Macro-creatine kinase (macro-CK) is a neglected cause of raised CK. Over a 10-year period, we observed five cases. Three patients had macro-CK type 1. One patient with fibromyalgia underwent several explorations to find a muscular pathology; another, who had elevated CK-MB (muscle-brain fraction) activity, was referred to a cardiologist, and statin therapy was erroneously discontinued in two patients. Two patients had macro-CK type 2: a man with a neuroendocrine carcinoma and a woman with rheumatoid arthritis. Diagnosis of type 1 obviates the need to carry out pointless and expensive investigations seeking a neuromuscular or cardiac pathology, and also, the unwarranted discontinuation of statin therapy. Type 2 must prompt investigations for a neoplasm.

BackgroundErosive degenerative disc disease, also known as Modic type 1 changes, is usually characterized by low back pain with an inflammatory pain pattern, as seen in spondyloarthropathies. Intravenous pamidronate has proven to be effective in patients with ankylosing spondylitis who are refractory to nonsteroidal antiinflammatory drugs, and in painful bone diseases in general, such as Paget’s disease, fibrous dysplasia or vertebral fractures. We therefore hypothesize that pamidronate would be effective in treating low back pain associated with Modic type 1 changes.Methods/DesignThis study, called PEPTIDE (short for the French title “Etude Prospective sur l’Efficacité et la tolérance du PamidronaTe dans les dIscopathies Degeneratives Erosives”), will be a double-blind, randomized, placebo-controlled, parallel group, phase two clinical trial. A total of 48 patients will be recruited. These patients will be randomly assigned to one of the two groups, with 24 patients in each group: one group will be given pamidronate and the other a placebo. Pamidronate will be administered at a dose of 90 mg per day for two days consecutively, and every patient, irrespective of treatment group, will be given paracetamol to maintain blinding by preventing drug-induced fever. The primary outcome measure is a between-group difference of 30 points on a 100 mm Visual Analogue Scale (VAS) at three months. Secondary outcome measures are improvement in functional status and the drug’s safety. Primary and secondary outcome measures will be assessed at each visit (inclusion, at six weeks, three months, and six months). If the primary goal is not attained, the patient will be offered a rigid or semi-rigid back brace, irrespective of the treatment group.DiscussionTo date, only local treatments, for example intradiscal corticosteroid therapy, lumbar arthrodesis or back braces have been studied in randomized, controlled trials, with controversial results. This trial is currently ongoing and, if conclusive, should provide physicians with an acceptable alternative to those treatments. The results should be publicly available in spring 2015.Trial registrationClinicalTrials.gov number, NCT01799616.

Background Serum levels of vitamin D (VitD) are usually inversely correlated with RA activity. However, the prevalence of VitD deficiency does not appear to differ from that of the general population. Hypertension (HT) and low levels of HDL-cholesterol (HDL-c) –two cardiovascular (CV) risk factors with an increased prevalence in RA – are inversely correlated with VitD levels. Objectives Determine the prevalence of VitD deficiency in RA patients versus a control population. Detect correlations between VitD levels and RA disease activity and/or characteristics, and between VitD levels and CV risk factors. Methods The COMEDRA study evaluated the impact of a visit with a nurse on the management of comorbidities in RA patients. VitD and lipids assays were performed in all patients. Controls were from the SUVIMAX cohort and were matched for gender, age, latitude and season during which samples were taken for assay. VitD deficiency was defined as VitD<10 ng/ml and VitD insufficiency as VitD between 10 and 29.9 ng/ml (VDI). Results 894 patients (79.3% women) with an average disease duration of 11.2 years [6.3 – 19.1] were analyzed. RA was erosive in 73.3% of patients and 83.9% had positive RF or anti-CCP antibodies. The DAS28ESR was 3.0±1.3. 630 patients (70.4%) were treated with biologic therapy and 341 (38.1%) received glucocorticoids (5.5±5.7 mg/day). BMI was 25.1±4.8. SBP was 124.9±16.5 mmHg, and DBP 75.6±11.4 mmHg. Total cholesterol was 2.2±0.5 g/l, LDL-c was 1.3±0.4 g/l, HDL-c was 0.7±0.2 g/l. 147 patients (16.4%) were smokers and 52 (5.8%) were diabetic. VitD levels were in the normal range in 362 patients (40.5%), whereas 501 patients (56.0%) had VitD insufficiency and 31 (3.5%) had VitD deficiency. Comparison of 861 RA patients with 861 matched controls revealed that the RA patients had a lower prevalence of VitD insufficiency (RA: 480 (55.8%) vs. controls: 508 (59%); p=0.04) and of VitD deficiency (RA: 31 (3.6%) vs. controls: 45 (5.23%); p=0.04). Among RA patients, males had a higher frequency of VitD insufficiency (117 (63.3%) vs 384 (54.2%); p=0.04) and VitD deficiency (8 (4.3%) vs.23 (3.2%); p=0.04 in males vs females respectively). There was no difference according to latitude, but the prevalence of VitD insufficiency and VitD deficiency were higher in springtime. Univariate analysis found an inverse correlation between VitD levels and RA activity defined by DAS28CRP (p=0.02), SDAI (p=0.05) and CDAI (p=0.05), but only a trend for DAS28ESR (p=0.08). No correlation was found with antibody status or with treatments. VitD levels were inversely correlated with BMI (p<0.001) but not with blood pressure, total-c, LDL-c, HDL-c or diabetes. Conclusions This study confirms that VitD is inversely correlated with RA activity and BMI but not with other CV risk factors. The prevalence of VitD deficiency was lower than in the control population, which could be explained by the fact that RA patients more frequently received VitD supplementation. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014...