Emergencies, Independence & Hemorrhage (1.23.2026) Save

It's the 01/23/2026, and this is the RheumNow podcast. Hi. I'm doctor Jack Cush, executive editor of rheumnow.com. This week, we got a lot to cover because last week, we did the year in review. Pretty popular, Thousands of views and listens.

That was great. But there's I got two weeks of news to cover. So let's get into it. Before we do, do me a favor. Three favors.

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That used to be an old commercial. So this week, we've got a lot to cover. I last week, I had a question about what to do with problematic rheumatoid scleritis. And you know, the good thing about knowing everybody, you can call everybody and get a good answer. So I called Alvin Wells, who is really good at eye disease, and a few other people, but Alvin was the he always picks up for me.

And we do that in rheumatology. We call each other when we got a question or a head scratcher and whatnot, and I have them just like you. And the question was what to do, and Rituximab was the best drug of choice except we couldn't use Rituximab. And he brought up, you know, there's a sub q Rituximab, I think, and So I looked it up and I tweeted it this week. There is a subcutaneous Rituximab.

It's called Hysella. It was FDA approved in June 2017. The FDA approval was for B cell lymphomas, follicular lymphoma, large B cell lymphoma, and I think another one. It's not approved for RA, it's not approved for GPA, but it's out there, and it's sub q, and it's five to seven minutes as opposed to two to four hours of Rituxan infusions. The deal on this, it is the same as Rituxan, it's the same drug, except they combined it with hyaluronidase to make it accessible via the sub q route and faster administration.

The rule on this, however, is that you have to give IV rituxan first, and then SubQ can follow thereafter. Seems to be well tolerated. Seems to be a good drug option for those with lymphoma. I don't know why we can't apply to get it for Anyway, I'd like to have that in my arsenal should I need that in the future. An interesting study that we missed during ACR in October was on JIA and the early start of biologics.

This is the CAN DO study, C A N D U study. One hundred and eighty one JIA patients that were starting biologics, and they looked at what the odds were of having clinically inactive disease at six months, based on when they started the biologic. And so there was an early, middle, and late group. Early is less than six months after symptoms. Late is greater than twelve months after symptoms.

And you know what? If you started early, you had an eighty three percent versus, chance of being in remission, clinically active inactive arthritis, versus fifty seven percent if you started in the late starters. And for the and for every month you delay the initiation of a biologic, there is a nine percent increase in the odds that the patient is going to have future active arthritis at month six. Or after six months. So, anyway, a good proof of the window of opportunity, good proof that early aggressive therapy yields the best outcomes.

Good proof that use your best drug first. A lot of good proof here. Another JIA study was the ADJUST trial. Actually, it was published, I think, a year or two ago, and there was a follow-up to it. And in this follow-up, the original study was about two fifty patients with uveitis, JIA uveitis, that was in remission or inactive for greater than six months.

And then they were randomized to either continue the adalimumab or they were weaned off. And it turns out that if you weaned the adalimumab, it resulted in more flares of the uveitis sixty eight percent versus fourteen percent and more flares of uveitis than they did of the JIA. The other thing about that study was that there was no protective effect if the patient was on background DMARTs, like methotrexate, leflunomide, cyclosporine, whatever. And last point was that if you flared and you restarted adalimumab, the majority of people regain control of the disease and uveitis. I saw an interesting abstract and then publication this week in Frontiers of Medicine, I think it is: acupuncture in ankylosing spondylitis.

Spondyloarthritis. What? That sounds like nonsense to me. You know, I read it and it wasn't it was interesting, meaning, it was a meta analysis because you only see sporadic studies with low amounts of patients on this issue, acupuncture and spondyloarthritis. Who would do that?

Why would you do that? Anyway, they found 35 trials that met criteria included 200 sorry, two thousand five hundred and ninety one AS patients, and they found significant improvement in all the AS SPA measures: BASDAI, BASFI, ASDAS, the VAS Global Score, and significant lowering of CRP and ESR. What? I don't know what to think about this. And they did say that their study their meta analysis was limited by high heterogeneity of the studies, and and some studies with bias that, they had to allow for or you had to take note of.

But overall, there was a lack of really large, high quality, randomized controlled trials. So I think that's worthy of noting and putting that into your bag of tricks. A French study this past week looked at psoriasis patients who were on biologics and received antibiotics. Obviously they're on antibiotics, you would assume. This is like, I assume claims data, and they just found antibiotics being used.

