Emergencies, Independence & Hemorrhage (1.23.2026) Save
Transcription
It's the 23rd of January, 2026, and this is the RheumNow podcast. Hi, I'm Dr. Jack Cush, executive editor of RheumNow.com. This week, we got a lot to cover because last week we did the year in review. Pretty popular, thousands of views and listens. That was great. But there's — I got two weeks of news to cover. So, let's get into it.
Before we do, do me a favor. Three favors. One, sign up for RheumNow.live. You can register at RheumNow.live. Um, it's a great meeting coming up in two weeks. Two, give us a good rating on your podcast channel wherever you consume this podcast. And three, if you're not registered on the RheumNow website, please do. There's a lot of benefits to it, trust me, you'll like it. Try it. You'll like it. That used to be an old commercial.
So this week we've got a lot to cover. Last week I had a question about what to do with problematic rheumatoid scleritis and, you know, the good thing about knowing everybody is you can call everybody and get a good answer. So I called Alvin Wells, who's really good at eye disease, and a few other people, but Alvin was — he always picks up for me. And we do that in rheumatology — we call each other when we got a question or a head scratcher and whatnot, and I have him just like you.
The question was what to do, and rituximab was the best drug of choice except we couldn't use rituximab, and he brought up — you know, there's a subQ rituximab, I think — and so I looked it up and I tweeted it this week. There is a subcutaneous rituximab. It was FDA approved in June of 2017. The FDA approval was for B-cell lymphomas, follicular lymphoma, large B-cell lymphoma, and I think another one. It's not approved for RA. It's not approved for GPA, but it's out there and it's subQ and it's 5 to 7 minutes as opposed to 2 to 4 hours of Rituxan infusions.
The deal on this: it is the same as Rituxan. It's the same drug except they combined it with hyaluronidase to make it accessible via the subQ route and allow faster administration. The rule on this, however, is that you have to give IV rituximab first and then subQ can follow thereafter. Seems to be well tolerated. Seems to be a good drug option for those with lymphoma. I don't know why we can't apply to get it for — anyway, I'd like to have that in my arsenal should I need it in the future.
An interesting study that we missed during ACR in October was on JIA and the early start of biologics. This is the CANDO study — C-A-N-D-O study. 181 JIA patients that were starting biologics, and they looked at what the odds were of having clinically inactive disease at 6 months based on when they started the biologic. And so there was an early, middle, and late group. Early is less than 6 months after symptoms. Late is greater than 12 months after symptoms. And you know what? If you started early, you had an 83% chance of being in remission — clinically inactive arthritis — versus 57% if you were in the late starters. And for every month you delay the initiation of a biologic, there's a 9% increase in the odds that the patient is going to have future active arthritis at month 6 or after 6 months. So anyway, good proof of the window of opportunity, good proof that early aggressive therapy yields the best outcomes, good proof that you should use your best drug first. A lot of good proof here.
Another JIA study was the ADJUST trial, which was actually published I think a year or two ago, and there was a follow-up to it. In this follow-up, the original study was about 250 patients with uveitis — JIA uveitis — that was in remission or inactive for greater than 6 months, and then they were randomized to either continue adalimumab or they were weaned off. And it turns out that if you weaned off adalimumab, it resulted in more flares of the uveitis — 68% versus 14%. And they had more flares of uveitis than they did of the JIA. The other thing about that study was that there was no protective effect if the patient was on background DMARDs like methotrexate, leflunomide, or cyclosporine. And the last point was that if you flared and you restarted adalimumab, the majority of people regained control of the disease and uveitis.
I saw an interesting abstract and then publication this week in Frontiers of Medicine, I think it is — acupuncture in ankylosing spondylitis/spondyloarthritis. What? That sounds like nonsense to me. You know, I read it and it wasn't — it was interesting. It was a meta-analysis, because you only see sporadic studies with low numbers of patients on this issue — acupuncture and spinal arthritis. Who would do that? Why would you do that? Anyway, they found 35 trials that met criteria, included — sorry — 2,591 AS patients, and they found significant improvement in all the AS/SpA measures, BASDAI, global score, and significant lowering of CRP and ESR. I don't know what to think about this, and they did say that their
study their meta-analysis was limited by high heterogeneity of the studies and some studies with bias that they had to allow for, or you had to take note of. But overall there was a lack of really large high-quality randomized control trials. So I think that's worthy of noting and putting that into your bag of tricks.
