ACR2018 Chicago Day2 Part2 Save
ACR2018 Chicago Day2 Part2 by Dr. Cush
Transcription
Hi. You are listening to ACR two thousand eighteen podcast. I'm Jack Cush, executive editor of RheumNow. This is a compilation of podcasts from the ACR two thousand eighteen meeting in Chicago wherein you'll hear daily reports from the experts, the KOLs, and people making the news. Hope you enjoy the recording.
Hi. I'm Kathy Calbrace. I'm here in Chicago at ACR twenty eighteen, and I am pleased to have a few days like Elvries and Jack Cush to talk about vaccinations in patients with rheumatic diseases. Starting with this morning, there was an abstract episode I certainly can see some coverage issues getting paid for, but what do you guys think about that, Jack?
Well, I I I sort of start off with some of the issues in trial design. You know, it's a very large trial. It was done over started 2016, twenty sixteen-seventeen season, twenty seventeen-eighteen season, not this year. They had a large number of patients and the trial design was basically everybody was on methotrexate and then they had groups based on what drugs you were on and I had no problem with the groups except for the last group which was the rituximab abatacep group with or without methotrexate or a DMARD and I don't see adding those. Mean rituximab by itself makes sense, but, and they said that it was because it was before the data was known fully about Avatacep, that's why they included that that group.
That was one thing. The other thing is, you know, I understand this is all RA patients and you have really no information about how active or bad they are or whatever, but it's mainly getting used in the elderly population and that's where it seems to be pushed and they're asking for it. In the general population, I don't know that it really has applicability unless it's really gonna be that much more effective in a regular RA patient. So question is, is the data good enough or compelling enough that we should be pushing in RA patients?
I was very impressed and I think the the effect sizes were not trivial. No. These were threefold levels in mean geometric means and protective levels of antibodies. And I mean I really was moved by that data. Yeah, there's a lot of issues in trials and I but we've been talking about this for a couple years now.
I wonder what would happen. Well, actually did the trial and the results were trivial. I would change my practice based on this if I could get this.
That's the key issue because I don't think enough rheumatologists are pushing their patients. It's hard enough to get them vaccinated. We're really bad at getting them vaccinated, period. But then to push them to get the high dose, which is generally not available in the clinic in most places, it's gonna have to it's gonna be a substantial change in practice. Does the data merit it?
Think it does. It's it is very strong data. Changing practice is gonna be hard.
We'll hear if you guys know what the best difference is between high dose and traditional.
She said she said $10 for traditional, you know, versus, like, over a $100. But I I think it I I looked it up on Hippocrates. I saw 40. So basically, four to 10 times higher would probably be
a reasonable estimate. If you gotta pay out a bucket. Right.
Yeah. That's a very good point. We certainly do carry the items vaccine in our department. We run out of it very closely. They have the state's police.
It's gonna cover that
I give them credit for studying vaccines Absolutely. In a vulnerable population.
That's an important result. I think it's a we need to have a discussion amongst our amongst our colleagues about how to best vaccinate patients. This is the season, and putting information out there is really important. So I might be starting.
You know, this is a vaccine that everybody knows is highly efficacious. It's been studied in virtually the same identical fashion as live vaccine. You know that it is a preferred in the general population. We have an abundance of caution about this vaccine. I am concerned and disappointed that we know so little about Shingrix in patients with significant immune related adverse events on aggressive therapy.
So I have an abundance of caution from it. Yes, I've used it on a few patients. I've had people because of our discussions contact me over the country with anecdotes of you know, asking me whether flares of rheumatoid arthritis or lupus were related to it. I said, I don't know.
Yeah, my experience has been kind of interesting in that learning from the master and talking about this with Lenny and and there is concerns about how our immune driven populations are going to respond to this and we'll be the same response and I believe the company should have the obligation to study this. But you know the feeling is because an active vaccine therefore it should be safe as other inactive vaccines are and while this has come up a lot in my practice the amazing observation is way, way, way more patients are getting this without my knowledge or consent.
Hey, everybody. Arthur Lau reporting for, RheumNow from ACR twenty eighteen from Chicago. Want to give you guys an update on the GI op trial for glucocorticoid induced osteoporosis. Ken Sag just presented the twenty four month data today at a plenary session. So I want to give you guys a quick update.
So at twenty four months, significantly greater, BMD increase at lumbar spine compared to the, risidronate group, six percent versus about three percent at twenty four months. And in terms of, total hip and femoral neck, again, significant increases for, tenosumab versus risigernate, about 3% versus, point five to zero percent increase in the, risigernate group group for, both, for both femoral neck and, total and total hip respectively. Overall, in terms of fracture rates, similar fracture rates between both groups at twenty four months for vertebral fractures and for clinical fractures. Numerically, there was actually a few a few lower number of vert fractures in the denosumab group, but it the the study was actually not powered to show fracture reduction. But overall, things look really good for this, drug.
There was no significant safety concerns as well. So, you know, overall, the update here is at twenty four months, continued improvement from the twelve month data that was presented last year. And, you know, soon enough, we're be using this more in in our clinical practice. Signing off from RheumNow, 2018. Hopefully, you'll have more videos from me, later this week.
My name is Atul Devdar. I'm a rheumatologist in Portland, Oregon, and I'm here at the ACR twenty eighteen at WhomNow. I want to talk about the question of inflammatory bowel disease in patients receiving IL-seventeen inhibitors. As we know, there is a lot of, information about ixekizumab in this, particular Congress. We already have secukinumab approved for the treatment of psoriasis, psoriatic arthritis, and ankylosing spondylitis.
And now we have ixekizumab being shown to be effective in the treatment of ankylosing spondylitis in this meeting. Having said that, one of the questions in the minds of rheumatologists is what about the new occurrence or incidence of inflammatory bowel disease or flare of existing inflammatory bowel disease in patients receiving IL-seventeen inhibitors? Because IL-seventeen as a cytokine has got protective effects on keeping the gut permeability less or keeping the mucosal junctions tight. And if you block the IL-seventeen, then at least there is a theoretical possibility that there could be leaky gut. So just like secukinumab, execizumab studies, which were done for psoriasis, psoriatic arthritis, and ankylosing spondylitis, allowed patients who had a history of inflammatory bowel disease, but those who had active inflammatory bowel disease were not allowed.
So today, I went to an oral presentation by Mark Genovese, and the presentation was this was number eighteen sixty six, and this was incidence of inflammatory bowel disease among patients treated with ixekizumab and update on adjudicated data from an integrated database of patients with psoriasis, psoriatic arthritis. So they looked at about 1,100 patients who participated in the psoriatic arthritis trials on ixekizumab and about 5,000 patients who participated in psoriasis trials on ixekizumab. And they adjudicated the cases reported by the principal investigators, those who had suspected ulcerative colitis, those who had suspected Crohn's disease, etcetera. At the end, what they found out was the incidence exposure adjusted incidence rate was one point one per one hundred patient years or less. This is not different from the population based rate that you see of inflammatory bowel disease in patients with psoriasis, psoriatic arthritis.
Now mind you, spondyloarthritis as a class and psoriasis, psoriatic arthritis, is part of that, and ankylosing spondylitis, all of them have increased risk of IBD to start with. And here, this number, one point one per hundred patient years or slightly less is not different from that particular number. So this is kind of another reassuring fact about, use of this IL-seventeen inhibitors in rheumatology. So I'm reporting from ACR twenty eighteen, RheumNow. Thank you.
Hi, I'm Cassie Calabrese here in Chicago at ACR twenty eighteen, and I wanted to share with you an interesting abstract I saw in the poster hall by a colleague and mentor of mine, Carmen Goda, and our amazing student, Chin Mi, on IgG4 related disease, a disease considered by some rheumatologists to be an orphan disease and often difficult to diagnose and what they did was search the Cleveland Clinic database for all tissues stained for IgG4 and out of 1,500 samples 119 met staining criteria for IgG4 related disease however only half of these met full histopathologic criteria for IgG4 related disease. They found that the patients were mostly men, middle aged, Caucasian men and the most commonly affected organ systems were the pancreas, salivary, and lacrimal glands. The pathology was quite variable. I think this speaks to how difficult this disease is to diagnose and this is one of the largest case series now and has added a lot I think to this mysterious entity of IgG4 related disease. If you want to hear more, us on roomnow.com.