These weren't chart reviews where they knew exactly why the antibiotic was being used. Thirty six thousand psoriasis patients on biologics, twenty six percent of them received an antibiotic, either at baseline or during follow-up. Twenty six percent at baseline and sixty one percent at follow-up. So the number of people was about a quarter of patients, nine thousand three hundred out of thirty six thousand. It turns out that these people who received antibiotics were twelve percent more likely to stop their biologic therapy.

And if they received multiple courses of biologics, they were twenty nine percent more likely to stop their biologic. So who's worried about what here, right? Is the patient worried about what they're seeing on TV that talks about the risk of infection with biologics? Or the doctor is worried about infections with biologics. Most of these are NSIEs, non serious infectious events.

I don't stop a biologic for antibiotic use or non serious infectious event. I only stop a biologic for a hospitalized serious infectious event only until I figure out what's going on or if fever is greater than 102. Those are my rules, and I've been studying this for twenty two years now. So again, I don't think you need to stop a biologic, is what I would say. Fibro scans.

Do you do them? You know, methotrexate, the liver, you know, we worry about cirrhosis. No, we really don't. I did a survey of rheumatologists, I think two years ago, showing that, I don't know, 80% of you don't even consider this. And then there's a few of you, I think the question scared you into saying, Well, I might do it under the right circumstances, but really you don't.

Anyway, this is an Egypt study, 60 RA patients on methotrexate for five years, and they studied everybody in a complete sort of liver panel, if you will. These people had a normal BMI, disease duration of eight years, methotrexate either between twelve point five and twenty five mg for eight years, cumulative dose was a median, I think it was six thousand seven hundred mg. Anyway, all sixty patients had normal AST, ALT, abdominal ultrasounds, and the FibroScan scores were a mean of 170, which is astiatosis grade zero. Only six point seven percent, or four patients, had mild fibrosis by the FibroScan scores. I don't think you need to do it unless you feel the patient is at risk for another reason.

Certainly RA is not a reason and methotrexate by itself is not a reason. But that maybe could be added to other reasons. Speaking of RA, an interesting Canadian study looked at how many of their RA patients were going to the emergency department. And they did this study and published it looking at emergency department visits for what they call ambulatory care sensitive conditions. And they compared the, RA patients it was a high number.

It was like a few 100, many 100 patients. But anyway, RA patients had a thirty percent higher risk of going to the emergency room, compared to normal controls. And of those that went to the emergency room, two thirds were being treated for these A. S. C.

These, again, ambulatory care sensitive conditions that really are better managed as outpatients, rather than being triaged and treated in the expensive emergency room. All our patients are capable of this. You know, I gave my patients for many years instructions on what to do when something goes wrong. And by the way, I never was on call, you know, for, I don't know, twenty five, thirty years. I had my own practice.

I never had an on call. My you've called my office, it didn't say call his beeper number if you got an emergency. My my line said, you have an emergency, go to the emergency room or call the office tomorrow. And that worked out just fine because there are so few rheumatologic emergencies. I know medical legally, you might have all your if, ands, or buts, but my point is I instructed my patients what to look for, and what to go to the emergency room for, and what to call me about.

That's a real important part of every visit. The journal PLOS, did an interesting publication on '76 patients with diffuse alveolar hemorrhage syndrome. Not surprisingly, again this was first off, this was a retrospective study, and sort of a single center cross sectional view. Not surprisingly, almost seventy percent of those patients had lupus. The other thirty percent had GPA.

But the point of the paper was that a third of these patients had concurrent pulmonary infections. And that's sort of, you know, to me a surprise. I've had many of these over my career, but I can't think of one even that it was alveolar hemorrhage complicated by pneumonia. And in their study, the infections were sixty two percent bacterial and twenty one percent fungal. And when they found hemorrhage on bronchoalveolar lavage, they were more likely to have been the ones associated with infections.

Three quarters of the infection and DAH, diffuse alveolar hemorrhage, had alveolar hemorrhage on bronchoscopy versus half the patients that didn't have it. So, a nice teaching point from an interesting obscure journal. Clinical Experimental Rheumatology published a nice full readreview, I think. Oh actually no, I had to get access. So, but it's a nice reference on mimics of myopathy, including drugs that can cause toxic myopathy, presentations of muscle dysfunction with weakness and elevated muscle enzymes that could be confused with any of the inflammatory myopathies, the idiopathic inflammatory myopathies.