A French study this past week looked at psoriasis patients who were on biologics and received antibiotics. Obviously they're on antibiotics — you would assume, and this is like claims data — and they just found antibiotics being used. These weren't chart reviews where they knew exactly why the antibiotic was being used. 36,000 psoriasis patients on biologics, 26% of them received an antibiotic either at baseline or during follow-up. 26% at baseline and 61% at follow-up. So the number of people was about a quarter of patients, 9,300 out of 36,000. It turns out that these people who received antibiotics were 12% more likely to stop their biologic therapy. And if they received multiple courses of antibiotics, they were 29% more likely to stop their biologic.
So who's worried about what here, right? Is the patient worried about what they're seeing on TV that talks about the risk of infection with biologics, or is the doctor worried about infections with biologics? Most of these are NSIEs, non-serious infectious events. I don't stop a biologic for antibiotic use or a non-serious infectious event. I only stop a biologic for a hospitalized serious infectious event — only till I figure out what's going on, or if fever is greater than 102. Those are my rules and I've been studying this for 22 years now. So again, I don't think you need to stop a biologic is what I would say.
Fibroscans — do you do them? You know, methotrexate, the liver, you know, we worry about cirrhosis. No, we really don't. I did a survey of rheumatologists I think two years ago showing that I don't know, 80% of you don't even consider this. And then there's a few of you — I think the question scared you into saying well, I might do it under the right circumstances — but really you don't anyway.
This is an Egypt study, 60 RA patients on methotrexate for 5 years, and they studied everybody in a complete sort of liver panel if you will. These people had a normal BMI, disease duration of 8 years, methotrexate either between 12.5 and 25 milligrams for 8 years, cumulative dose was a median — I think it was 6,700 milligrams. Anyway, all 60 patients had normal ALT, abdominal ultrasounds, and the fibroscan scores were a mean of 170, which is steatosis grade zero. Only 6.7% or four patients had mild fibrosis by the fibroscan scores. I don't think you need to do it unless you feel the patient is at risk for another reason. Certainly RA is not a reason and methotrexate by itself is not a reason, but that maybe could be added to other reasons.
Speaking of RA, an interesting Canadian study looked at how many of their RA patients were going to the emergency department. They did this study and published it looking at emergency department visits for what they call ambulatory care sensitive conditions, and they compared the RA patients — it was a high number, like a few hundred, many hundred patients — but anyway, RA patients had a 30% higher risk of going to the emergency room compared to normal controls. And of those that went to the emergency room, two-thirds were being treated for these ACSC — these ambulatory care sensitive conditions — that really are better managed as outpatients rather than being triaged and treated in the expensive emergency room.
All our patients are capable of this. I gave my patients for many years instructions on what to do when something goes wrong. And by the way, I was never on call — for I don't know, 25, 30 years I had my own practice, I was never on call. If you called my office, it didn't say call his beeper number if you've got an emergency. My line said if you have an emergency go to the emergency room, or call the office tomorrow. And that worked out just fine because there are so few rheumatologic emergencies. I know medically legally you might have all your ifs and buts, but my point is I instructed my patients what to look for, what to go to the emergency room for, and what to call me about. That's a real important part of every visit.
The journal PLOS did an interesting publication on 76 patients with diffuse alveolar hemorrhage syndrome. Not surprisingly, again, this was first off a retrospective study and sort of a single-center cross-sectional view. Not surprisingly, almost 70% of those patients had lupus; the other 30% had GPA. But the point of the paper was that a third of these patients had concurrent pulmonary infections, and that sort of — you know, to me — a surprise. I've had many of these over my career but I can't think of one even that it was alveolar hemorrhage complicated by
pneumonia and in their study the infections were 62% bacterial and 21% fungal and when they found hemorrhage on bronchoalveolar lavage they were more likely to have been the ones associated with infections — three-quarters of the infections — and diffuse alveolar hemorrhage had alveolar hemorrhage on bronchoscopy versus half the patients that didn't have it. So, a nice teaching point from an interesting sort of obscure journal.
Clinical and Experimental Rheumatology published a nice full review, I think. Oh, actually, no. I had to get access. So, but it's a nice reference on mimics of myopathy, including you know drugs that can cause toxic myopathy — presentations that can present with muscle dysfunction with weakness and elevated muscle enzymes that could be confused with any of the inflammatory myopathies, idiopathic inflammatory myopathies. So, you should look at this, but I'll just list for you the drugs that could cause myopathy that could be confused. Glucocorticoids, statins, antiretroviral drugs, the antimalarials, chloroquine, hydroxychloroquine, colchicine, tacrolimus, cyclosporin, alcohol, amiodarone, and alpha interferon. If you look at my RK card at the RheumNow.com website or my chapter in Harrison's, you'll see the list of drugs that cause myopathy and myositis and I can add to that list protease inhibitors, quinolones, checkpoint inhibitors and a number of different cytotoxic agents including Gleevec which is imatinib — something like that. Anyway.
