ACR20 - Day 5.2 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 at RheumNow. I'm thinking about a roundup of some of the learnings from this great ACR twenty twenty convergence. So I'd like to tell you about learning from a cohort. So I'm going to talk about the early rheumatoid arthritis incident cohort or the CATCH cohort from Canada.

So this has over 3,000 patients. And the first thing I'd like to talk about is very applicable to us doing telemedicine during compared the CDAI that would be the traditional clinical disease activity index, which as you know is MD global, patient global, swollen joint count, tender joint count. And it compared with the patient CDAI that obviously would be the patients doing their own tender and swollen joints and giving their global assessment. And what it found was that there was really high agreement at both ends. The agreement or CAPA was about 0.7 which is pretty good at both ends.

So if the patient says my RA is doing really well and I've actually gone through this and my tendrils will and joint counts are low, you should agree with them. And at the other end, they say my tendrils will and joint count is high, my C. Is really high, you should probably agree with them as well because agreement in the middle was a little bit more scattered but the ends were quite in agreement. So I think that's important when we're doing telemedicine. The next is what about regional and widespread pain?

So we've published in the CATCH cohort before that incident fibromyalgia is about five to tenfold higher in the first two years of getting rheumatoid arthritis. What abstract 01/1987 looked at was what about regional pain and widespread pain and how does it change in the first year? So first of all, pain is common when you have new rheumatoid arthritis. One third of patients at the beginning of the study had regional pain and fortunately it went down to a quarter at the end of a year. Whereas widespread pain was one in five at the beginning of the study and at one year it also cut in half to about one in ten.

So some of these patients will have residual pain and it does affect their global assessment of what's going on. Then to look further, what about remission? So Abstract seventeen fifteen looked at remission. So I'll give you the good news and then not the good news. The good news is fifty five percent of the patients followed, over three thousand patients had an SDI remission ever.

So the good news is more than half, the bad news is forty five percent never achieved a remission in early RA that are being followed over time. But there's even more bad news of the fifty five percent of patients who were in SDI remission over the next two years, half won't stay in remission. So we need predictors of who will get into remission and who won't, but also who will sustain remission. And maybe it's related, maybe it's not to medication beliefs. So abstract number 151 said half the patients don't believe meds are necessary for their RA.

That doesn't mean they're taking the meds. They might think they're not necessary long term because they have what they think of as an acute problem of pain but they do have a chronic disease. The final lesson learned from this cohort is that if you have poor function reported as your HAC, you have a far higher chance of dying. So abstract seventeen thirty six looked at mortality related to HAC and it's not just the comorbidities of coming in with a high HAC because it was predictive at one year for mortality and it was less predictive at baseline. So what does that mean?

That if you can't improve function from your RA deficits over that first year, you have a poor predictor of survival in the long term. So I think we can learn an awful lot from cohort studies. These are sometimes difficult to fund because the questions can vary depending on what we're finding but these are all important lessons learned. So take care and follow us at RheumNow. Thank you.

Hi everyone, I'm Nicola Delbeth from Auckland, New Zealand and today I'm going to be talking about the results of the FAST study. This is abstract l o eight, and this was presented today at the, ACR convergence meeting. So, of course, cardiovascular disease is a very common comorbidity in people with gout, and our treatment options have been, somewhat uncertain in the last couple of years following the publication of the CARES trial, which reported increased cardiovascular and all cause mortality in patients prescribed febuxostat compared with allopurinol. So we've all really been waiting, eagerly for the results of the FAST trial. So this is essentially the European, post regulatory approval cardiovascular outcome study comparing febuxostat with allopurinol.

This was mandated by the EMA at the time of approval of febuxostat. So this is an open label non inferiority trial, with a cardiovascular outcomes as the primary endpoint. So participants in the study all had gout. They were 60 years old or older. And, at the time of going into the study, they were all taking allopurinol.

All had at least one cardiovascular risk factor, and about a third had established cardiovascular disease. I think it is important to note that, people with severe heart failure were excluded and also those who'd had a cardiovascular event or stroke in the preceding six months. So there was a run-in period where participants, had a dose escalation of allopurinol to achieve a serum uric, target of less than six milligrams per deciliter, and then they were randomized to, either continue with allopurinol or switch to febuxostat initially eighty milligrams daily increasing to one hundred and twenty milligrams daily if needed. Most people were able to, achieve a serum urate target on fevoxostat eighty milligrams daily, so there was actually very little, dose escalation of fevoxostat. The primary outcome measure was adjudicated cardiovascular events or death.

