RheumNow Podcast – Back Talk Questoins Fro Save

It is the 10/23/2020. This is the RheumNow podcast. Hi. I'm doctor Jack Cush, executive editor of rheumnow.com. The podcast is brought to you by RheumNow's coverage of ACR twenty twenty, the virtual meeting, ACR convergence.

We're all going to converge here at RheumNow because if you give us two hours, we'll give you the meeting. Let's get right to it. A nice study about hydroxychloroquine comes out. Again, you know, there are still many of us out there who think hydroxychloroquine might could be indicated in people who have early disease, nonhospitalizable disease. But really, there's so much data.

And Annals of Internal Medicine just published yet another trial. This one, a randomized controlled trial, has a weakness in that it's four ninety one probable COVID patients. They were early, they were not hospitalized, about eighty percent of them were PCR positive, but others were thought to be positive nonetheless. And I could certainly screw up the results. But when you compare hydroxychloroquine eight hundred milligrams followed by six hundred milligrams followed by six hundred a day for four days, compared to placebo, there was no difference in the outcomes as far as symptom re reduction.

Obviously, these are early patients, though death was not a reasonable outcome. We do have a number of studies about COVID in this report, including death. An interesting study actually comes out in New York this week, which looked at death rates in COVID and why it's changed that death rates at their peak in New York City in hospitalized COVID patients was as high as twenty seven percent. That was in April. It's gone down to the current rate of three percent.

The question is why? The analysis done by these researchers says the reduction in death rates is largely because of who's now getting infected. The ones who are getting infected are younger, they're healthier, and they get to the hospital sooner with less symptoms. Hence, they're easier to treat, have better outcomes, etc. You, they also make reasonable allowances here for advances in the care of COVID, which in, you know, March and April, we were flying by the seat of our pants on what to do next.

Here we are kind of expert where we, know how to manage the complications of COVID. We know many of the complications of COVID. I don't know if you're following the website, but we are back to doing QD clinics, QD videos. They're also available as QD podcasts. This week, we got a few of them, including one called I'm Not Stupid.

I have to do a podcast to remind myself I'm not stupid. Another one on triage rheumatology, there's a few of them out there you might want to look at that. New England Journal published last week in its report, about bariatric surgery in obese patients, and survival. You know, people undergo bariatric surgery and there are obviously many forms of that that were included in the study, but they do that for quality of life, reduction in morbidity, maybe reduction in mortality. And in this analysis, they did show that bariatric surgery was associated with longer life expectancy and about a twenty three percent reduction in overall mortality when compared to those who were not treated surgically for their obesity and usual obesity care.

However, whether you had bariatric surgery or didn't have a bariatric surgery and you were obese, you still live five years shorter than the general population. So yes, there was an advantage to bariatric surgery, you live three years longer than you would have if you didn't have the surgery. So I think it's still a good recommendation for those who are morbidly obese and don't seem to make any headway in managing their obesity. So I found this study kind of exciting or really perplexing. And that is, it's a market scan and rise registry study of seropositivity and how often does seropositivity correlate with actual ICD 10 codes for rheumatoid arthritis.

And you think, well, gee, you'd hope that in, patients, you know, who are coded as having RA that they should be seropositive, or that at least eighty percent of them should be seropositive. And in their study, it showed that actually, it was a good correlation that, an m o five point seven nine had a sensitivity of somewhere between point seven three and point seven six, meaning seventy three to seventy six percent of them had, were zero positive and that's on par with what you would expect in a population cohort of Rheumatoid. The question is, and it had a positive predictive value also about 80. But are we missing people when we're coding them for RA, meaning that, you know, that there isn't a great agreement here. There is obviously some population here, it could be as high as twenty five percent, but I think it's actually less than that, who, are miscoding patients, who, as RA when they in fact don't have RA.

I don't think that that's what the study was intended to actually look at, but I do think that good agreement between seropositivity and your coding efforts. A Swedish study looked at the risk of gout and who gets gout and they, in their population of really a large number of people, this was a CV risk study, they found almost a thousand patients who had gout, they found five clusters of gout. They, they said the first cluster had few or no comorbidities, the second cluster had CKD, the third cluster cardiovascular disease, the fourth obesity and dyslipidemia, and the fifth diabetes and hypertension on diuretics. They found out that about eighty six percent of all incident gout came from the first and fourth cluster, Those with no comorbidities and those who had obesity and hyperlipidemia. Kind of interesting.

