ACR20 - Day 4.5 Save

This is the RheumNow podcast, and you're listening to highlights from the ACR twenty twenty virtual meeting. Our faculty reporters have been doing videos and recordings so that you could stay up to date. Hope you enjoy these and our panel discussions.

Hi. I'm doctor Janet Pope, a reporter at RheumNow. My Twitter handle is at JanetBurdo. I'd like to talk about one of the very interesting plenary sessions. So this is abstract number fourteen forty one.

It's by Richard Fury. And as any of you watching the meeting of the ACR virtual meeting know Doctor. Fury has been a wonderful advocate and author on multiple SLE trials. So this is looking at the already published bilimumab trial in lupus nephritis and giving us more results. So what's really interesting about this trial is number one it allowed standard of care of active lupus nephritis.

So a lot of patients were on mycophenolate mofetil but you could have also been induced by cyclophosphamide. Number two, it was new lupus nephritis or an active recurrence. Number three, they cut down on prednisone so that if by twenty four weeks your prednisone dose was greater than ten milligrams a day you were considered a non responder. What's also important about this study is they went to one hundred and four weeks because things like proteinuria don't resolve over time. So they looked at partial responder and complete renal responder.

As I say, some of the data are already published. Then they looked in the subsets of drugs that were being used, the subsets of race and other subsets such as lupus nephritis and slam dunk belimumab ten milligrams IV q monthly was better added to standard of care than standard of care alone with a minor exception of lupus nephritis class five where it wasn't as big as slam dunk. What's the take home? Number one in lupus nephritis we need to do better and this is an adjunct to care that can help our patients. Number two, I would advocate that we can have belimumab reimbursed in our communities as it is an expensive but highly effective drug.

And number three, I believe we can rationalize that this would also help the same way if it was belimumab sub q as the drug is now available both IV and sub q. Please follow us at RheumNow and enjoy ACR twenty twenty. Thank you.

Hi, everyone. From ACR Convergence twenty twenty, this is Doctor. Robert Chow coming to you live from RheumNow. Today I wanted to talk to you about specifically enthesitis and enthesitis and psoriatic arthritis. As you know, enthesitis can be difficult to diagnose and assess.

We're sort of used to the old, but some would say tried and true method of poking at an enthesis point and somebody asking if it hurts. The problem though lies in a few things. Number one is how accurate that method really is. And especially in the smaller enthesis points, unlike the Achilles, for example. And number two, there's been a rise of musculoskeletal ultrasound, which actually provides us with much more objective data.

It's really useful, especially in patients with subclinical disease. And number three, evaluating enthesitis objectively can be very helpful for us in rheumatology, especially with our patients who have concurrent pain syndromes such as fibromyalgia. So I wanted to share with you a few abstracts today dealing with enthesitis in particular. The first one's eighteen fifty three. This was a pretty interesting abstract in the gut microbiome and differences in that in patients with Axle Spondyloarthritis.

They had 33 patients and they found some significant differences overall in the gut microbiome and patients with AxSpA versus healthy. Also found differences in inactive patients, axSpA patients versus active. And very interestingly, also gut microbiome differences in patients with enthesitis and also radiographic versus non radiographic axSpA. I think that's very interesting data, very useful data, but it continues to beg the question, what do we do about the microbiome? You know, is this something we can target?

Because already some studies have shown that diet alone does not change the diversity of the gut microbiome. The next abstract is fifteen fifty two. This is a study showing improvements in ultrasound nephritis, with biologic DMARR treatments. Had about twenty five patients with active disease who are either starting or switching biologic DMARDs. And the ultrasound of the enthesis were performed at baseline, three months, and six months.

Results show there was improvement of ultrasound enthesitis at those time periods, and the clinical activity outcomes were associated with the decrease in enthesitis counts. I think studies like this continue to show the validity of musculoskeletal ultrasound, especially in our everyday use. The next study is fifteen forty three. This is very interesting. It showed an importance of ultrasound in our pediatric population.

