Owing to the heterogeneity in the clinical phenotype of haemophilia A and B, it is now recognized that disease severity (based on factor VIII/IX activity) may no longer be the most appropriate guide for treatment and that a 'one-size-fits-all' approach is unlikely to achieve optimal therapy. Based on the present literature and consensus views of a group of experts in the field, this article highlights key gaps in the understanding of the diverse relationships between bleeding phenotype and factors such as joint health, genetic susceptibility, laboratory parameters, quality of life and management of pain. Early prophylaxis is a potential 'gold standard' therapy and issues surrounding inhibitor development, variations in its clinical use and long-term outcomes are discussed. Comprehensive treatment should be individualized for all patients (including those with mild or moderate haemophilia and carriers). Wherever possible all patients should be given prophylaxis. However, adult patients with a milder haemophilia phenotype may be candidates for ceasing prophylaxis and switching to on-demand treatment. Regardless, all treatment (on-demand and prophylaxis) should be tailored towards both the patient's personal needs and their clinical profile. In addition, as the associations between risk factors (psychosocial, condition-related and treatment-related) and clinical features are unique to each patient, an individualized approach is required to enable patients to alter their behaviour in response to them. The practical methodologies needed to reach this goal of individualized haemophilia care, and the health economic implications of this strategy, are ongoing topics for discussion.

Osteoporosis is complicated by the occurrence of fragility fractures. Over past years, various treatment options have become available, mostly potent antiresorptive agents such as bisphosphonates and denosumab. However, antiresorptive therapy cannot fully and rapidly restore bone mass and structure that has been lost because of increased remodelling. Alternatively recombinant human parathyroid hormone (rhPTH) analogues do increase the formation of new bone material. The bone formation stimulated by intermittent PTH analogues not only increases bone mineral density (BMD) and bone mass but also improves the microarchitecture of the skeleton, thereby reducing incidence of vertebral and nonvertebral fractures. Teriparatide, a recombinant human PTH fragment available in Switzerland, is reimbursed as second-line treatment in postmenopausal women and men with increased fracture risk, specifically in patients with incident fractures under antiresorptive therapy or patients with glucocorticoid-induced osteoporosis and intolerance to antiresorptives. This position paper focuses on practical aspects in the management of patients on teriparatide treatment. Potential first-line indications for osteoanabolic treatment as well as the benefits and limitations of sequential and combination therapy with antiresorptive drugs are discussed.

Hintergrund: Bei der vorliegenden Studie handelt es sich um eine Anwendungsbeobachung unter Praxisbedingungen in der Schweiz, durchgefÜhrt mit einem Weidenrinden-Spezialextrakt (Assalix®). Ziel der Studie war es, eine bessere EinschÄtzung zur HÄufigkeit von Nebenwirkungen (und mÖglicherweise die Identifizierung bisher nicht bekannter Nebenwirkungen) und zur Wirksamkeit zur erhalten. Methoden: In die Studie aufgenommen wurden Patienten im Erwachsenenalter, die aufgrund ihres Beschwerdebildes fÜr eine Behandlung mit dem Extrakt geeignet waren. Die Studiendauer betrug 6–8 Wochen, wobei eine Kontrolle nach 3–4 Wochen erfolgte. Neben den Üblichen demografischen und anamnestischen Daten wurden die Variablen (Intent-to-treat) SchmerzintensitÄt, BeeintrÄchtigung im tÄglichen Leben sowie globale Beurteilung von Wirksamkeit und VertrÄglichkeit erhoben. Ergebnisse: Die 204 teilnehmenden Ärzte behandelten 877 Patienten mit unterschiedlichen rheumatisch bedingten Schmerzen (Frauen 64,2%, Alter 58,76 ± 15,69); 763 Patienten konnten die Studie abschliessen. In 68% der FÄlle betrug die Dauer der Beschwerden mehr als 6 Monate und 81,2% der Patienten hatte bereits eine andere Medikation erhalten. Eine anti-inflammatorische Comedikation erfolgte bei 39,3% der Patienten. Der Schmerz-Score betrug 5,32 ± 1,62 (auf einer Skala von 0–9) zu Studienbeginn und bei der letzten Konsultation 2,51 ± 2,04 (p < 0,001); vÖllige Schmerzfreiheit wurde von 14% der Patientinnen berichtet. WÄhrend zu Studienbeginn lediglich 0,6% der Patienten Über keine BeeintrÄchtigungen in ihrem tÄglichen Leben berichteten, waren dies bei der Schlussvisite 27,4%. 38 Patienten (4,3%) berichteten Über insgesamt 46 unerwÜnschte Wirkungen, die vorwiegend das Verdauungssystem (3,1%) und die Haut (1,6%) betrafen. «Ernsthafte» Nebenwirkungen wurden nicht beobachtet. Nebenwirkungen traten hÄufiger unter der anti-inflammatorischen Comedikation auf. Schlussfolgerungen: Der untersuchte Weidenrindenextrakt (Assalix®) wurde gut vertragen, unerwartete Nebenwirkungen traten keine auf. Unter BerÜcksichtigung des Studiendesigns kann festgestellt werden, dass der Extrakt eine moderat analgetische Wirksamkeit bei Dorsopathien, Weichteilrheuma, entzÜndlichen Polyarthropathien und bei Arthrose besitzt.

A considerable percentage of the population suffers from chronic musculoskeletal pain (CMP) and patient management does not appear to be optimal. The aim of the present investigations was to assess and evaluate epidemiologic data and discover eventual deficits in patient management. This investigation included several sequential steps: First a European study including Switzerland evaluated the prevalence and characteristics of patients with CMP as well as of the treating physicians. The results were discussed and elaborated in two workshops, where general practitioners and patients were included. In a further step the results of these workshops were evaluated again in a telephone survey addressing patients and physicians both in the French and German speaking parts of Switzerland. Considerable deficits were discovered in the management of patients with CMP: In 35% no firm diagnosis was established, the life quality was considerably reduced in about 13 of the patients, the patients' information on their disorders were found to be rather limited, furthermore, there were misconceptions about medical treatment. The two workshops confirmed the results of the first study. The causes of pain often remained unclear, there were considerable communication problems between patient and physician, medical treatment appeared to be inappropriate, and there were deficits in the time management during consultations. The telephone survey confirmed these deficits. In conclusion management of patients with CMP is characterized by considerable deficits such as missing or unclear diagnosis, misconceptions in medical contexts and treatment. Many of the deficits may be improved and call for measures for optimizing the management of patients with CMP.

No abstract