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Aim: To test the efficiency of tumour necrosis factor blockers (adalimumab) in patients with painful refractory (non-responders to analgesics and non-steroidal anti-inflammatory drugs (NSAIDs)) hand osteoarthritis (OA)., Methods: We performed a randomised, double-blind, placebo-controlled, parallel group, multicentre study. Patients were randomised to: 1/1 adalimumab 40 mg for two subcutaneous injections at a 15-day interval or placebo and monitored for 6 months. The primary outcome was the percentage of patients with an improvement of more than 50% in global pain (Visual Analogue Scale) between week 0 (W0) and week 6 (W6). Secondary outcomes included the number of painful joints, swollen joints, morning stiffness duration, patient and practitioner global assessments, functional indexes for hand OA, and consumption of analgesics. Analysis on the mean primary outcome measure was done on patients who received at least one injection., Results: 99 patients were recruited and 85 patients were randomised. Among them, 37 patients in the placebo group and 41 in the adalimumab group received at least one injection and were evaluated at W6 (n=78) on the main efficacy outcome. Mean age was 62 years, 85% were women, and mean level of pain was 62 mm at W0. At W6, 35.1% in the adalimumab group versus 27.3% in the placebo group had a pain reduction ≥50% (RR 1.12 (95% CI 0.82 to 1.54; p=0.48). There were no statistical differences for all secondary end points. The rate of adverse events was similar in the two groups., Conclusions: Adalimumab was not superior to placebo to alleviate pain in patients with hand OA not responding to analgesics and NSAIDs., Trials Registration Number: NCT00597623., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To assess anti-tumour necrosis factor (anti-TNF) agents in patients with refractory systemic rheumatoid vasculitis (SRV)., Methods: 1200 rheumatologists and internists were asked to provide medical files for patients with anti-TNF agents given as a second-line treatment for active SRV refractory to cyclophosphamide and glucocorticoids., Results: We identified nine cases in which anti-TNF drugs were given for active SRV, despite previous treatment with a mean cumulative dose of 8.4 g of cyclophosphamide in association with high-dose glucocorticoids. The mean prednisone dose before anti-TNF therapy was 29.6 mg/day. After 6 months, six patients were in remission (complete in five, partial in one). The treatment failed in one patient and two patients stopped taking the anti-TNF treatment due to side-effects. Mean prednisone dose was reduced to 11.2 mg/day. Severe infection occurred in three patients. Relapses were observed in two patients. Remission was re-established by reintroducing anti-TNF therapy in one case and increasing the dose in the other., Conclusions: This study provides evidence of efficacy of anti-TNF therapy in adjunct to glucocorticoids for treating active refractory SRV. Remission was achieved in two-thirds of patients, with a significant decrease in prednisone dose, although there was a high rate of infection in these severely ill patients.

Background: The cause of recent onset polyarthritis can be difficult to identify., Objective: To determine which laboratory and imaging studies French rheumatologists recommend, not taking cost into account, for the diagnosis of recent onset polyarthritis without extra-articular manifestations., Methods: From the list of the French Society for Rheumatology, a random sample of 210 rheumatologists was selected, who were asked to complete a questionnaire on the laboratory and imaging studies they would recommend in two fictional cases of recent onset polyarthritis (possible rheumatoid arthritis (RA)-case 1 and probable RA-case 2)., Results: In case 1, the following were recommended by over 75% of respondents: hand radiographs, rheumatoid factors (RFs), and antinuclear antibodies (ANA) (92%, 98%, and 98%, respectively). 50-74% of respondents recommended radiographs of the feet, knees, and chest (50%, 57%, and 66%, respectively); blood cell counts, erythrocyte sedimentation rate (ESR), serum assays of C reactive protein (CRP), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (65%, 74%, 67%, and 62%, respectively). 25-49% recommended determination of creatinine and proteinuria, HLA-B27, antikeratin antibody, radiographs of the pelvis, and synovial fluid analysis. Several investigations were recommended less often in case 2 than in case 1. Nevertheless, some laboratory and imaging studies (radiographs of hand, feet, knees, chest x rays, blood cell counts, ANA, RF, antikeratin antibody, CRP, ESR, creatinine, AST and ALT, proteinuria, and joint aspiration) were recommended by more than 25% of respondents in both cases., Conclusion: Wide variations were found among rheumatologists, indicating a need for standardisation. Some laboratory and imaging studies are recommended by at least 25% of respondents in recent onset polyarthritis with or without clues suggesting RA. In contrast, many tests were considered useful by fewer than 25% of the respondents in both cases.