Psoriatic Arthritis List NEWSLETTER

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News & Views Newletter
edited by Jack Nicholas, cornishpro@aol.com

PSORIATIC ARTHRITIS NEWS AND VIEWS
VOLUME 4 ISSUE 01 January 15, 2004
PSORIATIC ARTHRITIS MEDICAL NEWS

WONDER DRUGS USING PHARMAZOOTICALS
New drug discovery from unusual animal sources is just around the corner. By Leanna Skarnulis WebMD Feature Reviewed By Brunilda Nazario, MD

Unless you're a scientist, you might not find much to love about pigs' and cows' pancreas, horse urine, snake and spider venom, or Gila monster spit. Yet all of these are existing or potential sources of drugs, some of which are life saving. These "pharmazooticals" represent just a small portion of drugs derived from natural sources. In western medicine -- plants rule.

Modern investigation of animal sources may have started in 1921, back when they called diabetes "sugar disease." The Nobel prize-winning work of Canadian surgeon Frederick Banting and his assistant Charles Best led to the discovery of insulin and its ability to lower blood sugar. It's estimated that since that time, insulin -- mainly derived from the pancreas of pigs and cows -- has saved the lives of 15 million people with diabetes.

Today, another creature brings hope to people with type 2 diabetes whose blood sugar levels remain high in spite of treatment. An investigational drug called exanetide comes from lizard spit, specifically an enzyme in the venom of the Gila monster. It also appears to promote weight loss.

We have the animal kingdom to thank for some very important drugs already in use. The ACE inhibitor Captopril used to lower blood pressure comes from the Brazilian arrowhead viper. ARA-C, modeled after compounds from the Caribbean sponge, treats leukemia and lymphoma. Integrelin, which comes from a protein in the venom of the southeastern pygmy rattlesnake, is used to treat acute coronary syndrome. Calcimar and Miacalcin are calcitonin hormones derived from Coho salmon and used to treat osteoporosis.

One of the most widely used and most controversial drugs derived from animals is Premarin, an estrogen given as menopausal hormone therapy. The drug is derived from the urine of pregnant horses, and the treatment of those animals and their foals on so-called PMU (pregnant mares' urine) farms have come under attack from animal rights groups.

Animal rights issues may be one reason most scientists look mainly at spiders, reptiles, and sea creatures rather than at mammals, says Elliott Sogol, PhD, spokesperson for the American Pharmacists Association. "I think there's always been hesitation from researchers because of organizations that don't want to see any animals used for research, and maybe some concern about coming from an ethical standpoint. If you're just milking a snake you're not harming it." Another reason might be that reptiles and spiders are more readily available and easier to handle, says Sogol, who is pharmaceutical sciences director at Campbell University in Buie, N.C.

Mother Nature Knows Best
Some scientists once predicted that doing drug discovery in nature would be made obsolete by laboratory synthesis of various molecules and computer simulations, a field known as combinatorial chemistry. However, Mother Nature has a dazzling array of sophisticated, natural products.

It's hard to exaggerate the potential for drug discovery in nature's storehouse. Jerrold Meinwald, PhD, researches the role of chemistry in insect interactions, especially how they employ chemicals in mating, defense, and communication. Some of these chemicals, such as components of spider venom, may prove to have medical applications. "The venom they inject to paralyze prey contains novel neurotoxins that block certain receptors," he says. "It would seem very promising to go after spiders that haven't been looked at as potential neuropharmacological agents."

That would be a lot of spiders. Meinwald tells WebMD perhaps only 100 to 200 of the 30,000 known spider species have been studied. "There are many lifetimes of work," says Meinwald, who is Goldwin Smith Professor at Cornell University in Ithaca, N.Y.

One company, NPS Pharmaceuticals, specializes in researching and developing drugs based on spider and scorpion venoms. In the pipeline is a new class of drugs called "delucemines" (NPS1506) which act to protect brain cells and minimize brain cell death in stroke victims until blood flow can be restored. The drugs might also have potential in the treatment of depression.

With spiders, as with most species, the goal is to synthesize the active chemicals rather than depend on animals. "You can milk spiders' venom without killing them, but you don't get sufficient quantities," says Meinwald.

Synthesizing drugs to preserve the properties of a natural drug can be challenging. For example, Sogol tells WebMD some ingredients from saliva stay longer in the human body than a synthetic version. "They'll stay in the body longer, and that can be very positive. If you have diabetes and your current drug lasts four hours, it's better to have one that lasts 12 hours."

