ACR20 - Day 1.1 Save

This is the RheumNow podcast, and you're listening to highlights from the ACR twenty twenty virtual meeting. Our faculty reporters have been doing videos and recordings so that you could stay up to date. Hope you enjoy these and our panel discussions.

Hello. I'm Jonathan Kaye from the University of Massachusetts Medical School in Worcester. I'm reporting to you from ACR Convergence twenty twenty, which means that I'm in my office at home and I'm looking at my computer. And I'm gonna talk today about a very interesting abstract that was presented in the first plenary session, today is Friday. And this was an abstract about hydroxychloroquine use and QT interval prolongation in patients with lupus and rheumatoid arthritis.

This was presented by Elizabeth Park, a third year fellow from Columbia University Medical Center, who worked with colleagues, John Giles, Joan Baython, and Laura Geraldino, as well as several others. The study looked at, QT interval prolongation as a result of the COVID-nineteen data, which suggested that patients with COVID-nineteen treated with the combination of hydroxychloroquine and azithromycin had QT interval prolongation. Rheumatoid arthritis patients have been treated with hydroxychloroquine for decades as have patients with systemic lupus erythematosus. So Doctor. Park and your colleagues looked at two rheumatoid arthritis cohorts, one that had been established at Johns Hopkins Arthritis Center when, John Giles and Joan Baythong were there.

And then a second cohort that they established at Columbia University Medical Center when they arrived in 2011. They also looked at a cohort of patients with lupus, that had been evaluated, with EKG screening at Columbia University Medical Center between 2015 and 2019. All patients met ACR classification criteria, either for rheumatoid arthritis or for systemic lupus erythematosus, and patients were excluded if they had a physician diagnosed cardiovascular event or procedure for rheumatoid arthritis or self or physician diagnosed cardiovascular event or procedure for patients with lupus. Hydroxychloroquine use or non use was assessed at the time that they had an electrocardiogram, and they assessed variables related to cardiovascular disease, as well as to rheumatoid arthritis or lupus, and, also assessed whether they were taking concomitant medications that might prolong the QT interval. The primary outcome was the corrected continuous QT interval length, with lengths of four forty or five hundred milliseconds or longer, being categorical cutoffs.

And they performed multi variable analysis to look for associated covariates that might be contributing to this effect. The two groups, there were three seventy one patients between the two, diseases who were taking hydroxychloroquine and one hundred and fifty nine patients who were not taking hydroxychloroquine. The groups were relatively comparable, although hydroxychloroquine patients were treated, hydroxychloroquine treated patients were about ten years younger, than the patients who were not taking hydroxychloroquine. And they were also more likely to be taking corticosteroids or statins or low dose aspirin. The patients who were taking hydroxychloroquine had a lower prevalence of QT corrected interval prolongation than those who were not taking hydroxychloroquine.

The patients who were taking hydroxychloroquine, lower proportion were also taking antidepressants, a lower proportion were also taking muscle relaxants. When they looked at the corrected QT interval, the unadjusted QT interval was higher for patients not on hydroxychloroquine compared to those taking hydroxychloroquine. However, when adjusted for age, race, current prednisone use, hypertension, current smoking, diabetes, aspirin use, and antimicrobial use, this difference in QT corrected interval disappeared and the two groups had comparable adjusted QT corrected intervals. When they looked at clinical characteristics that might be associated with QT interval length. They found that age, current prednisone use and current smoking were associated with QT interval prolongation.

Of the groups, the patients, with rheumatoid arthritis, there were thirty nine patients who had QT prolongation of five hundred milliseconds or longer, and eleven of the lupus patients had similar prolongation of the corrected QT interval. However, were, only nine of the eleven lupus patients and four of the thirty nine rheumatoid arthritis patients with QT corrected interval prolongation were hydroxychloroquine users, therefore they could not ascertain any statistically significant differences between users and non users of hydroxychloroquine. The conclusion of this study was that they found corrected QT interval prolongation in a small number of patients taking hydroxychloroquine, but there were no arrhythmic episodes or associated deaths among the lupus patients. There was no QT corrected interval prolongation observed in those using hydroxychloroquine in combination with other QT, interval prolonging medications, and only in the lupus cohort did they find a significant interaction between hydroxychloroquine use and antipsychotic medication use. So, this study is a very well done epidemiologic study in established cohorts that found no association between correcting QT interval length and hydroxychloroquine use, at least in patients, with rheumatoid arthritis or lupus, not taking azithromycin.

