QD Video - Week 8 Save

Hi, this is QD Video brought to you by RoomNow Live, where keen mind bending rheumatologists will go to see a great rheumatology meeting in three weeks, but you don't have to go. It's also now a free online streaming internet thing. So go to roomnow.live and register and watch sixteen hours of some of the best education and interactive education you'll see. Today's case is pregnancy and dermatomyositis. It's a 25 year old African American female who was diagnosed with dermatomyositis about a year and a half ago.

She had a CPK of 10,000, an abnormal EMG, and, was put on steroids and methotrexate. Had a sort of slow response, know, dermatomyositis with steroids including eighty milligrams of steroids doesn't always respond right away. It often can take up to twelve weeks to respond, but she did really well and, was doing well and then this year since she's newly married she wanted to get pregnant. We told her can't get pregnant on methotrexate but can get pregnant on azathioprine. We substituted azathioprine for methotrexate and told her to stabilize on azathioprine for two or three months and then get pregnant.

She shows up now pregnant and just stopped her azathioprine about a month ago. She says she's six weeks pregnant and she's doing well, and there's no other issues at hand. So the first question is, can, patients with polymyositis, dermatomyositis get pregnant and since many of them are female, many of them are young, the answer is yes. And the rules are basically the same as that for especially lupus, but really all autoimmune disease and that is best to get pregnant when you're well controlled. She's very well controlled.

Best to get pregnant when you're on pregnancy safe medicine. She's on pregnancy safe medicine. And it's best to get pregnant when you're ready to do so and understand understand the rules. So she's done very, very well. Her CPK has been normalized.

She's on, was on azathioprine and now she's really on nothing prenatal vitamins and whatnot and she's six weeks pregnant. I think the checklist here is, as I said, beyond the safe pregnancy medicine, you probably need to assess her as you would a lupus patient. And the bottom line though is do patients with polymyositis, dermatomyositis have worse pregnancies as can be seen in lupus, not as much in rheumatoid and other inflammatory arthritis? And the answer is, it seems like it behaves more like a lot of the other inflammatory arthritities rather than lupus because there's not a high rate of pregnancy failures. There's not a high rate of miscarriage.

It might be a little bit elevated. Many patients with autoimmune disease have a slightly higher rate of spontaneous fetal loss but again the numbers when I look at a bunch of series and they're usually like twenty, thirty, fifty. Here's one from seminars arthritis rheumatism from last year from Kolstad and colleagues and they had you know what was their their cohort was they did actually a controlled study from the from actually claims data and they really did not show any higher rate of length of stay or complications in women who had myopathy who also had pregnancy. There was also no higher rate of hypertensive disorder. So doesn't seem this group has a higher rate of complications, doesn't seem has a higher rate of pregnancy, induced hypertension or of anti phospholipid syndrome but I would go ahead I did go ahead and tested her for anti phospholipid tests.

I did three of them. The RPR, the loop anticoagulant and specific antibodies for anti cardiolipin and beta two glycoprotein. And then also test her for SSA SSB. I don't expect it to be an issue. She's gonna go forward.

We're gonna follow her closely. Again, she still just stopped the azathioprine a month ago. She's gonna come back and see me in two months. During this pregnancy I'm going to see this patient probably three or four times including right before she delivers and about a month after she delivers especially if she chooses to be on no medicine. So the story is you know that the mother's health is good she's got a good chance of making a healthy baby.

That's the big and first priority. So you know, she's good going into the pregnancy, it's likely she's good to be, continue to be good during the pregnancy and then the issue is what will happen in the post partum era. Again, you can restart the DMARD therapy if needed at any time at this point. You could even be more aggressive with DMARD therapy or other therapies since the baby is soon to be already made, organogenesis being completed at eight weeks. So again, I'm optimistic, and encouraging on this pregnancy and, we'll watch her closely.

We'll see her at two months, six months, eight months and then postpartum. That's pregnancy and dermatomyositis. Tune in for more QD videos this week. Welcome to QD Clinic brought to you by roomnow.live. Guess what's free?

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Today's case is when it's not rheumatoid arthritis, what is it? A 67 year old white fellow comes to see me for the first time. He's coming as a second opinion consult. He's been treated by another rheumatologist for the last four years with a diagnosis of seropositive rheumatoid arthritis. At that time, he presented with pain in his hips and his knees, later spread to his fingers and feet, he says with swelling.

And he did have an elevated, CCP antibody at 160 units, but a negative rheumatoid factor. X rays were done repeatedly, did not show any evidence of erosion. He's been treated largely for the last four or so years with methotrexate. Says he's done relatively well, but he intermittently has to take steroid pulses or bursts for two or three weeks for his flares. He's had a problem in the last few months in that he's had carpal tunnel surgery on both hands.

