Cancer Treatment Today » Rheumatology

Rituxan for leukocytoclastic vasculitis – pro

M Levin, MD — Sun, 20 Jan 2013 22:03:23 +0000

The U.S. Food and Drug Administration in April 2011approved Rituxan (rituximab), in combination with glucocorticoids (steroids), to treat patients with Wegener’s granulomatosis (WG) and microscopic polyangiitis (MPA), two rare disorders that cause blood vessel inflammation (vasculitis). Case reports and sereis suggest that it may also be effective in various subsets of vasculitis patients, particularly those with antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis. Several patients with chronic cutaneous small-vessel vasculitis have also been treated effectively with this agent. Interestingly, one case report suggested that Rituxan itself can cause leukocytoclastic vasculitis.

Keogh KA, Ytterberg SR, Fervenza FC, Carlson KA, Schroeder DR, Specks U. Rituximab for refractory Wegener’s granulomatosis: report of a prospective, open-label pilot trial. Am J Respir Crit Care Med. Jan 15 2006;173(2):180-7. [Medline].

Chung L, Funke AA, Chakravarty EF, Callen JP, Fiorentino DF. Successful use of rituximab for cutaneous vasculitis. Arch Dermatol. Nov 2006;142(11):1407-10. [Medline].

Harper L. Recent advances to achieve remission induction in antineutrophil cytoplasmic antibody-associated vasculitis. Curr Opin Rheumatol. Jan 2010;22(1):37-42.

Baerlecken NT, Schmidt RE. Essential mixed cryoglobulinemia type III with leukocytoclastic vasculitis: remission by rituximab.Clin Rheumatol. 2010 Mar 7.

Kandula P, Kouides PA. Rituximab-induced leukocytoclastic vasculitis: a case report.Arch Dermatol. 2006 Feb;142(2):246-7.

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Rituxumab for lung involvement of scleroderma – pro

M Levin, MD — Mon, 12 Nov 2012 23:29:32 +0000

Rituximab is an agent with a variety of immunologic effects mediated thorugh its effects on B-lymphocytes. Unfortunately, there is no effective therapy for severe interstitial lung disease associated with connective tissue disease (CTD-ILD), progressing despite maximal conventional immunosuppression. Two observational studies, one with 8 and one with 15 patients revealed conflicting results. One very small prospective study with 8 patients who received rituximab and six who had not had been performed and revealed encouraging results(Daoussius et al). These remain preliminary findings and more research clearly is required.

Keir GJ, Maher TM, Hansell DM, Denton CP, Ong VH, Singh S, Wells AU, Renzoni EA

Severe interstitial lung disease in connective tissue disease: rituximab as rescue therapy.

Eur Respir J. 2012 Sep;40(3):641-8.

Daoussis D, Liossis SN, Tsamandas AC, Kalogeropoulou C, Kazantzi A, Sirinian C, Karampetsou M, Yiannopoulos G, Andonopoulos AP Experience with rituximab in scleroderma: results from a 1-year, proof-of-principle study.Rheumatology (Oxford). 2010;49(2):271

Lafyatis R, Kissin E, York M, Farina G, Viger K, Fritzler MJ, Merkel PA, Simms RW

B cell depletion with rituximab in patients with diffuse cutaneous systemic sclerosis. Arthritis Rheum. 2009;60(2):578.

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Cytoxan for scleroderma – pro

M Levin, MD — Thu, 13 Sep 2012 17:03:11 +0000

Immunosuppressive agents such as cyclophosphamide have long been used to treat autoimmune disease, but the dose is often limited by bone marrow suppression. In a randomized placebo-controlled trial, those with scleroderma-related alveolitis and interstitial lung disease who received Cytoxan for one year had better forced vital capacity than patients on placebo, a difference still seen at two-year follow-up. In addition, patients who had taken Cytoxan had modest improvement of dyspnea, skin thickening, functional ability, and some health-related quality-of-life measures. In an accompanying NEJM editorial, Fernando J. Martinez, M.D., and W. Joseph McCune, M.D., of the University of Michigan Health System in Ann Arbor, commented that “this well-designed trial will be regarded as a sentinel study confirming a beneficial response to cyclophosphamide in highly selected patients with scleroderma-related interstitial lung disease.”

Tashkin DP et al. “Cyclophosphamide versus Placebo in Scleroderma Lung Disease.” N Engl J Med 2006;354:2655-66.

Martinez FJ and McCune WJ. “Cyclophosphamide for Scleroderma Lung Disease.” N Engl J Med 2006;354:2707-09.

