Showing papers by "Marc C. Hochberg published in 2008"

Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.

Abstract: Objective To provide a single source for the best available estimates of the US prevalence of and number of individuals affected by osteoarthritis, polymyalgia rheumatica and giant cell arteritis, gout, fibromyalgia, and carpal tunnel syndrome, as well as the symptoms of neck and back pain. A companion article (part I) addresses additional conditions.

National Arthritis Data Work-group. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II

Abstract: OBJECTIVE To provide a single source for the best available estimates of the US prevalence of and number of individuals affected by osteoarthritis, polymyalgia rheumatica and giant cell arteritis, gout, fibromyalgia, and carpal tunnel syndrome, as well as the symptoms of neck and back pain. A companion article (part I) addresses additional conditions. METHODS The National Arthritis Data Workgroup reviewed published analyses from available national surveys, such as the National Health and Nutrition Examination Survey and the National Health Interview Survey. Because data based on national population samples are unavailable for most specific rheumatic conditions, we derived estimates from published studies of smaller, defined populations. For specific conditions, the best available prevalence estimates were applied to the corresponding 2005 US population estimates from the Census Bureau, to estimate the number affected with each condition. RESULTS We estimated that among US adults, nearly 27 million have clinical osteoarthritis (up from the estimate of 21 million for 1995), 711,000 have polymyalgia rheumatica, 228,000 have giant cell arteritis, up to 3.0 million have had self-reported gout in the past year (up from the estimate of 2.1 million for 1995), 5.0 million have fibromyalgia, 4-10 million have carpal tunnel syndrome, 59 million have had low back pain in the past 3 months, and 30.1 million have had neck pain in the past 3 months. CONCLUSION Estimates for many specific rheumatic conditions rely on a few, small studies of uncertain generalizability to the US population. This report provides the best available prevalence estimates for the US, but for most specific conditions more studies generalizable to the US or addressing understudied populations are needed.

American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis

Abstract: Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.

Comparison of 2 Frailty Indexes for Prediction of Falls, Disability, Fractures, and Death in Older Women

Abstract: BACKGROUND: Frailty, as defined by the index derived from the Cardiovascular Health Study (CHS index), predicts risk of adverse outcomes in older adults. Use of this index, however, is impractical in clinical practice. METHODS: We conducted a prospective cohort study in 6701 women 69 years or older to compare the predictive validity of a simple frailty index with the components of weight loss, inability to rise from a chair 5 times without using arms, and reduced energy level (Study of Osteoporotic Fractures [SOF index]) with that of the CHS index with the components of unintentional weight loss, poor grip strength, reduced energy level, slow walking speed, and low level of physical activity. Women were classified as robust, of intermediate status, or frail using each index. Falls were reported every 4 months for 1 year. Disability (>/=1 new impairment in performing instrumental activities of daily living) was ascertained at 4(1/2) years, and fractures and deaths were ascertained during 9 years of follow-up. Area under the curve (AUC) statistics from receiver operating characteristic curve analysis and -2 log likelihood statistics were compared for models containing the CHS index vs the SOF index. RESULTS: Increasing evidence of frailty as defined by either the CHS index or the SOF index was similarly associated with an increased risk of adverse outcomes. Frail women had a higher age-adjusted risk of recurrent falls (odds ratio, 2.4), disability (odds ratio, 2.2-2.8), nonspine fracture (hazard ratio, 1.4-1.5), hip fracture (hazard ratio, 1.7-1.8), and death (hazard ratio, 2.4-2.7) (P < .001 for all models). The AUC comparisons revealed no differences between models with the CHS index vs the SOF index in discriminating falls (AUC = 0.61 for both models; P = .66), disability (AUC = 0.64; P = .23), nonspine fracture (AUC = 0.55; P = .80), hip fracture (AUC = 0.63; P = .64), or death (AUC = 0.72; P = .10). Results were similar when -2 log likelihood statistics were compared. CONCLUSION: The simple SOF index predicts risk of falls, disability, fracture, and death as well as the more complex CHS index and may provide a useful definition of frailty to identify older women at risk of adverse health outcomes in clinical practice. Language: en

A meta-analysis of the incidence of malignancy in adult patients with rheumatoid arthritis

Abstract: Introduction The risk of malignancies in patients with rheumatoid arthritis (RA) has raised some concern, particularly with immunosuppressive approaches to disease management.

The risk of hospitalized infection in patients with rheumatoid arthritis.

