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
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