54K Peptic Ulcers Annually (12.13.2024) Save

It's Friday 12/13/2024, that is. This is the RheumNow podcast, and I'm Jack Cush with RheumNow. Hope you're ready for the holidays coming up. We are getting ready. We've got another full week of good news.

I think the big news this week were the results of the match. You know, we've talked about the match before. You know, it's adult rheumatology has done really, really well. You know, they've actually expanded the positions from, this year. There were five new programs and 11 more fellowship positions for adult rheumatology.

And the, match rate was, what was it, a hundred, two eighty four out of two eighty seven positions. That's 99%. Congratulations to all the program directors, in developing these programs and making them attractive. It's become competitive, rheumatology has been. But again, the big bad news story is, what are we going to do about pediatric rheumatology?

And it's actually gone down. So there, the number that matched was always less than 50%. So, there were, 27 of 55 positions filled this year. That's 49%. In 2023, 21 of 38 programs and 32 of 52 programs, so 32 has gone down to 27 matched positions.

There's a desperate need for more pediatric rheumatology. Pediatric rheumatology is wildly exciting. I mean, I must say, got into rheumatology because of my love of pediatrics and medicine, And it was bridged by my learning about JIA and Still's disease. And then, you know, throw on top of that, the only other things that you manage, you know, including juvenile dermatomyositis and juvenile lupus and juvenile PSA. You know, older onset males with, axSpA.

I mean, it's an exciting area. And why more people are not going into it, I don't know. But it behooves us as a discipline to promote this as a career, to lean on our societies and our program directors to make these more attractive. We've got to turn this around because this is a large, large unmet need in medicine. Two reports this week about diseases we don't see much of in The United States, but mainly in the tropics and in Southeast Asia, chikungunya and dengue fever.

When I was in medical school in Grenada, a number of my classmates had dengue fever, a mosquito borne illness that has had a resurgence in its frequency, especially during 2024, thirteen million new cases reported by the CDC, most of that in The Americas. In the last fourteen years, fifteen thousand cases were hospitalized. But the fatality rate has not changed, that's a good news thing. Most of these are the DNV-three strains that had a recent outbreak in Puerto Rico. Chikungunya also is marching on becoming a global health problem that in the last ten years, it's disabled millions of people and has amassed over $50,000,000,000 in health care costs and disability related costs in 110 countries.

This was covered in BMC Global Health. Again, I don't know about you, but I've seen two cases of chikungunya in the last three years. You have to be open to it and get a good history as to where the patients have been. One of mine was from The Caribbean and the other one was from someone in India who had migrated to The United States. And they both ended up having a chronic RA appearance, and positive serologies.

So again, you need to be aware of this, especially if you're living in endemic areas. ILD is all the rage. The question is, what is the risk factor? We know it's an extra articular manifestation of RA, it comes on with more severe disease, it comes on with seropositivity, is it affected by the drugs we use? Is it affected by the amount of, of activity, these patients have?

So this is a cohort study that compared one hundred and thirty nine incident RA ILDs to, six eighty six controls that had be followed for more than a year. And the risk factors for incident ILD were inflammation, as measured by ESR and SED rate, which upped the odds either eighty six percent or fifty five percent. And what did not increase the odds was DAS 28 scores, tender joint counts, and swollen joint counts. This is data from a very reliable registry, the rabbit registry, the German biologics register. They do fabulous, research with their cohort analyses.

You know, I've been covering this the last few years at ACR and ULAAR, we're coming across more reports where patients who were treated more aggressively were also less likely to get disease. Is that because they're lowering the inflammation that's driving this or what? Again, I think more, research is needed in this area because, I think we have to have a really strong preventative strategy. It's good news that we have drugs that work and that are FDA approved. But at their best, they cause a plateau of ILD worsening.

