QD Clinic - Week 5 Save

Hi, this is QD Clinic brought to you by RheumNow Live. I'm Jack Cush with RheumNow. QD Clinic as in daily cases from the arthritis clinic. In these series, we discuss interesting things that happen on a daily basis in the clinic that are things that we could talk about that I'm sure are happening to you. So my case today is in fact about a 78 year old rheumatoid arthritis patient who and the question is or the case of the title would be, I'm having surgery.

And the question is, what do you do with arthritis medicines in someone who's going to have surgery? Specifically, a rheumatoid patient on a biologic, on methotrexate, or any other kind of DMARD, on steroids, on nonsteroidals, aspirin, etc. So the rules are pretty simple. And most people do this wrong. Surgeons are always doing this wrong.

They think that if you're on a biologic, you're going to impair wound healing. There's no evidence of that. Wound healing is largely related to risk of infection. Wound infections, which all patients are at risk for, especially patients on steroids, are what cause wound healing problems. So you want to lower infection risk and whatnot, but the research that's been done on it, there's been a lot recently, says a few things.

Number one, stress doses of steroids are no longer necessary. They don't even work. If you're on steroids, you continue on the same dose the day of surgery, the day after surgery. Stress dosing is no longer needed. Number two, aspirin nonsteroidals, aspirin should be stopped a week before, nonsteroidals should be stopped, you know, five to seven days before, and you can resume a nonsteroidal again when the surgery is over, maybe the day after surgery, as long as there's no bleeding issues or renal issues, can resume the nonsteroidal quickly right after surgery.

Number three, DMARDs. DMARDs should be continued throughout surgery. And there's a lot of reports that say patients can continue on methotrexate, Arava, again, some of these really being Arava, really long half life drug, sulfasalazine, hydroxychloroquine, azathioprine, tofacitinib, all of them. There's really no reason to stop, an oral, conventional DMARD in someone who's having surgery. However, surgeons will wig out over this.

They'll, I mean, they'll lose their mind, they'll hang up on you, they'll think you're a nut job. So what do you do? I mean, honestly, if if the surgeon is willing and take to will take your advice, continue the the the D Mart and don't stop. You think the surgeon is really skittish, tell them stop the DMARD a week before and start it a week later. No one's gonna be harmed by that kind of mentality.

But again, you do need to have to know your surgeon and who you're dealing with and whether they'll take your advice fully or not. And then the easy part is the biologic. The rule is stop the whole biologic for one dosing interval. So etanercept, be off for a week. You know, weekly tocilizumab, be off for a week.

Monthly tocilizumab be off for a month or actually maybe a few weeks. The idea is you don't want to give the surgery or have the surgery when they just got their dose of a biologic. You didn't get a Remicade infusion or any kind of infliximab infusion on Monday and having Wednesday having a total hip replacement. You should wait a week or two. You wanna be on the nadir as far as blood levels.

You wanna be but you don't wanna be washed out because research shows that when you have them off for a really long time and you wash them out, guess what? They flare, inflammation takes over, and risks go up. Bad outcomes including infections go up. So it's okay to be on them, be off them for one dosing interval, offer one week, two weeks, usually works for most patients. You could say four weeks for everyone and that would be a little bit of a risk, but I would say really two weeks for everyone and probably the smartest advice if you had one rule.

But the rule by many societies is one dosing interval and you restart when the sutures come out. So assuming there's no complications of surgery, there's no bleeding, there's no wound infection and the sutures are coming out, boom, you start the biologic right away. The biggest mistake made is when patients do not have their biologic or DMARC started until six months after surgery. And guess what? By then, the patient's a mess and you've contributed to the failure of the arthroplasty, failure of whatever major surgery was done.

Do these rules apply for dental surgery, eye surgery? No. But then again, there are no good rules for dental surgery and eye surgery. There I would hold the nonsteroidal and and the bleeding potential. I would I would otherwise not change the use of a DMARD or biologic.

I would continue that for most eye procedures unless they're gonna be in the OR for five hours. Then what I just told you, those guidelines are for major, operating room kinds of surgery. That's it for this week at RheumNow clinic, QD clinic. Tune in tomorrow for another one. Welcome to QD video brought to you by RheumNow live.

