Rheumatoid arthritis

News in brief: 3 analogies to explain gout; Lymphoma risk with MTX; New Zostavax warning for immunosuppressed patients

Thursday, 3 Jun 2021

Three analogies that can help patients understand gout

People with gout are more likely to adhere to urate lowering therapy (ULT) if they understand the underlying pathophysiology of the disease – and hemisphere appropriate analogies may help.

In a letter in the International Journal of Rheumatic Diseases Prof. Nicola Dalbeth from Auckland New Zealand and Dr Kanon Jatuworapruk from Pathumthani, Thailand, write that a ‘snow melting on a roof’ gout analogy recently shared by colleagues from Japan was commendable but might not be appropriate for patients living in the tropics.

A geographically more relatable analogy for patients who don’t regularly encounter snow included the ‘dirty dish’ hypothesis in which the dish represents the joints in which the MSU crystals (the food residue) are continually building up.

Alternatively, gout patients could be asked to imagine a glass of salty fluid with coarse grains of salt. The grains keep growing as long as the liquid is saturated with salt. The salty fluid must be exchanged with fresh water to make the grains of salt disappear.

“Explaining gout to patients is more art than science. It depends on each patient’s level of health understanding, as well as geographical and cultural factors,” Professor Dalbeth writes.

“Regardless of the methods used to explain gout, the key message that must be effectively delivered is that gout is a chronic condition that needs regular long-term treatment to keep serum urate at a target level”.

EBV-positive lymphoma with MTX

Lymphoproliferative disorders (LPD) are a rare but significant complication of long-term methotrexate use in patients with rheumatoid arthritis and further complicated by the Epstein-Barr virus (EBV), a new paper shows.

Two Australian case studies of EBV-positive LPD highlight the interplay between RA, LPD, EBV and MTX use.

“In Case 1, the association between MTX and lymphoma was strong as evidenced by the 20-year duration of MTX use and subsequent clinical improvement once MTX was ceased,” the report said.

“In comparison, Case 2 had a shorter duration of MTX (eight years) but showed evidence of high EBV load in lung parenchyma at autopsy.”

“Our cases highlight the need to consider methotrexate reduction in rheumatoid arthritis patients whose disease has been well controlled for many years,” the authors said

Internal Medicine Journal

More warnings on Zostavax for immunosuppressed patients

The TGA has revealed the wording of new warnings for Zostavax vaccine to address the risk of fatal disseminated varicella-zoster virus infection in immunocompromised patients.

A new boxed warning has been added to the Product Information (PI) with information about managing this risk, including pre-screening and risk-based assessment prior to use of the vaccine, and management of suspected cases.

The warning states that have been several fatal cases of disseminated vaccine-related VZV infection in Australia, including in patients on low dose immunosuppressive medication, and that the risk increases with the degree of immunosuppression.

It advises that the vaccine is contraindicated in patients with current or recent severe immunocompromising conditions from either a primary or acquired medical condition or medical treatment.

“Careful pre-screening and a risk-based assessment is required prior to administration of any dose of Zostavax. If appropriate, this assessment should include medical specialist consultation and potentially screening for pre-existing antibody to VZV. In such cases, vaccination should be deferred until such advice and/or results have been obtained,” it advises.

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