APPs in the news (12.05.25) Save

It's 12/05/2025. This is the RheumNow podcast. Hi. I'm doctor Jack Cush, executive editor of roomnow.com. This week on the podcast, dermatomyositis scleroderma, e consults, and a whole lot on advanced practice providers, APP.

Let's begin with the word coming down from on high at the WHO talking about GLP ones. I don't know if this is necessary, but when the WHO comes out with a recommendation on GLP-one, I think I should report it. They basically said that they're recommending, it's a conditional recommendation I must say, -1s for use in patients with long term obesity, in adults, but not in pregnant women, because there's really no data on that. Their second recommendation was: it can't be used alone. It's got to be used in conjunction with lifestyle modification and activity and exercise.

And they really spend more time in their recommendation talking about the gigantic need and the significant problem of access to these drugs, especially given the fact that obesity worldwide is a $3,000,000,000,000 industry. Not good. I found two interesting reports this week on myositis and scleroderma. They always get lumped together, do they not? They're diseases we see that most people are plagued by or don't know what to do.

I thought this was interesting. This is a report on over five hundred patients with dermatomyositis in subsets, and looked at what are the predictive factors for developing a malignancy. In that cohort there were like fifty something cancers that were seen, and they identified five factors and gave one point to each factor to come up with a point system. But the five factors associated with a higher risk of cancer was: number one, having dermatomyositis and certain subtypes, for instance not having CADM dermatomyositis. We know a lot of those are going to be some of those are going be MDA-five and a risk of lung disease.

But other, you know, just dermatomyositis, by itself, for instance, has a significant risk. The biggest risk was seen with the antibodies to TIF-one gamma. This gave a three point eight fold higher risk. Poikiloderma, a three point one fold higher risk. Poikiloderma is that generally the rash that you see in that shawl rash, the V neck rash, right?

It's got telangiectasias, areas of hyper and hypopigmentation. It can be seen elsewhere in the body, but that usually is a poikiloderma, not a very common manifestation and myositis would be one of the causes. Anaemia is another risk factor with over two fold higher risk, and interestingly having ILD lessens your risk by sixty one percent. In this study, when they looked at it multiple ways, getting one point for each of these factors, if you had a high score of four or five points, you had a significantly higher risk of developing cancer. So I thought that this is the kind of stuff I want to see, is the kind of data that I want to be tested in larger cohorts to see what its true predictive value is.

Speaking of malignancy, let's see what happens in systemic sclerosis. This is a study from Sweden where they have a national study in a registry, and they looked at the number of incident cases of systemic sclerosis between two thousand and four and 2019, comparing seventeen hundred scleroderma patients to almost seventeen thousand general population, and overall, the scleroderma patients had a two fold higher risk of hematologic malignancies. Hazard ratio 2.2. Three fold higher risk if it was a B cell malignancy. The risk was higher in men, and higher in those with a diagnosis between the ages of 18 and 49.

Interestingly, the occurrence of the hematologic malignancy was going to be early, like a few months after the scleroderma diagnosis, when it was a myeloid malignancy, but if it was a lympho lymphomatous or lymphoid malignancy, that tended to happen three to four years later, like as does happen with for instance RA. I thought that was interesting. Another report on systemic sclerosis comes from a retrospective study from the TriNetX, registry, you know, a billion patients basically, from EMR data, and they looked at systemic sclerosis patients who were on and those who were not on SGLT2 inhibitors. And we know that they've been beneficial as far as reversing mortality in diabetes and in a lot of other conditions, it's been seen in gout, for instance. And they found the use of SGLT2 diabetes drugs in scleroderma was associated with a significantly lower risk of all cause mortality, almost a halving of the risk, a decrease by forty six percent, a thirty six percent decrease in stroke, and a twenty four percent decrease in hospitalizations.

And again, this was more so in systemic sclerosis who did not have a history of heart failure. Obviously, you know, the heart failure patients would have a much different risk, much higher risk, but in basically patients who have no risk, and they start out with being on SGLT2 inhibitors, these have been protective as they have been in other autoimmune diseases and rheumatic diseases. Again, when SGLT2s are compared to the GLP-one agonist, usually GLP-one has a better rate of cardiovascular mortality protection. That was not done in this TriNetX study, they were just looking at SGLT2s. I like this report this week out of the University of Colorado that compared traditional consults to the rheumatology service, to e consults.

