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Welcome to QD Clinic. I'm Jack Cush from roomnow.com. QD Clinic is brought to you by RheumNow live, where we will change minds and change practice. Our meeting begins in just two weeks. Go to rheumnow.live to check it out.

Today's case is called less is dangerous. So I saw a patient recently who is a non English speaking older woman who has rheumatoid arthritis. And I almost blew a pupil over her non compliance. It's been a repeated issue every visit. It's really hard to tell what she is taking and what she is not taking.

It's totally maddening because guess what? At every visit, she's doing horrible, has a pain of, you know, six, seven, eight, nine, sometimes 10. You know, sometimes she has swollen joints. Today, she had swollen joints. You know, what are you going to do with this?

Noncompliance is a gigantic problem, and I think you need a strategy. Lord knows I need a strategy on how to manage this. You have to recognize the problem. The problem is number one, age. Older patients really suffer from this issue more so than do younger.

Language is a major problem here. Polypharmacy just compounds the problem, and comorbidities just makes the problem scarier. So my solution in dealing with this is as follows. Number one, I have to impress upon the patient that I need to have certain things at every visit or else I can't do this, meaning take care of you. Number one, I need another person present.

It's not enough just to have you. I need a daughter, a spouse, a best friend. It's got to be the same person. It can't be a series of volunteers who are pitching in to help with translation and or transportation. It's got to be the same person who's going to get involved in that person's prescribing and taking of medicines and filling of medicines.

Number two, I don't see the patient unless the medicines are in the clinic in a bag and we're gonna count them off. We're gonna go over them. We're gonna throw away the ones we're not taking. We're gonna change the ones we need to change. We're going to accentuate the ones that need to be taken correctly.

Number three, the goal has got to be reduced medicines. If the patient is taking less medicine, they'll believe that they're safer and they'll be motivated to actually take the medicine. You've got to work real hard at reducing medicine, which means number one, get rid of all the vitamins, it's a bunch of crap, it ain't really going to change the story, unless it's folic acid for methotrexate, it's all crap, forget it, get rid of it. Number you also need to work with other doctors on this, you probably need to call the primary care doctor. If your clinic is lucky enough to have a clinical pharmacologist around, get them involved.

And again, another prob you know, there are other doctors who are contributing to this problem as well. Number four, rheumatology is easy. If they have advanced RA and they're on advanced therapies, go IV. Stop screwing around with pills that you hope they may or may not be taking. In this case, the patient stopped the medicine months ago when the surgeon stopped the medicine because he thinks he knows what he's doing.

He's getting his education from the television. He doesn't know what he's doing and the patient's been off of a DMARD for three and a half months and guess what? She's worse. So go IV. Go monthly infusion.

Go whatever it is. You know, you can control it and you can be sure that she's getting it, he's getting it and go IV. Number five, as frustrating as this is, you probably need to see the patient more frequently. See them every month until you get this right. Let them know that you're really concerned.

And that's my last point. Show your concern, either your frustration, worry, your sense of urgency. You've got to back it up by seeing the patient more frequently, getting more frequent labs. And then lastly, you need to tell them less is dangerous. Less is not safer.

Less is dangerous because taking less medicine means that they're gonna get worse. And worse means more pain, more disability, more damage, more hospitalizations, and ultimately just really poor RA care that's got your name all over it. You as the physician need to take control of this less is dangerous situation, which is rooted in non compliance polypharmacy, etcetera. Tune in tomorrow for another good case of QD clinic. This is QD clinic.

I'm Jack Cush from RheumNow. QD clinic is brought to you by RheumNow live, a master class for the master rheumatologist. You can be there on March 13 in Fort Worth, roomnow.live to register. Today's case called Derm Alone, meant to be a little bit of a play on Home Alone. You need to see the visual for that one.

So what do I mean by Derm Alone? A 30 year old male comes in with psoriatic arthritis. Having already been to the dermatologist comes to me to consider what his arthritis might be due to. There's a history of uveitis, there's enthesitis, there's an oligoarticular inflammatory arthritis, and yes, there's active psoriatic plaque and nail pitting and onycholysis. So the diagnosis is easy, and my stepping up and starting the patient on a biologic doesn't really matter whether it's a TNF inhibitor or an IL-seventeen inhibitor, IL-twenty three inhibitor, twelve twenty three inhibitor, whatever I did, it works, and it works really, really well.

