The ACR17 RheumNow Week In Review - 1 December 2017.mp4 Save

It's the 12/01/2017, and this is the RoomNow week in review. I'm doctor Jack Cush, executive editor of roomnow.com, and this is the week in review for the last two weeks. We sort of skipped last Friday because of the Thanksgiving holiday here in The US, and I'll sort of fold some of those reports into today's report. An interesting survey I found just today was a survey from mainly nurses and pharmacists and health care providers, some doctors talking about texting and texting of orders. I thought that was interesting because everybody's using the phone these days for everything.

Some of that I don't like, some of that I think is good. But in this case, there was a survey done and showed that forty five percent of pharmacists and thirty five percent of nurses said that they received text orders regularly, up to a third of the time in at least once a week and, 20% of the time almost every day. This is interesting because these same people admitted that only twelve percent of them had a formal official policy accepting texts as a means of a medical order, and this included hospitals and teaching hospitals and even outpatient situations. So only 12% approved this, but when you looked at how people really felt about this, more than half, 58%, had concerns about the possibility of a miscommunication or a medication error on the basis of texting. So this is sort of a trend that we need to watch and be wary of.

In fact, would advise against it. Another interesting report just recently found large claims database looking at those who have infertility and comparing those people with infertility to those who don't have that diagnosis, and it was like a 10 to one comparison, very, very large numbers and the association that they were looking for was the development of an autoimmune disease. And so what they found was those who were infertile, and actually the reason they were infertile is because they think they were going to be or had been prescribed testosterone, but yet they were still infertile officially, that there was a significantly higher risk of developing autoimmune disease, specifically rheumatoid arthritis, multiple sclerosis, psoriasis, thyroiditis, and Graves' disease. Again, the, augmented risk on these vary quite a bit and some it was only about a ten percent, some was as much as sixty percent increased risk. And we do know that testosterone and androgens tend to be anti inflammatory, so it's not surprising that this finding would be seen in those who may be shy on their testosterone levels.

I found a nice report this week looking at the utility of using an ice cube before giving anesthetic injections. And I thought that that applied to our patient population where injections and dysesthesia from subcutaneous injections are sometimes an impediment to use. And remember Hippocrates was the one who said that you can treat pain and inflammation with cold or ice. So in their study, they suggested two minutes of an ice cube. I don't think you need two minutes, think a minute of an ice cube prior to the administration of a pen injector or subcutaneous injection would probably be a good idea for those who are experiencing problems.

Another study looked at the comparison of those who have either ACMA positive and ACPA negative in at risk individuals so called preclinical RA. And the differences in the overall outcomes were that ACPA positive patients actually had a longer duration of symptoms prior to inclusion in this study, but they had a shorter time to develop actual arthritis. It was six weeks versus eighteen weeks, when compared to the ACPA negative individuals. ACPA negative individuals had less lower extremity symptoms. Not sure what that really means, but there clearly are some clinical differences and obviously ACPA would be another at risk factor in a preclinical population, but certainly there's a large number of people who will be ACPA negative who will go on to develop arthritis and rheumatoid arthritis specifically.

So, again, the story on preclinical RA continues to play out. If you hadn't noticed in 2017 there were a lot of new FDA approved drugs in the field of rheumatology and then dermatology and gastroenterology drugs in patients who we take care of. It began with the approval of the IL-seventeen inhibitor, redalumab, called SILIQ, not getting as much use because of the associations and warnings about depression and suicide. There was another methotrexate put on the market this one being an oral methotrexate solution called x a t m e p. Zatmep?

Let's go with that. There was a valoparatide, the follow-up to teriparatide. This is the trade name is Timlose. Tocilizumab was approved for use in GGCA, and that's a good thing for those who are needing that drug. Cirilumab was approved as another IL six inhibitor.

Guselkumab, another IL twenty three inhibitor was approved. Its trade name is called Tremfya. Subcutaneous belimumab was approved, but Lista now has a subcutaneous version that's out there for use in lupus and lisinirad in combination with allopurinol is another approved product. The combined product goes with the name Duzalo for those who are interested in using that for gout. Speaking of gout, there was an interesting study that looked at gout, not just gout, but actually the risk of arthritis associated with the intake of high fructose corn syrup and sodas and other beverages that contain high fructose corn syrup.