Kowal-Bielecka, O, Landewe, R, Avouac, J, Chwiesko, S, Miniati, I, Czirjak, L, Clements, P, Denton, C, Farge, D, Fligelstone, K, Foldvari, I, Furst, D E, Muller-Ladner, U, Seibold, J, Silver, R M, Takehara, K, Garay Toth, B, Tyndall, A, Valentini, G, van den Hoogen, F, Wigley, F, Zulian, F, Matucci-Cerinic, M
EULAR recommendations for the treatment of systemic sclerosis: a report from the EULAR Scleroderma Trials and Research group (EUSTAR)
Ann Rheum Dis 2009 0: ard.2008.096677

Fibromyalgia and cancer – pro

M Levin, MD — Thu, 13 Sep 2012 17:02:07 +0000

There is no reported causal association between cancer and fibromyalgia to my knowledge and that I could fing in a literature search. However there is an association between chronic fatigue syndrome and cancer (an association does not establish a causal connection). A recent report analyzed 1361 patient records. While they found no association between fibromyalgia and cancer in patients whose fibromyalgia diagnosis was confirmed, they found that women referred to the hospital for muscle pain and/or tenderness who did not meet the fibromyalgia diagnostic criteria did have an increased overall cancer rate, with an increase specifically in breast, lymphatic and hematological cancers.

Dreyer L, Mellemkjaer L, Kendall S, Jensen B, Danneskiold-Samsøe B, Bliddal H.Increased cancer risk in patients referred to hospital with suspected fibromyalgia.J Rheumatol. 2007 Jan;34(1):201-6.

McBeth J, Symmons DP, Silman AJ, Allison T, Webb R, Brammah T, Macfarlane GJ.
Musculoskeletal pain is associated with a long-term increased risk of cancer and cardiovascular-related mortality. Rheumatology (Oxford). 2009 Jan;48(1):74-7.

Rituximab for rheumatoid artritis – pro

M Levin, MD — Thu, 13 Sep 2012 17:01:03 +0000

Rituximab in combination with methotrexate is recommended as an option for the treatment of adults with severe active rheumatoid arthritis who have had an inadequate response to or intolerance of other disease-modifying anti-rheumatic drugs (DMARDs), including treatment with at least one tumour necrosis factor alpha (TNF-alpha) inhibitor therapy. This combination treatment is FDA indicated.

However, in a situation in which ,methotrexate is contraindicated, literature supports Rituxan alone. In the phase II trial, the ACR responses of patients treated with rituximab in combination with MTX (ACR20, ACR50 and ACR70: 73%, 43% and 23%, respectively) were numerically superior to those receiving rituximab monotherapy (65%, 33% and 15%, respectively). As the difference between responses to rituximab monotherapy and the placebo control arm (ACR20, ACR50 and ACR70: 38%, 13% and 5%, respectively) did not reach statistical significance for ACR50 and ACR70 responses14 (category Ib), rituximab is licensed only in combination with MTX. Nevertheless, rituximab monotherapy was also shown to be more effective (ACR20 response) than placebo (category Ib).

National Institute for Health and Clinical Excellence (NICE). Rituximab for the treatment of rheumatoid arthritis. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 Aug. 26 p. (Technology appraisal guidance; no. 126).

J S Smolen, E C Keystone, P Emery, F C Breedveld, N Betteridge, G R Burmester, M Dougados, G Ferraccioli, U Jaeger, L Klareskog, T K Kvien, E Martin‐Mola, and K Pavelka, The Working Group on the Rituximab Consensus StatementConsensus statement on the use of rituximab in patients with rheumatoid arthritis, Ann Rheum Dis. 2007 February; 66(2): 143–150.

Edwards JC, Szczepanski L, Szechinski J, Filipowicz-Sosnowska A, Emery P, Close DR, Stevens RM, Shaw T.
Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis.N Engl J Med. 2004 Jun 17;350(25):2572-81.

MRA for temporal arteritis – pro

M Levin, MD — Thu, 13 Sep 2012 16:56:42 +0000

Temporal arteritis, or giant cell arteritis, is a common systemic vasculitis of unknown etiology. Ttemporal artery biopsy, a fairly easy procedure, is standard for the diagnosis of temporal arteritis. Angiography can be used when biopsy results are negative, or it can be used to help guide biopsy by demonstrating areas of abnormality. Magnetic resonance angiography (MRA) has results comparable to those of angiography in evaluating medium to large vessels. In some reported cases, MRA has successfully depicted disease in the temporal arteries. MRA can demonstrate stenoses, irregularity of the vessel wall, and beading or thickening of the vessel wall. Most of tehe vidence for usefullness of MRA is based on case reprots.

ACR assigns a score of 5/10 to MRA in the cases of “New headache in patient older than 60. Sedimentation rate higher than 55, temporal tenderness. Suspected temporal arteritis.”

