Telling You Where to Go (12.19.2025) Save

It's 12/19/2025, and this is the RheumNow podcast. Hi, I'm Jack Cush with RheumNow. When I reviewed this week's content, I was scratching my head saying, who'd have thunk it? A relationship between FMF and psoriatic arthritis, labs predicting who's going to get ILD if you have scleroderma, what IgA, rheumatoid factor could be important, or that recombinant zoster vaccines may not work in those on JAK inhibitors when they need it. What about if I just got upset by all this and I told you where you could go and that's where we're gonna start?

This is where you can go. If you wanna be a rheumatologist and wanna practice somewhere, the top 10 states to practice rheumatology in are number one, North Dakota. Number two, Wisconsin. Three, Alaska. Four, Montana.

Five, South Dakota. Six Nebraska, seven Minnesota, eight Washington, nine Utah, and 10 Maine. I can tell you that I have been banned from at least six of those states. Maybe that's why you should go there. Why those states?

Well, is a publication I found that was looking at salary potential, growth opportunities, supportive healthcare and public health infrastructure. Those are states where there's probably a good need for rheumatologists and hence the salaries are good and the lifestyles are good. And plus, if you go there, you won't see me in at least six of those states. An interesting study this week comes out from Lilly. It's the phase three TRIUMMPH four trial where they have a new GLP-one.

It's a dual GIP GLP-one glucagon receptor agonist, and this was given to people without diabetes who were obese, who had knee osteoarthritis. This is a phase three trial. This is just a press release, but I put it up because I think it's really important. Weight loss at sixty eight weeks, a little more than a year, was 29% with a significant reduction by 76% in their Womack pain scores. So we've hinted, and I first learned this from Joel Block about GLP-1s possibly being effective in osteoarthritis and this is another study showing the same thing.

So there's a few studies out there. This is a new sort of next generation, GLP-one drug and I think you'll be hearing more about this next year, which is right around the corner, is it not? I found a nice review article about IgA rheumatoid factor and IgA ACPA. IgA RF seen in fifty percent of RA patients, IgA ACBA in twenty to forty percent. They are just as specific as they are with the other normal tests that we do.

The interesting thing about this article is it points out a few reasons why this could be important. Number one, that you can find these and others by the way, IgG, IgM, in serum saliva and synovial fluid. That at least the IgA and its importance would, you know, of surface immunology may underlie the mucosal hypothesis to RA and IGARF has been seen in worse RA patients with more severe outcomes, more extra articular manifestations and a blunted TNF inhibitor response. I thought, gee, you know, I've kind of always not paid attention to this IgA literature because it just seems like another thing to do and you got to wait for it and whatnot. And there's people who are always saying, hey, but what about IgA rheumatoid factor, IgA, ACPA.

The bottom line is that, the ability of IgA autoantibodies to identify RA in the cases of serone negative RA, meaning they're RF negative and, traditional CCP or ACPA negative is limited. There's only a few patients. However, if you wanted to, you could go that far and its detection would tell you, confirm the diagnosis or confirm a future risk of developing RA in those who may have preclinical presentations. It's a nice review of IgA autoantibodies and its role in RF. I still don't think I'm gonna do it though.

Maybe you can convince me. Lancet had a nice review of skin cancer basically asking the question, isn't it time that or about time that we started doing skin exams? I don't know about you. Well, I'm no. Actually, I do know about you.

You're not doing skin exams like you're supposed to. Did you know that everyone on TNF inhibitors are supposed to get a skin exam periodically, annually? Look at the package insert, it says that. Why does it say that? Number one, RA patients are at higher risk for cancers, some cancers and lower other cancers.

One of the cancers they're at higher risk for is skin cancer, non melanoma skin cancer, and probably melanoma skin cancers. And then that association carries over to an association with some drugs and when TNF inhibitors were being developed, they said you should do skin exams, you know, once every year and whatnot. This Lancet review basically points out the association between skin cancer and inflammatory arthritis and it's a strong one, especially for the non melanoma skin cancers, but also melanoma. It's increased in RA, PSA and other forms of inflammation. So again, I'll remind you package insert says that you should do it with TNF inhibitors.

By the way, it doesn't say that with IL-seventeen inhibitors. And what it does say is that, skin exam should be done periodically. If someone's had a skin cancer and you're going put them on a biologic, I would recommend that they see a dermatologist for complete skin exams annually. I don't know about you, I go to my skin doctor for annual, actually more than annual skin exams and yeah, I gotta get almost totally naked and they're all over me with microscopes and all kinds of lamps. I'm on three d, I'm UV light, it's just kind of a scary but fun kind of encounter but I leave there with a lot assurances that I'm okay and I'll come back and whenever they tell me to.

