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Immunosuppression Increasing (2.23.2024)

Dr. Jack Cush reviews the news and journal reports from the past 2 weeks on; but begins with a discussion of what constitutes "immunosuppression" and how it applies to our patients.

  1. 2021 NHIS Survey data suggests the prevalence of immunosuppression in the USA is 6.6% (4.4% immunosuppressive Dz;  3.9% immunosuppressive meds; 1.8%  both); higher in women 7.9% ages 60-69 (9.5%) & Alaskan/Native indian (8.4%)

  2. BC, Canada study of 149,902 new rheumatology referrals showed 31% more referrals 2019–2020 (vs 2010–2011). New inflammatory arthritis increased (28% to 51%), delays decr by 22 days; but time to 1st DMARD in RA decreased by only 4 days (6%) to 62 days

  3. EMG fibrillation potentials (insertional activity) & positive sharp waves (Fib/PSW) are found in 95% study of 75 pts dx w/ idiopathic inflammatory myositis (44 PM, 17 DM, 7 ADM, 11 IBM); but also in 4 pts not meeting EULAR criteria

  4. False positive COVID tests (+Rapid Ag; neg PCR) are rare, 1.7% of 11,297 tests; Persistent false positives seen in 13/191 and usually in women, with autoimmune dz (6/13; RA, SLE etc) & using the Quidel QuickVue rapid antigen test

  5. Week 52 outcomes of 180 lupus nephritis pts (IV, VI, III) from AMP academic centers (rx w/ standard of care) showed 22% complete resp,  22% partial resp, 42% non-responder& 14% undetermined. 8/180 (4.4%) had CR sustained Wk 12 to 52; 10% PR. An unmet need!

  6. Serious infx (SIE) is prevalent in SLE given RTX. TOtal of 174 SLE pts on RTX -- SIE rate was high at 51/100 PYs (Pneumonia 30/100 PYs; PJP in 6.1/100 PYs).12 deaths. SIE risk factors were CKD (HR 2.9), Pred ≥15 /day (HR 3.5). HCQ decreased SIE (HR 0.35)

  7. Retrospective analysis of the Australian Scleroderma Cohort Study, finds 43% of SSc pts have evidence of myopathy. From 1786 participants, 155 had prox. weakness, 24% CK elevation & 4% prox weak+CK^ (latter in more severe SSc)

  8. Study of 43 SSc patients w/ gangrene shows Smoking Hx ; positive-ACA, ANCA, APL Abs & high ESR were independent risk factors for digital gangrenes in SSc. Vasculitis and macrovascular disease may contribute to the progression of digital gangrene

  9. In 551 juvenile myositis pts, 36% had myositis assoc Abs (MAA); 13% had >1 MAA. MAA+ pts had more overlap dz (18 vs 6%, p<.001) & assoc w/ Raynauds (OR 2.44), ILD (OR 3.43), chronic Dz (OR 1.72), mortality (OR 3.76). # MAAs was assoc w/ mortality (OR 1.83)

  10. Favorable Survival w/ MDA-5 Ab+. 154 pts w/ MDA5+DM; 40 died (26%) Rx induction (mostly resp. failure). 114 survived, w/ 5-yr survival of 97% & relapse-free survival 77%. Survival improved w/ JAKi use (P=.03). 8% achieved complete drug-free remission.

  11. TLL-018 (oral dual JAK & TYK2 inhibitor) studied in chronic urticaria unresponsive to H2 blockers and was well tolerated and showed high efficacy in moderate-to-severe patients

  12. Oral IL-23 Inhibitor Effective in Psoriasis The NEJM has published the results of the FRONTIER 1 trial demonstrating the efficacy of JNJ-77242113, an oral interleukin-23 (IL-23) receptor antagonist peptide, in patients with psoriasis (PSO).

  13. Orismilast is a novel oral phosphodiesterase-4 (PDE4) B/D inhibitor studied in phase 2b RCT in 202 moderate-to-severe psoriasis pts vs PBO. At wk 16, Orismilast was better at PASI 75 (40%-49% vs PBO 16.5%; P <.05) and PASI90 (22%-28% vs 8%; P <.05)

  14. Retrospective cohort analysis of 330 psoriasis pts - 83 (25%) developed #PsA after mean of 36 (3.5–114) mos. PsA Predictive factors include being female (OR=3.33), nails involved (OR=5.4), severe PSO (OR=27.4), po systemic Rx prior to PsA (4.1)

  15. MMPs play pathogenic role in RA-ILD. Multicenter VA study of 2,312 RA pts, 96 had prevalent ILD & Incident ILD developed in 130 (IR 7.5/1,000PY). High MMP-7 increased ILD (adj OR 3.78) & incident ILD (adj HR 2.33). Higher MMP-9 did same

  16. Brazilian registry of 1316 RA pts on bDMARDs or JAKi-Added use of antimalarials reduced SAEs & total AEs, & incr survival. 19% were on HCQ, & had signif less SAEs (mIRR: 0.49); AEs (0.68); serious infections (0.53); hepatic AEs (0.21); & mortality (P=.003)

  17. Retro study of 1,169 pts (age 66 yrs) receiving intra-articular steroids & changes on A1C. A1C increases were assoc w/ higher baseline A1C (OR 1.84) for A1C 7–8 (vs <7%) or A1C >8% (OR 4.8 ). YET most patients do not experience increase A1C after IACS

  18. Sarcoid arthritis (SA) seen in 19% of sarcoid pts. Metanalsysis of 49 articles (8574 pts) found Ankles most frequent (80%) followed by knees & wrists. Monoarthritis was uncommon (1%). Acute , 0-2, I2 55%). Acute SA (oligo & poly) was linked to E nodosum.

  19. CD19 CAR T-Cell Therapy in Autoimmune Disease


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