He's had a few flares. His other doctor is toying with giving him a TNF inhibitor or tocilizumab as an infusion and he comes to me for a second opinion. So when I see him, he has a number of tender joints. In fact, he's got 13 tender joints, no swollen joints, and he has a CDAI score of 38. He's got a really high HACS score and a nine out 10 pain score.

And, but really nothing to show for rheumatoid arthritis even though he's done really poorly, and says that well now he's on five milligrams of prednisone. He was on fifteen then ten now he's on five. He says last week his MCPs were all swollen up. Okay. So but I don't see any evidence of rheumatoid arthritis.

So the question is, is it rheumatoid arthritis or not? And the rules on managing these kind of cases is if you really doubt the diagnosis, first thing to do is nothing. Meaning give the patient time, you might need to see them two or three times to make sure that they're not going to have synovitis especially if you start to withdraw therapy or try to restrict the use of steroids. Second, you want to look for a sequelae of inflammation meaning if this person has had repeated chronic intermittent long term inflammatory synovitis there should be some sequelae meaning he should have what? Limitation of motion, contractures, evidence of deformity or in the least x-ray evidence of joint space loss and erosions compatible with the diagnosis.

And lastly, you might want to look for a laboratory evidence of inflammation. We're doing that at this visit, although past labs have not shown him to have a high ESR or CRP. So forget about this case, we're gonna see where what he has and we're gonna just continue his methotrexate for now. He does not merit, you know, aggressive therapy. I want him to be off of prednisone.

I'm gonna slowly wean him off his five milligrams and I'm going to treat him for pain and sleep problems. And I'll tell you my experience with these kind of cases. My experience with like, I have to have a few thousand of these kind of cases is that when I don't think that they have rheumatoid arthritis I'm right eighty percent of the time. Meaning that if I withdraw therapy, we're slowly wean them off therapy, I'm gonna be wrong ten to twenty percent of the time. Meaning they're gonna flare up, they're gonna show synovitis, I'm gonna eat, you know, eat crow and reinstitute anti inflammatory or DMARR therapy.

But 80% of the time I'm right. And so when I'm right, what was it that they really had? Very common is they had osteoarthritis or inflammatory osteoarthritis. Most of them actually have fibromyalgia and a sleep disorder along with an other arthropathy, usually osteoarthritis. This is more common in the elderly.

So pain that gets amplified, pain that doesn't respond is often pain being driven by poor sleep, fibromyalgia, myofascial pain disorder. Uncommon are other inflammatory arthritities, specifically, truly inflammatory erosive OA or palindromic rheumatism, which can be intermittent as you know. I'm not sure I truly believe in that diagnosis of palindromic rheumatism, but I've seen it enough where I'll keep it on the list. Uncommon, less than uncommon, or exceptional are actually other inflammatory arthritis like masquerading or being called rheumatoid arthritis. That would include psoriatic arthritis, a peripheral spondyloarthritis, even polymyalgia rheumatica, the occasional undiagnosable undifferentiated inflammatory arthritis or idiopathic, meaning I have no idea arthritis.

Don't use that term but it's on some lists. Very rare these cases were actually reactive arthritis that went into remission or IBD or enteropathic associated arthritis that ultimately rears its ugly head. And almost unheard of is, a patient called rheumatoid arthritis when in fact they really have another auto inflammatory, not auto inflammatory, sure, but really another autoimmune disease like scleroderma, lupus, myositis, you know, those sort of things. So most of these really do turn up to be degenerative disease with or without sleep disorders. Some will actually have inflammatory OA, but I think that's where most of them go.

So that's my experience with what it is when it's not rheumatoid arthritis. Be interested in hearing your thoughts. Tune in tomorrow for more QD Clinic. Hi, this is QD Clinic. I'm Jack Cush, QD Clinic is brought to you by RheumNow Live, where you can see a free sixteen hour educational event in a few weeks from your home.

You can register online at roomnow.live. So today's case is entitled Five Pearls on Leflunomide, and it arises from a patient I just saw who came to me and needed some cleanup and some insight regarding the use of leflunomide to control his rheumatoid arthritis. So here are five things that you may not have thought of or may not have heard of in the past. Number one, you can use a hundred milligrams once a week instead of twenty milligrams every day. So leflunomide has a half life of around eighteen to twenty days, very long half life, and therefore, it's perfect for once a week dosing.

I don't do this from the outset, I usually use the usual doses of twenty milligrams a day to achieve a therapeutic effect, and either because the patient's doing very well, or the patient wants to take less medicine or you want to maybe limit some toxicity from the drug, you can take the drug as a once a week dose. I usually take patients who are doing well at twenty milligrams once a day and change them to one hundred milligrams once a week. There are some studies showing the efficacy of this. It tends to have a little less toxicity, and it's very well tolerated. You just have to have to have the patient take five twenty milligram tablets once a week just like they would their methotrexate.

You have to be doubly sure they're not gonna take it every day, so you need to be careful in patient selection as to who you want to use this in. And, again, you wanna continue to ask them, are you sure you're taking this? What day do you take this? Etcetera. Again, they could take, three twenty milligrams tablets once a week or four or five, but I find five tends to work for a lot of people.

