RheumNow Podcast - RWCS Quick Hits (2.14.20) Save
Dr. Jack Cush reviews the Highlights from the 2020 RWCS meeting in Maui, HI
Transcription
It's the 02/14/2020. This is the Room Now podcast, and I'm doctor Jack Cush, executive editor of roomnow.com. Yes. The guy that's been pushing RoomNow live. It's coming up in four weeks, you know.
Go to roomnow.live and check out the program. This week we're in Maui and had a fabulous conference. It's not quite done. I'm just gonna give you a bunch of quick hits and a few things from the website. All this coming from the great teaching here at the Rheumatology Winter Clinical Symposia run by Artie Cavanaugh and George Martin.
Great speaker from La Jolla, Doctor. William Bugbee, an orthopedist, talked about a number of very interesting topics. I'll give you two. One is, how long does a hip or knee replacement last? You know, for years they've been saying ten years, fifteen years, but obviously the technology has gotten better, the materials have gotten better.
Recent data is pretty consistent. It shows that basically twenty five years is the right number in about seventy to eighty two percent of patients, depending on the circumstance and which knee and for what reason, OA versus RA, hips versus knees. The highest number is eighty two percent of patients over twenty five year survival when it's a hip replacement for OA. I think the number is like seventy or seventy two percent for a knee replacement for RA. Another recent trend that's really quite interesting and really got the, I guess the hair on the back of the rheumatologist neck to go up, and that is same day arthroplasty, meaning, yes, we cut in the morning, we send you home by Uber in the afternoon or evening.
And this has really been a new trend that has been afforded by several things. Number one, and most of all, is Medicare has been pushing on this. Medicare basically has rules that say, tell us why the patient can't actually have a same day procedure. Other things driving this would be, new changes in both anesthesia and surgical techniques, including minimally invasive, disease. Obviously the economics and there are a few entrepreneurs that are sort of, showing that this does really work.
What's happens here is that the surgery is different. They use little or no narcotics. People get a pain cocktail. They use, Tremexanic acid to reduce the blood loss. And again, they do very, very well.
Soon after the surgery, they're up standing. They have their first physical therapy session. If they do well and have no apparent complications, they go home to a support system in the evening. And this is not completely universal, but boy, I was surprised at the number of people at this, national meeting in, RWCS where a number of people are seeing it in their practice. A quote from the meeting comes from me, and that is a C.
Dye over 40 is a patient who's got fibromyalgia on top of their rheumatoid arthritis. We were analyzing data on their trajectory of C. Dye changes or disease activity changes, people changing very fast, people changing really slow, people not changing at all. Turned out the people had changed not so fast and didn't change at all, people where started out with very high C. Dies over 40, meaning that there may be an element of fibromyalgia in people who have a high disease activity score.
By the way, it's the same number, four rapid, or would I do a GaAs score, etc. There's a new report out that we talked about, the shingles vaccine, from a neurological meeting held this week in California showing that the use of the shingles vaccine was accompanied by a sixteen percent reduction in stroke events in older adults. Now, this was a study that was done in people who received the live virus vaccine, the Zostavax vaccine, but it was a very large study showing a sixteen percent reduction. That's important because Lenny Calabrese and others have reported that the shingles vaccine, I'm sorry, shingles as an event, as an infectious event, does predispose to more strokes. And that's based on some epidemiologic data.
Now you have sort of, Koch's postulates being sort of, examined, where now the intervention is proven to yield a positive benefit. So I think that's very interesting. It turns out that again, those who may be at greater risk, especially the elderly, may want to get it not just for protection of shingles, but also against stroke. And again, the interesting thing is that the people who were protect in the study, unlike the data for Zostavax, were those who are older, 70 and 80 year olds. Eric Rimmand did a series of lectures, one devoted to, some, truths and myths regarding some strange therapies that are advocated for osteoarthritis.
Myth number one is that, stem cell therapy, didn't pair out very well. There's very little consistent evidence. The science behind it is weak. The costs behind it are astronomical. It's entrepreneurialism.
It's not regulated by the FDA. Stem cells are largely a hoax until they are taken seriously and done with some real research. But on the other hand, PRP injections, plasma rich, injections for knee OA have been shown to work, in clinical trials, not always great clinical trials. And the problem really here is that they're just very expensive and not generally covered. For one injection could be as high as 700 or $800.
