ACR2019 Day3 Save

Hi. I'm doctor Jack Cush, and this is the ACR 2,019 podcast. We're coming to you from the annual meeting in Atlanta, Georgia. This episode is a collection of our faculty reports, interviews, and panel discussions recorded live from the RheumNow booth. I hope you enjoy and learn.

Hi. I'm Chad Deal. I'm at ACR in Atlanta. Just attended session on metabolic bone disease called Bad to the Bone. The session included hyperparathyroidism, hypophosphatasia, and osteomalacia.

I want to mention few points on, hypophosphatasia. It's of interest to rheumatologists who are interested in metabolic bone and fracture, and also rheumatologists because of its articular manifestations, specifically chondrocalcinosis, pseudogout, calcific periarthritis. The key to making this diagnosis is a low alkaline phosphatase, almost always less than 40, many times less than 30. That's the real key to making the diagnosis. Occasionally, you will need genetic studies.

It's caused by a gene defect in, the gene that controls tissue non specific alkaline phosphatase. Patients may present as adults, which is where adult rheumatology comes in, and it's treatable because there's a new medication released in 2015 called Aphotase Alpha or Strinsic that's very effective for this medication. Medication. More information, please go to room now.

Good afternoon. My name is Doctor. Guillermo Valenzuela. I'm a rheumatologist, clinical immunologist. I practice of South Florida precisely in the location of Plantation which is close to Fort Lauderdale in Miami.

I had the opportunity here today and I thank RheumNow for allowing me the chance to share some of the thoughts I have about one of the disease states that we are quite interested. Traditionally what made us rheumatologists or historically made us rheumatologists which is gout, a condition that is I guess coming back I would say because we have now more science about the understanding of what gout is and where gout is positioned in our whole diagnostic process in the patient especially with polyarthritis and other conditions that are perhaps not symptomatic arthritic. So I won't be speaking about a specific poster but there's some collective information that we're gathering here during this meeting that relate to the ways with which we can diagnose gout and therefore potentially help patients with this diagnosis. We had a presentation yesterday where we saw the impact that specialized imaging has in recognizing patients and helping make a differential diagnosis especially the utilization of the DECT dual enhanced CT. So that is one of the technologies that I would like to see that in the future we have more available in order to help stratify patients and also to design clinical trials with the hope of getting more patients to be diagnosed in the early phase.

And also I would like to make the point that many of the cases we see lately with for example seronegative rheumatoid arthritis, if we look back in the literature we find a high degree of association in those patients with gout that is clinically diagnosed. Models of synovial biopsies have demonstrated the presence of micro topphies deposits spread out through the synovium. I just remind you that patients with seronegative arthritis as such always think about gout even if the serum uric acid levels are not as high as we normally know. So this is one of the pearls that I like to use in our practice with our doctors and with our students. Just remind about the importance of gout, think about gout always in the differential diagnosis.

Don't forget about gout. Gout is traditionally the condition that has made us a rheumatologist that has made the specialty rheumatology grow for years. So I encourage you to review the very many publications, especially the ones that relate to the imaging related to gout diagnosis and how we can treat it. Just make sure you don't hesitate in treating patients as aggressively as you can and have the same aggressive approach as we have when you treat rheumatoid arthritis or psoriatic arthritis or for that matter any other autoimmune condition. So I think this is the time we have for now, I thank you very much, and I thank RheumNow for giving me the opportunity to talk to you and just swing by the booth here at RheumNow, and have a good afternoon.

Hi. I'm Paul Sefka, coming to you from the RheumNow booth at ACR two thousand nineteen in Atlanta. I'd just like to talk about a couple abstracts that are pretty popular at this meeting regarding hand osteoarthritis. They're numbered right next to each other. The first one is seventeen fifty nine.

This is an abstract for patients were tried, patients with hand osteoarthritis were actually tried on low dose methotrexate, for erosive hand osteoarthritis. It's a fairly small but randomized controlled trial. It lasted one year and the primary endpoint was a decrease in pain. Unfortunately, that endpoint was not met, but very interesting. It did decrease progression of erosive and damage type changes in these osteoarthritis patients.

So interesting study. There's a lot of things that we don't really have that we can offer these patients with hand osteoarthritis, so maybe this is something that we'd think about for some of these patients. The other abstract is 1760. 1760D. This was a six week treatment with low dose prednisone for the pain of hand osteoarthritis, so the thing that wasn't met in the prior abstract.

This was again a randomized controlled trial of ninety two patients and very significant improvement in hand pain, which therefore improves function. Between these two abstracts, maybe not something that you're going offer all of your patients, but if you discuss risks and benefits with your patients, maybe this is something that you'd like to offer. Thanks. For more information, go to roomnow.com.

Hi, Jack Cush, coming to you from the ACR booth here in Atlanta. The ACR twenty nineteen meeting has been a great one. Saw a fine presentation by Doctor. Dan Solomon Monday afternoon about the tox city of methotrexate. His data was drawn from a very large trial that you're familiar with, the CIRT trial, C I R T, published in New England Journal last year.

