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Correspondence

To the Editor:

We read with interest the recent editorial by Prof. H.R. Schumacher¹. Our team recently published a longterm followup study of seronegative oligoarthritis². Of 441 patients with recent (< 6 mo) arthritis, 64 had rheumatoid factor negative seronegative oligoarthritis (< 5 swollen joints). All patients except 2 did not fulfill the American College of Rheumatology criteria for rheumatoid arthritis (RA) at onset. At 23 year followup we noted that 40 (62.5%) patients had had putative features of spondyloarthropathy. However, only one patient with HLA-B27 developed bilateral sacroiliitis. Ankylosing spondylitis often begins with joint (knee) swelling in lower limbs, but not necessarily vice versa. We also propose that HLA antigens help to reveal the nature of seronegative oligoarthritis³. The endpoint outcome of seronegative oligoarthritis was excellent compared with seropositive RA, exactly as Prof. Schumacher suggested.

As the main complaint was arthritis, not back pain, this kind of patient should be diagnosed as seronegative oligoarthritis. Patients also seem to accept it.

KALEVI KAARELA, MD; JUHA K. JANTTI, MD, KARI LEHTINEN, MD, Rheumatism Foundation Hospital, Heinola, Finland.

REFERENCES

1. Schumacher HR. Early arthritis clinics. Much early arthritis is unclassified. J Rheumatol 2002;29:2258-9.

2. Jantti JK, Kaarela K, Lehtinen KES. Seronegative oligoarthritis: a 23-year follow-up study. Clin Rheumatol 2002;21:353-6.

3. Kaarela K, Alekberova Z, Lehtinen K, et al. Seronegative rheumatoid arthritis: a clinical study with HLA typing. J Rheumatol 1990;17:1125-9.

Dr. Schumacher replies

To the Editor:

I appreciate the comments of Kaarela, et al. They direct our attention to their important work that adds further support to the relatively benign course of much initially unclassified oligoarthritis.

I especially want to emphasize the comment that their patients seem to accept a "diagnosis" of "seronegative oligoarthritis." Eventually, we may be able to give more definite diagnoses and prognoses, but for now I hope we will not try to force patients into diagnoses of rheumatoid arthritis or even spondyloarthritis, as those without full-blown features may do well with more conservative therapies.

H. RALPH SCHUMACHER Jr, MD, University of Pennsylvania, VA Medical Center, Philadelphia, Pennsylvania, USA. E-mail: schumacr@mail.med.upenn.edu

Effect of a Diet Program on Lipid and Lipoproteins, Body Weight, Nutrient Intakes, and Quality of Life in Patients with Systemic Lupus Erythematosus

To the Editor:

We read with interest the article by Shah and colleagues¹. In their randomized study of patients with systemic lupus erythematosus (SLE) they demonstrated that a cholesterol-lowering diet was highly accepted by their patients and was accompanied by a significant and sustained improvement in their quality of life after 12 weeks.

Despite these findings, only a modest decrease in total (-6%) and low density lipoprotein (LDL) cholesterol (-2%) was achieved at the end of study, contrasting with a more prominent reduction in very low density lipoprotein (VLDL) cholesterol (-34%) and triglycerides (-24%). Nevertheless, dietary intervention should be considered as a first-line intervention in all SLE patients who present a pattern of dyslipoproteinemia secondary to corticosteroid therapy², although its beneficial effect would be more evident in those with higher doses of this drug³.

Unfortunately, in the study, an undesirable reduction of 4% was also detected in high density lipoprotein (HDL) cholesterol¹. It should be pointed out that low HDL, the benign lipoprotein, is one of the most common findings in the "lupus pattern of dyslipoproteinemia"⁴ and has an inverse association with cardiovascular risk in SLE⁵. For this reason the authors recommended including in future dietary intervention physical activity as a treatment modality to improve HDL concentrations.

We would like to extend this proposition to include antimalarials. Indeed, we recently demonstrated an increase in HDL levels with continuous use of chloroquine diphosphate in SLE patients, regardless of the use or not of prednisone⁶. This increase in HDL was also observed in rheumatoid arthritis after 6 months of exclusive use of hydroxychloroquine, reaching a 15% increase after 12 months⁷.

Finally, the relevance of this diet program on lipid profile needs further clarification, since at least one-half of the patients in each studied group were receiving cholesterol-lowering therapy. It is important to elucidate if these drugs achieved their maximum improvement in every patient included in the study, in order to define if some of the effect observed could be attributed to these drugs.

EDUARDO F. BORBA, MD, PhD; ELOISA BONFÁ, MD, PhD, Rheumatology Division, University of São Paulo, São Paulo, Brazil.

REFERENCES

1. Shah M, Kavanaugh A, Coyle Y, Adams-Huet B, Lipsky PE. Effect of a culturally sensitive cholesterol lowering diet program on lipid and lipoproteins, body weight, nutrient intakes, and quality of life in patients with systemic lupus erythematosus. J Rheumatol 2002;29:2122-8.

2. Ilowite NT, Samuel P, Ginzler E, Jacobson MS. Dyslipoproteinemia in pediatric systemic lupus erythematosus. Arthritis Rheum 1988;31:859-63.