This study provides evidence to support the relative cardiovascular safety of hydroxychloroquine, in patients with rheumatoid arthritis and patients with lupus, and helps to dispel the fear of this complication that was observed in patients with COVID-nineteen treated with high doses of hydroxychloroquine in combination with azithromycin. This was a terrific presentation by a third year rheumatology fellow with great mentorship from the group at Columbia, John Giles, Joan Baython and Laura Geraldino. I congratulate and commend her on her plenary presentation today. And for more information about this and other presentations at ACR Convergence, please tune into RheumNow. A number of my colleagues are tweeting on a regular basis, and we'll be filming additional videos with panel discussions, interviews, and other reports from ACR Convergence.

Thanks and I look forward to seeing you again on RheumNow. I'm Jonathan Kaye.

Hi, I'm Doctor. Janet Pope. I'm with RheumNow. I have a Twitter handle of janetburdeaux. I'm reporting with RheumNow at the ACR twenty twenty, our Convergence virtual meeting.

I'd like to talk about something that's really a buzz at the meeting, looking at hydroxychloroquine and whether it prolongs a QT interval or not. So this was a plenary session abstract four thirty one. It's from Elizabeth Park et al. And that's a large group out of Columbia University. And the question here was looking at over six hundred patients with rheumatoid arthritis and SLE and asking the question, if patients are on antimalarials, is there prolongation of the QTC interval?

It's important for two reasons. One is the annoying facts as we get from pharmacists that say there could be drug drug interactions and hydroxychloroquine in the doses we use. Sometimes an alert will come up. So that's the first reason. The second reason is at very high doses, sometimes with azithromycin or clarithromycin in patients who were trialed with COVID, now negative results in those COVID studies on hydroxychloroquine, but there was prolongation of the QT interval.

So this was an excellent study to answer that. They did propensity scoring. They had RA patients and lupus patients. In general, some patients had imbalances on some comorbidities such as heart disease, which obviously an imbalance could be important. There were imbalances in the amount using corticosteroids and a few other differences with either adjusted or unadjusted propensity scoring of these patients, it was found very reassuring that hydroxychloroquine and chloroquine, the vast majority on hydroxychloroquine did not prolong the QTC interval.

And in fact, the heart disease patients were excluded as they had active heart disease at the time, but patients with known past coronary artery disease also did not have prolongation of the QTC interval. The next part of the study was to look, are there drug drug interactions where this could be occurring on the ECGs if there were other drugs that could prolong QTC interval as well. And bingo, no other changes there as well. Take home message is I do believe that this is helping to convince me still that antimalarial drugs are safe for our patients with RA and lupus and the doses we use and that we don't have to worry about the QTC interval in our patients and we don't have to worry about drug drug interactions. I appreciate this study.

I think it's clinically relevant for us when we practice every day. Thanks, enjoy the meeting, and we'll see you at room now.

Hi, this is Eric Ruteran from Northwestern University, coming to you for RheumNow from ACR Students twenty twenty, which interestingly seems to be happening in my basement. I wanted to talk today about a couple of abstracts, one of which is today and one of which is tomorrow, in the psoriatic arthritis arena. And I wanted to talk to you about them, not so much for the specific results of the abstract, but actually for some implications that I think are really important as we think about, new trials and new studies, in psoriatic arthritis and in fact in other diseases. So the main abstract, is going to be presented tomorrow, is called the Achilles study. And this is a study of secukinumab in patients with Achilles tendonitis who had either psoriatic arthritis or axial spondyloarthritis.

They looked at two hundred patients, the bulk of which 128 of them had psoriatic arthritis, the rest with axial spondyloarthritis, and they had imaging and clinical evidence, according to the local site, of Achilles tendonitis. Patients were enrolled in the study and were randomized to secukinumab, or placebo with the usual loading dose of secukinumab for the first, month. Interestingly, the primary endpoint of the study, which is clinical resolution of anthazitis, and that's going to be presented in a poster tomorrow, was a negative outcome. And they did not show, any significantly increased, resolution of the anthazitis of the Achilles tendon in the patients who got sacituzumab versus placebo. Though many other measures of disease activity, including, sort of overall, measures of enthesitis, improvement in enthesitis, a variety of other things, did show that secukinumab worked, not surprisingly.