We certainly know that this is associated with an increased risk of gout, but they went and looked at the NHANES study, a recent study that looked at 1,200 young adults between ages of 20 and 30, and enrolled them between 2,003 and 2,006, and they found that those who drank more than four sodas a week or five or more sodas or high fructose corn syrup containing beverages per week had a significant threefold higher risk of developing arthritis. Now this particular study did not look at whether it was inflammatory arthritis or arthritis from, stubbing your toe, but nonetheless this was doctor diagnosed arthritis. Interestingly the same risk was not seen when with the ingestion of diet sodas and diet drinks. A nice association reviews the autoantibody profile associated with cancer We know that patients with myositis, think more so in dermatomyositis may be at risk of an incidental cancer. And now we have a biomarker for that and specifically there are autoantibodies to a TIF one, which has an increased risk of a seventeen fold increased risk, NXP two, which has an eight fold increased risk, and SAE one autoantibodies, which has almost a 13 fold increased risk.

The same study showed that patients who were negative for the myositis specific an antibody profile, you know, the joe ones, p l sevens, etcetera, were also at increased risk for cancer. Not at increased risk were those who have antibodies against HMGCR, the antibody associated with statin associated myopathy, anti MDA five which is associated with CADM or clinically amyopathic dermatomyositis, dermatomyositis sinomyositis And the myositis specific antibody panel jo one p l seven p l twelve m I two p l anti e and anti o j also mi two I think I said that already. So again, these are autoantibody profiles. I don't use a lot of these. I may use them in a situation where cancer is a worry.

That's a new revelation to me. Finding these autoantibodies could be a challenge, but I do know that they are offered by RDL lab in California. That's Alan Metzger's lab, does a number of these different tests including MDA five, HMGCR, TIFF one, and I believe NXP two. So again, maybe you use these, maybe you don't. There's good news about them.

There was a report from ACR that got a little play this week that you could find the link on the website about the use of extracorporeal shock wave therapy, what you would normally use for renal stones, has been used to actually treat, the calcinosis and the finger ulcerations associated with, scleroderma. As you know, they're a very difficult thing to treat. There is no effective therapy. My concoction is probably no better than your concoction for that meaning that neither work. This is a promising new development.

The FDA this week issued a warning about Limbrel. Limbrel is a flavonoid, much like cherry pills and that sort of thing that has been advocated for use in osteoarthritis. It is commercially available, but the FDA has issued a warning about its safety saying that it's under investigation because they've received a total of a 194 serious adverse event reports linking it to either liver injury or hypersensitivity pneumonitis. So if you have that in your sample cabinet, you may want to throw that out or talk to whoever's giving it to you or watch for that that research, that investigation by the FDA. The EMR is something we have to live with.

The New York Times has a nice review article about the impact of the EMR on physician practice, specifically time spent with patients. And the data is pretty clear that all studies show that physicians spend more time with their EMR than they do talking to patients. In fact, sometimes the amount of time spent with the EMR is twice the amount of time spent talking to patients. And the article was on to discuss what are the benefits of this. Is this really a benefit?

Is this a bean counter perk for your hospital system, or is this really helping patient care? I been doing EMR since 1994 and I think that they do make me more organized and help in many aspects, but I'm really good at talking to the patient and collecting my EMR data at the same time. So I don't waste a lot of time I get both things done. Most people can't double task that way a lot of people stay after work or on weekends and write their notes that way That's got to be horrible. So again the EMR is not all it's cracked up to be and what we're gonna do about it It's hard to say because right now all of our payment is linked to metrics and performance of certain tasks which we have to document with the AMR.

Good luck with that. The CDC had a report last week about Lyme disease and The US report from 2015. The top seven states in as of 2015 in decreasing order of prevalence was Vermont which had a incidence rate of seventy eight cases per 100,000 patients in a year, and then after that was Maine, Pennsylvania, Rhode Island, Connecticut, New Jersey and Massachusetts. Again, you might want to look at that if you're a Lyme state and you're not a Lyme state You're wondering why these people coming to me with Lyme disease when I live in Texas and there is no Ixodes Domeni tick, and just a lot of blue haired 80 year old women who've been told they have Lyme disease. Go figure.

Another public health issue is the Zika virus as you know, it could be the big outbreak that's going to face this current administration in our population. It seems to have tailed off in recent months. There's been a lot of work on a Zika virus vaccine, and there's some new in vitro work showing that chloroquine is able to reduce the viral replication at least in in vitro controlled systems. It has not yet been studied in humans, but this may be something to consider and you may want to look at this report if you're gonna be in those areas where Zika virus may be more prevalent. JAMA Derm, JAMA Dermatology came out with an interesting study about dermatomyositis showing that if looking at clinical outcomes for skin that only about thirty eight percent of patients are actually able to achieve remission with dermatomyositis and that that means the vast majority do not.