Hi, my name is John Goldman. I'm a solo practicing rheumatologist in Atlanta, a dying breed, and I'm here at the American College of Rheumatology meeting in Chicago. And I just went to a session that was so great, it should have been a plenary session. It was the study group on autoantibodies. The issue that's so important was a paper presented by Stan Nades about looking at the way different laboratories actually report and study antinuclear antibodies.
Now, we learned from the ACRANA study group in 2009 that the gold standard for antinuclear antibody is the immunofluorescent test. The problem is this is not used by all laboratories, and patients who have lupus and other connective tissue diseases are missed because they don't do those patterns. Some of the laboratories don't even talk about the cytoplasmic patterns, and all of these are really very important. What we're finding out is that patients therefore don't get the appropriate testing for the appropriate diagnosis. What needs to be done is to do the immunofluorescence and then follow-up with what we call multiplex.
And some labs are using multiplex as a screen, which is incorrect. Some are using other techniques. I once saw a lab that used latex ANA, which is terrible. So I think it's really important when this paper comes out, we need to know about it. This session should have been a plenary session because this is the meat and potatoes of rheumatology, a positive ANA and what to do about it.
So I strongly support you look for that data. Anyway, I'm happy to be here at the ACR and happy to let you know about what this data is. There hopefully will be more data on this on RheumNow. Thank you very much.
Hi, I'm Sam Whittle from Adelaide Australia and I'm here at the ACR twenty eighteen meeting in sunny Chicago. So in medicine in general and in rheumatology more specifically, changes in our practice often come slowly, often due to the slow and deliberate accrual of evidence from a wide range of sources over many years. But sometimes a trial comes along that in itself can be enough to change our practice. To my mind one of those trials is the Scott trial. It was published earlier this year in the New England Journal of Medicine and it compared myeloablative autologous stem cell transplantation versus intravenous cyclophosphamide in patients with severe scleroderma.
What it showed was that across a range of endpoints including mortality that transplant group did better than the cyclophosphamide group. It came at a cost though, the cost was that there was a high early mortality from the treatment itself. Six percent of patients in the transplant group died as a result of the transplant within the six years. In today's plenary session we were presented with the long term extension results of the Scott trial. So these are the data from year six through to year eleven.
Essentially what it showed is that the benefits that were seen in the transplant group were sustained out to eleven years. Interestingly, there were no further deaths in the transplant group after the sixth year, but deaths continued to accrue in the cyclophosphamide group. The transplant group tended to be better in general, they had a better performance status, they gained more weight and they had higher rates of employment than the cyclophosphamide group. So this tells us that transplant, if you can get through the difficult early stage, seems to be a really beneficial intervention for patients with severe scleroderma. The big challenge of course is going to be for us as clinicians to decide not only which patients to treat but when to treat them.
The key will be to intervene at the exact right time that maximises these risks and benefits and this will not be an easy decision. Thankfully with data like these we at least have much more useful data that we can present to our patients to help make a shared decision together for this really devastating disease. So for more updates like this don't forget to stay tuned to roomnow.com.
Hi, I'm Sallam Anbana. I'm a practicing clinical rheumatologist from New York and we're here at ACR eighteen in Chicago. I just finished giving my talk on technology tools for rheumatologists. This was version four of the talk. So what I thought we could do is discuss some of those tools which we have here, and I have some of my colleagues with me to help in that discussion.
So part of the inception of this talk was a need for us to involve personal technology that advances very quickly into our rheumatology practice where technology is a little bit slower to adapt. And how can we take things which are very expensive to take into a rheumatology practice in ways that are much more cost effective but still give us the results that we need. So a lot of these things are add ons to smartphones or tablets, electronics that you can use within a rheumatology practice. So, one of the things that, we have been using, are devices that we clip on. So one example is, this particular device, which is called a, a thermal imaging camera.
This is from a company called FLIR, which makes thermal imaging, and it allows us to look at heat maps of patients' skin and joints for purposes of inflammatory arthritis or vasculopathy. And in terms of using it, it's pretty simple. You just have to activate the little attached device here and it gives you a thermal imaging scan of that area though. I know John, we were speaking about thermal imaging. Do you think you could have a use for use of this in your office?
So definitely, I mean I'm interested in two of the applications that you mentioned. The first one is to see whether joints are inflamed. As you know, sometimes one of the challenges that we have in clinical practice is that sometimes for patients either because of their body habitus or other issues, it's sometimes challenging to tell whether a joint is actually swollen or not or if there is synovitis or not. I know that musculoskeletal ultrasound can play a role in trying to distinguish those two cases, but this seems like a much more simple way of seeing whether joints are inflamed or not.
Yeah, there's a low barrier of entry for use of a thermal imaging camera as opposed to an ultrasound where it's high cost, there's a lot of training involved in it too. I think the downside is that, at least right now for these consumer grade devices, thermal imaging is probably not great for very small joints just because of the resolution you need. But I think for a medium to large joint, it's something you can be fairly confident that you can look for an inflammatory joint and have pretty good reliability compared to an ultrasound.
Great. And then I think the other application that you mentioned is for patients that have vasculopathy such as Raynaud's Phenomenon. Do you think that you would use it to diagnose patients or to monitor treatment?
You can probably use it for both. Raynaud's is more of a clinical diagnosis if you're having the biotriphasic color changes, But in terms of the severity of it and then monitoring progress, I think that's where the thermal imaging comes in. So ideally capturing images prior to interventions, whether it's pharmaceutical, non pharmaceutical, the patient comes back now on an intervention, and can you reliably track them over time by using an image capture equipment that you can then import the image into a chart. And now we can always go back and look. It's like, well, let's look at their thermal scan from three months ago when it was winter versus now it's spring.
Is it any different, though? So it it may have applications for that too.
Yeah. I I mean, I'd love is it how much does it cost? Is it something that, you know, many of us can purchase on our own?
Yeah. You probably could. It's not extremely cheap, but the device has two different models. There's a standard model, which is $2.99, 299 US dollars. Then there's a more advanced model with better resolution for $399.
But if you look at an industrial grade thermal imaging camera, it could be anywhere from $2,000 up to $10,000 So you have look at it in relative means.
I imagine at least using it clinically, just trying it on a few patients, maybe patients that you're going to send for that ultrasound anyways because you're unsure what's going on, maybe sort of seeing whether the images that you get in your clinic would match whatever they find in ultrasound. I think that would be an interesting test case where I think I would definitely use cameras such as this.
That's what I've been trying to do now that I have incorporated ultrasound into our practice, is try to see if there's some ability to correlate thermal imaging with ultrasound. In some cases there is, some cases there isn't. Paul, you've seen some vasculitis patients also, large vessel vasculitis. Do you think you could use thermal imaging for of large prognostic vessel vasculitis?
Right, you had described a case of Takayasu's disease affecting someone's hand in your presentation, improvement in the temperature of their extremity with treatment, that would be a great thing to monitor some of these patients. Patients can have damage, mononeuritis multiplex or similar problems that might be neuropathic type pain, and if they come back to you having problems with pain and your exam is a little bit equivocal, something like this could totally make the difference in defining their therapy.
Yeah. So I think it's a matter of using it, trying it. The challenges are right now, it's not reimbursed by insurances. That this is really something you would use on your own ability, but, you know, if it takes more time to do a thermal imaging and then assessment, you can bill on time if you need to. But hopefully with alternative payment models, these extra technologies can get wrapped up into that as well.
Moving along, we have some other devices that we use. This device here is called an Aloclip. Aloclip is a company that makes lenses that you attach onto a smartphone or in this case an iPod Touch. And what it allows you to do is enhance the camera to allow better digital photography. This particular camera lens is called a macro lens where it gives you 21 times magnification and it can have applications within rheumatology, particularly for nail fold capillaroscopy.
So if you're evaluating for somebody with Raynaud's disease and they have symptoms of systemic conditions, you may be able to use this. So Paul, were playing with this for a little bit. Do you think this is something you'd probably use or what kind of aspects would you use this for?
Right, so this is extremely useful, put right up to someone's nail fold capillaries. I can actually snap a picture, take a look at it, show it to the patient, and if they have nail full dilations or drop out of their capillaries, that really suggests to me that there's a secondary process such as scleroderma, myositis, so I have to worry a lot more about that patient. Whereas if it's relatively normal, I can probably be more reassured that this person just has a primary type of Raynaud's, they're not going to be at risk for other organ dysfunction, and we can treat them and ease their worries. This is a great device and I think you said it's How much does this cost?