The question is, what's going to happen to the patient and their dermatologic care henceforth? How do you manage that? Do you take over the management of patients who have skin disease and joint disease, and because you're the master biologic therapy person, then can you just manage the skin disease without the derm being involved? Often the patient wants whoever is the one that helps them the most to manage the problem and they only want to go to one physician, but do they need to see two? Certainly, if it's all joints and very little skin and the skin goes away, there's not much reason to get the dermatologist, involved, or is there?

I tend more often than not to keep the dermatologist involved, one, by getting copies of my notes just so they can see what's going on. But reasons why, and I'll give you a few, why you should send those patients back to the dermatologist for at least an annual visit would include mild to moderate skin or nail disease that might require other therapies other than the biologic. Topicals, I have no clue. They're all 0.1% ointments, creams, salves, poultices, God knows what it all is. And to me, they all look the same, and I don't wanna have to refill not a one of them.

The extent of my topical steroid prescribing goes to one percent hydrocortisone cream from Walgreens. That's about it. So, yeah, mild to moderate disease that may require topicals, maybe even Geckerman's therapy, UV therapy, or maybe even other therapies would be smart to have them involved. Secondly, there are some people who have really severe disease and are going to need the ongoing input. Remember, you're the low hanging fruit on the therapeutic challenge here.

Treating the joints is a whole lot easier than treating the skin. So quite often, we'll do fabulous with whatever we do, but the skin is an incomplete responder, and they're gonna need more. So you'll need a good dermatologist to manage that. If the skin disease is still problematic and you're on aggressive therapy, combination therapies and the derm doesn't know what to do, my advice is get a second opinion. Get another derm, maybe someone who's more skilled in medical dermatology and biologic therapy and psoriatic arthritis.

Maybe this isn't psoriatic arthritis. Maybe that's why you need a second opinion. But maybe the most important reason to send them back to the dermatologist is to continue that very strong relationship you have with the dermatologist in co managing these patients. In a perfect world, if you're like Eric Ruderman and others around the country, in Boston, they have a combined clinic. Eric Ruderman has a combined clinic at Northwestern, dermatologists, rheumatologists getting together and all taking care of the patient in the same clinic.

That would be ideal, but you don't. You live in disparate locations, talk to each other rarely if ever, but you can talk to each other about these cases. Whether it's by phone, by text, by secure messaging, whatever, it fosters a really strong important relationship between you and the dermatologist that you may or may not need in the care of this particular psoriatic patient, but you may need in the future for another patient with another cutaneous articular condition that only the two of you can manage. I think that's a really smart approach. The other thing is, of course, to consider that the dermatologist will do the skin checks that you don't want to do.

You know, doing skin checks means they got to get naked and you got to look at all their skin looking for moles and cancers. If you don't really know this, the package insert for every TNF inhibitor says that patients on TNF inhibitors need to have annual skin exams done annually looking for skin cancer. I know you're not doing it if you're a dermatologist, and my patients on the table, God forbid, that they might have something serious going on. They sit in a chair and keep their clothes on for God's sakes. So, sending them back to having a derm involved to do annual skin checks would be a really smart and important idea.

That's it for this edition of QD Clinic. This is QD Clinic. I'm Jack Cush from roomnow.com. QD Clinic is brought to you by roomnow.live. So this case is called seven d Martin County.

A CCP positive rheumatoid arthritis patient comes to you with many swollen and tender joints, 11 tender, nine swollen, a C. I. Of 32, it's the same as rapid, same as a gas. The patient had previously been treated with methotrexate, etanercept, adalimumab, abatacit, baricitinib, tofacitinib, Kevzara, otezla, Primalast. Right now the patient's on a Primalast, cerilumab and ten milligrams of prednisone is doing poor.

Why is the patient on Tesla? Someone thought the patient might have psoriatic arthritis. This is a strongly c c CCP positive individual. And the question is, what would you do next? This patient had been doing really, really well for a long time on methotrexate and etanercept, like seven, eight, nine years, and then boom, out of nowhere, a secondary loss of response.

So this is like seven or eight DMARDs in, and what are you going to do next? What is your next choice? What do you offer the patient? Here are the offerings, but and we have to go with drugs that patient hasn't seen yet. How about sulfasalazine with Anakinra?

Number one. How about number two, leflunomide plus rituximab? Number three, methotrexate plus cerdulizumab? Four, triple DMAR therapy? Five, some other concoction that only you are known for.

