Influential Rheumatoid Factors(5/8/2026) Save

It's 05/08/2026. This is the RheumNow podcast. Hi, I'm doctor Jack Cush, executive editor of roomnow.com. I'm back at the podcast. Last week, I was away lecturing, so I put up a lecture.

It was called great lectures, great presentations. I hope you enjoyed it. Let's do a little catch up and talk about what's new and exciting in the news. I'm gonna lead with, something from Clinical Infectious Diseases, a journal that did a survey of three eighty internal medicine residents from 41 different programs that had a response rate of about seven percent. And they asked them, Why aren't you going into infectious disease?

Apparently, there's a shortage of ID specialists. Apparently, fellowship applications are down for infectious disease. And, you know, what they came up with wasn't surprising. It sounds like the same old story that we have in rheumatology, that interest in ID as a career has gone down. And why?

It's because there are significant issues that still remain. Lack of exposure to infectious disease during PGY1 and PGY2. Lack of exposure to outpatient infectious disease clinics. Lack of exposure to ID related research. When those were present, people more likely went into infectious diseases.

And I put it up because it begs the question, what are we doing in rheumatology? The good news is that rheumatology fellowships, applications are up, and that's great, and we're filling all our programs. Not in pediatric rheumatology, that's a gigantic problem that needs to be addressed. But we still have a tremendous shortage of rheumatologists, and that's going to be so for the future. And how are we going to, you know, overcome that?

In that report of internal medicine residents, they cited reasons for not going into I. D. Was low pay, long hours, lack of a procedure. Sounds like rheumatology. And you know, I was thinking maybe I should complain about this, maybe I should make all of you responsible for fixing this problem, and I went to the ACR website and did some searching.

And you know, the ACR has had a substantial effort in this regard. There's a number of different programs that are sponsored by the Rheumatology Research Foundation and by the ACR, including a Choose Rheumatology scholarship that offers funding for scholarships and training for underrepresented, medicine background individuals, or people from underserved areas who want to go into rheumatology. And, scholarships are for them to attend ACR and learn more about, rheumatology. There are student and research, student resident research awards that are substantial in their amount, and they can be for one year or two years. There's efforts being made to promote pediatric residents into going into pediatric rheumatology fellowships.

There's medical mentorships and other programs from the Rheumatology and Research Foundation. The point is, we should all be interested in this. I think that we can fix this at the grassroot level, meaning encourage people to do a rotation with you, shadow you, do a project with you, and then you show them how wonderful rheumatology is. That's the surefire way to get people in. It would help you if you knew about these programs from the ACR, and I'm gonna ask the ACR to make a big pitch to all of us, to let all of us know about how we can overcome the future shortage of rheumatology for society.

It's a big problem, and I think the first step is identifying the problem. The next step is having programs to deal with it, and we are halfway there. Next, comorbidities are big no matter what the disorder is. A systematic review of difficult to treat RA (D2T) RA using the EULAR definition shows significant associations with comorbidities that make D2TRA worse. What were the comorbidities that made it worse and were most linked?

Smoking, obesity, fibromyalgia, and depression. Meaning it's not always the inflammatory things, right? It's sometimes the fibromyalgia, and functional things that need to be paid attention to when dealing with that difficult patient that hasn't responded to two or three advanced therapies. What about rheumatoid factor? I like Rheumatoid factor was in the news this week.

Two interesting reports. A thousand patient cohort of psoriatic arthritis who are having serologic tests annually. I don't know. Isn't that a special kind of stupid? Why are you doing serial rheumatoid factors on people?

Nonetheless, they found five percent who are rheumatoid factor at baseline, sixteen percent overall. That's a historic number that does that they basically reproduce. Sixteen percent of PSAs are going to be seropositive. Those are the ones who are to have bad arthritis, or worse arthritis, and more polyarthritis, more RA like variant of PSA, right? But again, the interesting thing is that rheumatoid factor, when present in a PSA patient, reduced the odds of: one, achieving MDA with less half of them getting there, and it increased the odds of a discontinuation or failure of biologic DMARR therapy.

So it's a marker for more severe PSA when it happens. Remember I talked last week about, or last time about rheumatoid factor, and then long ago about rheumatoid factor in EGPA being a bad marker there. There's something to this rheumatoid factor thing. I'm glad it was invented in the 40s. But then there's another report this week about that reviews rheumatoid factor as being a potential marker of cardiometabolic disease and hepatic disease.

And it's a really nice review, said a lot of things I didn't really know outside of rheumatology, that rheumatoid factor by itself, without having an association with rheumatoid arthritis, is associated with more atherosclerotic disease, more MI, more coronary artery disease, more ischemic stroke, more obesity, more insulin resistance, more type two diabetes, more metabolic syndrome, and more liver disease. Again, this rheumatoid factor thing, I wish we knew more about it. So, two exciting pieces. Lancet Rheumatology did a real world study of two sixty seven new DMARD starts, and this is a study from Taiwan, and it compared people starting on tofacitinib or TNF inhibitor. 145, 122, unselected, real world, meaning why did they go on TOFA, as opposed to going on a TNF.

