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Does AntiTNF Therapy Alter The Presence Of Foot Symptoms In Patients With Rheumatoid Arthritis

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2.Department of Rheumatology, Southampton University Hospitals NHS Trust; ... The rheumatology nurse specialist team. ARC Interns (Mike Backhouse and Lindsey Hooper) ... – PowerPoint PPT presentation

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Title: Does AntiTNF Therapy Alter The Presence Of Foot Symptoms In Patients With Rheumatoid Arthritis


1
Does Anti-TNF- Therapy Alter The Presence Of Foot
Symptoms In Patients With Rheumatoid Arthritis?
Catherine J Bowen1, Keith Dewbury3, Madeline
Sampson3, Sally Sawyer2, Sarah P Bennet2, Jane
Burridge1, Christopher J Edwards2,4 and Nigel K
Arden2,4 1.School of Health Professions and
Rehabilitation Sciences, University of
Southampton 2.Department of Rheumatology,
Southampton University Hospitals NHS Trust
3.Department of Radiology, Southampton
University Hospitals NHS Trust 4.MRC
Epidemiology Resource Centre, University of
Southampton. (email cjb5soton.ac.uk)
2
Background
  • On average it takes about two years for erosion
    to develop and be seen on XRay.
  • Good evidence that US can show both damage to
    joints and synovitis earlier than in XRay.
    (Wakefield et al 2000, Balint et al 2001)
  • As soon as there is any soft tissue disease
    within the foot the biomechanics become altered.
  • TNF- inhibition is an effective way of reducing
    synovial hypertrophy yet its effect on the foot
    is unknown.
  • The aim of this study was to evaluate the effect
    of anti-TNF- therapy on forefoot synovial
    hypertrophy (joint and bursal) and foot pain

3
Method (N24)
  • 24 Consecutive RA patients (ACR criteria)
  • Starting anti-TNF-therapy (infliximab,
    etanercept, adalimumab)
  • All assessed for presence of bursitis and
    synovitis in the forefoot
  • Using diagnostic musculoskeletal ultrasound
    (MSUS)
  • At baseline and 12 weeks.

Clinical picture of swollen bursitis of the
plantar forefoot area.
4
MSUS scanning
  • All participants were scanned according to a
    standard protocol by an experienced radiologist
  • The presence of synovitis of the 2nd and 5th
    metatarso-phalangeal joints of both feet and
    presence of bursitis within the forefoot was
    documented.
  • All US measurements were recorded by an
    experienced radiologist
  • A Philips HDI 5000 System broadband linear 5 - 12
    MHz probe.

5
Figure 1. An MSUS image of the left 4th/5th
intermetatarsal space in a healthy adult. The
image is seen from the plantar aspect and was
taken in the transverse plane.
Figure 3 An MSUS image of synovitis within the
left 3rd MTPJ. The image is seen from the dorsal
aspect and was taken in the longitudinal plane.
Figure 4. An MSUS image of synovitis within the
right 5th MTPJ. The image is seen from the
plantaraspect and was taken in the longitudinal
plane.
Figure 2. An MSUS image of bursitis within the
right 4th/5th intermetatarsal space. The image is
seen from the plantar aspect and was taken in the
transverse plane.
6
Overview of MSUS Scanning Protocol
7
Results Participant demographics
  • 24 patients
  • 19 female, 5 male
  • 9 seronegative, 15 seropositive
  • Mean age 59.9 (SD 11.1) years,
  • Mean weight 72.5 (16.01) Kg,
  • Mean disease duration 11.58 (11.0) years,
  • Mean previous number of DMARDs 2.9 (1.4).

8
Results Clinical Tests
  • At baseline
  • mean ESR was 40.6 (25.3),
  • Mean CRP 32.9 (26.8),
  • Mean DAS28 5.8 (0.9),
  • Mean VAS 59.1 (20.7),
  • Mean MFPDQ scores 22.5 (9.7).
  • At 12 weeks
  • mean ESR was 27.1 (16.4),
  • Mean CRP 13.2 (15.2),
  • Mean DAS28 4.6 (1.4),
  • Mean VAS 47.2 (22.3),
  • Mean MFPDQ 17.9 (10.0).

