ACR20 - Day 3.2 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.

Hi. This is doctor Eric Dine coming to you from Baltimore, Maryland for RheumNow. We just completed day one of ACR twenty twenty convergence. And I'm here to talk about abstract four eighty three from the afternoon oral abstract presentations. This study by Doctor.

Beikirk at HSS looked at patients' C. D. I. Scores. How well do physicians and patients predict swollen and tender joints?

And can you calculate a patient's C. I. To match a physician's C. D. I.

This is obviously incredibly relevant right now as we are talking about providing telemedicine, providing remote care, not being able to see our patients in the office as much as we'd like. So they reported from two cohorts of early rheumatoid arthritis, the CATCH study, which is a Canadian cohort study, and the CATCH US, the American cohort study. And in both of them, they followed 28 joint counts. And for this study, looked at patient assessment of swollen and tender joints, as well as MD physician assessment of swollen and tender joints. From that, they calculated a CDAI score to follow disease activity levels.

What they found was a fair bit of agreement, a pretty high amount that in the CATCH cohort, the MDs had a score of 26. The patients were on average 27. In the CATCH US, MDs 15.3, patients 15.1. So quite close on those means. And particularly at low levels of disease activity, the numbers seem to correlate extremely well.

They diverged as it got higher when patients were more active. There was some more disagreement and swollen joints were a little bit easier to assess than tender joints. We know that telemedicine is part of clinical medicine. If that wasn't clear prior to COVID, it's certainly part of our toolbox now and I think it's going to be with us for some time indefinitely. How do we use this finding into our clinical medicine?

I think it tells us that we should listen to our patients. We should ask them how they feel their disease activity is, particularly those patients that are doing well. If they say that they're doing well and don't have any disease activity, or if they say that they have one or two joints that are active, those patients tend to be pretty well reliable with what the physician would then assess. Patients that have higher disease activity, that's a pretty good indication for me that that's a patient that I would want to see in the office, either because their disease is active and they need a closer follow-up, or that there's some divergence with physicians more commonly in those patients with perhaps just very high scores that it's hard to keep track of the swollen and tender joints, or there's some difference in expectation or understanding of their disease activity. How generalizable is it?

This is a cohort of early rheumatoid arthritis patients. So you can think about if those patients that have had long standing RA for decades and decades, would they report similarly and when they tell you that they're having a flare or that their symptoms are under control. These are also patients that were in a pretty close cohort study. So they have seen physician visits in the past and they may have a little bit more understanding of what goes into the joint analysis, although they were not expressly taught how to do it in the office. But my takeaway would be when you see the patients in the office, you would empower them to keep track of their own symptoms, show them what swollen and tender joints are present, and talk to them, listen to your patient, see what they say, correlate it with a video examination if not able to do an in person examination, and use their history, use their reports to help get them the care that they need.

When things seem to be active, when things are not going well, those are patients that you would then want to see in the office and keep close eyes and talk to them about what disease activity looks like. I thought that was a great study by Doctor. Beikirk and phenomenal information for me to use moving forward. This is Doctor. Dine reporting for RheumNow.

I look forward to day two of ACR convergence.

Hi. Dave and Lou here again for roomnow.com from ACR twenty twenty. Another abstract from one of the plenary sessions about Kawasaki disease. And we've always thought that with the ready availability of IVIG in the modern era, that we know it reduces coronary artery aneurysm. And I guess the implication has always been that the long term cardiovascular risks might improve as well.

That's really what we're worried about with Kawasaki disease in the long term. What does it mean for these young patients? What does it mean for their long term prognosis and their cardiac prognosis? So some really interesting data from sick kids in Ontario, Canada, looking at some of these data, looking for data from Ontario province. And the associations, they were able to really cohort that data as a population based cohort study and follow these patients through for really quite a long time, up to twenty four years in this modern IVIG era.

And they looked at composite cardiovascular events, as well as, and considering whether coronary artery aneurysms might have an effect or not. And what they saw was that while the risk was high in that first initial period after the initial episode, the risk kept on going on right past ten years for cardiac events, which was somewhat surprising to me. And then, in addition to that, we could see that that occurred in patients obviously with coronary artery aneurysms, but also patients who didn't have coronary artery aneurysms did also seem to have that same risk. I think that raises all sorts of questions about the morbidity that's associated with this disease. There's a lot that we still need to try and address to help these patients with their long term comorbidities.

For this and much more about ACI twenty twenty, head along to roomnow.com.

