RWCS 2016 – Rheumatoid Review, Psoriatic Arthritis and Medical Marijuana Save

The Rheumatology Winter Clinical Symposia launched its 9th annual conference yesterday in Maui. Highlights of this meeting will be covered by RheumNow from Wednesday 2/10 till Saturday 2/13.

Rheumatoid Arthritis Year in Review

Day one sessions began with the “Year in Review” by Drs. Artie Kavanaugh and Jack Cush. Highlights from this review included the following:

• Review of ERA and ERAN databases show that lower disease activity (DAS28) yields significantly fewer orthopedic surgeries in RA patients
• Several recent studies by Aletaha and abstracts from ACR 2015 show that the early rate of change (or trajectory) in disease activity is vitally important to long term outcomes and ability to achieve remission - on or off drug (http://buff.ly/1SKs5c1).
• Results from the AVERT trial show that when early RA patients receive abatacept and MTX within 3 mos. of onset, they a) have a faster onset than other patients and b) once all therapies are halted at month 12, they demonstrated a greater propensity to be in drug free remission (33% vs 10%) 6 mos. later.
• Two recent studies have shown that polyarticular JIA patients who achieved remission and then attempt to withdraw therapy were largely unsuccessful. Stopping the TNF inhibitor resulted in >80% flares. Stopping MTX had fewer flares.
• The SURPRISE study from Japan, showed that for patients not responding to MTX alone, it was far better to add on tocilizumab (TCZ+MTX) than to switch to TCZ monotherapy. This same design and results were seen the Japanese JESMR trial.
• Advances in biosimilar research, drug approvals, legislative changes and issues were reviewed. The Feb. 9th FDA hearing on CT-P13 (voted for approval 2103) was reviewed and discussed as well. 

Psoriatic Arthritis – Past, Present and Future

Dr. Dafna Gladman's lecture on Psoriatic Arthritis covered the history of PsA, dating back to 1818 when Luis Aliberti first noted the association between psoriasis (PsO) and PsA. She reviewed some of the seminal advances, including those by famed British rheumatologist Verna Wright, MD, who prolifically wrote on this subject between 1956 and 1973. In 1973 the historic “Moll and Wright” classification was published. Interestingly, it wasn’t until 1964 when the American Rheumatism Association recognized PsA as a distinct clinical entity.

Many sources quote a wide range of risk for developing PsA among psoriasis (PsO) patients, ranging as high as 40%. Dr. Gladman showed that the risk appears to be linear over time with recent incidence estimates to be 2.7-3.2 new PsA cases per 100 PsO patients per year (http://buff.ly/1o6W8Ok). Prevalence numbers have been consistent suggesting that ~30% of PsO patients will develop PsA. Whereas men with PsA have more axial disease and radiographic damage, women have worse functional and quality of life outcomes. Predictors of cardiovascular events in PsA include worse skin disease, males, diabetes and hyperlipidemia.

She reviewed the treatment of dactylitis and showed many agents to be effective, including certain TNF inhibitors (infliximab, golimumab, certolizumab), ustekinumab, secukinumab, ixekizumab and apremilast. Clinical trial data did not show benefits with etanercept, adalimumab and brodalumab. Lastly she reviewed the TICOPA trial showing that tight control has advantages in PsA as is does in RA.

Medical Marijuana

A debate by Drs. Alvin Wells (pro) and Eric Ruderman (con) reviewed the issue, benefits and misuse of medical marijuana. Currently, there are 23 states that have legalized the sale and use of medical marijuana in the USA. Dr. Wells reviewed the FDA approved cannabinoids (Marinol, Cesamet) and commonly available cannabis preparations. Cannabis is used for pain management and in vitro and animal models is shown to have anti-inflammatory properties. He reviewed the Illinois Physician Certification form for cannabis use wherein the indications for using includes debilitating conditions: cancer, fibromyalgia, RA, MS, Parkinson’s, myoclonus, RSD, HIV, lupus, Sjogrens syndrome, interstitial cystitis, chronic inflammatory demyelinating polyneuropathy.

Dr. Ruderman countered the assertion that there are good indications and a role for cannabis in medical management. Although approved in 23 states, marijuana is a schedule I agent per the DEA and is illegal under federal law (Marijuana Tax Act of 1937). A recent metanalysis of cannabinoids showed little evidence of short term benefits. Moreover, many feel that if Cannabis were submitted as a new drug application it would never be approved, largely because of a lack of evidence for efficacy. In addition, cannabis is associated with a higher rate of adverse events – 300% increase risk of all side effects and a 41% increase in serious adverse events.