News & Views Newletter
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PSORIATIC ARTHRITIS NEWS AND VIEWS
VOL. 3 ISSUE 18 - October 15, 2003
PSORIATIC ARTHRITIS MEDICAL NEWS

STOPPING THE SPREAD OF PSORIASIS
By Amanda Gardner Sept. 8, 2003 HealthDay Reporter from HealthDayNews

For the nearly 5 million Americans who suffer from psoriasis, life can be a painful odyssey of pills, creams and even light therapy. Worse yet, the condition can spread beyond large swaths of skin to the joints, leading to debilitating arthritis.

Fortunately, knowledge about the condition is increasing and, with it, the stock of available remedies. The most promising are new biologic treatments that work with few side effects, experts say.

"I'd say [psoriasis] is very treatable. It's just not curable," says Dr. Ted Daly, director of pediatric dermatology at Nassau University Medical Center in East Meadow, N.Y.

Psoriasis is immune-mediated, meaning that abnormal immune system responses are somehow involved.

"There's no question that the immune system plays a role in the development of the disease," says Dr. Mark Lebwohl, professor and chairman of the department of dermatology at the Mount Sinai School of Medicine in New York City and president of the medical board of the Psoriasis Foundation.

Other than that, no one is sure what causes the disease, although there does seem to be a genetic component. "We have not identified the psoriasis gene, but [the disease] seems to be a combination of genes and external factors," Lebwohl says.

While the precise causes are unclear, some triggers have been identified, including strep throat, cold weather, being out of the sun and even the drug lithium, which is commonly prescribed for bipolar disorder.

What is certain, however, is the suffering it can cause. Psoriasis manifests as an uncomfortable itchy, thickening of the skin with red patches and silvery scales. These abnormal patches are really areas of extra skin cells. Inside the body, defective immune systems trigger a series of events that lead to the skin's outer layer growing at a much faster rate than normal.

"Instead of being a month, the turnover of cells happens within a week or even less," Daly explains. There's not enough time for the dead cells to slough off, so these buildups occur. The red comes from the excess blood supply needed by the rapidly growing cells.

For some people, the rash is confined to a small part of the body, such as elbows, knees or scalp. Others aren't so lucky. The scaly area can spread to cover a much greater area. "It can go from a patch or two to 100 percent of the body," Daly says.

And the disease can strike at any age. "Just because you don't have it now doesn't mean you won't get it in the future," Lebwohl explains. "It can come as early as birth and as late as 100 years of age."

Luckily, recent treatment advances are making life easier for many sufferers. Most exciting is the development of biologic treatments. "These drugs target specific receptors on molecules or specific chemicals without affecting the entire immune system," Lebwohl says. That means they have far fewer side effects than conventional treatments.

The U.S. Food and Drug Administration approved the first biologic treatment for psoriasis in March: alefacept (brand name Amevive). A study published in the June issue of the Archives of Dermatology found that people taking 15 milligrams of the drug had a 75 percent reduction in their Psoriasis Area and Severity Index, or PASI, a measure of the severity of the condition.

Alefacept stops the overproduction of skin cells by destroying the defective immune cells that are responsible for the abnormality.

"That's one of at least five new agents that are in development for psoriasis and probably more will be coming after that and probably we haven't even seen the best of them," Lebwohl says. "As time goes on, we're going to see better and better molecules."

Enbrel, or etanercept, another biologic agent, was approved for psoriatic arthritis in January 2002 and is currently being considered by the FDA for moderate to severe psoriasis.

Many patients still rely on the traditional arsenal of treatments, many of which have been around for decades. "Those treatments are still very useful," Lebwohl says.

Some, such as cyclosporine, may be more effective than the biologics, but can entail severe side effects. Cyclosporine can damage the kidneys, and methotrexate, a chemotherapy drug, can cause liver damage. Both of these drugs are for more severe forms of the disease, doctors say.

Varieties of treatments are available for milder versions of psoriasis, including creams you put directly on your skin (for instance, steroid creams and topical vitamin D). People with larger affected areas might benefit from light therapy, or even a combination of this and topical creams.

Copyright 2003 HealthDayNews, Inc

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CTLA-4 EXPERMENTAL DRUG NOW IN TRIALS

BOSTON -- Excerpted from the Boston News Channel and provided by Micky in London

There's a new drug under study for rheumatoid arthritis. It's still experimental, but some believe it could be the best alternative to stop the debilitating disease.

News Center 5's Liz Brunner reported that rheumatoid arthritis patients participating in the study are praising the results.

