Smoking and the ACR 2015 Meeting in San Francisco

I cannot discuss all the 25 studies on smoking in detail, which were presented at the ACR 2015 Annual Meeting in San Francisco, but I have selected a few and will summarize the others. Effects on pain are seen with and without concomitant inflammation. So we see worsening in inflammatory rheumatic diseases as well as in fibromyalgia.

Adam Schiffenbauer and colleagues looked at smoking and the development of mysitis antibodies. Conclusion: “These data suggest that in Caucasians smoking is a risk factor for developing ILD, as well as anti-Jo-1 Abs and ASA, but is protective for anti-TIF-1, -Mi-2, and -MJ Abs.”Interestingly they didn’t find this impact in African Americans.

Jasvinder A. Singh and colleagues presented a study on “Perioperative Interventions for Smoking Cessation in Hip and Knee Arthroplasty for Osteoarthritis and Other Non-Traumatic Diseases”. They’ve concluded: “With an overall high grade of evidence, Perioperative smoking cessation therapy is significantly more efficacious than placebo in preventing incidence of complications after knee or hip replacement.”

Karin Magnusson and colleagues’ study: “Smoking and Alcohol Use Are Associated with Structural and Inflammatory Hand Osteoarthritis Features in a Population Based Study”. The authors come to a rather irritating conclusion: “Our results suggest a protective effect of smoking on radiographic hand OA whereas alcohol consumption may increase the risk of joint inflammation in hand OA.”

Axel Finckh1and colleagues  Inform us on: “The Impact of Tobacco Smoking on the Effectiveness of Abatacept in Rheumatoid Arthritis: […]”.Conclusion: “Data from this Pan-European registry analysis suggest that smoking is associated with a decreased effectiveness of ABA, with higher discontinuation rates and lower response rates, as has previously been reported for methotrexate and anti-TNF agents.”

Daniel Wendling and colleagues presented this study: “ASDAS-Based Remission Was Less Frequent Than Basdai-Based Remission, and Both Were Related to CRP and Smoking in Early Axial Spondyloarthritis”. Conclusion: “[…] smoking appears as a major marker of disease activity and remission in early AxSpA.”

Kristina SCHREIBER and colleagues concluded from their study: “Current and past smocking is associated with an increased disease activity (BASDAI and ASDAS-CRP respectively) and functional impairment. Pathogenesis remains to be determined. Smoking cessation should be encouraged in axSpA although these results suggest that it may not impact disease prognosis.”

Jeffrey A. Sparks and colleagues: “Smoking Behavior Changes after Rheumatoid Arthritis Diagnosis and Risk of Mortality during 36 Years of Prospective Follow-up”. They concluded: “Despite the known harmful effects of smoking in chronic diseases, only 16% of smokers quit after diagnosis with RA and maintained smoking cessation during follow-up. Smoking >5 pack-years after RA diagnosis was associated with increased mortality, independent of smoking before RA diagnosis. Interventions promoting cessation of smoking for patients newly diagnosed with RA may diminish the excess mortality of RA.”

Patricia P. Katz and colleagues on: “Impact of Smoking on Patient-Reported Disease Status and Symptoms Among Women with Lupus”. Conclusion: “While current smoking was not common, it was associated with significantly worse patient assessments of lupus status and worse symptoms. […].”

These and other studies underline the importance to actively promote the cessation of smoking in all of patients, who are treated in rheumatology.

References:

Schiffenbauer A, Smith N, Rider LG, Miller FW. Tobacco Smoking in Different Racial Groups Is Differentially Associated with the Development of Myositis Autoantibodies and Interstitial Lung Disease in the Idiopathic Inflammatory Myopathies [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/tobacco-smoking-in-different-racial-groups-is-differentially-associated-with-the-development-of-myositis-autoantibodies-and-interstitial-lung-disease-in-the-idiopathic-inflammatory-myopathies/. Accessed November 15, 2015.

Bharat A, Singh JA. Perioperative Interventions for Smoking Cessation in Hip and Knee Arthroplasty for Osteoarthritis and Other Non-Traumatic Diseases [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/perioperative-interventions-for-smoking-cessation-in-hip-and-knee-arthroplasty-for-osteoarthritis-and-other-non-traumatic-diseases/. Accessed November 15, 2015.

Magnusson K, Mathiessen A, Hammer HB, Natvig B, Hagen KB, Østerås N, Haugen IK. Smoking and Alcohol Use Are Associated with Structural and Inflammatory Hand Osteoarthritis Features in a Population Based Study [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/smoking-and-alcohol-use-are-associated-with-structural-and-inflammatory-hand-osteoarthritis-features-in-a-population-based-study/. Accessed November 15, 2015.