Abstract: OBJECTIVE: To determine whether patients with rheumatoid arthritis (RA) are at increased risk of hospitalized infection and whether the risk varies by RA treatment. METHODS: A retrospective cohort study was conducted using data from a medical and pharmacy claims managed-care database from 1999 to 2006. A total of 24,530 patients were included in the RA cohort; a random sample of non-RA patients served as a comparison cohort (n = 500,000). Rates of hospitalized infection were compared between the cohorts. A nested case-control analysis was performed within the RA cohort to assess the effect of current RA medication use on hospitalized infection risk. RESULTS: A total of 1,993 patients with RA and 11,977 non-RA patients experienced a hospitalized infection. The rate of first hospitalized infection was higher in the RA cohort [adjusted hazard ratio = 2.03; 95% confidence interval (CI) 1.93-2.13]. In the case-control analysis, the current use of biological disease modifying antirheumatic drugs (DMARD) was associated with slightly increased risk of hospitalized infection [rate ratio (RR) = 1.21; 95% CI 1.02-1.43]. Methotrexate and hydroxychloroquine were associated with decreased risk. Oral corticosteroid use increased risk (RR = 1.92; 95% CI 1.67-2.21), and there was a dose-related effect [ 10 mg/day: RR = 2.98 (95% CI 2.41-3.69)]. CONCLUSION: These data confirm that individuals with RA are at increased risk of hospitalized infection compared to those without RA. Oral corticosteroid use was associated with a dose-related increase. Biological DMARD use was associated with slightly elevated risk; however, this may reflect confounding and channeling bias.

Mortality in osteoarthritis.

Abstract: Mortality has not been a major area of investigation in osteoarthritis. The author conducted a systematic review and identified seven studies that provided data on either mortality or survival in persons with osteoarthritis; an additional two articles with relevant data were identified through review of reference lists. Studies included persons with radiographic evidence of osteoarthritis as well as clinical samples of patients with osteoarthritis. Results were pooled using the method of best evidence synthesis. Overall, there was moderate evidence of increased mortality among persons with osteoarthritis compared with the general population. Increased cause-specific mortality was observed in some studies from cardiovascular and gastrointestinal disorders. Risk factors for mortality in persons with osteoarthritis included an increased burden of osteoarthritis, advanced age, and presence of comorbid conditions. Possible explanations for the excess mortality include reduced levels of physical activity among persons with osteoarthritis due to involvement of lower limb joints and presence of comorbid conditions, as well as adverse effects of medications used to treat symptomatic osteoarthritis, particularly non-steroidal anti-inflammatory drugs.

The incidence and prevalence of extra-articular and systemic manifestations in a cohort of newly-diagnosed patients with rheumatoid arthritis between 1999 and 2006.

Abstract: Objective: To evaluate the incidence and prevalence of extra-articular (ExRA) and systemic (SysM) manifestations in a cohort of newly-diagnosed patients with rheumatoid arthritis (RA) in the United States.Patients and methods: Retrospective analysis using inpatient, outpatient, and pharmacy claims data contained in the Thomson Healthcare MarketScan research data­bases. Patients ≥ 18 years of age with a diagnosis of RA (ICD‑9‑CM 714.0x) on three non-diagnostic claims on different days between January 1, 1999 and September 30, 2006, and at least 12 months of continuous enrollment prior to, and at least 2 years following diagnosis were included in the analysis. Thirty ExRA/SysM, classified into six groups (cardiovascular, blood, mucosa, pulmonary, other, and non-specific), were evaluated. Patients were followed until in-hospital death, disenrollment, or study end.Results: A total of 16 752 patients were included (mean age 59.8 ± 13.5 years; 72.0% female), and were followed up for a mean of 3.9 ± 1.4 ...

Prevalent Vertebral Fractures in Black Women and White Women

Abstract: Vertebral fractures are the most common osteoporotic fracture. Hip and clinical fractures are less common in black women, but there is little information on vertebral fractures. We studied 7860 white and 472 black women ≥65 yr of age enrolled in the Study of Osteoporotic Fractures. Prevalent vertebral fractures were identified from lateral spine radiographs using vertebral morphometry and defined if any vertebral height ratio was >3 SD below race-specific means for each vertebral level. Information on risk factors was obtained by questionnaire or examination. Lumbar spine, total hip, and femoral neck BMD and BMC were measured by DXA. The prevalence of vertebral fractures was 10.6% in black and 19.1% in white women. In age-adjusted logistic regression models, a 1 SD decrease in femoral neck BMD was associated with 47% increased odds of fracture in black women (OR = 1.47; 95% CI, 1.12–1.94) and 80% increased odds in white women (OR = 1.80; 95% CI, 1.68–1.94; interaction p = 0.14). The overall lower odds of fracture among black women compared with white women was independent of femoral neck BMD and other risk factors (OR = 0.51; 95% CI, 0.37–0.72). However, the prevalence of vertebral fractures increased with increasing number of risk factors in both groups. The prevalence of vertebral fractures is lower in black compared with white women but increases with age, low BMD, and number of risk factors.