From One Beautiful, Deadly Snail
The cone snail is celebrated for its beauty and feared for its poison, which on occasion has been known to kill swimmers. The deadly venom, however, is exceptionally rich in compounds called conopeptides that could be used or synthesized to make an array of pharmaceuticals. Cognetix, Inc., is researching applications for acute and chronic pain, epilepsy, local anesthesia, heart disease, stroke, neuromuscular back pain, multiple sclerosis, and spinal cord injury. Scientists are urging protection of the cone snail, which is on the brink of extinction.

On the Horizon
Here are some of the areas in which drugs derived from animals are being investigated:
Painkillers. ABT 594 comes from the skin of the South American frog. It appears to be more effective than morphine without being addictive. Cancer. TM 601 is derived from the Israeli yellow scorpion and attacks malignant brain tumors called glioma tumors responsible for two-thirds of the cases of brain cancer, without harming healthy cells. ET 743, which comes from sea squirts, is being tested for treatment of ovarian cancer and soft tissue sarcoma.
Stroke. Ancrod, which will be marketed in the U.S. as Viprinex pending FDA approval, is an anticoagulant with potential to prevent cell damage and death when someone suffers a stroke. The active ingredient comes from the venom of the Malaysian pit viper. In Germany, where Ancrod has been marketed for a number of years, a specially built facility houses about 3,000 snakes. Several other sources of anticoagulants are being looked at. "We're still trying to find medicine that will be useful long-term for stroke victims," says Sogol. "There's saliva of vampire bats, for example. When they bite their prey, the enzyme in their saliva doesn't allow blood to clot. There's also something in the saliva of leeches that is an anticoagulant."
Antibiotics. A substance called magainin 2 -- comes from the skin of frogs and looks promising in the search for antibiotics that bacteria can't develop resistance to. Studies began when biomedical researcher Michael Zasloff, MD, PhD, of Georgetown University in Washington, D.C., wondered how frogs could swim in filthy ponds without getting sick.

Save the Rainforest
One of the most biodiverse and pharmaceutically promising regions of the world is the Brazilian rainforest, yet it's rapidly disappearing -- along with untold numbers of plant and animal species -- because of clear cutting. Moreover, fewer and fewer nations are now willing to collaborate with foreign researchers. "It's become very hard to establish any sort of international research effort because someone will say that the amount of financial reward offered to the supplier of natural products isn't fair," says Meinwald. "It's the concept of 'bio-piracy.' They think drug companies take their valuable resources, make a fortune and just give them crumbs. It's true that some drugs can sell at the level of a billion dollars a year. What people don't appreciate is that this happens, however, only after 10 or 12 years of research and investment. Most drug candidates fall through because of side effects or other problems."

How Did It all Begin?
When you think about folk remedies dating back before the dawn of scientific discovery, what ever gave people the idea that, say, taking cod liver oil would relieve a cold or eating pearls would cure insanity?

"I don't know, but the same thing occurs to me about food," says Meinwald. "How in the world would people decide you could eat oysters? He surmises that people observed seagulls picking up oysters, dropping them from high in the air to break them open, then swooping down to eat them. Humans seem to have tried practically everything for eating. They may have noticed by similar experimentation that some things make you very sleepy or take away pain."

SOURCES: Cognetix, Inc. "Strategies for Discovering Drugs From Previously Unexplored Natural Products," Drug Discovery Today, July 2000. Jerrold Meinwald, PhD, Goldwin Smith professor, department of chemistry & chemical Biology, Baker Laboratory, Cornell University, Ithaca, N.Y. NPS Pharmaceuticals. PBS A Science Odyssey: People and Discoveries, "Banting and Best Isolate Insulin." RSC Chemical Society Network. Smithsonian Ocean Planet web site. Elliott Sogol, PhD, spokesperson, American Pharmacists Association; director, pharmaceutical sciences, Academic Affairs for Clinical Research, Campbell University, Buie, N.C. WebMD Feature: "Lizard Spit Drug Helps in Diabetes."

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YOU HAVE CHRONIC PAIN; NOW WHAT?
By the Mayo Clinic staff

After years of uncertainty, you've finally learned what's causing your discomfort. Perhaps it's arthritis, fibromyalgia or any number of conditions. The result is the same. It's chronic.

Knowing the source of your pain isn't enough to alleviate your discomfort. There aren't any quick fixes for chronic pain. Moreover, often, there's only so much doctors can do. You're the key ingredient. If you want your life to improve, you need to take steps to manage your pain.