But the interesting piece of this I think was actually the presentation today. This was abstract four forty seven, presented today in an oral session in which they looked at the baseline data. And what was particularly interesting was that patients got into this study, based on having clinical evidence of Achilles tendonitis and an MRI that was read at the local site, either by the rheumatologist or the radiologist, as showing tendonitis of the Achilles tendon. One hundred percent of the patients had abnormal MRIs locally, but when they sent those MRIs to be read and evaluated by two central readers, only fifty six percent of them had an abnormal MRI or had a positive MRI for tendonitis. So let me say that again, fifty six percent of them.

So just about half actually had what they considered the inclusion criteria for the study. So this brings up a bunch of issues. And the first question is, all of these patients, at least as far as we know, had clinical enthesitis as judged by the investigators at the local site, and yet only half of them had abnormal MRIs when read, by a central reader. And this would suggest that there's a big disconnect between what we see clinically and what we see on MRI. And that's not news.

We've seen that before with ultrasound imaging. We've seen that before with MRIs and other location. MRI and other imaging tools tend to be more sensitive. But what I think is actually the most interesting thing about this was the disconnect between what was seen locally, or at least read locally on the MRI, and what was seen centrally. And there it turns out that, again, only half of the patients who had abnormal MRIs when read locally still had abnormal MRIs when read centrally.

And we've seen this sort of data before. We've seen this before, not in psoriatic arthritis, but axial spondyloarthritis, where local reads of sacroiliac imaging don't really match up with central reading, and it's pretty similar numbers that about half of the central reads turn out to be negative even when there was a positive local read. And I think this gives us some pause. And I think that particularly as we're thinking about studies and trials that rely on imaging as an entry criteria, this study and in the presentation today, Doctor. Baraliakos, who was the presenter who led this study, acknowledged this, that in studies that use imaging as an entry criteria, we really need to have consistent central reading of the imaging in order to know that we're dealing with apples and apples and not apples and oranges.

It seems like a small point, but I think going forward as we, get more and more trials, and particularly trials that look at comparisons between different drugs, it's going to be critically important to think about this. And so that's my takeaway. Does this change clinical practice? I'm not really sure, but I think it does give us some pause as to what's really there when MRIs are read locally. And, it's a totally separate topic, but there's some other interesting, papers at this meeting looking at using computer analysis and machine learning to identify, features on imaging studies.

And maybe that's the way forward, and maybe that the central read could be done by a computer and not by a radiologist. That's down the road, and that's certainly speculative. But for me, the key takeaway is, in this study, the local reads didn't match up to the central reads, and perhaps, and this is also speculative, perhaps had they matched up, maybe it would have been a positive study. Unfortunately, we'll never know that. Anyhow, lots of information on psoriatic arthritis in this meeting.

This is just another tidbit. I look forward to seeing more and tune into RheumNow for all the information about ACR convergence.

The age old question in rheumatoid arthritis is always about methotrexate and the liver. This is Eric Dine, MD reporting on behalf of RheumNow at ACR twenty twenty, ACR Convergence from Baltimore, Maryland. There is lots of great information from the morning poster sessions today. I wanted to talk about Abstract 181 by Doctor. Choi from Korea.

It looked at ninety two patients with non alcoholic fatty liver disease, NAFLD and to see if there's a difference in patients with methotrexate that was a risk factor for development of NAFLD. This was a case controlled retrospective study. The prevalence of NAFLD did not appear to significantly differ across the cumulative methotrexate dose p value of 0.9. So what did increase the risk for non alcoholic fatty liver? The things you'd expect.

So triglycerides, odds ratio for that was almost fivefold and high BMI odds ratio there being one point two. Does that answer the question? A bit. So they say that the benefit of the studies that is real world data, but we are subject, of course, to the bias of this being retrospective analysis. What made the patients different that were on higher doses of methotrexate?

Were there patient characteristics that weren't fully accounted for biasing the patients that did well on the higher doses of methotrexate without hepatic disease? I think that is a limitation in my mind, but I do agree with Doctor. Choi and their team's takeaway that you should look at the whole patient picture, not just the methotrexate. So we treat the whole patient. So if you're worried about the liver, talk to them about their weight, their diet, not just focusing on the methotrexate dosage.