He talked about leeches. That's kinda creepy that leeches and osteoarthritis, there in fact may be some evidence that they work. But boy, it sure is creepy and icky and he wouldn't recommend it. And then lastly, talked about lateral wedge insoles for patients who have knee OA, especially medial compartment OA. It's been shown to be effective in improving function, but not necessarily shown to improve pain in people who have knee OA.
Alvin Wells gave a series of lectures on, and really great points on the management of inflammatory eye disease. He said epi, meaning episcoritis. Epi is wimpy and scleritis is the real deal. That's what you gotta remember. Meaning, no one's gonna get into too much trouble with episcoritis.
However, scleritis is worrisome. He also went on to say that scleritis is basically a vasculitis and requires aggressive systemic therapy, and also made a case for, you know, the monoclonal antibody, TNF inhibitors, adalimumab, infliximab, and or rituximab as being the drug of choice in that situation. There's a new drug that's been approved for use in thyroid ophthalmopathy. It inhibits, insulin growth factor one. It's called teprotumumab, and it's been shown to be effective in patients who have thyroid ophthalmopathy.
I've got two patients with this. I don't know about you, but it is seen by the rheumatologist. A tweet that we put out that came from the literature this week was a small study, 66 patient study that showed exercise is not just good for one's physical being, it actually has cognitive benefits. And when patients were put on an exercise program, not just did those things improve, but so did C reactive protein, fatigue, and truncal fat, significantly so. So exercise makes sense, but who'd have thunk that it would improve inflammatory markers and even fatigue.
The JBMR, a metabolic bone journal, actually discussed a large study of 150,000, adults over the age of 50, and examined the use of certain drugs and their effects on, fracture risk. So they compared 150,000 on tramadol to one hundred to one hundred and fifty thousand taking other drugs, including, ibuprofen, naproxen, codeine, celicoxib, and atoricoxib. And guess what? Tramadol, that very benign, weak narcotic, was associated with twenty eight to seventy eight percent higher risk of hip fracture. The question is why?
They're certainly not getting drunk and falling over or falling downstairs, or is this going to be more like the nerve growth factor data where because of such effective control of pain, patients with advanced OA may go on and damage the joint in a Charcot joint like way, loss of proprioception and neuropathic control and restraint, leading to damage, fractures, etc. That was seen with the nerve growth factors, but is that the manner in which, tramadol exerts its effect here? We don't really know. There's a report this week about abatacep, open label study in seventy nine patients with Sjogren's syndrome, and guess what? All other drugs in Sjogren's syndrome, it doesn't work.
No benefit compared to those who were treated placebo in open label trial. And lastly, we'll close with a very interesting report from the ACR's RISE registry coming from Jeff Curtis and colleagues talking about how good are we when we're measuring and doing treat the target supposedly in patients with rheumatoid arthritis. How good are we at changing therapy? Well, when they looked at patients who had moderate or high disease activity, and this is everyone's mandated to measure here, treat to target is promoted here. Seventy plus percent of patients were using a rapid three, thirty percent of patients were using I think C Dye.
And the data is pretty convincing that you don't change very much, and somewhere between thirty five, thirty six and fifty five percent of rheumatologists fail to change their DMARD or add on or escalate even when the patient has moderate to severe activity. When there was agreement between the CDAI and the RAPID three, the amount of change that went on, if you were on monotherapy, was about sixty percent of patients had a change. Whereas if you're on a combination, only about thirty percent, forty percent of people had a change in their therapy. If there was a disagreement, Rapid three for instance was high and CDAI was not and vice versa, the numbers were less, you know, thirty to fifty percent if you're on monotherapy made a change and only about twelve to eighteen percent made a change if you're on combination. Meaning that even in the face of objective evidence of activity, we need to be more stringent.
We need to really practice treat the target. You need to look at the numbers and look at the trends and be more aggressive in managing these patients. That's it for this week. Go to the website, check out our links. You can learn more.
Follow our videos. We got a ton of videos on the RheumNow site this week, and we'll put out some podcasts this week from a lot of the video presentations we have coming from RWCS. Great faculty, Anne Stevens, Allen Wells, Eric Ritteman, Marty Bergman, Orin Traum, Artie Cavanaugh, Mark Genovese, Roy Fleishman, myself, Uma Mahadevan, and Bill Bugbee, and I'm sure I'm leaving someone out. George Martin. We'll try to get them all on video and also on podcast this week.