9
Results Imaging
  • At baseline
  • Observed presence of bursitis on ultrasound was
    noted in 81.25 (39) of feet
  • Observed presence of synovitis from 48 feet (96
    joints) was noted in 64.6 (62 31 right, 31
    left)
  • At twelve weeks
  • Observed presence of bursitis on ultrasound was
    noted in 72.9 (35) of feet
  • Observed presence of synovitis from 48 feet (96
    joints) was noted in 53.1 (51 26 right, 25
    left)

10
Results changes in prevalence of bursitis
synovitis

11
Key Results Summary
12
Data Analysis
  • No significant tendency for changes in the
    presence of bursitis or presence of synovitis
    between baseline and twelve weeks.
  • McNemar test
  • Significant differences between baseline measures
    and twelve weeks were found for
  • DAS28 (t5.463, plt.0.01),
  • CRP (t3.499, plt0.01),
  • ESR (t3.575, plt0.01),
  • Foot pain and disability (t3.575, plt0.01)
  • VAS for wellbeing (t2.541, plt0.05).

13
Discussion
  • There was a trend towards reduction in the
    presence of synovitis and bursitis (greater for
    synovitis than bursitis) detected by US within
    the forefoot after twelve weeks of
    anti-TNF-therapy although the perceived reduction
    was not statistically significant.
  • Significant reductions were observed in clinical
    and laboratory assessments of RA disease status
    ie. ESR, CRP, DAS28 and MFPDQ.
  • It may be that the treatment switches off the
    disease but twelve weeks is not enough time for
    synovial hypertrophy to regress
  • OR subclinical disease remains longer than
    thought as also reported recently by Brown et al
    (2006) for the hands.

14
Discussion
  • In some patients MFPDQ scores (perceived foot
    status) improved whilst bursitis counts
    increased.
  • This increase could be attributable to increased
    mechanical stress on the forefoot as mobility
    improved for those patients.
  • If this is so then patients on anti-TNF-therapy
    would require frequent reassessment of their foot
    status and of any interventions such as foot
    orthoses and footwear.

15
Conclusions
  • Findings from this study indicate that forefoot
    symptoms associated with inflammation within the
    forefoot do reduce after twelve weeks of
    anti-TNFa-therapy, although in a minority of
    patients these increases.
  • There are implications for clinical practice, in
    particular in the prescription and fitting of
    foot orthoses.
  • Further work is required to determine
    associations of the physiological effects of
    forefoot inflammation, in particular bursitis,
    with mechanical influences during gait.
  • It would also be useful to determine how often
    foot orthotic and footwear interventions should
    be reassessed for change in inflammatory status
    of the foot?

16
References
  • OConnell PG Lohmann Siegel K Kepple TM
    Stanhope SJ Gerber LH.(1998) Forefoot deformity,
    pain, and mobility in rheumatoid and nonarthritic
    subjects. J Rheumatol. 1998 Sep25(9)1681-6.
  • Wiener-Ogilvie (1999) The foot in rheumatoid
    arthritis. The Foot, Vol 9169-174.
  • Costa, M, Rizak, T, Zimmermann, B (2004)
    Rheumatologic Conditions of the Foot. J Am
    Podiatr Med Assoc.2004 94 177-186
  • Helliwell P Woodburn J Redmond A Turner D
    Davys H. (2007) The Foot and ankle in rheumatoid
    arthritis. Churchill Livingstone, UK.
  • Shi K Tomita T Hayashida K Owaki H Ochi
    T.(2000) Foot deformities in rheumatoid arthritis
    and relevance of disease severity. J Rheumatol.
    2000 Jan27(1)84-9.
  • Hulsmans HM Jacobs JW van der Hejide DM van
    Albada-Kuipers GA Bijlsma JW. (2000) The course
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    of rheumatoid arthritis.Arthritis Rheum. 2000
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  • Prevoo ML van Riel PL vant Hof MA van
    Rijswijk MH van Leeuwen MA Kuper HH van de
    Putte LB. (1995) Validity and reliability of
    joint indices. A longitudinal study in patients
    with recent onset rheumatoid arthritis. Br J
    Rheumatol. 1993 Jul32(7)589-94.

17
Acknowledgements
  • Dr Nigel Arden (Reader Consultant
    rheumatologist)
  • Dr Jane Burridge (Senior Research Fellow)
  • Dr Keith Dewbury (Consultant Radiologist)
  • The rheumatology nurse specialist team.
  • ARC Interns (Mike Backhouse and Lindsey Hooper)
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