Information about osteoarthritis, from the Journal of Arthroplasty — I think it was a report about pre-operative GLP-1 agonist use, in this case semaglutide, when used for one, two, three or six months had benefits in patients undergoing total knee arthroplasty. Specifically, the ones that had pre-operative GLP-1s had significantly less adverse events, and that was p=0.001, and of course this is a retrospective study of 745 type 2 diabetics that were needing TKRs that were on the semaglutide drug and they did show that it was not just for non-serious infections, which is what they mainly counted, but even serious infections like hospitalizable infections — SIEs or SAEs — and that the benefit was only seen with 2 to 3 months of the GLP-1 agonist with a 75% significant reduction.
The Lancet had a few letters to the editor about an article they published a few months ago, an overview article in 2025 about osteoarthritis, and the write-ins were complaining that you didn't endorse platelet-rich plasma treatment for the treatment of osteoarthritis. Obviously these are probably orthopedists who believe in such literature. The response back I think was instructive and smart and worth reading and you can find the link and look at it and they said basically despite the popularity — and by the way the income-generating potential — of PRP therapy, there are very few placebo-controlled high-quality studies that would allow for them to even mention it, no less endorse it, and certainly I would not have mentioned it or endorsed it either.
A review — a meta-analysis of tramadol. You know, the bad news is we just don't have good drugs for osteoarthritis. Non-steroidals you're not supposed to use, Tylenol supposedly doesn't work, gabapentins are dangerous really, and tramadol is dangerous really. Well, a meta-analysis of tramadol — 6,500 patients, 19 placebo-controlled randomized trials — showed that yes it does work with a very modest benefit in controlling chronic pain, and that is classified as low-certainty evidence, but definite certainty about the doubling of risk for serious adverse events, an odds ratio of 2.13, and more side effects than benefit with tramadol including nausea, dizziness, constipation, and somnolence, where the NNH — numbers needed to harm — for nausea was 7, dizziness 8, constipation 9, and somnolence 13, meaning one out of 13 patients needed to treat to get somnolence as a side effect. That sounds about right. I'm using less tramadol, like you are I assume. But I still need a better option. Do we not?
Speaking of opioids, tramadol being a weak opioid — the government, I think it's a CDC report, reported this last week that US overdose deaths have dropped significantly in 2024, and the trends are continuing in 2025. We're talking about opioid-related overdose deaths from opioids, heroin, and especially fentanyl. In the last 10 years, peaked at 110,000 in the US in 2022, dropped a little bit in 2023, but really dropped 27% to 80,000 in 2024, with the same numbers looking like they're being repeated for 2025. Basically, opioid deaths are down in all states except for Arizona, Hawaii, Kansas, New Mexico, and North Dakota. Isn't Breaking Bad — wasn't that from New Mexico?
The highest, if you look at the map on where opioid deaths are, is the Northeast — New England, Northeastern states, and Atlantic states — lowest in the Midwest, northern states, and the West.
Okay, hopefully you're one of the good ones and not living in the high death rate areas, but I think a lot of the education and policies have addressed this. Well, if you haven't read Malcolm Gladwell's follow-up book on Blink, or is it his first one? He goes into one of the reasons why opioid deaths are higher in some states than other states. And the bottom line is that if your state requires opioid prescriptions to be written in triplicate, the numbers are way down. If they don't require triplicate prescriptions, the numbers are way up. That's shocking to me.
A retrospective vaccine study looked at the recombinant zoster vaccine, what we call Shingrix, and when it's being used in rheumatic disease patients on disease-modifying drugs, 32% of whom were taking JAK inhibitors. They compared the Shingrix vaccine in rheumatic disease patients — 114 versus 65 non-rheumatic patients. Number one, basically no zoster reactivation. Number two, only one disease flare that required steroids. The point being that our patients are at higher risk, that there's an adjuvant in the recombinant vaccine that could excite the immune system. This is now I think the third study that I've seen that says that it doesn't cause flares of the underlying rheumatic disease like rheumatoid or psoriatic arthritis, etc. Minor side effects were actually seen in only 17% with the first injection and 21% with the second injection. The side effects were mainly injection site reactions, headaches, myalgia, that sort of thing. In the clinical trials it's like 30 to 50%, but in the real world I think those numbers are about right — 20% is what I've kind of seen.
