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Extercorporeal photochemotherapy in systemic IupusReply.

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LETTERS
Extracorporeal photochemotherapy in systemic lupus:
reply
Extracorporea. photochemotherapy an the
psychological effects of new procedures
To the Editor:
We were very interested in the article by Knobler et
a1 on the treatment of systemic lupus erythematosus with
extracorporeal photochemotherapy (1). This is a new treatment that should be more thoroughly investigated. The
actual results are good, but they may be too good. Seven
patients improving among a group of 8 patients treated is too
perfect.
This reminds us of the beginnings of azathioprine
therapy for the rheumatic diseases. When one of us treated
his first patients with this drug in 1963, the results were quite
impressive (2). Since the treatment was the same as that
used for kidney-graft recipients, the azathioprine was administered with actinomycin C, intravenously, in weekly doses.
At each treatment, 150 cc of blood was also drawn for
immunologic studies. All this was done not in the hospital,
but at the bedridden patient’s home, very often with a family
member assisting, and, during insertion of the venous catheter, blood sometimes spurted all over the sheets-all of
which was very impressive for the patient. The results of
treatment were wonderful, and the first articles very enthusiastic about azathioprine (3).
But as azathioprine therapy become more routine,
major laboratory work, and thus, part of the show, was
dropped; so too, the very good results. Azathioprine then
became what it is now: fair, but no miracle.
We believe that the good results are related to the
psychological impact that a new procedure may have on the
patient: He (or she) knows it is new; he sees quite a bit of
excitement around him; he has lots of people taking care of
him; he senses the doctor’s anticipation . . . and he feels
better.
What is the psychological factor worth?-that is the
question.
Christian Moens, MD
Centre Mtdico Social
Philippe Moens, MD
Clinique Ste. Elizabeth
Brussels, Belgium
1. Knobler RM, Graninger W, Graninger W, Lindmaier A, Trautinger F, Smolen JS: Extracorporeal photochemotherapy for the
treatment of systemic lupus erythematosus: a pilot study. Arthritis Rheum 35:31%325, 1992
2. Moens C: Les antimetabolites dans le traitement de la PCE. J
Belge Med Phys Rhum 19: 165-167, 1964
3. Moens C, Broctaur J: Treatment of rheumatoid arthritis with
immunosuppressive drugs. Acta Rheum Scand 11:212-220, 1965
Arthritis and Rheumatism, Vol. 35, No. 12 (December 1992)
To the Editor:
We were certainly aware of the possible favorable
psychological effects this treatment might have had on our
patients. And, we clearly drew attention to this possible
beneficial side effect of treatment in the published article. As
we stated, “Since this was not a controlled study, the
presence of a placebo effect during the treatment phase
cannot be excluded.”
We do not know whether Drs. Moens also had a
similar experience when they evaluated azathioprine, but we
do believe that the fact that the clinical response did not
occur until after 4-6 months of treatment provides evidence
against a psychological effect. We have extended our studies
and, at the present time, appear to be able to confirm our
initial impressions, with maintenance of remission even
upon significant extension of the treatment intervals. At this
stage, it is of major importance, though, to emphasize that
our study brought forth a second critical observation not
previously observed, namely, that an autoimmune disease
such as systemic lupus erythematosus, with known cutaneous photosensitivity, is not exacerbated by this form of
photochemotherapy .
Clearly, the next step must be a control!ed clinical
trial, which is warranted on the basis of our experience.
Then, the place of this therapeutic approach in SLE can
ultimately be determined.
Robert M. Knobler, MD
University of Vienna
Vienna, Austria
Fibromyalgia: comment on the article by Russell et a1
To the Editor:
The article by Russell et al, on cerebrospinal fluid
(CSF) biogenic amine metabolites in fibromyalgia, leaves so
much to the imagination of the reader that the conclusions
are not supported by the results (Russell IJ, Vaeroy H,
Javors M, Nyberg F: Cerebrospinal fluid biogenic amine
metabolites in fibromyalgidfibrositis syndrome and rheumatoid arthritis. Arthritis Rheum 35550-556, 1992). There are
no data to substantiate that the methods give reproducible
results. When the difference of 2 ng between means supposedly gives statistical significance and the range within the
group is 10-11 ng, proof of the reliability of the method is
necessary. This is most important for the values of 3methoxy-4-hydroxyphenethyleneglycol (MHPG) but is also
cogent for 5-hydroxyindole acetic acid (5-HIAA) and homovanillic acid values.
The interpretation of differences between 2 groups
requires looking at more than the P values generated by the
computer. All of the levels of biogenic amines in the fibromyalgia group were within the range of the levels in the
controls, except for one MHPG value in the primary fibromyalgia group that was higher than that in any of the
controls. The data for 5-HIAA revealed that only 2 patients
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