And that's a good thing, but it's probably a whole lot better to avoid this. More research is needed. I like the review this week that was published on IgA vasculitis, also known as Henoch Schonlein purpura, making some basic points that are good test question points that we know it's a bimodal distribution, that kids that are usually young, eight to 12 or something like that, tend to get seasonal stuff, they tend to get more GI manifestations, and adults tend to get more glomerulonephritis, and adults are usually over the age of 40 or so. And this particular review was reviewing the, treatments, especially for those with mild disease or with more severe disease. And they were emphatic in saying the first line treatment was steroids.

I don't know if that's really true. First line treatment is observation and, you know, treating underlying infection and whatnot. Steroids in its role, you know, may be reserved for more severe cases. Colchicine, dapsone, methotrexate can be used in minor disease. And this review said cyclosporine, tacrolimus, mycophenolate can be used in steroid sparing.

I do think that this is a highly contested area, that, chapters I've written in the past said that there's no clear winner when it comes to treatment here, especially in patients with glomerulphritis. But again, you gotta use something. And I'm pointing out a review that you may want to refer to. A failed trial, we don't often talk about failed trials. This was a trial that occurred post COVID, which means that its enrollment was cut short.

This was an anti IL-twenty three guselkumab being used in patients with lupus, looking at proteinuria as an outcome. At week twenty four, the primary endpoint was met by fifty six percent on placebo and only thirty six percent on giselkumab, therefore suggesting, maybe that doesn't work. Again, there's a biologic rationale here, but at least in this small trial, no signal to indicate that, you might want to do this on your own. I'd be waiting for other trials, but I don't even know if we're going to see trials in this. You do know we have the trials with the IL-twelve twenty three inhibitor that worked great in phase two, but not so great in phase three.

JAMA had a review this week on peptic ulcer disease in The United States, affecting one percent of the population, with fifty four thousand people admitted annually for bleeding peptic ulcers. And the sad part is that is dangerous, and is morbid, if not mortal, risk associated with that. The warnings are few, less than ten percent of these patients with peptic ulcer disease, especially bleeding, will present with upper abdominal pain and, you know, epigastric pain, etc. The causes for, main causes for peptic ulcer disease, forty two percent, H. Pylori infection a big player, and nonsteroidal still a big player affecting thirty six percent, then a myriad of factors that are doing the remainder.

We're gonna be covering upper GI disease at RheumNow a lot, I think you're gonna like that. We've a great speaker, lined up. The old corona registry now called CORE Evitas looked at the frequency of fibromyalgia and widespread pain in their cohort of eighteen hundred plus PSA patients, what do you think the number is? How many have coexistent fibromyalgia by definition or widespread pain? It's eleven and twenty one percent respectively.

Widespread pain is more frequent. And half that rate, eleven point one percent met definition of fibromyalgia. Who was more likely to get this? Women, coexistent depression or anxiety impaired function, higher BMI, and higher numbers of comorbidities were associated with these two unfortunate findings, which will color the outcomes or whatnot. These patients will be less likely to respond, be harder to treat, may very well be classified as difficult to treat or recalcitrant disease.

Another report this week from CORE Evitas and a certain study, was that the metabolic syndrome was associated with poor outcomes and poor response to therapy in RA. If you had metabolic syndrome, a CDAI, MCID, was only achieved at 0.6, so a forty percent reduction. And didn't matter whether they were starting on a TNF inhibitor or another biologic or other therapies. Also, what didn't matter was the contribution of adipokines to therapeutic resistance. So it's a complex formula as to why patients with metabolic syndrome are going to be harder to treat.

We talked about this before, the patients with obesity harder to treat. Again, just it's important to identify and know what you're up against and to fight like hell. Lancet this week did a forecast of arthritis in the great country of Australia, down under, the problems are just like they are up over here in The United States. Can I say that? Comparing down under and up over?

Am I the first to do that? Am I on to something? Or am I just plain crazy? There'll be a quiz later on that. Australia has got four point five million people, and it's expected that by 2040, it's going to increase a 31%, over the 4.1 in 2025.