Rooms like us go to meetings like this, roomnow.live. Check it out. Our case today is called the undertreated RA patient. She's a 28 year old female who's had rheumatoid arthritis for about three and a half years. When she was first diagnosed, she went to a rheumatologist who put her on methotrexate, put her on some low dose prednisone and non steroidal.

And then in the next two or three years, the patient sort of went in and out of care based on insurance, would occasionally entertain the idea of going on a new therapy or a higher dose. And even though the methotrexate was, worked up to a total of twenty milligrams per week, it would intermittently go between ten and twenty based on who was prescribing, sometimes a primary care, sometimes a rheumatologist. Rheumatologist. And basically, this is the undertreated RA patient coming to you, a year and a half to I'm sorry, three and a half to four years later, and you're now left to right the ship. And it's not pretty, meaning that we're looking at positive prayer sign, contractors of the PIPs like this, swan neck deformities, a limited grip.

The patient's unable to make a full fist. It's about as far as she can go. She cannot get her fingers into her palms. She has evidence of erosions on X rays. Someone even did an MRI.

I'm not sure what that was about. Showed more more erosions, not surprisingly. So she comes in at this point undertreated with feeling very poor pain on a zero to 10 scale of seven and hurts kind of in many places, fingers, ankles, wrists, knees. And the question is what are you going to do? She's currently on ten milligrams of prednisone I'm sorry, ten milligrams of methotrexate a week, no prednisone, and meloxicam once a week.

So I think you need a strategy. And my strategy for dealing with things like this is number one, start all over. Clean the slate, do a total reassessment. If you think you need x rays, do them. If you think you need serologies, do them.

This patient has positive rheumatoid factor and CCP. I'm gonna check and see how high because obviously a higher titer seropositivity means more and is more dangerous in someone like this than a barely positive rheumatoid factor or CCP. Could you have another diagnosis? And I think that that's possible, but honestly not likely, and you might want to consider that. Number two, forget the past, meaning don't dwell on the fact the patient has been undertreated.

Boy, your doctors had no idea what they were doing. Boy, you really screwed up by not going back and not being steady with one doctor. Boy, you know, so this it's built milk, it's gone. Basically, you declare to the patient you have really severe disease. The ability to get back function and improve pain and reduce swelling is going to be limited.

The ability to correct deformities is going to be close to nil. So again, forget the past, but tell her where we are. Tell her in no uncertain terms, this is mild disease that merits any kind of therapy or this is aggressive disease that merits only aggressive therapy. She has aggressive disease. So she's going on methotrexate and some other combination agent.

She can go on triple DMARD, she can go on pills and take a JAK inhibitor plus methotrexate, She can go on methotrexate plus a biologic, hopefully a TNF inhibitor to start with. Given those options, this patient prefers pills. I won't say what she got into because ultimately it's going be determined by her insurance what pills she's allowed to take, what biologics she's allowed to take. But she has aggressive disease, we're gonna be very aggressive with her. We told her that.

That means she needs to be seen here every four to six weeks. If she's not returning if she's not responding right away, we're changing right away. I'm not waiting six months for her to have a response to any therapy I use. If she's not hitting a home run or a major change at six weeks, well, guess what? We're changing.

Right now her C. I. Score is 20, and she has 10 swollen joints and she's one of these patients who actually doesn't say ouch when you squeeze on her joints. So she's got a lot more swollen joints and tender joints which which scares me even more. But the idea is if she at six weeks, if she's not made a major change, a 50% reduction in her C.

I. Score, a 50% reduction in her swollen joint count, we're moving on to some other therapy. And you need to set goals like what is expected as a result of this more aggressive approach far as mobility, as far as damage, as far as the long term consequences of disease driven by inflammation. And tell her that the reasons you have to be aggressive is that you can avoid further long term consequences. Not sure what we're going to do as far as deformity.

Deformity is often a train that's left to station, meaning once they start having deformities, you can use the most aggressive therapy available and it's not going to change the natural course of disease in that deformed joint. That early Swan neck is going to become a fused Swan neck at some point, doesn't matter whether you control synovitis and drop their sed rates and CRPs to zero. So again, maybe it's possible, but it may not be possible. These are the kind of cases that, make you lay awake at night. Why didn't this person get more aggressive care?

