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LETTERS
1269
derma. Treatment with penicillamine and colchicine was
instituted, but the patient did not improve. By June 1980,
painful ulcerations appeared over the proximal interphalangeal joints of both hands, and the degree of flexion contracture increased. Despite warm weather, the episodes of
Raynaud’s phenomenon became almost continuous, numbering more than 20 per day. Initially, she responded to
intraarterial reserpine, which resulted in partial healing of
the ulcers and a lessening of the frequency and severity of
the vasospasm. After 6 treatments in a 4-month period, the
reserpine had lost most of its effectiveness, and arterial
access became increasingly difficult due to the thickening of
the skin in the forearms and axillae.
She was admitted to the hospital on 3 occasions for
intravenous PGEl administered via a central catheter. This
resulted in improvement in the Raynaud’s phenomenon,
confirmed by doppler, but the benefit was transient, and
there was no healing of the lesions. New ulcerations formed
over both elbows as the skin became more hidebound.
Successive courses of treatment with hydralazine (100 mgi
day), prazosin (4 mg/day), and captopril (200 mg/day) were
attempted, but there was no response to any of these drugs,
perhaps because postural hypotension was a dose-limiting
side effect to all of them. A series of stellate ganglion blocks
was performed without benefit.
In September 1981, nifedipine was begun at a dose of
20 mg 3 times daily. There was a prompt and progressive
decrease in the frequency of the Raynaud’s phenomena to an
average of 2 episodes daily. The secondary infection in some
of the ulcers, which had responded poorly to various antimicrobial agents, cleared completely by the end of the second
week. After 1 month of treatment, all of the ulcers including
those on the elbows showed definite healing. At the end of 2
months, there were signs of partial relapse, as evidenced by
an increase in the Raynaud’s phenomenon and some breakdown of newly formed skin. The dose of nifedipine was
raised to 20 mg 4 times daily, and the relapse abated. The
only adverse effect to the drug was moderate nausea that
developed with the higher dose. By 3 months, all of the
ulcers had completely healed (Figure I), but there was no
improvement in the scleroderma itself.
A controlled trial of calcium channel blocking agents
in the treatment of cutaneous ischemic ulceration in progressive systemic sclerosis is warranted.
Treatment of hip damage in children with juvenile
rheumatoid arthritis
To the Editor:
Garcia-Morteo and colleagues (1) have again demonstrated that remodeling of the hip joint is possible in children
with juvenile rheumatoid arthritis (JRA), but have failed to
associate the unusually severe changes initially seen in their
patients with the bed rest and skin traction they prescribed,
and to recognize that the radiographic improvement follows
ambulation. This was most clearly defined by Bernstein ( 2 )
and reiterated in a recent communication of ours (3).
Experimental and clinical evidence indicates that
joint motion alone, in the absence of normal loading (weight
bearing), does not maintain normal articular cartilage.
Weight bearing actually seems to prevent some of the
damage that occurs in the hips of children with severe JRA.
A therapeutic program for such children must have the
maintenance of weight bearing as one goal, no matter how
severe the disease, since accelerated hip destruction seems
inevitable if the child is confined to bed (3).
The authors state, “Remodeling of the hip joint in
JRA is an interesting phenomenon.” It is more than that.
The advantages of patients with rheumatoid arthritis leading
an active life and maintaining good muscle tone and life style
are well known to all rheumatologists. However, this knowledge is not always applied to children. Bed rest is not an
acceptable treatment for children with arthritis and should
not be prescribed for them.
Jerry C. Jacobs, MD
Professor of Clinical Pediatrics
Director, Section of Pediatric
Rheurnatology
College of Physicians & Surgeons
of Columbia University
New York, N Y 10032
1. Garcia-Morteo 0, Babini JC, Maldonado-Cocco JA, Gagliardi S ,
Yabkowski J: Remodeling of the hip joint in juvenile rheumatoid
arthritis. Arthritis Rheum 24: 1570-1574, 1981
2. Bernstein B, Forrester D, Singsen B, King KK, Kornreich H,
Hanson V: Hip joint restoration in juvenile rheumatoid arthritis.