Hope you enjoy. Check out room now. Live. Register and come. We're gonna have a blast in Fort Worth in four weeks.
Go to roomnow.live and check out the program. This week we're in Maui and had a fabulous conference. It's not quite done. I'm just gonna give you a bunch of quick hits and a few things from the website. All this coming from the great teaching here at the Rheumatology Winter Clinical Symposia run by Artie Cavanaugh and George Martin.
Great speaker from La Jolla, Doctor. William Bugbee, an orthopedist, talked about a number of very interesting topics. I'll give you two. One is, how long does a hip or knee replacement last? You know, for years they've been saying ten years, fifteen years, but obviously the technology has gotten better, the materials have gotten better.
Recent data is pretty consistent. It shows that basically twenty five years is the right number in about seventy to eighty two percent of patients, depending on the circumstance and which knee and for what reason, OA versus RA, hips versus knees. The highest number is eighty two percent of patients over twenty five year survival when it's a hip replacement for OA. I think the number is like seventy or seventy two percent for a knee replacement for RA. Another recent trend that's really quite interesting and really got the, I guess the hair on the back of the rheumatologist neck to go up, and that is same day arthroplasty, meaning, yes, we cut in the morning, we send you home by Uber in the afternoon or evening.
And this has really been a new trend that has been afforded by several things. Number one, and most of all, is Medicare has been pushing on this. Medicare basically has rules that say, tell us why the patient can't actually have a same day procedure. Other things driving this would be, new changes in both anesthesia and surgical techniques, including minimally invasive, disease. Obviously the economics and there are a few entrepreneurs that are sort of, showing that this does really work.
What's happens here is that the surgery is different. They use little or no narcotics. People get a pain cocktail. They use, Tremexanic acid to reduce the blood loss. And again, they do very, very well.
Soon after the surgery, they're up standing. They have their first physical therapy session. If they do well and have no apparent complications, they go home to a support system in the evening. And this is not completely universal, but boy, I was surprised at the number of people at this, national meeting in, RWCS where a number of people are seeing it in their practice. A quote from the meeting comes from me, and that is a C.
Dye over 40 is a patient who's got fibromyalgia on top of their rheumatoid arthritis. We were analyzing data on their trajectory of C. Dye changes or disease activity changes, people changing very fast, people changing really slow, people not changing at all. Turned out the people had changed not so fast and didn't change at all, people where started out with very high C. Dies over 40, meaning that there may be an element of fibromyalgia in people who have a high disease activity score.
By the way, it's the same number, four rapid, or would I do a GaAs score, etc. There's a new report out that we talked about, the shingles vaccine, from a neurological meeting held this week in California showing that the use of the shingles vaccine was accompanied by a sixteen percent reduction in stroke events in older adults. Now, this was a study that was done in people who received the live virus vaccine, the Zostavax vaccine, but it was a very large study showing a sixteen percent reduction. That's important because Lenny Calabrese and others have reported that the shingles vaccine, I'm sorry, shingles as an event, as an infectious event, does predispose to more strokes. And that's based on some epidemiologic data.
Now you have sort of, Koch's postulates being sort of, examined, where now the intervention is proven to yield a positive benefit. So I think that's very interesting. It turns out that again, those who may be at greater risk, especially the elderly, may want to get it not just for protection of shingles, but also against stroke. And again, the interesting thing is that the people who were protect in the study, unlike the data for Zostavax, were those who are older, 70 and 80 year olds. Eric Rimmand did a series of lectures, one devoted to, some, truths and myths regarding some strange therapies that are advocated for osteoarthritis.
Myth number one is that, stem cell therapy, didn't pair out very well. There's very little consistent evidence. The science behind it is weak. The costs behind it are astronomical. It's entrepreneurialism.
It's not regulated by the FDA. Stem cells are largely a hoax until they are taken seriously and done with some real research. But on the other hand, PRP injections, plasma rich, injections for knee OA have been shown to work, in clinical trials, not always great clinical trials. And the problem really here is that they're just very expensive and not generally covered. For one injection could be as high as 700 or $800.
He talked about leeches. That's kinda creepy that leeches and osteoarthritis, there in fact may be some evidence that they work. But boy, it sure is creepy and icky and he wouldn't recommend it. And then lastly, talked about lateral wedge insoles for patients who have knee OA, especially medial compartment OA. It's been shown to be effective in improving function, but not necessarily shown to improve pain in people who have knee OA.