10,000 traditional versus six forty. And the idea here was that the e consults, the vast majority of them, 75% of them, were completed without the need for a face to face evaluation. 25% were further referred for face to face evaluation. But of the 75% e consults that were done, they were done within three days. The efficiency of e consults was also shown by that twenty five percent that was referred to a face to face on-site consult with a rheumatologist did better as far as, completion rates of the consults compared to traditional consults.

The one hundred and eighty day case completion rate was thirty six percent with e consults and 19 with the traditional consults. Now, certainly could be channeling bias here. Most of these consults came from primary care, but the diagnoses that were seen and the outcomes and treatment rates between traditional and e consults were the same. So, I'm a big believer in telemedicine, big believer in the utility of e consults. I think we should be doing e consults not just on patients, but on for our colleagues and find a way to charge for that.

There are tons of people that would like to get the input of a rheumatologist on a complex case and they don't know what to do. You can do, consults with, I think, the Mayo Clinic and also with I certainly know you can do it with the Cleveland Clinic, you know, physician to physician. And then whether or not it can be billed to the patient is something that needs, I think, legislative change to make that a significant reality. Especially in light of the fact that we have a manpower shortage, which we'll talk about at the end of this report. Last week I had a patient who had coccidinia, or pain from the coccyx, so I started looking things up, and yeah, coccyx pain is often misdiagnosed, and it's only after they find out it wasn't lumbosacral, pelvic, or gastrointestinal disease that they find out it was from the coccyx.

Coccydynia accounts for no more than three percent of all low back pain, but it's five times as prevalent in women and three times as prevalent in the obese. The diagnoses are usually hypermobility or degenerative. The causes are usually trauma, obesity, significant changes in weight, degenerative disc disease, or I'm sorry, degenerative disease that would lead to hypermobility or dislocation, obstetric injuries, especially in multiparous women, and the things that you worry about are really uncommon: infection, neoplasm, pelvic floor dysfunction, etc. The diagnosis is best made with initial imaging by doing seated and standing radiographs to see what happens to the coccyx, whether it moves, whether it's hypermobile, and then if necessary you can do CT or MR to look for degenerative, structural, inflammatory causes. And this actually helped me in the evaluation of my patient.

Let's move on to RA. Taiwan did a study of insurance claims looking at RA patients, five thousand seven hundred, treated with either a biologic or a targeted synthetic, followed for more than two and a half years, and they found that four point seven had a rate of serious infections. That's one point three SIEs per 100 patient years. That's really low, right? That's what we want to see.

But, and as we probably have said before, most of the SIEs that are reported are half of them were pneumonias, twenty five percent were UTIs, ten percent were TB. And the question was, in their insurance claim situation, what happens when patients were lowered their biologic or targeted synthetic, and what happens to the rates when they discontinued? Sixty percent of that fifty sevenforty nine that were on biologic targeted synthetics had a dose reduction. And you know what? No real change in SIE rates.

It went from the comparison here is three point four percent versus four point two percent amongst that sixty percent that had a dose reduction. Meaning they were probably doing well enough that they could dose reduce, right? But what about the ones in whom they discontinued the SIE? Oh, it didn't work out so well. There were more SIEs than those who discontinued versus versus those who didn't.

Thirty five percent versus twenty six percent. So, again, I think this is an important lesson. You may be able to if the patient is doing well, you may be able to lessen the drugs, but don't go off them as we have said as I have said in the past. Another RA study comes from Korea claims data, over sixty thousand RA patients, and they looked at the risk of having, an atypical mycobacterial infection, what we call non tuberculous mycobacterial, infection. They specifically looked at, NTMs in the lung and found a threefold higher risk.

It's really uncommon, point two three percent in RA patients versus zero point zero six percent in the population. That equates to a zero point five four versus zero point one four event rate per one thousand patient years. These are rare events, and that's an endemic region, right? Taught by Kevin Winthrop many years ago, Kevin, you know, being an ID specialist who consults on a lot of our patients, knows the rheumatology literature, the biologic biologic and targeted synthetic literature. He says NTMs it's one of his earliest papers when he was working with the NTM is much more common, 10 fold or higher more common than is TB.

And it's often not considered. It's often seen in younger males and whatnot, but again, it's something that you should be worried about. I like this report on 2,200 JIA patients. It was called the Prospero meta analysis, looking at the, what happens with JIA associated uveitis. And they looked at these people when they got into adulthood, and they found that once these kids, there's 22 studies, twenty two hundred patients, got to adulthood over the age of 18, sixteen point six percent had some evidence of severe visual consequences, if not visual impairment.