This is one of the first studies to evaluate joints and enthesis in that population. And this was in children with psoriasis. This had forty nine patients and the ultrasound abnormalities were higher in the symptomatic group and especially in the synovitis, emphesitis. They found a difference of seventy seven percent versus thirty nine percent. And it was also, they found very useful in the detection of subclinical involvement.

And lastly, was actually an oral presentation by Doctor. Eder. This was abstract 2021. And this was the DUET study, which is a novel sonographic scoring system for enthesitis to help with psoriatic arthritis diagnosis. This focused on scoring with the following factors at 16 sites, Overall, there was good agreement between sonographers.

The thickness measurement and total score showed good inter rater agreement. The lowest agreement was for hypoechogenicity and thickening, which kind of varied by site. I think overall, these were very promising studies, especially for the evaluation of emphacitis. I think as we know more about the evaluation, the recognition and diagnosis of emphacitis in an objective matter, especially with real time objective data with radiographic evidence. This will be very useful for us and very pragmatic for the rheumatologists who's treating the psoriatic arthritis patient.

So thank you very much for tuning in. Again, this is Doctor. Robert Chow coming to you from RheumNow at ACR Convergence twenty twenty. And please follow RheumNow for coverage of ACR twenty twenty and follow me on Twitter drrbc. Thanks.

Hi, ACR Convergence. I'm Doctor. Rachel Tate coming to you from my home in West Palm Beach, Florida. I am honored today to be interviewing Doctor. Irene Blanco, Professor of Medicine and Associate Dean of Diversity Enhancement at Albert Einstein College of Medicine, Montefiore Medical Center in the Bronx.

Thank you so much for being here, Doctor. Blanco. I really appreciate it. No, thanks for having me. Of course.

Well, it's been such a busy ACR and I wanted to touch on something that it's near and dear to your heart. And obviously diversity and inclusion issues really pepper the landscape, I think in medicine and especially right now. And you've done some wonderful work regarding these issues predominantly in rheumatology. Can you share with us some of your findings?

Sure. My focus in rheumatology is predominantly on education and how we can start to think about addressing these issues through our fellowship curricula. It's my point of view that this is literally the last time that we have our trainees in a training setting where they can be in a safe space to really think about and investigate and talk about these issues. And it's also a place where we can correct anything that we see before we have to kind of depend on them to look for the CME in order to address these issues, right? And so I presented two ACRs back and then last ACR.

So we've done a couple of needs assessments. So the first one was a needs assessment of the fellows, right? So like, what are they seeing in terms of this landscape? What are they talking about in their fellowship programs, etcetera? And we did it as a qualitative survey because sometimes these better said qualitative interviews because these issues can be delicate, can be really hard to address.

And oftentimes, the complexity of the issue isn't grasped sufficiently in a survey. So to really get to the meat of the matter, we did these focus groups. And it's funny because I do a lot of sort of iterative stuff in qualitative interviewing. And we could have probably stopped at the first interview because they were so similar one after the other. So number one, the fellows are seeing issues on disparate care.

Poor patients are not getting the care that they need. Black and brown patients are not getting the care that they need. Access is a huge issue. But other than them sort of talking about it and trying to grapple with discussing amongst themselves, there's not really a formal structure through their programs to address these issues. So program directors are not talking about it.

And rarely, but on occasion, they're seeing their faculty not be ideal role models. So it leaves them with the sense of, well, how do I address this? They're powerless. But at the same time, because of that hidden curriculum and by, as a faculty member, the things that we leave unsaid, a lot of them start to think, well, is this rheumatology? These social aspects of medicine, if you were to put this and I'm paraphrasing a quote.

If you were to put this in the curriculum, what would you take out? So there's not a sense of, well, if I really want to take good care of my lupus patients, I need to address their psychosocial needs in addition to their pure biochemical, pathological, pathophysiological needs. And so it's this disjointedness of, well, if I address their poverty and their access and all this stuff, I don't have time to think about rheumatology. I'm like, no, the two have to come together. And so then last year, we presented the needs assessment from the program directors.

And the program directors are saying very similarly the same things, right? That they don't have much of this content in the curriculum. They don't know how to teach the curriculum necessarily themselves. They don't have faculty that know how to assess the curricula. So they need resources, right?

