Meditation therapy for rheumatoid arthritis patients

A revered contemplative practice for centuries, meditation has recently inspired research into its therapeutic value for everything from anxiety disorders to heart attack prevention. A painful, progressive autoimmune disease, rheumatoid arthritis (RA) is associated with a high risk of depression—double the risk of the healthy population, by conservative estimates—and various forms of psychological distress. Increasingly, RA patients are turning to alternative therapies like meditation to ease the toll of their disease.
Mindfulness-Based Stress Reduction (MBSR) is a meditation training program developed by Dr. Kabat-Zinn and colleagues at the University of Massachusetts Medical School. MBSR teaches participants to relate differently to thoughts and emotions, and continually focus the mind on the present moment to increase clarity and calmness. The program has been shown to improve psychological symptoms in patients with fibromyalgia, cancer, and multiple sclerosis, among other conditions. Researchers with the University of Maryland School of Medicine set out to assess the effect of this meditation therapy on depressive symptoms, psychological distress, general well-being, and disease activity among RA patients. Featured in the October 2007 issue of Arthritis Care & Research (http://www.interscience.wiley.com/journal/arthritiscare), their study supports the potential benefits of prescribing a course in MBSR along with the conventional course of physical and pharmacological therapy.
Recruited through community health fairs and ads in Baltimore newspapers, 63 adult RA patients were selected to participate in this novel pilot study. Averaging 54 years in age, participants were mostly female, white, married, college educated, and comfortably middle-class. None had a history of psychiatric illness, alcohol or drug addiction, or other chronic pain disorders. All patients remained under their rheumatologist’s care and continued to take their routine medications throughout the study.
Through random assignment, 31 of the participants received intensive MBSR therapy, starting with an 8-week training course followed by a 4-month maintenance program. The remaining 32 participants were designated to a waitlist, agreeing to attend assessment sessions in exchange for free MBSR training after the study’s end. At baseline, and again at 2 months and 6 months into the study, both groups of participants underwent psychological and rheumatological examinations. To evaluate depressive symptoms and psychological distress, researchers used the Symptom Checklist-90-Revised, a self-report questionnaire widely recognized for its reliability and validity. Overall well-being was measured by the Psychological Well-Being Scales, comprised of questions designed to gauge positive outlook and approach to coping with difficulties. RA disease status was assessed by the Disease Activity Score in 28 joints (DAS-28).
Researchers compared scores of psychological and physical disease symptoms among MBSR participants with those among controls. Overwhelming, MBSR students embraced the program and kept up their mindfulness practice throughout the followup period. After 2 months, both groups showed improvements in depressive, psychological, and emotional symptoms, with no significant benefits attributed to MBSR. By 6 months, however, gains in the control group had largely disappeared, while MBSR participants maintained or improved further in psychological outcomes. By the culmination of the study, the MBSR group achieved a significant 35 percent reduction in psychological distress. Despite this dramatic improvement, the therapy had no impact on RA disease activity, measured by the DAS-28, which takes into account number of tender or swollen joints, a blood measure of inflammation, and the patient’s own report of disease status.
As the researchers acknowledge, the study had limitations, primarily its small sample size and its likely floor effect. On the strength of their backgrounds, participants might have been less vulnerable to psychological distress and depression than RA patients with fewer socioeconomic advantages, not to mention those with a history of mental illness or substance abuse. Yet, these limitations should not overshadow the positive findings and applications. “The study demonstrated that for patients with RA under routine medical supervision, an 8-week MBSR class plus a 4-month maintenance program had beneficial effects, and that it was safe and appealing to participants,” notes investigator Elizabeth Pradhan, PhD. “For doctors wishing to offer patients a complement to medical management, mindfulness meditation may offer hope for improving psychological distress and strengthening well-being in patients with RA.”

Isoniazid for Latent Tuberculosis Well Tolerated in Patients Taking Methotrexate

August 30, 2007 — The use of isoniazid for latent tuberculosis (LTB) was well tolerated in patients with rheumatoid arthritis (RA) who were already receiving treatment with methotrexate, according to a retrospective chart review reported in the August 20 Online First issue of the Annals of the Rheumatic Diseases.
"Reactivation of Mycobacterium tuberculosis (TB) is a significant problem with all available tumor necrosis factor (TNF) antagonists when used to treat rheumatoid arthritis (RA), psoriatic arthritis, psoriasis and other inflammatory diseases," write Adam Mor, PhD, from New York University School of Medicine in New York, and colleagues. "Concerns have been raised regarding the appropriate management of patients with latent TB (LTB) exposure (or active TB infection) before initiating TNF antagonists since the safety data of combined therapy with two potentially hepatotoxic medications, methotrexate (MTX) and isoniazid (INH), is lacking. The goal of this study was to investigate the toxicity of MTX and INH therapy in RA patients before initiating TNF antagonists."
The study authors retrospectively reviewed the medical records of 44 patients seen at the Bellevue Hospital Arthritis Clinic, New York, NY, between 2002 and 2006, and who were treated simultaneously with methotrexate and isoniazid. The main endpoint was increase in liver function tests (LFTs).
Although 11% of patients had transient increases in LFTs, this in no case exceeded twice the upper limit of normal values, and all resolved spontaneously without intervention. When isoniazid and methotrexate were given together, the incidence of abnormal findings on LFTs was no higher than that seen with either drug given alone.
"The use of INH for LTB was well tolerated in RA patients on a background regimen of MTX," the investigators write. "While the risks and benefits of all therapy must always be considered, in our experience the additive risk of INH to MTX in terms of hepatotoxicity was low. Nonetheless it is prudent to follow LFT closely on patients taking this combination."
None of the patients developed evidence of reactivation of TB reactivation.
Limitations of the study include a small sample, possible selection bias, exclusion of patients with abnormal findings on LFTs at baseline, folic acid treatment used in combination with methotrexate in all patients, and the inability to identify any subset of patients with an increased risk of developing abnormal findings on LFTs during treatment with both drugs.
This study has received no external funding, and the authors have disclosed no relevant financial relationships.
Ann Rheum Dis. Published online August 20, 2007.

Combination Drug Therapy Retards Early RA Damage

LEIDEN, The Netherlands, March 20 -- For early rheumatoid arthritis, aggressive combination therapy can slow progression to joint damage, investigators here found.
Among 508 patients treated in a randomized multicenter trial, initial combination therapy plus either tapered prednisone or infliximab (Remicade) and other medications outperformed monotherapy in the first year, reported Yvonne P.M. Goekoop-Ruiterman, M.D., of the University of Leiden, and colleagues and other centers.
"We conclude that the difference in disease activity during the first year is clinically relevant and will probably have an economic impact," the investigators wrote in the March 20 issue of the Annals of Internal Medicine.
The combination therapy with prednisone or infliximab was also better at suppressing progression to joint damage in the early stages of disease, but by two years about 42% of patients in all treatment groups were in remission, and many were being maintained on only one disease-modifying antirheumatic drug (DMARD), or none, the authors noted.
http://www.medpagetoday.com/Rheumatology/Arthritis/tb1/5283