Hello everyone. I'm Olga Petrina from New York and I'm recording today some updates from the virtual ACR meeting. I would like to share some updates about the use of peglodecase in patients with severe refractory gout. There are several abstracts that talk about how to better or safer use a peglodecase and I would like to start with the abstract 65 which talks about the increase of use of peglotticase in combination with immunomodulatory therapy, to improve the outcomes. So in this particular study authors report that while the use of immunomodulators along with pegloticase was extremely low in the period of time between 2015 and 2018 the average use during that time was between one point two 4%.

It exploded in 2019 up to fifteen percent of, use in combination with immunomodulators. I think it's partially because we are coming across more and more data on safety of use of such combined treatments and there are some clinical trial results pertaining to use of methotrexate, azathioprine, or CellCept along with peglodecase. So based on that data, it seems that the implementation of immunomodulatory therapy into peglodecase infusion schedule becomes more popular overall amongst rheumatologists. And speaking about some background why such combination is effective and safe, the abstract six eighty three speaks about pharmacokinetics concomitant use of peglodecase with methotrexate. So in this abstract, authors outline, the results of the concomitant use of methotrexate and peglodecase in eleven patients with severe refractory gout, and in these patients the trough and cmax was measured with and without use of methotrexate.

So, this particular study, they showed that patients who received methotrexate along with peglodecase tend to have significantly lower levels of trough below quantitative limit. In this study three point six patients, I'm sorry, only thirty six percent patients with methotrexate and seventy seven percent of the patients without it experienced the trough levels below the quantitative limit. And then also maximum concentration of peglodecase seemed to be higher at two microgram per milliliter in patients who used it with methotrexate as opposed to use without. So the study points to the fact that methotrexate probably prevents developing anti drug antibodies and it improves the retention of the medication and the concentrations, although it did not have any effect on clinical response to treatment in those patients who received combined therapy. And speaking of the results of the of the effectiveness of this combined therapy, the ABRSAF six seventy seven, which is a result of the open label MIRROR trial, which initially was staged as a six month trial but later extended to fifty two weeks, which is twelve months.

In this trial patients received methotrexate starting thirty days prior to initiations with Lodecate infusions, and then out to 14 patients enrolled 11 were able to complete the trial at six months and then, three patients dropped out of the trial for reasons unrelated to side effects and interestingly enough patients who were responders in the trial were actually able to successfully continue treatment up to 12 with a good retention of serum uric acid below one. And in this trial it showed that when methotrexate was added to pegloticase, response rates improved significantly in patients and more patients were able to retain efficacy of the medication. When it comes to side effects, the frequency of flares was significant in the first twelve weeks of trial, so ninety two point nine patients experienced the flare of gout in the treatment group, which is, in my opinion, is expected when you start effective uric acid lowering therapy, and then over time at weeks thirty six and on the frequency of flares dropped to only twenty five percent. Also, there's one severe side effect which was sepsis in this trial and the remainder of the side effects were diarrhea, upper respiratory infections, arthralgia, and nasopharyngitis.

No serious events, adverse events were were recorded. So overall it says that the use of methotrexate in combination with peglodecase seems to be effective and safe way to administer on the medication and it is worth considering patients with severe gout who are in need of this important and sometimes scary infusion. They definitely benefit from it. I hope you enjoyed the ECR so far and I'll keep you updated with more information going forward. For now, I wish you all a good day and I'll see you soon on RheumNow again.

Hello, I'm Anthony Chen. I'm consultant rheumatologist from Reading in The United Kingdom, and I'm reporting here from ACR twenty. One of the interesting areas that have been looked at in the ACR and in terms of the sessions, presentations and posters is the area of patient reported outcomes or PROs. Now many of you may be using PROs in your clinic, often it's used for as a research tool, but what we have seen in the presentations and posters is the use of PROs in terms of clinical practice, in terms of informing assessing our treatment outcomes. And there are a few posters, I wanted to highlight to you poster 169, which you looked at the use of PROS, patient reported outcomes in psoriatic arthritis.

Now we have clinical scores that we use in our clinic to measure objectively the patient's disease activity in psoriatic arthritis, such as the minimal disease activity or low disease activity scores. We also have the DEP, we also have the DEPSA score. We also have the CDAI score and so we have few of these scores that we use. Now, if what we have learned from the COVID-nineteen pandemic is that often we found it difficult to meet patients in clinic because we, due to the isolation or the shielding or the social distancing that we had, we had to do a lot of our clinics virtually. Now, when we do our clinics virtually, one of the problems that we face is that we can't physically examine our patients in terms of assessing the number of tendons, swollen joints.

So this study I think is quite useful and practical as well because they use a patient report and outcomes to see whether they correlated with the clinical scores that we would have done in clinic. And they used two scores. Firstly, the score called PSA12, and the other score is called the rapid three. Now they use these two scores and they then try to correlate to see how well they perform against the clinical scores that we, the ones that we use in our clinics, such as the MDA, LDA, CDAI and CDAPS score. And what they found, there was a very strong correlation between the use of the patient reported outcome scores and the clinical scores that would have used in clinic.

