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Reading Rheum

Gail C. Davis, RN, EdD; Michael M. Ward, MD;  |  Issue: October 2009  |  

As a routine part of assessment in the office setting, clinicians can use a simple tool, such as the RA-WIS, in order to determine whether treatment changes or workplace adaptations need to be made. Continuing evaluation will be necessary to determine whether treatment changes are successful.8 Such attention to “at-work disability” can improve the personal and economic outcomes for both the individual and society.11

References:

  1. National Center for Disease Prevention and Health Promotion. National Arthritis Action Plan: A Public Health Strategy. Atlanta, GA: Centers for Disease Control, 2009 [Online]. Available at www.cdc.gov/nccdphp/publications/aag/pdf/arthritis.pdf. Accessed July 21, 2009.
  2. Theis KA, Murphy L, Hootman JM, Helmick CG, Yelin E. Prevalence and correlates of arthritis-attributable work limitation in the US population among persons ages 18-64: 2002 National Health Interview Survey Data. Arthritis Care Res. 2007;57:355-363.
  3. Tang K, Pitts S, Solway S, Beaton D. Comparison of the psychometric properties of four at-work disability measures in workers with shoulder or elbow disorders. J Occup Rehabil. 2009;19:142-154.
  4. Allaire SH. Measures of adult work disability. Arthritis Care Res. 2003;49:S85-S89.
  5. Hazes JMH, Geuskens GA, Burdorf A. Editorial: Work limitations in the outcome assessment of rheumatoid arthritis. J Rheumatol. 2005;32:980-982.
  6. The DASH outcome measure. Available at: www.dash.iwh.on.ca/index.htm. Accessed July 24, 2009.
  7. Lerner D, Amick BC, Rogers WH, Malspeis S, Bungay K, Cynn D. The work limitations questionnaire. Med Care. 2001;39:72-85.
  8. Gilworth G, Chamberlain MA, Harvey A, et al. Development of a Work Instability Scale for Rheumatoid Arthritis. Arthritis Care Res. 2003;49:349-354.
  9. Pelletier KR, Koopman C. Bringing health to the bottom line. Managed Healthcare Executive [online]. 2003. Available at: http://managedhealthcareexecutive.modernmedicine.com/mhe/article/articleDetail.jsp?id=134250. Accessed July 23, 2009.
  10. Walker N, Michaud K, Wolfe F. Work limitations among working persons with rheumatoid arthritis: Results, reliability and validity of the Work Limitations Questionnaire in 836 patients. J Rheumatol. 2005;32:1006-1012.
  11. Sokka T. Work disability in early rheumatoid arthritis. Clin Exp Rheumatol. 2003;21(5 Suppl 31):571-574.

Lupus

Head-to-head Trial of Lupus Nephritis Drugs

Appel GB, Contreras G, Dooley MA, et al. Mycophenolate mofetil versus cyclophosphamide for induction treatment of lupus nephritis. J Am Soc Nephrol. 2009; 20:1103-1112.

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Abstract

Recent studies have suggested that mycophenolate mofetil (MMF) may offer advantages over intravenous cyclophosphamide (IVC) for the treatment of lupus nephritis, but these therapies have not been compared in an international randomized, controlled trial. Here, we report the comparison of MMF and IVC as induction treatment for active lupus nephritis in a multinational, two-phase (induction and maintenance) study. We randomly assigned 370 patients with classes III through V lupus nephritis to open-label MMF (target dosage 3 g/d) or IVC (0.5 to 1.0 g/m2 in monthly pulses) in a 24-week induction study. Both groups received prednisone, tapered from a maximum starting dosage of 60 mg/d. The primary end point was a prespecified decrease in urine protein/creatinine ratio and stabilization or improvement in serum creatinine. Secondary end points included complete renal remission, systemic disease activity and damage, and safety. Overall, we did not detect a significantly different response rate between the two groups: 104 (56.2%) of 185 patients responded to MMF compared with 98 (53.0%) of 185 to IVC. Secondary end points were also similar between treatment groups. There were nine deaths in the MMF group and five in the IVC group. We did not detect significant differences between the MMF and IVC groups with regard to rates of adverse events, serious adverse events, or infections. Although most patients in both treatment groups experienced clinical improvement, the study did not meet its primary objective of showing that MMF was superior to IVC as induction treatment for lupus nephritis.

The results of ALMS suggests that the poorer responses of blacks and Hispanics to cyclophosphamide is likely not due to socioeconomic differences, and that ethnicity should be considered in treatment decisions.

Commentary

Based on promising results of small controlled trials, mycophenolate mofetil (MMF) has quickly gained popularity as an alternative to cyclophosphamide for the treatment of serious lupus nephritis. However, because the evidence was limited, questions remained about the relative efficacy and safety of these two medications. The Aspreva Lupus Management Study (ALMS) was done to help answer these questions. The initial phase of ALMS compared the efficacy and safety of MMF and monthly intravenous cyclophosphamide as induction treatment of active lupus nephritis. A subsequent phase, not yet reported, will test the relative efficacy of MMF and azathioprine as maintenance treatment.

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