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Welcome to QD Clinic. QD Clinic is brought to you by rheumnow.live. I'm doctor Jack Cush, executive editor of rheumnow.com. Today's case is called Arrevorama. That means everything Arreva.

45 year old woman comes to clinic, previously treated with methotrexate, didn't like it, didn't respond to it, was put then on adalimumab. Kind of better, but not really. Still has polyarthritis with some swollen joints. She's kind of a failure, maybe a partial responder. And the question is, what do you do?

In discussions with the fellows on this case, it's we talked about, you know, what are the options. In a cost efficient world, you probably would have gone actually from methotrexate to combination DMAR, triple DMAR therapy, and then maybe a TNF inhibitor, and then maybe another TNF inhibitor, another non TNF biologic, or another JAK inhibitor. But somewhere along the line, the drug leflinamide has fallen off the menu, and that doesn't seem to make a lot of sense given how effective leflunomide is. Outside of North America, leflunomide may be the best selling DMARD worldwide. It works.

It works just like as well as methotrexate and seems to have a similar side effect profile, though my partner says methotrexate has side effects from here up, meaning from, like, the chest up, head, and sores, and leflunomide's got it from the chest down. I'm not sure it's quite that simple. A few things you should know about leflunomide. I I I was a non believer in leflunomide until I got involved in the leflunomide trials, and then I became a big believer. So maybe I've drunk the Kool Aid or maybe I have more experience using it, but it's a highly effective DMARD.

A few things you need to know, the main thing of course would be liver enzyme. Well, main thing would be the box warning on the package insert. The box warning says it's a teratogen shouldn't be used in people who want to get pregnant. Although there are reports of successful pregnancies in people who are on leflinamide. And people who are pregnant should undergo a drug washout procedure, we'll talk about that next.

And then it's hepatotoxicity is a is a warning. There are reports of threefold or higher elevations of LFTs are tenfold higher, but true hepatic cirrhosis, necrosis, death is really quite rare. When the FDA did an analysis of the hepatotoxicity of leflunomide, It was pretty much shown to be equal to that of methotrexate with looking at specifically at threefold or higher elevations of LFTs, especially AST, two to 4%, threefold or higher elevations ALT about one percent. So it's something that's quite manageable. You need to monitor and look for it.

The standard dose here is twenty milligrams a day. Forget the one hundred milligram loading dose that nobody uses that anymore. There is also a ten milligram pill. Generally, everybody should be on the twenty milligram pill unless they can't tolerate tolerate it, and then you can go to the ten milligram pill, or people are doing very, very well, can go from twenty to ten milligrams a day and usually maintain the efficacy once being used as monotherapy or as combination therapy. You should recognize the half life of leflunomide is really really long.

It's twenty one days. The primary metabolite, the M1 metabolite of leflunomide is a drug that's also market on, also on the market for, neurologic considerations and that's terraflunomide. Leflunomide not so expensive, the M1 metabolite, very expensive, It has to do with the indications, guess. But nonetheless, you're only gonna use leflinamide, but the long half life is an advantage that you can exploit, meaning people who've done well on leflinamide can be switched over to once a week leflinamide. I do it all the time with no loss of efficacy and no added toxicity.

I generally use twenty milligram pills and tell people they were taking twenty milligrams once a day. Most of them I switch to a hundred milligrams once a week. Some need a hundred and twenty milligrams or sixty milligrams once a week. You can titrate it depending on whether it's monotherapy or in combination. The package insert says that you should test for TB prior to or as you're using leflunomide.

There is a real risk of TB in people who are taking this drug. We know the intolerances and the side effects of this. GI toxicity, mainly in the form of cramping and diarrhea, about twenty percent of individuals. Somewhat bothersome and often often limiting as far as the use is either a ten percent risk of hair loss or ten percent risk of hypertension. After that, everything's really quite rare.

We talked about the, the long half life. You should know there are a number of drug interactions that you should be aware of. Because of cytochrome P450 activity, it will increase the dose of drugs like Xanaflex, Cymbalta, and Warfarin, so you have to watch those drugs. Taking rifampin will increase the dose of leflunomide, and patients who are taking rosuvastatin should not take dose higher than ten milligrams a day of rosuvastatin if they're on leflunomide. If you get into trouble with this drug, either extreme toxicity or pregnancy, the recommended procedure is eight grams, eight gram packets of cholestyramine three times a day times eleven days.