Arthritis Rheum 20:109Y-1104, 1977
3. Jacobs JC, Dick HM, Downey JA, Edgar A, Sternstein R,
Berdon WE: Weight-bearing as treatment for damaged hips in
juvenile rheumatoid arthritis. N Engl J Med 305:409, 1981
Israeli A. Jaffe, MD
College of Physicians & Surgeons
of Columbia University
New York, N Y
1. Kahan A, Weber S, Amor B, Saporta L, Hodara M, Degeorges
M: Nifedipine and Raynaud’s phenomenon. Ann Intern Med
Y4:546, 1981
2. Vayssairat M, Capron L, Fiessinger J-N, Mathieu J-F, Housset
E: Calcium channel blockers and Raynaud’s disease. Ann
Intern Med 95:243, 1981
Use of azathioprine for rheumatoid arthritis
To the Editor:
We read with interest Dr. Franck’s letter (1). He was
concerned about the statement in the February 1981 issue of
Arthritis and Rheumatism (the 24th Rheumatism Review)
1270
that “azathioprine has now been approved for use in the
treatment of RA” (2).
According to J. R. MacDougal, MD, Medical Director of Burroughs Wellcome in Montreal (personal communication), azathioprine was approved by the FDA for use in
the treatment of rheumatoid arthritis (RA) on April 13, 1981.
Moreover, the last five issues of Arthritis arid Rheumatism,
including the October 1981 issue that contained Dr. Franck’s
letter, have carried full-page advertisements on the use of
azathioprine “for adults with severe, active erosive rheumatoid arthritis.” Surely the authors of the RA section of the
24th Rheumatism Review anticipated this FDA approval
because it was pending when the statement in question was
written.
Although the use of azathioprine for the treatment of
adults with severe active RA may no longer be considred
“experimental,” we agree with Dr. Franck that its use in RA
should not be taken lightly (3). The use of azathioprine in
RA requires careful medical supervision and long-term fol-
LETTERS
lowup. For this reason, one of u s (MBU) has set up a registry
at the Wellesley Hospital in Toronto to document possible
side effects of azathioprine.
Duncan A. Gordon, MD
Murray B. Urowitz, MD
University of Toronto Rheitmatic Disease Unit
The Toronto and Wellesley Hospitals
Toronto, Ontario, Canado
I . Franck WA: Use of azathioprine for rheumatoid arthritis. Arthritis Rheum 24:1327, 1981
2. Rheumatism Review Subcommittee, American Rheumatism Association: Rheumatoid arthritis. Arthritis Rheum
24:147, 1981
3. Azathioprine (Imuran) for rheumatoid arthritis. Med Let
Drugs Ther 23237-88, 1981
BOOK REVIEW
Joints and Synovial Fluid, Volume 11. Edited by Leon Soko[off,MD. New York, The Academic Press. 1980. 561 pages.
Illustrated. $55.00.
In the second volume of this series, contributions
include chapters by Dr. Sokoloff on in vitro culture of joints
in articular cartilage, Helen Muir on the chemistry of ground
substances, F. Happey on the structure and aging of the
intervertebral disc, John Paul on the kinetics of joints, Geoff
Kempson on the mechanical properties of articular cartilage,
Alice Maroudas on the physical chemistry of cartilage and
disc, and Dan McCarty on the physiology of synovium. In
the last third of the book, devoted to the pathology of
synovial joints, Dougal Gardner discusses the pathology of
peripheral joints and Eric Bywaters the pathology of the
spine. All in all, the scholarly contributions are intended for
the prepared mind. Most require a degree of sophistication
for a complete understanding. Particularly appealing are the
chapters on ground substance chemistry and the pathology
of the spine, which are gems. Starting from the most
elemental beginnings, they carry the reader to the heights of
current sophisticated understanding. As in the preceding
volume, the scope of techniques discussed is diverse and
considerable. From this volume one gains understanding, for
example, of x-ray diffraction, dissociative biochemistry,
tensile and compressive mechanical testing. gait analysis,
and cartilage culture. The book is extremely strong in its
discussion of the changes with age of the target tissues, both
structurally and chemically. Taken as a whole this volume is
well worth having and will be referred to often by anyone in
this field.
Eric L. Radin, MD
Morgantown, WV
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