808

BRITISH JOURNAL OF RHEUMATOLOGY VOL. 35 NO. 8

elevated. However, we too have recorded pre-treatment
with steroids prior to the onset of her effusion.
L. D . HORDON, J. H. TURNEY

Rheumatology and Rehabilitation Research Unit, 36

Clarendon Road, Leeds LS2 9NZ
Accepted 10 March 1996
1. Tokuhira M, Hama N, Hirakata M el al. Massive pericardial
effusion in scleroderma: a review of five cases. Br J Rheumatol
1995^4:564-7.

Rheumatoid Arthritis and Heparin

SIRA recent editorial on rheumatoid arthritis [1]

states that, despite current treatments, many patients
continue to have pain, stiffness and progressive
disability, and advocates the use of combination
therapies. We would like to suggest that the
combination of heparin and sulphasalazine is worth
trying in early-stage rheumatoid arthritis.
The use of carbohydrate molecules to inhibit
binding of leucocytes to adhesion molecules has
been identified as a therapeutic target in rheumatoid
arthritis [2]. Heparin (a polysaccharide) has potent
anti-inflammatory actions based on the ability of
heparin saccharides to bind the adhesion molecules
L- and P-selectin, inhibits leucocyte rolling on
the endothelium, and is 'an interesting candidate
for further study as an anti-inflammatory therapeutic'
[3].
We have reported remission of disease in nine of
10 patients with refractory ulcerative colitis treated
with combined heparin and sulphasalazine [4]. These
patients were commenced on 30-36 000 U i.v. for
10-21 days, followed by a variable period on
s.c. heparin (10 000 U twice daily). Ulcerative colitis
and rheumatoid arthritis share certain features
(arthritis associated with ulcerative colitis, colitis
with arthritis, and a similar range of treatment
options). Our attention was drawn to the therapeutic possibilities of heparin in rheumatoid
arthritis by the experience of a patient with poorly
controlled disease admitted to another centre with
occlusion of her tibial vessels. During 3 weeks on
heparin, she was remarkably free of arthritic symptoms, which returned 1 week after discharge on
warfarin.
As we are not involved in the treatment of
rheumatoid arthritis, we felt that we should offer the
idea for consideration by rheumatologists as a safer
alternative to the use of immunosuppressive agents.
Our experience with ulcerative colitis suggests that
heparin is more effective when combined with
sulphasalazine, but the use of non-steroidal antiinflammatory agents with heparin is obviously
contraindicated.
A. GAFFNEY, P. GAFFNEY*

* Department of Child Health, University College Cork

and *Mallow General Hospital, Mallow Co. Cork,
Ireland
Accepted 9 March 1996

Downloaded from http://rheumatology.oxfordjournals.org/ by guest on October 5, 2014

tamponade clinically and confirmed by echocardiogram. Her clinical condition was poor and she
required pericardial aspiration; 300 ml straw-coloured
fluid, initially under high pressure, were removed.
Microscopy showed scanty leucocytes and biochemistry a protein content of 13 g/1.
After aspiration, she had no respiratory or
oesophageal symptoms, and barium swallow showed
normal peristalsis and a small sliding hiatus hernia.
At the time of admission in December 1984, ANF,
ENA screen and RhF were negative, and ESR was
2 mm/h.
She was treated with prednisolone 60 mg daily,
reducing to 10 mg daily over the next month, and has
remained on prednisolone 2.5-10 mg daily since.
Penicillamine 250 mg daily was also started, and
continued long-term. She had no clinical recurrence of
her pericardial effusion, although echocardiography
detected a small anterior effusion in January 1986. At
this time, she complained of dysphagia of 2 months'
duration. Barium swallow showed a slow primary
stripping wave which faded away in the lower
oesophagus. There was no reflux or dilatation.
Pulmonary function tests performed for the first time
showed a pure restrictive defect with a degree of
alveolar capillary block. She had developed calcinosis
at the wrist. Repeat autoantibody studies showed ANF
positive for the first time (titre 1:50 speckled), with Sm,
RNP, Ro, La and ScL70 antibodies negative. ESR was
4 mm/h.
Between January and April 1986, she received
plasmapheresis five times in the hope of improving her
skin disease and dysphagia. There was some subjective
and objective improvement. She reported severe
Raynaud's phenomenon in 1988, but was otherwise
reasonably well until an episode of severe hypertension
[blood pressure (BP) 240/120] in July 1992, despite
pre-treatment with enalapril 5 mg daily. This responded rapidly to an increase in enalapril and the
addition of nifedipine, and she remained well and
normotensive until a second hypertensive episode (BP
250/130), this time accompanied by renal impairment
(creatinine 319/imol/l), and urinalysis showing
microscopic haemaruria and granular casts. Renal
function and BP improved on treatment, and at last
follow-up, in July 1995, she was well with BP 120/70
and renal function stable, but impaired (creatinine
135/xmol/l), and taking prednisolone 10 mg on
alternate days, penicillamine and lisinopril.
Our case differs from the ones presented in that she
is younger and a long-term survivor. Her disease
duration was short and her effusion, which appeared
acute, responded to aspiration and high-dose
prednisolone, and has not returned. Her episodes of
accelerated hypertension, latterly with renal
impairment, occurred 8 and 10 yr after presentation
with pericardial tamponade. Autoantibodies, last
measured in September 1995, have repeatedly shown
Sm, Ro, La, RNP ScL70 and Jol negative, although
the titre of ANF (speckled) has risen to 1/160. ESR, or
more recently plasma viscosity, has never been

LETTERS TO THE EDITOR

1. Breedveld FC. New perspectives on treating rheumatoid arthritis
[Editorial]. N EngI J Med 1995;333:183-4.
2. Fitzgerald O. Advances in understanding and novel therapeutic
targets in inflammatory arthritis. IT J Med Set 1995;164:4-11.
3. Nelson RM, Cecconi O, Roberts WG et ai. Heparin

809

oligosaccharides bind L- and P-selectin and inhibit acute

inflammation. Blood 1993;82:3253-8.
4. Gaffney PR, Doyle CT, Gaffney A, Hogan J, Hayes DP, Annis
P. Paradoxical response to heparin in ten patients with ulcerative
colitis. Am J Gaslromterol l995;90:220-3.

Downloaded from http://rheumatology.oxfordjournals.org/ by guest on October 5, 2014