Pfizer, and Mesoblast; and owning stock in Exact Sciences.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

LAS VEGAS – Up to 30% of patients diagnosed with polymyalgia rheumatica actually have a different disease, according to Dr. Eric L. Matteson.

The proximal pain and stiffness syndrome, which is a commonly accepted phenotype of polymyalgia rheumatica (PMR), also occurs in many other rheumatologic and inflammatory illnesses, Dr. Matteson said at the annual Perspectives in Rheumatic Diseases. Laboratory tests are nonspecific, and there is significant overlap – in terms of pathobiology – with other forms of inflammatory diseases associated with synovitis and vasculitis. Further, multiple conditions can coexist – including osteoarthritis, rotator cuff lesions, secondary capsulitis, and other periarticular lesions – and several conditions can mimic PMR.

Dr. Matteson of the Mayo Clinic College of Medicine, Rochester, Minn., described one 73-year-old patient with “discitis” who was initially thought to have PMR. She was admitted to the hospital with acute stiffness in the shoulder and acute onset backache. In keeping with a PMR diagnosis, her C-reactive protein (CRP) level was 113 mg/L, and she responded to 20 mg of prednisolone.

Another case involved a 63-year-old man with metastatic cancer. He presented with typical symptoms of PMR, a CRP level of 150 mg/L, and an alkaline phosphatase level of 1.5 times the upper limit of normal. He did not respond to 15 mg/day of prednisolone but felt better on 30 mg/day, with alkaline phosphatase rising to three times the upper limit of normal.

A third case involved a patient with antineutrophil cytoplasmic autoantibody vasculitis who was initially thought to have PMR. The patient presented with constitutional symptoms and was started on 15 mg/day of oral prednisone. Hemoptysis occurred 4 weeks later.

In an effort to improve diagnosis, the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) developed consensus candidate classification criteria. An expert panel that included Dr. Matteson had recognized that opinions differ as to the definition of PMR and its treatment, and that classification criteria are needed. In pursuit of this goal, the panel identified seven core criteria that 70% of survey respondents agreed upon, including age of 50 years or older, duration of at least 2 weeks, bilateral shoulder and/or pelvic girdle aching, morning stiffness duration of more than 45 minutes, elevated erythrocyte sedimentation rate (ESR), elevated CRP level, and rapid corticosteroid response with greater than 75% global response within 1 week to 15-20 mg of prednisolone or prednisone daily.

In addition, more than 70% of survey respondents agreed on the importance of assessing shoulder pain and limitation and/or hip motion. Agreement was low for peripheral signs such as carpal tunnel syndrome, tenosynovitis, and peripheral arthritis (J. Rheumatol. 2008;35:270-7).

Dr. Matteson suggested a stepwise approach to diagnosis, which includes evaluating for inclusion criteria, evaluating for exclusion criteria, prescribing steroids and evaluating patient response, and confirming the diagnosis at follow-up.

Inclusion criteria include age of 50 years or older, bilateral shoulder or pelvic girdle aching, morning stiffness for at least 45 minutes, symptom duration of at least 2 weeks, and acute phase response with an ESR greater than 30 mm/hr or a CRP level greater than 10 mg/L. All of these features must be present, he said at the conference held by Global Academy for Medical Education.

The panel also found that typical findings of synovitis in the shoulder and hip regions can assist in the classification of PMR.

Core exclusion criteria include active infection, neoplasia, and giant cell arteritis. Other criteria that reduce the likelihood that PMR is present include rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and inflammatory myopathy.

Drug-induced myalgia, pain syndromes, endocrine disorders, and Parkinson’s disease are mimics of PMR and must be excluded.

Corticosteroid response should be carefully assessed in those thought to have PMR, and the response should be rapid, complete, and sustained. Especially high doses increase the probability of diagnostic error, and nonresponse is an indication for reevaluation of the diagnosis and reassessment of the disease, Dr. Matteson said.

A scoring algorithm that incorporates ultrasound findings is also useful in the evaluation of a patient with suspected PMR. In patients aged 50 years or older with bilateral shoulder aching and abnormal ESR/CRP levels, points are awarded as follows: 2 points for morning stiffness for more than 45 minutes, 1 point for hip pain or limited range of motion, 2 points for normal rheumatoid factor or anticitrullinated peptide antibodies (ACPAs), 1 point for the absence of other joint pain. Further, 1 point is awarded if ultrasound identifies subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis in at least one shoulder. Also, 1 point is awarded if ultrasound shows subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis in both shoulders.

A score of 5 using this algorithm has 71% sensitivity and 70% specificity for discriminating all comparison subjects from PMR. The specificity is higher (85%) for discriminating shoulder conditions from PMR, and lower (65%) for discriminating rheumatoid arthritis from PMR, Dr. Matteson noted.