"Before I came in here, I wanted to sit down and cry, I hurt so much," said arthritis patient Janet Smith.

The first time Smith went to see Dr. Charles Birbara, she was in a wheelchair. Just hours later, she said, she walked out, and her life had been restored.

"I go to work part-time, I cook. I still have a hard time peeling potatoes, but that's alright," said Smith.

What made the difference was a new drug called CTLA-4. Given by infusion once a month, it is the latest experimental drug to be studied for rheumatoid arthritis.

"We are seeing some rather dramatic results," said Birbara.

Birbara runs one of 100 sites testing the new drug worldwide. He said CTLA-4 was designed to be more selective than current arthritis drugs Enbrel and Remicaid. The new drug fights cells that cause painful inflammation while leaving other cells, those that prevent infections, alone.

"Our therapy is much more targeted now than it was in the past and frankly, in properly selected patients, it's significantly safer," said Birbara.

Birbara is testing CTLA-4 on patients who have failed all existing arthritis treatments. It's not for women who are going to become pregnant soon, or for those with uncontrolled health problems or serious infections.

While final results are a few years away, it is already making a difference for study subjects.

"These people are getting out of bed better," said Birbara. "Their quality of life is significantly improved, because they can do so much more."

Study participant Maria Rebmenn can now garden -- something she hadn't done in years.

"It helped me change my life around," said Rebmenn. "This year, my tomatoes grow like they were out of style."

Dr. Stuart Schneller, of Caritas St. Elizabeth's Medical Center in Boston, said this is another new approach that has emerged in the treatment of rheumatoid arthritis, but warns it is still undergoing study and is too early to know how well it will work

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SENATE PASSES GENETIC EQUALITY BILL****DISCRIMINATION FOR PREDISPOSITION TO ILLNESS WOULD BE BANNED

WASHINGTON, Oct. 14 - The Senate voted unanimously Tuesday to approve a landmark bill that would bar health insurers and employers from discriminating against people who have a genetic predisposition to disease.

Bill sponsors said that as the mysteries of the human genetic code were unraveled, people needed protection so breakthroughs were used to treat and heal, not to isolate and discriminate. "It's about all of us. You could say this is the bill for people with DNA," said Dr. Francis Collins, director of the National Human Genome Research Institute, who was on hand for the vote. "This is the bill for people with flawed DNA. That's all of us, too." The White House released a statement backing the bill and saying President Bush would sign it. The lead sponsor of companion House legislation, Louise Slaughter, D-N.Y., said she hoped the strong Senate support, plus Bush's backing, would give it momentum in the House, where it has languished for years. The Health Insurance Association of America opposes the bill, saying current laws provide adequate protection.

"Health insurers continue to believe it will only add unnecessary and costly regulatory burdens without, in any way, improving consumer protections," the HIAA's president, Dr. Donald Young, said in a statement.

Collins told reporters after the vote that studies had shown that about a third of people who could benefit from certain genetic tests did not take them for fear that they would lose their health insurance.

The bill would prevent health insurers from excluding people from coverage or charging them higher rates because they had a genetic risk or predisposition to a disease. In many cases, a gene could cause elevated risk for a disease, but the person would not necessarily develop the illness or might not get it for decades. However, knowing someone is at risk could lead to better monitoring and early detection.

"Unlocking our genetic code unleashes new power. And power produces new responsibilities in protecting the privacy of our genetic information and protecting it from misuse," said Sen. Judd Gregg, R-N.H., chairman of the Health, Education, Labor and Pension Committee. The legislation would also shore up medical privacy laws and prohibit employers from making hiring, firing or promotion decisions based on someone's genetic information.

Sen. Olympia Snowe, R-Maine, who has been trying to work out a bipartisan consensus on genetic nondiscrimination and privacy for seven years, said the legislation would put genetic nondiscrimination on a civil rights par with race, religion and disability." No American should be denied health insurance or fired from a job because of a genetic test," added Sen. Edward Kennedy, D-Mass.

The bill would also bar insurers from requiring genetic tests. It would cover all public and private health plans, employers, employment agencies, labor organizations and training programs. © 2003 Reuters Limited. All rights reserved.

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LIMBAUGH'S ADDICTION TOUGH TO KICK****PAINKILLER ABUSE HAS QUADRUPLED IN THE LAST DECADE - ASSOCIATED PRESS -

BOSTON, Oct. 15 - Rush Limbaugh is not alone. Addiction to prescription painkillers has boomed in recent years, and they can be as tough to kick as heroin.

