ACR2019 Day 1A Save

Hi. I'm doctor Jack Cush, and this is the ACR two thousand nineteen podcast. We're coming to you from the annual meeting in Atlanta, Georgia. This episode is a collection of our faculty reports, interviews, and panel discussions recorded live from the RheumNow booth. I hope you enjoy and learn.

Hey. I'm Jack Cush with RheumNow. I'm here on the Convention Floor. It's the first day of ACR two thousand nineteen in Atlanta, Georgia. It's busy.

It's gonna get busier. Looks like a really big meeting. Atlanta, great host city. We've had a great time so far. So am I gonna do here?

Tons of things. RheumNow is gonna be covering a lot of the meeting. We've got, like, fifteen, sixteen reporters. We expect to have a lot of videos, a lot of podcasts, a bunch of news articles, and a bazillion tweets. So follow us on Twitter or just go to the website, acr19.roomnow.com.

I'm looking forward to some new presentations here. I'll give you three. One, a lot of gout stuff being presented today. It's gonna be really interesting. One thing is this new VA study about febuxostat and allopurinol.

As you know, febuxostat got a black box warning this year because for the second time showed an increased cardiovascular risk compared to allopurinol. Well, the VA studies got data that refutes that suggesting it's not so bad. So that'll be sort of interesting if not controversial. The exceed data is gonna be presented. That's secukinumab head to head against adalimumab.

It was a press release about it. We put it in room now last week. This week, we get to see the data and the particulars about was it equal? Was it numerically better, but not statistically significant? Again, the the story was it was not any different than adalimumab, although in some ways numerically better.

We'll see the data and report that here at RheumNow, acr19.roomnow.com. And lastly, there's two abstracts here that are kinda interesting about Shingrix and its use in our patients who have rheumatoid arthritis and other autoimmune diseases and who are on background biologics in DMARDs saying that you can give the inactive form of the shingles vaccine Shingrix safely to your patients without any risk of flare of disease or the new onset of shingles. So exciting stuff. Tune in all week here at roomnow.com or specifically the website. Redesigned for this meeting, ACR.

Nineteen, roomnow.com. We'll talk to you later.

It's doctor Daugherty Kavanaugh at the ACR meeting in Atlanta 2019. Looks like it's gonna be a good meeting. Few things that I'm really looking forward to, looking through the abstracts ahead of time. A lot of new stuff on lupus. Lupus has been an area where we've had approaches to treatment over the years, but some exciting data that looks like it's going to come out at this meeting.

Also, in psoriatic arthritis, new mechanisms of action. We've had a lot of new data in recent years, but it looks like it's going to be even more presented here, which is going be great for the rheumatologists and the patients they have to take care of. Across other diseases as well, lot of progress, rheumatoid arthritis, some important data for clinicians and vasculitis. So it looks like it's going be a full meeting, looks like it's going be a lot of good medical information there. So I'm really looking forward to it and we'll bring you some of this on RheumNow.

This is Doctor. Artie Cavanaugh for RheumNow at ACR twenty nineteen.

Hi, I'm Mike Putman. I'm a rheumatologist at Northwestern coming at you from ACR twenty '19. I just got back from the ANCA associated vasculitis guidelines talk, which was really excellent, and I wanted to share a couple of things that I learned there. The first is that they're recommending Rituximab over cyclophosphamide for induction of severe ANCA associated vasculitis. I think a lot of us have been practicing that way but I wasn't totally sure which direction the guidelines were going to go with that.

The next couple things actually relate to the PEXAVAS study which was a large randomized controlled trial of plasma exchange that also had an arm for low dose or normal dose steroid regimen. Two interesting recommendations come from that study. The first is that they recommend against using plasma exchange for patients with severe ANCA associated vasculitis. In the trial it did not look like it was beneficial. There are some cases where I think many of us will still try it but it's an important thing to note.

The second is that they recommended a low dose steroid regimen as opposed to a higher dose steroid regimen. The protocol is available. I put it out on Twitter. Another important take home from the guidelines is that they recommend against using ANCAs, titers and B cells to dose rituximab. The main RITSIN-two trial, which was published last year, had suggested that that was an option.