I think it retails for about probably $60 to $70 So if you compare that to a Dermlite imaging, system, that's over a thousand dollars, and you can get as good resolution, probably more because you're using your digital zoom as well too.
I think one of the things that I think this two things that this does not have so I have one of the the cheap dermatoscopes. I think that my dermatoscope has a polarizing lens that sort of allows for to prevent some of the bounce of the of the light that goes in there so it the images look a little bit better. And then the the other thing is the light. So, you know, you mentioned that this device blocks the your flash.
Yes.
And it blocks the light. And the only way that you get light in is through the sides.
Through the cone.
Yeah. So, you know, the derm light is nice because the light is directly from, you know, sort of from around the the lens. So I I think have you had any issues with with lighting?
So so far not I mean, granted within my examination rooms, it's pretty bright fluorescent lighting
Okay.
That's in there. So and the walls are all painted white in our exam rooms. So, I mean, there's been enough ambient light to do that. But I can imagine if you're maybe on an inpatient setting where it's like kind of a darker room and you don't have necessarily an external light source, there's maybe an issue. You can't really look at what you need to.
And a separate issue is immersion oil. I haven't really tried using this with immersion oil to see if you get the same resolution, which you can do by using a germline. The price difference is in order of magnitude different. If you have unlimited funds, can get whatever you want. But, you know, like I said, we're we're rheumatologists.
We have to be mindful about, cost and quality.
Right. And
and the newer iPhones, such as the iPhone 10 s, has such really, really good, you know, pickup For low
light. Yeah.
For light low light aperture. So That's a good point. It might not even be an issue.
Yeah. Yeah. Because their their image sensor is much more robust than it used to be. That that's a good point, though. Just got moving on to imaging as well.
This is hard to appreciate, but this is what's called the Gosky universal microscope lens attachment. So this is meant for using on a microscope to capture still images or video. The way it works is this part of the device you put on the microscope objective, and this is where your smartphone kind of fits into. So for example, if this is your smartphone, it would basically clip in this way, and you would point your camera right over the microscope objective, and it all locks into place pretty solidly. You can use that to capture synovial microscopy or if you are doing some dermatology biopsies, you want to look at the light microscopy, you can do that and you don't need a very cumbersome setup.
Typically image capture equipment can be over $1,000 or more, and you can get it all from about a $30 device. Yeah. So not too bad.
I think this is great. I mean, two weeks ago, was with my fellows. We were trying to look for crystals, under the microscope, and one of the fellows had issues in, using the microscope to focus. And even though, one of the other fellows was able to see the images, she was not able to see them. So having some a device like this that all three of us could sort of appreciate at the same time would have been very, very valuable in that setting.
Sure. I think we're all old enough to remember the teaching microscopes that had multiple objectives, So that's the way we used to do it, to share images.
I think we still do that.
We still do it, right? Yeah. Yeah. So I mean, do you do any microscopy often on your own?
We do a little bit in our clinic, but for those of us that might not do it as much, you said we can get on FaceTime or text someone an image and get a second or third opinion with this. That's true. Easier to collaborate.
That's a great point. So let's say John, you have a microscopy you're looking at, you're not 100% sure, you can take a still image, you can launch Skype or FaceTime, you can call a call if you want, be like, Hey, could you take a look at this for me? It's all being done through the power of your phone with this very simple device.
Yeah. You
know? So so it's pretty neat and not not too expensive, easily obtainable. Also, while we're on kind of smartphone and tablet devices, so we were looking at kind of a range of applications from a company called three d for Medical, which is based in Ireland. And three d for Medical was featured in one of Apple's keynotes, I think a couple of years ago for one of their new iPads. And Since then, it's been using universities and teaching sessions.
They have a different suite of apps and they have literally 20 or 30 different applications. I just picked out a few of them that rheumatologists can use. We were looking at one of the hand applications here. So you can manipulate a three d model of a hand here, can do cross sections and look at it all in real time rendering, you can look at pre canned videos of different pathologies that are going on, procedures also too. And this is great for education, for trainees also.
Think Paul, you work with trainees as well, right? Yeah. Do you think this is something they would probably like or help them through their training?
What I'm actually seeing is a lot of them will purchase this to correlate their the anatomy that they're seeing on ultrasound. Yeah. You know, being able to peel away layers of a joint or some atypical position and just get a better understanding of it. I don't know if any of us are strongly ultrasound trained, you're kind of learning it.
Getting there, yeah.
Are you using this to help?
I am using it to augment ultrasound, trying to extrapolate a two dimensional image to three-dimensional. So this does help for that though. Yeah, absolutely. I mean, John, so you treat pediatric and adult patients also too. Do you find that when you're explaining maybe things to the parents about how an illness or anatomy works that these visual apps can help with that capacity?
I think, yeah. I mean, parents, especially parents children with chronic diseases, always very concerned about the illness and really want to get to the bottom of trying to understand what's going on. So this would be very helpful to sort of explain to them exactly, like, you know, about speaking with a parent of a child with JIA, know, sort of having them understand what JIA is all about and how we use medicines to affect the inflammatory pathways. So I think this would be very helpful.
Yeah, I was thinking also when we do arthrocentesis for adult patients, it's a very quick consent, it's done point of care in the exam room, you have more challenges from a pediatric point of view. You have to book studies, there's sedation involved, there's more involved consent. When you're consenting for a knee arthrocentesis with sedation, how much AV material are you using with parents?
Currently, none at all, but I can imagine this can be helpful.
They have applications here for the knee where you can render the knee in real time and you can kind of, strip down layers of the knee and get down to different parts of the anatomy and see the places that you may need to give an arthrocentesis or an injection.
And I wonder, Sulaiman, if you have any tools here today that may help patients during procedures.
Yeah, so that's a great point. So we've been having a few talks in the past couple of years, last year and this year, on use of virtual reality in management of pain, anxiety relief, pre procedural management. And there's different ways to incorporate virtual reality, know. Some of the devices can be very expensive because they're medical grade, thousands of dollars per year, and they can be very helpful. There's some ways to be able to do it a little bit cheaper.
So what we found here was a very generic kind of virtual reality headset, literally just bought off Amazon, And it's about maybe $30 $35 and it's essentially a shell, where within that shell you have a smartphone that clips in here. It has an attachment for the headphone jack or for a data port to get audio. And it has a stereoscopic lens, and so the smartphone basically fits right within here, and the application you're using has a split screen, a stereoscopic view, that then the user would look inside the goggles and have audio that comes in through the headset. And there's dozens of applications that can be used for VR. Some of them are used for what's called mindfulness based stress reduction.
So basically taking a user to a virtual environment, either that's three d rendered or maybe captured from a real environment so that they're away from their stressful situation. So whether it's in an operating room, a procedure, or maybe they have chronic anxiety, chronic pain, there's a neurobiologic effect that can happen with that. Know Paul, we've talked about chronic pain that come in. Do you see a lot of patients on chronic opioids or narcotics from other providers? What do you do with those patients typically in terms of how to manage them?
You're obviously not the person prescribing their opioids, but how do you get them off their opioids? Right,
I'm fortunately working in a system where we have an amazing pain clinic and management group, but a lot of patients have trouble with anxieties or issues with how all that works. This would be a great adjunctive piece of equipment and therapy that they can use.
Absolutely, though. I think for your pediatric patients, I'm sure if you're about to do a procedure or something, there's also a lot of anxiety and stress involved. How would a child respond to a VR headset?
Doctor. I know that in my hospital, they're using VR in the emergency department for procedures like IV placements or blood draws, lumbar punctures and things like that, so it's been already well used. We currently don't have a setup in the rheumatology clinic, but I can imagine that something like this that is not too expensive, I think would be very welcome for our patients.
Sure, absolutely though. So anyway, these are all tools that are readily available, easily obtainable, not too expensive. It's just a matter of if you're practicing and want to incorporate these, will it fit into your workflow? But it only takes a little bit to try it. So I would encourage anyone to think about it, you can contact any of us and we'd be happy to help with more information.
So thanks for joining us for a look at some of these products and hope you have a good conference. Thanks.
Hi. I'm Jack Cush with RheumNow. I'm here in the RheumNow booth at ACR two thousand eighteen in Chicago. It's been a great meeting so far. So far, I've convened a panel of friends to talk about what's hot in rheumatoid arthritis.
I'm joined by Doctor. Jeff Sparks from Boston and Doctor. Artie Cavanaugh from San Diego and I'm Jack Cush, as you know.
