RheumNow Podcast- A Good First Impression (1.24.20) Save

It's the 01/24/2020, and this is the Room Now podcast. Hi. I'm doctor Jack Cush, executive editor of roomnow.com. This podcast is brought to you by, guess what, roomnow.live, next best meeting in rheumatology. This week on the podcast, the challenge of auto inflammatory disease.

And when you're dashing and dining, what are you doing to your gout? And remember, your grandmother said you only get one chance to make a good first impression. I think she was talking to you about rheumatology. So let's start with a discussion on psoriatic arthritis and what happens before you get psoriatic arthritis. This particular study looked at health care utilization by primary care doctors and primary care practice, and also amongst musculoskeletal specialists in a cohort, almost five hundred patients with psoriatic arthritis, and compared that to what was about twenty three hundred psoriasis patients.

What they showed that there was a doubling of health care utilization, with the primary care doctors, mainly for musculoskeletal complaints in the people who later on developed psoriatic arthritis. This was seen one year prior to diagnosis, it was also seen as far out as five years prior to diagnosis. The same can be said as far as the utilization of healthcare specialists that are musculoskeletal specialists, maybe orthopedist, rheumatologist, etc. There was also a doubling of the need for more healthcare services, visits, diagnoses, testing, etc, suggesting that prior to the onset of arthritis there's still a lot going on, maybe as much as five years prior to the diagnosis. Now, we do know there's some delay in the diagnosis here, but it's not five years and not even one year in most people.

So is there such a thing as pre clinical psoriatic arthritis? Yes, it's called psoriasis. A thirty percent, what is it, a third or thirty percent of patients with psoriasis are going to develop psoriatic arthritis. They should be watched, should be treated seriously especially when they have sort of nuanced musculoskeletal complaints not necessarily having swollen joints or, DIP disease or even axial complaints. I think it's an interesting study.

Another interesting study comes from the, Swedish registry, it's called the Rheumatology Quality Register, and they looked at what happens when, patients are put on biologics. And they looked at all biologics, they also looked specifically at abitacip. And what they showed was that the patients who went on biologics, they had much longer drug survival of that biologic when it was the first drug that was being used, meaning it was the first biologic. So people who were biologic naive had a better chance of staying on that biologic compared to people who are on their second or third biologic. Now does that make sense?

It kinda does, but remember that the biologic survival, that we really do experience. Well, I'll ask you, how often do your patients who start a TNF inhibitor or maybe even Avatazep, how long do they stay on that? You'd say, well, really a long time. Well, the data actually argues against that. The what is it, the five year survival or four year survival is only fifty percent.

About fifteen to twenty percent dropout in the first year and it's about ten percent per year after that. So the patients, not a lot of patients actually stay on their first biologic. So knowing that you're going to do best with your first biologic, I would suggest use your best drug first. Work on that. They did show that patients who are on methotrexate had a longer drug survival, especially when it looked they looked at abatacet.

They were fifteen percent less likely to discontinue the abatacet. I tweeted a tweet from the ACR meeting because I was at a meet a a conference this week and we're talking about auto inflammatory disease. Now, you know, they're the well known auto inflammatory diseases like Mucklewell syndrome and traps and familial cold or inflammatory syndrome, there's many of them. Still's disease could be under that category, but there's a lot of in betweeners. You know, patients with problematic urticaria, low grade fevers, intermittent, LFT abnormalities.

Again, it's hard to tell who has auto inflammatory disease or not. I won't go into the particulars of the case that was seen today, at least I will. It was actually urticaria, polyoligoarthritis and sort of oral ulcerations, and the patient responded wonderfully to an IL-one inhibitor, initially anakinra, and probably needs to be on canakinumab because the patient's tired of doing daily injections. Anyway, the point of this, my tweet today was that which was presented by Michael Umbrella from the NIH at the ACR meeting where he on stage said, of all the patients seen in their auto inflammatory clinic at the NIH, this is a world class best service, smartest people, you know, Raphael Golbakmanski, Dan Kastner, all those people are there. Sixty percent of those patients don't have a diagnosis.

So don't feel bad when you're having a hard time reaching a diagnosis. Genetic testing may be helpful, and that's more easily attained these days. Empiric trials of maybe an IL-one inhibitor, might also be the way to go. What about flares of RA? I don't know about you, but I think this is one of the biggest challenge in RA management.

Meaning patients flare, they can call in and do you treat them? Do you bring them in to verify it? Well, this one study actually looked at 80 patients and followed them prospectively over time. Thirty six percent of them actually had a flare with an increase in pain and swelling, and it was documented. But these were initially patient reported flares, and so those patients they brought in and they then did exams and ultrasounds, and showed that there was pretty good agreement between the patient's complaint of swelling and or pain and the clinician's assessment, like in seventy nine to ninety three percent, much more so for swollen joints, that was a big surprise to me, than for tender joints.

So this was very the patient complaint was actually quite specific, maybe not as sensitive as you'd like it to be, but nonetheless, when patients complain with RA, about a flare, they probably are flaring. I think that this is a big challenge because we have what to treat flares. Steroids. Steroids, steroids, steroids, nothing else. We need better strategies.

The DASH diet. I alluded to it in our opener. This is in a very interesting study about the DASH diet, which has been proven to be helpful in reducing cardiovascular risk, in managing hypertension. A DASH diet is rich in vegetables and fruits, low fat dairy, whole grains, poultry, fish, nuts. It's been proven to help gout patients.