And what can do to change the outcome? Tune in for more QD videos. Take care. This is QD Video and I'm Jack Cush. QD Video is brought to you by rheumnow.

Live. Curious mind bending rheumatologists who like to teach will show up at room now live in Fort Worth on March 22. So today's case is zero to sixty in two months. This is a 41 year old gal with psoriatic arthritis. She also has a diagnosis of psoriasis, pretty widespread I would say, has had fibromyalgia in the past, been treated with Arava, Cimzia, Aleve, Tramadol and Trazodone.

Seems that she was treated by a previous rheumatologist, her insurance changed, she lost the doctor, she had to stop taking her last DMARD which happened to be cerdulizumab and, she comes to me having not seen a rheumatologist in about, twelve weeks. When I see her, she's a gigantic mess. I mean, she's a polyarticular, poly synovitis, you know, three hours of stiffness. Her CRP is two ten milligrams per liter. She her her CDAI score, I use a gas score, is equal to a CDAI score, GAS standing for global arthritis score, was 45 which is like gigantic.

She had I believe 14 swollen, 19 tender joints. And when I saw her she's just taking Aleve Tylenol number three and that's it. And the question is, what can you expect from reinstitutional therapy? Again, twelve weeks she's been without Cimzia. Again, she's got really, really bad numbers of presentation, a lot of juicy joints, very active skin disease.

And so what did we do? We put her back on methotrexate. That seems like the right thing to do. She has no real contraindication of methotrexate. We gave her the choice of going back on a TNF inhibitor, she'd only received one, or going on, tofacitinib, and she chose to go on, she really wanted to be on pills, she said she's having a problem with the shots.

So she goes on the pills. We see her on 12/13. She comes back on six weeks later. And what would you expect six weeks later when you see this patient? Well, she had a dramatic response.

Her skin basically all went away. I'd say she had about 10% BSA total body surface area as far as her psoriatic lesions including her scalp and behind the ears. Her joint count went from nineteen and fourteen tender and swollen down to, survey says, ten and six. Her gas score, C. Dye score went from 45 to 11.

She still has active disease and she's about to break the threshold, probably soon into getting into low disease activity state. And her labs are pretty bad. She has marginally elevated sed rate, I'm sorry, rheumatoid factor and CCP 16 and I think the other one was 20 something. Her ETA, her fourteen thirty three ADA Identra was really high at two point six nine nanograms per milliliter. But we do know that that can be elevated in up to fifteen-sixteen percent of patients with erosive polyarticular psoriasis.

Is this RA? It looks like RA, it's polyarticular, but her other seropositive markers are relatively titer. She's got very bad skin disease. This is very bad polyarticular psoriatic arthritis. I guess the point here is that aggressive treatment can result in aggressive, reductions in disease activity in inflammation really overnight.

And again, that CRP that was two ten is now 10. The ESR, what was it? It was a 100. I think it's 20 something at this visit. I'm So making a pitch for aggressive disease merits aggressive therapy.

I'm making a pitch for rapid turnaround times and assessment. The idea of waiting six months for someone to respond is a gigantic mistake. Mistake. And often that's like, let's see what happens and whatnot. No, many of the drugs we use have a zero to 60.

It's really quite impressive. And that's what happened here in this case. This patient had, again, almost a 75% reduction in disease activity in six weeks. It is expected that she's going to continue, so I'm going to keep her on the same course. We did not need to use any steroids in this individual.

She's just on methotrexate, which she just started six weeks ago, and we're going to keep her on both drugs until she gets into full remission. And we'll follow her. So again, cue six weeks until they get better. If they're not better in six weeks, dramatically better after the first six weeks, think about changing. Why not?

Why prolong the misery? If they don't hit a home run within six weeks and have a home run response, are you looking for just a little bit better in someone who's got severe polyarticular RA or PSA? I think not. That's it for QD. See you next time.

Hi. This is QD Video brought to you by rheumnow.live, the next best meeting in rheumatology for rheumatologists like you. Today's case is called aches and pains. This is a 58 year old gal who has rheumatoid arthritis. She comes to me doing really well taking a small molecule inhibitor, doing great actually for a number of years, but today she comes in complaining of aches and pains.