Gentlemen, today, we've a
few things I want to go down the list to discuss, but let's start off with what you have seen that you think is really a highlight in RA so far or maybe something you're gonna see in the next few days.
I'll start out the data with the JAK inhibitors.
Maybe not new, but really there's so much more of it now that we're seeing, of course, longer term data with tofacitinib, additional data with baricitinib, a lot of data with upicitinib, and further data with filgotinib. So I think it's exciting that we may see, are these all gonna be the same? Is there really anything to the putative in vitro differences in terms of their cell activity? I think we've adopted them in the clinic, and I think that's gonna increase.
I'm going to get back to Jackson in a second. Jeff, so far?
I think the thing that stood out for me from an epidemiologic perspective for rheumatoid arthritis is looking at interstitial lung disease risk factors. In particular, the MUC5B SNP, is associated clearly with rheumatoid arthritis is interstitial lung disease. And the fact that this is related to interstitial pulmonary fibrosis may mean that these drugs that are used for IPF could be used in RA ILD and those trials are ongoing. And obviously, rheumatologists take care of patients before the ILD develops and our work and others are looking at things that happen for rheumatologists. So disease activity being the things that, we did show that active disease did increase risk for, interstitial lung disease within RheumNow.
So the
the SNP was presented today as
a plenary session and that, that was new and information surprising. I do want to talk about some of your posters that you had, maybe sort of getting to drug safety and whatnot, but still safety I should say or comorbidity issues and that's the ILD story, which we know ILD and lung disease is a very bad player in rheumatoid arthritis, which I think is what has gotten you into this. You had a few presentations here, one a podium presentation on disease activity, another one looking at rheumatoid factor negative versus factor positive. Can you sort of summarize those results?
Well, sure. The first is the disease activity. We look very carefully to look at dynamic measures of disease activity and to see whether active disease was related to subsequent risk of incident interstitial lung disease. And we did in fact find that high and moderate disease activity were put you at a two to three fold increased risk. As rheumatologists, we really think about the risk mostly within the seropositive subset, particularly CCP positive.
However, some of our work also shows that you can get interstitial lung disease, you can get bronchiectasis even within the seronegative population. So this is something that should be on rheumatologists' minds as far as serostatus and obviously treat to target might have other downstream ramifications of decreasing interstitial lung disease.
Yeah. The the the seronegative story is really interesting in that you found in the population that you looked at, know, it was like fifteen, sixteen percent in seropositives. Mhmm. But it was almost same number in seronegatives. Right.
Which I find found really surprising and changes my thinking. Yeah. Your finding of disease activity driving it, you know, moderate to high disease activity led to a two to three fold increased risk, I guess. But the number of patients that qualified as having ILD in your follow-up period was still quite low. So how are going to answer the question of which of a high disease activity patients are the ones who are going to get into having ILD down downstream.
Well, clearly further work has to be done to identify other risk factors you could use in clinic. Doubtful that this new, SNP that they found, the MUC5B, is something that would be useful in clinical care. And whether there's, understanding the natural history, you know, what's going on underneath the surface before patients get symptoms, how big of a problem really is this, are things getting better because we're treating patients better as well. So I think there's still a lot of work that needs to be done as far as, understanding risk strat ification, things we can use in clinic to really go after the people that are most likely to benefit.
So as it as it I think is one of the ways that translates environmental signals to what we see in our patients epigenomics. Though it's still in its infancy, may be an important factor with interstitial lung disease. It's hard to see how it wouldn't be. I don't think we understand enough of it, but as you said, genetics alone aren't going to explain it, the seropositivity and negativity aren't going to explain it, but there's an additional thing. And maybe it's an epigenetic factor that we can identify indicating the history of exposures.
So, Artie, you brought the issue of the JAKs here and they are sort of front and center. We've got some data about, you know, baricitinib extension studies showing good data when you continue on barrier switch from, TNF inhibitor to Bari and whatnot. We've got new TNF inhibitors that are in development, some pretty close, some pretty far. How what's the lessons that the new JAKs can take from the old JAKs in drug development and where they're gonna sort of grow this brand or or or get greater respect for JAKs in in treating RA patients?
Well one thing is the dosing. I think across the JAK inhibitors what we see is that the companies can often find two doses that can be effective. The lower dose generally has a little bit better safety signal. As we found out today, we had a session I moderated with the FDA we're kind enough to come and they pay a lot of attention to safety as we all know and they're very keen on that so I think how best to how to look at the optimal dosing I think as rheumatologists we love to play around we love to have many doses and tailor the therapy, but the FDA is very concerned about safety of these new molecules. So I think, one of the
things that I think may come is as we get additional safety data, maybe we'll see additional dosing options for each of the jackets.
You know, the issue is are they going to affect care and will they be taken up well. It was obviously hard for the first one tofacitinib to grow the respect and comfort with rheumatologists, but you know, we're gonna we may have one next year. I mean, one there after we got upadacitinib and filgotinib and what's the other one that doctor Pepcitinib. Pepcitinib was presented at this meeting and there are others still. Jeff, do you think that this is they're gonna become more acceptable as they get more in the market or what what might be the the tipping point for rheumatologists and having comfort with JAK inhibitors?
Yeah. Well, mean, I think obviously it's really good news for both patients and providers that there's a long list of approved medications for RA. And obviously the new kid on the block is gonna be sort of at the bottom of the line. But I feel like the convenience factor both from a patient and physician is moving up the JAK class. And the other thing is the longer they've been approved and the no new safety signals are coming out and actually several abstracts here showing the fear about DVT.
PE may not be founded in the sort of real world clinical use. And as it's being used in other diseases, I think it's only gaining traction as far as people are becoming more comfortable as far as moving this up as far as the line of succession.
The last thing I want to just bring
up things that there's a
few things here like fine that seem to be an overwhelming recurring theme. There's a lot on biosimilars, there's a lot about weaning therapy, but the new thing that was surprising to me was this issue of seroconversion. Patients, you know, are factor positive, CCP positive, patients who become seronegative or drop their titers over time. A lot of reports here about that and the question is, are rheumatologists doing this and then what are they doing with the data? So, Artie, you've looked at some of this, what's the is there a message right now about seroconverters?
Does it mean anything?
I think the the bottom line message is that it doesn't mean anything to the individual patient in your clinic when you go back to clinic on Friday or next Monday. You shouldn't worry if they don't see a convert. If they do, that's maybe a good thing, but it certainly doesn't seem to be strong enough signal that it's worth pursuing as a target. Meaning, I'm gonna keep changing therapy until you see a convert and you know you think back to rheumatologists older than us who chased rheumatoid factor for years and the hope was that if you decrease the titer that that would not only be a biomarker but that would be a goal of treatment I don't think it's that case. Certainly not an individual patient.
And it remains to be seen whether clearly not all drugs can will do this. And the other issue is if you do see it, is there really an association there whether you have better outcome or or no effect on outcome? How do you consider this when you're, talking about factor? Do you do you recommend repeating it in patients? Yeah.
Or
Well, I think we have clear already goals of target that are already underutilized. To So add CCP in the mix where it's questionable that the number needed to treat are ever going to be cost effective. Certainly it's interesting from a research perspective, but how are you going to understand when you're treating a patient whether it's noise, you repeat the same assay two times, you're going get the same different result. So is it really going down or is it just noise of the assay? Not ready for prime time.
Such sage advice from such a young rheumatologist. Arty, we should worry.
Yeah. No, you think back of of you kind of alluded to, there are probably drugs that change rheumatoid factor like Dilantin. There are people on Dilantin whose rheumatoid factor would go away of course had absolutely no clinical relevance so there may be a dissociation between that and I think think Jeff hit it on the head that is it cost effective? Is it worth doing for that next patient you see in the clinic? Alright,
I want to thank my friends Jeff and Arty for joining us on his RA panel. Thank you. See you at the meeting.
Hi. I'm doctor Janet Pope. I'm a room reporter. I'm here at RheumNow at the booth at ACR twenty eighteen here in Chicago. I wanted to talk about two studies.
They were oral presentations nine six two and nine six three. They were both updates of the long term extension LTE or now called open label extension studies of two of the JAKs of baricitinib and toficitinib. And they were presented side by side, and what was very reassuring is up to six and a half years on one and nine or so years on the other, we found or they found that there were no new safety signals. So looking at incidents of MACE events, looking at cancer, looking at serious infections. What I kind of thought by the eyeball test with that was that herpes zoster rates were both the same in both studies and not increasing over time, and the VTE rates or PE rates were very low and not increasing over time.
