The RheumNow Week in Review - 5 May 2017 Save

Hey now. I'm Jack Cush, executive editor of roomnow.com. It's 05/05/2017. This is the RoomNow we can review. Today, we're going to talk about magnesium.

Could it possibly help nocturnal leg cramps? And guess what? There's a new, expensive, and also a really cheap way of giving methotrexate to kids. And there's a new drug that's been approved by the FDA called abaloparatide. Get out your pencils.

We'll talk about it later. At the top of the news, a Japanese study by Tom Taguchi's group looked at the possibility of either escalating or de escalating the dosing of IV Actemra in patients who are doing well or not doing well. So if you've achieved low dose activity state, maybe you could deescalate. And they changed those patients who had achieved that state at four at the usual dose eight milligrams per kilogram of IV Actemra. They changed them from every four weeks to every five weeks.

And guess what? They did just fine. Likewise, patients who were not doing well, who had not achieved an LDAS, they escalated their frequency from every four weeks to every three weeks. And guess what? They also proved efficacy.

So there's good data to actually support going up or down, you can reference this in patients who you have to give Actemra in an otherwise, dose than q four weeks. A study about, interstitial lung disease and the risk factors that looked at a large cohort found that the risk factors are many that we know, a few that might surprise you, high disease activity, rheumatoid factor and CCP, smoking, especially in those who are HLA Doctor beta one allele positive. And what they did find is that overall, this tends to occur in the first ten years of RA onset. I've always taught that ILD as other extra articular manifestations of RA occur in patients with seropositive, bad disease, with long standing disease. Well, this says they don't have to have really long standing disease.

It can occur within the first ten years. The FDA has approved a new drug called Xamet, x a t m e t. It's a oral methotrexate solution at a dose of twenty five, I'm sorry, two point five milligrams per ml, and it's being approved for patients with polyarticular JIA. It's out there, and there is it's the first of its kind, in fact. But I don't know about you.

I'm sure this drug is gonna be quite expensive. Like all new methotrexate that have been repurposed, for the marketplace. I've been using this for for a long while, and, basically, you just get the parenteral solution that comes in a two ml vial or twenty five ml vial. And take the right amount, you squirt it into juice or water, you drink it. It's a 100% absorbed, up to fifteen milligrams a week.

And it's just like taking a pill, but it's dirt cheap, and it can be drank. So, again, whether you wanna buy the new expensive version or the old cheap version is up to you. What's the deal with rheumatoid arthritis and cardiovascular disease? Is it the RA? Is it the inflammation?

Is it the test? Well, a recent study actually looked at a number of patients, not with RA, but just those who had, SD segment elevation m MIs, and they subsetted them according to whether they were ACMA positive or not. They found the patients who were ACMA positive. Again, they don't nobody here has rheumatoid arthritis. These are just ST segment elevated MI acute MIs that they had a higher degree of mortality, a threefold higher degree of mortality, and a higher rate of reinfarction, two and a half fold greater rate, if they were ACPA positive compared to those who were ACPA negative, suggesting that there may be something to the, autoantibody, the the, CCP or ACPA positivity that says that there's something going on at a, more basic level at the vascular level that may put these people at greater risk for poorer outcomes with myocardial infarction.

Magnesium oxide for nocturnal cramps has actually been studied. I don't know if you've ever looked into this, and I have. There's very little data about why people get nocturnal cramps. You know, there's a lot of myth and folklore and best advice from your mother-in-law that says that it's bananas and potassium and dehydration and you should fix this by, running to the refrigerator and squirting mustard in your mouth. Crazy things.

But the fact is no one really understands the pathophysiology of this or what really drives the risk. I I firmly believe that dehydration can be a factor. I don't think there's no evidence that potassium is is what will cure it. But there is some evidence out there. Maybe it could be magnesium.

Remember in the old days, we actually used to use quinine, the quinine sulfate over the counter with great success, but the FDA took that off the market suggesting that there may have been some cardiac risks associated with over the counter quinine use. Nonetheless, there's been this study that of ninety four patients showing that magnesium oxide really did not achieve better outcomes than placebo in preventing and treating those with nocturnal leg cramps. If you wanna make yourself famous, go into the nocturnal leg cramp research business, and I think you'll do fine. I wrote down as just a thought this week that you should praise your patients for a few things. Losing weight, stopping smoking, achieving remission that you measure and say, congratulations, ta da, your CEDAI or your DAS score is x and that they should buy into that.

Also their birthdays and important events, including important life events. Someone in Twitter actually said, RheumNow is being kinda strict or hard in his demands or, you know, I thought it was sort of an odd statement, but it's not I don't think I am being too, demanding or, of what we should do our patients. Remember, rheumatologists went into rheumatology because of the relationships with patients, and we need to foster that. And, you know, to praise patients for these milestone and big achievements really helps the relationship quite a bit. A very interesting study answers the question about FM and enclosing spondylitis.