Finckh A, Gottenberg J, Hernández MV, Iannone F, Lie E, Canhao H, Pavelka K, Turesson C, Lund Hetland M, Mariette X. The Impact of Tobacco Smoking on the Effectiveness of Abatacept in Rheumatoid Arthritis: Data from a Paneuropean Analysis of RA Registries [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/the-impact-of-tobacco-smoking-on-the-effectiveness-of-abatacept-in-rheumatoid-arthritis-data-from-a-paneuropean-analysis-of-ra-registries/. Accessed November 15, 2015.

Wendling D, Guillot X, Gossec L, Prati C, Saraux A, Dougados M. ASDAS-Based Remission Was Less Frequent Than Basdai-Based Remission, and Both Were Related to CRP and Smoking in Early Axial Spondyloarthritis [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/asdas-based-remission-was-less-frequent-than-basdai-based-remission-and-both-were-related-to-crp-and-smoking-in-early-axial-spondyloarthritis/. Accessed November 15, 2015.

SCHREIBER K, Barnetche T, Combe B, Morel J, Daien CI. Current and Past Smoking Are Associated with Functional Impairement and Increased Disease Activity in Axial Spondyloarthritis: Systematic Review and Meta-Analysis [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/current-and-past-smoking-are-associated-with-functional-impairement-and-increased-disease-activity-in-axial-spondyloarthritis-systematic-review-and-meta-analysis/. Accessed November 15, 2015.

Sparks JA, Nguyen USDT, Chang SC, Zhang Y, Choi H, Karlson EW. Smoking Behavior Changes after Rheumatoid Arthritis Diagnosis and Risk of Mortality during 36 Years of Prospective Follow-up [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/smoking-behavior-changes-after-rheumatoid-arthritis-diagnosis-and-risk-of-mortality-during-36-years-of-prospective-follow-up/. Accessed November 15, 2015.

Katz PP, Chakravarty E, Katz RS, Michaud K. Impact of Smoking on Patient-Reported Disease Status and Symptoms Among Women with Lupus [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/impact-of-smoking-on-patient-reported-disease-status-and-symptoms-among-women-with-lupus/. Accessed November 15, 2015.

Fibromyalgia at the ACR 2015 Meeting in San Francisco / Miscellanea

As I cannot discuss all studies presented at the ACR 2015 Annual Meeting in San Francisco, I have selected a few more without a context – miscellanea.

Robert S. Katz and colleagues presented an observational study: “Patients Who Take Many Medications for Their Fibromyalgia Symptoms at the Initial Office Visit Tend to Have a Worse Clinical Course”. Conclusion: “Those patients taking more prescription for their fibromyalgia symptoms at their initial office visit tended to have a worse clinical course, evidenced by higher HAQ scores, poor general health, and more pain and fatigue.” I guess all rheumatologists treating fibromyalgia can agree to these findings. Now, we’d like to know, what’s behind this observation. My guess is: a different way of coping, patients in this group might be classified as being passive, avoiding, externalizing, alexithymic.

Thomas Romano presented a study (?): “Correlation of Magnesium Levels and IGF-! Levels in Fibromyalgia Patients”. Background/Purpose: “To determine if there is a correlation between RBC Mg levels and IGF-! levels in Fibromyalgia (FM) patients”. “All [patients] fulfilled ACR 1990 Criteria for FM.” Conclusion: “There was a statistically significant positive correlation between IGF-1 levels and RBC Mg levels in the 60 FM patients studied. This has implications for treatment and further diagnostic testing.” Maybe there is a correlation, so what? And maybe it’s time to use the new ACR criteria. For sure it’s a bold statement that this correlation of (unnecessary?) lab tests of selected patients should have implications for treatment and further diagnostic testing.

Low IGF-1 levels in fibromyalgia patients have already been shown in 1992; please refer to the study by RM Bennett and colleagues; somatomedin C has been renamed IGF-1. So, again I must say: nothing new under the sun.

Daniel Kim and colleagues addressed weather in their study: “Evaluating Weather’s Effect on Fibromyalgia Patients Using the Revised Fibromyalgia Impact Questionnaire and the Brief Pain Inventory”. They used a broad set of parameters, but the authors “did not find any statistically significant effect of weather on fibromyalgia symptoms”. It’s like a pendulum. We know from our patients that weather changes and rainy, humid, cold weather conditions are attributed with increased pain and other symptoms of fibromyalgia (as well as inflammatory rheumatic diseases!), but as strange as it may seem, stressable scientific proof is yet to come. I hope that research on this topic will go on.