And for the first time, we found the long term data and tofacitinib where they did the analysis as well. So I think the JAKs looking in the long term are showing no new safety signals, which is very reassuring. Thank you.
Hi. I'm Kathy Calbrace. I'm here in Chicago at ACR twenty eighteen, and I am pleased to have a few days like Elvries and Jack Cush to talk about vaccinations in patients with rheumatic diseases. Starting with this morning, there was an abstract episode I certainly can see some coverage issues getting paid for, but what do you guys think about that, Jack?
Well, I I I sort of start off with some of the issues in trial design. You know, it's a very large trial. It was done over started 2016, twenty sixteen-seventeen season, twenty seventeen-eighteen season, not this year. They had a large number of patients and the trial design was basically everybody was on methotrexate and then they had groups based on what drugs you were on and I had no problem with the groups except for the last group which was the rituximab abatacep group with or without methotrexate or a DMARD and I don't see adding those. Mean rituximab by itself makes sense, but, and they said that it was because it was before the data was known fully about Avatacep, that's why they included that that group.
That was one thing. The other thing is, you know, I understand this is all RA patients and you have really no information about how active or bad they are or whatever, but it's mainly getting used in the elderly population and that's where it seems to be pushed and they're asking for it. In the general population, I don't know that it really has applicability unless it's really gonna be that much more effective in a regular RA patient. So question is, is the data good enough or compelling enough that we should be pushing in RA patients?
I was very impressed and I think the the effect sizes were not trivial. No. These were threefold levels in mean geometric means and protective levels of antibodies. And I mean I really was moved by that data. Yeah, there's a lot of issues in trials and I but we've been talking about this for a couple years now.
I wonder what would happen. Well, actually did the trial and the results were trivial. I would change my practice based on this if I could get this.
That's the key issue because I don't think enough rheumatologists are pushing their patients. It's hard enough to get them vaccinated. We're really bad at getting them vaccinated, period. But then to push them to get the high dose, which is generally not available in the clinic in most places, it's gonna have to it's gonna be a substantial change in practice. Does the data merit it?
Think it does. It's it is very strong data. Changing practice is gonna be hard.
We'll hear if you guys know what the best difference is between high dose and traditional.
She said she said $10 for traditional, you know, versus, like, over a $100. But I I think it I I looked it up on Hippocrates. I saw 40. So basically, four to 10 times higher would probably be
a reasonable estimate. If you gotta pay out a bucket. Right.
Yeah. That's a very good point. We certainly do carry the items vaccine in our department. We run out of it very closely. They have the state's police.
It's gonna cover that
I give them credit for studying vaccines Absolutely. In a vulnerable population.
That's an important result. I think it's a we need to have a discussion amongst our amongst our colleagues about how to best vaccinate patients. This is the season, and putting information out there is really important. So I might be starting.
You know, this is a vaccine that everybody knows is highly efficacious. It's been studied in virtually the same identical fashion as live vaccine. You know that it is a preferred in the general population. We have an abundance of caution about this vaccine. I am concerned and disappointed that we know so little about Shingrix in patients with significant immune related adverse events on aggressive therapy.
So I have an abundance of caution from it. Yes, I've used it on a few patients. I've had people because of our discussions contact me over the country with anecdotes of you know, asking me whether flares of rheumatoid arthritis or lupus were related to it. I said, I don't know.
Yeah, my experience has been kind of interesting in that learning from the master and talking about this with Lenny and and there is concerns about how our immune driven populations are going to respond to this and we'll be the same response and I believe the company should have the obligation to study this. But you know the feeling is because an active vaccine therefore it should be safe as other inactive vaccines are and while this has come up a lot in my practice the amazing observation is way, way, way more patients are getting this without my knowledge or consent.
Hey, everybody. Arthur Lau reporting for, RheumNow from ACR twenty eighteen from Chicago. Want to give you guys an update on the GI op trial for glucocorticoid induced osteoporosis. Ken Sag just presented the twenty four month data today at a plenary session. So I want to give you guys a quick update.
So at twenty four months, significantly greater, BMD increase at lumbar spine compared to the, risidronate group, six percent versus about three percent at twenty four months. And in terms of, total hip and femoral neck, again, significant increases for, tenosumab versus risigernate, about 3% versus, point five to zero percent increase in the, risigernate group group for, both, for both femoral neck and, total and total hip respectively. Overall, in terms of fracture rates, similar fracture rates between both groups at twenty four months for vertebral fractures and for clinical fractures. Numerically, there was actually a few a few lower number of vert fractures in the denosumab group, but it the the study was actually not powered to show fracture reduction. But overall, things look really good for this, drug.
There was no significant safety concerns as well. So, you know, overall, the update here is at twenty four months, continued improvement from the twelve month data that was presented last year. And, you know, soon enough, we're be using this more in in our clinical practice. Signing off from RheumNow, 2018. Hopefully, you'll have more videos from me, later this week.
My name is Atul Devdar. I'm a rheumatologist in Portland, Oregon, and I'm here at the ACR twenty eighteen at WhomNow. I want to talk about the question of inflammatory bowel disease in patients receiving IL-seventeen inhibitors. As we know, there is a lot of, information about ixekizumab in this, particular Congress. We already have secukinumab approved for the treatment of psoriasis, psoriatic arthritis, and ankylosing spondylitis.
And now we have ixekizumab being shown to be effective in the treatment of ankylosing spondylitis in this meeting. Having said that, one of the questions in the minds of rheumatologists is what about the new occurrence or incidence of inflammatory bowel disease or flare of existing inflammatory bowel disease in patients receiving IL-seventeen inhibitors? Because IL-seventeen as a cytokine has got protective effects on keeping the gut permeability less or keeping the mucosal junctions tight. And if you block the IL-seventeen, then at least there is a theoretical possibility that there could be leaky gut. So just like secukinumab, execizumab studies, which were done for psoriasis, psoriatic arthritis, and ankylosing spondylitis, allowed patients who had a history of inflammatory bowel disease, but those who had active inflammatory bowel disease were not allowed.
So today, I went to an oral presentation by Mark Genovese, and the presentation was this was number eighteen sixty six, and this was incidence of inflammatory bowel disease among patients treated with ixekizumab and update on adjudicated data from an integrated database of patients with psoriasis, psoriatic arthritis. So they looked at about 1,100 patients who participated in the psoriatic arthritis trials on ixekizumab and about 5,000 patients who participated in psoriasis trials on ixekizumab. And they adjudicated the cases reported by the principal investigators, those who had suspected ulcerative colitis, those who had suspected Crohn's disease, etcetera. At the end, what they found out was the incidence exposure adjusted incidence rate was one point one per one hundred patient years or less. This is not different from the population based rate that you see of inflammatory bowel disease in patients with psoriasis, psoriatic arthritis.
Now mind you, spondyloarthritis as a class and psoriasis, psoriatic arthritis, is part of that, and ankylosing spondylitis, all of them have increased risk of IBD to start with. And here, this number, one point one per hundred patient years or slightly less is not different from that particular number. So this is kind of another reassuring fact about, use of this IL-seventeen inhibitors in rheumatology. So I'm reporting from ACR twenty eighteen, RheumNow. Thank you.
Hi, I'm Cassie Calabrese here in Chicago at ACR twenty eighteen, and I wanted to share with you an interesting abstract I saw in the poster hall by a colleague and mentor of mine, Carmen Goda, and our amazing student, Chin Mi, on IgG4 related disease, a disease considered by some rheumatologists to be an orphan disease and often difficult to diagnose and what they did was search the Cleveland Clinic database for all tissues stained for IgG4 and out of 1,500 samples 119 met staining criteria for IgG4 related disease however only half of these met full histopathologic criteria for IgG4 related disease. They found that the patients were mostly men, middle aged, Caucasian men and the most commonly affected organ systems were the pancreas, salivary, and lacrimal glands. The pathology was quite variable. I think this speaks to how difficult this disease is to diagnose and this is one of the largest case series now and has added a lot I think to this mysterious entity of IgG4 related disease. If you want to hear more, us on roomnow.com.
Hi, my name is John Goldman. I'm a solo practicing rheumatologist in Atlanta, a dying breed, and I'm here at the American College of Rheumatology meeting in Chicago. And I just went to a session that was so great, it should have been a plenary session. It was the study group on autoantibodies. The issue that's so important was a paper presented by Stan Nades about looking at the way different laboratories actually report and study antinuclear antibodies.