So, you should look at this, but I'll just list for you the drugs that could cause myopathy that could be confused: glucocorticoids, statins, retroviral drugs, the antimalarials: chloroquine, hydroxychloroquine, colchicine, tacrolimus, cyclosporine, alcohol, amiodarone, and alpha interferon. If you look at my RK card at the rheumatology.com website or my chapter in Harrison's, you'll see the list of drugs that cause myopathy and myositis, and I can add to that list protease inhibitors, quinolones, checkpoint inhibitors, and a number of different cytotoxic agents including Gleevec, which is imatinib, something like that. Anyway, information about osteoarthritis. From the Journal of Arthroplasty, I think it was, a report about preoperative GLP-one agonists, in this case semiglutide, when used for one, two, three, or six months, had benefits in patients undergoing total knee arthroplasty. Specifically, the ones that had preoperative GLP-1s had significantly less adverse events, and that was point zero zero one.

And of course this is a retrospective study of seven forty five type two diabetics that were needing TKRs, that were on the semaglutide drug. And they did show that it was not just for non serious infections, which is what they mainly counted, but even serious infections like hospitalisable infections, SIEs or SAEs. For that, the benefit was only seen with two to three months of the GLP-one agonist, with a 75 significant reduction. Lancet had a nice journal a few letters to the editor about an article they published a few months ago, an overview article in 2025 about osteoarthritis, and the write ins were complaining, you you didn't endorse, you know, platelet rich plasma treatment for the treatment of osteoarthritis. Obviously these are probably orthopedists who believe in such literature.

The response back, I think, was instructive and smart and worth reading, and you can find the link and look at it. And they said basically, despite the popularity, and by the way, the income generating potential of PRP therapy, there are very few placebo controlled, high quality studies that would allow for them to even mention it, no less endorse it. And certainly I would not have done, mention it or endorsed it either. A review, a meta analysis of tramadol, you know, the bad news is we just don't have good drugs for osteoarthritis. Know, nonsteroidals, you're not supposed to use them, Tylenol supposedly doesn't work, gabapentin's are dangerous, really?

And tramadol is dangerous. Really? Well, a meta analysis of tramadol, six thousand five hundred patients, 19 placebo controlled randomized trials, show that yes, it does work with a very modest benefit in controlling chronic pain, and that is classified as low certainty evidence, but definite certainty about the doubling of risk for serious adverse events (an odds ratio of two point one three) and more side effects than benefit with tramadol, including nausea, dizziness, constipation, and somnolence. Where the NNH for nausea seven, dizziness eight, constipation nine, and somnolence 13. Meaning one out of thirteen are needed to treat it to get somnolence as a side effect.

That sounds about right. I'm using less tramadol like you are, I assume, but I still need a better option, Do we not? Speaking of opioids, tramadol being a weak opioid, the government I think it's a CDC report reported this last week that US overdose deaths have dropped significantly in 2024, and the trends are continuing in 2025. We're talking about opioid related overdose deaths from opioids, heroin, and especially fentanyl in the last ten years, peaked at one hundred and ten thousand in The US in 2022, dropped a little bit in 2023, but really dropped twenty seven percent to eighty thousand in 2024, with the same numbers look like they're being repeated for 2025. Basically, opioid deaths are down in all states except for Arizona, Hawaii, Kansas, New Mexico, and North Dakota.

Isn't Breaking Bad, wasn't that from New Mexico? The highest if you look at the map on where opioid deaths are, the Northeast, New England, Northeastern states, and Atlantic states. Lowest in the Midwest, Northern states, and the West. Okay. Hopefully, you're one of the good ones and not living in the high death rate areas.

But I think a lot of the education and policies have addressed this well. If you haven't read Malcolm Gladwell's follow-up to follow-up book on, Blink or is it this first one? He goes into one of the reasons why opioid deaths are higher in some states than other states. And the bottom line is that if your state requires opioid prescriptions to be written in triplicate, the numbers are way down. If they don't require triplicate prescriptions, the numbers are way up.

That's shocking to me. A retrospective vaccine study looked at their recombinant zoster vaccine, what we call Shingrix, when it's being used in rheumatic disease patients on disease modifying drugs, thirty two percent of whom were taking JAK inhibitors. And they compared the Shingrix vaccine in rheumatic disease patients, one hundred and fourteen, versus sixty five non rheumatic patients. Number one, basically no zoster reactivation. Number two, only one disease flare that required steroids.

The point being that our patients are at higher risk, that there's an adjuvant in the recombinant vaccine that could excite the immune system. This is now, I think, the third study that I've seen that says that it doesn't cause flares of the underlying rheumatic disease like rheumatoid or psoriatic arthritis, etc. Minor side effects were a little bit more, or were actually seen in only seventeen percent with the first injection, and twenty one percent with the second injection. And the side effects were mainly injection site reactions, headaches, myalgia, that sort of thing. In the clinical trials, it's like thirty to fifty percent.

