Dr. Artie Kavanaugh - Don't Stop! Save

Hi, I'm Jack Cush with RheumNow. I'm here with good friend Doctor. Artie Cavanaugh from University of California San Diego. Artie, how's it going?

Going good so far.

Yep. Are you working from home or are you going in and out?

Little bit of both, televisits which I I just do not like, and less inpatient, less in person visits, but, still trying to get things done. A lot of emails.

I've said for years that practicing medicine over the phone is dangerous, puts you the physician at risk, but now we're forced to practice by phone or by video and I don't know if the video makes us that much better, but we we are in the time of Corona. We've got to get through this. So one of the things that we're hearing repeatedly is, you know, should I stop? Should I stop my medicines? I even heard doctors now going to maybe less medicine as a way of dealing with less visits or some other limitations.

For instance, Eric Rittemann talked in a great video about how they had to change their infusion suite by maybe doing infusions a little less frequency, a little less frequent, like for drugs like Actemra or Rentsia or Benlysta, and that's because they have reduced staffing, numbers of infusion, chairs, but they have to cope. So there's a big issue about stopping drugs. So, first off, there's what's your take on this and how are you handling this when you get this question?

Well, think it's the probably the most common mind chart question that we get and it's a whole group of different people because people are on all sorts of medications. Some of them strongly immunosuppressive, some of them really mildly immunomodulatory. And then of course, it's the individual person and the comorbid conditions they have, which are probably the most important to the their ultimate outcome. But it's a very common question. I have kind of it's getting to be a boilerplate.

I tell them that regrettably, there's not data that informs the decision so that they have to balance the potential risk, which you can't say there may not be, but if they practice the good isolation, hopefully that will be minimized. But there's also the risk of stopping the medication, and on that, we have some great history in rheumatology. So I'd just like to review a little bit of that. There's a beautiful study from the Canadian Hydroxychloroquine Study Group, they called it, and it was a lovely design. It was a lupus study.

Patients with lupus on hydroxychloroquine who were doing well. And they said, what happens if you stop? So it was randomized discontinuation, like the pediatric rheumatologists like to do. And they found that it is actually a beautiful study, very small. Forty seven or twenty five versus twenty two patients.

So forty seven patients total. Of the twenty five patients who stayed on the Placronil, nine had some sort of flare, so thirty six percent. But among those who stopped, sixteen of twenty two did, so seventy three percent. And that included many more serious flares. So hydroxychloroquine getting a lot of press now as a potential therapy for COVID or patients with COVID infections, should our lupus patients just, stop it and give it to their moms or their sister or their mailman, there is the risk that you will flare.

And I think that's something that we have to be aware of. The risk of stopping effective medicine is that the disease may flare. Getting all historical, there was another, I think, the premier or the original tapering and discontinuing study in rheumatoid arthritis, which that's, of course, a very hot topic these days. But the Tenvoldi study from The Netherlands, which Ferry Breedbold was actually second author on. This is published in The Lancet in 1996.

And they took people with rheumatoid arthritis in deep remission for a prolonged period of time and randomized them to continue the medicine or to stop it. And these were some old medicines. There was Chloroquine. There was D Penicillamine. There was sulfasalazine.

Remember, '80s, methotrexate wasn't that much of a thing. And what they found over a year is that there were about twice as many flares among those who stopped, even though they were a D permission, thirty eight percent, compared to twenty two percent of people who flared even though they were on their medication. So a lot of more modern studies that address this as well, but if you stop your medication or you cut the dose, there is a chance you could flare, and there's a hope that you would get back to where you were before you tapered or stopped, but that doesn't always come fast, and that's not always guaranteed.

So the downside here is that people will flare and people say, if they flare, then I can manage them, you know? But you know, we're seeing a lot more studies in the last few years about the damage incurred by flares. It could be the ugly side of rheumatology and rheumatoid arthritis management, especially that really we're not really dealing well with. So I worry about flares, especially a fifty percent flare rate in these kind of patients.

Yeah, and there's, there's so many studies. There's, there's, retro, there's the optimum, there's dozens of studies in rheumatoid arthritis. One consistent theme is we have no idea who we can taper. We know some people seem to. There's a great study from Europe that they presented at Ulorn eighteen, and they were forced by the government to cut down on the dose.

I think it's a nice study. It's one hundred and fifty people, and they found that, forty percent of them couldn't taper. They start to taper, and the disease acts up. Fifteen percent came off drug, and the rest were split between a half and two thirds dose. But there was absolutely no other way to predict who could do that.

And I tell my patients that if they want to try to taper or want to stop, especially in this era where we have such worries, that that's a concern that they may flare.

You know, these trials which were done in the last decade where the the forced, withdrawal trials or the programmed withdrawal trials, he might best return them as programmed, you know, disaster trials because only bad things happen. It was seen in JIA, it's been seen in pregnancy. Women who get pregnant on TNF inhibitors stay on it, women who go off their TNF inhibitors when they become pregnant. Clearly those who stay on do way better and there's no downside to continuing. The JESMR study patients who were not doing well in methotrexate were then randomized to methotrexate alone, I'm sorry methotrexate plus Enbrel or Enbrel alone, but they stayed on a drug that wasn't working, they did way better.

They had less x-ray damage, they had less disease activity at the end. So I think we're imploring our colleagues that even though it seems like mild medicine, withdrawing or stopping Plaquenil, there are grave consequences to this and we should really be safeguarding the patient's safety during this sort of trying period.

Yeah, and going way back before we had the highly effective therapies we have now for many of our diseases, uncontrolled raging systemic inflammation is also immunosuppressive and the old epidemiologic studies of active RA show that those patients were at a greater risk of infection than the age and sex matched population. So uncontrolled systemic inflammation is not just something that you can say, oh, they'll put up with it. And what do we do when people do flare? We give them steroids and steroids are, you know, always about the worst when it comes to risks for infections, including some viral infections.

So I've heard a few docs say, you know what, it's probably not a bad idea to withdraw or lessen therapy because, you know, lupus, the non adherence rate to Plaquenil is as much as eighty percent and as little as forty percent. And then the same can be said for non adherence to biologics and our other DMARDs. And then plus patients who go on these drugs the withdrawal rates are roughly about ten percent a year and you know we kind of live through all that but this is different. Here you're making a big choice to actually do the wrong thing.

Yeah and it's exactly I could agree completely. At the end of the day, it's really up to the patient and, it's dissatisfying to us that we're not able to give them better data to say what would be the best choice. It's really a personal decision.

Well, it's even more dangerous because the patients are already pre programmed and want to take less medicine. Now they got an out because they're in the news is telling them they're immunosuppressed. You should be on talking to your doctor and they're making decisions, you know, on their own. I think it's our responsibility to guide them through some really difficult decisions.

Yeah absolutely.

All right all right thanks so much for this we'll talk soon.

All right take care thanks everybody out there in the room now.