An Austrian study of a thousand patients called the Paracelsus cohort, actually I looked up what Paracelsus was and now I forgot, but it's got a story behind it, you can look it up. Out of their thousand patients with RA, they analyzed the ones that they could include, and they found from nine thousand six hundred and sixty five patients that three point one percent of those people had RA. And then they look to see, this is actually a study of laboratory tests in the population. And they showed that there was a higher CKD, stage three CKD and worse in RA versus controls. RA patients had an almost twelve percent risk of CKD versus six point seven percent, in controls.

The dominant finding was albuminuria, was, the major manifestation of renal disease. But again, think that, you know, this has been brought up before that there may be a risk of CKD in RA patients. It's a low risk and aren't you already getting plenty of routine laboratory screenings, certainly creatinine. So it's something to keep in mind. And there are probably multiple etiologies that may underlie that.

A Japanese retrospective study did an important study that actually mirrors what the Swedes did a few years ago at ACR. There's one hundred and ninety four, RA patients that are taking, a JAK inhibitor. Seventy four of them were vaccinated against the recombinant zoster vaccine that we call Shingrix in The United States. It's RZV recombinant zoster vaccine is its, initials, and compared to one hundred and twenty JAK inhibitor RA patients who are not vaccinated. Yes, if you took the RZV, you had a lower risk of developing zoster going forward.

Four point eight per one hundred years versus seven point eight actually zoster vaccine, zoster rates are often reported per 1,000 patient years. So that's forty eight on the RZRZ versus seventy eight per one thousand that were not vaccinated. By the way, those are very very high in rheumatology terms. The average rate risk of all of us is less than ten per one thousand. An OA patient or an inflammatory arthritis patient or an OA patient is like, I don't know, fourteen to seventeen.

A Wegener's patient, a GPA patient on steroids and his cytotoxic might have twenty five to thirty five. A patient on a JAK inhibitor could be as high as forty five. These rates are high but there it may be in a more endemic region. But here's the important point. Overall vaccine efficacy was fifty nine percent, meaning it wasn't as high as has been reported in the ZOE 50, ZOE 70 studies for the zoster vaccine Shingrix, which was like greater than ninety percent.

So the point is that if you're on a JAK inhibitor and you're gonna take the zoster vaccine, it may not be a hundred percent effective. Maybe you should stop the JAK inhibitor for two weeks or one week like you do methotrexate and then do the zoster vaccine. Again, that's not part of their study. They basically said that, the predictive features for getting Zoster was having a lower lymphocyte count, higher C dye, higher S dye. So, you know, they have more activity stopping the JAK inhibitor for one or two weeks could be a little risky, right?

So not a lot of clarity here but I think I'm gonna in the future probably hold the JAK inhibitor for a week and give the zoster vaccine and then resume it. Actually, I'm sorry, give the zoster vaccine, yeah, hold it for a week, the zoster vaccine, start it a week later or a few days later would be the way I'll go. Interesting study on one hundred and seventy seven patients with systemic sclerosis, and sixty one did not have ILD, one hundred and sixteen did have ILD. Those who had systemic sclerosis related ILD had more diffuse disease, Raynaud's, more GI disease. They found that you could predict the development of ILD in systemic sclerosis by having this triad, one, an elevated neutrophil to lymphocyte ratio.

I assume that's greater than four point o. A prolonged prothrombin time and the presence of an anti SCL70 antibody. The area under the curve here was almost 88%, sensitivity 83%, specificity 85%. Seems pretty easy, seems pretty cheap. If you have your patient with systemic sclerosis, look at the CBC, look at the neutrophil lymphocyte ratio or PT, and you'll already know hopefully their status as far as SCL 70.

An Israeli retrospective cohort study looked at almost, 10,000 patients with FMF and they matched them, against controls. So, and what they found here was that patients that were on colchicine with FMF, actually it was a retrospective database that looked at people on colchicine And they found that the FMF patients on colchicine had a higher risk of developing psoriatic arthritis. Wow, forty three versus one hundred and nineteen in those who had FMF on Taltzia. Hazard ratio 3.5 fold increased risk. Risk was increased by having, being older, being a smoker and socioeconomic status.

And we know that smoking and age and socioeconomic status are risk factors for psoriatic arthritis. If you look at the patients who had FMF in the study at a higher risk of psoriasis, had a higher risk of obesity, had a higher risk of metabolic disease like diabetes and hypertension. So I'm not sure that FMF and colchicine is the risk factor as much as being sick in that Israeli cohort of FMF patients where it's much more prevalent, makes you at higher risk of developing psoriatic arthritis. But nonetheless, why not? Why not to be they did the exercise, you should consider it.

Another study in psoriasis was a small study called the Medispo study. This was a study of 38 patients, half of whom were given a, Mediterranean diet for sixteen weeks. The other half was given a low fat diet. And at the end of sixteen weeks, the patients on the Mediterranean diet had a significant reduction in PASI scores, minus 3.4 versus zero on the control diet and almost half the patients, forty seven percent achieved PASI 75 response as opposed to none on the others. We know the importance of diet, right?