3. Hearth-Holmes M, Baethge BA, Broadwell L, Wolf RE. Dietary treatment of hyperlipidemia in patients with systemic lupus erythematosus. J Rheumatol 1995;22:450-4.

4. Borba EF, Bonfá E. Dyslipoproteinemias in systemic lupus erythematosus: influence of disease, activity and anticardiolipin antibodies. Lupus 1997;6:533-9.

5. Svenungsson E, Jensen-Urstad K, Heimbürger M, et al. Risk factors for cardiovascular disease in systemic lupus erythematosus. Circulation 2001;104:1887-93.

6. Borba EF, Bonfá E. Longterm beneficial effect of chloroquine diphosphate on lipoprotein profile in lupus patients with and without therapy. J Rheumatol 2001;28:780-5.

7. Munro R, Morrison E, McDonald AG, Hunter JA, Madhok R, Capell HA. Effect of disease modifying agents on the lipid profiles of patients with rheumatoid arthritis. Ann Rheum Dis 1997;56:374-7.

Drs. Shah, et al reply

To the Editor:

We appreciate Drs. Borba and Bonfa's interest in our article¹. They suggest that the beneficial effect of a cholesterol-lowering diet would have been more evident in patients with systemic lupus erythematosus (SLE) with higher doses of corticosteroid therapy. This, however, needs to be studied further. The SLE diet subjects in the cholesterol-lowering study by Hearth-Holmes and colleagues² had higher prednisone intake, and thus higher total and low density lipoprotein (LDL) cholesterol at baseline than the diet subjects in our study (prednisone 14.6 ± 3.0 vs 3.8 ± 4.4 mg; total cholesterol 240.9 ± 6 vs 222.4 ± 24.3 mg/dl; LDL cholesterol 157.5 ± 5.3 vs 136.4 ± 23.7 mg/dl). These higher values were associated with greater decreases in total (14.9 vs 12.3 mg/dl) and LDL cholesterol (9.6 vs 2.0 mg/dl). However, in both the studies, the decrease was significant only for total cholesterol. Serum triglycerides, which were similar in the 2 studies (151.9 ± 10.6 vs 151.6 ± 85.2) at baseline, decreased less in the study by Hearth-Holmes and colleagues than in our study (4.8 vs 37.0 mg/dl).

As Drs. Borba and Bonfa point out, high density lipoprotein (HDL) cholesterol decreased by 4% at the end of the study. This decrease, however, was not significant in the diet group at the end of the study and neither was the change in total and LDL cholesterol ratio. Nevertheless, since low HDL has an inverse relationship with cardiovascular disease in SLE³, we recommended including physical activity, a well known way of increasing HDL cholesterol, as a treatment modality to improve HDL concentrations. Drs. Borba and Bonfa propose adding antimalarials as another treatment modality based on their recent findings that continuous use of choloroquine diphosphate in SLE patients increases HDL levels regardless of prednisone use⁴. Earlier, Kavanaugh and colleagues⁵ also reported an increase in HDL levels (7.6%), although not significantly, in SLE patients taking 800 mg of hydroxychloroquine. Antimalarials thus may be an alternative strategy, especially for SLE patients who are unwilling or unable to exercise enough.

Drs. Borba and Bonfa's final comment was to clarify whether some of the changes in lipids and lipoproteins seen in our diet subjects were due to the cholesterol-lowering drugs that 4 of them were taking. We believe that the improvement seen in our diet subjects was caused by the dietary intervention and not related to the cholesterol-lowering agents, since they had been taking cholesterol-lowering drugs for an average of 7.1 months (5.4-17.2 mo) before entering the study and thus should have already achieved their maximum improvement attributed to the drugs. Also, the dose remained constant in each subject before and during the study.

MEENA SHAH, PhD, Department of Kinesiology, Texas Christian University, Fort Worth, Texas; ARTHUR KAVANAUGH, MD, Center for Innovative Therapy, Division of Rheumatology, Allergy, and Immunology, University of California in San Diego, San Diego, California; YVONNE COYLE, MD; Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; BEVERLEY ADAMS HUET, MS, Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; PETER E. LIPSKY, MD, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Maryland, USA.

REFERENCES

1. Shah M, Kavanaugh A, Coyle Y, Adams-Huet B, Lipsky PE. Effect of a culturally sensitive cholesterol lowering diet program on lipid and lipoproteins, body weight, nutrient intakes, and quality of life in patients with systemic lupus erythematosus. J Rheumatol 2002;29:2122-8.

2. Hearth-Holmes M, Baethge BA, Broadwell L, Wolf RE. Dietary treatment of hyperlipidemia in patients with systemic lupus erythematosus. J Rheumatol 1995;22:450-4.

3. Svenungsson E, Jensen-Urstad K, Heimburger M, et al. Risk factors for cardiovascular disease in systemic lupus erythematosus. Circulation 2001;104:1887-93.

4. Borba EF, Bonfa E. Longterm beneficial effect of chloroquine diphosphate on lipoprotein profile in lupus patients with and without therapy. J Rheumatol 2001;28:780-5.

5. Kavanaugh A, Adams-Huet B, Jain R, Denke M, McFarlin J. Hydroxychloroquine effects on lipoprotein profiles (the HELP trial): A double blind, placebo controlled, pilot trial in patients with systemic lupus erythematosus. J Clin Rheumatol 1997;3:3-8.