And importantly, this was a study done in, predominantly Denmark and, The UK. So there was very good record linkage, and they were able to achieve very good follow-up. So just briefly to mention the gout outcomes. So, there was slightly more serum urate lowering with febuxostat compared to allopurinol, but really no appreciative appreciable difference in the gout flares between the two groups. But now getting on to the really, important outcome, for this trial, which was the primary outcome of cardiovascular safety, overall febuxostat was non inferior to allopurinol with respect to the primary outcome and also for, mortality, outcomes.

In fact, the hazard ratio was actually slightly lower, although not statistically different, at 0.85 for the primary outcome, which actually, showed a potential benefit of febuxostat compared to allopurinol. Again, not statistically significant, but really no, signal of worse outcomes with febuxostat. With respect to the deaths, there were numerically fewer deaths in the febuxostat group compared with the allopurinol group. So seven point two percent with febuxostat, and eight point six percent with allopurinol. And overall SAEs were otherwise, similar.

Importantly with this study, there was very good follow-up. So, ninety four percent had complete follow-up, and this was really enhanced by the record linkage. And I think this is really an important point because there was a huge amount of, loss to follow-up in the CARES trial. So, what's the implication for, of this of this result? Well, I think it really does provide us, with some reassurance that switching from allopurinol to febuxostat is safe, and this is includes in people who have cardiovascular risk factors.

And so I think this will change my practice, and, I think will also help us a lot to reassure patients, when we're talking about the safety of urate lowering therapy. Thanks.

This is doctor Katherine Dow reporting for RheumNow. I want to introduce you to an amazing man who was instrumental in making me into a rheumatologist when he accepted me into the UT Southwestern fellowship program almost two decades ago. Doctor. David Karp was recently installed as our eighty fourth American College of Rheumatology Doctor. Karb, welcome and thank you for allowing me to ask you a lot of questions like I did during fellowship.

Oh, thank you for inviting me, Katherine. And yes, you were a great fellow and I've followed your career since then. And, you know, it is with great pleasure that we welcome you back to UT Southwestern about a year ago and have you now on our faculty.

Thank you. Well, first question I'm going to ask is something a lot of viewers want to know, but they're really ashamed to ask. What's the job of an ACR president in the event one of us wants to apply for the position in the future?

Well, the job of the ACR president has changed a little bit just like all of our jobs have changed in the last year. If you asked me about this a year ago, I would say it's spending a lot of time in airport lounges and hotel meeting rooms. But now we're doing it like we're having this interview tonight. It's all on Zoom. But there's a lot of meetings.

The executive committee, which consists of the president, the president-elect, the secretary, the treasurer, and then the foundation president and president-elect and the AARP president and president-elect all get together typically on a monthly basis and talk about a lot of the sort of details that go on behind the scenes. I mean, lot of people, you know, think of the, you know, of the ACR as the annual meeting convergence that we just had. But there's a lot that goes on in between times. Our the committee updates, the work of the college, such as our guidelines or criteria, our collaborations with ULAR and ILAR and other organizations. So there's a lot of that sort of minutiae, if you will.

It's just like running another business. You have to get together. And of course, we have our board of directors meetings that occur throughout the year and ACR president leads those. So, it's kind of like being a division chief or a department chair, but for a much bigger group of people.

That's a lot of work. It's almost like, when I was growing up, my dad went to work, but I never knew what he did. So thanks for clarifying that.

Yeah.

So what are your goals for the college during your tenure?

Well, you know, there are a couple of things and thank you for I saw you tweeted today because the rheumatologist article came out as well. So there have been, you know, a number of things that that we put in place this year that are not related to COVID. And we really do need to operationalize them and get them going. You know, the first of launch is that, you know, we have not taken a good look at how the ACR is organized, you know, for almost thirty years. And just like any other business or organization,

it's important to be self reflective and make sure that you are organized in a

way 30 that meets the needs of your customers. Our customers are our members, the physicians and health professionals who make up our membership. And when I say organized, I'm talking about the volunteer committees as well as the staff in Atlanta that have been in place, things like our Committee on Training and Workforce and Education and Research. And those have served us remarkably well for the past three decades, and we've gotten a lot done. But we need to make sure that we are really organized in a way that's nimble and can allow us to take on new challenges, you know, the year.