Here's a very large study from China. Seventy two thousand patients compared to who are on the DASH diet compared to, I think, a 140,000 people, and it showed that those on DASH diets had basically 30% lower uric acid levels. Now none none of these people had gout going in, but they just monitored their uric acid levels. These reductions were greatest in people over the age of 50, women, and those who are physically inactive. Those were very significant.

So, again, a DASH diet, not a bad idea in everyone, and maybe those who may be at risk for gout. We tweeted a a sort of review about IL-thirty seven. IL-thirty seven is a cytokine from the IL-one family. And this particular review, they talked about it being a potential target in the management of psoriasis. Why?

Because IL-thirty seven, has actually been, down regulated in lesional skin compared to non lesional skin of people with psoriasis. IL-thirty seven levels seem to correlate with dysorgia psoriasis activity. IL-thirty seven is a self anti inflammatory immunosuppressive cytokine. It will suppress a number of things including IL-ten and IL-eighteen and whatnot. And maybe it should be the target of therapy.

The authors of this paper interestingly note that tofacitinib has been shown to increase IL-thirty seven levels and maybe that's the mechanism by which it works in psoriatic arthritis. It was not quite as effective in psoriasis, not approved for that in psoriasis because you needed very high doses. But nonetheless, it's interesting to to see how IL-thirty seven, another cytokine, could be involved. A meta analysis looked at the role of hydroxychloroquine, its clinical and and radiographic success, showed basically the success, the efficacy of hydroxychloroquine was similar to or slightly lower than that seen with methotrexate or sultazalazine. Also, hydroxychloroquine was added to other DMARDs, it increased the efficacy by standardized validated measures.

However, the ability of hydroxychloroquine to improve structural outcomes really hasn't been very well documented. I put up a report about TB and the risk worldwide. This is a sort of country by country evaluation of TB risk, especially in people on TNF inhibitors. The worldwide risk for people on TNF inhibitors is about ten cases per one thousand. It was higher in Asia where it was thirteen and a half per one thousand, and in South America where it was eleven point seven per one thousand.

It was lower in non TB land countries, non endemic areas like Europe where it was six point three per one thousand, and in North America where it's four point three. The number of TB cases in The United States is about four four cases per one thousand. It's gone down actually every year for the last several years. And this says several things. Number one, that number of four point three is people on TNF inhibitors in North America suggesting that in North America where it's not an endemic problem, putting a TNF in there doesn't raise the TB risk very much from four to maybe four point three.

The same can be said in Europe, again a non endemic country. But in endemic countries where risk is higher, it clearly augments the risk and the risk you should recognize that those countries are and people who live in those countries who may come to United States and live here are have a higher constitutive risk. We put a tweet out about the role of TIF1 gamma antibodies in the diagnosis of patients with dermatomyositis, especially the TIF1 antibody being linked to a risk of cancer in patients with dermatomyositis, and that it may impart a risk of cancer when found otherwise, that's part of what the paper was about. I bring it up because this is a new profile of myositis antibodies that you may consider ordering. Now we have all the other ones we would get, the j o signal recognition particle, e j o j m I two p l seven p l 12.

That's part of a panel that you may do, many of which are involved in the antisynthetase syndrome that we're all familiar with. But now we have these new antibodies, TIF one gamma, dermatomyositis in cancer. We have MDA five, those are patients who have myositis without much in the way of skin I'm sorry, skin disease without much in the way of myositis, and are high risk for lung disease, and really bad skin disease, and ulcer lesions. And then NXP-two antibodies we've talked about in the past, those are also cancer associated antibodies in patients with dermatomyositis. They're also seen in people who get calcinosis.

So I'd like to see those in myositis panels. It is actually offered in, myositis panels with some companies, but not all. You may have to order them separately, and it may be worth ordering all three. The CDC came up with a nice report about, The United States and how common physical inactivity is. Across the board at least fifteen percent of Americans are guilty and admit to being totally inactive physically.

And that's a sort of cry and shame because the inactivity has been proven to contribute to at least one in ten deaths in The United States. The numbers basically range from a low about seventeen percent to a high of about forty seven percent, really higher in southern country southern states like Oklahoma, Louisiana, Mississippi, Alabama, also Puerto Rico, higher in Hispanics and non whites. This is a big problem. And while I think physical inactivity is a problem, I think strength is an even bigger problem that no one's talking about. But anyway, this CDC report was about physical inactivity.

We'll end with a discussion of hidradenitis suppurativa. As you know, this is an uncommon problem. It's sort of grouped in the spondyloarthropathies pile, I'm not sure it really qualifies. The question is if you develop hidradenitis suppurativa, for which there is an FDA approved drug now with adalimumab, achieve that through an orphan application, orphan drug application. The question is how many of those people will develop inflammatory arthritis?

Well, turns out that having that diagnosis increases the risk of developing ankylosing spondylitis by sixty five percent, psoriatic arthritis by forty four percent, rheumatoid arthritis by sixteen percent. It sounds like it's somewhere, it's not quite doubling, but it's an increased risk of developing inflammatory arthritis with hydradenitis suppurativa and then maybe aggressive therapy like anti TNF therapy might be appropriate. The bad news is that this is a rare disease and this manifestation is still going to only result in about two to six additional cases per ten thousand per one thousand patients who have hidradenitis for one to two years. Nonetheless, it's good information for those of you who do see these patients. Be sure to check out roomnow.live.

It's a RoomNow Live is a meeting that's designed to change your mind and your practice. More next week on the podcast.