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This is QD Clinic brought to you by rheumnow.live. Yes. We're back for 2020. QD clinic is a daily video devoted to patient care and patient vignettes. This case is about nonadherence and what to do about it.

So last week, while at the county hospital and discussing a case with our rheumatology fellows, the issue came up of a patient who was roughly 35 had lupus, was taking hydroxychloroquine, or was she? Meaning, she should have been on an effective dose, but she still had active skin disease. And this is a patient who had previously expressed concern about the safety of hydroxychloroquine and was it going to hurt her eyes and whatnot. So I think there are two issues at stake here. One is the issue of treatment decisions, and the second issue is that of the relationship between the patient and the rheumatologist.

As far as what to do therapeutically, this patient has active disease. This patient needs more drug. Does she need more hydroxychloroquine? Does she need to take hydroxychloroquine, or does she need another agent? Well, the first step here is actually easy.

Do a hydroxychloroquine blood level. It'll tell you whether the patient's on the drug or not or whether the patient needs a higher drug. Because if you up the dose in this particular patient who's thin, you'll be going from a almost therapeutic dose of below five milligrams per kilogram in a very, thin young woman to going up to four hundred milligrams a day where she'll be, over the five point five milligram threshold, should be over six something, and you worry about then toxicity. Michelle Petrie and colleagues have shown that doing hydroxychloroquine levels are very effective in telling whether the patient is taking the drug or not, maybe not so effective in telling you about the efficacy of the drug or optimization or correlating that with clinical outcomes. But nonetheless, doing a hydroxychloroquine level, which is widely available, can be easily done as a measure of compliance.

You know, when this comes up with other drugs and other situations, if you have the choice between a subcutaneous injection or an IV infusion of a TNF inhibitor, a CTLA-four inhibitor, a IL-six inhibitor, and compliance is an issue, go for the IV, you'll know what they're taking. So the data on compliance is really shockingly, bad. When it comes to primary care, a study from Consumer Reports showed that, when a primary care physician writes a new prescription for an antibiotic, only a third of patients would fill the actually, one third of patients would not fill the prescription, even though they went to the primary care for their cold and a want of an antibiotic. So that's kind of messy. And how do you deal with that?

It's just as bad in rheumatology where the data on hydroxychloroquine compliance and adherence is really quite bad. Several different studies show that fifty to fifty eight percent of patients are adherent to hydroxychloroquine when they have a diagnosis of lupus. That means that forty to fifty percent of patients are not taking the drug that you prescribed or certainly not taking as much as you prescribe. So that's problematic. Does this happen in other disorders?

Yes, it happens in psoriatic arthritis. It happens in rheumatoid arthritis where the data on biologics is that somewhere between thirty and thirty five percent of patients don't take the biologic that you prescribed for their problematic inflammatory disease. So the question is, what can you do about it and what's the consequence of this? Well, the consequence is cost. The costs are large.

It's the cost of the disease not being controlled, which is sort of silent and deadly. It's the cost of delay in therapy, and it's the cost of, an eroded relationship between you and the patient. So how do you deal with this issue of non adherence? I mean, are many ways to look at this. I think that you have to realize it's a matter of trust.

And trust is in short supply in this world. And when patients are sick, newly sick, going to you and new doctor, and you're Mr. Scientific with all your big words, you're scaring them, and trust is hard. So you need to engender trust. I love this quote from Seth Godin that says, nobody believes what I tell them.

Nobody believes what I show them. They often believe their friends, and they always believe the story they tell themselves. That means if you want them to believe in you, you gotta be their friend, or you have to be, you know, somehow get inside the story that they're telling themselves in their head. How do you be their friend? Well, obviously, your attitude issue, a communication issue needs to be, under sort of made a priority by you.

And I know that you didn't go to medical school to become friendly and to talk, down to the patient level, but that's what's necessary to be successful as a physician. I think you should think about, our paradigm which says is see them, diagnose them, bring them back in two or three months. That's two or three months of them not taking what you prescribed. Maybe you should bring back new patients with new important therapeutic starts in two weeks to find out if they're taking the medicine or not, to find out why they're not taking the medicine, and to work on the issue of trust between you and the patient. Be sure to check out RheumNow live.

It's March 13 through the fifteenth in Fort Worth. Go to roomdown.live. Check out the faculty. Great rheumatologists like you go to great meetings like this. Tune in for more QD videos this week.

This is QD clinic, and I'm doctor Jack Cush. QD Clinic is brought to you by RheumNow live, 03/13/1415 in Fort Worth, Texas. You know, great meetings are actually scarce. There are a lot of meetings you could go to, but great meetings, they're scarce. What's a great meeting?

I think meetings that are ones where you can meet your peers, ones where you can talk to the faculty easily and frequently, ones that allow you to talk, question, and vote, and one that delivers content the way you want it, when you want it, how you want it. As best I can tell, RheumNow Live is maybe the only one that meets those criteria. Go to roomnow.live to register and check out the meeting. Today's case is called, I don't know why I'm here. You've seen this.