Now, if you're and that's for extreme stuff and you can actually measure drug levels and whatnot if you're really worried about pregnancy issues. I rarely have ever had to do that. I rarely actually ever use the 11 full dose elimination procedure. I often will use an abbreviated procedure, either four or eight grams, whatever the patient will tolerate, three times a day for five days. And doing that, can lower drug levels by more than 50%.

If you don't do an elimination procedure because of the long half life of the drug, it's gonna be in the patient's body for, I don't know, like nine years. It's really gonna be a long time. So to get it out, gotta do one of these elimination procedures. But an abbreviated regimen, again, TID times five days, drops levels by more than 50%, and that might be effective enough to reduce this toxicity the patient is worried about. Hypertension, diarrhea, mild to moderate elevations of LFTs.

These often respond well, and then either you can stop the drug or you can resume it at a lower dose. Arava is a very effective drug and should be used. You know, it's another very effective means of education is RheumNow Live. We're three days away. Check it out.

Go to roomnow.live and you can register. Make sure when you register, choose the online free registration, and then you can participate in the meeting starting on Friday afternoon, all day Saturday, half day Sunday morning. It's gonna be a great program. Registration is free for online access. Be there or be online.

It's gonna be a great meeting. That's it for this week, for this day of QD Clinic. This is QD Clinic. I'm doctor Jack Cush from RheumNow. QD Clinic is brought to you by rheumnow.live.

The meeting occurs in two days. You can choose. You can choose to be in the room in Fort Worth, join a 100 plus of your colleagues, or you can choose to watch from home on Friday, Saturday, and or Sunday in the comfort of your fuzzy slippers. Go to roomnow.liveregister. Choose which one you want to attend.

It's gonna be a fabulous meeting. You're gonna really enjoy it. And by and if you're home, you can be connected the same way people who are in the room are connected. You'll be watching the same lectures. You'll have the same downloads.

You can vote on the same questions. You can ask questions from the comfort of your desk and or living room. We'll see you on Friday, Saturday, and Sunday at RheumNow live. This case is called chat them up. Last week, I saw a patient, and as I was starting the visit and going through medicines and some tests and things that were done, just reviewing some data, I just had an offhand conversation with the patient about a movie.

And what ensued was a delightful fifteen minute discussion on things that made her happy, and I got to listen to that and make some suggestions that furthered our relationship and discussion and honestly made the rest of the visit a whole lot easier. So my point is I think at some point with most patients you need to spend time talking about something other than their medicines and their HAC score and side effects and insurance problems and which what hurts and what's not working right and one of 95 different medical problems. I know there's a lot to do and chitchat might not be your game, but, you know, chitchat is really how the rest of the world lives and communicates and learns to trust each other. So to spend some time, a little bit of time, learning what movies they like, what hobbies they have, what's their project that they're working on, where they travel to. You know, my patients love for me to tell them about where I just came from and what that was like.

And they think it may be glamorous or or exciting or it may often they tell me about places I should go to when I'm in Italy or wherever it is I might be going. And those are good things to know. I find it really interesting when I can start a conversation with a patient that begins with the following words. You know, because of you, and I tell them a story. Or, you know, last visit, you taught me a really important lesson.

Or, I've been thinking about you. I'm really glad you're here today because I wanna talk to you about. All those statements are about you, the patient. And it tells the patient, I'm thinking about them. I've got something to say with them that is gonna be pleasing or interesting or important to them.

They always like to talk about their family. They wanna talk about medical things going on in other members of their family. You know, patients who have chronic illnesses and see you regularly may be the smartest medical person in that whole family, And they go to that person asking for advice. And when you can impart some advice on your patient that lets them take care of their husband or their child or their mother, boy, they really appreciate that. You further the relationship between the two of you.

Again, with them, what's in it for me? It should be what's in it for them. And discussion and conversation is big. I think when you engage in this, they can appreciate you and you can appreciate them, and it really furthers what it is that you have in a long term relationship, which is at the core of best medical care. We'll see you at RheumNow Live.

Welcome to QD Clinic. QD Clinic is brought to you by RheumNow live. I'm Jack Cush from RheumNow. RheumNow live starts today. You can go online and register and consume it all from home, roomnow.live.