They're like, I need resources. Help me figure out how to teach this to my fellows so that we can all move the needle, right, and actually address a lot of the issues that our patients have. And so that's sort of in the midst of where we are right now thinking, okay, we're going to need probably a one point zero and a two point zero kind of curriculum because it seems like we really need to train the trainers to a certain extent, right, on how to have these courageous conversations because potentially there's going to be some introspection on the programs, right? So once we start to talk about this landscape, then we start to look at our own individual programs and saying, well, are we doing enough? And people have to have the courage to have that conversation.

Well, and I'm sure you've done beta testing even in your own institution. I mean, that's that's the importance of education. And so and I know that you've kind of touched on this a little bit, but kind of where do you think the rheumatologist role in in and outside of academia really is?

I mean, I think that when we talk about, for example, health disparities and access issues, I think we have so much data, right? We have a lot of data in terms of RA, OA, lupus. Even if you look at a lot of the abstracts that were presented this week, Doctor. Goodman presented that Black and Brown patients are not getting arthroplasty at the same rates. Potentially, racial and ethnic minorities are not faring as well.

There was a great abstract on providers not feeling comfortable assessing lupus rashes and skin of color. So we really need to think about what are we teaching our fellows? How do we open up access for our patients? How do we bring the two together? How do we create those resources?

And I mean, it's hard. It's hard. I think there are lots of conditions where disparities are very well described in and out of rheumatology. It's to the individual practitioners in that specialty to really address those issues. Can't leave it to primary care to talk about lack of access to transplant, for example, right, for Black and Brown patients.

I can't leave it to primary care to be the only ones to think about my patients not getting knee replacements. I can't leave it to primary care to think about lupus patients not doing as well as they should be doing, right? Like we have to take the onus of our disparities and therefore really start to think about the, what are we going to implement? Right? What are our interventions?

I mean, is so important. I think that's something that we at RheumNow feel really strongly about as well as the rest of the community. So I really thank you for honing in on that. We have just a little bit of time left, and I wanted to ask you more about the hub. Can you tell us a little bit about what's new from the ACR Equity and Inclusion hub this year or that it's new this year?

Well, it's brand new. Mean, the hubs in general have really expanded. And it was a way to really get other sections of the community that would normally find each other right at the exhibit hall, typically, meet me by Booth 6, right? That now it was just to find these meeting spaces, glorified breakout rooms, if you will. So and this year is the first year that we have an equity and inclusion hub, which was fantastic.

We were able to have a DNI town hall where we could just listen to members, right, and convergence attendees to what are their thoughts in this space? You know, what do they want to see happen? We had a great debrief on one of our speakers, Doctor. Marc Nevaeh, on implicit bias. He's an incredible speaker and a huge resource.

So I think for the people that were able to speak with him in the hub, that was a really enriching experience. But at the same time, we were able to post a lot of resources. So for people that are really interested in thinking about how to move the needle in terms of D and I initiatives for their programs, for their residencies, for their divisions. There's tons of resources there, things to educate yourself, things to use to look at your own curricula and the things that the content that you're teaching and ideas on how we can better assess our trainees, how we can write more equitable letters of recommendation and letters of support for people to make sure that we're not necessarily using gendered language, etcetera. So there's a huge span of resources that I think Doctor.

Blazer and I are really, really proud of. And I'm hoping that people will make, use of them as they move into these spaces.

Absolutely. And these, just for clarification, I know I can download them now. I'm hoping they'll be available after the conference as well.

I believe so. I believe the hubs are going to stay up for a while longer. And so you know, there's there if you can't download them today, ideally within the next few weeks, they should still be up.

Okay. Oh, my goodness. Thank you so much. I really appreciate you taking the time out of your busy day, your busy schedule. I know what it's like to be working remotely and being at home and listening to ACR as well.

So I just I really thank you so much. For more news, be sure to go to roomnow.com and please follow me on Twitter, ActoTate. Thank you so much. Thank you.

