The Journal of rheumatology. Supplement
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Review
Integrating biologic therapy into the comprehensive care of patients with rheumatoid arthritis.
The advent of biologic therapy has not only provided the opportunity for better care of patients with rheumatoid arthritis (RA), but also has permitted a better understanding of the pathogenesis of this autoimmune/inflammatory disease. The capacity of these agents to suppress signs and symptoms as well as radiographic progression of RA strongly indicates that they can alter the course of the disease. Appropriate analysis of the effect of biologics should provide new insight into the role of the specific targeted molecules in rheumatoid inflammation, and provide information about means to optimize therapy with these highly potent therapeutics.
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Back pain is ubiquitous and probably plagues almost everyone in all cultures and ethnic groups at some time (around 20% annually), and in up to 50% of these at least once a year. The WHO-COPCORD epidemiologic investigations have established its prevalence even in countries that had been unaware of its frequency in their populace, and factors involving type of work and training probably accounted for this misperception. Medical journals are replete with articles addressing diagnosis and treatment, but the majority fail to meet the standards needed for metaanalysis or comparison. ⋯ Even if the "disease" names classify like presentations but are not necessarily etiologically discrete, syndromic diagnoses that subsume a variety of causes receive less attention; international rankings of common disabilities and public health problems tend to emphasize the named disorders rather than the grouped disorders. Moreover, back pain is often self-treated with nonprescription medications or alternative therapies, and by nonmedical practitioners or treatments in many parts of the world. Validation of outcomes therefore not only reduces invalidism and direct costs but also reduces the indirect costs of absenteeism and medical care.
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Research strongly indicates that increased expression of the isoenzyme cyclooxygenase-2 (COX-2) is responsible for elevated production of prostaglandins in inflamed joint tissues and is involved in the mediation of pain. In contrast, COX-1 is a constitutively produced isoenzyme that is involved in the synthesis of eicosanoids that have important homeostatic functions, for example, in the gastric mucosa and platelets. This new knowledge led to the development of drugs that are highly specific inhibitors of COX-2 while not inhibiting COX-1 at maximally efficacious dosages. ⋯ Another large multicenter trial also demonstrated that celecoxib 200 mg BTD and 400 mg BID is as effective as naproxen 500 mg BID in patients with rheumatoid arthritis (RA). A comparative trial showed that celecoxib 200 mg BID is as effective as diclofenac SR 75 mg BID in patients with RA. The potential of COX-2 specific inhibitors to provide antiinflammatory and analgesic efficacy equivalent to that of conventional nonsteroidal antiinflammatory drugs without the adverse gastrointestinal mucosal and platelet effects associated with nonspecific COX inhibitors promises to revolutionize the clinical care of arthritis patients.
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Primary fibromyalgia remains a controversial and puzzling condition. The diagnosis is based on subjective symptoms, exclusionary criteria and the presence of tender points. ⋯ The utility of this approach is illustrated from research with groups of patients with chronic pain. The implications of the multiaxial taxometric approach for understanding primary fibromyalgia and its treatment are described.