Bley TA, Uhl M, Carew J, Markl M, Schmidt D, Peter HH, et al. Diagnostic value of high-resolution MR imaging in giant cell arteritis. AJNR Am J Neuroradiol. Oct 2007;28(9):1722-7. [Medline].

Khoury JA, Hoxworth JM, Mazlumzadeh M, Wellik KE, Wingerchuk DM, Demaerschalk BM. The Clinical Utility of High Resolution Magnetic Resonance Imaging in the Diagnosis of Giant Cell Arteritis: A Critically Appraised Topic. Neurologist. Sep 2008;14(5):330-335.

Jordan JE, Wippold FJ II, Cornelius RS, Amin-Hanjani S, Brunberg JA, Davis PC, De La Paz RL, Dormont D, Germano I, Gray L, Mukherji SJ, Seidenwurm DJ, Sloan MA, Turski PA, Zimmerman RD, Zipfel GJ, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® headache. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 8 p. [51 references]

Metanx for scleroderma – pro

M Levin, MD — Thu, 13 Sep 2012 16:55:36 +0000

Nutritional deficiencies in scleroderma and related disorders often include folate and Vit. B12, and as more recently reported, Vit. D and E, due to bacterial overgrowth in the gut. Metanx is sometimes prescribed for these conditions. Metanx is a food which is formulated to be consumed or administered by mouth under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. Specifically it is formulated for diabetic neuropathy. The usual adult dosage of Metanx® is one tablet twice daily .Each Metanx® tablet contains: L-methylfolate Calcium (as Metafolin®) 3mg, Pyridoxal 5′-phosphate 35mg, Methylcobalamin.

Metanx is a “legend vitamin”. Legend vitamins are specific formulations that are intended to reverse nutritional deficiencies in various conditions. Metanx® tablets are indicated for the distinct nutritional requirements of patients with who present with loss of protective sensation and neuropathic pain in their arms and legs associated with diabetic peripheral neuropathy. Metanx® tablets are indicated for the distinct nutritional requirements of patients with endothelial dysfuction and/or hyperhomocysteinemia who present with lower extremity ulceration(s).

Fiori G, Fiori G, Galluccio F, Braschi F, Amanzi L, Miniati I, Conforti ML, Del Rosso A, Generini S, Candelieri A, Magonio A, Goretti R, Rasero L. “Vitamin E gel reduces time of healing of digital ulcers in systemic sclerosis.” Clin Exp Rheumatol. 2009 27(3 Suppl 54):51-4.

Vacca A, Cormier C, Piras M, Mathieu A, Kahan A, Allanore Y. “Vitamin D deficiency and insufficiency in 2 independent cohorts of patients with systemic sclerosis.” J Rheumatol. 2009 36(9):1924-9.

Scleroderma: From Pathogenesis to Comprehensive Management By John Varga, Christopher P. Denton, Fredrick M. Wigley, Springer 2011

U.-F. Haustein, MD Systemic sclerosis – scleroderma Dermatology Online Journal 8(1): 3

Sacroiliac Injection – pro

M Levin, MD — Fri, 03 Aug 2012 02:43:41 +0000

Sacroiliac injection can be used diagnostically or therapeutically. There are no prospective a controlled trials to support this procedure. Most support comes from case reports or case series. Case series are unreliable evidence due to the variable natural history of back pain, the presence of confounders of outcome, and the potential for a placebo effect. In general, the literature regarding injection therapy on joints in the back is of poor quality. The current evidence on sacroiliac joint arthrography and injections is insufficient to consider it medically appropriate.

Manchikanti L, Datta S, Derby R, et al. A critical review of the American Pain Society clinical
practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician.
2010 May-Jun;13(3):E141-74.

Rupert MP, Lee M, Manchikanti L et al. Evaluation of sacroiliac joint interventions: a systematic
appraisal of the literature. Pain Physician 2009; 12(2):399-418.

Manchikanti L, Datta S, Gupta S et al. A critical review of the American Pain Society Clinical
practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician.
2010; 13(4):E215-64.

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Nutritional Deficiencies in Scleroderma and Related Disorders – pro

M Levin, MD — Tue, 19 Jun 2012 15:55:07 +0000

Vacca A, Cormier C, Piras M, Mathieu A, Kahan A, Allanore Y. “Vitamin D deficiency and insufficiency in 2 independent cohorts of patients with systemic sclerosis.” J Rheumatol. 2009 36(9):1924-9.

Scleroderma: From Pathogenesis to Comprehensive Management By John Varga, Christopher P. Denton, Fredrick M. Wigley, Springer 2011

U.-F. Haustein, MD Systemic sclerosis – scleroderma Dermatology Online Journal 8(1): 3

Read the Layperson version here.