RheumNow Week In Review Father Knows Best %28Paternal Drugs OK%29 %288.31.18%29 Save

It's the 08/31/2018. This is the Room Now We Can Review. Hi, I'm Doctor. Jack Cush, Executive Editor of roomnow.com. This week we're going to talk about unmet needs in Still's disease, what to do with your biologic when a hurricane hits, paternal exposure to DMARDs and biologics is always a big issue, never an answer.

I got it for you right here. Start off with a study about osteoarthritis. A cohort of almost 3,000 patients looked at what drives utilization, what makes those patients seek health care delivery. Turns out obviously pain. More than half the patients are seeking care for their osteoarthritis because of pain.

Really right on the coattails and almost as important are issues of insomnia and depression. Again, numbers around fifty percent for all of these. And if you think about it, pain, insomnia, depression, how good are we at managing those things? Pain has become more problematic with the restrictions on narcotics. Insomnia, most rheumatologists do not deal with, don't even ask about, and depression, ditto, same thing.

These are drivers to health care. We need to pay attention to it. An interesting study comes from the British Society of Rheumatology, the BSRBR, who has a biologics registry, as you know, and had come up with a lot of good data. They have a study, a sort of smaller study compared to their RA studies, but nonetheless, a study of seven zero nine psoriatic arthritis patients and looked specifically at the risk of malignancy and the risk of mortality. And what they did find was that overall in their cohort there was not an increase in malignancy rates compared to the general population.

The SIR, the standardized incidence ratio was roughly one. But there was a twofold increase with an SIR of two for non melanoma skin cancer. At the same time they did look at the SMR, the standardized mortality rates, and they did show a fifty six percent increase in the SMR for their psoriatic patients. And most of that death rate was related to coronary artery disease. This is important because we believe that inflammation drives risk of cancer, drives the risk of inflammation and coronary disease, if not the risk of infection.

The question is maybe there's not enough inflammation in PSA compared to RA and other conditions. Interesting finding may be useful in guiding patients. An interesting study looks at the use of contraception by patients with rheumatic disease. Two thousand five hundred patients were looked at, only a third were taking contraception, only eight percent were using highly effective methods of contraception. By that we mean IUD implant or sterilization.

And that in spite of these low numbers, almost half, actually more than half, seventy percent of patients were taking at some point a fetotoxic medication, medications that theoretically you shouldn't be using if you are childbearing potential or about to have a child. There seems to be a low rate of contraceptive use and that seems to be a big unmet need in women who become pregnant with rheumatic disease. The FDA has released some data about what to do during a hurricane and specifically looks at what to do with insulin. They say that the manufacturers will step up and make the insulin available to those people whose insulin has been destroyed or damaged during a hurricane or, in whom the temperatures led to, a lack of supply. So there's measures in place for that by the companies.

Hopefully that's true in rheumatology. But more important was the data that says how the drug should be stored and that insulin should be stored at roughly 36 to 46 degrees Fahrenheit, your temperature, in the refrigerator. And again, remember, don't use the crisper. The crisper tends to be cooler and could lead to extremes as far as temperatures there. But like data we published before, if it is unrefrigerated, taken out of the refrigerator, these drugs, biologics and insulin, can be kept at 59 to 86 degrees Fahrenheit for up to a month.

So, again, this is good news for patients who travel and patients who are going through a disaster like this. I tell my patients to avoid the extremes, to avoid the sunlight, etc. The worst thing to do would be to put your biologic on the dashboard of your car and go shopping, especially if you live in Texas or Florida or Arizona. So again, I think this is instructive data you can find from the FDA. Site.

We have the link for you on RheumNow. The BSRBR looked at cancer risk and showed I think I already talked about that. I guess I did. Yeah, I did. So I'm not going to talk about that again.

Put it in there twice. Maybe I thought it was doubly important. We did a survey, one of our live oath surveys on RheumNow. We did it in the month of July and it was about Still's disease and your perceptions as rheumatologists about the pathogenesis of Still's disease and maybe how it should be treated. Some really interesting data came out about that.

We reported that in yesterday's news. Roughly seventy percent of rheumatologists believe that Still's disease, whether systemic JIA or adult onset Still's disease is driven by IL-one. And that's sort of reflected in what is your preferred biologic when choosing a biologic, seventy percent said they would choose an IL-one inhibitor in this case Anakinra is what we used in the survey. Second was not surprisingly tocilizumab, again twenty five to thirty percent believe that IL-six may be driving it but a lesser number about 15% using tocilizumab as their first choice of biologic. Interestingly, when we ask the question, what do you do after steroids?

Do you prefer to use DMARD or you go to a biologic? It's roughly split, about 48 for both, suggesting it's not clear what the next best therapy is after a high dose of corticosteroids. And to me, the surprising data was who referred you your last patient. There, was percent of the referrals were coming from non rheumatologists, unexpected sources, primary care doctors, hospitalists and infectious disease doctors leading the way. Only ten percent came from other rheumatologists or pediatric rheumatologists and ten percent were being self referred by the patients themselves.

Maybe more important was about fifteen to twenty percent of you who said I don't have any Still's disease patients suggesting again there's an education gap here about treatment Since this is a rare disorder and most people don't see it enough to be comfortable in managing it, we should look for that in the future. So what happens when you are starting out your gout therapy, you take it, you get better, do you stay on it? We've had a number of reports in the last few weeks on non adherence and non persistence being painfully low in lupus and rheumatoid arthritis will now add gout to the list. Adherence to gout therapies is painfully low. A UK clinical practice database study of almost forty eight thousand individuals with gout starting on allopurinol showed that nonpersistence, nonadherence, roughly half or less.

This is sort of shocking. I'm not surprised that, the non persistence, you know, many patients will start on allopurinol and then stop often at their own choice. But non adherence to therapy is equally bad, suggesting again that the most common disorder that we treat, gout, tends to be something for which there are, problems in its management. The safety of parenteral drugs in fetal outcomes and looking at fertility. An interesting study actually was a meta analysis of I believe the number was 48 papers, originally two twenty three papers down to 48 papers looking at six eleven males who are exposed to DMARDs and or biologics.

It encompassed almost six thousand pregnancies. And the data was somewhat what you might suggest as far as cyclophosphamide and sulfasalazine, and that they do impair spermatogenesis and probably should be avoided. But when it comes to their effect on fertility, these drugs have no effect on fertility and no effect on the outcome of the infant that included azathioprine, cyclosporine, hydroxychloroquine, leflinamide, methotrexate, and mycophenolate. The latter three being all class X or class D, actually class X, teratogens and but in males it doesn't seem to affect the outcomes. Similarly, biologics that had adequate data that showed also safe to use in the fathers was TNF inhibitors, abatacept and rituximab.

Insufficient data for which there could be no, assumptions made included IVIG, tacrolimus, glimimumab, anakinra and tocilizumab, we need more data there. Nicola Dalbeth and colleagues looked at four very large databases to look at the effects of hyperuricemia showing a lot of the numbers that you've seen in the past, but maybe showing you some things you didn't know. So a serum uric acid of six, had a roughly one point one percent risk of causing gout. But if that serum uric acid rose to greater than ten, the risk rose up to forty nine percent of those people developing gout or hazard ratio rising up to sixty four fold increased risk of gout. Bottom line though is that extreme level of uric acid is not always associated with the onset of gout.

Hence, there must be other factors in play in such patients. That's it for this week's report coming to you from Grenada where the weather is hot and mosquitoes are out. We'll talk to you next week. Bye.