ACR 2019 - Report from Day One (Sunday) Save

Sunday was the first full day of scientific sessions at the 2019 ACR/ARP meeting in Atlanta. Yesterday we shared our initial news articles, videos and more with you. Following is my roundup of day one. 

Delays in Diagnosis

There were two interesting abstracts about delays in the diagnosis of spondylitis. The first was number #633 from Scarafia and colleagues. This Argentinian report detailed their experience with 201 low back pain patients that were referred to rheumatologist. In 2010 the time to referral was 48 months, but by 2019 this had dropped to 12 months. While barriers to referral remain there has been significant improvement in referral of patients with back pain.

Abstract # 631. From Magrey and colleagues from the Cleveland Clinic surveyed 1690 healthcare providers (HCPs) about their referral experience in patients who have chronic low back pain. These HCPs claimed to see a median of about 100 back pain patients per year. Nearly two-thirds of primary care doctors reported that they were the first doctor the back pain patient sought out.  nearly 90% said there was a 2 months or more wait time for their patient to see a specialist. Most said the problems with referral issues included long wait times, half with insurance limitations, 35% said there was no specialist in their area, and 25% said patient reluctance was the reason. The authors felt that primary care HCPs are important cog in the wheel of optimal referrals to the rheumatologist.

Blacks and SLE

Abstract #805 was a plenary session presentation by Dr. Garg that addressed disparities amongst Lupus patients regarding mortality.  Prior research has shown lupus patients, especially blacks, have a higher risk of mortality, die 13 years younger, and have 2-3 times higher mortality than other lupus patients. Dr. Urowitz has shown that in SLE early deaths were related to lupus or infection and later deaths were from cardiovascular causes. The plenary abstract was a review of several registries specifically looking at cardiovascular outcomes.  They studied 336 SLE patients of whom 75% were African American. The risk for cardiovascular disease was significantly higher, with and 18 fold increased risk of cardiovascular disease in African Americans compared to whites. Blacks had accelerated cardiovascular risk that was high at both the first year and tenth year after the diagnosis. An odd finding - patients with discoid LE rash also had an increased cardiovascular risk,reasons  for this were not apparent. 

EMBRACE (abstract # 860) was another presentation focussed on black SLE patients. Delivered by Dr. Furie was a study of belimumab (BEL) in AA/Black lupus patients. This research stems from original BEL approval wherein the efficacy of this drug in blacks was questioned, leading to this commitment to do a future study. This is that study. They enrolled 496 patients who were randomized to either receive placebo or belimumab plus the usual standard of care. Patients were followed for 52 weeks and the primary endpoint of the study was the SRI-S2k response at week 52. Overall there was no significant difference with a placebo response of 42% and BEL response of 49%. However, subgroup analysis showed that black patients who had more severe disease and activity (SS-S2K score >10, or low C3/C4 or high dsDNA with low C3/C4) there were significantly better belimumab responses seen. Moreover, these patients were half as likely to experience a renal flare (proteinuria) during the trial. Thus, it appears African Americans especially those who have more severe disease will respond reasonably well to BEL therapy. 

Guselkumab in Psoriatic Arthritis

Dr. Atul Deodhar presented the results all of the DISCOVER-1 trial (Abstract #807) where in guselkumab, an IL-23 inhibitor, was tested in patients with active psoriatic arthritis. This study enrolled 381 patients and randomize them to receive either placebo or two different GUS (100 mg given every 4 weeks or every 8 weeks). These psoriatic arthritis patients had relatively low skin scores (PASI = 7.7 to 9.5). but had active polysynovitis (mean of TJC = 15. SJC = 8)entering the trial. The primary outcome was the ACR 20 response at 6 months and was significantly higher on the guselkumab. Nearly a third of the patients had received a prior TNF inhibitor that did not seem to affect the ACR 20 outcomes with ACR20 rates of 60% regardless of whether you had previously received a TNF inhibitor or not.  The ACR 50 responses were roughly 30% and the ACR 70 responses were 11 to 20%. GUS was not as powerful in treating dactylitis and enthesitis, but the results were still significantly better than placebo. There were no new safety signals.