The number of Americans who begin misusing painkillers each year has almost quadrupled from 1990 to 2001, according to government figures. And many abusers don't recognize the insidious slide into addiction. "It's just so much more acceptable in society for people to be taking prescription drugs," said Sean Evans, 31, of Everett, Mass., a construction worker who became addicted to the pain reliever OxyContin, then moved on to heroin. "You can always rationalize the reason to take it."

Limbaugh, the conservative radio commentator, told his audience he is addicted to prescription painkillers that he began taking after spinal surgery "some years ago." He said he had checked himself in for treatment twice before, without success. This time, he said he was headed to a rehab center for a month "to once and for all break the hold this highly addictive medication has on me."

Limbaugh may be overly optimistic about the time frame, said Alice Young, a psychology professor and a drug researcher at Wayne State University in Detroit. "He had said he was going into treatment and lick it within 30 days. I think that's probably an unrealistic expectation," she said.

Limbaugh didn't name the medication, but the National Enquirer, which first reported his abuse, said Limbaugh's drug connection said he used OxyContin and other painkillers.

Most patients who become addicted have taken more medication than their doctors prescribed. However, addiction can take hold quickly - within weeks - for some drugs. The addicts often buy their drugs on the street when their prescriptions run out.

SCRIPTS THAT ADDICT
o OxyContin
o Percodan
o Vicodin
A record 36 million Americans have abused prescription drugs at least once in their lifetime, a government study found.

OXYCONTIN
Maker: Purdue Pharma L.P.
Known as the "hillbilly heroin," OxyContin is the brand name for an opioid analgesic prescribed for chronic moderate to severe pain. Its active ingredient Oxycodone is more potent than hydrocodone and has a greater potential for abuse. Oxycodone is also found in at least 45 other drugs on the market, including Percocet. Since hitting the U.S. market in 1996, OxyContin has become one of the most popular -- and most abused -- medical painkillers. More than 7.2 million prescriptions were dispensed in 2001, according to the company. It is a time-released narcotic, which provides continuous relief for up to 12 hours. Like other opioids, it works primarily through interaction with the mu opioid receptors, especially in the brain and spinal cord. It produces a euphoric effect. Because of its time-release function, the medication comes in large doses and can be fatal if it is crushed or chewed. According to published reports, maker Purdue Pharma is researching for a method to mask the drug's effects if it is crushed, a common way it is abused by addicts.

PERCODAN
Maker: Endo Pharmaceuticals
Prescribed for moderate to severe pain, Percodan is the brand name for a combination of two pain-killing drugs, the narcotic oxycodone and aspirin. Percocet combines oxycodone and acetaminophen. Both are in a class of opioids that includes morphine, heroin, Demerol and others. It works by blocking pain signals from the brain and spinal cord. Available in tablet, capsule, and liquid form, it is taken every 6 hours by mouth. Side effects include sleepiness or dizziness, nausea or vomiting and constipation. People taking the drug should avoid alcohol or any other medications containing aspirin or acetaminophen.

VICODIN
Maker: Knoll Pharmaceutical
The drug taken in large doses by Rush Limbaugh and that nearly killed "Friends" star Matthew Perry, Vicodin is the brand name of an opioid analgesic similar to heroin and morphine. One of the most frequently prescribed medications for moderate to severe pain such as migraines, back pain and cancer, Vicodin's active ingredients are hydrocodone bitartrate and acetaminophen, which work on pain receptors in the brain. It can become physically addictive after only several weeks of use. In fact, it is one of the top 20 most abused controlled substances in the United States, according to drug addiction researchers. It is an older drug than OxyContin and is effective for only a 3-4 hour period. Chronic use of opioids can result in tolerance, which means that users must take higher doses to achieve the same effects. Side effects of Vicodin include dizziness, drowsiness, lightheadedness, constipation, nausea, or vomiting. Some doctors assert that abuse of Vicodin can cause hearing loss.

Doctors say the biology and treatment of addiction are similar in many ways for both legal and illegal drugs - from tobacco, alcohol and prescription painkillers to cocaine and heroin. Addiction sets in when users become dependent on the intense feelings evoked as the drug works on primitive pleasure points within the brain. "In our field, a drug is a drug is a drug," said Bill Carrick, program manager at the CAB Boston Treatment Center. Evans, the construction worker, was undergoing detoxification there. Initial treatment often entails detox, sometimes with a substitute drug such as methadone. Long-term therapy may aim to substitute healthy rewards in family or work life for drug-induced euphoria.

