Early RA Referral Clinics Work (9.18.2026) Save

It's 09/18/2026. This is the RheumNow podcast. Hi, I'm Doctor. Jack Cush, executive editor of roomnow.com. This week we begin with a report on fibromyalgia.

Very common, very undiagnosed, and proven by this paper. This is from the UK Biobank, which is a large data collection coming out of The UK, mostly from primary care. From this very large many thousands of patients, they identified four thousand two hundred patients with fibromyalgia who meet criteria for fibromyalgia. But in their chart reviews, only a minority have a diagnosis of fibromyalgia. Seventy two point six percent were not diagnosed with fibromyalgia.

What's that about? Well, it's primary care, maybe they need more support, maybe it's hard to get those patients in to see you. People not likely to be diagnosed were more likely to be males, older, have milder symptoms, or have symptoms ascribed to another rheumatic condition like OA, CRPS, chronic fatigue syndrome. They also are likely to have less fatigue. So it's not it's almost like they have to have full blown fibromyalgia before they get diagnosed.

Gee, that shouldn't happen. We need to spread the word, we need to teach more on this. An open label study of, calcinosis cutis in juvenile dermatomyositis patients. You know, we see calcinosis in our scleroderma patients, we see it occasionally in dermatomyositis. It's a bigger problem in JDM in the pediatric population.

In this study of open label study of 20 JDM patients, 11 boys, age 10, they had calcinosis cutis for thirty one months, they were all treated with tofacitinib in standard doses. And the interesting thing about this open label report was tofacitinib was associated with a decrease in calcium mass as measured by the Agaston ston scores. That's the same as you get with your calcium coronary artery scores on CT scan. It measures total calcium, and prior treatment the mean result was 34.49 and post treatment it went down to 4,000. That's a significant decrease.

They measured other things including the clinical dermatomyositis activity score of Victoria Wirth's group, but they didn't report on that. So I'd like to know, you know, did the tofacitinib do to the disorder? As you know, we had a recent brepocitinib approved for dermatomyositis, right, and that's a JAK1, tick two drug. So I would assume it would have helped the other features of disease including the cutaneous features, but this is impressive that it would lower a calcinosis burden. A Trinetix evaluation of many thousands of electronic health records showed that VTE is not increased in RA patients who are taking JAK inhibitors.

In this study they looked at patients undergoing either hip replacement or knee replacement, and if they were on a JAK or if they were on a TNF inhibitor two eighty four versus two eighty eight. The VTE events were 17 with the JAK inhibitor six percent and eleven with the TNF inhibitor three point eight percent. Although that's a numeric increase it was not significant with a relative risk of one point five seven. So, but again this data does not negate the results of the oral surveillance study. That was this is a retrospective, you know, view trying to refute oral surveillance which was a prospective double blind randomized controlled trial that was appropriately powered.

It's going to take a lot to undo that data. The FDA this week had a few interesting actions. They did grant a priority review for zazocitinib for plaque psoriasis. This is a drug that's been through phase three trials with about 3,000 patients. That's their latitude pso three thousand and one three thousand and two clinical trials.

It's expected that they're going to have a regulatory decision first quarter of twenty twenty seven. Azazocitinib is another TYK2 inhibitor that will compete with ducravacitinib. Sobi also received a notice from the FDA this week of a fast track designation for a drug for vexus syndrome. This is called pakritinib. Pakritinib, the trade name is Vonjo, I'm not familiar with this drug because it's approved for intermediate or high risk myelofibrosis.

And so, not surprising that I would know about it, but anyway, this is a JAK two FLT3 inhibitor that they are putting on the fast track to study INVEXA syndrome. There's a little bit of debate up in the air about what the best drug for VEXA syndrome is these days. A lot of drugs have been tried, including cytokine inhibitors, but the JAKs have looked good in anecdotal reports. So we'll we gotta like this because it's gonna lead to a well designed trial which will hopefully answer the question even in a rare disorder like vexus. A meta analysis of 87 studies gives us some insight into who is not going to respond to methotrexate.

Well, we all think that most of our patients respond to methotrexate. The data from last week's JAMA review by Smolin et al. That out of the gate forty percent of patients respond to methotrexate, which means sixty percent don't. In this meta analysis it says people who are likely to respond to methotrexate have early disease, have low disease activity, who receive methotrexate early, and do not have erosive disease. Things that can sort of undermine the efficacy of methotrexate would include smoking and a higher BMI.

So it makes sense mild disease, early disease is going to respond better almost no matter what you give them, but why not give them methotrexate? It is your first line therapy. A study coming out of India looks at how frequent RA patients flare. There's eighty five patients who are either in remission or low disease activity state with a -twenty eight sed rate less than 3.2. They were followed for six months.

Forty six percent had one or more flares with the dash jumping higher than 3.2. The time to flare was twelve weeks ranging from eight to eighteen weeks and that was unrelated to activity, right? It's not like they had, you know, again these people were doing pretty well therefore it's somewhat unpredictable. If there was a predictable variable for who was going to flare, it seems like seropositivity, either for rheumatoid factor or CCP, gave you greater than a twofold higher risk of flares. Interesting.