You get consults, patients walk in. Hi. Who sent you? Doctor Smith. What are you here for today?

I don't know. It's nowhere on the paper. It actually is reflected in a pre visit questionnaire where there's not much written down. And these patients may have tons of problems or no problems at all, but they don't know why they're here. The question is, how do you handle this very special challenge, otherwise known as a really bad consult?

It's sort of the clinic version of being in a purgatory situation stuck in traffic, stuck in an intersection, what do I do when the patient declares, I don't know why I'm here? Well, have a few resolutions for you to think about and to employ as I do in this situation. Number one, when the patient says, I don't know why I'm here, the immediate decision from that is this is a one visit consultation only. We're done. I'm going to give the patient the time that they need to figure out why they're here, but we're done for almost everyone.

And of course there's going be a few people that will be the exception to the rule. In that visit, I'll figure out why you're here. I may even do labs and I may follow-up remotely, by mail or by email. But most importantly, I'll end the visit by sending a copy of my note to the referring MD, finding in a very subtle way to chastise him for this sort of ambiguous consult, including information like, I saw your patient, provided her with information. The notes that you did not send were blatantly not helpful in my achieving a diagnosis and plan.

You know, again, guilt goes a long way so this doesn't happen again. After that, I think that there are two kinds of consults that you're going to see here. One is a one issue or one lab patient. They're there for one lab problem or they're there for one issue that may or may not be related to their other comorbidities. These are easy consults.

I mean, it's an ANA consult, you press a button, you know what you're doing for the rest of the visit, and you can educate the patient on this one issue or this one lab and whether they need to worry about it or not. And then also, you have to give every patient hope, goals, and rules. So tell them where they're going to go to get further resolution to this problem which you're highlighting for them since they didn't come in with a highlighted problem to begin with. The other kind of patient is that even though the patient doesn't know why they're there, when you talk to them there's a floodgate of information, problems, symptoms, abnormal tests, hospitalizations, and it's overwhelming. Like if we were trying if we try to actually fix these, we would be there for three hours.

I think you have to quickly focus on the issue or the issues that you can best manage, things that you can fix. Fix them, educate the patient, and move on. Give the patient rules for why and when they might could return for a re evaluation by you, the rheumatologist, who they may not need to see in the future. Anyway, that's how I handle I don't know why I'm here. RheumNow is where you should go to find more information.

RheumNow Live, you can register. More QD videos each day. Welcome to QD Clinic. I'm doctor Jack Cush. QD Clinic is brought to you by RheumNow Live, the best damn little meeting in Texas, if not The United States.

Today's case, hepatitis B and choice of biologics. So I get this message from a great buddy of mine, doctor Alan Kivitz out there in Altoona, Pennsylvania asking me, what would you do if the patient who needed a biologic also was being treated for active hepatitis B? Meaning the patient's hepatitis B surface antigen positive is currently taking entecavir as chronic antiviral therapy, and the patient has active inflammatory arthritis. Now, didn't ask whether this is rheumatoid arthritis or psoriatic arthritis, but I answered the question nonetheless. It's important to note here whether the patient has active hepatitis B infection with a hepatitis B surface antigen positivity, a high risk situation, or is a resolved hepatitis B infection where B surface antigen is negative but B core antibody is positive, hepatitis B core antibody positive.

So what you need to know is that there's a lot of data about reactivation and worsening of hepatitis B with certain biologics. So, it's been reported reactivation of hepatitis B usually in core antibody positive patients, resolved patients, but nonetheless reactivation or worsening has been reported with TNF inhibitors, with abatacept and with rituximab. Now there's a lot of data, sketchy data nonetheless about rituximab worsening chronic viral infections and reactivating it, and it's been especially seen with hepatitis B, not with hepatitis C interestingly. TNF inhibitors well reported, and certainly the same with abatacep. The bottom line here is that in those situations, can probably use hepatitis, you could probably use TNF inhibitors and abatacep in people who are core antibody positive, but monitor them with obviously LFTs and viral load testing.

Rituximab, I don't know if I would use it, some people have and probably only with chronic antiviral therapy, but people with a core antibody positive resolved infection can receive biologics with a low risk of reactivation, roughly, about one point five to two percent risk. So they need to be monitored both with LFTs and with, viral load testing. Now there are other biologics, obviously. We do know that, tocilizumab and tofacitinib have LFT elevations as a problem. No real reports of that.

In fact, there's a number of reports showing tocilizumab can be given to people who are core antibody positive. We do know that there's a problem with LFTs and liver with methotrexate, leflunomide, and sulfasalazine. So I probably wouldn't use those drugs. Again, this patient has a core and I'm sorry, a B surface antigen positive acute infection, it's a high risk situation, very high risk. So, I pretty much would not use any of the above therapy even though the patient is on background, antiviral therapy.

