Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement
Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.
Defining the Aromatase Inhibitor Musculoskeletal Syndrome: A Prospective Trial.
Singer1, Ora, Levine1, Alana B., Cigler3, Tessa, Moore2, Anne B., Do1, Huong T., Mandl1, Lisa A.
Aromatase Inhibitors (AIs) are standard of care therapy for post-menopausal breast cancer, AIs have been associated with debilitating musculoskeletal symptoms, predominantly in the hands and wrists. Up to 15% of symptomatic patients discontinue this potentially life saving therapy. The purpose of this study is to define the AI syndrome.
Post-menopausal women with hormone-sensitive, non-metastatic breast cancer and no rheumatic disease were included in this prospective cohort study. Subjects were evaluated by a rheumatologist before starting AIs and at 6 months. Women who reported new or worsening musculoskeletal symptoms were classified as "symptomatic." The primary outcome was grip strength; secondary outcomes included 66/68 swollen and tender joint count, HAQ-DI, SF-36, AUSCAN Hand Index, and serum testing for CPK, CRP, ESR, CCP, SSA, SSB, RF, ANA. Contrast enhanced MRIs of the hands and wrists were performed at baseline and 6 month or at symptom onset. MRIs were read by two blinded radiologists using the OMERACT Rheumatoid Arthritis MRI Scoring with Tenosynovitis subscale (RAMRIS-TS).
Of 35 women enrolled, 19 (54%) were symptomatic and of these 2 (5.7%) discontinued the AI. Mean time to onset of symptoms was 6 weeks (range 2 to 18). Fifty-eight percent of symptomatic subjects had involvement of the hands. Two had De Quervain's TS, 4 had tenderness over the flexor digitorum tendons, including 1 trigger finger, and 5 had generalized bilateral hand and wrist stiffness. Three subjects had ball of the foot and/or heel pain with weight bearing. Cancer stage was the only significant predictor of symptom development, (OR 5.9; 95% CI 1.2, 28.1) There was no difference in the mean change in grip strength between the symptomatic and asymptomatic groups, (-2.3 kg vs -1.4 kg, p-value=0.97). There were also no differences in the mean change in HAQ, SF 36, 66/68 tender and swollen joint counts and laboratory values. There was a statistically significant worsening of the AUSCAN pain, stiffness and total subscales in the symptomatic group (P-values = 0.004, 0.001 and 0.001, respectively). Although some symptomatic subjects with hand/wrist involvement had MRI abnormalities, there was no significant change in any RAMRIS score. ICC's were 0.8, 0.76, 0.19 and 0 for erosion, edema, synovitis and TS RAMRIS scores respectively
In this prospective study, more than half of subjects reported new or worsening musculoskeletal complaints on AIs. Later stage cancer increased the risk of developing pain, and clinical exam suggested underlying tenosynovial pathology. While TS was detected on MRI in some symptomatic subjects, the RAMRIS, developed for inflammatory arthritis, was not able to differentiate symptomatic from asymptomatic women. There was no difference in serum findings between the two groups. These findings suggest the AI syndrome is not due to the triggering of an autoimmune or systemic inflammatory process. Although symptoms were not limited to the hands and wrists, the AUSCAN was associated with increased pain, suggesting this instrument may be discriminative in diseases other than OA.
To cite this abstract, please use the following information:
Singer, Ora, Levine, Alana B., Cigler, Tessa, Moore, Anne B., Do, Huong T., Mandl, Lisa A.; Defining the Aromatase Inhibitor Musculoskeletal Syndrome: A Prospective Trial. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :898