ACR2019 Day 1B Save

Hi. I'm doctor Jack Cush, and this is the ACR 2,019 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.

Hi. I'm Chad Deal. I'm at ACR in Atlanta. Just attended session on metabolic bone disease called Bad to the Bone. The session included hyperparathyroidism, hypophosphatasia, and osteomalacia.

I want to mention few points on, hypophosphatasia. It's of interest to rheumatologists who are interested in metabolic bone and fracture, and also rheumatologists because of its articular manifestations, specifically chondrocalcinosis, pseudogout, calcific periarthritis. The key to making this diagnosis is a low alkaline phosphatase, almost always less than 40, many times less than 30. That's the real key to making the diagnosis. Occasionally, you will need genetic studies.

It's caused by a gene defect in, the gene that controls tissue non specific alkaline phosphatase. Patients may present as adults, which is where adult rheumatology comes in, and it's treatable because there's a new medication released in 2015 called Aphotase Alpha or Strinsic that's very effective for this medication. More information, please go to, RoomNow.

Hi, I'm David Liu from Melbourne, Australia, from RoomNow from ACR twenty nineteen here in Atlanta. Some really interesting anchor associated vasculitis abstracts on the floor today and really practice changing kind of stuff. The first one was reporting results from the RITASAREM trial which looked at Rituximab versus Azathioprine as maintenance for ANCA associated vasculitis following Rituximab induction. Multi center study, really important study and the results were fairly clear in that Rituximab really did outperform azathioprine as maintenance therapy. Really impressively though, the safety profile comparing between rituximab and azathioprine was pretty similar even in terms of hypergammaglobulinemia, the kind of thing that you might worry about if you're giving rituximab every four months like they were doing in the study.

Second practice changing study on ANCA associated vasculitis today was actually from the French from a large French collaborative that's been collecting vasculitis data since 1983. They looked at seven hundred and ninety five GPA vasculitis patients, and it was really examining the question, do we ever cure patients, and do those cured patients ever do better than the ones who aren't supposedly cured, the ones that stay on therapy versus the ones who have a sustained remission off therapy? And comparing these patients at three years, five years, greater than seven years, they didn't find any difference between the two groups. Really comes down to the fact that anchor associated vasculitis is one of those conditions that you often have to treat ongoingly with maintenance therapy on an ongoing basis to really get the best outcomes. So really thought provoking stuff in anchor associated vasculitis today.

There's some interesting abstracts from the French group in coming days as well. Log on to the roomnow.com for more data from this whole meeting, and I'll see you there. Hi. I'm David Liu from Melbourne, Australia reporting from RheumNow from ACI twenty nineteen here in Atlanta. Really interesting poster on the floor today from the IgG4 related disease clinic at MassGen.

Obviously, these guys have been collecting a lot of data over time and they've got a large co cohort looking at their 205 patients. They wanted to see whether there was a mortality difference between the patients that they had versus age age and disease match controls. And so they looked at the standardized mortality rates between their patients and comparing that to normative data. The really interesting thing, and I wouldn't have expected this, is the fact that, in fact, these patients it's not a life limiting condition in these patients, but these patients have at least short term mortality, which is comparable to what they would look like otherwise. And didn't matter how you splice or dice it, if you looked at criteria positive patients, male patients, patients with internal organ involvement, they all seem to do okay.

Now is this because gen are really good at treating IgG four related disease, or is this because that this isn't a life limiting condition or somewhere in between? That question still remains to be answered. And really what we need to do is get broader data, longer term data, data from more centers, and data from places where they're maybe not giving as much rituximab upfront where steroids steroid first line therapy is more common. So more data needed in this space really starts to ask question though, is IgG4 related disease a life limiting condition or not? I'm David Liu, and for more information, go to roomnow.com.

It's Eric Ruderman from Northwestern University in Chicago. I'm coming to you live from the ACR meeting in Atlanta for RheumNow. What's going on today on Sunday? Well, one of the exciting abstracts we're going to see today is the first of the phase three trials of guselkumab in psoriatic arthritis. We've seen progression of treatment options in psoriatic arthritis looking at different approaches, different pathways and now we've got the first phase three data for an interleukin twenty three inhibitor.

These drugs are really hot in the psoriasis space. We've seen phase two data in psoriatic arthritis and now we're seeing two trials at this meeting. The first of which is a plenary session today in phase three data for gazelkumab. Very effective in psoriatic arthritis, effective at two different dose arms either given every eight weeks as is, conventional for psoriasis and every four weeks, thinking that perhaps psoriatic arthritis would need a higher dose. The trial today looked at patients who are both biologic naive and a small percentage of patients who are biologic experienced.

