DERM on RheumNow PODCAST (September 2026) Save

Welcome to the September 2026 edition of the Derm on Room Now podcast. You're the experts on rashes, right? We rheumatologists, we got the joints. But, you know, we both deal with a lot of overlap. We both deal with inflammation and autoimmunity.

Our patients overlap, so should our knowledge. I'm Jack Cush, executive editor of roomnow.com. The Derm on Room Now podcast is for you, and it's for you to know our take on what happened in dermatology this past month that we covered on roomnow.com. So let's get to the news. This past month the FDA granted a priority review for Zazocitinib, a new investigational TYK2 inhibitor like ducravacitinib, and this priority review is for the indication of plaque psoriasis.

There's an expectation that this drug could be approved in the first quarter of twenty twenty seven. The data supports its use. There's at least three randomized controlled trials, over 3,000 patients in what's called the Latitude PSO 3,001, 3,002 trials. This is the basis for future approval. It's up in front of the FDA.

It's also been submitted in the EMA for potential approval in Europe. A study this week looked at pregnancy in psoriasis patients. Two hundred and ninety pregnancies and two hundred and eleven of those ended up in live births, that's a seventy three percent rate. And the interesting thing about these... All these pregnancies is that there was biologic exposure.

Interestingly, the most commonly used biologic at the time of conception was that ustekinumab in two forty one of those two ninety cases. In forty two, TNF inhibitors. And the interesting thing about this data is that, one, that there were favorable outcomes, meaning expected rates of live births, good fetal outcomes, low birth weight, miscarriages, very few congenital anomalies. But the other surprising thing about this dataset were that only twenty four of those, exposed patients carried the pregnancy while on a biologic, and they stayed on a biologic. Split between cerdulizumab and adalimumab, and that did not affect the outcomes.

The point here is that, it seems that dermatologists are not likely to continue the biologic. Maybe it's the dermatologist, maybe it's the patients. I want to put that in contrast to GI, gastroenterology with IBD, everybody continues biologic and thiopurine, either six MP or azathioprine therapy. In rheumatology it's about seventy percent of RAPSA and enclosing spondylitis patients continue their biologic therapy, with cerdulizumab, etanercept leading the way. Less is known about newer drugs like IL-seventeen, IL-twenty three JAK inhibitors, where their use would be speculative at best.

So what's the deal there? Maybe you can tell me. An analysis of the SELECT PSA two study SELECT means it's a Nupacitinib study, right? One hundred and ninety five PSA patients not responding to an TNF inhibitor were either switched to a JAK inhibitor, upadacitinib, or placebo, and guess what? Upadacitinib was significantly better.

Fifty eight percent versus twenty two percent with arthritis outcome. MDA minimal disease activity twenty four versus three percent. The point here is after you fail a TNF inhibitor in psoriatic arthritis, looking at mainly arthritis outcomes, it's far better to switch drug classes than to keep playing the TNF inhibitors where some will respond, but you're gonna lose response rates. Switching classes is currently the norm in rheumatology management, and is endorsed by EULAR, the European League Against Rheumatism, in their guidelines for rheumatoid arthritis and other diseases. So switching MOAs is the way to go.

A number of studies we've talked about in the past have examined whether taking a biologic on for psoriasis lowers the risk of future psoriatic arthritis. So patients with psoriasis, it's a thirty percent risk of future psoriatic arthritis. In rheumatology terms, we think of this as a pre clinical psoriatic arthritis condition. It's not yet psoriatic arthritis. It might be.

Maybe if you gave them more aggressive treatment, they wouldn't get psoriatic arthritis. We do know that patients with more aggressive psoriasis are higher risk to develop psoriatic arthritis. Anyway, a meta analysis of 15 studies, 124,000 PSA patients and seven and eighty thousand patient years of follow-up show that biologic use lowers the risk of PSA by forty six percent, and that's significant. The best data was seen with IL-seventeen inhibitors, a thirty five percent lowering, and IL-twenty three or twelve twenty three inhibitors, a fifty four percent lowering when compared to those who were treated with a TNF inhibitor. Looks like head to head that IL-twenty three may be superior to IL-seventeen inhibition in preventing future psoriatic arthritis.

There, the lowering was 33% in favor of the IL-twenty three inhibitor. Again, studies are always retrospective, large cohort analyses, there is no prospective study here, but I think there's a consistency of messaging that says that, yeah, when you guys are aggressive, we rheumatologists benefit. Please be aggressive. Juvenile dermatomyositis can be a big problem, especially in the management of calcinosis cutis. I have here a 20 patient small study, open label study of tofacitinib in JDM.