Most common findings were: cataracts, forty four percent. Much lesser degree of glaucoma, synechiae, Bancaretopathy, and a few other things. They did show that patients who were treated with biologics had much lower rates, suggesting that they're in fact protective. While we're on the topic of juvenile arthritis, a ten year European multicenter retrospective study looked at the frequency of hemophagocytic lymphohistiocytosis, HLH, And overall, from these 29 countries over ten years, they found thirty three hundred and forty five deaths from HLH. The crude mortality rate was five point three per ten million.

That's in the population. Right? I bring this up because, one, we know HLH and MAS, very common in our diseases, very common in systemic JIA, much more so than lupus or vasculitis or infection, but it has a very high mortality rate. You know, twenty to forty percent mortality rates in our pediatric and adult patients when it does happen. Again, they did also show in a ten year period a doubling of the rate from three point nine to six point six HLH deaths per ten million patient years.

So, yeah, rare, but we do see the rare stuff, do we not? This past week I was looking at the news, I saw this report on Medscape about low dose naltrexone. I don't know why, I've always had a bias against it. I read the report and they're quoting one of my friends, a great rheumatologist from Dallas, Scott Zaschen. He's been using it for a number of years and has some ideas, and it's anecdotal based on his experience, but of course he got into it not knowing how to treat fibromyalgia, and the use of low dose Naltrexone has been an important adjunct to him.

Again, it is an off label use, and this report basically said that it's, deemed by some physicians and by patients to be: a) beneficial b) not FDA indicated and c) the data supporting it is in fact limited. So, this sort of overview led me to look at a lot of reports, and they all come to the same conclusion: low dose naltrexone is safe. It's modestly effective compared to placebo, but there are no head to head trials with active comparators in treating fibromyalgia. But the strength so, because of the numbers and the sort of limited trial designs, the strength of evidence is low. More importantly, there are recent studies that with larger trials, head to head with placebo controls, that does not prove significant benefits.

In fact, shows us no better. The good news, it's an old drug. It's cheap. It's been around a while. You do have to get it compounded, however, because over the counter stuff, the doses are too high.

So it has to go to a compounding pharmacy where the the doses that they use are much much lower, When treating opioid or alcoholism, the doses are like, I don't know, ten milligrams or something like that or higher. But in our patients, it starts at point five and goes up to three or five milligrams, but you've to get it from a compounding pharmacy. Again, if you look at the report that we have, that the meta analyses and reviews sort of claim some benefit and pain reduction compared to placebo. But when you look at the clinical trials, there are a few that show benefit, they're kind of small. The ones that are larger show no benefit, and there's a, you know, a bigger trial, called the INOVA trial, 120 patients, it's a randomized controlled trial, multiple outcomes, looking at biomarkers to see if it's going to work out.

I've never used this, but after reading this, and knowing how difficult fibromyalgia is to manage, I might consider it. You should look at the report and do your own research. So what's the deal with rheumatologists? The last the workforce. The last report that comes out says it's not all that good, and maybe it has something to do with compensation.

I did a report this week on rheumatology compensation that says, one, Rheumatologists are amongst the lowest paid of the specialties at an average it's a nationwide number it varies in your region, I'm sure but the average is about 284,000 per annum. Those are 2024 salaries. But in 2024, those salaries did rise, 2%. Woo hoo. Not much at all, right?

When you ask rheumatologists in these surveys, more than half of them say they're underpaid. And 41 of rheumatologists have to supplement their income with something outside their practices. The good news is that in hiring rheumatologists, six out of 10 rheumatologists receive incentive bonuses. So when you look at the last published data on the adult rheumatology workforce from arthritis and rheumatology in 2024, there were 5,667 rheumatologists and three seventy nine APPs. When I saw that, I was like, what?

There's a lot more APPs than that. But we do know that from in that report, from 2009 to 2000 '20, rheumatology numbers increased 23%, APPs increased 141%. It's a lot more since then. And we do know right now that no one knows the real number of APPs in The United States. I can tell you on RheumNow we have about a thousand registrants.

I believe there's about 2,000 APPs working in the field of rheumatology. This is a gigantic problem because there's going to be a projected shortage of at least 4,000 full time clinical equivalents for rheumatology providers five years from now. And that's been covered in the past. Many reasons for that. So, again, that's one of the reasons why we're doing a campaign this month on advanced practice providers, nurse practitioners, and physician assistants.

