On examination there was extreme tenderness to palpation along both distal tibiae. The range of movement of her ankle and knee joints was normal, and there was no evidence of synovitis. She had thin hair, mucositis of the mouth, but no psoriatic skin rash. Initial radiographs of her ankles showed a poorly defined area of sclerosis at the distal left tibial metaphysis ( figs 1A and B). A bone scan showed increased blood pool activity and delayed technetium uptake in the metaphyseal regions of the proximal and distal tibiae, suggestive of stress fractures (fig 1 C).Radiographs performed six months later showed bilateral distal tibial fractures and a proximal left tibial fracture, but no abnormalities in the hands, feet, or sacroiliac joints.A complete blood count was normal. Serum B-12, folate and red cell folate, and serum biochemistry were normal. Serum alkaline phosphatase was 100 U/1 (normal range 20-95 U/1), but other liver function tests were normal. Serum calcium (2.35 mmol/l), phosphate (1.05 mmolIl), and thyroid function tests were normal. Serum parathyroid hormone was 0-26 ng/ml (normal <0 4 ng/ml), (table) and iliac crest bone histomorphometry (table) showed reduced osteoid surfaces and osteoid thickness and low bone formation rates (fig 2). There was no evidence of osteomalacia or hyperparathyroidism.Methotrexate was stopped with a gradual resolution of bone pain, but the tenderness over the distal tibiae and the proximal left tibia persisted for several months. Twelve months later the patient reported weightbearing pain in the right forefoot. A technetium bone scan showed features compatible with a metatarsal fracture of the right foot. In addition there appeared to be a reduction in isotope uptake in the proximal and distal tibiae compared with previous scans. CASE 2 A 75 year old white woman with a 15 year history of seropositive, erosive, nodular rheumatoid arthritis had been treated with methotrexate, 10 mg/week, for six years. She presented with a history of several months of left leg and ankle pain, which on examination showed marked swelling and tenderness predominantly over the distal left tibia. Examination showed evidence of a clinicially inactive chronic deforming arthritis. She had never received corticosteroids by mouth. Her past history included a total thyroidectomy which required thyroxine replacement of 50 ,ug/day to maintain a euthyroid biochemical status. She had smoked 10-15 cigarettes a day in the past, but did not drink alcohol. She was 582 on 26 April 2019 by guest. Protected by copyright.
1. Enteric coated sodium salicylate 4.8 g daily was compared with the same dose of enteric coated aspirin in 18 patients with rheumatoid arthritis. 2. After an initial washout period lasting 3 days, patients were randomly allocated to treatment with sodium salicylate or aspirin. After 2 weeks the two treatments were crossed over. 3. Pain relief, reduction in articular index of joint tenderness, increase in grip strength, decrease in digital joint circumference and patients' assessment showed significant improvement with both treatments compared with the washout period. No significant differences were found between the two therapies. 4. No correlation was found in the degree of improvement in any of the clinical outcomes and the salicylate concentrations at steady state.
1. A clinical trial was conducted with flurbiprofen 100 mg three times a day by mouth in rheumatoid arthritis to determine variability in response. 2. Forty patients entered the study, but only 32 completed it. Patients were treated with flurbiprofen on two occasions at a month's interval, each being preceded by a 3 day wash out period. Pain relief and a Ritchie articular index of joint tenderness was assessed at the beginning and end of each treatment period. 3. Flurbiprofen produced significant improvement in both pain relief and articular tenderness. No significant differences were observed between the two trial periods in the mean of these outcome measures. 4. No evidence was found to support the concept of responders and non‐responders.
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