The rate of decline of joint space width in patients with osteoarthritis of the knee: a systematic review and meta-analysis of randomized placebo-controlled trials of chondroitin sulfate .

Abstract: Background: Chondroitin sulfate has been shown to relieve pain and improve functional limitation in patients with osteoarthritis (OA) of the knee in numerous clinical trials and meta-analyses. Its role as a potential structure-modifying drug for knee OA, however, remains controversial.Objective: To perform a meta-analysis of randomized double-blind placebo-controlled clinical trials to assess the efficacy of chondroitin sulfate as a structure-modifying drug for knee OA.Research design and methods: A Medline search was conducted from 1996 through 2007 and five articles that reported results from three trials were identified; one additional trial was identified through review of presentations at annual rheumatology meetings. There was no evidence of heterogeneity across the trials and results were pooled using a fixed effects meta-analysis.Results: Pooled results demonstrated a small significant effect of chondroitin sulfate on the reduction in rate of decline in minimum joint space width of 0.07 mm...

Genetic variation in candidate osteoporosis genes, bone mineral density, and fracture risk: the study of osteoporotic fractures.

Abstract: Candidate osteoporosis gene variants were examined for associations with fracture risk and bone mineral density (BMD). A total of 9704 white women were recruited at four U.S. clinical centers and enrolled into the Study of Osteoporotic Fractures, a longitudinal cohort study. Genotyping of 31 polymorphisms from 18 candidate osteoporosis genes was performed in 6752 women. Incident radiographic fractures were identified at the third and eighth examinations compared with the baseline examination. BMD was measured at the total hip by dual-energy X-ray absorptiometry. Analyses were adjusted for age, clinic site, and self-reported ethnicity. During a mean follow-up of 14.5 years, a total of 849 hip, 658 vertebral, and 2496 nonhip/nonvertebral fractures occurred in 6752 women. Women carrying the ALOX15_G48924T T/T genotype had a higher rate of hip fracture (hazard ratio [HR] = 1.33;95% confidence interval [95% CI] = 1.00–1.77) compared with the G/G genotype. Compared with those carrying the PRL_T228C T/T genotype, women with either the C/C (HR = 0.80; 95% CI = 0.67–0.95) or C/T (HR = 0.81; 95% CI = 0.68–0.97) genotype had a lower rate of nonvertebral/nonhip fractures. Women carrying the BMP2_A125611G G/G genotype had a higher rate of vertebral fracture (odds ratio [OR] = 1.51; 95% CI = 1.03–2.23) compared with the A/A genotype. Women with the ESR1_C1335G G/G genotype had a higher rate of vertebral fracture (OR = 1.64; 95% CI = 1.07–2.50) compared with the C/C genotype. Compared with those with the MMP2_C595T C/C genotype, women with the C/T (OR = 0.79; 95% CI = 0.65–0.96) or T/T (OR = 0.44; 95% CI = 0.27–0.72) genotype had a lower rate of vertebral fracture. In conclusion, polymorphisms in several candidate genes were associated with hip, vertebral, and nonhip/nonvertebral fractures but not with total hip BMD in this large population based cohort study.

Osteoprotegerin Lys3Asn polymorphism and the risk of fracture in older women.