Lin Ge and colleagues looked at: “Association of Smoking and Cognitive Function in Patients with Fibromyalgia”. Conclusion: “The results of this study indicate that smokers with FM report worse cognitive function. Although the cause-effect relationship between smoking and cognition is unclear, clinicians who care for patients with FM should be aware of this association.” I think, I’ll take this study and others to look more closely at the diseases we treat and the effects of smoking. Some studies are congruent with these findings, others are not. I guess we all agree that smoking isn’t healthy and may worsen symptoms and make treatment less effective. Concerning cognitive function there seems to be a link to Alzheimer’s and dementia per se.

References:

Katz RS, Katz Small A, Leavitt H. Patients Who Take Many Medications for Their Fibromyalgia Symptoms at the Initial Office Visit Tend to Have a Worse Clinical Course [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/patients-who-take-many-medications-for-their-fibromyalgia-symptoms-at-the-initial-office-visit-tend-to-have-a-worse-clinical-course/. Accessed November 12, 2015.

Romano T. Correlation of Magnesium Levels and IGF-! Levels in Fibromyalgia Patients [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/correlation-of-magnesium-levels-and-igf-levels-in-fibromyalgia-patients/. Accessed November 12, 2015.

Bennett RM, Clark SR, Campbell SM, Burckhardt CS: Low levels of somatomedin C in patients with the fibromyalgia syndrome. A possible link between sleep and muscle pain. Arthritis Rheum. 1992 Oct;35(10):1113-6. PMID: 1418002. http://www.ncbi.nlm.nih.gov/pubmed/1418002.

Kim D, Chan R, Plans M, Hackshaw K. Evaluating Weather’s Effect on Fibromyalgia Patients Using the Revised Fibromyalgia Impact Questionnaire and the Brief Pain Inventory [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/evaluating-weathers-effect-on-fibromyalgia-patients-using-the-revised-fibromyalgia-impact-questionnaire-and-the-brief-pain-inventory/. Accessed November 12, 2015.

Ge L, Oh TH, Vincent A, Mohabbat A, Jiang L, Whipple M, McAllister S, Wang Z, Qu W. Association of Smoking and Cognitive Function in Patients with Fibromyalgia [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). http://acrabstracts.org/abstract/association-of-smoking-and-cognitive-function-in-patients-with-fibromyalgia/. Accessed November 12, 2015.

Fibromyalgia and smoking: http://rheumatologe.blogspot.de/2011/11/fibromyalgia-and-smoking.html

Quit Smoking and Weight Gain

I have been interested in smoking and rheumatic diseases for quite a while. Some of my blog posts are only in German as I use these texts also for real life patient education and information. About 10 years ago we developed a leaflet for patient to promote smoking cessation. Some did und some had problems with weight gain. As weight gain is a constant problem in a setting, where steroids are used, I’m very concerned about this issue.

Today I stumbled upon a study by L. Biedermann and colleagues: “Smoking cessation induces profound changes in the composition of the intestinal microbiota in humans.” They observed “profound shifts in the microbial composition after smoking cessation” and “an increase in microbial diversity.” They concluded: “These results indicate that smoking is an environmental factor modulating the composition of human gut microbiota. The observed changes after smoking cessation revealed to be similar to the previously reported differences in obese compared to lean humans and mice respectively, suggesting a potential pathogenetic link between weight gain and smoking cessation.”

I think the paper is important not only as there is an explanation for the weight gain and a rehabilitation of people, who didn’t gain weight because of consuming more sweets, but it might also lead to therapies that actively change the composition of the intestinal microbiota. If this would help people, who quit smoking, maybe it could also help obese people.

Links:

Abstract on Pubmed: http://www.ncbi.nlm.nih.gov/pubmed/23516617

Full article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3597605/

http://rheumatologe.blogspot.de/2011/12/smoking-and-axial-spondyloarthritis.html

http://rheumatologe.blogspot.de/2011/11/fibromyalgia-and-smoking.html 

30.08.2013

Besides the above mentioned changes in the intestinal microbiota there are other mechanism involved as well, which will lead to weight gain. Nicotine suppresses appetite. Food might act as a replacement for smoking. Sweets and nicotine act on dopaminergic receptors in the brain, which make us feel good.

Link: http://quitsmoking.about.com/od/weightgain/a/weightgainquit.htm

Psoriatic Arthritis at the ACR 2012 in Washington

Non-anti-TNF Biologics in Psoriatic Arthritis at EULAR 2011. http://rheumatologe.blogspot.de/2012/07/non-anti-tnf-biologics-in-psoriatic.html. I hope for new results on new drugs as therapy for psoriatic arthritis still lags behind.