Well, the good news is we've put this out to a Twitter poll and we asked rheumatologists on Twitter, got back two thirty one responses in twenty four hours, and the number one answer by seventy eight percent of your peers was that's right. Number two, leflinamide plus rituximab. What do you think was second most common? Methotrexate plus cerdulizumab at eleven percent. So that locks up eighty nine percent of the choices.

Only eight percent would do a d a triple DMARD and only two point six percent have any faith in Anakinra. By the way, Anakinra is FDA approved and works in forty percent of people the same way etanercept works. But nonetheless, all of you think it's not a good drug, but it is a good drug. It just happens to have happens to require to be given, once daily. So, what's the wrap on Rituximab?

You put it last on your list because you've got so many other choices, But realize there's a lot of data about rituximab working great as the second biologic. There's a lot of data about rituximab working great as the first biologic. To put any biologic ninth in the list really means that you're stacking the odds against it, right? I mean, so someone who fails multiple biologics is gonna continue to fail future biologics or future therapies because there's probably much more involved here than a unique biology that you haven't quite, hit upon yet. So, my point is don't wait until the ninth biologic or the ninth DMAR to use rituximab, I think it merits a consideration soon after you fail a TNF inhibitor or maybe right after they fail methotrexate.

Of course, everybody's afraid of a one in thirty thousand risk of PML, which again, that's like chance of getting hit by lightning or getting, married to a donkey. You know, I don't know that either of those are possible or even legal. So, this case is a tough case. We'll see what happens when the patient comes back on her next combination of therapy, but if you chose rituximab plus leflinamide, you're falling in line with over eighty percent of your peers. That's it for this edition.

Go to roomnow.live to register. Hi. This is QD clinic brought to you by RheumNow live. I'm Jack Cush from RheumNow. Today's case, kid arthritis.

14 year old comes in with her mom. Mom has rheumatoid arthritis. Arthritis worried about her child who's had joint pains going on for the last year. Exam as you can imagine largely unrevealing a number of joints are tender PIPs and shoulders and hips and knees, but really not much to show despite you know two hours of morning stiffness, polyarthralgia, no systemic features, a history of a prior, ligamentous tear, not necessarily provoked by trauma. So I learned this lesson like thirty years ago when seeing kids and I don't know what the diagnosis is because I'm not really finding much and I'm considering a diagnosis of myofascial pain syndrome or fibromyalgia in a child although they often don't have you know tender points.

I've been surprised by the diagnosis of hypermobility syndrome. It's really quite common especially in young adolescent females. It's easy to diagnose you just have to look for it. And the way you look for it is typical signs of hypermobility being able to bend your finger back and touch your your forearm, being able to bend your thumb inwards and touch the volar first surface of your forearm. I can't get there.

I am not hypermobile. Hyperextension of the elbow. So the it's actually the Bayton score, the Bayton criteria, which is five elements. One is hyperextension of the fifth metacarpal greater than 90 degrees, passive apposition of the thumb to the flexor aspect of the forearm, hyperextension of the elbows greater than 10 degrees, hyperextension of the knees greater than 10 degrees, and, flexing the trunk and placing the hands flat on the floor. Those are all five of Bayton score, and then you have to have four or more Bayton score to meet Brighton's criteria along as as long as you have arthralgias and, marfanoid habitus and other musculoskeletal findings and extra articular findings.

That's what this patient had. Again, you should know that such patients, again, more likely female, more likely adolescents. They can have other things including ligamentous injuries, which this person had, either a marfanoid habitus, flat feet. They may have lens problems. The differential diagnosis is Ehlers Danlos, Marfan syndrome, osteogenesis imperfecta, homocystinuria, Rheumatic Fever or Acromegaly.

I'm reading from my textbook rheumatology.com or rktext.com and I think it's again, I refer to it all the time. You know, heard something really smart from a colleague of mine the other day talking about teaching medical students or residents. He held up his cell phone and said, you know what? This is my my puck. Imagine it's a cell phone.

You know, they should make cell phones in the shape of a puck. Wouldn't that be cool? Especially for people who like hockey. Anyway, he holds up his cell phone to his residence and students says, I'm not gonna ask you anything that isn't already in this thing, so don't memorize anything. Just know how to use this thing, the phone, to find key information.

It's true. You know, rote memorization is a thing of the past. It helps to memorize stuff, but, you know, I mean, there's an information glut. Use the phone. You can use the phone to look up stuff on my textbook rheumatology.com.