I like the Cochrane review that I found this week that looked at cannabis. We had a treatise on cannabis back in December. A lot of reports I wrote about it, a compilation article on RheumNow. This is a meta-analysis from the Cochrane review that looked at 21 clinical trials, 2,100 adults that were taking cannabis versus placebo for the treatment of chronic neuropathy nerve pain, and said basically regardless of whether it was given as a THC prep or a CBD prep, in trials of 2 to 26 weeks, it was not effective — not effective for chronic neuropathy pain.
All right. EGPA — a retrospective study of EGPA and cardiac involvement. Cardiac involvement happens with EGPA, not so much with GPA. In this study of 103 EGPA patients, 35% had cardiac involvement with cardiac symptoms with usual cardiac biomarkers. The most common was pericarditis in three-quarters, cardiomyopathy with or without heart failure in about half, myocarditis in 36%, cardiogenic shock 14%, cardiac arrest 6%, and coronary vasospasm 8%. All found in EGPA patients.
So we had a big campaign on nurse practitioners and physician assistants. I got a few more reports — we're continuing the campaign into January. Here's a report about the use of APPs in dermatology care. It's gone up significantly. It turns out that advanced practice providers are delivering a large amount of dermatologic care in the United States. Amongst all the care, it's 37% of care and 27% of derm-specific visits in 2020. Their prescription prescribing costs — or how much they were giving out in prescriptions in dollars — was $140 million in I think 2010 or 2013, and it rose to $952 million by 2022. That's all prescriptions. Specialty drug prescriptions rose from $24 million in 2013 to $744 million in 2022. That's a 46% increase by APPs writing for biologics and specialty drugs. And at the same time, while all this is going on, the number of MD derms going into the business was less than the number of APP derms joining dermatology practices. So that's a trend that really reflects the difficulty in providing care to an expanding base. That's dermatology, where they have a bazillion dermatologists and they're relying heavily on APPs. I think we should be too.
A 2024 cardiology APP income survey showed that salaries increased 15% between 2019 and 2023, the median being $123,000. In those practices that had APP programs where APPs were leading the program as opposed to MDs leading the program, 90% or more of the APPs are working in outpatient clinics. But in those clinics, two-thirds of them are being deployed to manage lipids or to manage cardiac prevention strategies. Overall in cardiology, where they were being employed, there were roughly two APPs for every three cardiologists.
So another report from JAMA this week — actually from the AMA — said that one in three APPs will switch their specialty at least once in their career, and then obviously they're doing the switching without formal training, just like they had when they entered their first career and specialty — they had no formal training. And you know, that's a problem.
formal training for APPs the AMA has got a position against APPs wanting to have a better push towards expanding their scope of practice so that they can be more independent. The AMA is against that, saying that the survey data that they've done show that they depend on MDs for mentorship and training. So they're opposed to removing physician supervision or these collaboration requirements for non-physician providers.
So again they say removing physician supervision or collaborative requirements carries a risk of undermining the quality of care and patient safety. They actually don't have data for that, but that's their impression given that there's problems with training and that there is this issue of switching. And they provide as proof that over 150 bills were introduced into government last year that were defeated in 2025. And there seems to be no signs of a 2026 letup in this perennial push to expand scope of practice, which again the AMA says is inappropriate. I don't know that I would agree with that. I also wrote this past week about independence and it is a big issue amongst APPs.
That's it for this week's podcast. I want to point you to both social media and the website where you can see the RheumNow Live pre-learn video by Dr. Mike Putman. Mike is our pre-learn director and he's put up — I think five of these pre-learn videos along with pre-learn assignments along with the actual reading that you're supposed to do prior to coming to the meeting. So when you get to the meeting you're prepared and the lectures are short and the discussion is really great. But Mike's done a great job. We put one of these up there for you to see if you're undecided about whether or not to return to RheumNow Live either in Dallas or online.
You can look, and in this pre-learn assignment he goes over the pre-learn materials for vasculitis and autoimmune disease as provided by Drs. Nancy Olsen, who's going to talk about the SMILE study and hydroxychloroquine, Dr. Matt Baker from Stanford talking about Sjögren's disease and advances, and Clay Cochran talking about small vessel vasculitis. Check it out. I think you'll like what Mike does. It may be another good reason to go to RheumNow Live — RheumNow.live — to register. Take care of yourselves. Bye-bye.