But nonetheless, it's you know, they did some adjustments and whatnot. And this study comes on the tail of my last podcast where I talked about a Chinese study showing that a JAK inhibitor was superior to methotrexate and more cost effective. Here we have a JAK inhibitor against a TNF inhibitor as their new DMARD starts. And they had the similar efficacy. But then their long term safety was no different either.

Adverse event rates. Serious adverse event rates twenty percent in both groups. Mace zero versus 0.8. Cancer two percent versus 0.8. Deaths one point four percent versus three percent.

SIE serious infectious events a little more with TOFO thirteen percent versus eight point two with TNF and clearly more H zoster. So maybe those more SIEs were all the s the zoster difference 12% versus 3%. Again, this begs the question now with tofacitinib going generic in 2026, what is your best first drug? When are we going to start considering JAK inhibitors as potentially first line therapies? I don't know, I'm just kind of stirred up, caused trouble, but I and I know there's guidelines that speak otherwise, right?

And the question still is, you know, what are you going use first? I guess the next question is, if you fail a TNF inhibitor, what are you going to use next? So that was published this week or two weeks ago. The SELECT switch study done with upadacitinib versus adalimumab in refractory RA after a TNF inhibitor, showing that again patients responded better to switching classes and going to the JAK inhibitor as opposed to cycling and going to another TNF inhibitor. Again, do you fight or switch?

Do you cycle or switch? The EULAR guidelines from 2025 say you're one and done. Use a drug, move on to the next class. Even though you got five options amongst TNFs, you know, four or five options amongst Jacks, three options in two options in IL six. The idea is change classes.

You got enough choices. That and and that's is borne out by good evidence. Another report this week looked at B27 and testing rheumatoid factor in psoriatic arthritis. What about looking for B27? So this is a study of Caspar, it's a cohort of PSA patients, three thirty three in whom they did B27 testing.

Twelve percent were B27 positive. Were those people different? Oh, yes, they were. They had earlier onset disease. They had more axial disease, more enthesitis and more FIB4 scores that survey questionnaire that identifies people at risk for hepatic fibrosis.

B27, however, had no influence on the sex of the patient, dactylitis, uveitis, treatment responses, comorbidities, or the number who went on to develop D2T PSA. So, you know, I've always said B27 clearly infant wherever it is, influences the risk of axial disease, sacroiliitis, starting with sacroiliitis, And then also the risk of uveitis. And then other studies argue about other points. I think that this data sort of supports that contention that I've always taught. Osteoarthritis has been in the news.

A random this is sort of an idiot trial. You got bad moderate to severe hip OA, Kellgren Lawrence grade two, three or four. What should you do? A hip replacement or a program of exercise? I thought that was kind of a like, why would you even do that study?

Well, they did. It's a randomized controlled trial, 120 patients. You either had hip replacement and a rehab program or an exercise program and they looked at twelve month outcomes. As you would expect, as I expected, it was a slam dunk on Womack outcomes, pain outcomes, hip survey score outcomes, it was a slam dunk in favor of surgery. More importantly, the ones who were treated conservatively with just exercise, thirty eight percent of them went on to need total hip replacement during the surgery.

So if you're wondering, maybe I can hold that off in a few people or you know, you know, patients who are confronted with the need for joint replacement are sometimes a little reticent to do so. And by the way, you're looking at one of them right here. You know, I had end stage knees like thirty years ago from football injuries and being overweight and whatever. I was bone on bone medially for twenty five, thirty years, took medicine every day for it, gimped around, people want to know what's wrong with me. But, you know, I I kept doing it.

And it took me two years of great advice from a great surgeon saying, dude, do the surgery already. And it was life changing. So anyway, this kind of data should help you to encourage your patients to get arthroplasty when it's in fact going to be beneficial. Another big report was a JAMA review on knee pain. Now, I know you know a lot about knee pain, we all do, we see a lot of it.

It's kind of an interesting review. I must say it's got a lot of great facts in there that it might be worth pulling it, downloading it, scanning it. I think you'll find some really good teaching points for, for yourself and for when you're educating trainees. And so, here's some of the numbers: six fifty four million patients worldwide have knee pain. It accounts for at least five percent of all outpatient PCP visits.

Twenty five percent of knee pain is patellofemoral pain, you should suspect, in people under the age 40 who are physically active, who have anterior knee pain, especially on squatting. Anterior knee pain on squatting is ninety one percent sensitive, 50% specific. Alright, I like that. Patellofemoral OA. Meniscal tears account for about twelve percent of knee pain in adults, and you know the procedures to diagnose that.

By exam that is. And you can order an MRI, but remember we had that MRI a few weeks ago that showed us MRIs of the shoulders in people over the age of 60. Everybody had rotator cuff tears showing it's totally useless. As we get older, you're going to find abnormalities of the menisci, as well with MRI. So what can you do by joint exam?