But in the real world, I think those numbers are about right. Twenty percent is what I've kind of seen. Like the Cochrane review that I found this week that looked at cannabis. We had a treatise on cannabis back in December. A lot of reports I wrote about it, a compilation article in OnRoomNow.

This is a meta analysis from the Cochrane Review that looked at 21 clinical trials, 2,100 adults that were taking cannabis versus placebo for the treatment of chronic neuropathy nerve pain, and said basically, regardless of whether it was given as a THC prep or a CBD prep in trials of two to twenty six weeks, it was not effective. Not effective for chronic neuropathy pain. All right. EGPA. A retrospective study of EGPA and cardiac involvement.

Sure, cardiac involvement happens with EGPA, not so much with GPA. In this study of one hundred and three EGPA patients, thirty five percent had cardiac involvement with cardiac symptoms, with usual cardiac biomarkers. The most common was pericarditis in three quarters, cardiomyopathy with heart failure with or without heart failure in about half, myocarditis in thirty six percent, cardiogenic shock fourteen, cardiac arrest six, and coronary vasospasm eight percent. All found in EGBA patients. So you know we had a big campaign on APPs, nurse practitioners and physician assistants.

I got a few more reports. We're continuing the campaign into January. Here's a report about the use of APPs in dermatology care. It's gone up significantly, And it turns out that advanced practice providers are delivering a large amount of dermatologic care in The United States. Amongst all the care, it's thirty seven percent of care, and twenty seven percent of derm specific visits in 2020.

These dermatology APPs, their prescribing costs, or how much they spent or were giving out in prescription in dollars was a 140,000,000, in, I think, 2010 or 2013, and it rose to 952,000,000 by, 2022. That's all prescriptions. Specialty drug prescriptions rose from 24,000,000 in 2013 to 744,000,000 in 2022. That's a 46% increase by APPs writing for biologics and specialty drugs. And at the same time, while all this is going on, the number of MD derms going into the business was less than the number of APP derms joining dermatology practices.

So that's a trend that really reflects the difficulty in providing care to an expanding base. That's dermatology, where they've got a bazillion dermatologists, and they're relying heavily on APPs. I think we should be too. A 2024 cardiology APP, income survey showed that, APP salaries increased 15% between 2019 and 2023, the median being 123,000. In those practices that had APP programs, that APPs were leading the program as opposed to MDs leading the program, 90% or more of the APPs are working in outpatient clinics.

But in those clinics, two thirds of them are being deployed to manage lipids or to manage cardiac prevention strategies. Overall, where they were being employed, there were roughly two APPs for every three cardiologists. So another report from JAMA this week, actually from the AMA, said that one in three APPs will switch their specialty at least once in their career. And then obviously they are doing the switching switching without formal training just like they had when they went through their first career in specialty. They had no formal training.

And, you know, that's a problem. Formal training for APPs. The AMA has got a position against APPs wanting to have a better a push towards expanding their scope of practice so that they can be more independent. The AMA is against that, saying that the survey data that they've done show that APPs depend on MDs for mentorship and training. So they're opposed to removing physician supervision or these collaboration requirements for non physician providers.

So, know, again, they say removing physician supervision or collaborative requirements carries a risk of undermining the quality of care and patient safety. They actually don't have data for that. But that's their impression, given that there's problems with training and that there is this issue of switching. And they provide as proof that over 150 bills were introduced into government last year that were defeated in 2025, and there seems to be no signs of a 2026, let up in this perennial push to expand scope of practice, which again, the AMA says, is inappropriate. I don't know that I agree with that.

I also wrote this past week about APP independence, and it is a it is a big issue amongst APPs. That's it for this week's podcast. I want to point you to both social media and the website, where you can see the Room Now Live pre learn video by Doctor. Mike Putman. Mike is our pre learn director, and he's put up, I think, five of these pre learn videos along with pre learn assignments, along with the actual reading that you're supposed to do prior to coming to the meeting.

So, you get to the meeting, you're prepared and the lectures are short and the discussion is really great. But Mike's done a great job. We put one of these up there for you to see if you're undecided about whether or not to return to RheumNow Live either in Dallas or online. You can look and in this pre learn assignment he goes over the pre learn materials for vasculitis and autoimmune disease as provided by doctors Nancy Olsen, who's going to talk about the SMILE study and hydroxychloroquine, Doctor Matt Baker from Stanford talking about Sjogren's disease and advances, and Clay Cockrell talking about small vessel vasculitis. Check it out.

I think you'll like what Mike does. It may be another good reason to go to rheumnow, live. Rheumnow. Live to register. Take care of yourselves.

Bye bye.