The RheumNow Week in Review - 12 May 2017 Save
The RheumNow Week in Review - 12 May 2017 by Dr. Cush
Transcription
Hey now. I'm Jack Cush, executive editor of roomnow.com. It's the 05/12/2017 and this is the RheumNow we can review. This week in the news, adalimumab is all over the news and you'll see why. The ACP has come up with guidelines on how to use bisphosphonates and how to test and monitor patients, but they have gone out of their way to irritate us by having guidelines that say no DEXA screening for five years except in certain situations.
And lastly, osteoarthritis of the hand, a gigantic big problem for which no solutions exist and very little research is out there. In the news, prevalence of psoriatic arthritis was studied in Denmark. And interestingly, they showed recently that the incidence of psoriatic arthritis has risen from seven point three to twenty seven point three, almost a three fold increase in about a thirteen year period, in that population. They saw that this increase was greatest in patients, who were women, those between the ages of 50 and 59. So, women between the ages of 50 and 59.
They also saw more DMARD use, methotrexate sulfasalazine cyclosporine use in this time period and the introduction also of biologics that was on the rise. So, changes are afoot in psoriatic arthritis. An interesting case report showed that cutaneous ulcers and lupus, digital ulcers, DUs, can be treated with more than vasodilators. And an interesting case report, these authors showed that the use of minocycline could be beneficial in someone who has DU, digital ulcers, due to calcinosis. I looked at that and said what in the world?
And talked to my partners about it, we didn't agree with that but you know if you look in the literature there are some case reports about the use of minocycline as adjunctive treatment especially when there's calcinosis involved. Didn't know it, thought you may wanna be aware of it because we don't have many options for such patients. The CAMR study is one of those treat to target studies out there that has a cute little name where it's computer assisted dosing of methotrexate in rheumatoid arthritis, don't ask me what CAMR stands for. But what they basically showed in one of these wrap up studies is that their cohorts, patients were either given, ten mg of prednisone or were not as they were started out on methotrexate. When they followed these, I think over 200 patients over a five year period or more, they showed that the addition of prednisone to the methotrexate regimen did have benefits.
In fact, there was a higher rate of biologic use in patients who did not get the steroids. So, those who got steroids had less biologic use, they had less erosions, probably as expected from the Kerwin data. And they really didn't show much in the way of an increased risk of toxicity. There were some unique steroid related toxicities but it wasn't out of proportion. So, again, there's a little bit, to be said about a little bit of prednisone in a combination regimen.
This past week was World Lupus Day on the May 10. Led me to reflect on that particular day as I was managing a few patients that, you know, lupus is best managed when it's managed by one person who can manage the whole disease and take a look at the many facets of it. You may need other people at different times but to treat lupus because they have four organ systems by involving four consultants who are all gonna be like the four blind men grabbing hold of some part of the elephant, it's a bit problematic. So, thank God for rheumatologists as they manage lupus. Stroke, a recent study looked at stroke in RA and showed it to be a very uncommon event, about three per one thousand patient years.
They found this to be, much more common though after patients had a serious adverse event. And no particular kind, that was just any kind of serious adverse event that resulted in a hospitalization for instance. These were higher with age, smoking, and hyperlipidemia and then Lenny Calibre saw this and actually retweeted it and said, and also even higher with, after the onset of herpes zoster where he's shown and others have shown that herpes zoster is associated with increased risk of stroke especially in RA patients. Plaquenil is in the news, not Plaquenil, Adalimumab is in the news, usually it's Plaquenil in the news. Adalimumab is effective in pediatric psoriasis.
As you know, it's approved for plaque psoriasis in adults in pediatric populations, approved for Crohn's and in polyarticular JIA. It has not been studied in pediatric psoriasis where it was, about a two hundred something patient trial compared, sub q adalimumab to, given after the first week every other week to weekly, methotrexate given orally. And in that study they showed hands down that adalimumab was more, effective in treating the skin, the plaque psoriasis with Posse 75s of like 60 versus 30. And no matter what the measure was it superior to methotrexate and there was really no new signals, no increased signals, there were three serious adverse events, those were seen in the adalimumab group but it was not thought to be related to the drug. A recent Medscape report looked at physician salaries and they included rheumatologists in there.