Some abusers of painkillers are no longer in pain and take the drug purely for pleasure. Others, as Limbaugh said of himself, are also getting relief from pain. During their treatment, nonaddictive pain relievers can be used. Such patients may also receive electrical stimulation, acupuncture, counseling and other treatments to help cope with their pain.

Even with all the techniques, however, patients and therapists agree that it is difficult to overcome the addiction to many prescription drugs. "Honestly, I think OxyContin is a lot harder to come off than heroin," said Evans, who has been treated for both. The maker of OxyContin, Purdue Pharma, disputes the notion that the painkiller is stronger than heroin, saying there is "absolutely no scientific basis" for such a contention.

WARNING SIGNS OF A PAIN KILLER ADDICTION
o Changes in personality or inappropriate behavior
o Mood swings
o Loss of appetite
o Slurred words, but no smell of alcohol on the breath
o Lies about whereabouts or periods of unexplained absence
o Isolation from friends or family
o Frequent trips to the doctor or various doctors, called "doctor shopping" for a physician who will write a prescription

While Limbaugh joins a long list of celebrities who became hooked on prescription drugs - actress Marilyn Monroe, pop entertainer Michael Jackson, country singer Tammy Wynette and football player Brett Favre among them - many more ordinary Americans succumb to this kind of addiction. Evans, for example, started taking painkillers when he had his wisdom teeth pulled.

The rate of abuse has risen dramatically for such drugs. About 2.4 million Americans began misusing prescription pain relievers in 2001, almost quadrupling from 628,000 in 1990, according to the federal government's Survey on Drug Use and Health.

An estimated 6.2 million Americans or 2.6 percent of adults, misuse prescription drugs of all kinds. About 4.4 million of them misuse pain relievers, taking more than their prescribed amount. The rate of full-blown addiction is about 0.3 percent, but patients who don't follow their prescriptions are considered at risk.

Other abused prescription drugs include sedatives for anxiety and stimulants prescribed for attention deficit disorder and obesity.

It isn't clear why more Americans appear to be misusing prescription drugs. Howard Chilcoat, a drug-use researcher at Johns Hopkins University, said more may be available through illegal channels, more abusers of illegal drugs may be switching, and people may be more aware of the power of prescription drugs through news stories.

© 2003 Associated Press. All rights reserved.

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HOSPITAL CARE: DOES YOUR STATE RATE?
By Jennifer Warner WebMD - Reviewed By Michael Smith, MD

All states -- even ones at the bottom of the barrel when it comes to hospital care -- have good hospitals and bad hospitals. What do you look for in a good hospital?

Suffering a heart attack in a state such as Mississippi is likely to be much more dangerous than in Colorado. In fact, a new report shows where you live may play a major role in the quality of hospital care you get for various conditions.

The sixth annual HealthGrades Hospital Quality in America Study shows the quality of healthcare at the nation's hospitals varies greatly among states. Researchers ranked each of the country's nearly 5,000 hospitals on 26 common procedures and conditions and found better-performing hospitals tended to be in northern or sparsely populated states.

Here's how the 50 states and District of Columbia fared:
RANK---STATE

1. North Dakota
2. Florida
3. Ohio
4. Michigan
5. Maryland
6. Colorado
7. Pennsylvania
8. Connecticut
9. Utah
10. South Dakota
11. Virginia
12. Minnesota
13. Arizona
14. Montana
15. New Jersey
16. Maine
17. Illinois
18. Rhode Island
19. Washington
20. Indiana
21. Oregon
22. Washington, D.C.
23. New Hampshire
24. Idaho
25. California
26. Massachusetts
27. Missouri
28. Louisiana
29. North Carolina
30. Texas
31. New Mexico
32. Nebraska
33. New York
34. Kentucky
35. Delaware
36. Nevada
37. Georgia
38. Wisconsin
39. Alaska
40. Iowa
41. West Virginia
42. South Carolina
43. Wyoming
44. Hawaii
45. Oklahoma
46. Vermont
47. Kansas
48. Tennessee
49. Arkansas
50. Alabama
51. Mississippi

Although there are exceptional hospitals in even the lowest-ranking states, researchers say that, on average, patients get better quality healthcare in the higher-ranking states. For example, the report shows that a person has a 55% increased chance of dying if he or she had a balloon angioplasty or other similar heart procedure in Texas rather than in New York.

"In Mississippi, your chance of dying from a heart attack is 49% higher, on average, than if you were treated in Colorado," says Collier.