In especially psoriasis. And we do also know the importance of the anti inflammatory diet, the Mediterranean diet in especially psoriasis, but also even rheumatoid other inflammatory conditions. So here's a good example, again, where diet leads to better outcomes in the underlying disorder, this case being psoriasis. A few reports, you know, this month is a month devoted to nurse practitioners, physician assistants, advanced practice providers. A few reports on that I thought were interesting.

The Nurse Practitioner Association did a survey of almost 2,400 nurse practitioners, mostly primary care and asked about their interaction with rheumatology and rheumatology consult and rheumatologists. They, basically said that there needs to be improvement in communication and their need, the nurse practitioners requested more education on RA management. So when we asked them about their confidence, these nurse practitioners, their confidence in managing RA, only 47% said they were somewhat confident, 6% said they were very confident, 19% not too confident. The point is that if you're the consultant and you're communicating with a nurse practitioner, you need to educate them about the condition that you're asking their help with as well. I think this is important, about how we actually communicate and deal with our consultants.

It is not enough to make a diagnosis, adult treatment plan. Somewhere in your note, somewhere in that process, you got to teach them about what you know so they can also better help your patient. Walters Kluwer, a med ed company did a survey of two zero three physician assistants, and most of them said that they wish they had more clinical experience before they released out into the world. And then, most of them wanted training, more training on AI. A lot of them said that they were using AI.

56% were using AI daily, 19% were using AI, artificial intelligence extensively. Yet, the majority of them, nine out of 10 said they need to learn more about AI. They designed more formal employer led training on AI. And again, nine out of 10 said that AI is going to change the way they practice. But one third said that there are no at least one third said that there are no clear guidelines on how AI should be used in their practice.

Again, there's a tremendous need here. It's going to be used. If you're not adopting it, training on it, having do's and don'ts, I like to say things like, tell me five things I can't do. Tell me the guardrails where it doesn't work. Like one notorious guardrail with AI is don't trust references provided by AI on any topic.

Like tell me everything about, clinically, amyopathic dermatomyositis, CADA, right, often associated with MDA five antibodies and give me seven references. If you go and check those references, at least on the earlier versions of CHAT GPT and other forms, you're going to find some inaccuracies there, maybe some things that are made up. So, but AI is going to be used, we need to be guiding therapy. Interesting, article this week that's been presented at ACR and ULAR, appears in arthritis care and research I believe optimizing hydroxychloroquine, blood levels in lupus patients. This is study of eighteen forty two patients amongst whom almost five percent had, hydroxychloroquine ocular toxicity, and they showed that, having ocular toxicity was associated with at least a twofold higher, rate of blood levels being greater than eleven fifty nanograms per ml.

So, and also the rate, the risk of ocular toxicity goes up with cumulative exposure hydroxychloroquine being greater than 1,000, grams. So the idea here is that we should, I think everyone and Don Thomas, a great rheumatologist very interested in lupus said it's about time we start advocating for this and doing this. He's been doing it I think he said since 2018 and it clearly guides therapy, meaning you have to have blood levels definitely more than you know, 500 but actually really more like 900 and you know, whether you go up as high as eleven fifty as indicated by this article or whether you go up as high as 1,500 is sort of up to different publications but at least you know, 900 to eleven fifty and you can go higher but clinical benefits may not be great after eleven fifty and toxicity risk may rise. Point is, are you doing it? And the point is it's commercially available at LabCorp and most of the commercial labs are out there, Quest, and probably at your site if you jump up and down and yell and scream about it.

Our last report, we have a few reports this week written by, APPs. This one was written by an APP in orthopedics, Jordan Lyon's five fractures you don't want to miss. It's a nice article, it's a quick read. It includes, femoral neck fractures which are often seen in the elderly often due to low energy falls and if you don't look for it, you won't find it and if you don't suspect it, you won't look hard enough. A Jones fracture, I don't know what that is.

It's a fracture of the fifth metatarsal at the metaphyseal diaphyseal junction. And these are often related to inversion injuries and you need three views of the ankle to actually find that. And then scaphoid fractures. The scaphoid is really prone by its biology and vascular supply to fractures that often occur by falling on an outstretched hand. And you may see that but you need again a three view x-ray and if you suspect it and because they have pain in the snuff box that's unrelenting and it's not found on x-ray, an MRI will prove the presence of a scaphoid fracture.

The other two, you're gonna have to go to the article and read. One of them I can't pronounce. Maybe you should go and look at it. RheumNow Live, it's coming in 2026, February in Dallas, Texas. Go to Room Now.

Live to register. It's filling up. We've got close to 300 people already registered. We're expecting about 500 total both on-site and online. We hope that you'll be one of them.

It's the holiday season. We do hope that you're going to have a blessed and wonderful holiday with you and your family. It's all about love. It's all about friendship. It's all about good food.

You can go off the Mediterranean diet for Christmas. Take care.