Before we do, do me a favor. Three favors. One, sign up for RheumNow.live. You can register at RheumNow.live. Um, it's a great meeting coming up in two weeks. Two, give us a good rating on your podcast channel wherever you consume this podcast. And three, if you're not registered on the RheumNow website, please do. There's a lot of benefits to it, trust me, you'll like it. Try it. You'll like it. That used to be an old commercial.
So this week we've got a lot to cover. Last week I had a question about what to do with problematic rheumatoid scleritis and, you know, the good thing about knowing everybody is you can call everybody and get a good answer. So I called Alvin Wells, who's really good at eye disease, and a few other people, but Alvin was — he always picks up for me. And we do that in rheumatology — we call each other when we got a question or a head scratcher and whatnot, and I have him just like you.
The question was what to do, and rituximab was the best drug of choice except we couldn't use rituximab, and he brought up — you know, there's a subQ rituximab, I think — and so I looked it up and I tweeted it this week. There is a subcutaneous rituximab. It was FDA approved in June of 2017. The FDA approval was for B-cell lymphomas, follicular lymphoma, large B-cell lymphoma, and I think another one. It's not approved for RA. It's not approved for GPA, but it's out there and it's subQ and it's 5 to 7 minutes as opposed to 2 to 4 hours of Rituxan infusions.
The deal on this: it is the same as Rituxan. It's the same drug except they combined it with hyaluronidase to make it accessible via the subQ route and allow faster administration. The rule on this, however, is that you have to give IV rituximab first and then subQ can follow thereafter. Seems to be well tolerated. Seems to be a good drug option for those with lymphoma. I don't know why we can't apply to get it for — anyway, I'd like to have that in my arsenal should I need it in the future.
An interesting study that we missed during ACR in October was on JIA and the early start of biologics. This is the CANDO study — C-A-N-D-O study. 181 JIA patients that were starting biologics, and they looked at what the odds were of having clinically inactive disease at 6 months based on when they started the biologic. And so there was an early, middle, and late group. Early is less than 6 months after symptoms. Late is greater than 12 months after symptoms. And you know what? If you started early, you had an 83% chance of being in remission — clinically inactive arthritis — versus 57% if you were in the late starters. And for every month you delay the initiation of a biologic, there's a 9% increase in the odds that the patient is going to have future active arthritis at month 6 or after 6 months. So anyway, good proof of the window of opportunity, good proof that early aggressive therapy yields the best outcomes, good proof that you should use your best drug first. A lot of good proof here.
Another JIA study was the ADJUST trial, which was actually published I think a year or two ago, and there was a follow-up to it. In this follow-up, the original study was about 250 patients with uveitis — JIA uveitis — that was in remission or inactive for greater than 6 months, and then they were randomized to either continue adalimumab or they were weaned off. And it turns out that if you weaned off adalimumab, it resulted in more flares of the uveitis — 68% versus 14%. And they had more flares of uveitis than they did of the JIA. The other thing about that study was that there was no protective effect if the patient was on background DMARDs like methotrexate, leflunomide, or cyclosporine. And the last point was that if you flared and you restarted adalimumab, the majority of people regained control of the disease and uveitis.
I saw an interesting abstract and then publication this week in Frontiers of Medicine, I think it is — acupuncture in ankylosing spondylitis/spondyloarthritis. What? That sounds like nonsense to me. You know, I read it and it wasn't — it was interesting. It was a meta-analysis, because you only see sporadic studies with low numbers of patients on this issue — acupuncture and spinal arthritis. Who would do that? Why would you do that? Anyway, they found 35 trials that met criteria, included — sorry — 2,591 AS patients, and they found significant improvement in all the AS/SpA measures, BASDAI, global score, and significant lowering of CRP and ESR. I don't know what to think about this, and they did say that their
study their meta-analysis was limited by high heterogeneity of the studies and some studies with bias that they had to allow for, or you had to take note of. But overall there was a lack of really large high-quality randomized control trials. So I think that's worthy of noting and putting that into your bag of tricks.