We had a great Tuesday night rheumatology webinar where we talked about hiring, onboarding, and training of APPs. And so here's a few reports that we put in on the website this week. A survey of 500 rheumatology patients. Thirty seven percent of them reported that their primary provider is an APP. That's the one they primarily see, more so than the rheumatologists.

That seeing the APPs led to easier scheduling, and the patients who saw APPs preferred the APPs over the rheumatologists significantly so, and they were more likely to recommend other APPs for clinical care. But when it came down to, overall APP versus MD rheumatologist experience, no real difference. Another, good article by Lindsey Tom, a physician assistant, wrote an article about APP retention, this week that you should probably read. It's a very important issue. Why hire and train an APP and then not make them career happy?

They can make a whole lot money, more money outside of rheumatology. We covered that in our our webinar this week that you can watch or listen to. And it's a Tuesday night rheumatology, etcetera. It's the on the program was, Corey Doing, an APP, Kayla Alexander, an APP, Philip Meese, who's hired a million APPs and trained them, and myself. And we cover a lot of things.

The salary, most people when we surveyed them this week didn't get the the starting salary for an APP right. On average it's a 130,000, which is less than half the price you'd pay for a fellow. Good luck trying to find and hire a fellow. But they are certainly a tremendous addition to your practice, and you should hire them, keep them. If you wanna hire them and retain them, Lindsay's advice is, number one, define the scope of practice at the beginning, and then live up to it.

Second, do a comprehensive and thoughtful onboarding process to let them hit the ground running with and with satisfaction. Next, you should be investing in their training, and their education, and their ongoing learning. Fourth, competitive salaries if not incentive programs. And then she suggests you need to empower the APP and live up to that expectation that you set in them. To take an APP and make them see fibromyalgia and osteoarthritis follow ups and not let them do what I do, and what Philip Meese does: they see new patients, they see vasculitis, they see problematic lupus, they do joint injections, they do everything I do.

You know, when I'm working with my APP, if there's a vasculitis patient in Room 2, and a fibromyalgia patient Room 3, I'm seeing the fibromyalgia. The APP is seeing the difficult patient. And if it's diff too difficult, they're gonna come and talk to me, and then everybody wins. So, the other things that we discussed in our webinar is that mentoring is really important at retention, and dedicated feedback time. Meeting them after the patient, during lunch to talk about things that happened in the practice this week, case reviews, case feedback, that's tremendously satisfying to all your employees, not just the APPs.

I wrote an article this week about the new legislation that affects loan limits for health care providers. The one big beautiful bill from the Trump administration, HR one, was signed into law in July and goes into effect, mid twenty twenty six. And the part that bothers me, and I got into this originally because it affects medical student loans. Previous to this legislation, medical student loans were unlimited. And the numbers were something like, the most recent medical school graduate, 60% leave medical school with over $300,000 in debt.

And they're getting those loans from federally guaranteed loans. Not anymore, because professional students, MDs, are now capped at 50,000 a year and $200,000 lifetime. That is going to be a significant blow to anyone wanting to go to medical school who has no money. It's going to be a significant problem. Oh, wait, there's more!

That could apply to physician assistants, but no, it's worse because advanced nurses, advanced practice RNs, and probably physician assistants, their loans are capped at $20,500 per year and a $100,000 lifetime cap. At the current time, it looks like the PAs are going to be declared nonprofessional program students like the a the, nurse practitioners. But this is a lot of this is gonna is under protest right now. It hasn't been finalized by the Department of Education. And but know that, you know, both the American Academy of Physician Associates and the American Nursing Association are are against this against this in many ways, because it's going to hurt health care.

It's gonna hurt the number of people going in. It's gonna hurt the number of people who stay in, who become faculty, who become teachers. It's a big issue. It's one that APPs need to know about, and you as as clinicians need to know this is gonna also going to affect those the number of people going to medical schools. And we already have shortage issues, do we not?

That's it for this week on the on the podcast. I hope that you'll be attending RheumNow Live twenty twenty six, February. This year we cover vasculitis, autoimmune disease, PSA, RA, spondyloarthritis, and more. Go to roomnow.live to register. Next week, on Tuesday at 7PM Eastern Time, we have another Tuesday at rheumatology dedicated to APPs.

This week, we're gonna be talking about cases: RA, lupus, PSA, and vasculitis, and the application of guidelines by APPs. Be there, be square, take care.