You know, people with low body mass could get away with less, and especially if it's being used as part of a combination regimen. One hundred milligram tablets are hard to come by. They were out when the drug was first introduced back in 1998, but I find that, again, converting patients is a very easy thing to do, and the monitoring is exactly the same. You'll find that, again, they'll have either the same efficacy and safety profile and may have better safety. Item number two, leflinamide is actually uricosuric.

It actually does enhance uric acid excretion, and in those patients who have hyperuricemia, it may be able to lower, serum urate levels by as much as 20%. So could this be used in patients in whom you have some question as to whether the patient has RA and gout? I always teach, you can't have RA and gout, they don't coexist. Well, literature shows there actually are a few patients. If you look at all RA series, there's about five to eight percent who have hyperuricemia.

Most RA patients tend to have very low uric acid levels. And similarly, you look at all gout series, you'll find rheumatoid factor in five to, again, eight percent. So there are some patients even whom I'm a little confused about and if you wanna cover your bases, Arava or leflunomide might be an effective drug in that instance and yes, you should monitor uric acid levels if that's your goal of using the drug in that instance. Number three, the package insert says that when you start leflitomide, you need to do a test for TB, PPD or QuantiFERON or TB spot, because there's actually a higher risk of developing TB or reactivate reactivating latent TB in patients who take leflinamide. I know it's a head scratcher, but it is one of the DMARDs, it's probably the only DMARD that I know of, that actually requires you, actually, I guess you could say the JAK inhibitors now require you to do TB testing, but methotrexate, plaquenil, sulfasalazine, hydroxychloroquine, all the ones we used in the past, cyclosporine, aprimolase, again, are not required, but you, we do them by convention because we're doing them for all the TNF inhibitors where it's more important.

But for this drug, you do need to do a TB test, and you do need to treat it exactly the same way as you would a TNF inhibitor. There is a higher rate of reactivation of people on, on leflunomide. Number four, the washout. So when do you do a cholestyramine washout? You could use charcoal, but cholestyramine, also known as Questran, comes in four and eight gram packets.

You well, the issue is whether you're gonna do a full washout for someone who's pregnant and you want to or wants to get pregnant, you wanna totally get the drug totally out of their system. Again, it has a very long half life. It stays in the enteral hepatic circulation for a long time, And to get this, fully out of their system, you must use cholestyramine. The regimen, look it up online, but it's basically eight grams TID for eleven days, and you're supposed to, in the case of pregnancy, check for the m one metabolite that can be measured online with commercial laboratories. And it's in the package insert the details as to how you go about doing that.

I have found that in toxicity management, whether it be hair loss, diarrhea, GI symptoms, or or hypertension that you might do well to lower the dose and or by using a lesser regimen, and that would be, either four or eight grams TID for five days. Eight grams TID for five days basically washes out about 80 to 90% of the drug out of the enteropathic circulation and can be a good way of managing toxicity. And lastly, the data on pregnancy. We just mentioned you need to do a full eleven day washout for people who wanna get pregnant or people who are pregnant. The data on pregnancy and leflunomide exposure are surprising.

Leflunomide in the old days, as you know, it was called a category X drug. It is fetotoxic, but yet the data in two large series, these are not really large, one was like 71 patients or seventy eight patients. The other one was like fifty one patients. And all the reports out there show that in women who are on leflinomide who conceived, after being exposed had no greater incidence of fetal malformations and tended to have the same outcomes as do other RA patients. Again, not all of those patients were washed out.

A lot of them were continued. So while it should be an aborted patient or a fetotoxic, the clinical experience shows that it's really not that bad, so I wouldn't, panic if someone actually got pregnant on this drug. Also, data on paternal exposure is like other, DMARDs and biologics, it just simply doesn't matter. Fathers who are taking DMARDs and biologics with the exception maybe of cyclosporine, not cyclosporine, cyclophosphamide and, sulfasalazine, which lower sperm counts, really, DMARDs and biologics have no impact on fertility, on offspring, etcetera. So same thing here.

If a father's taking leflunomide and, the mother gets pregnant, no read no news no reason to panic or, or send the patient, you know, with urgency to the, obstetrician. Those are five pearls. I'll I'll I'll give you one more. I use this drug in managing myositis. It's very effective in managing myositis at the usual RA doses and maybe in conjunction with other drugs.

As you know, the drug is broken down into the m one metabolite which is also known as teriflunomide. That drug was actually approved, I think, a year or two ago for use in multiple sclerosis, and it's the m one metabolite that is marketed and it's about 50 to 500 times more expensive than leflunomide. So, it is being used in other disorders, multiple sclerosis. I use it in my eyes with great success. There's a little bit of, literature on that, but not a lot.

Anyway, we're done with pearls for the day. Tune in tomorrow for more QD pearls.