MTX +dual DMARD compared to MTX + etarnecept

My original comments published in http://www.nejm.org/doi/full/10.1056/NEJMoa1303006#t=comments


The study showed a very promising results for triple therapy (methotrexate plus sulphasalazine plus hydroxychloroquine) with no difference significantly compared to methotrexate and etarnecept. The study potentially will give impact to management of rheumatoid arthritis as conventional triple therapy is much cheaper than methotrexate and etarnecept . Firstly combination conventional triple therapy potentially cheaper than methotrexate plus biologics. Secondly the initiating of triple therapy with relatively higher dose as starter therapy compared with normal treatment of DMARD with tapering dose according to response to therapy. NICE guideline only suggest initiate methotrexate with at least one other DMARD. I find this study commencing the aggressive therapy with the results of severe adverse events been observed ( 1mortality in biologics arm and severe infection in both arm). There is not mentioned folate in addition of methotrexate to prevent side effect of methotrexate . I personally suggest and conduct a routine chest radiograph before initiate biologics as pulmonary tuberculosis is relatively common in Malaysia.

Dental procedure during warfarin

From :http://www.neurology.org/content/80/22/2065/reply#neurology_el;58083
Published comments

This guideline is especially helpful in my daily management of patients. [1] Patients taking warfarin come to my clinic to obtain referrals for dental extraction because most dental surgeons in Malaysia refuse to perform dental procedures without clearance. I agree with the continuation of warfarin during dental procedures but certain precautions should be taken. Oral surgery may be completed safely at INR of 1.5-2.5 [2] and up to INR 4 for a small procedure. [3] The INR should be checked prior to surgery. For simple extractions, bleeding should be controlled by minimizing surgery to only one site and post-operative packs or firm sutures should cover the wound. Local anesthetic should be given cautiously to avoid venepunctures. [4] I hope a future guideline will address novel anticoagulant therapy for use during dental procedures.

1. Melissa J. Armstrong, Gary Gronseth, David C. Anderson Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: Report of the Guideline Development Subcommittee of the American Academy of Neurology

2.Little JW, Falace DA, Miller CS et al. Dental management of medically compromised patient. 5th ed. St. Louis: Mosby; 1997

3.Devani P, Lavary KM, Howell CJ. Dental extraction in patient on warfarin: is alteration of anticoagulant necessary? Br J Oral Maxillofac Surg 1998; 36:107-111

4.Savage N. Managing dental patients receiving warfarin therapy. Aust Prescr 2002; 25:69

Dabigatran post-AF ablation may be riskier than warfarin

Periprocedural anticoagulation in patients undergoing radiofrequency ablation for atrial fibrillation may entail a small but statistically increased risk of stroke or transient ischemic attack, according to a meta-analysis of 10 observational cohort studies.
The meta-analysis, which included 1,501 patients on periprocedural dabigatran (Pradaxa) and 2,356 on warfarin, had dual primary end points.
 One was stroke or TIA, which occurred in 0.7% of the dabigatran group, compared with 0.2% of those on warfarin – a statistically significant difference (P = .0007), Dr. Benjamin A. Steinberg reported at theannual meeting of the Heart Rhythm Society.

Major bleeding, was recorded in 1.6% of the dabigatran group, with a closely similar 1.7% incidence in the warfarin group.

Rates of cardiac tamponade, a secondary end point, were also similar: 1.1% with dabigatran and 0.9% with warfarin.
Conclusion: Dabigatran posted higher risk of stroke periprocedural anticoagulation with equal risk of bleeding and tamponade comparing to warfarin

Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease

Reference neurology journal 2013
Stroke patients undergoing dental procedures should routinely continue aspirin (Level A).
 Stroke patients undergoing invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound–guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery should probably continue aspirin (Level B).
 Some stroke patients undergoing vitreoretinal surgery, EMG, transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy and biopsy/sphincterotomy, and abdominal ultrasound–guided biopsies should possibly continue aspirin (Level C).
 Stroke patients requiring warfarin should routinely continue it when undergoing dental procedures (Level A) and probably continue it for dermatologic procedures (Level B).
Some patients undergoing EMG, prostate procedures, inguinal herniorrhaphy, and endothermal ablation of the great saphenous vein should possibly continue warfarin (Level C).
Whereas neurologists should counsel that warfarin probably does not increase clinically important bleeding with ocular anesthesia (Level B), other ophthalmologic studies lack the statistical precision to make recommendations (Level U).
Neurologists should counsel that warfarin might increase bleeding with colonoscopic polypectomy (Level C). There is insufficient evidence to support or refute periprocedural heparin bridging therapy to reduce thromboembolic events in chronically anticoagulated patients (Level U). Neurologists should counsel that bridging therapy is probably associated with increased bleeding risks as compared with warfarin cessation (Level B). The risk difference as compared with continuing warfarin is unknown (Level U).