A French study this past week looked at psoriasis patients who were on biologics and received antibiotics. Obviously they're on antibiotics — you would assume, and this is like claims data — and they just found antibiotics being used. These weren't chart reviews where they knew exactly why the antibiotic was being used. 36,000 psoriasis patients on biologics, 26% of them received an antibiotic either at baseline or during follow-up. 26% at baseline and 61% at follow-up. So the number of people was about a quarter of patients, 9,300 out of 36,000. It turns out that these people who received antibiotics were 12% more likely to stop their biologic therapy. And if they received multiple courses of antibiotics, they were 29% more likely to stop their biologic.
So who's worried about what here, right? Is the patient worried about what they're seeing on TV that talks about the risk of infection with biologics, or is the doctor worried about infections with biologics? Most of these are NSIEs, non-serious infectious events. I don't stop a biologic for antibiotic use or a non-serious infectious event. I only stop a biologic for a hospitalized serious infectious event — only till I figure out what's going on, or if fever is greater than 102. Those are my rules and I've been studying this for 22 years now. So again, I don't think you need to stop a biologic is what I would say.
Fibroscans — do you do them? You know, methotrexate, the liver, you know, we worry about cirrhosis. No, we really don't. I did a survey of rheumatologists I think two years ago showing that I don't know, 80% of you don't even consider this. And then there's a few of you — I think the question scared you into saying well, I might do it under the right circumstances — but really you don't anyway.
This is an Egypt study, 60 RA patients on methotrexate for 5 years, and they studied everybody in a complete sort of liver panel if you will. These people had a normal BMI, disease duration of 8 years, methotrexate either between 12.5 and 25 milligrams for 8 years, cumulative dose was a median — I think it was 6,700 milligrams. Anyway, all 60 patients had normal ALT, abdominal ultrasounds, and the fibroscan scores were a mean of 170, which is steatosis grade zero. Only 6.7% or four patients had mild fibrosis by the fibroscan scores. I don't think you need to do it unless you feel the patient is at risk for another reason. Certainly RA is not a reason and methotrexate by itself is not a reason, but that maybe could be added to other reasons.
Speaking of RA, an interesting Canadian study looked at how many of their RA patients were going to the emergency department. They did this study and published it looking at emergency department visits for what they call ambulatory care sensitive conditions, and they compared the RA patients — it was a high number, like a few hundred, many hundred patients — but anyway, RA patients had a 30% higher risk of going to the emergency room compared to normal controls. And of those that went to the emergency room, two-thirds were being treated for these ACSC — these ambulatory care sensitive conditions — that really are better managed as outpatients rather than being triaged and treated in the expensive emergency room.
All our patients are capable of this. I gave my patients for many years instructions on what to do when something goes wrong. And by the way, I was never on call — for I don't know, 25, 30 years I had my own practice, I was never on call. If you called my office, it didn't say call his beeper number if you've got an emergency. My line said if you have an emergency go to the emergency room, or call the office tomorrow. And that worked out just fine because there are so few rheumatologic emergencies. I know medically legally you might have all your ifs and buts, but my point is I instructed my patients what to look for, what to go to the emergency room for, and what to call me about. That's a real important part of every visit.
The journal PLOS did an interesting publication on 76 patients with diffuse alveolar hemorrhage syndrome. Not surprisingly, again, this was first off a retrospective study and sort of a single-center cross-sectional view. Not surprisingly, almost 70% of those patients had lupus; the other 30% had GPA. But the point of the paper was that a third of these patients had concurrent pulmonary infections, and that sort of — you know, to me — a surprise. I've had many of these over my career but I can't think of one even that it was alveolar hemorrhage complicated by
pneumonia and in their study the infections were 62% bacterial and 21% fungal and when they found hemorrhage on bronchoalveolar lavage they were more likely to have been the ones associated with infections — three-quarters of the infections — and diffuse alveolar hemorrhage had alveolar hemorrhage on bronchoscopy versus half the patients that didn't have it. So, a nice teaching point from an interesting sort of obscure journal.
Clinical and Experimental Rheumatology published a nice full review, I think. Oh, actually, no. I had to get access. So, but it's a nice reference on mimics of myopathy, including you know drugs that can cause toxic myopathy — presentations that can present with muscle dysfunction with weakness and elevated muscle enzymes that could be confused with any of the inflammatory myopathies, idiopathic inflammatory myopathies. So, you should look at this, but I'll just list for you the drugs that could cause myopathy that could be confused. Glucocorticoids, statins, antiretroviral drugs, the antimalarials, chloroquine, hydroxychloroquine, colchicine, tacrolimus, cyclosporin, alcohol, amiodarone, and alpha interferon. If you look at my RK card at the RheumNow.com website or my chapter in Harrison's, you'll see the list of drugs that cause myopathy and myositis and I can add to that list protease inhibitors, quinolones, checkpoint inhibitors and a number of different cytotoxic agents including Gleevec which is imatinib — something like that. Anyway.