2025, we have 4.1 in Australia, expected in 2040 go up to 5,400,000. You know, in the other projections and other jurisdictions, most of this increase has been attributed often to obesity and many lifestyle factors, but it's not fully known. The numbers, for instance, of RA patients included in here was seven hundred and fifty thousand, three point two million with OA, eight thousand five hundred with AIA. OA was going to increase in males from six point three percent to seven percent by 2040. More so in females from ten point eight to twelve point two.

RA is supposed to grow one point five percent to one point seven five percent in males and more in females, where it's going to go from two point six to two point nine percent in a fifteen year period. These are sobering numbers. We need public health strategies to deal with this. A report this week on the bidirectional relationship between pain and sleep. That means pain causes bad sleep, or bad sleep causes more pain.

Which one is worse? In this analysis, sleep impairment more strongly predicted pain than pain predicting sleep. So this becomes crucial in your day to day management. Again, such patients have higher disability, more depression, more pain related catastrophizing. I like this report that, comes out of Leiden cohort study about, hand pain in osteoarthritis of the hand.

This is a total of three fifty six hand OA patients enrolled in the hand osteoarthritis and secondary can or HOSTAs cohort. And they measured, outcomes in a number of different ways, OS scan and other tools, including MCID and patient acceptable symptom satisfaction. Over a four year period, hand OA, what did it do as far as the pain? You know, I always thought of this as being sort of progressive in most patients. And yet it comes to a point where the hands are ugly.

They have DIP and PIP hypertrophy, Hebert's and Bouchard's nodes, and then they may no longer hurt. In this four year period, thirty eight percent had improvement of their pain, thirty percent had their pain deteriorate and get worse, and thirty two percent remained stable. So patients with disease of more than a year, only thirty percent really got worse. Two thirds either improved or remained stable. I find this really encouraging and maybe a bit of hope that you can embark upon your patients when talking to them about what we're going to do about the pain while we're waiting for it to self, correct itself.

Again, you can't correct the bony deformities, but you can hope that the pain will change. Pain worsening was associated with higher BMI, poor coping, poor illness comprehension. A report this week from a Spanish retrospective cohort of seven hundred eight seventy two GCA patients, this is called the ARTESR registry, where patients are followed for at least two years. In this registry, over about half the patients were on background DMARs that you use, either tocilizumab, methotrexate, or other immunosuppressants. And the sad part about this follow-up study, where patients were followed for three to four years, only twenty one percent of patients successfully reached a sustained drug free remission.

Oh, that's only one in five, Followed for up to four years. Maybe we need to be more aggressive. Maybe we need to be using more steroid sparing agents. Maybe we need to stop, you know, lying to patients saying, one or two years on high dose steroids and you'll go into remission. You've all said that, many of you said that, I said that, and the data doesn't agree with that.

In their first year of study, only, at year two, only six point three percent of patients were in sustained drug free remission. By again, years, four, it was over twenty percent, which is good and got up as high as twenty five percent in some. So, again, the goal here would be getting down to prednisone ten milligrams a day or five milligrams a day. But the good news is if the patients do go into sustained drug free remission, they're less likely to have flares. They're more likely to be on substantially lower doses or off of steroids.

This is where we need to be. The other place where you need to be is RheumNow Live, February eighth and ninth. Now's the time to join, before the holidays come. Look at the agenda, we've posted it. The speakers we have are incredible.

The session on vasculitis, an expert lecture on EGPA from Denver Jewish Hospital, Doctor. Michael Wexler, vascular imaging by Reni Ray from Penn, and Richard Conway from Ireland talking about modern management of PMR. We've got Desiree Vanderheit talking about advances in care. We've got Peggy Crow from HSS talking about interferon's role in lupus and Michele Petrie talking about new rules on steroids. We had Artie Kavanaugh talking about combination biologics in PSA and Alexis Agde addressing prevention of PSA.

What? And then, again, Ken Gordon, a great speaker out of Chicago, talking about head to head trials, in psoriatic diseases. A whole bunch more of the STEP Talks, the TED Talks we're going to have are just killer. Check out the agenda. It's at roomnow.live.

Now's the time to register. We'll see you in Dallas in the New Year. Take care.