Clues that a patient does not have PMR include younger age, chronic onset, male gender, severe constitutional symptoms, lack of shoulder involvement, peripheral arthritis, rheumatoid factor­–positive/ACPA status, normal acute phase reactants (CRP, ESR) levels, peripheral arthritis, foot and ankle involvement, and poor response to low-dose corticosteroids. Also, keep in mind that the closest mimic of PMR is late-onset spondyloarthropathy, he said.

The severity of PMR is based on the intensity of pain, stiffness, and disability. Comorbidities should also be assessed, as these may affect the choice of corticosteroid dose. The corticosteroid dose, as well as other therapy, should be individualized based on the severity and comorbidities, and on the patient’s preference.

Patients diagnosed with PMR should be educated about the disease, its treatment and the potential related complications, and about precautions and monitoring requirements, Dr. Matteson said. Range-of-motion exercises for the shoulder and pelvic girdle muscles should be encouraged, and referral to physiotherapy should be made if necessary.

Patients should be monitored for relapse; in a recent study, relapse-free survival at 1 year and 2 years among patients with PMR was 68.8% and 42.4%, respectively, he noted.

Dr. Matteson reported serving as an advisory board member for Janssen; providing editorial services for UpToDate and inPractice; receiving research grants from the ACR, EULAR, Celgene, Biogen Idec, Centocor/Janssen, Genentech, Novartis, Roche, Ardea Biosciences, UCB Group, Sanofi, the Veterans Administration, the National Institutes of Health, Pfizer, and Mesoblast; and owning stock in Exact Sciences.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

LAS VEGAS – Up to 30% of patients diagnosed with polymyalgia rheumatica actually have a different disease, according to Dr. Eric L. Matteson.

The proximal pain and stiffness syndrome, which is a commonly accepted phenotype of polymyalgia rheumatica (PMR), also occurs in many other rheumatologic and inflammatory illnesses, Dr. Matteson said at the annual Perspectives in Rheumatic Diseases. Laboratory tests are nonspecific, and there is significant overlap – in terms of pathobiology – with other forms of inflammatory diseases associated with synovitis and vasculitis. Further, multiple conditions can coexist – including osteoarthritis, rotator cuff lesions, secondary capsulitis, and other periarticular lesions – and several conditions can mimic PMR.

Dr. Matteson of the Mayo Clinic College of Medicine, Rochester, Minn., described one 73-year-old patient with “discitis” who was initially thought to have PMR. She was admitted to the hospital with acute stiffness in the shoulder and acute onset backache. In keeping with a PMR diagnosis, her C-reactive protein (CRP) level was 113 mg/L, and she responded to 20 mg of prednisolone.

Another case involved a 63-year-old man with metastatic cancer. He presented with typical symptoms of PMR, a CRP level of 150 mg/L, and an alkaline phosphatase level of 1.5 times the upper limit of normal. He did not respond to 15 mg/day of prednisolone but felt better on 30 mg/day, with alkaline phosphatase rising to three times the upper limit of normal.

A third case involved a patient with antineutrophil cytoplasmic autoantibody vasculitis who was initially thought to have PMR. The patient presented with constitutional symptoms and was started on 15 mg/day of oral prednisone. Hemoptysis occurred 4 weeks later.

In an effort to improve diagnosis, the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) developed consensus candidate classification criteria. An expert panel that included Dr. Matteson had recognized that opinions differ as to the definition of PMR and its treatment, and that classification criteria are needed. In pursuit of this goal, the panel identified seven core criteria that 70% of survey respondents agreed upon, including age of 50 years or older, duration of at least 2 weeks, bilateral shoulder and/or pelvic girdle aching, morning stiffness duration of more than 45 minutes, elevated erythrocyte sedimentation rate (ESR), elevated CRP level, and rapid corticosteroid response with greater than 75% global response within 1 week to 15-20 mg of prednisolone or prednisone daily.

In addition, more than 70% of survey respondents agreed on the importance of assessing shoulder pain and limitation and/or hip motion. Agreement was low for peripheral signs such as carpal tunnel syndrome, tenosynovitis, and peripheral arthritis (J. Rheumatol. 2008;35:270-7).

Dr. Matteson suggested a stepwise approach to diagnosis, which includes evaluating for inclusion criteria, evaluating for exclusion criteria, prescribing steroids and evaluating patient response, and confirming the diagnosis at follow-up.

Inclusion criteria include age of 50 years or older, bilateral shoulder or pelvic girdle aching, morning stiffness for at least 45 minutes, symptom duration of at least 2 weeks, and acute phase response with an ESR greater than 30 mm/hr or a CRP level greater than 10 mg/L. All of these features must be present, he said at the conference held by Global Academy for Medical Education.

The panel also found that typical findings of synovitis in the shoulder and hip regions can assist in the classification of PMR.

Core exclusion criteria include active infection, neoplasia, and giant cell arteritis. Other criteria that reduce the likelihood that PMR is present include rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and inflammatory myopathy.

Drug-induced myalgia, pain syndromes, endocrine disorders, and Parkinson’s disease are mimics of PMR and must be excluded.