Average age 10 years, they had on average calcinosis cutis for thirty one months. They measured calcinosis using calcium scores by CT, the Agustin scores, and showed the calcium content went down on these tofacitinib treated JDM kids from a score of 60 three-forty nine, that's kind of high, to 4,000. No serious adverse events with tofacitinib. Obviously this is a setup for what should be a prospective randomized either active control or placebo controlled trial going forward, except it's not going to happen with tofacitinib because tofacitinib just went generic this year. By the way, if you're not using tofacitinib, you should be: five milligrams bid is $25 a month using cost plus pharmacy that's Mark Cuban's pharmacy.

If you use GoodRx, it's a $140 a month. If you... There are some other sources using... Selling generic tofacitinib at, like, $1,400 a month. That's a rip off.

But, again, cost plus pharmacy, people who need drugs... And, again, you have a lot of indications for JAK inhibition use in your patients. They gotta use the five milligram BID dose. There is no two five milligram pills once a day. That's not equivalent to the eleven milligrams once a day.

But still, it's dirt cheap. Why not know about it? Why not use it? A lupus analysis looked at metabolic syndrome. We both treat lupus.

This was a meta analysis of 65 articles, 11,000 patients. And you're used to this with psoriatic arthritis, and we're trying to grapple with comorbidities in rheumatology, especially in psoriasis and lupus and RA. Anyway, the metabolic syndrome is twenty seven percent elevated in lupus patients. Higher in males than females, thirty six percent in males. But the interesting thing on this study was that those patients who were treated with lupus, who were treated with hydroxychloroquine, had a significant thirty three percent lower risk of metabolic syndrome.

In contrast, patients treated with Citoxan significantly higher, thirty nine percent. Azathioprine, twenty five percent, and mycophenolate. And this reflects the severity of disease that they're getting these aggressive therapies, and the severity of disease brings with it metabolic syndrome, maybe because of steroid use and whatnot in lupus. But it turns out that steroids and methotrexate don't change the metabolic syndrome risk, and as expected, these patients with lupus who have metabolic syndrome were older, obese, high cholesterol, high LDL. You guys are dealing with the JAK inhibitor story, oral surveillance, you know, the worries about venous thromboembolic events, malignancy risk, cardiovascular risk, you've got to use a TNF inhibitor before a JAK inhibitor.

I want to point out for you two bits of data that came out that are recent, that you should know about. There's a Trinetix study, which is a massive few million patients retrospective EHR review of venous thromboembolic events in RA patients taking a JAK inhibitor, and they did not show an increased risk of VTE events. And these were RA patients undergoing joint replacement surgery. But anyway, the... It was higher, but it wasn't significant.

The relative risk was one point five seven, six percent versus three point eight percent. But I don't know if I can believe this, because it's retrospective, it's an EHR review, TriNetX gives you some funny data, the propensity matching isn't as good as it should be, unless it's done by real epidemiologic professionals. I want to contrast this data with something that was just presented at the EULAR meeting in London in June. It's called the RA branch study. This was a study of baricitinib.

When baricitinib was approved, they had in the label a risk of VTE. They made them do a post regulatory commitment to do a large scale study looking at the VTE risk. That completed and was reported at in EULAR, it's going be reported in November at ACR meeting. Three thousand six hundred patients randomized to receive either a TNF inhibitor, etanercept or adalimumab, or baricitinib two milligrams a day or four milligrams a day. They followed them out three or four years, and they showed a very clear increase in VTE events with either the two or the four milligram baricitinib dose compared to TNF inhibitors.

That was significant. By the way, what was not significant was the MACE or cancer risk in that study. The bottom line here is I believe JAK inhibitors do carry a VTE risk. If your patients have had a prior pulmonary embolism or DVT that was serious, they probably should not be put on a JAK inhibitor. I think the risk for cardiovascular events and cancer is highest in those who are older than 65 with a cardiac history and with a smoking history.

And that's how I guide my use of JAK inhibitors. This month, September, on RheumNow, we committed to a large campaign on obesity and rheumatic disease. You guys deal with this. It's a big problem in diabetes. I want to give you a few reports on obesity that will keep you up to date with what the rheumatologists were presented with.

An analysis of the Swiss data on PSA showed that the risk of being overweight or obese was sixty six percent in Switzerland versus a general population risk of forty three percent. In The United States, this is not in part of this study, but I know the recent data, seventy two percent of US patients are either overweight or obese if they have psoriatic disease, psoriatic arthritis. It's ten percent... It's 10 points lower if they don't have psoriatic disease. Not good.

So, again, this is a big problem. Obesity was also associated with higher CRPs, higher patient global, MD global, and functional scores as well. Obesity is a bad player, as you know. The question is, when your patients go on these new GLP-one drugs, what happens? A study of one hundred and nineteen rheumatic patients on GLP-one therapy, two thirds for diabetes, one third for obesity, that had a mean BMI of thirty five.