Understand your role
The first and most important step in controlling your pain is accepting the fact that you may always have pain. Some people can significantly reduce or eliminate their pain. However, if you're like most people with chronic pain, your pain always will be a part of your life.

Managing chronic pain isn't about making your pain disappear. It's about learning how to keep your pain at a tolerable level. It's about enjoying life again, despite your pain. And it's about accepting that only you can control your future.

Find the right doctor
Being in charge of your pain doesn't mean that you can't or shouldn't look for help from others. A doctor can be especially helpful when you have questions or need assistance. But make sure it's a doctor who understands your condition and communicates well with you.

The right doctor for you could be your family physician or a specialist who's overseeing your condition. Or you may want to see a physician or a psychologist who specializes in pain management. If you're not sure where to find a pain specialist, ask your doctor to refer you to one.

When selecting a doctor, in general, look for someone who has these characteristics:
Is knowledgeable about chronic pain
Wants to help
Listens well
Makes you feel at ease
Encourages you to ask questions
Seems honest and trustworthy
Allows you to disagree
Is willing to talk with your family or friends
Has a positive attitude toward life and your condition
Before selecting a new doctor, however, check with your health insurance
provider to make sure that the doctor is covered under your policy.

Learn about your condition
Finding the right doctor isn't the end of your job. It'll take teamwork to manage your pain. To make this easier, make an effort to learn all that you can about your condition and your pain. One place to start is with the information provided in this Pain Management Center.

In addition, check the reference areas at your local library for medical dictionaries, books on health topics and health magazines. You also can browse through the health section in your local bookstore.

It's important to be informed about your health, but don't overdo it. Spending too much time reading about your condition or discussing your pain can be counterproductive. It draws your attention to your pain, instead of away from it.

Describe your pain
Accurately describing your pain will help your doctor learn about the pattern of your pain, make a diagnosis, plan treatment and follow your progress. You can help in advance of your doctor's appointment by preparing yourself to answer these questions:

Where is the pain located?
How long have you had pain?
Does the pain come and go or is it continuous?
How long does the pain last?
What makes the pain better?
What makes the pain worse?
What is the intensity of the pain? You may be asked to rate your pain on a scale of 0 to 10, with 0 indicating that you have no pain at all and 10 indicating that the pain is the worst possible.

What does the pain feel like? You can use words such as stinging, penetrating, dull, throbbing, achy, nagging or gnawing. Be as specific and descriptive as possible.
Has the pain changed since your last visit with your doctor? What medications or treatments have you tried for the pain? How effective were they?

Set goals
Everybody differs in the amount of pain that they can tolerate. A level of pain that is unbearable for you might be acceptable to another. Your doctor may help you determine your tolerance for pain by having you rate your pain on a pain intensity scale. Then you can set a goal for where you'd like to be.

For instance, if you rate your pain as 6 out of 10 on average and you decide you can tolerate 3 out of 10, then you and your doctor have a more tangible goal to work toward. You may not be able to get your pain level down to a zero, but usually you can make progress.

Focus on one pain problem at a time. For example, you may have both back and knee pain, but your back pain is worse. Start by treating your back pain and then, once your back pain is tolerable, work on your knee. The time it takes to reach your goal depends on your diagnosis, but people often see progress during the first several months. After that, you may work toward a general pain management goal.

Understand your treatment
Continue to be involved in your care when your physician recommends specific treatments for you. Ask why certain treatments are being proposed and find out their risks, benefits and alternatives. Be careful about accepting medications, injections or other recommendations without being aware of what each entails. Any intervention brings a chance of both benefits and complications. Talk with your doctor to ensure that the balance is in your favor.

Expect to commit some time to the treatment process. You may try a variety of treatments before your doctor finds one that works for you, so don't become discouraged if the first treatment isn't as effective as you had hoped. Your doctor may adjust your treatment over time, as he or she monitors how your body reacts to various regimens. People usually make progress in the first 2 to 3 months.

Maintain contact with your primary doctor
If you do seek specialized pain treatment, usually through a pain clinic or pain center, stay in touch with your primary care doctor. Your pain physician focuses on your chronic pain and generally won't monitor other health concerns that you may have or make sure that you receive routine health screenings, such as a mammogram or a prostate exam. Your primary care doctor manages your overall health.