Corticosteroid response should be carefully assessed in those thought to have PMR, and the response should be rapid, complete, and sustained. Especially high doses increase the probability of diagnostic error, and nonresponse is an indication for reevaluation of the diagnosis and reassessment of the disease, Dr. Matteson said.

A scoring algorithm that incorporates ultrasound findings is also useful in the evaluation of a patient with suspected PMR. In patients aged 50 years or older with bilateral shoulder aching and abnormal ESR/CRP levels, points are awarded as follows: 2 points for morning stiffness for more than 45 minutes, 1 point for hip pain or limited range of motion, 2 points for normal rheumatoid factor or anticitrullinated peptide antibodies (ACPAs), 1 point for the absence of other joint pain. Further, 1 point is awarded if ultrasound identifies subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis in at least one shoulder. Also, 1 point is awarded if ultrasound shows subdeltoid bursitis, biceps tenosynovitis, or glenohumeral synovitis in both shoulders.

A score of 5 using this algorithm has 71% sensitivity and 70% specificity for discriminating all comparison subjects from PMR. The specificity is higher (85%) for discriminating shoulder conditions from PMR, and lower (65%) for discriminating rheumatoid arthritis from PMR, Dr. Matteson noted.

Clues that a patient does not have PMR include younger age, chronic onset, male gender, severe constitutional symptoms, lack of shoulder involvement, peripheral arthritis, rheumatoid factor­–positive/ACPA status, normal acute phase reactants (CRP, ESR) levels, peripheral arthritis, foot and ankle involvement, and poor response to low-dose corticosteroids. Also, keep in mind that the closest mimic of PMR is late-onset spondyloarthropathy, he said.

The severity of PMR is based on the intensity of pain, stiffness, and disability. Comorbidities should also be assessed, as these may affect the choice of corticosteroid dose. The corticosteroid dose, as well as other therapy, should be individualized based on the severity and comorbidities, and on the patient’s preference.

Patients diagnosed with PMR should be educated about the disease, its treatment and the potential related complications, and about precautions and monitoring requirements, Dr. Matteson said. Range-of-motion exercises for the shoulder and pelvic girdle muscles should be encouraged, and referral to physiotherapy should be made if necessary.

Patients should be monitored for relapse; in a recent study, relapse-free survival at 1 year and 2 years among patients with PMR was 68.8% and 42.4%, respectively, he noted.

Dr. Matteson reported serving as an advisory board member for Janssen; providing editorial services for UpToDate and inPractice; receiving research grants from the ACR, EULAR, Celgene, Biogen Idec, Centocor/Janssen, Genentech, Novartis, Roche, Ardea Biosciences, UCB Group, Sanofi, the Veterans Administration, the National Institutes of Health, Pfizer, and Mesoblast; and owning stock in Exact Sciences.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

LAS VEGAS – New diagnostic criteria from the Systemic Lupus International Collaborating Clinics make the difficult task of diagnosing systemic lupus easier.

SLICC’s criteria are meant to supplant years-old criteria from the American College of Rheumatology. The SLICC criteria cast a wider net, without sacrificing specificity (Arthritis Rheum. 2012;64:2677-86).

SLICC coauthor Dr. Susan Manzi, chair of the department of medicine in the Allegheny Health Network and director of the Lupus Center of Excellence, both in Pittsburgh, explained how the new criteria work, and why they are an improvement.

At the conference held by Global Academy for Medical Education, she also explained why antinuclear antibody – “the lupus test” – isn’t completely reliable when diagnosing the disease.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – New diagnostic criteria from the Systemic Lupus International Collaborating Clinics make the difficult task of diagnosing systemic lupus easier.

SLICC’s criteria are meant to supplant years-old criteria from the American College of Rheumatology. The SLICC criteria cast a wider net, without sacrificing specificity (Arthritis Rheum. 2012;64:2677-86).

SLICC coauthor Dr. Susan Manzi, chair of the department of medicine in the Allegheny Health Network and director of the Lupus Center of Excellence, both in Pittsburgh, explained how the new criteria work, and why they are an improvement.

At the conference held by Global Academy for Medical Education, she also explained why antinuclear antibody – “the lupus test” – isn’t completely reliable when diagnosing the disease.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]

LAS VEGAS – New diagnostic criteria from the Systemic Lupus International Collaborating Clinics make the difficult task of diagnosing systemic lupus easier.

SLICC’s criteria are meant to supplant years-old criteria from the American College of Rheumatology. The SLICC criteria cast a wider net, without sacrificing specificity (Arthritis Rheum. 2012;64:2677-86).

SLICC coauthor Dr. Susan Manzi, chair of the department of medicine in the Allegheny Health Network and director of the Lupus Center of Excellence, both in Pittsburgh, explained how the new criteria work, and why they are an improvement.

At the conference held by Global Academy for Medical Education, she also explained why antinuclear antibody – “the lupus test” – isn’t completely reliable when diagnosing the disease.

Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.

[email protected]