Hooray, we're being paid finally. The average salary of rheumatologists, 235,000. They showed that twenty five percent of us have a net worth of over $2,000,000. Unfortunately 17% of us are paying off school loans and 11% have incurred financial losses due to our practices and our practice situation. So, again, we are doing better than internists and pediatricians but not really better than most medical specialties.
We love our patients, we love what we do. The U Star study is very large cohort study of scleroderma patients and recently they looked at the associations of autoantibodies with some complications of scleroderma systemic sclerosis. Specifically, they looked at what the influence of RNA polymerase three antibodies might be and specifically they showed a higher risk of cancer in such patients. In fact, seven point three fold higher risk of cancer, especially in those who were older and those who had more extensive skin involvement. A nice clinical tip from the USAR study.
The ACP, in Annals of Internal Medicine, has recently published its, practice guidelines update, updating a 2008 guideline on the use of bisphosphonates. And in their guideline they make some several strong statements. Not surprisingly, they say that we should be using, you know, bisphosphonates, alendronate, risidronate, solindronic acid and denosumab to reduce fracture risk in patients, especially women with osteoporosis. They strongly recommend in favor of using generics when available. They strongly advise against the use of estrogen, and hormonal based therapies to treat such patients.
And then they said that women should treat, who have osteoporosis should be treated with one of these agents, for at least five years and during that period of treatment they should not be tested or have their density monitored because the evidence does not show any benefit for monitoring during the treatment period. The evidence also did not, support the monitoring of women who have normal bone densities and doing repeated DEXs, and that such patients really could just be followed over a fifteen year period without such measurements. So, again, there's something there controversial for the rheumatologist to yell and scream about, good luck, have fun. Another somewhat irritating report comes from the British medical journal where a group of Canadian investigators have looked at a number of different cohorts and specifically they looked at cohorts in The EU and in Canada where they had outcomes, especially acute myocardial infarction, amongst patients who were taking nonsteroidals. And specifically that was naproxen, diclofenac, ibuprofen, rofocoxib, celecoxib.
What they showed in matching sixty one thousand patients who had acute MIs to a cohort of patients who took those drugs, and over three hundred and eighty five thousand of such patients, thus studying almost a half million patients, they showed that even being on a non steroidal for one week resulted in a significant increase in acute MI, episodes. During this period, again, the odds ratios being significantly higher than one were one point two four for celecoxib, one point four eight for ibuprofen, one point five zero for diclofenac, one point five three for naproxen, and one point five eight for roficoxib. So, again, this is out there. This is the kind of stuff internists and cardiologists love. Again, these are pretty rare events, and are certainly less, less common compared to the GI events associated with nonsteroidals.
And lastly, there's a lot in the news, this week about hand osteoarthritis. Specifically, a CDC study reviewed the results of the Johnson County Osteoarthritis Initiative where they studied over 2,500 patients with, they surveyed over two thousand five hundred patients who have and found out that the risk of developing symptomatic hand osteoarthritis was forty percent in the population. The numbers specifically were thirty nine point eight percent with a higher percentage in women. Women, by the time they reached age 85, had a forty seven percent chance of getting symptomatic hand osteoarthritis, twenty five percent for men. The rate was higher in whites than blacks, higher in those who are obese than not obese, forty seven percent versus non obese, thirty six percent.
This is a gigantic public health problem for which there really are no effective therapies. There isn't. And I spent my lifetime looking for them. Thank God the, Orsi, an organisation who is focused on osteoarthritis led by people like Mark Hochberg, have recently submitted a white paper to the FDA declaring osteoarthritis a serious medical condition that reserves special consideration by the FDA to develop new therapies. And there are people who are trying new therapies.
There's IL-one inhibitors that are in trials or hand osteoarthritis. Those results are not in but I don't have high hopes for that. And Humira did a recent study called the HUMIRA study. We reported on that this week. Unfortunately, the HUMIRA study, which is only a 43 patient crossover study, failed to show any efficacy of adalimumab in patients with symptomatic hand osteoarthritis.