Lilly has actually done a study on a new compound, actually a new biologic, an IL-twenty three inhibitor. The market's getting crowded. Their study was done in patients with, inflammatory bowel disease. It's the phase two SERENITY trial using their IL-twenty three inhibitor called Mirikizumab, a twelve week trial against placebo in moderate to severe Crohn's disease showed great outcomes with regard to their usual outcome measures and also endoscopic outcomes. So congratulations to them for that result.

Last week, we talked about the select choice study. You know, some gotta win, some gotta lose. If you had to listen to that, I'm so sorry, for the singing. I'm taking lessons. It may pay off.

The, so I did actually, I told you what I was gonna do and I, in fact, did it. I did a Twitter poll. And the Twitter poll asked the question, head to head study of upa versus aba in TNF IR patients, which one would you use knowing upa had better clinical responses and aba had better safety outcomes? Over 200 rheumatologists answered. The winner is OOPA forty four percent, ABBA thirty six percent.

Again, it's a toss-up, tastes better, less calories. It's kind of the same, you know, it's a it's a toying cause here. Seven percent said they'd use another TNF inhibitor. Congratulations. That's the real rheumatologist speaking right there.

And thirteen percent maybe gave the wisest answer of all, I don't know. You know, meaning that they want more data. So sometimes getting more data doesn't necessarily make you smarter. So here's data about an IL-six study in hand osteoarthritis, a randomized clinical control trial of IL-six in a hundred and four OA hand patients, non inflammatory OA, OA hand, and the twelve week outcome showed tocilizumab was no better than placebo in pain reduction, using a VAS probable zero to 100 scale, about 10 points versus eight points, not significantly different, but tocilizumab had more, numerically more adverse events, not significantly so. So maybe the big news this week is remdesivir was approved, is the first FDA approved drug, was just approved yesterday by the FDA, for use in patients who have, for acute care, in hospitalized patients, not for, you know, those patients who they gave to hydroxychloroquine in the early RA trial.

No, it's really for hospitalized patients like the president was hospitalized, maybe that's why he was hospitalized, so he could get remdesivir. I want to remind you that the approval is based on three clinical trials, all showing clinical improvement, including faster time to improvement or, but really no difference in mortality or any of the more severe outcomes of COVID nineteen infection. So that's interesting. If you look at the report that we had called boom or bust in clinical trials in COVID, you know, we talked about the remdesivir data showing it works, you know, and that's the trial that Doctor. Fauci was talking about.

But Doctor. Fauci said, it's not like the cure all, it's not the greatest thing since sliced tortillas. You know, he said it works. It's the first positive signal we've had in the clinical trial and it was a clinical trial. So he touted a little bit.

But then again, there's this big WHO trial with thousands and thousands of patients, the solidarity trial that and the problem is it was not, blinded. And in that trial, getting remdesivir or not did not alter the outcome. So while I think it's an advance in the treatment of COVID, and maybe it's a milestone in the treatment of COVID, I think we need better drugs, especially if we're going to thwart what looks like a two year pandemic. I did another, poll. Oh, actually, me tell you first about, Marty Bergman, and Arne Kavanaugh published their results of a survey that was done at an annual national, rheumatology review course, the RWCS course, that Artie runs every, February in Maui.

Great course. This was a really good exercise. Marty gave a great lecture on burnout, but before he did, he actually surveyed the audience full of rheumatologists. And looking at, I think it was about a 128 rheumatologists who have completed the survey fully. They showed that about half rheumatologists meet some criteria for burnout.

That's kind of a lot, don't you think? So fifty one percent, the criteria associated with burnout was dissatisfaction with electronic health records, increase your odds of burnout by 2.9. Lack of exercise, a fivefold increase in burnout. Work hours more than 60 per week. Who's doing less than 60 per week?

I want your job. Odds ratio two and a half. And there were those who had had less burnout and they were more likely to be in group practices. Being a group practice lowered a risk by about almost sixty percent. And those who had personally satisfying work outside of their usual work seem to be characteristics to help avoid burnout.

Last, issue. I did another, survey asking the Twitter Rheumatology World, how are you going to consume virtual CME rheumatology conferences? Thinking about ACR. And basically, it's kinda all over the map. A quarter are going to say, easy to do virtual learning.

I intend to attend live as the meeting happens. A third, 31% said, I'm gonna watch the content after the meeting, meaning asynchronous learning. About 25% said, I do about half of these CME virtual things. I don't know if that means they attend half or they only look at half the content. And about 19%, they don't or they seldom attend online, virtual CME.