Information about osteoarthritis, from the Journal of Arthroplasty — I think it was a report about pre-operative GLP-1 agonist use, in this case semaglutide, when used for one, two, three or six months had benefits in patients undergoing total knee arthroplasty. Specifically, the ones that had pre-operative GLP-1s had significantly less adverse events, and that was p=0.001, and of course this is a retrospective study of 745 type 2 diabetics that were needing TKRs that were on the semaglutide drug and they did show that it was not just for non-serious infections, which is what they mainly counted, but even serious infections like hospitalizable infections — SIEs or SAEs — and that the benefit was only seen with 2 to 3 months of the GLP-1 agonist with a 75% significant reduction.
The Lancet had a few letters to the editor about an article they published a few months ago, an overview article in 2025 about osteoarthritis, and the write-ins were complaining that you didn't endorse platelet-rich plasma treatment for the treatment of osteoarthritis. Obviously these are probably orthopedists who believe in such literature. The response back I think was instructive and smart and worth reading and you can find the link and look at it and they said basically despite the popularity — and by the way the income-generating potential — of PRP therapy, there are very few placebo-controlled high-quality studies that would allow for them to even mention it, no less endorse it, and certainly I would not have mentioned it or endorsed it either.
A review — a meta-analysis of tramadol. You know, the bad news is we just don't have good drugs for osteoarthritis. Non-steroidals you're not supposed to use, Tylenol supposedly doesn't work, gabapentins are dangerous really, and tramadol is dangerous really. Well, a meta-analysis of tramadol — 6,500 patients, 19 placebo-controlled randomized trials — showed that yes it does work with a very modest benefit in controlling chronic pain, and that is classified as low-certainty evidence, but definite certainty about the doubling of risk for serious adverse events, an odds ratio of 2.13, and more side effects than benefit with tramadol including nausea, dizziness, constipation, and somnolence, where the NNH — numbers needed to harm — for nausea was 7, dizziness 8, constipation 9, and somnolence 13, meaning one out of 13 patients needed to treat to get somnolence as a side effect. That sounds about right. I'm using less tramadol, like you are I assume. But I still need a better option. Do we not?
Speaking of opioids, tramadol being a weak opioid — the government, I think it's a CDC report, reported this last week that US overdose deaths have dropped significantly in 2024, and the trends are continuing in 2025. We're talking about opioid-related overdose deaths from opioids, heroin, and especially fentanyl. In the last 10 years, peaked at 110,000 in the US in 2022, dropped a little bit in 2023, but really dropped 27% to 80,000 in 2024, with the same numbers looking like they're being repeated for 2025. Basically, opioid deaths are down in all states except for Arizona, Hawaii, Kansas, New Mexico, and North Dakota. Isn't Breaking Bad — wasn't that from New Mexico?
The highest, if you look at the map on where opioid deaths are, is the Northeast — New England, Northeastern states, and Atlantic states — lowest in the Midwest, northern states, and the West.
Okay, hopefully you're one of the good ones and not living in the high death rate areas, but I think a lot of the education and policies have addressed this. Well, if you haven't read Malcolm Gladwell's follow-up book on Blink, or is it his first one? He goes into one of the reasons why opioid deaths are higher in some states than other states. And the bottom line is that if your state requires opioid prescriptions to be written in triplicate, the numbers are way down. If they don't require triplicate prescriptions, the numbers are way up. That's shocking to me.
A retrospective vaccine study looked at the recombinant zoster vaccine, what we call Shingrix, and when it's being used in rheumatic disease patients on disease-modifying drugs, 32% of whom were taking JAK inhibitors. They compared the Shingrix vaccine in rheumatic disease patients — 114 versus 65 non-rheumatic patients. Number one, basically no zoster reactivation. Number two, only one disease flare that required steroids. The point being that our patients are at higher risk, that there's an adjuvant in the recombinant vaccine that could excite the immune system. This is now I think the third study that I've seen that says that it doesn't cause flares of the underlying rheumatic disease like rheumatoid or psoriatic arthritis, etc. Minor side effects were actually seen in only 17% with the first injection and 21% with the second injection. The side effects were mainly injection site reactions, headaches, myalgia, that sort of thing. In the clinical trials it's like 30 to 50%, but in the real world I think those numbers are about right — 20% is what I've kind of seen.