Twelve months later, significant weight loss, and fifty six percent lowered themselves from one BMI category to the one lower. If they were obese category one, thirty, they dropped down to overweight, meaning twenty five to 30, etc. Significant decreases in these patients in A1C, blood sugars, lipids, LDL, triglycerides, LDL, CRP. These drugs have tremendous cardiometabolic benefit. A thing that our patients are often dealing with now is online pitches for getting on GLP-one.

You know, Serena Williams, Charles Barkley, the company Roe, they're, you know, they're pushing these things. These are largely online compounding pharmacies that are manufacturing the drug. These are not coming directly from Lilly or other manufacturers. It's estimated that 7,000,000 Americans are getting their GLP-one drug online from a compounding source. The problem is, these are not FDA approved.

They're allowed because one and two years ago there was a shortage of these GLP-one integrin therapies in incretin therapies, excuse me. And because of the shortage, the drugs could be compounded by a pharmacy, except there's no more shortage. And the government's about to shut down this, what's called five zero three b loophole, that will probably outlaw these copycat drugs. The problem for you and I is, yeah, seems like a good idea. Go ahead, get it.

Especially if you can save some money. But their purity and consistency and safety is very, very suspect. I mean, just look it up. It's a lot of problems. I don't recommend that you recommend your patients take these from online sources.

Look into the Medicare program for $50 a month for people to receive a GLP-one drug, that's a great way to go. You're gonna have to deal with, you know, prior authorizations and paperwork, but it does work well. Data presented at 2027, Bariatric Society meeting showed that weight loss surgeries dropped between dropped about twenty three percent from 2022 to '20, '24, and, you know, it's not good. The two hundred and thirty thousand twenty twenty two to a hundred seventy seven thousand, yet they say that despite this drop, very few people are getting weight loss surgery, bariatric surgery. Less than one percent who are actually eligible are getting...

And by the way, bariatric surgery is proven to actually work better than the GLP-one drugs, how greater durability and consistency over time. Don't take that off the table. Refer your patients to either weight loss centers who can discuss that with your patients, or to bariatric surgeons. An update of the Together PSA study and Together PSA study shows the twelve month benefits, the week 52 benefits, in the PSO study. Two seventy four patients, the primary endpoint was a PASI 100 plus 10% weight loss or more.

The week 52 data was thirty one percent for Taltz with Zepbound versus four percent Taltz alone, showing that there's a durability to this response. This is a major study for both of us. Two more reports: the FDA approved last month Brepocitinib for the treatment of dermatomyositis. Brepocitinib is a combination JAK1TYK2 inhibitor, approved for use in patients with dermatomyositis not responding to conventional therapy. It's estimated that there are about forty thousand or more patients with dermatomyositis in The United States.

The approval is based on the VALOR study, a phase three, two forty one patient study where they either got thirty or fifteen milligrams of brepocitinib, also called now LISRAYA. And LISRAYA was shown to be significantly better at what's called the total improvement score, it's the TIS score, which is an improvement of muscle function and CPK, but when they looked at skin outcomes, were also much, much better. Now we have two FDA approved drugs for dermatomyositis. One is IVIG, and the second now is brepocitinib. There are other drugs that are in development here, and of course I'm sure you're using methotrexate.

I use a lot of leflunomide, I must say, in my problematic or, actually in first line in my patients with either dermatomyositis or polymyositis. That's me, and there's anecdotal evidence of that. Lastly, IgA vasculitis we both see, we both deal with. There are maybe ten percent of those patients will have necrotizing arteritis on biopsy. That's a bad group.

This review paper looked at thirty patients with necrotizing arteritis with IgA vasculitis, compare them to two hundred adults with plain old IgA vasculitis and one hundred and ninety six PAN patients, the, again, IgA, vasculitis with necrotizing arteritis more severe, more life threatening disease, more morbidity, more mortality. When you see this, patients need to have vascular imaging large vessel vascular imaging, small vessel vascular imaging and need to be treated with intensive immunosuppression. When you looked at these patients, they had more GI bleeds, more perforations, surgical abdomens, neuropathy, pancreatitis, libido, and multi organ involvement, and yes, more mortality. I don't see many of those. I have seen a few in my career.

I think you're gonna see more than I see. Anyway, that's it for this month on Derm on RheumNow. Please share this podcast with your colleague, especially the nurse practitioners and physician associates. You and they can sign up for the daily or weekly RheumNow report, or you can sign up for just either a lupus weekly report or a psoriasis weekly report at roomnow.com. Until then, keep it up.

We're gonna continue to have this skin and joint crosstalk thing going forward. Take care.