So we have a committee, a governance task force that is now headed by Doctor. Angus Worthing, who is a community practitioner from Washington DC and Doctor. Abby Abelson, who is the chair of rheumatology at the Cleveland Clinic. And the task force has is about half community rheumatologists. So we want to be certain that we are meeting the needs of all of our members, not just the academicians who seem to have more time for to volunteer for the ACR, but the community rheumatologists that make up such a big part of our membership.

So they'll provide the board with some ideas in the the spring and we'll see where we go with that.

I love it. And I love the fact that you've you're always inclusive, whether, it's from diversity and race or in sex or anything like that. And when I read the rheumatologist saying how you're going to tackle this, and I mean, I just think that this is, something that we all need and I'm just so glad that you're up to this challenge. Do you think there are other challenges that rheumatologists will encounter and how is the ACR poised to help its members?

Well, you know, the big elephant in the room, the one that's, that's not going to go away for a while, I'm afraid is COVID-nineteen. And so, you know, one of the challenges, a very specific challenge that that rheumatologists are going to face, you know, hopefully pretty soon are questions from their patients. You know, you know, Doctor. Dow, should I get vaccinated against COVID-nineteen? And there are five vaccines.

Which one should I take? So, you know, the ACR has looked at this, you know, and I don't know if you saw, but there was a call for volunteers in the last month to staff another couple of task forces or groups that will work with our quality of care committee to look at number one vaccines in general because we really don't have much guidance for vaccinating our patients other than for RA. And we want to try and expand that to lupus and other conditions where the vaccine advice is probably going to be close to the same but might have some nuanced differences. And then, you know, as I just mentioned, we'll have a group that'll include experts from infectious disease and other areas that will help us decide whether there is a difference between an RNA vaccine or a protein vaccine or an adenovirus vaccine for COVID-nineteen and which ones will we recommend to our patients? Will they work in our patients who are getting immunosuppressive medications?

Will they be safe in somebody whose autoimmune disease might be triggered by a vaccination? So those are very important questions. And I think the ACR really needs to provide those answers to our patients and our members, because that's going to be upon us, you know, maybe by the first of the year, and we're getting on top of that very soon. Go ahead.

Yeah, no, that's a Herculean task for sure. And, I mean, I was very impressed with how the ACR had communicated with its membership and also like having these town halls. I mean, were so helpful and especially since we're so isolated where we are. Do you think that's going to continue and especially just to give us some guidance with these vaccines?

Well, yes, I mean, think the as Ellen gravelisi pointed out in her in her presidential address, you know, the the upside of COVID nineteen is that it's taught us how to react very quickly and thoughtfully and intentionally and how to be able to work at a distance. I mean, you know, again, a year ago, you know, if you told me we want to put together a task force, the first thing we would have done was looked at everybody's schedules and could we get people on an airplane and a hotel and book this and book that. And now it's just like, can we meet tomorrow night on by Zoom? And yes, we can. So we can get a lot done quickly.

And that's how we're going to be operating I think for the next next year. I'm very hopeful that we can have some kind of meeting in San Francisco next year for convergence. But I'm not 100% optimistic. We'll have to see. But in the meantime, yes, we're going to be getting this information that's important to our members out via the channels that we have learned this past year.

That's great. And you had mentioned about next year's meeting. I mean, has been like a one of a kind experience, how the ACR had converged together with more than 16,000 people from around the world. I mean, I can only envision that future meetings, you can't eliminate the video and audio portion of this, because people who can't get to the meeting, you know, have access to like some world class research. I mean, is this something that we're going to look forward to even though, you know, maybe the world's opened up again?

Sure. So, you know, it's, again, a little bit ironic, but, you know, know, ACR leadership had been looking at how we deliver our education for over a year. You know, we did what we normally do. We have had some consultants look at the educational offerings and give us some suggestions of things that we could do. Last February, the board met for the last time in real life.

And one of the things we did was we passed our strategic plan for education, which included three years of building on what we did last year in Atlanta and some of the innovations that we had, including therapy dogs at the meeting, but lots of things like the community hubs that we tried out last year. And one of the things that we suggested was that at the end of three years, we were going to try doing some virtual meetings. And that got flipped. And so everything was virtual this year. And I think what we'll see is a hybrid meeting in the future.

You're right. You know, we got a fantastic number of people from around the globe coming to our meeting this year. And we want to continue to provide that high quality educational experience to people who, you know, whether it's somebody from a part of the world that is not rich in resources and can't get on an airplane and fly to The United States, or you know, who just doesn't have the time to come from Dallas, Texas because they have a busy practice and you know wants to drop in and get the education that they need, you know, when they want it, where they want it, rather than having to, you know, book a flight in a hotel and spend, you know, four or five days away from their family. So I think we're going to continue to see virtual offerings as part of our meetings, hopefully as a hybrid meeting because, you know, I just crave the networking and seeing my best friends in rheumatology at the meeting.

