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Heavy Metal Rheumatology (9.23.2022)

Jack Cush, MD

Below are this week’s highlights from RheumNow, as discussed by Dr. Jack Cush. Thanks to all of you for your kind comments and great reviews of our weekly podcast. Please let us know how we can improve by emailing me or recording your suggestion using the "Ask Cush Anything" link on our website.

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Is PMR the Next Indication for Tocilizumab?

MedPage Today

About half of patients with steroid-dependent polymyalgia rheumatica (PMR) were able to get off steroids altogether when they were started on tocilizumab (Actemra) infusions, which also improved disease control in most cases, a randomized phase III trial showed.

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CD19 CAR T Cell Therapy in SLE (9.16.2022)

Jack Cush, MD

The big news this week: the approval of deucravacitinib (a new class of drug?) for psoriasis; the 2022 ACR guidance on glucocorticoid-induced osteoporosis; a national poll of older adults over the age of 50 who claimed self-reported or doctor-diagnosed arthritis; and much more. Let's review these and other news, journal reports and announcements from this past week.

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STING/IFN Activation Promotes ANCA-Associated Vasculitis Progression

Jack Cush, MD

Research presented in the Journal of Experimental Medicine shows that ANCA-associated vasculitis (AAV) may be propagated by pathogenic mechanisms triggering cGAS/STING/IRF3-dependent IFN-I release.

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Hit Parade Review (8.12.2022)

Jack Cush, MD

We've got a lot to discuss this week: psoriasis; fatigue; sleep; sural nerve biopsies; uveitis and SpA; diet and RA; tofacitinib and the ORAL surveillance study; what not to take with mycophenolate - and more. In what order should these items be discussed? This week the run down is based on popularity, measured by rheumatologist engagements on the website and social media.

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Cytomegalovirus Increases Thromboembolism Risk in ANCA-associated Vasculitis

Jack Cush, MD

Infection may play an important role in the genesis of vasculitis and ANCA seropositivity; this report suggests that past cytomegalovirus infection may be a risk in the occurrence of venous thromboembolism (VTE) in patients with anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis. 

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Increased Mortality in Giant Cell Arteritis

Jack Cush, MD

A population-based study from Ontario, Canada suggests an increased mortality risk in patients with giant cell arteritis (GCA), according to a recent report in Arthritis Care & Research.

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12 pts w/ new onset IgA vasculitis (IgAV) post COVID- 19 vaccination (5F; age 52 yrs) - 10 had mRNA & 2 viral vector Vax. Time from Vax to Sxs=11.5 d; 8/12 had vasculitis w/ 1st dose; all skin (7 Jts, 4GI, 2 renal). All Rx w/ steroids https://t.co/eCcUkGeAwV https://t.co/VU1LwFxITC

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Dr. John Cush RheumNow ( View Tweet)
Chest CT Airway Dz compared betw GPA (n26) & relapsing polychondritis (n19). Subglottic involvement favors GPA (OR 28.6) & Extensive airway Dz favor of RP (GP OR 0.02). Lesser RP assoc w/ Posterior tracheal sparing & tracheal calcifications. https://t.co/TaaEjpPm76 https://t.co/mwljLYIymH

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Dr. John Cush RheumNow ( View Tweet)
Highlights from the @ACRheum Kawasaki Disease Guidelines 🥇IVIG is mainstay therapy (2 g/kg) 👶🏼 Use ASA in acute KD 🗣Refractory cases may require steroids or additional immunosuppression 🫀Get echos on all patients to assess for coronary aneurysms

Catherine Sims, MD DrCassySims ( View Tweet)

NEJM: 70 yoWM w/ 3-wk temporal headaches, jaw pain with chewing, temporal artery tender and thickened, but NO vision Sxs. a 15, CRP 24 mg/L. and Doppler US showed “halo sign” . Temp art Bx confirmed the Dx of GCA https://t.co/ayPcVKctEA https://t.co/g3iP0Akbzs

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Dr. John Cush RheumNow ( View Tweet)
IL-6i in Behcets? Lit Review finds 25 articles papers, 74 pts (31 TNFi naive, 45 TNFi prior Rx). Pts Rx w/ tocilizumab IV. TCZ given for vascular, CNS , ocular & mucocutaneous. TCZ was effective in 87% TNF naive & 80% in TNFi Experienced pts. https://t.co/u1jnR9gb1L https://t.co/Rkqch4MVWi

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Dr. John Cush RheumNow ( View Tweet)
Worldwide, IL-6 inhibitors are approved for RA, poly JIA, systemic JIA, AOSD, GCA, Takayasu arteritis, Castleman’s dz, CAR-T-cell-induced cytokine release syndrome, neuromyelitis optica spectrum disorder and severe COVID-19 https://t.co/SRPjerXnGS

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Dr. John Cush RheumNow ( View Tweet)

Is PMR the Next Indication for Tocilizumab? About half of patients with steroid-dependent PMR were able to get off steroids altogether when they were started on tocilizumab (Actemra) infusions, a randomized phase III trial showed. https://t.co/LUMG4NnZzs https://t.co/zdFacyYyud

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Dr. John Cush RheumNow ( View Tweet)
A longitudinal study of 506 ANCA-associated vasculitis (AAV) pts showed pts w/ negative ANCA serologies within 180 days of induction had signif lower risk of relapse (HR 0.55; 0.38 to 0.81) but not for ESRD or death within 5 years. https://t.co/qFb2Usov8L https://t.co/faogbabc2W

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Dr. John Cush RheumNow ( View Tweet)
Mayo study of 3817 temporal artery biopsies performed on 2539 pts (1994-2004) - 681 (27%) +Bx on one side. Biopsy length HAD NO significant effect BX positivity. If 1-side initially Bx-, then Bx of the contralateral side yielded an added 7% Bx positivity https://t.co/Lr8hYHIlG7 https://t.co/alIpklPtsw

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Dr. John Cush RheumNow ( View Tweet)
A longitudinal study of 506 ANCA-associated vasculitis (AAV) pts showed pts w/ negative ANCA serologies within 180 days of induction had signif lower risk of relapse (HR 0.55; 0.38 to 0.81) but not for ESRD or death within 5 years. https://t.co/Dn8GGXnSDi https://t.co/C73hG9T7Au

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Dr. John Cush RheumNow ( View Tweet)
Cluster analysis of 649 #GPA patients (age 60 yrs) finds 3 clusters: 1)Limited dz w/ ENT + cough(n=426) - many evovle to gen dz @ yr 1 2) Generalised non-renal Dz (176) ) 3) Renal dominant Dz(47) Mortality in #1, signif lower than mortality in #2 & #3 https://t.co/XgZVt9b73n

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Dr. John Cush RheumNow ( View Tweet)

Should you do sural nerve biopsy (SNB) to Dx vasculitis? Study of 91 pts undergoing SNB suggests the SNB must be off sufficient length to improve Dx yield. 40/91 (44%) showed vasculitis. +SNB assoc w/ longer SNB sample, other organ Sxs & +ANCA https://t.co/6S00ySj0fL https://t.co/WbY400YsWX

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Dr. John Cush RheumNow ( View Tweet)
CMV Increases Thromboembolism Risk in ANCA-associated Vasculitis Infection may play an important role in the genesis of vasculitis and ANCA seropositivity; this report suggests that past CMV infection may be a risk. https://t.co/K8HzolqLJ9 https://t.co/2VUasoinnL

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Dr. John Cush RheumNow ( View Tweet)
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