September 25, 2013

DynaMed EBM Journal Volume 8, Issue 39

DynaMed Weekly Updates

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: September 25, 2013

Expiration Date: September 25, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1210393U


Last week 285 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 198 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Ustekinumab Improves Symptoms of Psoriatic Arthritis
Reference: PSUMMIT 1 trial (Lancet 2013 Aug 31;382(9894):780) (level 1 [likely reliable] evidence)

Psoriatic arthritis is common in patients with psoriasis, with estimated prevalence ranging from about 7% to 20% or more in this population. Usual treatments include NSAIDs for mild disease and tumor necrosis factor inhibitors or disease-modifying antirheumatic drugs (DMARDs) for more severe disease. Ustekinumab, an anti-interleukin monoclonal antibody, is FDA approved for the treatment of moderate-to-severe plaque psoriasis in adults. The PSUMMIT 1 trial evaluated the efficacy of ustekinumab for psoriatic arthritis in 615 adult patients previously treated with or intolerant to NSAIDS and DMARDs.

Patients (median age 48 years) with active psoriatic arthritis for ≥ 6 months were randomized to ustekinumab (45 mg vs. 90 mg) subcutaneously vs. placebo at baseline and at 4 weeks, then once every 12 weeks for up to 1 year. At baseline, all patients had ≥ 5 tender joints and ≥ 5 swollen joints and all had been previously treated with either ≥ 3 months of DMARDs and/or ≥ 4 weeks of NSAIDs or had intolerance to both. At 16 weeks, patients who had < 5% improvement in both tender joint and swollen joint counts were switched from the placebo group to ustekinumab 45 mg and from the ustekinumab 45 mg to ustekinumab 90 mg. At 24 weeks, all patients still receiving placebo were switched to ustekinumab 45 mg.

The primary outcome was the proportion of patients achieving an American College of Rheumatology 20% response (ACR20) at 24 weeks. ACR 20 requires at least 20% improvement in tender and swollen joint counts and 20% improvement in 3 of 5 measures: patient global assessment, physician global assessment, self-reported physical disability, an acute phase reactant, and patient pain assessment. ACR50 response (50% improvement) was a secondary outcome. For patients who changed treatment at 16 weeks, the 16-week response was carried forward to 24 weeks.

ACR20 response was achieved in 49.5% with ustekinumab 90 mg, 42.4% with ustekinumab 45 mg, and 22.8% with placebo (p < 0.0001 for each ustekinumab dose vs. placebo), with a number needed to treat (NNT) of 4 with the higher dose and 6 with lower dose of ustekinumab. ACR50 response was achieved in 27.9% with ustekinumab 90 mg, 24.9% with ustekinumab 45 mg, and 8.7% with placebo. (p < 0.0001 for each ustekinumab dose vs. placebo). Both doses of ustekinumab were associated with significant reductions in dactylitis and enthesitis and significant improvements in physical function and health-related quality of life. There were no significant differences among groups in adverse events at 16 weeks. The most common adverse events with ustekinumab were nasopharyngitis, upper respiratory tract infection, and headache. Treatment responses with ustekinumab were maintained at 1 year (ACR20 in 58% for 2 doses combined).

For more information, see the Psoriatic arthritis topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

DynaMed Events

American Academy of Family Physicians (AAFP) Conference, September 24-28, 2013
Senior Deputy Editor Alan Ehrlich, MD, will be attending the American Academy of Family Physicians conference, held at the San Diego Convention Center in San Diego, California. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the American Academy of Family Physicians website to learn more about the event and for registration information.

ID Week, October 2-6, 2013
Deputy Editor Sheila Mitsuma, MD, will be attending ID Week, held at the Moscone Convention Center in San Fransisco, California. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the ID Week website to learn more about the event and for registration information.

Pediatric Case Study Presentation: Septic Shock, Acute Abdominal Pain, and Suspected Meningococcemia, September 30 & October 3, 2013
Join Ron Dieckmann, MD, Professor Emeritus of Pediatrics and Medicine at University of California San Francisco and learn how he navigates complicated pediatric clinical presentations. During this 45-minute session, Ron will take an in-depth look at 3 different complex pediatric emergency presentations: septic shock, acute abdominal pain, and suspected meningococcemia

To register select the appropriate time:

  • Monday, September 30, 2013 at 8am PST
  • Monday, September 30, 2013 at 1PM PST
  • Thursday, October 3, 2013 at 9AM PST
  • Thursday, October 3, 2013 at 12 PM PST

    If you would like to meet with a DynaMed representative at an event, please contact us at

    Call for Peer Reviews

    We are currently seeking reviewers for:

    Mucopolysaccharidosis type I (MPS I)

    Ross River virus disease