RheumNow - EULAR 2018 - Day 4 Save

Hi. I'm Doctor. Jack Cush, executive editor of rheumnow.com, coming to you from Amsterdam and the site of EULAR two thousand eighteen. This podcast is part of our expanded coverage of EULAR. You can find us on our daily email from RheumNow or by going to the website, eular18.rheumnow.com.

Now the podcast. This is gonna be a collection of audio reports from RheumNow faculty, key opinion leaders, or abstract presenters from the meeting. I hope you enjoy the podcast, and be sure to tell your friends to tune in to RheumNow, to follow these podcasts, and to subscribe. Take care. Hi.

I'm Jack Cush with RheumNow coming to you from EULAR two thousand eighteen in Amsterdam. I just got off the poster floor where I saw a lot of interesting abstracts. I wanna talk to you about one abstract that I thought was notable. It was about calcium pyrophosphate disease, specifically pseudogalp, the acute form of CPPD. This is a single center study that actually looked at the use of anakinra, the IL-one inhibitor, in patients who had active, uncontrolled, acute CPPD.

Their cohort was 33 patients. They were very old, on average at 79 years of age. They had a lot of comorbidities, and what was interesting was they were refractory to usual therapy. More than half had received colchicine, colchicine, about a quarter nonsteroidals, about a third had received steroids as high as twenty milligrams per day on average. So these people had active disease going on for an average of fourteen days and were then treated with open label Anakinra, usual dose of one hundred milligrams a day for four doses.

And what they saw was dramatic. They saw improvement, as judged by the physician in over eighty percent of individuals. They showed that the, the joint counts that were, six tender on average and four swollen dropped to one and one. They showed that c reactive protein, which was incredibly high, like a 126 milligrams per liter, dropped to around 20. Still high, but it's a dramatic reduction.

And the pain scores went from six down to one on average. So clearly, this is an important adjunctive therapy. It'd be nice to have it in our arsenal. Although it's quite expensive, it may be important to use such therapy in those who have refractory disease. That's it from the Abstract Floor at ULOG two thousand eighteen.

We'll see you again for more videos from RheumNow.

Hi. I'm doctor Janet Pope reporting at RheumNow. I wanted to talk to you about at EULAR twenty eighteen, an oral presentation zero three zero two about choosing wisely or not. Many of us know that choosing wisely campaigns are in The UK, various parts of Europe, Canada, and The US. And what this study did was looked at one of the Canadian recommendations of don't order an ANA test if you're not suspecting connective tissue disease.

Sounds obvious. However, what was found was that at least forty nine percent of the tests ordered to on patients who were referred to rheumatologists, both the accepted and rejected referrals in a large tertiary care center were inappropriate. And in fact, ANA testing cost about fifty percent of the inappropriate testing. And even more expensive was the fact that ANA was often repeated and anti double stranded DNA and ENA were done when there was no likelihood of lupus. The positive predictive value in a very specialized population like this referred to rheumatologists of a positive ANA being meaningful at all was only two percent.

So we really should choose wisely. Thank you. Hi. I'm doctor Janet Pope. Welcome to RheumNow.

I wanted to talk about some of the presentations on Thursday, EULAR twenty eighteen in Amsterdam. These are to deal with cardiovascular events and rheumatoid arthritis. So the first is a large study by doctor Jessica Whitifield from Toronto. And what it looked at was in two large population billing bay billing databases in Ontario and in BC that the gap of increased mortality in RA is still present. It's about twenty percent increased, and it starts about after six years and onward.

So it's something that the gap is closing, but our patients still die relative to age and sex match controls. The next study is that Plaquenil might indeed decrease cardiovascular risk. So in a large population study out of Sweden, oral presentation zero one nine one, what was looked at was patients receiving hydroxychloroquine often in combination with methotrexate had less mortality than not receiving hydroxychloroquine, which is often methotrexate monotherapy. Why would this be? Who knows?

But we found the same data over time in multiple reports with SLE. So hydroxychloroquine might be something to consider for your patients. The final thing is acute coronary syndrome on o p zero one four nine on Thursday at EULAR showed that patients with rheumatoid arthritis and their siblings had more acute coronary syndrome than age and sex match controls from a large Swedish register. And with the randomly selected controls who would be siblings of the randomly selected controls that had an odds ratio of one. The increased risk was highest in the RA patients, but still quite high in the siblings compared to the jungle population.

Population. Is that the comorbidity of other things happening with RA, genetics, lifestyle like smoking? Who knows? More to come. Thank you for coming to RheumNow.

Hi. I'm doctor Janet Pope. Thanks for coming to RheumNow. I wanted to talk to you about an oral abstract on Friday at ULAAR twenty eighteen, abstract o p zero three zero three. And it was a randomized controlled trial of French citizens with spondyloarthropathy.

And what they did was they wanted to see if randomizing patients and having a nurse intervention would help with comorbidities. Number one, we know comorbidities are high in ankylosing spondylitis. And number two, we know they're under recognized. So an intensive program is what one, one randomization scheme was versus some minor education. Interestingly, any smokers got education on smoking cessation in both groups because of the ethics of trying to get our patients to stop smoking.

So the good news is people stop smoking more, but actually in the control group, not the intervention. The intervention group overall didn't have a change, but had more vaccinations. But for other cancer screening, there was no difference. For cardiovascular risk treatment, no difference. So I think we have to recognize the comorbidities, but I'm not sure right now a multidisciplinary or nurse led intervention program is the way to go.

Thank you. Hi. I'm doctor Janet Pope. I'm reporting for RheumNow, and my, my handle on Twitter is Janet Burdope. I'd like to tell you about a study with gout that's a population based study from Denmark.