Falls in RA can be a bad thing. This is a study of one hundred and twenty four ambulatory females over the age of 50 in fact their average age was 68. Their DAS was doing good: two point six. Sixteen percent had sarcopenia, twenty five percent had a prior fall. In their follow-up study these people twenty seven percent had falls and predicted by if you had a fall before you're going to get a fall again.

And the odds ratio of that is two point seven six. Being on a hypnotic or anxiolytic gave you almost a fourfold higher risk. Although there was a trend suggesting that steroids or sarcopenia may be a risk factor, it was not significant. Because other studies suggested steroids or sarcopenia steroids because it would cause weakness, sarcopenia because it is weakness, that makes some sense. A meta analysis of gout patients shows that erectile dysfunction is about forty percent higher relative risk of one point three seven.

This is 11 studies, one hundred and four thousand patients with gout and hyperuricemia. Hyperuricemia is also increased has an increased risk of erectile dysfunction. The question is why? The one thing that they showed clearly on this was that it did have a relatedness to lower testosterone and lower estradiol levels. Other factors were obesity, age, diabetes, and cardiovascular disease.

But it's really thought to be an endothelial issue, and that there's endothelial dysfunction in patients with gout and with hyperuricemia. A Chinese study of a novel drug, another humanized anti IL-17A and AF inhibitor, this is called XKH004, studied in China, was studied with three twenty three ankylosing spondylitis patients and they looked at their outcomes at week sixteen. The dual IL-seventeen inhibitor was superior with regard to the ASAS forty forty five percent versus nineteen percent and by fifty two weeks sixty six percent of these people were improved. I think we'll see more of these dual inhibitors. There's another one in development beyond the one that's currently available.

In 2022, a study of Swiss psoriatic arthritis patients showed that overweight and obesity accounted for sixty six percent of the population. That compares to the risk of obesity and overweight in forty three percent. In The United States, the most recent numbers are eighty two percent of our population is either overweight or obese Sorry, seventy two percent are overweight or obese, but that in psoriatic arthritis it's eighty two percent. So both studies, both areas show a higher risk of obesity and being overweight. And in their study they showed things that you should know that obesity is associated with a higher CRP, fifty six percent versus thirty seven percent, meaning obese versus non obese, higher patient global assessments, worse MD global assessments, and lower functional scores with the EQ5D3L.

Don't ask me what that is, but it's another standard metric that is used for functional outcomes. As you know, this month is our obesity campaign, the obesity imperative. We have a lot of great things going on. Last week we had a number of really interesting videos. We had a great Tuesday night rheumatology on inflammation and obesity next week, next Tuesday, we had a great session on treatments for obesity that are out there, things that you probably want to know about.

Tune in Tuesday night 7PM. At the twenty twenty seven ASMBS, that's the American Society of Metabolic and Bariatric Surgery, showed that between 2020 and 2024 weight loss surgeries bariatric surgeries dropped twenty three percent going down from two hundred and thirty thousand to one hundred and seventy seven thousand. And they point out that less than one percent of eligible patients are going this route, suggesting that there's a higher amount of medical management with the new GLP-one drugs. Another article from JAMA Surgery showed that between 2022 and 2024 bariatric surgery fell thirty four percent. At the same time GLP-one directed drugs rose one hundred and forty percent.

So again, these shifts are on. They are real. But you know we had an article this week that says that bariatric surgery works. It should be considered. It's very effective.

And there's nothing to say you can't get bariatric surgery and be on a GLP-one. But I would recommend that being done with the guidance of a weight loss specialist. You may have seen my video on the therapeutic update videos that we have. I think we have six or seven of them up right now. All around the four pillars of weight loss.

Things that you really need to know if you're going to be talking about weight loss with your patients. We're going to go into nutrition, we're going to go into exercise, we're going to go into coping and, the psychology of weight loss. My video, fairly short, was called, Introducing Weight Loss, and it's about the three minute script. What can you do in three minutes as a rheumatologist with your patients to bring up this issue of weight loss? And I'll just quickly go over for you.

You know, I start by saying one other thing that can really affect your arthritis or your disease is your weight. Is it okay if we talk about this for a few minutes? You know, it's not just about the weight. You know, being overweight reduces your activity. That makes you weaker.

That makes you hurt more when you do things. Have you thought about losing weight? How much would you like to use? What are your goals? Find out whether they have buy in or not.

And then you have to hit them with, you know, the extra weight increases not just mechanical stress but the inflammation load. And that makes your disease worse. That makes your responding to drugs harder. So, you know, you have to point out you know, everyone has a plan, but it's not a good plan. And everyone's tried something, but it never worked.

And most of that is Going it alone is unsuccessful. Why don't you do something different? Why not go to a specialist? Why not start on a new medicine? Why not pair up and join Weight Watchers with your best friend?

Why not pair up and get into an exercise program with your best friend? Again, a new plan is needed. What do you want to talk about here? How can we do this? And then when you get into talking about diet and exercise, you can't say eat less, move more.

That ain't helping people who are overweight and in pain. You've got to give them really tangible goals. You know, how much weight can I lose by how much calorie restriction should I try? And if you are unfit or unable to do that, send them to a nutritionist. You'd be shocked at how good that is.

