Rheumination

Discosupplementation

Discosupplementation

It's not the first time that I've used the term viscosupplementation in one of my dictations, but it may be my last.  It refers, of course, to the use of hyaluronate injections for osteoarthritis of the knee, and I use the term instead of the brand names like Synvisc or Durolane when writing to my referring family MDs.  I guess it must have been a late friday afternoon dictation and my secretary was already thinking of hitting the clubs because instead of writing:

...if the corticosteroid injections don't help we can try viscosupplementation..

she wrote:

...if the corticosteroid injections  don't help we can try discosupplementation... 

Almost makes you wonder which would work better.

You're Right. It Isn't Fair.

Saw a new patient today.  21 years old, still studying.  New onset rheumatoid arthritis with many active joints, positive RF,  positive anti-CCP, markedly elevated inflammatory markers.  All signs of bad disease.  We discussed her disease, the  need for aggressive treatment, the plan, and what to expect.  She was very intelligent and asked all the pertinent questions. I felt optimistic that things were going to go well.  She  took in all I had to say and then gathered up her prescriptions, her blood test requisitions, Xray forms. 

 And then she cried. And cried.  And cried. 

I consider myself a pretty sympathetic physician, aware how distressing this disease must be, and go to fairly great lengths to assure and calm my new patients.  With the new drugs we have available, it's not just talk.  For most patients the disease will come into control, often complete remission.  But now they are patients. Even if they can see a day when their swollen joints will subside and their long gone energy might return, they are now patients with a chronic disease. And for the foreseeable future.  It doesn't seem fair.  It isn't.

As rheumatologists we are so happy with ourselves and our drugs that we only see a bright skinny-fingered future for our patients from day one.  I think we forget that controlling the inflammation, while a huge step forward, doesn't always fix the whole patient. 

Lyrica Suicides or Quinolone Tendinitis. Who Gets the Boxed Warning

Another interesting aspect of the recent FDA warning about the increased suicidal behaviour of patients taking Lyrica and other seizure meds was the level of warning given.  It did not receive a boxed warning, the highest level, but rather a simple addition to the warning section alone.  Recently the FDA also gave a warning concerning the association of quinolones and tendon rupture.  In this case the warning was a boxed warning, serious stuff indeed.  It seemed odd to me that tendinopathy would trump suicidal behaviour in the warnings rank of the FDA.   Being Canadian and not that familiar with the system I looked into the situation and found that at Dr. Mintz blog there is an explanation of the warning system of the FDA.  It includes:

A Serious Adverse Reaction is something (obviously) serious, that may have lead to death, hospitalization, disability or birth defect.


Based on the type of reaction or event, this can come under several places in the product's label.

WARNINGS AND PRECAUTIONS: Under this section, these recommendations are about adverse reactions, which may not necessarily be serious, but thought to be clinically significant. Warnings also and usually contain serious adverse reactions as well as drug interactions.

CONTRAINDICATIONS: This means that you shouldn't use this medications in these particular circumstances.

BOXED WARNING

This category is the most confusing and media hyped. First, there is no such thing as a "Black Box," which is a term created by the media.Boxed warnings are warnings that are thought to be important enough to go at the very top of the label and are highlighted by being surrounded by a box. A product can get a boxed warning for three reasons.

• "an adverse reaction so serious in proportion to the potential benefit from the drug (e.g., a fatal, life-threatening or permanently disabling adverse reaction) that it is essential that it be considered in assessing the risks and benefits of using a drug"
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• A serious adverse reaction that can be prevented by appropriate measures(i.e. avoiding drugs that interact).
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  It's still not all that clear why the quinolones warrant a more serious warning given this classification.  It might be that quinolones would be fairly easy to substitute in at risk populations while the neuroleptics, since they are all included, would not be so easy.  Still, it seems odd to consider tendinopathy as more serious than suicidal behaviour, no matter the circumstances.  It looks to me that the boxed warning for tendinopathy might have been a bit extreme.

 

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That's Gotta Hurt

You would think a medical centre dealing with pain would use a somewhat anatomically correct illustration for their web site.  Here the suffering patient apparently has only lumbar vertebrae, and they extend from the neck to pelvis.  They also appear to be the size of Mastodon bones  The lungs have been replaced by kidneys the size of  well...lungs.  And we know they are kidneys because it appears we are looking at a pyelogram? No wonder she's in pain.     

Heartfelt Reminder

Occasionally, while preparing to inject a knee or shoulder, my proviodine splatter will form the shape of a heart. A pleasant midday happenstance, reminding me of how lucky I am to be with the woman I married.

Yes, it's a reprint from last year, but it never gets old.

Occasionally, while preparing to inject a knee or shoulder, my proviodine splatter will form the shape of a heart. A pleasant midday happenstance, reminding me of how lucky I am to be with the woman I married.

Yes, it's a reprint from last year, but it never gets old.

Darwin's Big Toe

 

There were probably very few times that Darwin didn't think about evolution, but one of those times may have been during one of his many attacks of gout.  It's hard to ponder the origins of species when you're watching your big toe explode into a fiery throbbing digit of pain.  I wonder, though,  if it might have consoled him somewhat to know that his rheumatological curse would someday provide an interesting evolutionary conundrum.

Gout is an acute arthritis that occurs when uric acid crystallizes within and around joints, causing an intense inflammatory reaction.  Why the uric acid crystallizes, and why it does so where it does, remains a mystery, but it is known that it occurs much more commonly in people with elevated levels of serum uric acid.  Elevated uric acid, it turns out, is a characteristic that is shared between humans, great apes, and a few new world monkeys but no other mammals. It is the result of several mutations in the gene responsible for the production of uricase, the enzyme which breaks down uric acid in less gouty species.  There have apparently been several different mutations over time suggesting that this was an accident worth preserving.  But why?  Why preserve a mutation that raises uric acid?

Not that the answers are all in, but paleo-rheumatological sleuthing, some pretty interesting science and not just a bit of guesswork,  has provided some interesting theories.  The great  uric acid schism apparently took place during the Miocene era, a period when our hairy ancestors were likely limited to a diet heavy in vegetation and low in salt. Some researchers believe that this may have lead to a hypotensive crisis among those primates bent on a bipedal posture.  Raising uric acid may have been the solution to this dilemma.  Richard Johnson has been doing a ton of interesting work which appears to suggest that uric acid, through several mechanisms, raises blood pressure.  This may now be to the detriment of modern meat-eating, alcohol-swilling, salt-gorging primates, but would have been a boon to the wobbly pre-syncopal apes of the past.  A second theory, proposed by Bruce Ames, suggests that  uric acid is protective, being a very good free-radical scavenger.  An increase in uric acid should provide an anti-oxidant effect that may increase survival by decreasing cardiovascular damage.  If this were the case, however, I'm not sure why all species wouldn't jump on the uricase mutation bandwagon.  

No matter what the reason for the ancient Miocene conversion, it's not certain that it was all for the greater good.  Darwin, resting his swollen feet on puffy pillows, might have been among the doubters.