This is Doctor. Catherine Dao reporting for RheumNow. I'm at the ACR twenty twenty convergence meeting, and it is currently Monday. There's a great abstract. It's a late breaking abstract.

It's abstract LO4 and was presented by Doctor. Kevin Winthrop. And the reason why I like this abstract was they were following patients who were on tofacitinib. These are rheumatoid arthritis patients taking tofacitinib, and this is a post hoc analysis from phase one through phase four trials and how these patients do with the flu. So what they did was they followed these patients, there's almost 8,000 patients.

And these were patients who were on tofacitinib five or ten milligrams bid as monotherapy in combination with other DMARDs or, being compared to adalimumab, placebo or methotrexate. And they followed these patients for fourteen to fifteen flu seasons. And they found that actually it's no different whether or not you're on tofacitinib versus placebo, adalimumab or methotrexate. So the rate of the flu is the same. And the majority of cases, about two thirds of cases, were actually very mild, moderate cases in thirty four percent and severe cases in three percent.

Now, about one point eight percent of patients on tafasitamab actually had serious flu symptoms. And the average dose was basically five milligrams BID, in six patients and ten milligrams BID in two patients. There was two deaths, one in each five milligram and the ten milligram, dose, and both of them died from H1N1 flu. Now, is the part that I found very interesting is that tofacitinib was actually continued in seventy percent of the patients. About thirty percent of the patients stopped their medicine and on average they would stop it for about eleven days.

But in the end, there was no difference whether you continue it to stop it. So for me, if a patient has the flu and this is confirmed flu, not necessarily other respiratory viruses, there's really no need to stop tofacitinib based on this abstract presented from Doctor. Kevin Winthrop. So hope that changes your practice. Follow me on Twitter KDAU 2011.

This is Doctor. Catherine Dow for RheumNow.

Hi, I'm Doctor. Janet Pope on Monday at the virtual ACR 2020 welcoming you to AtRoomNow. I'd like to talk about osteoarthritis. There was really a lot going on today on osteoarthritis. It's almost the belle of the ball.

So the first abstract number sixteen fifty. It was a really neat trial, a small but interesting trial, double blind randomized controlled trial to look for primary knee osteoarthritis comparing intra articular steroids with methylprednisolone acetate at forty milligrams plus one cc of lidocaine versus two cc's of lidocaine. They gave the preliminary analysis. They planned 32 patients but they have 27 already with very strong results. As you might suspect, it was mostly men and they looked at the knee injury and osteoarthritis outcome score or KOOS and already with only 27 patients the p value was strong 0.007.

What improved? Pain, function and quality of life. The other neat part was that this was a factorial design. So they also randomized patients to some kind of social media intervention and maybe a wearable device. They haven't reported on that part but the reason I chose this trial is it shows IA steroids are better than lidocaine alone, number one.

Number two, it also showed that in a small trial in clinical care you can do a trial like this but you can also answer another question and we'll find out if people move more if they're given sort of cues to move. The next study just in brief was number sixteen fifty two and what it was was looking at two cohorts of primary knee osteoarthritis, again mostly men with a large and almost 800 patients. And what they did was they were looking at patients who got intra articular steroid injection of the knee or hyaluronic acid viscosupplementation of the knee and they looked at two questions. Is there more x-ray progression leading to knee replacement? If you received one injection or one course of either or multiple injections?

And the bottom line fortunately for us and our patients is that there is no difference of x-ray progression or worsening your knee OA comparing IA steroids to IA viscoelastics. I think it's an important take home message. The next one was if we lose weight, will we help knee osteoarthritis? That is in the ACR recommendations and it is well known. So this was an interesting little study, preliminary results number sixteen fifty six looking at bariatric surgery and offering patients either bariatric surgery or a consideration for a knee replacement for the morbid obese patients who had significant knee osteoarthritis.

Although not randomized and the ethics of randomizing would be difficult, it does trend that if you get bariatric surgery, your knee OA does improve a bit. So that's another benefit for those patients. The final one, number sixteen forty nine was looking again at intra articular steroid injections and doing a gait analysis. And the bottom line was in this study, it looked like quadriceps was better off if you had an IA steroid for primary knee osteoarthritis and your gait did improve. So I think the totality of the benefit are that we have things to offer our patients including intra articular steroids for knee osteoarthritis.