There was a slight difference, in dosing arms with the four week, patients getting a little bit better numerical response, though not statistically different. We're going to see the second phase three trial later in the week in which there wasn't a real difference between arms. The key point of the second trial, which includes patients who are all biologic naive, is that there was radiographic benefit statistically significant at the high dose arm. Really cool data, the safety profile of this pathway is tremendous. It does appear that we're going to see fewer infections, fewer adverse events than we've seen with other cytokine inhibitors.

We're really looking forward to having IL-twenty three inhibitors in our armamentarium for psoriatic arthritis as rheumatologists. Psoriatic our dermatologist friends have been using it for psoriasis for a while and we're excited to get on the bandwagon.

Hi everyone, my name is Kanika Monga and I'm with RheumNow and we are at the American College of Rheumatology Annual Meeting and wow, what a great start it's been. And I'm extremely excited to have Doctor. Rivel here with me right now. Can't wait to ask him lots of questions for us. Hi Doctor.

Rivel, how are you Hi,

Rivel, good to see you.

Nice to see you. So first off congratulations for being ACR Master, that's amazing.

Well I sort of feel a question of having survived that long. I mean, given the alternative. But it's an honor. It truly is an honor. I've been working with the ACR for, Lord, nearly forty years.

And this is a great honor to have been selected for this.

Well it's my honor to be here with you right now. What advice would you have for people that want to pursue a career in rheumatology?

Well this is a very good time to be going

to

rheumatology. We have a much clearer concept of pathogenesis, better aids in diagnosis, and by all means more and effective treatments, albeit expensive. And we really can now do something for our patients. We are taught diagnosis and to be skilled therein and we know that early diagnosis and early initiation of effective therapy is very important in outcome and that we have the tools now for that early diagnosis with genetics, with biomarkers, with new imaging techniques and the like.

That's that's extremely true and of course I'm biased and I love rheumatology as well. So doctor Ravelle how do you feel, the field has changed over the years?

Well when I joined, we were called the American Rheumatism Association when I, first joined this organization. Actually, first meeting I attended was in as a medical student in 1976. So that that it goes back quite a ways. Things have changed a great deal. The especially it's grown enormously.

The awareness of what it is and of the diseases involved they're in and especially like I said with this growing awareness we can diagnose earlier. The technology has remarkably moved forward and the ACR has, more and more been enabled to really help us in our mission.

That's actually very, yeah, very true. Now what are you most excited, to see at this year's meeting? What session are you most excited to attend?

Well, the plenaries are are remarkable and they they're they're they're especially highlighting novel treatments and novel pathogenesis. The the, I'm just completely bowled over how fast, the scene the scenery is changing and and how much that we're going to be able to do. And it it makes this this especially all the more exciting. I think there's so many different sessions that that one can attend. So many ways that appeal to an individual's own focus or expertise, that, it's like being a kid in a in a candy store.

The only danger is getting diabetic.

That's true. It's a Disney World for a rheumatologist. So I am extremely excited about the Hench Lecture that you're gonna give us on Tuesday morning. Can you tell us a little bit more about what's in store for us?

Well, that's a special passion of mine. Chronic back pain is a major challenge in this country it's the leading cause of disability huge billions of dollars in lost productivity work wages disability funding and all that kind of stuff And it's not well managed by the community, especially by the rheumatology community. Looking at some insurance databases, fourteen percent of patients with chronic back pain ever even encounter a rheumatologist. The problem is that one third in the NHANES study, twenty percent of The US population, twenty percent has chronic back pain. One third of them have chronic inflammatory back pain.

And of course that's a symptom and raises suspicion high for spondyloarthritis. With the diminishing manpower we have in rheumatology, will turn around, this represents a special challenge because mostly people don't counter rheumatologists because some of the novel terminology like that ankylosing spondylitis is now synonymous with radiographic axial spondyloarthritis. All this is unknown to primary care practitioners. And this is very troubling because spondyloarthritis represents a group of diseases where so many novel and effective treatments have come forward, but they work by far the best and do their best job preventing disability and deformity if initiated early in the disease course. So this is a big focus of mine.

We're gonna start with looking at specter of chronic back pain in The United States, to chronic inflammatory back pain, talking about non radiographic axial spondyloarthritis, the challenge that it represents, especially in women. Because the majority of people with non radiographic are women and too many are called fibromyalgia and again it's an issue we know that these medications work very well even before the x rays turned positive which seven to ten years after the onset of symptoms. So I'm going to really be focused on that and finally to where we've gone with this with some of the new advances in genetics where we're understanding more and more what causes this disease and especially where you got a gene, you've got a drug. I mean the genes predict the drugs that are going to work. All the novel treatments have been planned by genetics and so so this is important knowledge to have.

I just wish that we had the manpower and the focus to better address this at a national level from the denominator of chronic back pain.

Thank you so much for that explanation. I'm now even more excited and thrilled about the lecture. Once again, thank you so much for talking to us at RheumNow. And for everyone watching this, please log on to roomnow.com for more information. Thank you.

Thank you.

Hello. I'm Jonathan Kay from the University of Massachusetts Medical School in Worcester, Massachusetts. I'm at ACR 2019 in Atlanta, and I just heard an interesting presentation by Doctor. Ernest Choi about major adverse cardiovascular events and venous thromboembolic events in patients with rheumatoid arthritis from the integrated safety database of upadacitinib. He presented data from the five clinical trials in the phase three program of upadacitinib looking at two doses, fifteen and thirty milligrams, as well as the comparators, methotrexate, adalimumab, forty milligrams every other week, and placebo.

What he presented was that the rates of major adverse cardiovascular events and venous thromboembolic events overlapped for all of the treatment groups. Upadacitinib at fifteen and thirty milligrams taken by mouth daily, adalimumab forty milligrams taken subcutaneously every other week, methotrexate, and placebo. All of the patients with major adverse cardiovascular events had at least one cardiovascular risk factor, and patients with venous thromboembolic events also had risk factors for venous thromboembolic events, such as a prior deep venous thrombosis, knee replacement, or other risk factors. The conclusion of the study was that there was no dose relationship between upadacitinib and the occurrence of these events, and the rate of these events was similar through padacitinib with the comparators adalimumab, methotrexate, and placebo. What this does not answer is the question as to why patients treated with JAK inhibitors are developing venous thromboembolic events.

It's not related to platelet counts, since platelet counts did not change significantly throughout the time period that patients were treated with upadacitinib, and patients on placebo also developed these events. It would be very important to understand the mechanism whereby venous thromboembolic events occur in patients treated with JAK inhibitors so that we can predict which patients are at risk and treat them appropriately to prevent this devastating adverse effect, which may be an effect of this class of medications and may be completely unrelated. For more information, go to RheumNow. I'm Jonathan Kaye. Thanks.

Great.

You're always first take Doctor. K. Okay.

Hello. My name is Torkel Ellington. I'm from Odinson University Hospital in Denmark. I've been asked to add a few comments on poster five sixty three which is data from one of our PhD students, Rick Asmussen, who is unfortunately not able to be here. It's about sex differences in ankylosing spondylitis and non radiographic axSpA where Rege collected 100 patients consecutively from a university clinic setting in Swedenborg and Odense, Denmark And we decided to focus on pain parameters that we not usually collect when we evaluate disease activity in ankylosing spondylitis and non radiographic XPRA.

And the two main findings are that the Basti among females with non radiographic XPRA was higher than in the males and that in both ankylosing spondylitis and non radiographic axSpA we found significantly higher number of tender points when evaluated clinically and this is interesting because obviously pain is a challenge for both the patient and the physician when you deal with ankylosing spondylitis But when you see sex differences like this then you need to be very cautious when you make decisions on when you intensify or make evaluations that are needed for treatment changes. And Reaga will evaluate this further in her coming papers and the poster I just presented is last week published in Arthritis and Research Care, so please check it up there.

Hello, everyone. I'm Olga Petrina reporting from the annual ACR meeting here in Atlanta. Today, I would like to talk about the abstract number three zero one, which speaks about pamela recommendations on use of imaging studies in gout. So there is a lot been told about guiding our treatment based on serum uric acid, but there is not really a clear recommendation how we could use imaging modalities in monitoring and guiding treatment of, gout patients. So, Pamela's ultrasound study group included rheumatologists, radiologists, statisticians, and methodologists to develop recommendations in this regard.

After reviewing all available evidence, they graded most of their recommendations at level two and three and oh, based on the evidence in the literature, and then they developed following recommendations. Recommendation number one is that we can use ultrasound to detect the elementary deposits in the joints, and we could use dual energy CT scan to detect monosodium muroid crystals in patients with gout. The same group suggests that both ultrasound and dual energy CT scan can be not so sensitive in detecting monosodium muroid crystals in damage in patients who had disease duration of less than two years, but is very specific, so that justifies the use of

those

modalities. It also says that patients with gout do not present with very clear imaging results on X-ray and CT scan in terms of joint damage, but based on low cost of the study and high sensitivity, it is recommended to still use x-ray and CT scan as initial, imaging study in patients with gout. As it comes to an MRI and ultrasound, these modalities are considered, very effective synovitis and tenosynovitis, but they're not very useful in assessing for crystal deposition and gouty erosions in patients with gout. And also, there is no sufficient evidence to support using these modalities in guiding treatment choices or in monitoring patients over time, and it says it's best to use these modalities for initial diagnosis only. Although, it can be used as a complementary monitoring techniques, in most of the cases.

If you would like to learn more, you can read about us more on RheumNow, and also continue following us online. Thank you, and have a nice day.