So, that's it for this week at roomnow.com. Go to the website, register, become a lifelong member and we'll send you chocolate. Tune in next week, go to the website to find these citations and we'll keep you up to date on roomnow.com. Take care.
And lastly, osteoarthritis of the hand, a gigantic big problem for which no solutions exist and very little research is out there. In the news, prevalence of psoriatic arthritis was studied in Denmark. And interestingly, they showed recently that the incidence of psoriatic arthritis has risen from seven point three to twenty seven point three, almost a three fold increase in about a thirteen year period, in that population. They saw that this increase was greatest in patients, who were women, those between the ages of 50 and 59. So, women between the ages of 50 and 59.
They also saw more DMARD use, methotrexate sulfasalazine cyclosporine use in this time period and the introduction also of biologics that was on the rise. So, changes are afoot in psoriatic arthritis. An interesting case report showed that cutaneous ulcers and lupus, digital ulcers, DUs, can be treated with more than vasodilators. And an interesting case report, these authors showed that the use of minocycline could be beneficial in someone who has DU, digital ulcers, due to calcinosis. I looked at that and said what in the world?
And talked to my partners about it, we didn't agree with that but you know if you look in the literature there are some case reports about the use of minocycline as adjunctive treatment especially when there's calcinosis involved. Didn't know it, thought you may wanna be aware of it because we don't have many options for such patients. The CAMR study is one of those treat to target studies out there that has a cute little name where it's computer assisted dosing of methotrexate in rheumatoid arthritis, don't ask me what CAMR stands for. But what they basically showed in one of these wrap up studies is that their cohorts, patients were either given, ten mg of prednisone or were not as they were started out on methotrexate. When they followed these, I think over 200 patients over a five year period or more, they showed that the addition of prednisone to the methotrexate regimen did have benefits.
In fact, there was a higher rate of biologic use in patients who did not get the steroids. So, those who got steroids had less biologic use, they had less erosions, probably as expected from the Kerwin data. And they really didn't show much in the way of an increased risk of toxicity. There were some unique steroid related toxicities but it wasn't out of proportion. So, again, there's a little bit, to be said about a little bit of prednisone in a combination regimen.
This past week was World Lupus Day on the May 10. Led me to reflect on that particular day as I was managing a few patients that, you know, lupus is best managed when it's managed by one person who can manage the whole disease and take a look at the many facets of it. You may need other people at different times but to treat lupus because they have four organ systems by involving four consultants who are all gonna be like the four blind men grabbing hold of some part of the elephant, it's a bit problematic. So, thank God for rheumatologists as they manage lupus. Stroke, a recent study looked at stroke in RA and showed it to be a very uncommon event, about three per one thousand patient years.
They found this to be, much more common though after patients had a serious adverse event. And no particular kind, that was just any kind of serious adverse event that resulted in a hospitalization for instance. These were higher with age, smoking, and hyperlipidemia and then Lenny Calibre saw this and actually retweeted it and said, and also even higher with, after the onset of herpes zoster where he's shown and others have shown that herpes zoster is associated with increased risk of stroke especially in RA patients. Plaquenil is in the news, not Plaquenil, Adalimumab is in the news, usually it's Plaquenil in the news. Adalimumab is effective in pediatric psoriasis.
As you know, it's approved for plaque psoriasis in adults in pediatric populations, approved for Crohn's and in polyarticular JIA. It has not been studied in pediatric psoriasis where it was, about a two hundred something patient trial compared, sub q adalimumab to, given after the first week every other week to weekly, methotrexate given orally. And in that study they showed hands down that adalimumab was more, effective in treating the skin, the plaque psoriasis with Posse 75s of like 60 versus 30. And no matter what the measure was it superior to methotrexate and there was really no new signals, no increased signals, there were three serious adverse events, those were seen in the adalimumab group but it was not thought to be related to the drug. A recent Medscape report looked at physician salaries and they included rheumatologists in there.