I I personally can't imagine the overlap here, but there are some people who believe that there's a subset of those who have spondylitis or would be spondylitis who in fact really have fibromyalgia. Well, a study of ninety nine fibromyalgia patients took a different look at this and they actually MRI'd these patients looking for evidence of, inflammation, and sacroiliac involvement in the FM patients. And what they did find was that eight percent of patients met criteria for axial spondyloarthropathy, and that MRI sacroiliac I'm sorry, that was ten percent. Eight percent had actually had evidence of MRI sacroiliitis. So, I asked in the tweet, you know, could ankylosing spondylitis be masquerading as FM?

And a few people wrote back on Twitter that they thought it could. It may be something to consider in patients who meet the profile of spondylitis, young, inflammatory back pain. They may have other features and maybe further investigation is warranted. Personally, don't think I'll be be doing MRIs to diagnose spondylitis, in all my FM patients. The FDA has accepted the BLA application for the biologic, sorrelimab, an IL-six inhibitor.

This comes from Sanofi and Regeneron. They've accepted the application, the PDUFA action date to for decision about whether this drug should be approved or not for moderate to severe active rheumatoid arthritis will come in late May. An interesting early arthritis study looked at what is the utility of an MRI in early arthritis patients. So what is the predictive value of doing MRI? And quite interestingly, they showed, number one, that fourteen percent of their very large cohort this comes from the Leiden, or was it the Leeds?

So I think it was the Leeds, Early Arthritis Clinic, Early Undifferentiated Arthritis Clinic. 14 of patients developed, rheumatoid arthritis. And they found that MRI evidence of tenosynovitis, did have a significant predictive value for development of RA, an odds ratio of seven point five. Not having MRI tenosynovitis had a negative predictive value of ninety five percent, whereas having tenosynovitis by MRI had a positive predictive value of twenty five percent, suggesting that an early arthritis population, maybe there is a role for doing, early MRI. An interesting study comes from multiple groups, five groups, four in United States, one in Italy, that looked at, the the disease that is seen in children called enthesitis related arthritis.

This is a subset of those older onset polyarticular or oligoarticular patients who have spondylitis related disease, but specifically looks at enthesitis. There are ILR criteria in these five centers enrolled. There are several hundreds of patients. I think it was over four hundred patients. They showed that seventy eight percent of these, children had a pauciate pauciatecular onset JIA, that twenty three percent were ANA positive at the outset, and that sed rates and CRPs were less, were not present in in in half.

In fact, forty six percent for SED rates and twenty seven percent, or so for CRPs. B twenty seven was seen in a little bit more than half of patients that was associated with being male having higher, active joint counts, sacroiliitis, and an older age at onset, meaning over the getting closer to 16 as opposed to being over the age of nine. So this group has characterized this, this population of ERA, enthesitis related arthritis, may be useful for those of you who take care of children. Cassie Calabrese wrote an interesting article taken, in the literature, about the risk of veno venous thromboembolism in patients who have ANCA associated vasculitis. A study of a study of four different cohorts in four different European vasculitis studies looked at four seventeen patients and found forty one of them developing VTE.

So about ten percent risk of developing VTE. Half these people had GPA, the other half had, micropolyangiitis and and and renal associated ANCA disease. And overall, the risk factors, or the associations with VTE were seen in in those with higher creatinine and those who had either skin or GI involve involvement according to the BVAS, the Birmingham Vasculitis Activity Score. So, those are people who might be at risk. Again, a ten percent risk overall.

And lastly, the FDA has recently approved abaloparatide. The trade name of this is gonna be called TYMLOS, t y m l o s. It's only gonna be approved, however, for high risk postmenopausal osteoporosis patients, those who had a prior fracture, those who had recurrent fractures, and those who are unable to take other existing osteoporosis preventative therapies. So this is a new anabolic agent that, is sounds a little bit teriparatide, also known as Forteo, but this is the new one on the block. It's gonna be also a daily subcu injection.

It's also going to have a two year disease, use restriction because, it too has a dose dependent risk of osteosarcoma. So there's a two year limit until they can study it further. It's been shown very well to prevent, both vertebral and nonvertebral fractures and will be in a pharmacy near you by January, or, actually, I think they said June 2017. That's it for RheumNow. Be sure to go to look at our Twitter feed.

We had a lot of big tweets and about over a 100 tweets from last week's SOTA meeting, state of the art meeting from the ACR in Chicago. A lot of them from great speakers, and I think you would find that to be a nice review. You can go to the RheumNow website and find the citations for these reports. Tune in. Register.

We'll see you next week.