Alvin Wells gave a series of lectures on, and really great points on the management of inflammatory eye disease. He said epi, meaning episcoritis. Epi is wimpy and scleritis is the real deal. That's what you gotta remember. Meaning, no one's gonna get into too much trouble with episcoritis.
However, scleritis is worrisome. He also went on to say that scleritis is basically a vasculitis and requires aggressive systemic therapy, and also made a case for, you know, the monoclonal antibody, TNF inhibitors, adalimumab, infliximab, and or rituximab as being the drug of choice in that situation. There's a new drug that's been approved for use in thyroid ophthalmopathy. It inhibits, insulin growth factor one. It's called teprotumumab, and it's been shown to be effective in patients who have thyroid ophthalmopathy.
I've got two patients with this. I don't know about you, but it is seen by the rheumatologist. A tweet that we put out that came from the literature this week was a small study, 66 patient study that showed exercise is not just good for one's physical being, it actually has cognitive benefits. And when patients were put on an exercise program, not just did those things improve, but so did C reactive protein, fatigue, and truncal fat, significantly so. So exercise makes sense, but who'd have thunk that it would improve inflammatory markers and even fatigue.
The JBMR, a metabolic bone journal, actually discussed a large study of 150,000, adults over the age of 50, and examined the use of certain drugs and their effects on, fracture risk. So they compared 150,000 on tramadol to one hundred to one hundred and fifty thousand taking other drugs, including, ibuprofen, naproxen, codeine, celicoxib, and atoricoxib. And guess what? Tramadol, that very benign, weak narcotic, was associated with twenty eight to seventy eight percent higher risk of hip fracture. The question is why?
They're certainly not getting drunk and falling over or falling downstairs, or is this going to be more like the nerve growth factor data where because of such effective control of pain, patients with advanced OA may go on and damage the joint in a Charcot joint like way, loss of proprioception and neuropathic control and restraint, leading to damage, fractures, etc. That was seen with the nerve growth factors, but is that the manner in which, tramadol exerts its effect here? We don't really know. There's a report this week about abatacep, open label study in seventy nine patients with Sjogren's syndrome, and guess what? All other drugs in Sjogren's syndrome, it doesn't work.
No benefit compared to those who were treated placebo in open label trial. And lastly, we'll close with a very interesting report from the ACR's RISE registry coming from Jeff Curtis and colleagues talking about how good are we when we're measuring and doing treat the target supposedly in patients with rheumatoid arthritis. How good are we at changing therapy? Well, when they looked at patients who had moderate or high disease activity, and this is everyone's mandated to measure here, treat to target is promoted here. Seventy plus percent of patients were using a rapid three, thirty percent of patients were using I think C Dye.
And the data is pretty convincing that you don't change very much, and somewhere between thirty five, thirty six and fifty five percent of rheumatologists fail to change their DMARD or add on or escalate even when the patient has moderate to severe activity. When there was agreement between the CDAI and the RAPID three, the amount of change that went on, if you were on monotherapy, was about sixty percent of patients had a change. Whereas if you're on a combination, only about thirty percent, forty percent of people had a change in their therapy. If there was a disagreement, Rapid three for instance was high and CDAI was not and vice versa, the numbers were less, you know, thirty to fifty percent if you're on monotherapy made a change and only about twelve to eighteen percent made a change if you're on combination. Meaning that even in the face of objective evidence of activity, we need to be more stringent.
We need to really practice treat the target. You need to look at the numbers and look at the trends and be more aggressive in managing these patients. That's it for this week. Go to the website, check out our links. You can learn more.
Follow our videos. We got a ton of videos on the RheumNow site this week, and we'll put out some podcasts this week from a lot of the video presentations we have coming from RWCS. Great faculty, Anne Stevens, Allen Wells, Eric Ritteman, Marty Bergman, Orin Traum, Artie Cavanaugh, Mark Genovese, Roy Fleishman, myself, Uma Mahadevan, and Bill Bugbee, and I'm sure I'm leaving someone out. George Martin. We'll try to get them all on video and also on podcast this week.
Hope you enjoy. Check out room now. Live. Register and come. We're gonna have a blast in Fort Worth in four weeks.
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