Now, we learned from the ACRANA study group in 2009 that the gold standard for antinuclear antibody is the immunofluorescent test. The problem is this is not used by all laboratories, and patients who have lupus and other connective tissue diseases are missed because they don't do those patterns. Some of the laboratories don't even talk about the cytoplasmic patterns, and all of these are really very important. What we're finding out is that patients therefore don't get the appropriate testing for the appropriate diagnosis. What needs to be done is to do the immunofluorescence and then follow-up with what we call multiplex.
And some labs are using multiplex as a screen, which is incorrect. Some are using other techniques. I once saw a lab that used latex ANA, which is terrible. So I think it's really important when this paper comes out, we need to know about it. This session should have been a plenary session because this is the meat and potatoes of rheumatology, a positive ANA and what to do about it.
So I strongly support you look for that data. Anyway, I'm happy to be here at the ACR and happy to let you know about what this data is. There hopefully will be more data on this on RheumNow. Thank you very much.
Hi, I'm Sam Whittle from Adelaide Australia and I'm here at the ACR twenty eighteen meeting in sunny Chicago. So in medicine in general and in rheumatology more specifically, changes in our practice often come slowly, often due to the slow and deliberate accrual of evidence from a wide range of sources over many years. But sometimes a trial comes along that in itself can be enough to change our practice. To my mind one of those trials is the Scott trial. It was published earlier this year in the New England Journal of Medicine and it compared myeloablative autologous stem cell transplantation versus intravenous cyclophosphamide in patients with severe scleroderma.
What it showed was that across a range of endpoints including mortality that transplant group did better than the cyclophosphamide group. It came at a cost though, the cost was that there was a high early mortality from the treatment itself. Six percent of patients in the transplant group died as a result of the transplant within the six years. In today's plenary session we were presented with the long term extension results of the Scott trial. So these are the data from year six through to year eleven.
Essentially what it showed is that the benefits that were seen in the transplant group were sustained out to eleven years. Interestingly, there were no further deaths in the transplant group after the sixth year, but deaths continued to accrue in the cyclophosphamide group. The transplant group tended to be better in general, they had a better performance status, they gained more weight and they had higher rates of employment than the cyclophosphamide group. So this tells us that transplant, if you can get through the difficult early stage, seems to be a really beneficial intervention for patients with severe scleroderma. The big challenge of course is going to be for us as clinicians to decide not only which patients to treat but when to treat them.
The key will be to intervene at the exact right time that maximises these risks and benefits and this will not be an easy decision. Thankfully with data like these we at least have much more useful data that we can present to our patients to help make a shared decision together for this really devastating disease. So for more updates like this don't forget to stay tuned to roomnow.com.
Hi, I'm Sallam Anbana. I'm a practicing clinical rheumatologist from New York and we're here at ACR eighteen in Chicago. I just finished giving my talk on technology tools for rheumatologists. This was version four of the talk. So what I thought we could do is discuss some of those tools which we have here, and I have some of my colleagues with me to help in that discussion.
So part of the inception of this talk was a need for us to involve personal technology that advances very quickly into our rheumatology practice where technology is a little bit slower to adapt. And how can we take things which are very expensive to take into a rheumatology practice in ways that are much more cost effective but still give us the results that we need. So a lot of these things are add ons to smartphones or tablets, electronics that you can use within a rheumatology practice. So, one of the things that, we have been using, are devices that we clip on. So one example is, this particular device, which is called a, a thermal imaging camera.
This is from a company called FLIR, which makes thermal imaging, and it allows us to look at heat maps of patients' skin and joints for purposes of inflammatory arthritis or vasculopathy. And in terms of using it, it's pretty simple. You just have to activate the little attached device here and it gives you a thermal imaging scan of that area though. I know John, we were speaking about thermal imaging. Do you think you could have a use for use of this in your office?
So definitely, I mean I'm interested in two of the applications that you mentioned. The first one is to see whether joints are inflamed. As you know, sometimes one of the challenges that we have in clinical practice is that sometimes for patients either because of their body habitus or other issues, it's sometimes challenging to tell whether a joint is actually swollen or not or if there is synovitis or not. I know that musculoskeletal ultrasound can play a role in trying to distinguish those two cases, but this seems like a much more simple way of seeing whether joints are inflamed or not.
Yeah, there's a low barrier of entry for use of a thermal imaging camera as opposed to an ultrasound where it's high cost, there's a lot of training involved in it too. I think the downside is that, at least right now for these consumer grade devices, thermal imaging is probably not great for very small joints just because of the resolution you need. But I think for a medium to large joint, it's something you can be fairly confident that you can look for an inflammatory joint and have pretty good reliability compared to an ultrasound.
Great. And then I think the other application that you mentioned is for patients that have vasculopathy such as Raynaud's Phenomenon. Do you think that you would use it to diagnose patients or to monitor treatment?
You can probably use it for both. Raynaud's is more of a clinical diagnosis if you're having the biotriphasic color changes, But in terms of the severity of it and then monitoring progress, I think that's where the thermal imaging comes in. So ideally capturing images prior to interventions, whether it's pharmaceutical, non pharmaceutical, the patient comes back now on an intervention, and can you reliably track them over time by using an image capture equipment that you can then import the image into a chart. And now we can always go back and look. It's like, well, let's look at their thermal scan from three months ago when it was winter versus now it's spring.
Is it any different, though? So it it may have applications for that too.
Yeah. I I mean, I'd love is it how much does it cost? Is it something that, you know, many of us can purchase on our own?
Yeah. You probably could. It's not extremely cheap, but the device has two different models. There's a standard model, which is $2.99, 299 US dollars. Then there's a more advanced model with better resolution for $399.
But if you look at an industrial grade thermal imaging camera, it could be anywhere from $2,000 up to $10,000 So you have look at it in relative means.
I imagine at least using it clinically, just trying it on a few patients, maybe patients that you're going to send for that ultrasound anyways because you're unsure what's going on, maybe sort of seeing whether the images that you get in your clinic would match whatever they find in ultrasound. I think that would be an interesting test case where I think I would definitely use cameras such as this.
That's what I've been trying to do now that I have incorporated ultrasound into our practice, is try to see if there's some ability to correlate thermal imaging with ultrasound. In some cases there is, some cases there isn't. Paul, you've seen some vasculitis patients also, large vessel vasculitis. Do you think you could use thermal imaging for of large prognostic vessel vasculitis?
Right, you had described a case of Takayasu's disease affecting someone's hand in your presentation, improvement in the temperature of their extremity with treatment, that would be a great thing to monitor some of these patients. Patients can have damage, mononeuritis multiplex or similar problems that might be neuropathic type pain, and if they come back to you having problems with pain and your exam is a little bit equivocal, something like this could totally make the difference in defining their therapy.
Yeah. So I think it's a matter of using it, trying it. The challenges are right now, it's not reimbursed by insurances. That this is really something you would use on your own ability, but, you know, if it takes more time to do a thermal imaging and then assessment, you can bill on time if you need to. But hopefully with alternative payment models, these extra technologies can get wrapped up into that as well.
Moving along, we have some other devices that we use. This device here is called an Aloclip. Aloclip is a company that makes lenses that you attach onto a smartphone or in this case an iPod Touch. And what it allows you to do is enhance the camera to allow better digital photography. This particular camera lens is called a macro lens where it gives you 21 times magnification and it can have applications within rheumatology, particularly for nail fold capillaroscopy.
So if you're evaluating for somebody with Raynaud's disease and they have symptoms of systemic conditions, you may be able to use this. So Paul, were playing with this for a little bit. Do you think this is something you'd probably use or what kind of aspects would you use this for?
Right, so this is extremely useful, put right up to someone's nail fold capillaries. I can actually snap a picture, take a look at it, show it to the patient, and if they have nail full dilations or drop out of their capillaries, that really suggests to me that there's a secondary process such as scleroderma, myositis, so I have to worry a lot more about that patient. Whereas if it's relatively normal, I can probably be more reassured that this person just has a primary type of Raynaud's, they're not going to be at risk for other organ dysfunction, and we can treat them and ease their worries. This is a great device and I think you said it's How much does this cost?
I think it retails for about probably $60 to $70 So if you compare that to a Dermlite imaging, system, that's over a thousand dollars, and you can get as good resolution, probably more because you're using your digital zoom as well too.
