Trouble Sleeping?
Difficulty sleeping is a common problem. Between having pain, children crying, cats and dogs going in and out, worries and the call of nature, it's not surprising that many of us have disturbed sleep. It has been said the new biologic drugs (Enbrel, Humira, Remicade) improve fatigue because they specially improve sleep. We wondered whether this was true, so we studied whether people taking biologics had better sleep and less fatigue than persons not taking biologics. Remember those sleep and pain scales you fill out with each questionnaire? What we found-you may have guessed it-is that taking biologics did not have a special effect on sleep. The graph (above) explains this all pretty well. The more pain you have the less well you sleep. You may think this is a "no brainer," but many doctors don't think about troubles with sleep. They should. It is not the specific drug you are taking; it is how well the drug works.
Current RA therapies and Heart Problems
One potential worry associated with arthritis treatment is the affect some of the medications may have on your heart. Current cardiovascular research suggests that inflammation is an important risk factor for heart disease in the general population. Data indicate that rheumatoid arthritis patients have an increased risk of heart problems.
We evaluated people with RA who took biologic medications (such as Enbrel, Remicade, Humira) and/or DMARD therapy (Disease-modifying, anti-rheumatic drugs, such as Arava, Penicillamine, and Plaquenil). We found that arthritis therapy had no effect on heart problems.
In addition to inflammation, it is reported that diabetes may also increase the risk of heart disease. Diabetes development can be independent of arthritis, but it may be enhanced by the use of corticosteroids (drugs like prednisone), a commonly used RA treatment.
In a second study we evaluated people with RA who took biologic medications and other DMARD therapies and found these therapies did not have an effect on the development of diabetes. Prednisone, but not RA, appeared to increase the risk of diabetes. As diabetes is associated with increased risk for heart problems, use of prednisone among RA patients may be an independent risk factor for cardiovascular disease.
No Increase in Liver Problems or Hospitalizations Among RA Patients Using Biologics
Good news about biologic therapies. Recent reports indicated that the rate of serious liver problems (those requiring hospitalization) was higher for persons receiving biologic therapies than for those receiving arava and methotrexate.
We found that biologic therapies are associated with a lower rate of liver problems (about 10% lower) compared with arava and methotrexate. Also, the rates of liver hospitalization are similar among the four biologic treatments (Enbrel, Remicade, Humira, and Kineret) and the rates do not differ statistically from those patients not receiving biologic therapy.
How and Why Patients and Physicians Disagree
In another presentation at the EULAR meeting, the NDB presented information on how patients and physicians disagree on what is most important. In a study of more than 700 persons with rheumatoid arthritis who were examined by Canadian and US rheumatologists, doctors and patients carried out separate evaluations. We asked the doctors to rate how well the patients were doing ('physician's global rating') and then asked the patients the same thing ('patient's global rating'). Using those rating we were able to compare how patients and doctors rated other factors. In the graph above we present what we call the 'concordance difference' or how physicians and patients agreed and disagreed. When the concordance difference was 0 both groups agreed. The farther an item is to right (e.g. fatigue) the more important it is to patients in explaining their overall global severity rating, and the less important it seemed to physicians. The farther to left an item is the more important it is to physicians in explaining their global severity rating, and the less important it is to persons with arthritis.
The graph shows important differences. Physicians didn't rate fatigue, pain and function as importantly as patients, and patients didn't think joint swelling and tenderness was so important. In our report to the EULAR meeting we suggested, based on this study, that doctors should use questionnaires to understand how patients feel. It would make them better doctors, we think, and it would certainly put them more in tune with their patients. We are interested in your opinion about this, too. You might go to the 'forum' on www.artritis-research.org and let us know your thoughts.