This is Doctor. Eric Dine. Thank you for your time and look forward to checking back in with you throughout all of the convergent meeting and check-in to RheumNow throughout the meeting for more information. Thank you.

Hello. I'm Rinalini Day, and I'm an academic rheumatology trainee from Liverpool in The UK, and I'm reporting for RheumNow. And so I'd like to highlight one of the posters that was presented at one of today's poster sessions, with a focus on epidemiology and outcomes, specifically focusing on COVID nineteen. So this is abstract zero zero zero six entitled, race and ethnicity is associated with poor health outcomes amongst rheumatic disease patients diagnosed with COVID nineteen in The US. And this is from data taken from the COVID nineteen Global Rheumatology Alliance physician reported registry, authored by Gianfrancesco and colleagues.

So as the title suggests, this work really highlights the impact of factors such as race and ethnicity on health outcomes in our patients who contract COVID nineteen. The study included patients with rheumatic disease and COVID nineteen registered on the database between March 24 and 05/22/2020, which came to a total of 694 patients. And so the authors used multivariable and ordinal logistic regression and Poisson models in order to investigate hospitalization, ventilatory support, and mortality respectively. So the results showed that racial and ethnic minorities were more likely to experience poor outcomes, including hospitalization and the requirement for ventilatory support compared with white patients. And this was even after adjustment for their disease and comorbidities.

It's quite similar to the findings found in the general US population, and it really puts into sharp focus the health disparities relating to COVID nineteen and has wider implications for how we address the needs of the most vulnerable in our society. And it also raises the wider question of race and ethnicity in infection in rheumatic disease in general, and whether this affects adverse outcomes with relation to this. And finally, this is just one important piece of work that's come out of the COVID nineteen global rheumatology alliance, registry. And it really highlights the fantastic effort of the global rheumatology community in coming together at the start of the pandemic in order to conduct such vital work, which has real implications for our patients. And I'm sure we'll be hearing more about it, during the remainder of the ACR twenty twenty Congress.

And so thank you for watching. And don't forget if you'd like to receive more updates as the congress, takes place, don't forget to follow me on Twitter at doctor mini day, or you can follow the RheumNow Twitter feed as well. And thank you very much for watching.

This is doctor Katherine Dow reporting for RheumNow, and I'm at ACR twenty twenty watching this virtual conference, for the ACR convergence. And I wanted to share with you an abstract that was presented at the plenary session this morning. It's abstract number four thirty three. And basically this abstract was looking at race discrepancy and how, patients with lupus have a higher risk of stroke and heart attacks if they're black. So this is really important because you know the majority of patients who are affected by lupus severely actually are black patients and this only confirms it but also it identified some novel factors that can contribute to this risk.

So this is a Georgia study. It actually was looking at the Georgia Lupus registry from DeKalb and Fulton Counties where fifty percent of the population is African American, fifteen percent poverty rate, and forty one percent had college degrees. And they found three thirty six patients who had lupus and who actually suffered from either stroke or ischemic heart disease. The average age was about 40, eighty seven percent were female and eighty four percent had hematologic disorders so that could be anything from, low platelets, low white blood cells or hemolytic anemia. And then sixty six percent had arthritis thirty one percent suffered from lupus nephritis fourteen percent from discoid lupus and nine percent from neurologic disease.

What was interesting about this study was that the greatest number of strokes were found within the second year of diagnosis. And not only that, the greatest proportion of ischemic heart disease was after ten years of diagnosis. Now there's other studies out there that had mentioned how, cardiovascular risk is pretty high for strokes and heart attacks even within the first year. What the results of the study found was that black patients actually had a three times higher risk of strokes and twenty four times the risk of ischemic heart disease compared to white patients. It's a P score of 0.007.

And the predictors of stroke was being black, having discoid and also having renal disease. And then the predictors of ischemic heart disease is being older than 65 years, black race, neurologic and immunologic disorders. So this includes, antiphospholipid antibodies as well as other antibodies. Now the strength of the study is that this is a population cohort and it's a pretty diverse cohort looking at the highest risk population for lupus and their complications. They did a really robust cardiovascular screening.