I think one of the things that I think this two things that this does not have so I have one of the the cheap dermatoscopes. I think that my dermatoscope has a polarizing lens that sort of allows for to prevent some of the bounce of the of the light that goes in there so it the images look a little bit better. And then the the other thing is the light. So, you know, you mentioned that this device blocks the your flash.
Yes.
And it blocks the light. And the only way that you get light in is through the sides.
Through the cone.
Yeah. So, you know, the derm light is nice because the light is directly from, you know, sort of from around the the lens. So I I think have you had any issues with with lighting?
So so far not I mean, granted within my examination rooms, it's pretty bright fluorescent lighting
Okay.
That's in there. So and the walls are all painted white in our exam rooms. So, I mean, there's been enough ambient light to do that. But I can imagine if you're maybe on an inpatient setting where it's like kind of a darker room and you don't have necessarily an external light source, there's maybe an issue. You can't really look at what you need to.
And a separate issue is immersion oil. I haven't really tried using this with immersion oil to see if you get the same resolution, which you can do by using a germline. The price difference is in order of magnitude different. If you have unlimited funds, can get whatever you want. But, you know, like I said, we're we're rheumatologists.
We have to be mindful about, cost and quality.
Right. And
and the newer iPhones, such as the iPhone 10 s, has such really, really good, you know, pickup For low
light. Yeah.
For light low light aperture. So That's a good point. It might not even be an issue.
Yeah. Yeah. Because their their image sensor is much more robust than it used to be. That that's a good point, though. Just got moving on to imaging as well.
This is hard to appreciate, but this is what's called the Gosky universal microscope lens attachment. So this is meant for using on a microscope to capture still images or video. The way it works is this part of the device you put on the microscope objective, and this is where your smartphone kind of fits into. So for example, if this is your smartphone, it would basically clip in this way, and you would point your camera right over the microscope objective, and it all locks into place pretty solidly. You can use that to capture synovial microscopy or if you are doing some dermatology biopsies, you want to look at the light microscopy, you can do that and you don't need a very cumbersome setup.
Typically image capture equipment can be over $1,000 or more, and you can get it all from about a $30 device. Yeah. So not too bad.
I think this is great. I mean, two weeks ago, was with my fellows. We were trying to look for crystals, under the microscope, and one of the fellows had issues in, using the microscope to focus. And even though, one of the other fellows was able to see the images, she was not able to see them. So having some a device like this that all three of us could sort of appreciate at the same time would have been very, very valuable in that setting.
Sure. I think we're all old enough to remember the teaching microscopes that had multiple objectives, So that's the way we used to do it, to share images.
I think we still do that.
We still do it, right? Yeah. Yeah. So I mean, do you do any microscopy often on your own?
We do a little bit in our clinic, but for those of us that might not do it as much, you said we can get on FaceTime or text someone an image and get a second or third opinion with this. That's true. Easier to collaborate.
That's a great point. So let's say John, you have a microscopy you're looking at, you're not 100% sure, you can take a still image, you can launch Skype or FaceTime, you can call a call if you want, be like, Hey, could you take a look at this for me? It's all being done through the power of your phone with this very simple device.
Yeah. You
know? So so it's pretty neat and not not too expensive, easily obtainable. Also, while we're on kind of smartphone and tablet devices, so we were looking at kind of a range of applications from a company called three d for Medical, which is based in Ireland. And three d for Medical was featured in one of Apple's keynotes, I think a couple of years ago for one of their new iPads. And Since then, it's been using universities and teaching sessions.
They have a different suite of apps and they have literally 20 or 30 different applications. I just picked out a few of them that rheumatologists can use. We were looking at one of the hand applications here. So you can manipulate a three d model of a hand here, can do cross sections and look at it all in real time rendering, you can look at pre canned videos of different pathologies that are going on, procedures also too. And this is great for education, for trainees also.
Think Paul, you work with trainees as well, right? Yeah. Do you think this is something they would probably like or help them through their training?
What I'm actually seeing is a lot of them will purchase this to correlate their the anatomy that they're seeing on ultrasound. Yeah. You know, being able to peel away layers of a joint or some atypical position and just get a better understanding of it. I don't know if any of us are strongly ultrasound trained, you're kind of learning it.
Getting there, yeah.
Are you using this to help?
I am using it to augment ultrasound, trying to extrapolate a two dimensional image to three-dimensional. So this does help for that though. Yeah, absolutely. I mean, John, so you treat pediatric and adult patients also too. Do you find that when you're explaining maybe things to the parents about how an illness or anatomy works that these visual apps can help with that capacity?
I think, yeah. I mean, parents, especially parents children with chronic diseases, always very concerned about the illness and really want to get to the bottom of trying to understand what's going on. So this would be very helpful to sort of explain to them exactly, like, you know, about speaking with a parent of a child with JIA, know, sort of having them understand what JIA is all about and how we use medicines to affect the inflammatory pathways. So I think this would be very helpful.
Yeah, I was thinking also when we do arthrocentesis for adult patients, it's a very quick consent, it's done point of care in the exam room, you have more challenges from a pediatric point of view. You have to book studies, there's sedation involved, there's more involved consent. When you're consenting for a knee arthrocentesis with sedation, how much AV material are you using with parents?
Currently, none at all, but I can imagine this can be helpful.
They have applications here for the knee where you can render the knee in real time and you can kind of, strip down layers of the knee and get down to different parts of the anatomy and see the places that you may need to give an arthrocentesis or an injection.
And I wonder, Sulaiman, if you have any tools here today that may help patients during procedures.
Yeah, so that's a great point. So we've been having a few talks in the past couple of years, last year and this year, on use of virtual reality in management of pain, anxiety relief, pre procedural management. And there's different ways to incorporate virtual reality, know. Some of the devices can be very expensive because they're medical grade, thousands of dollars per year, and they can be very helpful. There's some ways to be able to do it a little bit cheaper.
So what we found here was a very generic kind of virtual reality headset, literally just bought off Amazon, And it's about maybe $30 $35 and it's essentially a shell, where within that shell you have a smartphone that clips in here. It has an attachment for the headphone jack or for a data port to get audio. And it has a stereoscopic lens, and so the smartphone basically fits right within here, and the application you're using has a split screen, a stereoscopic view, that then the user would look inside the goggles and have audio that comes in through the headset. And there's dozens of applications that can be used for VR. Some of them are used for what's called mindfulness based stress reduction.
So basically taking a user to a virtual environment, either that's three d rendered or maybe captured from a real environment so that they're away from their stressful situation. So whether it's in an operating room, a procedure, or maybe they have chronic anxiety, chronic pain, there's a neurobiologic effect that can happen with that. Know Paul, we've talked about chronic pain that come in. Do you see a lot of patients on chronic opioids or narcotics from other providers? What do you do with those patients typically in terms of how to manage them?
You're obviously not the person prescribing their opioids, but how do you get them off their opioids? Right,
I'm fortunately working in a system where we have an amazing pain clinic and management group, but a lot of patients have trouble with anxieties or issues with how all that works. This would be a great adjunctive piece of equipment and therapy that they can use.
Absolutely, though. I think for your pediatric patients, I'm sure if you're about to do a procedure or something, there's also a lot of anxiety and stress involved. How would a child respond to a VR headset?
Doctor. I know that in my hospital, they're using VR in the emergency department for procedures like IV placements or blood draws, lumbar punctures and things like that, so it's been already well used. We currently don't have a setup in the rheumatology clinic, but I can imagine that something like this that is not too expensive, I think would be very welcome for our patients.
Sure, absolutely though. So anyway, these are all tools that are readily available, easily obtainable, not too expensive. It's just a matter of if you're practicing and want to incorporate these, will it fit into your workflow? But it only takes a little bit to try it. So I would encourage anyone to think about it, you can contact any of us and we'd be happy to help with more information.
So thanks for joining us for a look at some of these products and hope you have a good conference. Thanks.
Hi. I'm Jack Cush with RheumNow. I'm here in the RheumNow booth at ACR two thousand eighteen in Chicago. It's been a great meeting so far. So far, I've convened a panel of friends to talk about what's hot in rheumatoid arthritis.
I'm joined by Doctor. Jeff Sparks from Boston and Doctor. Artie Cavanaugh from San Diego and I'm Jack Cush, as you know.
Gentlemen, today, we've a
few things I want to go down the list to discuss, but let's start off with what you have seen that you think is really a highlight in RA so far or maybe something you're gonna see in the next few days.
I'll start out the data with the JAK inhibitors.
