From the ACR/ARHP Annual Meeting
Pediatric antibacterial use increases arthritis risk1
Horton et al performed a nested case-control study to determine if antibiotic exposure increased the development of juvenile idiopathic arthritis (JIA). According to the authors, the development of inflammatory bowel disease (IBD) in children has been linked to antibiotic exposure. They evaluated a comprehensive United Kingdom population-based records database (The Health Improvement Network), including diagnostic data and outpatient prescriptions. Children diagnosed with JIA prior to age 17 were identified and matched for age and sex to control subjects. There were 153 patients with a JIA diagnosis identified and 1,530 control subjects. After adjusting for confounders, any antibiotic exposure was linked with a greater probability of developing JIA, which increased in a dose-dependent manner. Similarities existed among the antibacterial medication classes evaluated. These data may support the theory that increasing antibacterial drug exposure may contribute to inflammatory disease development.
Gout hospitalizations preventable through appropriate outpatient management2
Sharma et al retrospectively evaluated cases from 2009 to 2013 for patients hospitalized with a primary discharge diagnosis of gout (56 of 79 were identified). Cases were identified as to whether or not the hospitalization was preventable. Fifty cases (89%) were identified as being preventable in that they had gout without concomitant illness requiring hospitalization. Admission diagnoses were septic arthritis (76%), inflammatory polyarthritis (14%) and cellulitis (8%). Of the 50 preventable cases, 35 had a prior history of gout. Primary care providers managed 74% of these patients, and 26% of patients were managed by rheumatologists. Of the 26 patients followed by primary care providers, 31% (n=8) were receiving urate-lowering therapies, and 19% (n=5) were on prophylactic colchicine. Eighteen of 23 (78%) patients were not at goal serum uric acid levels (< 6 mg/dL) within one year of hospitalization. Of 15 patients receiving long-term gout therapy, 33% were nonadherent. The authors concluded that 89% of gout hospitalizations are preventable, and despite ACR/EULAR gout guidelines, many patients still suffer disease flares, pain and hospitalization while increasing healthcare utilization due to inadequate disease control. By decreasing gaps in clinical care, the authors hope to improve outcomes in their health system by better following of the guidelines. This includes doing a better job of putting patients on urate-lowering therapy and colchicine at the first sign of a disease flare. Involving rheumatologists in more patient care could also help improve patient outcomes.
Better integration of hepatotoxicity monitoring needed for improved patient care3
The broadly prescribed potentially hepatotoxic agents, leflunomide (LEF) and methotrexate (MTX), are used to treat rheumatologic and other immune-mediated diseases. Currently, guidelines suggest monitoring either the AST or ALT every two to three months, even for patients on a stable, long-term medication dose. Hepatotoxicity monitoring guideline adherence was evaluated in this Kaiser Permanente (KP) study of a large, community-based population. The KP database was queried for patients who received at least two prescriptions of MTX or LEF, with at least one prescription received in the prior six months. Monitoring guideline adherence was defined as having an ALT or AST measurement and result in the 90 days prior to data collection. There were 8,276 internal medicine patients identified. Adherence to guidelines for rheumatologists ranged from 62% to 95%. Rheumatologists were surveyed, and all were aware of the guidelines and prescribed a three-month supply or less of medicine, and 94% used standing laboratory orders. In addition, 71% of rheumatologists would not refill an MTX or LEF prescription without an AST or ALT in the prior three months. The authors note significant variation in liver toxicity monitoring in this managed care group of rheumatologists. They note the need for better tools and workflows that integrate prescribing and monitoring, which could be implemented at the system level and be applicable for many different drugs, different diseases and specialties.