This is a trial of methotrexate, not in rheumatoid or arthritic patients, but in patients at risk for cardiovascular disease. So it was a trial that actually looked at whether or not methotrexate would lower the risk of cardiovascular events in patients who are at risk, diabetics, hypertensive, those who are obese. So in a high risk population, they gave methotrexate or placebo, no other DMARDs or arthritis medicines to see what would happen. As you know, the study was ended for futility, it did not work in preventing events and maybe that didn't work because they did not require a high CRP to go into the trial. But there are a lot of offshoots of the SURDS trial showing the efficacy of these drugs in other conditions for instance.

So one analysis is what I'm talking about here and that is the toxicity of methotrexate. They enrolled I think seventy, forty seven, eighty six patients, almost four thousand eight hundred patients, and again treated, half of them treated with methotrexate, half of them not. Doses that we usually use, fifteen, sixteen milligrams a day, everybody on background folic acid. At the end of the fifty two week study, about a sixteen percent, seventeen percent increase in mild, adverse events, nothing really severe. There were actually serious adverse events were, very, very few and not significant here.

The most common things that they saw were, as you would expect, GI toxicity and nausea and oral ulcerations and things like that, that was almost a doubling of the rate. Pulmonary side effects was actually elevated, infection was elevated, most of those being very minor infections, URIs as opposed to pneumonias, although pneumonias were up as well. A doubling of the rate of skin cancers that included basal cell melanoma and non squamous cell cancers with an SIR hazard ratio of around two. So that's sort of something's been out there before and this has confirmed it. If you're worried about the risk of pancytopenia, number one, use folic acid in everyone.

Number two, know the data. The data says that it is increased with methotrexate, but it's a very, very low event rate. In the placebo population it was three per thousand, those on methotrexate it was thirteen per one hundred giving you a hazard ratio of two point one. So again, watch for it but it is relatively rare. Pulmonary manifestations were mostly mild, included a few cases of pneumonitis but methotrexate induced pneumonitis was rare.

Seven cases per one hundred, actually zero point two cases per 100 patient years, that's two per one thousand, it's a rare event, they only had seven cases in the whole study. The other side effects to be worried about would be infections, they had mostly an increase in non serious infections, mild URIs, skin pneumonia was increased twenty six percent but it was not significant and shingles, a slight increase in shingles as well, but again, not significant. So the bottom line here is in this trial, the drug was well tolerated, did very well, As far as safety, didn't work as far as cardiovascular outcomes. They had seven cases of possible methotrexate induced pneumonitis. It's a very low event rate of again, that's about two per one thousand patient years.

A mild increase in infections, about fifteen percent, a doubling of the risk of skin cancer, and the interesting thing was they did have cases of cirrhosis, very few, but guess what? Cirrhosis was only associated with mild to modest elevations of LFTs, not the big time elevations, which should bring you back to the original ACR guidelines on monitoring methotrexate, looking for a number of mild to moderate elevations, nine out of 12 over a year period, something along those lines, that would then make you suspicious, work it up, or discontinue the drug. Great presentations, the other presentation that Doctor. Solomon has, I think it's today, it's a poster twenty three fifty seven on the same subject. Again, that's it for this presentation on safety of methotrexate.

Tune in at twenty three fifty seven. Tune in for more videos here on RheumNow.

Hi. I'm doctor Janet Pope. I'm a reporter at RheumNow. We're at ACR twenty nineteen in Atlanta. I wanted to talk a little bit about viral reactivation and vaccination in in some posters that were presented at this meeting.

So these are early days preliminary results, but poster two one one five looked at whether there was viremia or reactivation of BK virus. The risk of VK virus is that it can be a slow virus that can potentially cause problems in the brain, leukoencephalopathy. So what they did early days fifty six patients with various inflammatory arthritis and connective tissue diseases and they saw no difference in viremia whether the patients by diagnosis or no difference with lupus and RA versus say psoriatic and no difference with the meds they were on steroids and DMARDs. Why is this important? Because corny virus, a cousin, gives, leukoencephalopathy and that has been shown by this group and others to be elevated in viremia, in RA and lupus and not other diseases such as other inflammatory arthritis and it was elevated in their old work, the corny virus with rituximab in particular.

So at this point in time we can rest assured that BK virus in the early days of looking at it doesn't seem to be a player of reactivation. The next thing is, number two zero nine three, and that was looking at the safety of the nonlives, so the the killed vaccine, for varicella zoster called Shingrix. And they were looking at the safety with respective flares, before you got the vaccine and after. So saying not will this vaccine work, that's a different question, but will it cause a flare in my patients because there's a surge of gamma interferon when you get vaccinated. So they only have forty seven patients, but so far by rapid three, they saw no change in flaring before or after the vaccine.

So it's something that probably is indeed safe for our patients, and you should use your country guidelines on when to vaccinate. That's it for RheumNow. Thank you.