Well, they the numbers that they quoted, I think, I liked because it kind of reinforced my thinking. The best test, the one that we were taught, is the McMurray test. You know, flex the knee, and then while torquing the knee medially or laterally, valgus or varus, and extending it, you get a click or a pain in the damaged meniscus inside or outside. And but you know what? Not so good.

61 sensitive, 84% specific. I can't say that I've ever felt the click. I often have gotten the pain. What I like much better is medial joint line tenderness or lateral joint line tenderness. 84% sensitive, 83% specific for diagnosing meniscal tears.

Check out that citation. I think you'll find it interesting. Data coming out of the AACE meeting, this is, I think that's an endocrine meeting, was the Freedom real world study that looked at atypical femoral fractures in patients taking denosumab versus a bisphosphonate. In a fairly large cohort, the denosumab risk of atypical femoral fractures, AFF, was low low low, Less than one in a thousand and same for bisphosphonates and denosumab. Denosumab zero point eight nine per one thousand, and bisphosphonates 0.82.

But they had no active treatment or other kind of comparators, and they excluded patients with comorbidity. But these numbers are in line with the historic numbers of atypical femoral fractures with bisphosphonates, about ten per ten thousand, one per thousand. So while this study said it's not increased with denosumab, it basically says it's the same. And and again the point is that it's low low low, and if you think someone needs to be on denosumab or bisphosphonate, the benefits of preventing fracture, I believe, far outweigh the risks. Now you know the patients who have high risk that you may not want to use those drugs, and that's another report another time.

EULAR recommendation on physical activity and arthritis sounds like a, you know, a no brainer. Worth looking at. You know, four overarching principles, and I think it was eight or nine recommendations. You know, I I like the third or or overarching principle. It said that cardiovascular fitness, muscular strength, flexibility and neuromotor performance evidence for all of those benefiting patients with both inflammatory and non inflammatory arthritis, including during periods of active disease.

And then their recommendation was: people with arthritis, all forms, should aim for at least one hundred and fifty minutes of moderate intensity, or seventy five minutes of vigorous intensity aerobic activity a week, or some combination thereof. Plus, muscle strengthening on two or more days. Short bouts of intermittent activity throughout the day are valid and accumulate meaningfully lower benefits for patients, especially as far as pain, fatigue and functional problems. You know, I've often thought, and I never did this in my own practice, I should have, but I always thought about putting a big banner out in the waiting room for that just said, be stronger. Strength is what matters.

We don't talk enough about being stronger because and my point is, when you hurt you do less. When you do less you get weak. When you get weak you hurt more. It's a vicious cycle down the toilet when you're not doing well with musculoskeletal problems. But if you can work on getting stronger, you can endure more with less pain and have better functional outcomes.

Strength and, again, physical activity should be encouraged. I don't know if you looked at or heard about, but I have a podcast for dermatologists. It's called Derma on RheumNow. It's kind of the same topics I cover here, but there are ones that are germane to derms. Please tell your derm colleagues, check this out.

I like the Rheum podcast, you'll like the derm podcast. You know, we talk about PSA, cutaneous lupus vasculitis, high radionitis, dermatology drugs, etc. I want to end with nurses. At the May, the US Department of Education finalized its rules coming out of the BBB, big bad beautiful whatever act that the administration put up, that really substantially cut graduate loans for medical students to cap them at 200,000. There was no previous limit.

It's substantially less for nurses and nurse practitioners and physician assistants physician associates. This is a gigantic problem. And they finalized it even though they had input from all the societies. The American Nurses Association response to the DE, Department of Education's final rule, said that they were profoundly dismayed by the DOE exclusion of nursing from being having granting a professional degree like doctors, which then gives them less funds for their training. That's gonna cut into the number of nurses, nurse practitioners, and PAs that we have.

Again, they had hundreds of thousands of people voting against this. They just went ahead and made the idiotic decision. I don't know if you saw, I wrote a blog this week called Nurses Calm Through Chaos. It's a love letter to all the nurses that we work with, that make us look better on a day, every day, in our, you know, protean days of starting out in medicine to our current mature delivery of expert care. It ain't happening without nurses.

Great care begins and ends with nurses. And I'm talking MAs, LVNs, LPNs, RNs, BSNs, PhD RNs, NPs, and the like. Again, their contributions to the welfare of our patients cannot be extolled enough. Congratulations, it's Nurses Week. I don't know if you've seen, but I have been doing a series of videos called Advanced Practice Rheumatology.

These are meant to be sort of starter courses in evaluation, lab testing, RA, steroids, methotrexate, etc. I think there's about seven of them up right now. I got a total of 13 to do. I would encourage you to tell your new trainees, your residents who are rotating, your new hires as NPs to take a look at these. It'll help them get started.

At least they'll know what I think is important when starting out in rheumatology and learning the hard stuff. Hope you enjoyed this podcast. We'll talk next week. Tell your derm colleagues about Derm on RheumNow. Thanks.