And, you know, you carry like two different hats, one as, chief and basically running this whole fellowship program, huge program in Dallas, and then the other as now ACR president. I mean, many of our viewers are younger, they're fellows, and they want to be involved. So how can they be involved, to kind of help with everything that the ACR has to offer and be a contributing member?

Well, I appreciate that because we have a lot of people who want to volunteer and we've over the years worried a bit about the fact that, you know, younger members and particularly, you know, women who unfortunately bear a lot of the jobs at home with childcare and the like, just can't take off for a weekend and go to a hotel and spend time at a committee meeting. And again, this is one of these, know, virtues, if you will, of a pandemic is it's taught us that we can have a lot of meetings at times when you know people can now you know, don't have to get on an airplane and can spend fifteen minutes here or a half an hour there or, you know, part of a day and actually, you know, give us some great ideas. And our governance task force is going to be thinking about some ways that we can improve that. So I would suggest that people just, you know, look at the offerings that the college has as far as volunteer offerings. And we are going to try and you know, make things available to people that are maybe outside the normal committee structure, but would give somebody a chance to contribute their experience, their knowledge, their expertise to the greater good of the college because there's just so much great experience within our college that we need to tap into that to become a better profession.

I agree. Now, the final question here because I know you're a busy man. In the rheumatologist, you mentioned you're an inveterate crucifervalist. You kind of tell me what that is?

Doctor. That's a clue. If you it's one of those things if you have to look it up, you know.

I read it as invertebrate instead of endeavor.

No not that. No I'm addicted to crossword puzzles and I try and get the New York Times done every day if I can and that's that's that's my relaxation is, you know, sitting down with a good crossword puzzle.

So you listen to NPR, the Puzzle Master too?

I did. That was always something to do on a Saturday morning. So yeah, there are some NBR some of my in addition to RheumNow, the other podcasts that I listen to are sometimes NPR, you know, quiz shows. But yeah.

Well, you, Doctor. Karp. I really appreciate you taking this time with me and with our viewers, to get you to know you better. And so this is Doctor. Catherine Dao for RheumNow.

Follow me on Twitter KDAU2011.

Thank you, Kat.

Hi, I'm Doctor. Janet Pope at RheumNow. I'd like to give a bit of a roundup and my first theme is really learning from a large database and this is going to be lifestyle behaviors prior to the onset of disease. So there were two large studies of the Nurses Health Study and the Nurses Health Study actually has two very large cohorts and it really is an incident cohort study because people don't have a particular disease of interest and then going forward. And the question in both these studies, well in this study of nurses' health study, the two abstracts were what about modifiable risks for obtaining diseases such as rheumatoid arthritis or lupus in the future?

And the first abstract was for rheumatoid arthritis abstract number eleven ninety eight and they looked at a validated cardiovascular risk of modifiable risk factors. So they looked at diet and better diet in the upper 40%, exercise that was somewhat aggressive each week, some degree of alcohol drinking, no smoking ever and having a normal BMI. And what they found was in a sort of dose response if you had none of these modifiable things in favor you had more rheumatoid arthritis than if you had say two, three or four or five of the modifiable risk factors. And basically one third of rheumatoid arthritis in the nurse's health study could be explained by not having these healthy living variables. Then they also looked at SLE, so Mei Choi and others from Harvard looked at the same idea in lupus and they actually found up to fifty percent of modifiable risk factors could explain getting lupus.

That was abstract number fourteen seventy three. So what we don't know in any large database like this is what about major life events? What about stress? What about infections prior? Also we know that lifestyle features are interrelated.

This group has already shown that high BMI or high BMI and smoking give more ACPA RA as a for instance. The other limitations are what about the generalizability? These were all nurses, they're completing their forms so education is higher. These were all nurses who were women for the study so we don't know about the generalizability of the men. And the elephant in the room I think is also what about poverty?

We can't address the higher impact that maybe poverty would have on people with overcrowding, more infections, worse lifestyles, health related behaviors that maybe are less modifiable. However, overall, I think that in general living a healthy lifestyle makes a lot of sense and in particular for our at risk patients such as first degree relatives when they say you know my relative has RA or lupus what should I do? I think we have a good recipe to give them. Hard to follow the recipe but it's a great one. Thanks follow us at RheumNow.