In my opinion, it hadn't entirely excluded the possibility of an increased rate of flares just because of a power issue. I have had trouble using this as a practical matter. I think it's hard to get rituximab restarted often if you stop giving it in a scheduled dosing regimen. Then the last thing is that they did recommend methotrexate for limited disease or for non severe disease, which I think is appropriate. I have a number of patients who I've had success in doing this with.

Great guidelines and it was a lot of work for the committee. If you'd like to learn more, please drop by the website at Now Live, for all the reporting on this event. Thank you very much.

Hi. I'm doctor Janet Pope. I'm a rheumatologist from London, Ontario, Western University, and I'm here at the Room Now booth, and this is the ACR twenty nineteen Atlanta. Welcome everyone. I wanted to talk to you about rheumatoid arthritis and use of hydroxychloroquine.

We know in SLE for a long time that hydroxychloroquine improves that disease markedly. It's the anchor drug and it actually prolongs survival and less cardiovascular events than lupus. There are two, presentations. One is number eight nine six by Jorge et al from the BC in Canada admin billing and one, number eighteen ninety one from Eyre et al looking at both major cardiovascular events in RA, one looks also at lupus, but in RA and they both show a reduction in cardiovascular events for our patients with RA taking hydroxychloroquine. In fact, the reduction might range anywhere from a fifteen percent reduction from the British Columbia database to even a forty to sixty percent reduction in major cardiovascular events and the other US big claims database.

What does this mean for our patients? We have no guidelines telling us to use antimalarials in RA. We often combine them in, use with methotrexate. Methotrexate also has cardiovascular reduction. So I ask you, follow us on at RheumNow and take my survey and tell me if it should be added to the guidelines in RA using antimalarials routinely if no contraindication in RA.

Thank you.

This is Doctor. Arti Kavanagh coming to you from room now at ACR twenty nineteen. Important topic in rheumatology, one that we've seen presented over the last few meetings is biosimilars. Important topic around the world. Some interesting posters, more than two dozen here at ACR twenty nineteen, a couple that were particularly interesting.

One looks at immunogenicity among patients who have to switch from one agent to another to another. And that's been a common fear practitioners and also among patients, is whether this might result in increased immunogenicity. There's a study from France, and it looked as if there was not a large increase in immunogenicity among patients who had switch, even with two subsequent switches from the originator to two different biosimilars. So we need further data in that regard because it's an important consideration. Another interesting biosimilar poster wasn't really a biosimilar poster, and this dealt with a biosimilar CTP-thirteen, a biosimilar of infliximab given intravenously, and a subcutaneous version of this, which is in essence a new drug, but question arises as to whether the regulatory pathway for biosimilars may be a little bit different than if it was a brand new drug, which would have important implications for drug development really worldwide.

So some important information that was presented today, additional information will be presented through the conference, important topics, and we look forward to looking at those and reviewing them with you here on RheumNow. Coming to you, this is Doctor. Arti Kavanagh for RheumNow.

I'm Chad Deal. I'm at ACR in Atlanta 2019, and I just attended a session, The Great Debate. The topic of debate was whether or not teriparatide should be primary therapy in patients with steroid induced osteoporosis. The impetus for this debate was the 2017 ACR guidelines, which made teriparatide only a second choice for even for high risk patients on steroids with osteoporosis. That's different from the previous guidelines that proceeded where teriparatide was a choice for high risk patients.

So Doctor. Saag and Doctor. Humphrey debated this topic, and my personal feeling is that teriparatide should be primary therapy in high risk patients just like it is for all the patients we see, especially those with very low T scores and previous fractures, especially vertebral fractures and hip fractures. More information, go to RheumNow.

This is Doctor. R. D. Kavanaugh for RheumNow at ACRR twenty nineteen here in Atlanta. Just want to say there's a tremendous amount of medical information being presented here, and a great way to review this data and to talk about it with your colleagues and see how that helps you take care of your patients is to come to RWCS, Rheumatology Winter Clinical Symposium, February 2020.