I like the Cochrane review that I found this week that looked at cannabis. We had a treatise on cannabis back in December. A lot of reports I wrote about it, a compilation article on RheumNow. This is a meta-analysis from the Cochrane review that looked at 21 clinical trials, 2,100 adults that were taking cannabis versus placebo for the treatment of chronic neuropathy nerve pain, and said basically regardless of whether it was given as a THC prep or a CBD prep, in trials of 2 to 26 weeks, it was not effective — not effective for chronic neuropathy pain.
All right. EGPA — a retrospective study of EGPA and cardiac involvement. Cardiac involvement happens with EGPA, not so much with GPA. In this study of 103 EGPA patients, 35% had cardiac involvement with cardiac symptoms with usual cardiac biomarkers. The most common was pericarditis in three-quarters, cardiomyopathy with or without heart failure in about half, myocarditis in 36%, cardiogenic shock 14%, cardiac arrest 6%, and coronary vasospasm 8%. All found in EGPA patients.
So we had a big campaign on nurse practitioners and physician assistants. I got a few more reports — we're continuing the campaign into January. Here's a report about the use of APPs in dermatology care. It's gone up significantly. It turns out that advanced practice providers are delivering a large amount of dermatologic care in the United States. Amongst all the care, it's 37% of care and 27% of derm-specific visits in 2020. Their prescription prescribing costs — or how much they were giving out in prescriptions in dollars — was $140 million in I think 2010 or 2013, and it rose to $952 million by 2022. That's all prescriptions. Specialty drug prescriptions rose from $24 million in 2013 to $744 million in 2022. That's a 46% increase by APPs writing for biologics and specialty drugs. And at the same time, while all this is going on, the number of MD derms going into the business was less than the number of APP derms joining dermatology practices. So that's a trend that really reflects the difficulty in providing care to an expanding base. That's dermatology, where they have a bazillion dermatologists and they're relying heavily on APPs. I think we should be too.
A 2024 cardiology APP income survey showed that salaries increased 15% between 2019 and 2023, the median being $123,000. In those practices that had APP programs where APPs were leading the program as opposed to MDs leading the program, 90% or more of the APPs are working in outpatient clinics. But in those clinics, two-thirds of them are being deployed to manage lipids or to manage cardiac prevention strategies. Overall in cardiology, where they were being employed, there were roughly two APPs for every three cardiologists.
So another report from JAMA this week — actually from the AMA — said that one in three APPs will switch their specialty at least once in their career, and then obviously they're doing the switching without formal training, just like they had when they entered their first career and specialty — they had no formal training. And you know, that's a problem.
formal training for APPs the AMA has got a position against APPs wanting to have a better push towards expanding their scope of practice so that they can be more independent. The AMA is against that, saying that the survey data that they've done show that they depend on MDs for mentorship and training. So they're opposed to removing physician supervision or these collaboration requirements for non-physician providers.
So again they say removing physician supervision or collaborative requirements carries a risk of undermining the quality of care and patient safety. They actually don't have data for that, but that's their impression given that there's problems with training and that there is this issue of switching. And they provide as proof that over 150 bills were introduced into government last year that were defeated in 2025. And there seems to be no signs of a 2026 letup in this perennial push to expand scope of practice, which again the AMA says is inappropriate. I don't know that I would agree with that. I also wrote this past week about independence and it is a big issue amongst APPs.
That's it for this week's podcast. I want to point you to both social media and the website where you can see the RheumNow Live pre-learn video by Dr. Mike Putman. Mike is our pre-learn director and he's put up — I think five of these pre-learn videos along with pre-learn assignments along with the actual reading that you're supposed to do prior to coming to the meeting. So when you get to the meeting you're prepared and the lectures are short and the discussion is really great. But Mike's done a great job. We put one of these up there for you to see if you're undecided about whether or not to return to RheumNow Live either in Dallas or online.
You can look, and in this pre-learn assignment he goes over the pre-learn materials for vasculitis and autoimmune disease as provided by Drs. Nancy Olsen, who's going to talk about the SMILE study and hydroxychloroquine, Dr. Matt Baker from Stanford talking about Sjögren's disease and advances, and Clay Cochran talking about small vessel vasculitis. Check it out. I think you'll like what Mike does. It may be another good reason to go to RheumNow Live — RheumNow.live — to register. Take care of yourselves. Bye-bye.
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