Their safest drugs might be hydroxychloroquine or Anakinra, maybe even cyclosporine or azathioprine. What I said to Doctor. Kivitz was, if the patient has mild disease, would use one of those drugs I just mentioned. If the patient has really severe arthritis, then you could undertake a TNF inhibitor or abatacept, watching the patient more closely as far as their risk, because again this is a high risk situation. So, not everybody needs antiviral therapy unless you have active infection or you think a patient with a chronic resolved situation might be at high risk reactivation, then you would use chronic antiviral therapy, in this case, Entecavir.

By the way, if this patient had psoriatic arthritis, I think you could safely use IL-seventeen, IL-twenty three or IL-twelvetwenty three inhibitors to treat psoriatic arthritis, and for that matter even ankylosing spondylitis. The bottom line is you want to know a few things. Is it core antibody positive or B surface antigen positive? Core antibody low risk, watch the patient. B surface antigen high risk, watch the patient.

Chronic antiviral or acute antiviral therapy is needed. Maybe the dividing line on risk other than the patient's clinical status and comorbidity could be the status of their hepatitis B surface antibody. If they have hepatitis B surface antibodies, they're immune and they may have a better a lower risk overall. It's been shown in several reports. However, if they are B surface antibody negative or low, they are at higher risk for reactivation and or worsening of that infection.

I hope this is helpful. Certainly, it's ominous and maybe we'll find out later what Doctor. Kivitz did. Go to roomnow.live to register. More QD clinic videos and podcasts coming up.

Hi. This QD video is brought to you by roomnow.live. I'm doctor Jack Cush from rheumnow.com. This case is called bugs versus crystals. So a 55 year old man shows up in clinic last week.

I've actually seen him three or four times before. He's come in with complaints of episodic joint pain, sometimes with swelling. He takes over the counter, naproxen, seems to get better. So I but I don't see much on exam. He doesn't really have anything.

He has no history of of arthritis or gout. I do labs on him. Everything's normal. No acute phase reactants, normal uric acid. He's got nothing to show so I'm not really doing any x rays.

And now on his fourth or fifth visit he shows up with boom, a right knee effusion that is hot and painful and he can't step on it and it's like dude that looks bad. And he says, Yeah, I know, that's why I'm here. So, what do we do? Well, the real problem here is that the knee that's swollen is also a knee that has an arthroplasty in there. He had a right knee arthroplasty about seven or eight years ago.

He said this happened once before and the orthopedist drained the fluid. And I said, I need that fluid to know what's going on, to know what to do with you, but you need to go back to your orthopedist and have them draw the fluid out. And that's exactly what happened. In the meantime, while waiting for that to happen, which took about two or three days for that to happen, we got x rays. And because he had complaints before in his shoulder and his hands and now the knee, we did x rays of all those spots and found, guess what?

Chondrocalcinosis in the shoulder, in the meniscus, and now also in the triangular fibrocartilage of the wrist, suggesting strongly that he has calcium pyrophosphate deposition disease and most likely is going to have pseudogout in that knee. So the orthopedist sticks a needle in. He says he gets back a lot of scary looking, mucky, opaque synovial fluid that he was sure was septic, and he sent it off for culture. And now four days later, it's not growing anything, but the cell count came back at 65,000 with 89% polys. He sent off some other special tests looking at defensin levels and whatnot, suggesting it might also be infection.

Wants to know what do I want to do. So the question is, does he have septic arthritis with 65,000 white count, or does he have a crystal induced arthropathy? You wanna know, of course, what did polarized microscopy show. He didn't do it. So when it's too late, that fluid's down the drain.

I think at this point, you gotta make a decision, and my decision along with his was to treat both. My approach is give him a course of prednisone, whatever you wanna do, intramuscular intramuscular or, you know, a Medrol dose pack, you know, something to take care of the steer, you know, the the acute, crystal induced, arthritis, mon arthritis, and then give him antibiotics. So he got, you know, twenty five milligrams for a few days, twenty, fifteen, ten, five, off. And while he's doing that, he's also taking Augmentin. The orthopedist wants to put him in the hospital and lavage it and get ID involved, and patient doesn't wanna do that.

So we'll see what happens. But I think that, you know, the point of this case is you can have both. You know, it's not uncommon for an acute crystal arthropathy to present, with a septic joint at the same time, and you have to always be aware of that or be wary of that. I think if this patient doesn't do well, then it'll be in the hospital. Why is the patient not in the hospital?

Patient looks great. The patient has a normal white count. The patient is afebrile. It's just this right knee that's really bad. So, yeah, I think you could make a case for putting the patient in the hospital.

The patient said, we'll try as an outpatient. I said, that's fine. We'll see how you do through the weekend. I guess I'll let you know at a later date. At another QD video or QD clinic, tune in next week.