So the RAPID-three and the PSAT twelve correlated very well with the LDA, CDAI and CDAPS score. The RAPID three was very sensitive and effective in terms of detecting near remission scores in patients. So in patients who did very well in terms of their treatment, when they did this in the rapid rate, that correlated really well with the near remission scores. And the PSAT twelve scores did well and had a sort of wider range of sensitivity and picking up a more global view of the patient's condition. Again, correlating with the moderate scores on the LDAC DEPS and CDI scores.

So I think this whole area of PROS is one that we should be thinking about how we can implement it in our clinic. You know, you might be using paper scores or electronic scores, and a lot of these scores can actually be completed at home prior to the patients attending your clinic. And you could then spend more time in clinic doing the physical examination, but having a whole rich data about their function and their performance at home in terms of their condition like psoriatic arthritis and how that correlates to their physical examination. Not only in the time of COVID, but I think beyond COVID when things hopefully start to return to normal, we should be considering how we can use PROs in our clinical practice to guide our treatment decisions and to guide our treatment outcomes. I'm Anthony Chan, thank you for listening.

I'm reporting from ACR20. Thank you very much.

This is Doctor. Catherine Dow reporting for RheumNow. So I'm at the ACR twenty twenty Convergence Virtual Meeting. And I wanted to share with you an abstract that I thought was very fascinating because this might actually change your practice. This is abstract number five forty, and this is a study by the Mayo Clinic.

And they wanted to look for what is the incidence, not the prevalence, but the incidence of hydroxychloroquine associated retinopathy with a five milligram per kilogram per day dose. Now, if you remember in the past ACR, we had a great debate where Michele Petrie was trying to argue for the fact that we really shouldn't be lowering our dose, right? But the American Academy of Ophthalmology really wanted us to try to stay low just to prevent retinopathy. So what this study did was they took five forty patients who were taking hydroxychloroquine mostly for rheumatoid arthritis or lupus. The average dose of these patients were three seventy two milligrams a day, where it's estimated to be approximately four point eight milligram per kilogram per day.

And these patients on average had been on the medicine for about nine point six years. And so they explored them at five years, there was zero cases of retinopathy. And then at ten years, there was a two point five percent rate. Now, if you remember the American Academy of Ophthalmology and previous traditional studies had said that at the six point five milligram per kilogram dose, the one that Doctor. Petrie had touted, it yielded at five years a one percent risk of retinopathy and a ten year risk of two percent retinopathy.

So here we have it. Five milligrams per kilograms, zero percent risk, but the six point five milligram per kilogram had a one percent risk. But at ten years, it's like there's really no difference between the two. So what do you think you're gonna do? For me, for sure, I think I'm just gonna keep my lupus patients at six point five milligrams per kilograms per day because this drug has been shown to decrease the risk of death, improve renal response, decrease thrombosis, improve pregnancy outcomes.

I just really think that this is such a good drug and we need to be using our tools effectively. This is Doctor. Catherine Dow. Continue to follow me on Twitter KDAU2011.

Hi I'm Doctor. Janet Pope here at RheumNow at the ACR twenty twenty virtual meeting or convergence meeting. There's a lot going on. There's been a lot of excitement on the posters and on the talks. What I'd like to talk about today is whether or not we think that methotrexate increases skin cancer in our patients such as in rheumatoid arthritis and also whether we should do skin exams.

So on abstract 1,001 there's a nice study looking from a great big billing database Medicare looking at people receiving methotrexate or hydroxychloroquine. And what they did was they looked at the incidence of both non melanoma skin cancer or NMSC or melanoma skin cancers and reassuringly with a very large N they found no difference in the rate of skin cancers and that was looking overall, looking at the two subsets, looking also for those who got eye examinations because of course more eye exams would be scheduled for hydroxychloroquine and things like melanoma and the retina are very rare but something that could be picked up. So the bottom line there was no difference. So what is my take home? There have been people suggesting that all their patients on biologicals and maybe also CSD marks such as methotrexate should have skin exams.

Number one, I'm not against the skin exam. I think it's important in high risk patients. They're fair, they had lots of sunburns, they've already had a skin cancer. But number two, I don't think we need to spend the dermatologist time for every one of my RA patients as a for instance, on either a BD MARD or on an advanced therapy or even on methotrexate. I think skin cancer is very common.

Most patients see that it's there and when we examine our patients we should look. So number one, methotrexate at least in this study doesn't increase skin cancers. Number two, I don't think a skin exam annually in every patient is needed. Thank you. Please follow us at RheumNow and my Twitter handle is JanetBurdope.

Thank you.