News September 2005 Issue

In the News: 09/05

Combination Therapy Best For RA
The advantage of combination therapy—using two drugs rather than a single drug to improve symptoms, increase function, and slow joint damage in rheumatoid arthritis—was demonstrated in a study presented at a recent meeting of the European League Against Rheumatism. The study involved 508 RA patients and compared four treatment approaches: 1) sequential monotherapy (one drug at a time, starting with methotrexate), 2) a step-up regimen beginning with methotrexate but with more drugs added as needed, 3) combination therapy consisting of methotrexate, sulfasalazine, and a tapered high-dose prednisone, and 4) combination therapy consisting of methotrexate and infliximab. During the study’s first months, symptoms and functioning of patients in groups 3 and 4 improved much more rapidly than those in groups 1 and 2.

By the end of the first year, the differences were less noticeable, and after two years, the results were virtually the same for all four groups, although patients in groups 3 and 4 had less joint-damage progression. In addition, 42 percent of patients in all groups were in remission. The study will continue for another eight years to determine whether the initial differences in the progression of joint damage remain and whether patient remission is permanent.

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Surgeon Predictions Fall Short On Back-Surgery Results
Although surgeons typically predict improvement in patients who have undergone back surgery, patients are generally less satisfied with the result. In a study published in a recent issue of Spine, researchers examined 197 patients with lower back pain or sciatica. They found that surgeons predicted “a great deal of improvement” in quality of life after surgery for 79 percent of patients and “moderate improvement” for 20 percent.

However, in cases where surgeons predicted “great improvement,” 56 percent of those patients reported no significant improvement one year after surgery. Oddly, the surgeons’ predictions were more accurate for patients who were not appropriate candidates for back surgery. Researchers labeled this the “curabo effect”—which unlike the “placebo effect,” referring to a patient’s confidence and expectation for improvement, is attributed to a surgeon’s confidence in his own work. In this case, researchers believe, patients who were not appropriate candidates may rate the results of their surgery higher when the surgeon has also expressed higher expectations.

In two earlier studies published in BMJ (British Medical Journal), it was shown that surgery for chronic lower back pain (lasting for more than 12 months) was no better than rehabilitation. The trial involved 349 chronic back-pain patients; 176 underwent spinal fusion surgery and 173 were assigned to an intensive rehabilitation program involving daily exercises and mental behavioral therapy. Although surgical treatment after two years appeared to have a slight advantage, the differences between surgery and rehab, researchers concluded, were minor considering the potential risk and cost of surgery (an average $13,763 in the surgery group  vs. $7,935 in the rehab group). 

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Cough Remedy May Benefit Fibromyalgia Patients
Dextromenthorphan, the active ingredient in many over-the-counter cough remedies, may help fibromyalgia patients control over-reacting nerves. In a study of 24 women published in The Journal of Pain, researchers found that the drug, popular in cold remedies because it suppresses the cough reflex without becoming addictive, reduces the intensity of “wind-up,” a phenomenon in which repeated touches generate pain that increases with each new contact.

What causes fibromyalgia, an incurable illness typified by widespread muscle aches, stiffness, fatigue, and affecting an estimated 10 million Americans (most of them women), is unknown. What is known is that the central nervous system—the brain and spinal cord—somehow magnifies pain to abnormally high levels. Dextromenthorphan was found to not only subdue fibromyalgia wind-up but also ease secondary pain induced in healthy volunteers.

Although the results were promising, researchers cautioned that patients should not resort to self-medicating by taking cough syrup for pain, since dextromenthorphan has side effects and at high doses can produce problems related to memory.