So please come to that meeting, and we'll enjoy the ability to discuss these new data, and we will see you there. Be there. Aloha.

Hi. I'm Jack Cush coming to you from ACR nineteen here in Atlanta. Just finished a presentation this afternoon, a combined ACR, ARP presentation on better presentations, PowerPoint presentations for health professionals and patients. There's a session that was run by Don Thomas and he invited me to join him. Don gave a presentation talking about how to talk to patients, to how give good presentations to patients, really masterful talk, but there are a few takeaways there.

One, forget about words and numbers. Get away do away with them. You can't have lines on your slides. Two, go with the blank slide, meaning show nothing. Also, and while you're showing nothing, use the pause.

These are powerful ways to get engagement by your audience. And third was actually know how to flow with mistakes. Mistakes are gonna happen. A bug's gonna fly in your mouth, you know, you're gonna drop your your your notes, something's gonna happen, go with it because it makes it very human, very relatable. In my presentation, I talked about knowing your audience.

You need to know who they are and ultimately, you know, you need to make them your friend. Great quote from Seth Godin is, people don't believe what you tell them. People don't even believe what you show them. They usually believe they're friends and they always believe the story they tell themselves. What does that tell you?

That tells you if you're teaching someone, they're not gonna believe you. They're not poised to do that. Not until you they see you as their friend, their ally, the person who's trying to feed their need. Actually, give them what it is that they want from a speaker. That's really important and you gotta do that in several ways and the more simple the better.

One thing, stay within your goal post. If you're not funny, don't try to be funny. If you're if you're, you know, a guitar expert, don't start talking about drums. You know, go with the things that you know well because it is gonna show up on camera. A big message from both of us was shorter is better.

Woodrow Wilson said, when asked how long does it take you to do the talk, he said how long is the talk? If it's a short talk, I need, you know, three weeks. If it's, you know, a half hour talk, I need one week. If I can talk for as long as I want, well, I'm ready to go right now. The point being that shorter talks are harder to do and take a big effort, but they are much much more powerful.

Remember, it's never about the data. I know that we're all about data when we talk, but when you talk data, it goes in one ear and out the other and they are not gonna remember it a week from from today or tomorrow or whatever. What they do remember is the emotion that you brought to bear. The story that you tell. Tell a good story, make it emotional, make it personal, and that becomes a great presentation.

Tune in for more videos here on RheumNow.

Hi, I'm Cassie Calabrese. I'm here at day one of ACR twenty nineteen in Atlanta, and I just left an excellent session on infection prevention in the setting of immunosuppression with two talks, one by Len Calabrese from Cleveland Clinic on immunizations, and another from Robin Avery from Johns Hopkins on Pneumocystis Prophylaxis in patients with rheumatic diseases. Takeaway points and pearls from the immunization section, flu shots are very important and all of our patients should be getting a seasonal flu shot every year. There are very few contraindications to seasonal flu vaccine. If you have egg allergy, you can have a flu vaccine.

If you have anaphylaxis to eggs, you can still have a flu vaccine. The only true contraindication is anaphylaxis to previous flu vaccine or if you've had Guillain Barre in the setting of a previous vaccine. Pneumococcal vaccine series is confusing to remember. C level data for administering the prime boost pneumococcal vaccine series in our patients, which is a conjugate pneumococcal vaccine followed by a polysaccharide vaccine. But this is what is recommended and what we do in our patients.

Lastly, Shingrix, the new, recombinant zoster vaccine, which is highly effective, over ninety percent effective at preventing shingles and herpes zoster in postherpetic neuralgia. Studies have not been done in patients with rheumatic diseases, and there is theoretical risk of disease flare in the setting of this vaccine. We await further data. There's some great abstracts here looking at this, including one by Mike Weinblatt, which was originally presented at UAR with several 100 patients who had underlying autoimmune diseases and received Shingrix, and there does not seem to be a significant safety signal in terms of flares or increase of adverse events. We await more data on this.

