Flu vaccine in the setting of Rheumatoid Arthritis

Vaccination against influenza in Rheumatoid Arthritis: the effect of disease modifying drugs, including TNF a blockers.I Fomin, D Caspi, V Levy, N Varsano, Y Shalev, D Paran, D Levartovsky, I Litinsky, I Kaufman, I Wigler, E Mendelson, O ElkayamAnn Rheum Dis 2005 7

This important paper from Israel addresses questions that often arise in peer to peer discussions among rheumatologists. Does vaccination against influenza affect rheumatoid arthritis (RA) disease parameters and do RA and/or the medications used to treat RA (steroids, disease modifying antirheumatic drugs (DMARDs), and/or biologic agents) affect the humoral (antibody) response induced by the vaccine? 82 patients with RA and 30 healthy control patients were vaccinated with a split-viron inactivated vaccine to address the above questions. The response to vaccination was defined as a >4-fold rise in hemagglutination inhibiting antibodies 6 weeks post vaccination or seroconversion in patients with non-protective levels at baseline. Significant increases in the geometric mean titers for each of the antigens was observed in both the RA and healthy control patients, however, the titers and the percentage of responders were higher in the healthy controls. The percentage of responders was not affected by the use of prednisone, DMARDs, infliximab, or etanercept. There also was no apparent affect of the vaccination on multiple disease activity measures. The results of this study will be very helpful and reassuring to the busy clinical rheumatologists. Similar studies with other inactivated vaccines are needed to address the safety and efficacy of such vaccinations in patients with RA.

Arthur L. Weaver MD, MS

In other words, it appears that patients with rheumatoid arthritis are protected by the flu vaccine but the immune system response to the vaccination is not as robust as in otherwise healthy individuals. It also appears to be true that this response was not affected by the medications that a given patient may be taking. Finally, giving the flu shot does not appear to result in flares of rheumatoid arthritis. Therefore, there is no good reason to withhold vaccination in these patients. A caveat: the vaccine was an inactive virus (the injection, FluVax) as opposed to a live, attenuated, virus (the nasal spray, FluMist).

Ricardo Pocurull, MD

Effects of Doxycycline on progression of Osteoarthritis

Effects of doxycycline on progression of osteoarthritis: results of a randomized, placebo-controlled, double-blind trial.KD Brandt, SA Mazzuca, BP Katz, KA Lane, KA Buckwalter, DE Yocum, F Wolfe, TJ Schnitzer, LW Moreland, S Manzi, JD Bradley, L Sharma, CV Oddis, ST Hugenberg, LW HeckArthritis Rheum 2005 7;52(7):2015-25

Our current management of osteoarthritis (OA) lacks pharmaceutical agents that are disease modifying (DMOADs). The search for agents that slow or halt radiographic progression has met with very limited success to date. Dr.Brandt and colleagues describe the results of a multicenter, randomized, placebo-controlled, double-blind trial of doxycycline in 435 obese women with moderately advanced OA in one knee (joint space narrowing {JSN} in the medial tibiofemoral compartment) and no disease in the contralateral knee. The patients were treated with doxycycline 100 mg twice daily or placebo for 30 months. The rationale for the use of doxycycline in OA was based on studies demonstrating doxycycline’s inhibition of collagenase enzymes. The involved knees showed 40% and 33% less JSN at 16 and 30 months compared to the placebo group. Doxycycline did not reduce joint pain despite slowing radiographic progression and had no apparent effect on pain or joint space narrowing in the contralateral knee. Side effects were unusual and included sun sensitivity, abdominal symptoms and vaginitis in the doxycycline group and less urinary tract and upper respiratory infections also in the doxycycline patients. An accompanying editorial in the same issue of Arthritis and Rheumatism by Dr. Dieppe suggests many unanswered questions remain :(1) Why the lack of effect on the contralateral knee? (2) Why the disconnect between radiographic slowing and pain relief? (3) Will further studies show similar results in men and in other sites of OA involvement? (4) Will long standing disease respond in a similar fashion? (5) Will doxycycline prove to be safe if used long term in older patients. More studies are needed to answer these and other questions regarding doxycycline and other potential DMOADs.

Arthur L. Weaver MD, MS

ON LUPUS: More on vascular disease

Preclinical vascular disease in systemic lupus erythematosus and primary antiphospholipid syndrome.S Jiménez, MA García-Criado, D Tàssies, JC Reverter, R Cervera, MR Gilabert, D Zambón, E Ros, C Bru, J FontRheumatology (Oxford) 2005 6;44(6):756-61

A bimodal pattern of mortality in SLE was recognized nearly 30 years ago (the second peak due to cardiovascular events), accelerated atherosclerosis in SLE has only become the subject of intense investigation in the last few years. This study from Barcelona, Spain adds to this body of literature by presenting data on 70 SLE patients, 25 with antiphospholipid syndrome (APS) and 40 healthy controls. Some classical atherosclerosis risk factors were more common in the SLE patients than in the other two groups (hypertension, dyslipidemia); however, others were not (smoking, obesity, family history). Carotid intima media thickness (IMT) was comparable in the three groups, yet plaque formation occurred more frequently in the SLE patients (28.6%) than in APS patients (8%) and controls (15%) (p<0.001).>
--Graciela S. Alarcon, MD

Carotid intima thickness is a measure of the thickness of the inner lining of the carotid arteries as measured by ultrasound. This thickness correlates well with the risk of coronary artery disease. In other words, the thicker this lining, the higher your risk of heart attacks. The take home message from Dr. Alarcon's analysis is that: 1) lupus patients have a higher incidence of thickened carotid lining when compared with healthy people and therefore a higher risk of coronary artery disease, 2) the incidence is even greater if one has both lupus and antiphospholipid syndrome. This correlation is present regardless of wether or not traditional risk factors are present. Nevertheless, traditional risk factors should be addressed as aggressively as someone who is at intermediate to high risk of heart disease.

Ricardo Pocurull, MD