Make sure your primary care doctor and your pain physician communicate openly. They both should know what pain medication you're taking, who's prescribing it and if you're taking additional medications unrelated to your pain. This decreases the chances of overdose or negative interactions between medications.

Ask your pain physician to send a copy of your records back to your primary care doctor. Often pain physicians will prescribe and adjust medications while determining the correct combination and dosage. Once you're on a stable regimen, your primary care doctor can provide ongoing prescriptions. This allows your primary care doctor to ensure that your medications and therapies are all compatible.

Take control
Most importantly, take responsibility for your pain. Don't become emotionally dependent on your physician. He or she should be compassionate but not overly sympathetic or enabling. Your doctor or pain physician can help you learn to manage your pain, but ultimately you're the one in control.

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VITAMIN D MAY PREVENT ARTHRITIS
By Salynn Boyles WebMD Medical News

Jan. 9, 2004 -- Move over vitamins A, B, C and E. It is beginning to look like the long ignored vitamin D is every bit as important for preventing disease as you are.

New research makes the case that vitamin D helps protect older women against rheumatoid arthritis -- an autoimmune joint disorder of unknown cause. Recent studies have also linked deficiencies of vitamin D to other disorders such as certain cancers, heart disease, diabetes, and even unexplained pain but its role in human autoimmune disease is less clear.

The studies are far from conclusive, but researcher Michael Holick, MD, says there is every reason to believe that the supplement plays a much bigger role in disease prevention than has been recognized.

"Vitamin D has always been considered sort of a ho-hum vitamin," Holick tells WebMD. "People think they get plenty of it from the sun or in their diets, but these days that just isn't the case."

Vitamin D and Rheumatoid Arthritis
The latest research drew on data from the Iowa Women's Health Study, which followed almost 30,000 women, aged 55 to 69, for 11 years. Over the course of the study, the women were questioned about their eating habits, their use of nutritional supplements, and other health-related issues.

During the trial, 152 of the women developed rheumatoid arthritis. The investigators found that women whose diets were highest in vitamin D had the lowest incidence of rheumatoid arthritis.

Women who got less than 200 international units (IU) of vitamin D in their diets each day were 33% more likely to develop rheumatoid arthritis than women w ho got more, researcher Kenneth G. Saag, MD, tells WebMD. Saag is an associate professor of medicine at the University of Alabama at Birmingham.

The association remained significant even after the researchers adjusted for other suspected rheumatoid arthritis risk factors, such as smoking. And even though many foods with vitamin D are also high in calcium, the vitamin's protective effect seemed to be independent of how much calcium the women ate.

The findings are reported in the January 2004 issue of the journal Arthritis and Rheumatism.

How Much Is Enough?
An 8-ounce glass of milk or fortified orange juice has about 100 international units (IU) of vitamin D and a typical multivitamin has 200 to 400 IU. Other good dietary sources of vitamin D include cod liver oil, which has 1360 IU of vitamin D per tablespoon; salmon, which has 425 IU per 3-ounce serving; and herring and sardines. The recommended intake of adequate amounts of vitamin D depends on a person's age. The Food and Nutrition Board (FNB) of the Institute of Medicine says that older women should consume 400 to 600 IU per day in order to have adequate vitamin D intakes.

Like Holick, Saag says he believes vitamin D deficiency is an under-recognized health problem in the U.S. today.

"General population studies indicate that about one in three people are vitamin D deficient," he says. "This is a particular problem during the winter months, when sun exposure is minimal. This is another reason why people should think about supplementing their diets with a multivitamin."

But Holick says most people need to take 1000 IU of vitamin D each day. And he says even this amount may be inadequate in people who have no exposure to the sun.

"Most people get between 90% and 95% of their vitamin D from sun exposure, so if you eliminate that you are setting the entire country up for vitamin D deficiency," he says.

The director of the Vitamin D Research Lab at Boston University, Holick advocates a limited amount of sun exposure, without sunscreen, every day -- a message that the nation's top dermatology group abhors. In a recent press release, officials with the American Academy of Dermatology expressed "deep concern" that the public is being misled "about the very real danger of [unexposed] sun exposure -- the leading cause of skin cancer."

But Holick counters that it does not take much sun to get more than enough vitamin D -- only a few minutes of unprotected sun exposure at most for most people.

SOURCES: Saag, K. Arthritis and Rheumatism, January 2004; vol. 50: pp. 72-77. Kenneth G. Saag, MD, MSc, associate professor, division of clinical immunology and rheumatology, University of Alabama, Birmingham. Birmingham. Michael Holick, MD, Vitamin D Research Lab, department of medicine, Boston University Medical Center. WebMD Inc.