When they looked at the risk factors or that which would portend a better outcome to the skin and lead to clinical remission, the factors that were influential included age, increasing age increased the risk, the use of mycophenolate, and the last one was having an associated malignancy with dermatomyositis. They tend to be able to all achieve a lower skin score. The ones who did the worst were those who had that MDA five antibody that is associated with clinically amyopathic dermatomyositis. The patients have really bad skin disease, high risk of lung disease, progressive severe lung disease, but don't really have much in the way of muscle weakness and objective myositis. A a little snippet from New England Journal in one of their cases of the week sort of thing presented a case of strawberry dermatitis in a 42 year old who had epistaxis and it was ANCA positive.

The patient had painful gingival hyperplasia. When you looked at it, it looked like strawberries almost overgrowing the tooth, and the patient went on to have granulomatosis with polyangiitis or GPA. So that's a new clue. You look at the literature on the oral manifestations of GPA, Much to my surprise, gum disease, gum or or or and and oral ulcerations are are quite up there and something to be considered when you have a patient who has oral manifestations and you don't quite know what it may be due to. One of my my more interesting cases, actually, a few years ago was a woman who had tongue necrosis, and she ended up having giant cell arteritis and not a GPA.

But you might wanna be thinking along those lines when having problematic oral lesions in the face of a systemic disorder. Another FDA approval that may be of note to rheumatologists is the, inhibitor of the IL five alpha receptor. This new drug is called Fasenra Fasenra. Yeah. It's benzralizumab.

It is an IL-five inhibitor. It becomes the second IL-five inhibitor joining mepolizumab, and you may remember that mepolizumab was in New England Journal a few months ago, was, prominently reported at the ACR meeting, for its results with EGPA or Churg Strauss that you can manage the allergic manifestations with an eosinophil activity with these two drugs. This drug when given has a rapid and near complete reduction of eosinophil counts with good clinical results. It was tested and approved for patients over the age of 12 who have severe asthma. It has not been tested thus far in systemic illnesses or any of our disorders including EGPA.

You may want to look at two other reports that are on the website. One about, low evidence of guidelines and this would appeared in JAMA as well. And the shocking thing here is that the vast majority of the guidelines that have been thus far reported by the ACR are not as strong as you might consider. Specifically, they looked at, was it nine different indications, glucocorticoid induced osteoporosis, JIA, RA, lupus nephritis, OA, ankylosing spondylitis, polymyalgia rheumatica, and when you look at the data only about twenty three percent of the recommendations from all these ACR guidelines are based on a level evidence, meaning that randomized controlled trials sort of, you know, prospective blinded studies. Unfortunately, the amount that relies on level C evidence, which is sort of review papers, things written on bathroom walls, actually I'm only kidding, actually based on expert opinion, the total here is 58% of all the guidelines rely on level C evidence.

You look at a few of the disorders like for instance JIA it's eighty six percent, lupus nephritis seventy percent, SPA fifty one percent, and RA sixty nine percent of the recommendations are level C, grade C, or expert opinion like evidence. This is quite disappointing, especially in light of the fact that payers are requiring these sort of guidelines to make treatment decisions about how they're gonna spend their money. This is a big problem. I think we need to change the way we grade evidence and maybe take into account, you know Registries and what happens in the real world that may not be double blind and randomized etc. But right now calling it all expert opinion therefore relies on who are your experts and how good are they?

There's a big problem with experts being included in guidelines because those who know the most may be people who did most of the research, but they're excluded because they're conflicted. So there's a big issue here that really impacts the way we practice medicine. The last one I think was kind of interesting comes from Boston University and David Felsen's lab. They actually had a nice report that the incidence of arthritis is really underestimated and their numbers suggest that it may be underestimated by as much as sixty or sixty five percent. Data from the CDC in 2014 said it was fifty four point four million people who have arthritis, all kinds, and then it was about twenty two point seven percent of The US population.

But the more recent data from David Felsen's group was as much as ninety one percent of the population I'm sorry, ninety one million of The US population has arthritis and that includes up to about thirty seven percent of the population. What they did was they actually looked at the NHIS surveillance system or survey that's done and unlike the former CDC studies, went and looked deeper into the questions that were asked to find more indicators of what may be considered arthritis. That's where they come up with this augmented number. And the last report that I think you might want to know about is the 2017 RheumNow ACR awards. That's right.

RheumNow was at the ACR. We covered the event. You can go and look at our coverage, which was expansive. We had more reports than anyone at the meeting and you can find that at acr17.roomnow.com, but specifically we came up with awards for the following. For rheumatoid arthritis, the award was for rates of malignancy associated with anti TNF agents and subsequent use of biologics after a pre existing malignancy showing that there was no increase in new cancer rates if you use TNF