Actually I’ve found only data on one drug: apremilast. Apremilast is a small molecule – a phospodiesterase 4 inhibitor. About a year ago, I’ve mentioned apremilast in ankylosing spondylitis: http://rheumatologe.blogspot.de/2012/01/efficacy-and-safety-of-apremilast-oral.html.

Juergen Rech and colleagues presented (Abstract No 272): “Interim Safety Analysis of a Phase 2, Multicenter, Randomized, Double-Blind, Placebo-Controlled, Parallel-Group, Efficacy Study of Apremilast (CC10004) in Subjects with Erosive Hand Osteoarthritis.” Conclusion: “ … we conclude that apremilast may also be well tolerated in patients with EHOA [erosive hand arthritis]. Apremilast, if proven to be efficacious in ongoing investigations, will be an interesting treatment option for patients with EHOA.”

There has been a second study by Arthur Kavanaugh and colleagues (Abstract No. L13): “Apremilast, an Oral Phosphodiesterase 4 Inhibitor, in Patients with Psoriatic Arthritis: Results of a Phase 3, Randomized, Controlled Trial”. Conclusion: “Apremilast significantly improved signs and symptoms of PsA and resulted in statistically and clinically meaningful improvements in physical function. Apremilast was generally well tolerated and no new safety or laboratory signals were detected.” Lets look at some side effects: diarrhea (placebo: 2.4%; apremilast 20 mg BID: 11.3%; and apremilast 30 mg BID, 19.0%), nausea (high dose: 18.5%), headache (10.1%, and 10.7%), and more.

There are still some hurdles to be taken by apremilast!

There’s another study of Bremander on smoking. B. I. Bremander and colleagues presented: "Smoking Is Associated with Worse and More Widespread Pain, Worse Fatigue, General Health and Quality of Life in a Swedish Population Based Cohort of Patients with Psoriatic Arthritis" (Abstract No. 1828). Conclusion: In this population based PsA cohort, patients who were ever smokers reported worse clinical outcomes compared with never smokers. ..."

I think the message is clear. Stop smoking!

Studies on ustekinumab are here: http://rheumatologe.blogspot.de/2012/12/ustekinumab-at-acr-2012-in-washington.html.

Smoking and Axial Spondyloarthritis

Pedro Machado and colleagues investigated the influence of smoking in axial spondyloarthritis. Smoking was associated with earlier onset of inflammatory back pain, higher disease activity as measured in the Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP) and the BASDAI, worse functional status (BASFI), more structural damage as shown in MRI or X-ray, and apoorer health-related quality of life. The authors see important implications in the education of patients with axial spondyloarthritis and “the need to consider smoking as one of the potential prognostic factors axial spondyloarthritis”.


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Smokers in Early Axial Spondyloarthritis Have An Earlier Disease Onset, More Inflammation and Damage: Results From the DEvenir Des Spondyloarthropathies Indifferenciées Récentes Cohort.
Pedro Machado1, Ho Y. Chung2, Desirée van der Heijde3, Maria-Antonietta D’Agostino4 and Máxime Dougados5.
1Leiden University Medical Center, Leiden, Netherlands&Coimbra University Hospital, Coimbra, Portugal, 2Leiden University Medical Center, Leiden, Netherlands & Queen Mary Hospital, Hong Kong, China, 3Leiden University Medical Center, Leiden, Netherlands, 4Versailles-Saint Quentin en Yvelines University-APHP, Ambroise-Pare´ Hospital, Boulogne-Billancourt, France, 5Paris-Descartes University, Cochin Hospital, Paris, France
Conclusion: In patients with early axial SpA, smoking was independently associated with earlier onset of IBP, higher disease activity, poorer functional status, increased axial inflammation on MRI and axial structural damage on MRI and radiographs, and worse HRQoL. These observations may have important implications in the education of patients with axial SpA and highlight the need to consider smoking as one of the potential prognostic factors in axial SpA as well as one of the environmental factors potentially involved in the pathogenesis of the disease.

Clinical Predictors Associated with Severe Radiographic Sacroilitis in Axial Spondyloarthritis

Grace Yoon and colleagues presented a study to determine if there were clinical predictors of severe sacroilitis. They found association with non-Caucasian ethnicity, disease duration, a history of total hip arthroplasty, and more. Smoking tobacco as measured by pack is also a predictor of severe sacroilitis. With other conclusions the authors see a modifiable risk factor in smoking.
I think, we as rheumatologists or patients’ organisations should put even more emphasis on counseling patients to quit smoking and provide links or access to quit smoking programs.