So in study on Friday, poster two two one, what was looked at was the population, excluding patients who already had cancer, and then looking in the population from there there forward and looking at patients who had gout and then cancer. And the question was, does gout increase the risk of cancer? And the answer is maybe. The absolute hazard ratio was one point o four or a small incremental risk that was statistically significant. But there was a cluster of lymphoma and lymphoproliferative right after gout, and that might have been cause and effect with high uric acid from the tumor, and then the tumor was diagnosed.

However, if you take that out, there still seem to be things that were associated with gout, lifestyle issues like metabolic syndrome, so increased breast cancer, cancer of the uterus in women, increased pancreatic cancer, and liver cancer. So I think the most important thing for your patients with gout is not to do cancer screening, but to treat their lifestyle. Thank you.

Hi. My name is Philip Robinson. I am from Australia, and I'm coming to you from the beautiful city of Amsterdam here at EULA two thousand and eighteen. I wanna tell you about some great gout abstracts today. The first one is from the NHANES study dataset, and that shows that the prevalence of gout is directly correlated to the serum lead levels.

Now that lead poisoning causes gout is not a new finding, but it's a reminder that to think about this in early onset patients or those with occupational exposure. There's some more NHANES data also that shows that rheumatologists aren't doing too bad a job. In fact, we're we're getting better at treating gout patients. The proportion with, at target is increasing over time. Still, the absolute level's pretty low.

It's less than twenty percent. So we've still got a way to go. And the next interesting poster, was one done by Hyon Choi from Boston, and he looked at the changes in blood pressure in the peglodecase trials. And he showed that, on average, you got a reduction in around eight to 10 millimeters of mercury with peglodecase treatment. So certainly, this is a pretty controversial area, there's been lots of studies about association with blood pressure and uric acid.

And this is a small study, but certainly something that needs to be followed up. There's another really interesting study looking at anakinra treatment in CPPD, and it was a small study, but it showed a substantial reduction in tender and swollen joints with with people with acute CPPD arthritis. And finally, I think it was a really lovely study from Ed Roddy in The United Kingdom. They took a 150 gout patients that came to their clinic and split them between follow-up medicine with a general medicine specialist, follow-up with rheumatologists, and discharged with a plan to general practitioners. And they found that those that were discharged to general practice had a lower level of attaining their serum uric acid target.

So I think the take home message is that these people probably need to be looked after until they're at target instead of being discharged with a plan. And there's lots more coverage at roomnow.com, so I encourage you to go to the site.

Hi. This is Ronan Cavanagh. I'm here at EULAR in Amsterdam. And in the last few days, there's been a few very interesting abstracts published on the use of methotrexate in arthritis. But one that particularly caught my eye is one from India about the use of caffeine in the form of coffee to try and offset the some of the nuisance symptoms and side effects of methotrexate toxicity.

There is a theoretical basis for the use of caffeine in this situation. The upregulation of adenosine in the central nervous system is thought to contribute to some of these side effects. And the use of caffeine and, in fact, theophylline as well, helps offset some of this. So, they did an uncontrolled study of six hundred patients, three hundred and fifteen of which had moderate to severe methotrexate related side effects. They gave them coffee, two cups of coffee the morning of their methotrexate dose, two cups two to three hours before their methotrexate dose in the evening, and then a further two cups of coffee the following morning.

Forty five percent of those patients, noted that their methotrexate side effects disappeared. Fifteen percent of them noted an improvement whereby they were able to continue on their methotrexate, but with the use of antiemetics. So this is a sixty percent improvement. It's an uncontrolled study, but it's certainly interesting. And it goes on the back of a smaller study by the same authors about the use of chocolate in offsetting methotrexate symptoms, will be of interest to our patients, I think.

Ronan Kavanagh, Euler Amsterdam.

Good morning everyone! This is Olga Petrina reporting from the last day of Mueller meeting here in Amsterdam. Today I wanted to share the findings of the study on effect of diabetes on outcomes in gout and healthcare utilization of patients with gout and diabetes. In this study patients who had both diabetes and gout showed to have more severe gout attacks, they had more joint involvement and more Tophi present. Although those patients used more uric acid lowering therapy, they tend to perform worse over time and had more ER visits and hospitalizations over time.

The reasons are not clearly known, but the belief is that possible comorbidities which were present in those patients such as COPD, kidney disease and high blood pressure could have played a role. Overall, tight uric acid control is important to these patients and may decrease their need for hospital admissions and ER visits. Thank you. And if you want to know more, please follow us on the room now.

Hi, this is Doctor. Lynn Calabrese coming at you from the Cleveland Clinic. Just got back from Amsterdam from EULAR twenty eighteen and wanted to update you on a few things happening in the field of vasculitis. I was privileged to chair the abstract selection committee for vasculitis. I also chaired the plenary session where Doctor.

David Jane, the noted nephrologist, discussed the use of the C5a inhibitor Avacopan in the treatment of ANCA associated vasculitis. It's long been a dream of people who treat vasculitis to use less and less steroids. And he reviewed the results of the Avacopan trial, the phase two that had recently been published, that demonstrated that in patients with ANCA associated vasculitis who are already treated with cyclophosphamide or rituximab, that the regimen of high dose steroids versus avacopan plus twenty milligrams of steroids versus avacopan alone, all were non inferior with interesting improvements in albuminuria in the avacopan groups that are not seen with standard of care. At the meeting, an abstract tried to look at the mechanisms of action of this and found that avacopan works independently of affecting complement levels. I personally am very excited about this.

I look forward to the phase three study of avacopan that hopefully will be a pivotal trial to be able to treat ANCA associated vasculitis without steroids sounds almost too good to be true. So Doctor. Lynn Calabrese coming at you. Please come back. I'll give you a few more tidbits on vasculitis.