I went to a nutritionist and she took me shopping, told me what not to buy, what I should buy. And that really has helped. They have to be motivated, they have to gradually increase their exercise. They got to go from doing two to three minutes on a treadmill to working themselves up to fifteen, and then thirty, and then sixty minutes. And who is their multidisciplinary team?

Lastly, you gotta write it down. I have a post it pad on my desk, and everybody leaves with a post it note, a sticky, and I tell them stick it on the refrigerator. You know, you gotta look at this. You gotta look at this repeatedly. Your family's gotta look at this.

And then the last thing you need to do is arrange for a follow-up, because follow-up is where all the great things happen. You know, there was a fifty two week follow-up to the Together PSA trial. We talked about that in our first week of Tuesday at Rheumatology. We did Journal Club. We talked about the Together PSA trial that showed that the combined endpoint at thirty six weeks for 10% weight loss and an ACR fifty was 31% versus 0.7%.

Now at week 52 it's 39% versus 1.7. So it goes up the same as it was held for the Together PSO trial, where the combined endpoint of a PASI 100 plus 10% or more weight loss was now up to 30%. Previously it was like, I don't know, 26%, I think, versus four point four percent with just Taltz alone. So again, encouraging data on combination therapy. An NHANES study looked at the utility of measuring waist size.

You know, I think this is a problem. I'm going to ask this on my Tuesday night rheumatology to my diabetes and rheumatology experts: Are you actually measuring the waist size of your patients? I have found that to be a really most patients don't even want to get on the scale, right? How many of them want to have their waist size measured? Know?

You know, they've been saying no, I Jerry Seinfeld, no, I have thirty six, you know, jeans, thirty six waist jeans, and they're not, you know? So, anyway, in this study of five thousand five hundred CKD patients, waste index was associated with a higher risk of all cause mortality and cardiovascular death seventeen to twenty four percent higher. And these were mediated by inflammation as measured by the neutrophil to lymphocyte ratio, a good measure of inflammation. So again, waist size probably should be something we're doing but I don't know that we're doing it enough. Are you doing weights on every there's some rheumatologists that don't do vital signs.

I don't understand that. That. You gotta do vital signs on everyone. Lastly, two more reports: the early, arthritis clinic from Leiden, they have an EAC clinic that's been going on a long time with the idea of reducing, of improving referrals from primary care. So from 2010 to 2020 they evaluated over two thousand patients.

Eight hundred had arthritis, not saying what kind. One hundred and thirty two of the two thousand had RA. These were people referred to the early arthritis clinic. That was compared to six ninety patients who were referred in usual ways. Three forty two, a higher percentage of those, had RA.

All right? The question is: which gave you a better outcome? It's shocking! The EAC referrals had lower disease activity like p equals 0.0003 over five years. They had less functional disability, also highly significant.

Higher rates of sustained DMARD free remission, two fold higher p. One and a lower time from GP delay to referral. A median of five weeks versus nine weeks. So early arthritis clinics do work, I haven't I mean I lectured on this long time with US rheumatologists and couldn't convince anybody to carve out an early arthritis clinic because it would leave open spots and most people are more interested in filling their spots than being proactive about early RA. Again, there's business to run here, I understand that.

But there is a benefit to having an early arthritis clinic. Another study this week looked at IVIG as you know that was approved a few years ago Octagam 10% was approved for use in myositis. This is a double blind randomized placebo controlled trial of forty four patients. It's not a big study, right? And the other thing that's interesting about this study is that they were not your run of the mill PMDMs.

There were sixteen patients with immune mediated necrotizing myositis. There was eleven with signal recognition particle myositis. There were two that were seronegative. No, no, no. There was 11 with HMGCR that's the statin associated HMG coreductase marker.

There were three with signal recognition particle disease, two serone gative, three with dermatomyositis, one tiff gamma, one nxp, two. But the good news is that the scores with IVIG versus placebo were significantly better. The TIS, total improvement score, which is a measure of functional CPK and functional outcomes, it's not measuring skin outcomes, it's just measuring myositis outcomes: sixty versus forty two. And the other point that was important here: the median time to a moderate response was four weeks with IVIG and twelve weeks with placebo. So, I want to encourage you to look at our Room IQ comes out every Saturday.

Last week, they didn't do very well as a group. A lot of people missed this question, about hydradenitis showed that the study of hydradenitis showed that IL-seventeen inhibitors significantly increased IBD risk. That was false. More of you answered true than false. The other question was that I was surprised a lot of people got this wrong.

Only about, I think it was 37% got this right. What is the minimum amount of weight loss that you need to improve psoriatic arthritis? And the number is five percent. Most of you answered ten percent, which is right, but the minimum threshold is five percent. Lastly, I want to remind you, RoomNow Live is coming January 3031, a little bit earlier this year, in Dallas.

Registration begins October 1. We hope to see you there. Our faculty, we're going put up the agenda really soon. It looks really, really good. I think you'll find that you're going enjoy the meeting whether you're on-site or online.

That's it for this week. Take care of yourselves. We'll talk next week.