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ONE IN 100 MAY GET TRAVEL BLOOD CLOTS
LONDON, (Reuters)

Up to one in 100 long-haul fliers could develop blood clots, and wearing compression stockings, taking aspirin and traveling business class may not help, a study showed on Friday.

New Zealand researchers tested almost 900 passengers who took long-haul flights over a six-week period. The subjects traveled for at least 10 hours and each flew an average of 39 hours.

They discovered nine cases -- four of pulmonary embolism and five of deep vein thrombosis (DVT), which involves the formation of blood clots, which can cause death if they invade the lungs or brain.

Seventeen percent of the passengers in the study by the Medical Research Institute of New Zealand wore compression stockings to aid circulation. Thirty-one percent took aspirin to thin the blood and reduce the risk of thrombosis.

The team, whose report was carried in The Lancet medical journal, said all air travelers were at risk, not just those in economy class.

"As a result, our findings lend support to the recommendation that the term 'economy class syndrome' should be avoided with the disorder renamed 'traveler' s thrombosis."'

The New Zealand team concluded that their findings might err on the side of conservative estimates.

During recent court action, victims have blamed cramped aircraft cabins for their blood clots and argued that airlines have known of the risks for years but failed to warn people.

But a British court agreed with the airlines, which claimed that DVT was not an accident under the 1929 Warsaw Convention that governs international air travel.

DVT made international headlines and airlines came under pressure to do more to prevent the condition after a 28-year-old British woman died from the condition about three years ago after a 20-hour flight from Australia to London.

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SCIENTISTS IDENTIFY GENES THAT REGULATE ALLERGIC RESPONSE TO DIESEL FUMES WASHINGTON (01/12/04)

According to a study funded by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), the risk of developing respiratory allergies from exposure to diesel emissions depends largely on genetics. The study is published in the Jan. 10 issue of the British journal The Lancet.

Given their findings, the researchers estimate that up to 50 percent of the United States population could be in jeopardy of experiencing health problems related to air pollution.

"This important study adds to previous data that suggest how modern environmental factors interact with the body's defenses to produce 'airway' diseases considered rare before the advent of industrialized society," says Anthony S. Fauci, M.D., director of NIAID.

"The knowledge provided by this work will help us identify people who are susceptible to the deleterious effects of diesel emissions on the clinical course of asthma and hay fever," says Kenneth Adams, Ph.D., who oversees asthma research funded by NIAID. "It will also help accelerate development of drugs to treat and prevent these diseases."

This study also received support from the National Institute of Environmental Health Sciences, another NIH component.

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MANY DOCTORS SUPPORT NATIONAL INSURANCE
By Jennifer Warner WebMD Medical News

Nearly half of American doctors say they support government action to establish national health insurance, a factor that may be crucial to future efforts to reform the current health care system.

Researchers found that 49% of doctors in a national survey said they support governmental legislation to establish national health insurance and 40% are opposed to the idea.

But only about one quarter of doctors endorsed the idea of a "single-payer" approach to national health insurance with the federal government footing the bill for all health care, and 60% opposed this approach.

More than 40 million Americans lack health insurance, and researchers say many believe creating a national health insurance system would remedy this situation. But many also believe that opposition by major medical organizations and lack of physician support are behind the failure of efforts to establish such a system.

Most Docs Support National Health Insurance
Researchers say previous physician surveys have found mixed attitudes about national health insurance and were often limited by poor response rates or involved only a particular group of physicians.

In this study, which appears in the Nov. 18 issue of the Annals of Internal Medicine, researchers polled 1,650 randomly sampled doctors from the American Medical Association Physician Masterfile.

Researchers found that doctors were most likely to support national health insurance if they worked in inner cities or nonprofit settings and if at least 20% of their patients were on Medicaid.

Those physician specialties with the highest levels of support for national health insurance were internal medicine, pediatrics, and psychiatrists. Family medicine doctors, anesthesiologists, and specialty surgeons expressed the lowest degree of support for such a system.

In an editorial that accompanies the study, Arthur L. Kellerman, MD, MPH, of Emory University in Atlanta, says the study shows a plurality of doctors support national health insurance but far fewer want the federal government to be the sole payer for health care.

