Microscopic Colitis / Lymphocytic Colitis

Lately one of my patients told me about microscopic colitis (in here case lymphocytic colitis) being diagnosed. As she had been on sulfasalazine, she asked me, if it would harm her. My first though was that sulfasalazine could be a good idea since there are hints that the lymphocytic colitis has a immunologic background.  There is an association with NSAIDs and some antidepressants, however. And my patient took NSAIDs.

There is only one publication from 2006 addressing the issue (1). M. Fekih and colleagues published: [Microscopic colitis. A 20 cases series] Original article in French. The authors reported 20 cases. “Endoscopic examination was normal in 95% of patients. We diagnosed collagenous colitis in 65% of cases and lymphocytic colitis in 35% of cases.” They observed a clinical remission in 41.2% of 16 patients. An interesting observation, but since it hasn’t been followed in the past 10 years, sulfasalazine shouldn’t be considered a therapeutic option in lymphocytic colitis.

Link:

(1) https://www.ncbi.nlm.nih.gov/pubmed/17039729

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Metaanalyse zeigt gleiche Wirksamkeit für NSAR und Opiate bei Kniegelenksarthrose

Schmerzen bei Arthrosen sind eine tägliche Qual für Patienten und ein tägliches Problem für Ärzte. Wenn die physikalischen Maßnahmen ausgeschöpft sind, werden Medikamente eingesetzt. Effektive Medikamente haben aber auch Nebenwirkungen. Da ist es gut zu wissen, welche Präparate oder Medikamentenklassen Vorteile haben und welche eher nicht. Opiate gelten schärfste Waffe der Schulmedizin gegen den Schmerz. Metaanalysen versuchen solche Fragen zu klären, indem die vorhandenen Studien ausgewertet und zusammengeführt werden. Nicht jede Studie eignet sich für solche Auswertungen. Die Studien müssen gewisse Qualitätsforderungen erfüllen.

S.R. Smith und Kollegen stellten eine Metaanalyse mit dem Titel: „Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review“ vor. 27 Therapiearme aus 17 Studien kamen zur Auswertung (9 für Celecoxib, einem COX-2-Inhibitor; 4 für nicht-selektive NSAR [Nicht-Steroidale Anti-Rheumatika] und zwar Diclofenac, Naproxen und Piroxicam; 11 schwach potente Opiate / Tramadol; 3 für hoch potente Opiate [Hydromorphon, Oxycodon]). Die statistischen Analysen zeigten keine Unterschiede für die verschiedenen Klassen der Medikamente. Patientengruppen mit höherem Anteil an Männern und höherer Schmerzstärke vor Therapiebeginn hatten eine stärkere Schmerzreduktion.

Aus der Studie folgt, dass Schmerzen bei Kniegelenks-arthrose individueller gestalten werden können. Opiate sind nicht erfolgreicher per se. Opiate bergen ein höheres Risiko für Stürze, so dass man dies berücksichtigen kann. NSAR haben andere Risiken. Die vorliegende Metaanalyse lässt sich nutzen, um die Risiken der Therapie mehr in die Therapieempfehlungen einfließen zu lassen.

 

Literaturangabe:

S.R. Smith et al.: “Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review”. Osteoarthritis Cartilage. 2016 Jun;24(6):962-72. doi: 10.1016/j.joca.2016.01.135. Epub 2016 Feb 1. http://www.ncbi.nlm.nih.gov/pubmed/26844640

 

Ankylosing Spondylitis – more myths

Today we’re going to discuss to further myths:
healing ankylosing spondylitis is around the corner
in ankylosing spondylitis nothing works.
Though considering before and after establishing TNF-alpha-inhibitors as an effective therapy is important, myths have a tendency to survive.
Before TNF-blockers therapeutic options for ankylosing spondylitis were limited to nonsteroidal antirheumatic drugs (NSAIDs) and physical therapy. Corticosteroids and disease-modifying antirheumatic drugs weren’t successful in ankylosing spondylitis. But even then, a high percetage of patients did well on NSAIDs and fighted ankylosis, stiffness, and deformations with physical therapy. It has been shown, that continuous NSAID-intake even delays radiographic progression. But there were patients (and there still are!) with ankylosing spondylitis not respoding to NSAID therapy! About 10-12 years ago TNF-blockers showed effectiveness in lots of patients, who were desperate while on NSAIDs. Or who couldn’t take NSAIDs because of adverse events. Today infliximab, etanercept, adalimumab, and golimumab are approved for the treatment of ankylosing spondylitis.
Diagnosis can be made earlier. We have an interest nowadays to diagnose the disease before radiographic changes appear. Therefore the New York criteria are a bit outdated. If you make the diagnosis with the help of this tool, it is already ankylosing spondylitis you see, whereas in axial spondyloarthritis you diagnose the inflammatory disease before radiographic damage begins to show. The question is: does early and more aggressive treatment with TNF-blockers show better responses? To cut the story short: early treatment with TNF-blockers in preradiographic axial Sponyloarthritis show a better clinical response and a higher rate of remission. Longer phases of sustained drugfree remission have been seen. But still you can’t call it healing ankylosing spondylitis. And please don’t forget that there are non-responders.
Even if healing ankylosing spondylitis isn’t around the corner, established therapies can improve quality of life in a large percentage of people with ankylosing spondylitis / axial spondyloarthropathies.

To be continued …

NSAIDs - a German observation

I've made a strange observation, quite a lot of both patients and physicians think that ibuprofene has less side effects than diclofenac, but think that diclofenac is the more potent NSAID.
I think it has something to do with dosage. Ibuprofene comes in a multitude of dosages 200, 300, 400, 600, 800 mgs and others. Diclofenac is mostly prescribed in the 50 mg or 75 mgs dosage, though other dosages exist as well. With 150 mgs diclofenac being the upper dosage, you reach this level with 2x75 mgs. If you start with 3x300 mgs ibuprofene, you'll have a long way to reach 2400 mgs, which is the upper level.
All in all diclofenac and ibuprofene have an equal share of side effect or efficacy given at comparable dosages.
If one has to take aspirin for vascular reason, diclofenac is the better choice, as ibuprofene which couteract the effect of aspirin.

PS.: This is internet and not a medical practice - don't change your medication unless you've asked your physician.