Lastly, pneumocystis prophylaxis in our patients is quite confusing. There are no guidelines. Is most important to remember risk is heterogeneous. It's based on underlying disease, underlying immunosuppression and comorbidities, and a factor, multiple factors will contribute to risk assessment and deciding who needs Pneumocystis prophylaxis. For more abstracts, more news, go to rheumnow.com.

Hey. Hi. I'm doctor Janet Pope. I'm a roving reporter for RheumNow at the ACR twenty nineteen conference in sunny but cool Atlanta. I'd like to talk to you about abstract four sixty four.

This is a Japanese study, and the reason I'm talking about it, even though it's a little study, is because it answers a clinically relevant question. The question is if you're seropositive and you have rheumatoid arthritis and you're treated with a TNF inhibitor, will reduction of the rheumatoid factor independent of improvement on your disease activity score affect erosion? So this was a small study and they only looked at seropositive patients. The mean, positivity was a level of 104 at the beginning, over fifty patients, and they looked at four months and twelve months. And patients who became lower in the rheumatoid factor positivity by at least thirty percent had less erosions at the end of the year even if you adjusted for DAS score.

So lowering your rheumatoid factor with a TNF inhibitor interestingly seems to give less erosions even if it was an equal change in DAS. I picked this paper because it's really important when we know that anti CCP has been looked at a lot and we know that as a, for instance, adalimumab doesn't lower anti CCP as much as, say, abatacep. This is looking at rheumatoid factor within people on TNF inhibitors. Will this change my practice repeating RF factors over and over? No, but it gives me a hint that there's a pathway independent of disease activity that causes joint erosions in RA.

RA. Thank you.

Hi, I'm Mike Putman coming to you from ACR twenty nineteen reporting for RheumNow. I wanted to talk briefly about the ACR urine review today. It was a wonderful lecture The SELECT monotherapy trial came up. Now, with trials like this, I think there's something important for you to remember. That trial was run on patients who were methotrexate non responders and went on to either continue methotrexate or get upadacitinib.

Now the implication when you hear the trial discussed is that upadacitinib was better than methotrexate. However, this isn't a population of patients who already didn't respond to methotrexate so it's not surprising that a new drug would perform better than the old drug that already wasn't performing. It's a very different question than saying I have a patient with rheumatoid arthritis, should I give them methotrexate or upadacitinib? In a blank slate population it may be that they're equivalent, may be that methotrexate even works better than upadacitinib. We're still waiting for a trial that's going to assess that question.

I think it's important to remember that a trial assessing a new therapy in non responders, continuing therapy, doesn't necessarily prove that point. Thank you so much. I hope you're all enjoying the meeting. If you're looking for more information, please go to RoomNow Live. RoomNow.

Hi. I'm Cassie Calabrese from the Cleveland Clinic, I'm here at day one of ACR twenty nineteen in Atlanta. I just left the poster session where there were some very interesting abstracts on treatment of rheumatoid arthritis. In particular, increasing interest in being covered at this meeting are new JAK inhibitors for treatment of RA, in particular two very interesting abstracts I just saw looking at long term extension data up to sixty weeks of use of in RA patients who were not responsive to DMARDs or not responsive to biologics. This was Select Next and Select Beyond, the first study by Gerd Burmester and second study by Mark Genovese et al.

They looked at up to sixty weeks outcomes of safety and efficacy in these RA patients. Most interesting to me was the safety profile. These studies all looked at placebo versus fifteen milligrams versus thirty milligrams of OOPA daily. And as to be expected, there's a significantly increased herpes zoster signal with the thirty milligram daily dose. Almost double, over double actually, up to eight per one hundred patient years per P zoster with the thirty mg dose.

Looking good, looking effective. No new safety signals noted, but we'll see what comes of this thirty mg dose and this increased zoster signal. For more, join us at roomnow.com.