Abstract: Context: Osteoprotegerin (OPG) is a soluble decoy receptor for receptor activator nuclear factor κ-β that blocks osteoclastic bone resorption. Objective: We investigated the association between a Lys3Asn polymorphism in the OPG gene and bone mineral density (BMD), and the risk of fracture in 6695 women aged 65 yr and older participating in the Study of Osteoporotic Fractures. Design: BMD was measured using either single-photon absorptiometry (Osteon Osteoanalyzer; Dove Medical Group, Los Angeles, CA) or dual-energy x-ray absorptiometry (Hologic QDR 1000; Hologic, Inc., Bedford, MA). Incident fractures were confirmed by physician adjudication of radiology reports. Genotyping was performed using an immobilized probe-based assay. Results: Women who were homozygous for the minor G (Lys) allele had significantly lower BMD at the intertrochanter, distal radius, lumbar spine, and calcaneus than those with the C (Asn) allele. There were 701 incident hip fractures during 13.6-yr follow-up (91,249 person-years), including 362 femoral neck and 333 intertrochanteric hip fractures. Women with the C/C (Asn-Asn) genotype had a 51% higher risk of femoral neck fracture (95% confidence interval, 1.13–2.02) and 26% higher risk of hip fracture (95% confidence interval, 1.02–1.54) than those with the G/G (Lys-Lys) genotype. These associations were independent of BMD. Intertrochanteric fractures were not associated with the Lys3Asn polymorphism. Conclusion: These results require confirmation but suggest a role for the OPG Lys3Asn polymorphism in the genetic susceptibility to hip fractures among older white women.

Relationship of Blood Lead Levels to Incident Nonspine Fractures and Falls in Older Women: The Study of Osteoporotic Fractures†‡

Abstract: Lead is stored in the skeleton and can serve as an endogenous source for many years. Lead may influence the risk of fracture, through direct effects on bone strength or indirectly by disturbing neuromuscular function and increasing the risk of falls. The objective of this analysis is to test the hypothesis that women with higher blood lead levels experience higher rates of falls and fracture. This was a prospective cohort study of 533 women 65–87 yr of age enrolled in the Study of Osteoporotic Fractures at two U.S. research centers (Baltimore, MD; Monongahela Valley, PA) from 1986 to 1988. Blood lead levels (in μg/dl) were measured in 1990–1991 by atomic absorption spectrophotometry and classified as “low” (≤3; lower 15th percentile, referent); “medium” (4–7); or “high” (≥8; upper 15th percentile). Total hip BMD was measured by DXA twice, 3.55 yr apart. Information on falls was collected every 4 mo for 4 yr. Incident nonspine fractures were identified and confirmed over 10 yr. Cox proportional hazards models were used to estimate the hazard ratio (HR) and 95% CI of fracture. Generalized estimating equations were used to calculate the incident rate ratio of falls (95% CI). The mean blood lead level was 5.3 ± 2.3 (SD) μg/dl (range, 1–21 μg/dl). Baseline BMD was 7% lower in total hip and 5% lower in femoral neck in the highest compared with lowest blood lead group (p < 0.02). Hip bone loss tended to be greater in the high lead group, but differences were not significant. In multivariable adjusted models, women with high blood lead levels had an increased risk of nonspine fracture (HR = 2.50; 95% CI = 1.25, 5.03; p trend = 0.016) and higher risk of falls (incident rate ratio = 1.62; 95% CI = 1.07, 2.45; p trend = 0.014) compared with women with lowest lead level. Blood lead levels are associated with an increased risk of falls and fractures, extending the negative health consequences of lead to include osteoporotic fractures.

Estrogen Receptor Alpha and Matrix Metalloproteinase 2 Polymorphisms and Age-related Maculopathy in Older Women

Abstract: In this study, the authors sought to determine whether single nucleotide polymorphisms in the estrogen receptor alpha (ESR1) and matrix metalloproteinase 2 (MMP2) genes are associated with age-related maculopathy (ARM) in older women. Subjects comprised a random sample of Caucasian women aged > or =74 years participating in the Study of Osteoporotic Fractures year 10 follow-up (n = 906) in 1997-1998. Fundus photographs were graded for ARM using a modification of the Wisconsin Age-Related Maculopathy Grading System. The prevalences of early ARM and late ARM were 46% and 4%, respectively. The MMP2 rs2287074 single nucleotide polymorphism (G-->A) was associated with ARM. The A allele was present in 47%, 43%, and 30% of subjects with no, early, and late ARM, respectively (p = 0.01), and was associated with lower odds of any ARM (for AG vs. GG, odds ratio = 0.80, 95% confidence interval: 0.65, 0.99; for AA vs. GG, odds ratio = 0.64, 95% confidence interval: 0.42, 0.98). An interaction with use of postmenopausal hormone therapy was significant (p = 0.02). The MMP2 rs2287074 A allele may be associated with a lower likelihood of ARM in older Caucasian women, particularly those who have never used hormone therapy. The role of MMP2 rs2287074 in ARM should be further elucidated.

Drug Insight: choosing a drug treatment strategy for women with osteoporosis-an evidence--based clinical perspective.