They did not account for smoking, hypertension, the traditional cardiovascular risk though, or the use of steroids and hydroxy chloroquine. They were missing a few data points. But the reason why I feel that this study was so important is because, you know what, most of our patients who have lupus and who are of ethnic minorities, they do suffer from more severe ischemic heart disease as well as strokes. And we have to be aware of that and modify as much risk factors as we can and be vigilant about symptoms that they may present. We need to be counseling them to exercise.

We need to be counseling them to, lose weight, eat a healthy diet. And then ask those traditional cardiovascular questions like, are you having any chest pain? Have you gotten your lipids checked? If you don't check your lipids with your primary care doctor, I think as rheumatologists that's something that we need to do, to help our patients. So I hope this gives you a little bit of a perspective in terms of how RACE affects lupus.

Again, this is doctor Katherine Dow reporting. Please follow me on Twitter kdao2011.

Hi, I'm Doctor. Janet Pope at RheumNow. I'd like to talk about abstract four fifty five. This is an interesting abstract because it's talking about reactive arthritis looking at chronic versus acute. First of all, we and others have published that reactive arthritis is quite uncommon.

We think it's decreasing over time. So what this study did was looked at those who had self limited reactive arthritis and those who were chronic. First of all, the ends are small because it's not very common. And secondly, it is from a database that's looking at seronegative spondyloarthritis in Canada. So they had twenty three self limited patients with reactive arthritis and thirty four with chronic.

And the big differences, no surprise were those who are HLA B27 positive were more apt to have chronicity. But interestingly, and I guess it would go with it, those with inflammatory back pain were also more apt to have chronicity. What didn't go with it was uveitis or conjunctivitis or other features. So I think what's important to implement in my practice is that if I see someone with chronic reactive arthritis and they have inflammatory sounding back pain, I will make sure I follow them more carefully as some of them will go on to need other DMARDs or biological drugs. So something to think about.

We don't see it that much, but it still is an important issue in our practice. Thanks. I'm reporting from AtRoomNow at ACR2020 twenty Convergence, Janet Pope. Thank you.

Hello, ACR Convergence twenty twenty. This is Doctor. Robert Chao, and I'm coming to you virtually from Fairfax, Virginia. I had the pleasure of reviewing several abstracts today, and I wanted to share with you two abstracts on treatment options for psoriatic arthritis. As you know, one of the holy grails in treatment of psoriatic arthritis is finding the right drug for a patient's predominant disease manifestation, whether it's more arthritis, enthesitis, staccolitis, etcetera.

The first abstract is abstract three seventy five. This is a large cohort of about twelve seventy psoriatic arthritis patients. And fifty percent of these patients had enthesitis with a mean tender and thesis count of around two. Therapies were relatively evenly distributed into three categories, the first being no medications or NSAIDs only versus conventional DMARDs versus biologic DMARDs. This study did not find a difference in enthesitis resolution in the three drug categories.

There was complete resolution of enthesitis in about eighty six percent of patients regardless of the medication category. The only statistically significant trend found was gender with males achieving complete resolution of enthesitis more than females. Furthermore, there is no difference in BMI or age. I think this raises a few interesting questions. Number one being, does enthesitis improve irrespective of treatment?

This study would say so. Number two, do we even need a tailored treatment specifically for enthesitis? And number three, I think we just need more data. And especially, I would like to see studies on comparing different biologic DMARDs against each other for treatment of enthesitis. The second abstract is Abstract three eighty one.

This is a post hoc analysis of data pulled from two Phase III studies involving three seventy three patients with psoriatic arthritis on tofacitinib five milligrams twice a day, tofacitinib ten milligrams twice a day, and placebo. Patients treated with tofacitinib had improvement in dacolitis, severity score, and number of dacolytic digits compared to placebo. Tofacitinib ten milligrams twice a day showed numerically greater improvements in dactylitis severity score compared to five milligrams twice a day. So I don't think the studies, the findings of the study were particularly surprising, but they are in fact pretty reassuring. It's nice to know that we have another tool in our arsenal for treatment with daculitis and psoriatic arthritis patients as we continue on our search for more tailored and individualized treatment options for our patients with psoriatic arthritis.

So thank you very much for tuning in and please go to roomnow.com for complete coverage of ACR twenty twenty. And please follow me on Twitter at doctor RBC. Thanks.