Morning, everyone. I'm Olga Petrina reporting from the annual ACR meeting in Atlanta. There's a lot of great information presented this meeting, and I wanted to speak about one of the posters three seventy seven, which presents the results of the retrospective study from Stanford University assessing use of TNF inhibitors in treatment of cardiac sarcoidosis. As you all well know, extrapulmonary sarcoidosis can be very challenging to treat, and when it comes to cardiac manifestations, there are not really any FDA approved treatments. So, typically based on our experience, we use conventional DMARDs and steroids to manage the disease.

But what about patients who don't respond to this therapy? So this particular study, selected seventy patients with cardiac sarcoidosis, and twenty of them were put on TNF inhibitor after they failed conventional DMARDs and moderate doses of steroids. Of course, the the main question and concern is, is it okay to treat those patients with TNF inhibitors? And that's the answer that researchers wanted to answer, as we all are concerned about possible exacerbation of CHF or worsening CHF in patients with impaired heart function. So as a result of this study, they showed that patient with pre existent decreased ejection fraction due to CHF did not experience any worsening of the ejection fraction after being treated with TNF inhibitors.

On contrary, all the patients stayed in the same level of EF around forty four percent, some improved to forty seven percent, as well as those patients were able to taper the dose of prednisone down, below twenty milligram daily. So this study supports use of TNF inhibitors in patients with Cardiac Sarcoidosis. The study presumes that there shouldn't be a concern for decreased ejection fraction in patients with preexisting CHF and sarcoidosis. And of course, the future prospective studies will be necessary to confirm this and evaluate the results of TNF treatment and cardiac sarcoidosis more. If you would like to learn more, please follow us on RheumNow, and have a wonderful day.

Good morning, everyone. I'm Olga Petrina reporting from the annual ACR meeting in Atlanta. There is a lot of great information presented this meeting, and I wanted to speak about one of the posters three seventy seven, which presents the results of the retrospective study from Stanford University assessing use of TNF inhibitors in treatment of cardiac sarcoidosis. As you all well know, extrapulmonary sarcoidosis can be very challenging to treat, and when it comes to cardiac manifestations, there are not really any FDA approved treatments. So, typically based on our experience, we use conventional DMARDs and steroids to manage the disease.

But what about the patients who don't respond to this therapy? So this particular study, selected seventy patients with cardiac sarcoidosis, and twenty of them were put on TNF inhibitor after they failed conventional DMARDs and moderate doses of steroids. Of course, the the main question and concern is, is it okay to treat those patients with TNF inhibitors? And that's the answer that research just wanted to answer as we all are concerned about possible exacerbation of CHF or worsening CHF in patients with impaired heart function. So as a result of the study, they showed that patient with preexistent decreased ejection fraction due to CHF did not experience any worsening of the ejection fraction after being treated with TNF inhibitors.

On contrary, all the patients stayed in the same level of EF around forty four percent, some improved to forty seven percent, as well as those patients were able to taper the dose of prednisone down below twenty milligram daily. So this study supports use of TNF inhibitors in patients with cardiac sarcoidosis. The study presumes that there shouldn't be a concern for decreased ejection fraction in patients with preexisting CHF and sarcoidosis. And of course, the future prospective studies will be necessary to confirm this and evaluate the results of TNF and cardiac sarcoidosis more. If you would like to learn more, please follow us on RheumNow, and have a wonderful day.

This is Doctor. Roddy Kavanagh at the ACR meeting in Atlanta 2019. Looks like it's going to be a good meeting. A few things that I'm really looking forward to, looking through the abstracts ahead of time. A lot of new stuff on lupus.

Lupus. Lupus has been an area where we've had approaches to treatment over the years, but some exciting data that looks like it's going come out at this meeting. Also, psoriatic arthritis, new mechanisms of action. We've had a lot of new data in recent years, but it looks like it's going be even more presented here, which is going to be great for the rheumatologists and the patients they have to take care of. Across other as well, a lot of progress.

Rheumatoid arthritis, some important data for clinicians and vasculitis. So it looks like it's going to be a full meeting. It looks like it's going to be a lot of good medical information there. So I'm really looking forward to it and we'll bring you some of this on RheumNow. This is Doctor.

Cavanaugh for RheumNow at ACR twenty nineteen.