[SUN] 512
Clinical Predictors Associated with Severe Radiographic Sacroilitis in Axial Spondyloarthritis.
Grace Yoon1, Thomas J. Learch2, John C. Davis3 and Lianne S. Gensler4.
1UCSF, San Franciscao, CA, 2Cedars-Sinai, Los Angeles, CA, 3Genentech Inc, South San Francisco, CA, 4UCSF, San Francisco, CA
Conclusion: Severe radiographic sacroilitis appears to be associated with predictable characteristics like disease duration and total hip arthroplasty, but also appears to be associated with less reported characteristics such as familial AS and tobacco use. Smoking may be a modifiable risk factor for the development of severe radiographic AS.


And here’s another study on the damage smoking is doing in ankylosing spondylitis.

[SUN] 550
Smoking Is Associated with Syndesmophyte Development in Ankylosing Spondylitis.
Dilek Solmaz1, Servet Akar2, Ismail Sari3, Ozgul Soysal1, Vedat Gerdan1, Fatos Onen2 and Nurullah Akkoc2.
1MD, Izmir,
Turkey, 2Professor, Izmir, Turkey, 3Dokuz Eylul University School of Medicine, Izmir, Turkey
Conclusion: Smoking, male sex, age and BASMI scores are independently associated with structural damage in AS. The association between the presence of calcaneal enthesophytes and syndesmophytes, which was present in univariate analysis but which disappeared after multivariate logistic regression analysis, needs to be further explored in future prospective studies.


And there’s still another study on the damage smoking is doing in ankylosing spondylitis.


[SUN] 777
Baseline Radiographic Damage, Elevated Acute Phase Reactants and Cigarette Smoking Status Predict Radiographic Progression in the Spine in Early Axial Spondyloarthritis.
Denis Poddubnyy1, Hildrun Haibel2, Joachim Listing3, Elisabeth Märker-Hermann4, Henning Zeidler5, Jürgen Braun6, Joachim Sieper2 and Martin Rudwaleit7.
1Charite´
Medical University, Campus Benjamin Franklin, Berlin, Germany, 2Charite´ – Campus Benjamin Franklin, Berlin, Germany, 3German Rheumatism Research Centre, Berlin, Germany, 4Dr. Horst Schmidt Kliniken, Wiesbaden, Germany, 5Medizinische Hochschule, Hannover, Germany, 6Rheumazentrum Ruhrgebiet, Herne, Germany, 7Ev. Krankenhaus Hagen-Haspe, Hagen, Germany
Conclusion: The presence of radiographic damage in the spine (syndesmophytes), elevated acute phase reactants and cigarette smoking status predict spinal radiographic progression in early axial SpA.

Fibromyalgia and Smoking

Concerning fibromyalgia and smoking there has been an interesting poster at the 2011 ACR Meeting in Chicago. The poster has been on display on Tuesday, the 8th of November. Jenna Goesling and colleagues looked into smoking and fibromyalgia. They found higher rates of smoking in patients with fibromyalgia than in patients not suffering from fibromyalgia. My interpretation is that smoking is used by patients to alleviate pain but leads to the opposite; same as for stress, which serves patients not to think of pain on a short term basis, but which enhance pain in the long run. And smoking was “associated with greater pain, more interference, anxiety, and depression.” We are already used to tell our patients to stop smoking, but now we have a sound scientific basis to do so.

Here is a part of the abstract of the mentioned poster shown at the 2011 ACR Meeting in Chicago:

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Smoking and Fibromyalgia: The Need for a Multidisciplinary Approach to Treatment.
Jenna Goesling1, Chad M. Brummett1, Kevin Rakovitis1, Daniel J. Clauw2 and Afton L. Hassett3. 1University of Michigan Health System, Ann Arbor, MI, 2University of Michigan, Ann Arbor, MI, 3University of Michigan Medical School, Ann Arbor, MI
Conclusion: Smoking rates were higher among patients who met survey criteria for FM compared to patient’s who did not meet FM criteria. When comparing only patients who met FM criteria, smoking was associated with greater pain, more interference, anxiety, and depression. These results suggest that smokers who met survey criteria for FM have several comorbid factors that likely interfere with functioning. In conclusion, a multidisciplinary approach to treatment of chronic pain among current smokers, especially in patients who meet FM criteria, should include both cessation advice and treatment for co-occurring mood disorders. It follows that further consideration of the complex relation between smoking, mood and pain may help inform treatment decisions and interventions among patients who meet survey criteria for FM. Future studies will focus on differences in post-treatment outcomes between smokers and non-smokers who meet FM criteria.