Maybe not new, but really there's so much more of it now that we're seeing, of course, longer term data with tofacitinib, additional data with baricitinib, a lot of data with upicitinib, and further data with filgotinib. So I think it's exciting that we may see, are these all gonna be the same? Is there really anything to the putative in vitro differences in terms of their cell activity? I think we've adopted them in the clinic, and I think that's gonna increase.
I'm going to get back to Jackson in a second. Jeff, so far?
I think the thing that stood out for me from an epidemiologic perspective for rheumatoid arthritis is looking at interstitial lung disease risk factors. In particular, the MUC5B SNP, is associated clearly with rheumatoid arthritis is interstitial lung disease. And the fact that this is related to interstitial pulmonary fibrosis may mean that these drugs that are used for IPF could be used in RA ILD and those trials are ongoing. And obviously, rheumatologists take care of patients before the ILD develops and our work and others are looking at things that happen for rheumatologists. So disease activity being the things that, we did show that active disease did increase risk for, interstitial lung disease within RheumNow.
So the
the SNP was presented today as
a plenary session and that, that was new and information surprising. I do want to talk about some of your posters that you had, maybe sort of getting to drug safety and whatnot, but still safety I should say or comorbidity issues and that's the ILD story, which we know ILD and lung disease is a very bad player in rheumatoid arthritis, which I think is what has gotten you into this. You had a few presentations here, one a podium presentation on disease activity, another one looking at rheumatoid factor negative versus factor positive. Can you sort of summarize those results?
Well, sure. The first is the disease activity. We look very carefully to look at dynamic measures of disease activity and to see whether active disease was related to subsequent risk of incident interstitial lung disease. And we did in fact find that high and moderate disease activity were put you at a two to three fold increased risk. As rheumatologists, we really think about the risk mostly within the seropositive subset, particularly CCP positive.
However, some of our work also shows that you can get interstitial lung disease, you can get bronchiectasis even within the seronegative population. So this is something that should be on rheumatologists' minds as far as serostatus and obviously treat to target might have other downstream ramifications of decreasing interstitial lung disease.
Yeah. The the the seronegative story is really interesting in that you found in the population that you looked at, know, it was like fifteen, sixteen percent in seropositives. Mhmm. But it was almost same number in seronegatives. Right.
Which I find found really surprising and changes my thinking. Yeah. Your finding of disease activity driving it, you know, moderate to high disease activity led to a two to three fold increased risk, I guess. But the number of patients that qualified as having ILD in your follow-up period was still quite low. So how are going to answer the question of which of a high disease activity patients are the ones who are going to get into having ILD down downstream.
Well, clearly further work has to be done to identify other risk factors you could use in clinic. Doubtful that this new, SNP that they found, the MUC5B, is something that would be useful in clinical care. And whether there's, understanding the natural history, you know, what's going on underneath the surface before patients get symptoms, how big of a problem really is this, are things getting better because we're treating patients better as well. So I think there's still a lot of work that needs to be done as far as, understanding risk strat ification, things we can use in clinic to really go after the people that are most likely to benefit.
So as it as it I think is one of the ways that translates environmental signals to what we see in our patients epigenomics. Though it's still in its infancy, may be an important factor with interstitial lung disease. It's hard to see how it wouldn't be. I don't think we understand enough of it, but as you said, genetics alone aren't going to explain it, the seropositivity and negativity aren't going to explain it, but there's an additional thing. And maybe it's an epigenetic factor that we can identify indicating the history of exposures.
So, Artie, you brought the issue of the JAKs here and they are sort of front and center. We've got some data about, you know, baricitinib extension studies showing good data when you continue on barrier switch from, TNF inhibitor to Bari and whatnot. We've got new TNF inhibitors that are in development, some pretty close, some pretty far. How what's the lessons that the new JAKs can take from the old JAKs in drug development and where they're gonna sort of grow this brand or or or get greater respect for JAKs in in treating RA patients?
Well one thing is the dosing. I think across the JAK inhibitors what we see is that the companies can often find two doses that can be effective. The lower dose generally has a little bit better safety signal. As we found out today, we had a session I moderated with the FDA we're kind enough to come and they pay a lot of attention to safety as we all know and they're very keen on that so I think how best to how to look at the optimal dosing I think as rheumatologists we love to play around we love to have many doses and tailor the therapy, but the FDA is very concerned about safety of these new molecules. So I think, one of the
things that I think may come is as we get additional safety data, maybe we'll see additional dosing options for each of the jackets.
You know, the issue is are they going to affect care and will they be taken up well. It was obviously hard for the first one tofacitinib to grow the respect and comfort with rheumatologists, but you know, we're gonna we may have one next year. I mean, one there after we got upadacitinib and filgotinib and what's the other one that doctor Pepcitinib. Pepcitinib was presented at this meeting and there are others still. Jeff, do you think that this is they're gonna become more acceptable as they get more in the market or what what might be the the tipping point for rheumatologists and having comfort with JAK inhibitors?
Yeah. Well, mean, I think obviously it's really good news for both patients and providers that there's a long list of approved medications for RA. And obviously the new kid on the block is gonna be sort of at the bottom of the line. But I feel like the convenience factor both from a patient and physician is moving up the JAK class. And the other thing is the longer they've been approved and the no new safety signals are coming out and actually several abstracts here showing the fear about DVT.
PE may not be founded in the sort of real world clinical use. And as it's being used in other diseases, I think it's only gaining traction as far as people are becoming more comfortable as far as moving this up as far as the line of succession.
The last thing I want to just bring
up things that there's a
few things here like fine that seem to be an overwhelming recurring theme. There's a lot on biosimilars, there's a lot about weaning therapy, but the new thing that was surprising to me was this issue of seroconversion. Patients, you know, are factor positive, CCP positive, patients who become seronegative or drop their titers over time. A lot of reports here about that and the question is, are rheumatologists doing this and then what are they doing with the data? So, Artie, you've looked at some of this, what's the is there a message right now about seroconverters?
Does it mean anything?
I think the the bottom line message is that it doesn't mean anything to the individual patient in your clinic when you go back to clinic on Friday or next Monday. You shouldn't worry if they don't see a convert. If they do, that's maybe a good thing, but it certainly doesn't seem to be strong enough signal that it's worth pursuing as a target. Meaning, I'm gonna keep changing therapy until you see a convert and you know you think back to rheumatologists older than us who chased rheumatoid factor for years and the hope was that if you decrease the titer that that would not only be a biomarker but that would be a goal of treatment I don't think it's that case. Certainly not an individual patient.
And it remains to be seen whether clearly not all drugs can will do this. And the other issue is if you do see it, is there really an association there whether you have better outcome or or no effect on outcome? How do you consider this when you're, talking about factor? Do you do you recommend repeating it in patients? Yeah.
Or
Well, I think we have clear already goals of target that are already underutilized. To So add CCP in the mix where it's questionable that the number needed to treat are ever going to be cost effective. Certainly it's interesting from a research perspective, but how are you going to understand when you're treating a patient whether it's noise, you repeat the same assay two times, you're going get the same different result. So is it really going down or is it just noise of the assay? Not ready for prime time.
Such sage advice from such a young rheumatologist. Arty, we should worry.
Yeah. No, you think back of of you kind of alluded to, there are probably drugs that change rheumatoid factor like Dilantin. There are people on Dilantin whose rheumatoid factor would go away of course had absolutely no clinical relevance so there may be a dissociation between that and I think think Jeff hit it on the head that is it cost effective? Is it worth doing for that next patient you see in the clinic? Alright,
I want to thank my friends Jeff and Arty for joining us on his RA panel. Thank you. See you at the meeting.
Hi. I'm doctor Janet Pope. I'm a room reporter. I'm here at RheumNow at the booth at ACR twenty eighteen here in Chicago. I wanted to talk about two studies.
They were oral presentations nine six two and nine six three. They were both updates of the long term extension LTE or now called open label extension studies of two of the JAKs of baricitinib and toficitinib. And they were presented side by side, and what was very reassuring is up to six and a half years on one and nine or so years on the other, we found or they found that there were no new safety signals. So looking at incidents of MACE events, looking at cancer, looking at serious infections. What I kind of thought by the eyeball test with that was that herpes zoster rates were both the same in both studies and not increasing over time, and the VTE rates or PE rates were very low and not increasing over time.
And for the first time, we found the long term data and tofacitinib where they did the analysis as well. So I think the JAKs looking in the long term are showing no new safety signals, which is very reassuring. Thank you.
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