Hi. I'm Philip Rumson. I'm, from Brisbane in Australia, and I've, just come back from Dan Claw's session on fibromyalgia, which was a fantastic summary on how to think about fibromyalgia and how to treat fibromyalgia. One of the things that he reminded us is that there are lots of chronic pain syndromes that we don't necessarily think about. Things like dry eye necessarily that might that's also like a fibromyalgia of the eye in a lot of people.

And think about these other syndromes in the patients that you're seeing. He reminded us that potentially the relevance of tender points isn't that relevant now and that you can ask questions like, are you uncomfortable when people hug you, are you uncomfortable when people do your blood pressure are much more relevant because these are chronic widespread pain disorders, not just focal pain disorders. He also reminded us that people really don't often just have one type of pain. They have mixed pain. And so you've got to think about the proportion of pain that each person has.

Do they have an amount of nociceptive pain, which you would expect from say rheumatoid, neuropathic pain and then central pain because you're never going to make progress unless you actually target the cause of their pain. Finally he reminded us that opiates, well, they often work to start with the longer you are on them and the higher doses that patients end up on, the less effective they are. And he reminded us that there are more effective therapies including SNRIs and gabapentinoids and simple tricyclics that have evidence. And he also reminded us of the burgeoning amount of evidence for non pharmacological treatments like CBT and regular activity. You're going to make progress with your patients when you actually put together a combination of these treatments because not each one of them is very effective but when you combine them together they often create a package that's actually effective for patients.

So if you want to know more about this I'd recommend you go to rheumnow.com.

Hi, I'm Doctor. Rachel Tate coming to you from Atlanta 2019 for ACR twenty nineteen. So I just got through an amazing poster session. Check them out if you haven't and follow us at at roomnow for Twitter and roomnow.com. But I wanna tell you a little bit about this year.

So 2019 and 2020 is gonna be a huge year for gout. In fact, on Wednesday, we're gonna have the updated gout guidelines or gout lines as I like to call them. And what I wanted to share with you as a little appetizer are the actual panlar recommendations for 2019. So panlar decided to put together a task force of nine rheumatologists, musculoskeletal radiologists, ultrasonographers, statisticians and methodologists, and they looked at a huge literature review to determine how we can best utilize imaging for our patients. So they came up with eight particular recommendations, and I will refer you to abstract three zero one or poster three zero one for further information, but I want to highlight two things.

The entire task force went together on two. There was a consensus on two of these recommendations. The first is for those difficult patients. So when you have a patient who is difficult to diagnose, you think that they're GABA, perhaps they are not, the group unanimously decided that ultrasound or deck scanning would be appropriate for these particular patients. The other subset is when you have patients who you believe have MSU or uric acid deposition in crystals and other tissues besides the joints, they again recommend ultrasound and deck scanning.

So they looked at all of the literature that they could to determine between x rays, CT scans, MRIs, and ultrasounds, and this is what they came up with. So if you come if you want to look at it a little bit further, a little more in-depth, I recommend abstract number three zero one, poster three zero one, and thank you for coming to share some time with us in Atlanta for ACR twenty nineteen. And check us out on Twitter. The handle is at room now or room now dot com. And more will come from gout.

I promise you. So stay tuned. Hi, I'm Doctor. Rachel Tate coming to you from Atlanta twenty nineteen for ACR twenty nineteen. So I just got through an amazing poster session.

Check them out if you haven't, and definitely follow us at at roomnow for Twitter and roomnow.com. But I wanna tell you a little bit about this year. So 2019 and 2020 is gonna be a huge year for gout. In fact, on Wednesday, Wednesday, we're going have the updated gout guidelines or gout lines as I like to call them. And what I wanted to share with you as a little appetizer are the actual panlar recommendations for 2019.

So panlar decided to put together a task force of nine rheumatologists, musculoskeletal radiologists, ultrasonographers, statisticians and methodologists. And they looked at a huge literature review to determine how we can best utilize, imaging for our patients. So they came up with eight particular recommendations, and I will refer you to abstract three zero one or poster three zero one for further information, but I want to highlight two things. The entire task force went together on two. There was a consensus on two of these recommendations.

The first is for those difficult patients. So when you have a patient who is difficult to diagnose, you think that they're gout, but perhaps they are not. The group unanimously decided that ultrasound or deck scanning would be appropriate for these particular patients. The other subset is when you have patients who you believe have MSU or uric acid deposition in crystals and other tissues besides the joints, they again recommend ultrasound and deck scanning. So they looked at all of literature that they could to determine between x rays, CT scans, MRIs, and ultrasounds, and this is what they came up with.

So if you want to look at it a little bit further, a little more in I recommend abstract number three zero one, poster three zero one. And thank you for coming to to share some time with us in Atlanta for ACR twenty nineteen. And check us out on Twitter. The handle is at room now or room now dot com. And more will come from gout.

I promise you. So stay tuned.