Choose the free online at home registration. Today we're going to talk about comorbidity in psoriatic arthritis. Just heard a fabulous lecture by Doctor. Alan Mentor on comorbidity and cardiovascular disease in psoriasis this morning. He's one of our speakers in a Friday afternoon pod entitled The Management of Psoriatic Disease.

He's going to talk about new therapies and exciting advances in psoriasis at RheumNow Live. But Jose Scherer is going to talk about the curse of comorbidity with psoriatic disease. Anyway, today's lecture, Doctor. Mentor covered a lot of this content, specifically about the links between inflammation, psoriasis inflammation, and cardiovascular inflammation as the driving force behind increased cardiovascular events and poor cardiovascular outcomes in patients with psoriatic disease, both psoriasis and psoriatic arthritis. I think it's important for us to be aware of this.

I think most rheumatologists are aware of the comorbidities. I think the question that I want to cover here is how do we manage comorbidities in the arthritis clinic or in the dermatology clinic? Let's go at them one by one. Number one, cardiovascular morbidity mortality. It's very clear that effective anti inflammatory systemic control of inflammation therapies are going to be effective at lowering cardiovascular risk.

This has been shown with methotrexate in rheumatoid arthritis, it's been shown with TNF inhibitors and other anti inflammatory biologics with rheumatoid arthritis, and there is data suggesting the same can be seen in psoriasis and psoriatic arthritis. Maybe not as much data, but it's still the same message, it's still the same pathogenesis that's being interrupted by effective therapy. So maybe the best thing you can do is get great control of either psoriatic skin disease or psoriatic arthritis. The second most important thing that you must do is manage the cardiovascular risk factors and either you're going to do that or have the patient seen by their primary care or cardiologist. Again, a psoriatic patient with cardiovascular risk factors and or history of cardiovascular events needs to be seen by the cardiologist in addition to the dermatologist and rheumatologist.

Of course, the cardiovascular risk is driven by other things like the metabolic syndrome and obesity and hyperlipidemia. I think that rheumatologists need to be very very clear and very very consistent in the message that reducing weight leads to better disease control. No, that's not a corona cough, it's a kennel cough. That means that patients who undergo dramatic weight loss either by, gastric sleeve or other kinds of gastric interruption surgeries or major diets that lead to weight loss repeatedly shown to improve psoriatic skin disease inflammatory arthritis both in rheumatoid and also in psoriatic arthritis. So, you know, it turns out that we talk to our patients a lot about weight loss and sometimes it seems like we're just talking at a stone, but if you talk, if you look at it from the other side, the patients who in fact do lose weight, the number one reason that they lost weight and continue to have successful weight loss is that their doctor was the driving force in them seeking a new solution.

So it is important that we counsel our patients on the strong need for weight loss as a way of managing their inflammatory arthritis, controlling their skin psoriasis. There's a lot of experience again here showing that weight loss leads to better disease control. And then lastly, depression. Depression, as you know, is constitutive for people who have psoriasis. It is sort of a burden that they carry with them, the disfigurement of having psoriasis that bothers them a whole lot more than it bothers other people, but at least a serious coping issues, if not overt depression.

I think it takes a heightened awareness by the clinician to continually ask the patient how they're coping with their disease. Do they need help? Do they need to see a counselor? Do they need to see a psychologist, psychiatrist? You know, do they need medication for this?

Because if you're not asking this question, this problem goes unnoticed and as you know depression is a serious big time problem including suicidal ideation and frank suicide, all elevating the people with active psoriatic disease, and our patients with psoriatic arthritis. So you need to be the person that drives that discussion. When we talk about comorbidities and inflammatory arthritis, everyone agrees it's a big issue and I should probably be involved, but I'm gonna pass it off to my primary care doctor. Well, the problem is the patients don't often see the primary care doctor because you may be the sharpest knife in the drawer. You may be the person who best tends to their needs, so they think you're gonna do everything.

That being said, you should take the initiative on doing total patient whole disease management and do the screening for A1C serum uric acid, Hep B, Hep C, TFT's lipid levels, and then use that either for you to manage the problem or to have another doctor who can be part of the team manage the problem. And lastly, fatty liver is a big issue when there's obesity and psoriasis that also may need to be further assessed and also be managed by the hepatology division. Again, your plate is full when you see patients with psoriatic disease. It's not just skin deep. See you at RheumNow Live.