"Whether this support is sufficient to mount a successful effort to cover the uninsured will depend in large part on whether the status quo remains 'everyone's second choice,'" writes Kellerman. SOURCE: Ackermann, R. Annals of Internal Medicine, Nov. 18, 2003; vol 139: pp 795-801. © 2003 WebMD Inc. All rights reserved.

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LUPUS LINKED TO ATHEROSCLEROSIS
Barbara K. Hecht, Ph.D. and Frederick Hecht, M.D.
Medical Editors, MedicineNet.com

This is very important for people with lupus. It has been known for some time that there is an increased risk of heart attacks with lupus. Now two new reports cast light on this problem. The first report found that the buildup of plaque in the carotid artery in the neck is increased in people with lupus. The second report found that calcium deposits, a sign of advanced atherosclerosis (hardening of the arteries), are increased in the coronary arteries of people with lupus.

What this means is that lupus speeds the process of atherosclerosis. The treatment of lupus needs to become more vigorous in reducing all of the traditional cardiovascular risk factors such as obesity, smoking and hypertension. The increased risk of arterial disease calls for more aggressive care in lupus.

LUPUS LINKED TO PREMATURE BLOOD VESSEL PLAQUES NEW YORK (Reuters Health)

Lupus seems to be a risk factor for the development of premature blood vessel plaques associated with atherosclerosis, sometimes referred to as "hardening of the arteries," according to two reports in The New England Journal of Medicine. However, treatment with immune-suppressing drugs may help reduce this risk.

Conventional wisdom holds that premature plaques develop from conventional risk factors that are worsened by treatment with steroids, Dr. Mary J. Roman and associates note in the first paper. Only recently has atherosclerosis been attributed to lupus itself.

Roman, of the Weill Medical College of Cornell University in New York, and her team conducted a study that included 197 patients with lupus and 197 similar "control" subjects without lupus. Ultrasound was used to test for plaques in a major neck artery.

Overall, the risk of atherosclerosis was 2.4-times higher in lupus patients compared with controls. The discrepancy was even larger in younger age groups: among people age 40 and younger, 13 percent of lupus patients had plaques compared with only 2 percent of controls.

Risk factors for plaques in the patient group included a long history of lupus and not being treated with immune-suppressing drugs.

Thus, the authors conclude, "more vigorous therapy might decrease the likelihood and burden of atherosclerosis in patients with lupus and, perhaps, in those with other chronic inflammatory diseases." Only using immune-suppressing drugs when lupus gets particularly bad may not be adequate enough to prevent plaques, they add.

In the second article, Dr. Yu Asanuma, at Vanderbilt University School of Medicine in Nashville, and colleagues used special CT scans to identify plaques in 65 patients with lupus and 69 control subjects. Unlike the first study, the researchers looked for plaques in the coronary arteries, the blood vessels that feed the heart.

Plaques were present in 20 patients and 6 controls. After accounting for the effects of smoking, high blood pressure and other factors, lupus patients were nearly 10 times more likely to have plaques than were controls.

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ARTHRITIS PILL MAY CAUSE LIVER DAMAGE
Drug Avara linked to rare, but serious, injury, company says - PARIS, Reuters Limited

France's largest pharmaceuticals company Aventis SA has warned doctors that the use of its rheumatoid arthritis drug Arava could, in rare cases, seriously damage the liver.

The once-a-day drug is available in 70 countries and was launched in the United States in 1998 and in Europe in 1999.

In post marketing experience worldwide, rare, serious hepatic (liver) injury, including cases with fatal outcome, have been reported during treatment with Arava, Aventis said in a letter to healthcare professionals in October.

‘Rare, serious hepatic (liver) injury, including cases with fatal outcome, have been reported during treatment with Arava.'

The letter is posted on the website of the U.S. Food and Drug Administration.

Aventis said it had updated the prescribing information and monitoring recommendations with the new information.

The overall safety profile and post marketing experience with Arava otherwise remain consistent with safety and efficacy demonstrated in our extensive clinical-trial program, Aventis said. Copyright 2003 Reuters Limited. All rights reserved.

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This is the beginning of my fourth year of publishing the newsletter. I will always try to bring you specific information about Psoriatic Arthritis and Psoriasis, as well as current items of interest pertaining to other diseases that affect many of us. If you have a particular subject that would be of interest to our membership, please send me an e-mail, and I will see what I can do about researching it and publishing in future newsletters.

Good Health to All

Jack Nicholas
Newsletter Editor
Cornishpro@aol.com
Issue 2004 01/15/04-01