Thank you and please follow us at RheumNow.

Hi, good afternoon from the final day of ACR Convergent. Here, I'm Doctor. Dine, Eric Dine coming from Baltimore, Maryland, reporting for RheumNow. Today, we heard from a bunch of the late breaking abstracts that came through and were very important to include into the ACR program this year. So I'm going to talk about the poster L01, the one of the late breaking abstracts on COVID risk, which we saw was one of the main themes of the late breaking just make the cut abstracts.

So one is from MGH, and it's looking at the outcomes of patients with rheumatic disease with COVID. Obviously, highly relevant to us. One of the biggest questions that we are asked by our patients is what the risks are and how they do compared to the general population. We had seen previously from the general rheumatology literature that patients did about as well as the general population, but we've been waiting trying to collect some more information. We've heard some mixed information over the course of the conference thus far.

So looking at the study, this is out of MGH. It's from their larger hospital association, so included both MGH and surrounding hospitals, including community and longitudinal clinics. The study is from January 30, when COVID first became relevant in Boston, to July 16. And they were looking at all COVID confirmed cases, so they had to have a positive test result for inclusion. The study was done using multivariable Cox proportional hazard regression.

They studied 143 rheumatic disease patients that were had a positive COVID test. These patients were seventy six percent female, mean age of 60 years old. And they selected six eighty eight matched comparators. This is out of a picture of a total of sixteen thousand positive COVID cases. So we had 140 rheumatic patients with six eighty comparisons.

They did a good job of matching for age, for gender. It was notable that the Charlson comorbidity index was higher in the rheumatic disease patients. What diseases were present in the patients that had a COVID diagnosis that had a history of rheumatic diseases was most commonly rheumatoid arthritis. Lupus was nineteen percent and a smattering of her other diagnoses as well. Thirty six percent of patients were on glucocorticoids, twenty one percent on hydroxychloroquine, twenty nine percent were on at least one biological DMARD, thirty one percent on at least one conventional synthetic DMARD.

The results showed that rheumatic diseases had a higher unadjusted risk of mechanical ventilation compared with comparators. That was a hazard ratio of one point seven five. But once you do all of the adjustments for variables, so adjustments for race, smoking, comorbidity index, there's no significant difference in higher risks of hospitalizations, intensive care unit admissions, mechanical ventilation, or death in rheumatic disease. How do we interpret this? I think it's hard to say.

So again, the Global Registry has been leading to the information that I've been providing my patients that patients with rheumatic diseases seem to do about as well as the general population. This I think overall supports it. We find that our patients do tend to have more comorbidities than the average population, at least with this population and the matched controls. And because of comorbidities, they tend to do at least be mechanically ventilated more often. But once we adjust out the risk, any increased risk appears to balance out in this abstract.

I think it's unfortunate with the high numbers of COVID that we are starting to get good analyses of lots of numbers of patients and we have six eighty patients here. So we're starting to collect big numbers of patients with COVID diagnoses, even with rare autoimmune diseases. But we are still affected by the fact that these are real world data. There's no way to control this information because of the nature of pandemic research. We also know that the behaviors are not controlled.

This is not an ideal study. There's no way to really control for patient and individual behavior. And we know that from some of our other late breaking abstracts. Abstract two showed that patients change their behavior. And the patients on biologic tend to stay indoors more often.

We know from Abstract five that they tend to make a lot of medication adjustments that didn't go through the physicians. So there's just a lot of noise here, a lot of patient behavior, societal behavior that it's hard for us to adjust for. But I think overall, this will help me to talk to my patients about what their risk is, let them know that there may be some signals of comorbidities leading to higher rates of complications with COVID, which we knew. But in general, if they take you know, they should take COVID precautions seriously as per the CDC recommendations. But the data is still supportive that they do about as equally as the general population.

This is Doctor. Eric Dine with RheumNow reporting from ACR Convergence final day. Thank you very much for your time.