RheumNow Podcast Delays In Diagnosis (3.8.19) Save

Hi, this is the RheumNow podcast for the 03/08/2019. I'm Doctor. Jack Cush, Executive Editor of roomnow.com. This week on our podcast, what's your go to drug for heel pain, Breastfeeding and rheumatoid arthritis, does it happen? How often?

Lastly, could I possibly give you five new pearls about leflunomide that you've never heard of before? You know a lot about leflunomide, but maybe I could tell you more. At the top of the news, an interesting review of shoulder replacement surgery. This is a fairly large cohort that looked at a large number of shoulder replacements. I've always been reared with the success of hip and knee surgery and then really in the last fifteen years, I've been convinced that shoulder replacement surgery is a very viable option for a lot of patients with a great deal of success.

I sort of been talking them up to some patients. I'm not really wild about ankle replacements and I'm not really even recommending MCP replacements, but certainly hip and knee and now shoulder, surely why not? Well, this interesting review came out showing that it's not quite as great as you might think. It turns out that while the risks are low, as far as, the risk of revision, meaning failure of the implant, it's very low in older women, it's actually quite high, maybe three percent. It's quite high in men in their 50s and 60s approaching one in five, twenty three percent.

The revision rate was highest, really in the first five years. And, it turns out really in the first ninety days, the serious adverse events are not minimal, they're actually only about five percent. But if you look at elderly people in that first ninety days, can go as high as twenty one percent. Pulmonary embolism risk was significantly higher, sixty one fold higher in women fifty sixty four. So again, this is a good procedure, it has generally good outcomes, but you do need to know that there is a risk of failure, there is a risk of thromboembolic events, there is a risk of SAEs.

I think I may have tweeted this or reported this before, but I wasn't sure so I'm reporting it again. What is the odds that the paternal exposure to a biologic or DMARD has a significant impact on the outcome of the offspring? Having been on the recent, ACR Reproductive Guidelines Committee, and you'll see those recommendations coming out in the next month or two, it's going to be astounding. It's a lot of information, And we say what this paper says, which is paternal use, so DMARDs and exposure, of the mother to a father who's on a DMARD or biologic has no impact on the outcome of either fertility or the pregnancy outcome. We do know that cyclophosphamide and sulfasalazine are known to cause oligospermia.

It is generally not regarded a safe move to use a cytotoxic in the father. But honestly, there's not a bad data about that other than sperm counts, and maybe sperm damage, but there are no major reports of major malformations. So drugs like abatacin, rituximab, azathioprine, cyclosporine, hydroxychloroquine, methotrexate, leflunomide, and even mycophenolate, in the father is probably fine, when it comes to the offspring and fertility. Remember, mycophenolate is a big, big no no, it's probably our biggest, teratogen of the drugs we use so they cannot be exposed to mycophenolate. Know you all know about methotrexate and leflinamide.

Another interesting study came out about aspirin this week. I don't know if you're watching the aspirin data, but the idea of using daily aspirin, every other day aspirin, low dose aspirin turns out to not be as protective as you would think, and is mainly has its advantages in those who are at risk. So routine use by everybody as you get older, probably not a great idea because there's more risk of bleeding events than actual protection from thrombotic events. An interesting study of almost six thousand-seven thousand AFib patients on warfarin, no arthritis here, this is a cardiology study, and it turns out that more than a third of them were on aspirin when they looked at those who are on aspirin, plus warfarin, there was actually significantly more bleeding 26 versus twenty percent, more major bleeding six versus three percent, and more ER visits, but they had no difference in thrombosis rates, meaning there was no protective benefit to the aspirin when added to warfarin. This sometimes comes up in patients and our patients who have anti phospholipid syndrome and people are waffling on what to use because they can't use this or that because of money or toxicity or whatever.

But basically if you're on Coumadin Warfarin, adding aspirin to it only increases risk. Claims data from the Taiwanese health insurance database looked at a large cohort of JIA patients to answer the question, do JIA patients when they grow up get adult autoimmune disease? Looked throughout their whole dataset, they narrowed it down to two sixty two patients who they followed longitudinally and basically showed that there's a 30 higher risk of autoimmune disease, when they become an adult. The hazard ratio, was 129 fold for RA meaning the JIAs that grow up can more likely become RA not surprising. We know that the JIAs who have the greatest chance of going into remission are the palsies, especially the young palsies and ones who have one or two joints.

But if they have polyarticular disease, seropositive disease, then again, they have a high chance of progressing on. The hazard ratio there was, again, really high. The hazard ratio for developing lupus also high 10. The hazard ratio for ankylosing spondylitis and psoriatic arthritis also very high, eight to forty or something like that. The highest risk was seen really in those who had a JIA onset between the ages of 11 and 12.

So later onset patients were more likely to progress and have autoimmune disease going forward. Speaking of kids, there's a famous study being done in Europe called the Paris study. It's been following, almost two fifty pregnancies, conceived and will follow prospectively, from 2002 to 2008, and the most recent report looked at breastfeeding. It turns out that, in RA, the rates of breastfeeding are actually quite low. So these are RA patients who become pregnant and deliver when I look at them four to six months later, only forty three percent are still breastfeeding.

When I look at twelve months later, four to six weeks, it's only forty three percent, not months, four to six weeks, it's only forty three percent. At twelve weeks, three months, it's only twenty six percent and at, one year, it's only nine percent. Those numbers are much, much lower compared to normal controls, who at four to six weeks, it should be two thirds and at twelve weeks, it should be a half, etc. So, turns out that many of these patients are discontinuing, breastfeeding really because they want to start a medicine to control their rheumatoid arthritis. Again, the particulars of activity and whatnot weren't spelled out in this paper.