Kinda thoughtful, don't you think? I mean, we really are trying to figure out our way during the pandemic, how we're going to learn. And that's gonna be the challenge with the upcoming ACR conference. As you know, we said, you give us two hours, we'll give you the meeting. Let's close with a little back talk.

I got two, call ins from back talk. The first one is from Doctor. Zena Yambay. Zena, I hope you pronounce your last name right. Let's just see what Zena has to say.

Thank you for an amazing podcast. I listen to you every week. I have an 83 year old female who has limited systemic sclerosis, and she has very extensive subcutaneous calcifications that have not responded to clitrocene, alendronate, calcium channel blockers, and topical sodium thiosulfate. I was wondering if you had any experience with IV sodium thiosulfate, or if you had any other suggestions. I would greatly appreciate it.

Thank you.

Thanks, Ina. I love questions that are unanswerable because I can say whatever I want and not really be wrong. But on this one, I'm not really going to be right either. As you know, if you look at the literature, I'm sure you have with what you've already done, is that there's no clear, consensus winner when it comes to managing calcinosis in association with scleroderma's diseases, inflammatory myositis, you know, MDA-five and, and, other forms of myositis are also associated with, NXP-two, we talked about at an earlier podcast, NXP-two antibodies are, which are associated with cancer, also associated with calc calcinosis in myositis. And interestingly, our division had a conference today with the dermatology division talking about this treatment.

It's all over the map, there isn't anything. I think maybe the more exciting thing that was mentioned at our conference this morning is the use of antithrombotic therapy that sort of was underlying the use of warfarin, but now they're using newer agents and you might find do a search on antithrombotic agents and calcinosis and calyphylaxis, thinking that if you can manage that, maybe you can reduce the, tissue ischemia that leads to a sort of pre programmed response by laying down calcium. My treatment previously or even now is aspirin, baby aspirin, calcium channel blocker and a bisphosphonate. And I've convinced myself it might could work, but who really knows? I haven't used sodium thiosulfate, I've talked about it.

If you look at the literature on that, patients with the worst calcinosis and calyphylaxis, they tend to get IV thiosulfate, you use topical. I think if you're really frustrated and it's developing ulcerative lesions, may want to do that. Lastly, I'll tell you that, I put this out on a Twitter poll, about a year ago, and, it gave everybody a lot of choices. And it was really nobody chose anything. And the best comments actually came from Dinesh Khanna, our scleroderma expert.

Dinesh actually wrote in there, maybe your best treatment modality in managing patients with problematic calcinosis is a good relationship with a plastic surgeon, because they are the ones who can remove the lesions, close-up the wounds, and keep the patient out of trouble. Think about that. Let's see what my friend Alan Malice has to say.

This is Alan Malice, rheumatologist in Scottsdale, Arizona, with a question for Doctor. Cush. Patient with significant osteoporosis without insufficiency fracture has been on bisphosphonate, which was stopped due to osteonecrosis of the jaw, period. Problem is resolved that patient needs additional treatment for osteoporosis, period. What would you recommend, period.

Alan, I love your punctuation. Short and sweet. I think this is an easy answer because on the patient viewpoint and side of things, clearly, you're not gonna go back to a bisphosphonate when you had osteonecrosis of the jaw, or atypical femoral fractures, or these very disastrous outcomes, which are rarely seen in patients with osteoporosis. They happen to be seen in people with really bad osteoporosis, and is it the drug and is it the osteoporosis? And it's a mess, right?

But the patient doesn't want to go back on such therapy. Will they go on other therapy if they know that there's another risk, also a risk with those other therapies for ONJ and atypical femoral fractures, they're unlikely to use them. I think that really the decision about whether a patient goes back on, anti resorptive therapy, is really contingent upon their osteoporosis. If they've got osteopenia and borderline, yes, take a holiday and you don't really need to use anything. But if they've got serious, you know, t scores worse than minus three, they need to be on something.

I tend to go to Prolia, others would go with maybe, the the anabolic agents that are now out and hope that they're going to be as well, tolerated, but maybe have less of a risk. I don't think there's enough data. I do know that these complications happen with pretty much all the therapies. They may be highest with the bisphosphonates, but you're not free of risk if you use the other ones. But in this situation, I tend to go back by using, Prolia or Denosumab.

That's it for this week on the podcast, tune in next week. Again, follow us on RheumNow during ACR.