Anyway, case, in an adolescent, I do see adolescents in kids because that was my interest in rheumatology and getting in was children with arthritis and Still's disease, etc. So that's it for this week. Actually, we'll have one more episode of QD Clinic, tomorrow and, check out RheumNow live. The weather for next week, eight days away in Fort Worth. Gonna be 75 and sunny or partly cloudy.

Let's pray for sun, but it'll be it's gonna be a good meeting in a great city. Hope you're there. Welcome to QD Clinic brought to you by RheumNow Live twenty twenty starting next week in Fort Worth. Register now. You can register now for the online access or to attend the meeting.

Be sure which button you click on when you do register. This edition of QD Clinic is called Hope for Hand OA. It's based on a journal club I attended this morning at UT Southwestern where we had a great presentation by one of our residents about the HOPE study, that's the H O P E. This is the hand osteoarthritis study wherein patients were treated either with placebo or ten milligrams of prednisolone. This is a study that's trying to answer the question, what can you do in patients with hand OA, or if you like patients with inflammatory OA of the hand, or even worse, erosive OA of the hand.

In this particular study, they studied one hundred and forty nine patients and I think that they randomized most of those patients to either placebo or prednisolone, ten milligrams per day, for six weeks. After that, they tapered steroids and then withdrew them to see what would happen and reassessed them at week fourteen. To get into the study you had to have hand OA, you had to have a swollen DIP or two, you had to have an abnormal ultrasound in many, and seventy four percent had erosive changes. Moreover, if you were taking an analgesic or non steroidal, had to stop it and you had to have a spike in your pain from 30 to over 50. Well, turns out that was the case for many, but they had to modify that to over 40.

So pretty stringent criteria to get in. Nonetheless, at the end of the treatment period, the blinded treatment period, those that were treated with prednisolone did better as far as single pane visual analog scale. I guess I should tell you first that going in, these people weren't simple in that they had an average of seven tender joints, an average of I think 4.3 swollen joints. This is not the kind of RA or OA of the hand I usually see, and clearly tenderness did improve by visual analog scale. They also, the patients did improve by OMRAC definition of response in hand OA, and they did improve somewhat, a little bit, but significant as far as powered Doppler ultrasound measurement of synovitis.

But that quickly went away when the drug was withdrawn. MRI studies did not show a difference in either bone marrow edema, a significant difference in bone marrow edema or synovitis between the two groups. So, yes, did improve and I think that that was laudable and expected. You know, you treat everybody with steroids and they all get better. Turns out the people who are on steroids knew they were on steroids, people who on placebo knew they were on placebo when they guessed, with almost like 90 plus percent accuracy, so you can't really hide steroid effects not from the patient, and again while this worked the worrisome thing was that there were no significant changes on imaging really, and that the benefits were short lived meaning as soon as you withdrew the therapy there was no sustained responses by imaging or certainly by clinic.

There were a few steroid related toxicities, they did not enroll patients with heart failure or diabetes, so that wasn't really a big issue. So, again, what's the takeaway? The authors say that you should use steroids only as short term therapy, mainly in managing a flare, mainly in managing people who have short bursts for improved activity, like if they're traveling or going to play in the next ping pong tournament. So I do think there might be a role for steroids because we ain't got much else. Analgesics work.

Acetaminophen non steroidals in moderate doses, turmeric, curcumin, even cherry pills have been shown to work at times. What doesn't work? DMARDs, Plaquenil has failed a bunch of times, methotrexate has failed, IL-one inhibitors are failed, TNF inhibitors are failed, so we got to get something else. I use a little bit of steroids as I said before in patients with problematic hand OA. I'll use two or two point five milligrams of prednisone along with acetaminophen up to three thousand four thousand milligrams a day, and then I'll intermittently splint the problematic finger and joints with two inch cohesive tape for ten to fourteen days at a time.

But I think if you're going to use steroids, one, use it short term if you can. Two, never use steroids unless you tell the patient about all the toxicities. You're going to get fat, diabetic, hypertensive, stretch marks, cataracts, weak bones, fractures, common infections, pneumonias, hospitalisable infections, bizarro infections, muscle weakness, stretch marks, acne, hair thinning, can I stop now? Obviously you want to motivate the patient to either not take steroids or certainly get off the steroids if you're going to use it. So there is hope for using some steroids in some people with hand OA, it's just that it comes with a lot of warnings and certain limitations.

That's it for this week of QD Clinic.