Journals watch: Methotrexate for pain relief | Control of type 2 diabetes | Protective effect of alcohol in RA

Too busy to read all of the journals? Dr Sally Hope selects papers of interest to primary care.

Osteoarthritis of the knee: study suggests methotrexate reduced synovitis
Osteoarthritis of the knee: study suggests methotrexate reduced synovitis

Methotrexate for pain relief in knee osteoarthritis

Rheumatology 2013; 52(5): 888-92

Long-term NSAIDs have been shown to increase heart attack and stroke. What can we offer patients with osteoarthritis (OA)?

This very small pilot study (30 patients) evaluated methotrexate as an antisynovitis therapy for pain relief in knee OA. The study showed that 43% had a greater than 30% reduction in knee pain at 24 weeks and 23% achieved ?50% pain reduction. The authors believe the methotrexate is reducing the synovitis, and call for a large study to be funded.

In my experience, patients really do not like taking methotrexate, but at least we can now say: 'This might reduce your pain significantly,' to help the compliance.

Control of type 2 diabetes, hypertension and hyperlipidaemia

JAMA 2013; 309(21): 2240-9

This two-group, unblinded, randomised study involved 120 patients with HbA1c 8% or higher, BMI 30-39.9, C-peptide level more than 1ng/ml and type 2 diabetes.

They were given Roux-en-Y gastric bypass surgery or intensive 'best practice medical management'.

After one year, 49% of those treated surgically, but only 19% of the medical group, had achieved the primary endpoints of lowering cholesterol, systolic BP <130mmhg and="" hba1c="" 7="" p="">

The surgically treated group, on average, each took three fewer medications. There were 22 serious adverse events in the surgical group (including 10 surgical complications), and 15 serious adverse events in the medical group.

This study only ran for one year. What we really need is follow-up of both groups for 10-20 years. This would enable us to understand the costs, benefits and risks of drastic surgical solutions to obesity, compared with our 'best' medical treatments.

Consistent and correct use of the oral contraceptive pill

Contraception 2013; 87(5): 605-10

This review looked at the number of combined oral contraceptive pill packs prescribed at one time and how this affected continuation of use, pregnancy testing and pregnancies.

Prescribing four months or more at a time was associated with fewer pregnancy tests, fewer pregnancies and less cost. It was, however, also associated with increased wastage.

There are arguments about offering STI screening, cervical smears and general health messages when women come in for 'pill checks', but these must be balanced against the cost and inconvenience of having to attend every three months, and the serious risk of unwanted pregnancy.

Most GPs find that if a woman is happy with a particular brand, a yearly review is useful and a six-monthly repeat prescription reasonable.

The protective effect of alcohol in rheumatoid arthritis

Rheumatology 2013; 52(5): 856-67

In a Medline search with meta-analysis, this group found a significant protective effect of alcohol on ever developing rheumatoid arthritis (RA ACPA-positive).

They looked at adults who drink alcohol versus never drinkers.

The RA risk in alcohol drinkers versus non-drinkers was 0.78 (95% CI 0.63-0.96). This effect was only confined to ACPA-positive RA. Alcohol intake is inversely associated with ACPA-positive RA, suggesting a protective effect.

The impact of coffee on health

Maturitas 2013; 75: 7-21

I have always thought coffee is wonderful, but this review of its impact on disease shows how complicated its effects can be.

A case-controlled study detected increased MI risk in the hour after coffee intake, and ischaemic stroke in non-habitual drinkers, but a weak inverse (10-20% risk reduction) in risk of stroke and coffee consumption.

The authors also conclude, using evidence from the Framingham Heart Study and the Third National Health and Nutrition Examination Survey, that 'there is no clinical basis for associating coffee intake and cardiac arrhythmias'.

There is an inverse association between coffee consumption and incidence of diabetes mellitus. There is also a 33% reduction in risk of Parkinson's disease with caffeine consumption (the mechanism is unknown).

Most meta-and pooled analyses show coffee has a neutral effect in different cancers and total cancer. In big nutritional studies, adjusted hazard ratios for death in coffee drinkers were 0.90 for two to three cups a day in men, 0.87 in women.

  • Dr Hope is a GP in Woodstock, Oxfordshire, and a member of our team who regularly review the journals

Reflect on this article and add notes to your CPD Organiser on MIMS Learning


These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Consider at what point an obese, poorly controlled type 2 diabetic patient should be referred for consideration of gastric banding.
  • Audit combined oral contraceptive pill prescribing by number of months and see if you should be giving more months at a time, to reduce unwanted pregnancies and aid patient compliance with the method.
  • Discuss with colleagues how much you consider coffee and alcohol intake when discussing lifestyle factors with patients who have long-term conditions.

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