Hooray, we're being paid finally. The average salary of rheumatologists, 235,000. They showed that twenty five percent of us have a net worth of over $2,000,000. Unfortunately 17% of us are paying off school loans and 11% have incurred financial losses due to our practices and our practice situation. So, again, we are doing better than internists and pediatricians but not really better than most medical specialties.
We love our patients, we love what we do. The U Star study is very large cohort study of scleroderma patients and recently they looked at the associations of autoantibodies with some complications of scleroderma systemic sclerosis. Specifically, they looked at what the influence of RNA polymerase three antibodies might be and specifically they showed a higher risk of cancer in such patients. In fact, seven point three fold higher risk of cancer, especially in those who were older and those who had more extensive skin involvement. A nice clinical tip from the USAR study.
The ACP, in Annals of Internal Medicine, has recently published its, practice guidelines update, updating a 2008 guideline on the use of bisphosphonates. And in their guideline they make some several strong statements. Not surprisingly, they say that we should be using, you know, bisphosphonates, alendronate, risidronate, solindronic acid and denosumab to reduce fracture risk in patients, especially women with osteoporosis. They strongly recommend in favor of using generics when available. They strongly advise against the use of estrogen, and hormonal based therapies to treat such patients.
And then they said that women should treat, who have osteoporosis should be treated with one of these agents, for at least five years and during that period of treatment they should not be tested or have their density monitored because the evidence does not show any benefit for monitoring during the treatment period. The evidence also did not, support the monitoring of women who have normal bone densities and doing repeated DEXs, and that such patients really could just be followed over a fifteen year period without such measurements. So, again, there's something there controversial for the rheumatologist to yell and scream about, good luck, have fun. Another somewhat irritating report comes from the British medical journal where a group of Canadian investigators have looked at a number of different cohorts and specifically they looked at cohorts in The EU and in Canada where they had outcomes, especially acute myocardial infarction, amongst patients who were taking nonsteroidals. And specifically that was naproxen, diclofenac, ibuprofen, rofocoxib, celecoxib.
What they showed in matching sixty one thousand patients who had acute MIs to a cohort of patients who took those drugs, and over three hundred and eighty five thousand of such patients, thus studying almost a half million patients, they showed that even being on a non steroidal for one week resulted in a significant increase in acute MI, episodes. During this period, again, the odds ratios being significantly higher than one were one point two four for celecoxib, one point four eight for ibuprofen, one point five zero for diclofenac, one point five three for naproxen, and one point five eight for roficoxib. So, again, this is out there. This is the kind of stuff internists and cardiologists love. Again, these are pretty rare events, and are certainly less, less common compared to the GI events associated with nonsteroidals.
And lastly, there's a lot in the news, this week about hand osteoarthritis. Specifically, a CDC study reviewed the results of the Johnson County Osteoarthritis Initiative where they studied over 2,500 patients with, they surveyed over two thousand five hundred patients who have and found out that the risk of developing symptomatic hand osteoarthritis was forty percent in the population. The numbers specifically were thirty nine point eight percent with a higher percentage in women. Women, by the time they reached age 85, had a forty seven percent chance of getting symptomatic hand osteoarthritis, twenty five percent for men. The rate was higher in whites than blacks, higher in those who are obese than not obese, forty seven percent versus non obese, thirty six percent.
This is a gigantic public health problem for which there really are no effective therapies. There isn't. And I spent my lifetime looking for them. Thank God the, Orsi, an organisation who is focused on osteoarthritis led by people like Mark Hochberg, have recently submitted a white paper to the FDA declaring osteoarthritis a serious medical condition that reserves special consideration by the FDA to develop new therapies. And there are people who are trying new therapies.
There's IL-one inhibitors that are in trials or hand osteoarthritis. Those results are not in but I don't have high hopes for that. And Humira did a recent study called the HUMIRA study. We reported on that this week. Unfortunately, the HUMIRA study, which is only a 43 patient crossover study, failed to show any efficacy of adalimumab in patients with symptomatic hand osteoarthritis.
So, that's it for this week at roomnow.com. Go to the website, register, become a lifelong member and we'll send you chocolate. Tune in next week, go to the website to find these citations and we'll keep you up to date on roomnow.com. Take care.
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