There's a nice report coming from Kiki Joints, as you know, Kiki Joints is a patient focused organization, they put out a lot of good information for patients. They've done a survey of their patients, asking them what do you think your doctors need to know? So what are the top 20 things your rheumatologist needs to know? Here's a few of them. One, fix the vocabulary.

You can't talk like they just got their PhD and MD from Harvard, you got to speak at the level they're going to understand. Two, don't rush me. You're rushed, but they don't have to be. They're a little overwhelmed. Three, don't sugarcoat it, meaning when you're giving them new diagnosis, a new therapy, they often think we tend to sugarcoat things.

Four, give them some good information on a realistic diet that may help them. Five, listen to me, we keep talking about that. Six, don't judge me, that's a big problem. Think in our attempt to be authoritative, sometimes we can come off as judgmental, especially when patients don't follow your advice. Seven, flares may last longer than you think.

Meaning I think in general in rheumatology and RA especially, we have a really bad set of plans for flare management. What's your plan? Steroids. What's your plan after that? Often not a lot.

Number eight, the last one I'm gonna say is do a mental health checkup, meaning that they feel that their mental health is often overlooked. You can go to the website, click on this link and see the original source material from Creaky Joints. This week I did a QD clinic that got a lot of play, lot of clicks. The QD clinics as you know, as you might know, are daily videos I'm putting out on patients I see and teaching points that I think we should discuss. They're short, you can see them either on Twitter or you can see them on the website.

We put them in the email. This week we put out one on five pearls on leflinamide. I'll give you the quick overview. One, the dose that you can use can be either what twenty or one hundred milligrams. And one hundred milligrams you say yes, the drug has a really long half life, and you can get away with one hundred milligrams once a week.

Two, the drug is uricosuric, meaning that those patients who you see who may have a question of gout, may have hyperuricemia, maybe leflunomide might be the good drug for the RA patient with hyperuricemia. Three, the package insert says you must do PPD screening or TB screening. Yes, they're at risk when they're taking leflunomide. Four, that we detail the washout regimens. There's eleven day washout for complete washout for people who get pregnant or in severe toxicity of people who want to get pregnant.

And then there's more of an abbreviated short five day washout using cholestyramine TID for five days. But again, go to the QD video, see more. Lastly, it used to be a category X drug in pregnancy while the data in pregnancy is not so bad for those who conceive of a baby while taking loflinamide. A few more reports, a study of almost two thousand four hundred patients with fibromyalgia showed that the meantime from their initial complaint to diagnosis was, what do you think? Actually more than six years, six point five years.

Factors that were associated with a longer time to diagnosis included comorbidity, being younger, the older physician age, meaning you're not recognizing it often enough if you're old like me, meaning I've got gray hair, white hair and you're thinking about retirement. No, I'm not going to retire. But again, there's a significant delay in, the diagnosis of fibromyalgia. Another interesting report came, from The UK on a study of the referral of new RA patients to the rheumatologist. They studied eight twenty two patients that came from a number of different, National Health Trust services throughout UK and Great Britain and Scotland.

They follow these patients, some of them came with a diagnosis of RA, some had inflammatory or undiagnosed arthritis. It turns out that the time from symptom complaint to a consult with the rheumatologist was twenty seven weeks. Shockingly, patients generally had four GP visits before they were referred. Also shocking is that only twenty percent were referred within the first three months of their illness or complaints. So where is the delay?

It turns out the patient is responsible for delay for up to five point four weeks, that the practitioner is responsible for the delay in, almost seven weeks and the hospital when the hospital is involved, is involved in delay for about five weeks. So the idea is we all share in the blame, there's a general letdown. I know that there's a big push for early diagnosis, early referral, early aggressive therapy, and we think we're doing better. There have been a few reports that suggest that my experience is that no, it's very uncommon for me to see an RA patient, new inflammatory RA, with less than four weeks of symptoms. Many of them are coming from primary care, many of them are still delayed, we need to do better.

Biologic agents can be used to manage the psoriatic arthritis, we know that. How good are they at managing enthesitis associated with PSA? Well, this particular report compared, a TNF inhibitor to the other drugs approved for use in psoriatic arthritis, namely the IL-seventeen inhibitor, secukinumab, and ixekizumab, and the IL-twelve twenty three inhibitor, ustekinumab. And it turns out that when you compare across the board looking at resolution of enthesitis, resolution dactylitis, that these drugs are all as equal in efficacy as is the TNF inhibitors, which you probably have a lot more experience with. And this is taken from a meta analysis of multiple studies.

And again, they're also, equal as far as their ACR 20 outcomes. Lastly, a report on lupus. The goal in lupus is low or no disease activity. Here's a nice report, that shows you when you achieve low disease activity as measured by an LL DAS, low lupus disease activity score, that you actually have less damage from lupus, and actually better survival in those patients. The LL DAS is defined as a sleet i2k of less than four, with no other major organ involvement.

The second will be no new features of lupus disease activity. Third would be a prednisone or prednisolone dose of less than seven point five milligrams per day. Lastly, those patients should be well maintained on standard dose of an immunosuppressive. Two zero six patients followed for, over ten years, twenty two percent of them had died. It turns out that three quarters of the cohort actually achieved an LLDAS at some point during the study, about a third of them spent, at least half their time in LLDAS and it's that third, that thirty three percent were the ones when you look at them, they actually had less, severe damage and better survival, when followed out longitudinally.

So the good news for those of you who are doing a good job in managing lupus. That's it for this week at RheumNow. Go to the website, see more about these reports and others. Check out rheumnow.live. It's not too late to register.

It's gonna be a fabulous meeting on March '24.