Background Dupuytren’s disease is a progressive condition, as the contracture angle and related disease stage often increase with time. Treatment with ≥1 injection of collagenase Clostridium histolyticum (CCH) has been shown to result in a 76% mean reduction in fixed-flexion contracture (FFC): from 50.2° at baseline to 12.2° after CCH in patients with Dupuytren’s contracture (DC).1
Objectives We evaluated whether CCH treatment of early- (ie, palpable cord/1-30° FFC) versus advanced-stage DC (>30° FFC) would result in better outcomes in actual clinical practice.
Methods This was a retrospective chart review of DC patients treated with CCH at community and academic practices across the United States (Mar-Dec 2010). Information on patient history and CCH treatment outcomes was collected at each site by physicians or their medically trained staff using a study-specific Case Report Form. Patients who had only 1 CCH-treated joint were included, and outcomes were assessed after the first injection. Results for early- versus advanced-stage DC were compared using t-tests.
Results Inclusion criteria were met by 60% (302/501) of patients from 10 sites. On average, patients were aged 66 years; 75% were male. Early- and advanced-stage contractures were observed in 61 and 241 of CCH-treated joints, respectively. Mean ± SD final FFC in CCH-treated joints with early-stage DC (3.8±6.9°) was significantly better than that in CCH-treated joints with advanced-stage DC (14.0±18.0°, p<0.0001). Nonetheless, joints with advanced DC had a significantly greater mean improvement in contracture (43.6±17.9°) versus joints with early DC (20.8±8.0°; p<0.0001). The results were statistically significant even after controlling for joint type (metacarpophalangeal, proximal interphalangeal) in a general linear model. A trend toward a larger mean percent reduction in FFC was observed with early-stage joints (85%) versus advanced-stage joints (78%); however, the difference was not statistically significant after controlling for joint type (p=0.15). No serious adverse events were reported in the study.
Conclusions On average, CCH treatment of early-stage DC resulted in a significantly better outcome, to near normal correction, than did treatment of advanced-stage DC. The extent of improvement after CCH was significantly larger in advanced DC likely because of higher baseline severity. This analysis did not assess whether additional CCH injections into advanced-stage joints would result in an equivalent final FFC, or if early treatment abated DC progression or recurrence. These cross-sectional findings favoring early treatment with CCH warrant validation in longitudinal studies. Based on careful assessment of risk-benefit ratio, CCH may provide an additional benefit over surgery, which is usually reserved for more severe cases of DC.
Hurst LC, et al. NEJM 2009;361:968-979
Disclosure of Interest C. Peimer: None Declared, G. Pess: None Declared, P. Skodny Employee of: Auxilium Pharmaceuticals, J. Tursi Employee of: Auxilium Pharmaceuticals, P. Szczypa Employee of: Pfizer Ltd, R. Gerber Employee of: Pfizer Inc