Abstract: Many randomized controlled trials (RCTs) have investigated drug treatment for women at high risk of fracture, with a reduction in fracture risk as their end point. There has also been progress in identifying women at the highest risk of fractures. The most important clinical determinant contributing to the clinical decision of initiating and choosing drug therapy for fracture prevention is a woman's fracture risk, which, in RCTs, was determined by menopausal state, age, bone mineral density, fracture history, fall risks and glucocorticoid use. Women with secondary osteoporosis were excluded, except in studies of glucocorticoid use. A second determinant of drug therapy is the evidence for fracture prevention in terms of spectrum (vertebral, nonvertebral and/or hip fractures), size and speed of effect. In the absence of head-to-head RCTs with fracture risk as the end point, however, the efficacy of antifracture drugs cannot be directly compared. Other determinants include the potential extraskeletal benefits and safety concerns of the drug, patient preferences and reimbursement issues.

Nonvertebral fracture risk reduction with nitrogen-containing bisphosphonates.

Abstract: Osteoporosis is a systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue resulting in compromised bone strength and an increased risk of fracture. There are two major fracture types: vertebral and nonvertebral. The latter include fractures involving the upper extremities, lower extremities (including hip), pelvis, and ribs. A recent review comparing the efficacy and safety of drugs approved by the US Food and Drug Administration for treatment of osteoporosis demonstrated that although all of the agents have been shown to reduce the incidence of radiographic vertebral fractures, they do not all reduce the incidence of nonvertebral fractures. This article summarizes the most currently available data relative to nonvertebral and hip fracture risk reduction for the N-containing bisphosphonates alendronate, ibandronate, risedronate, and zoledronic acid, and presents results of an analysis of comparative efficacy of these compounds using the technique of adjusted indirect comparisons.

Postmenopausal hormone therapy and age-related maculopathy in older women.

Abstract: Purpose: To examine the association between postmenopausal hormone therapy and Age-Related Maculopathy (ARM) in older women and to determine if these associations vary by smoking status. Methods: A cross-sectional analysis of 1065 women of European origin aged ≥ 74 years attending the year-10 examination of the Study of Osteoporotic Fractures was performed. Fundus photographs were graded for ARM using a modification of the Wisconsin Age-Related Maculopathy Grading System used in NHANES III. Multiple imputation methods were used to examine the associations of type and duration of postmenopausal hormone therapy use with early and late ARM as well as interactions with smoking history. Results: Compared to never users, Neither estrogen alone (E), Estrogen plus progestin (E+P), nor duration of use was significantly associated with early ARM [odds ratio (OR) E = 1.01, 95% confidence interval (CI) 0.77–1.34; OR E+P = 0.85, 95% CI 0.55–1.35; OR ≤ 3 years use = 1.04, 95% CI 0.74–1.47; OR > 3–12 years use = 0.93, 9...

Screening for osteoporosis in men: comment on the American College of Physicians clinical guidelines.

Abstract: Screening for osteoporosis in men: comment on the American College of Physicians clinical guidelines

Traditional Chinese medicine in the management of osteoarthritis

Abstract: ‘…some modalities of Traditional Chinese medicine are effective and should be included as part of a multidisciplinary integrative approach to management of patients with OA.’ Current recommendations for the management of patients with symptomatic osteoarthritis (OA) emphasize a multidisciplinary approach focused on the reduction of pain, functional limitation and disability [1–4]. This approach incorporates the use of nonpharmacologic modalities, including patient education, occupational and physical therapy, aerobic exercise, social support and weight loss, as well as pharmacologic therapies, including simple and opioid analgesics, NSAIDs including COX-2-selective inhibitors, and injectable agents including glucocorticoids and hyaluronan preparations. In patients whose symptoms are not adequately controlled with this approach, or who prefer not to take prescription medications because of fear of side effects, the use of traditional Chinese medicine (TCM) has been recommended as part of an integrated approach to care [5]. TCM can be defined as a range of traditional practices that originated in China and developed over a period of several thousand years [101]. Several treatment methods are considered to be part of TCM; these include herbal medicine, acupuncture (with or without moxibustion or electrical stimulation), food therapy, massage therapy, physical exercise such as T’ai Chi, mental exercise such as Feng Shui, and breathing and meditation exercise such as Qi Gong. This editorial will review the published evidence that supports the use of some TCM modalities as part of an integrative approach to the holistic management of patients with symptomatic OA. Herbal compounds