In fact, the last few visits, it's been aches and pains. No real swelling, no major one joint that's standing out, just quite quite not her same. The fact is that she's got ten minutes of stiffness. She has a TJC zero, SJC zero. She's doing great on her current RA therapy and has been for really two or three years.

But the aches and pains, what's that all about? Well, everything is great except for when you look at her survey form like this and you can get this from RheumNow, free arthritis clinic survey form that's useful in assessing patients. And everything is great except for sleep that she marks as only fair. When you get into the weeds and you ask for some detail, she falls asleep easily, but she wakes up 50 times at night. I say, No, really.

How many times do you wake up? A lot. And I say, That can't be 50. She says, Well, at least 20. I said, 20?

I said, That's like sleeping five minutes at a time. And she's never done anything about it. She, mainly because she doesn't want to take sleeping medicines because she doesn't want to get addicted. And I said, the interesting thing about people who don't want to get addicted is that they have no chance of getting addicted. Meaning that if you gave them hydrocodone or codeine or a sleeping pill, they wouldn't, they can't.

For the same reason that people who are afraid of guns don't buy guns. People who are afraid of haunted houses, don't go to haunted houses and etcetera, etcetera. So again, I like when people say I'm afraid of getting addicted, means that they won't. And you give them some rules and you tell them the safety of a medicine. So in her, sleep is the reason why she has aches and pains.

No. She doesn't have tender points and she doesn't qualify as full fibromyalgia. She's more of a myofascial pain syndrome due to bad sleep. And she has numerous symptoms that you can see on her survey form that say that she has bad sleep and that includes, she's got a lot of fatigue, she's got poor memory, she's got myalgias and weakness, low back pain, she has occasional headaches, a little depressed she says is sometimes dizzy, all related to her poor sleep. She's got no other good reason for those things.

She slept better, she'd feel better. Sleep bad, feel bad, sleep great, feel great. So number one, you have to explain and let the patient know these are the symptoms and the ones that really escape most of you and most of the patients are poor memory or strange numbness. Numbness that doesn't follow an anatomic distribution, strange neurologic sensations, is all due to bad sleep. Yet everyone's doing EMGs, nerve conduction studies, nerve biopsies, neurology consults, so I'm just you should work on fixing their sleep.

So again, the idea is you can do a few things here. If it's a man with a sleep problem, they all need to be referred for a sleep study because the risk of having sleep apnea is incredibly high, and they don't have to be obese to do that. If they're a woman, you can take a stab at it with a simple sleep aid and 12 Steps to Better Sleep that you can find as a handout, a download from RheumNow, including rule number five, your bed is your special place for sleep only. Do not read or watch TV in bed. Your bed should be free of remote controls.

No food, children, pets, snoring, spouses, computers, magazines or cell phones. I say it a million times a day so that's why I memorized it and it's just not even memorized, it's there. But you have patients like this who refuse to, you know, take medicine and you have to explain to them that this is the solution. If they broke their leg, they would go to an orthopedist and get it set. If they've got a sleep problem, they need to go to a sleep doctor or take a stab at it.

Use a simple over the counter preparation. In her, we just wanted to use a light muscle relaxant, Tizanidine. You could use a number of different things including low dose Elavil or trazodone or a number of things. And again, you need to discern whether it's a problem falling asleep for which, know, Ambien still probably one of the best drugs, Lunesta, benzodiazepines, those are really good at making people fall asleep, making people shut down, but they need to learn how to shut down that brain that's going, going, going. If they have problems staying asleep, it's easier.

You can use the amitriptyline, the trazodone, the muscle relaxants, cyclobenzaprine, etc. To keep them asleep. But again, the patient needs to buy into the fact that sleep is the problem when it comes to muscle to aches and muscle pains and strange sensations. That's today's case. We'll see you tomorrow with another good one.

Hi. This is QD clinic brought to you by rheumnow.live being held in Fort Worth on March. Fort Worth has it all. It's a great walkable town. It's got two of the best museums in the world, the Kimbell and the Aman Carter.

It's got the biggest honky tonk in the world and Billy Bob's. It's there's a ton of things to do including the stockyards. It's a great town for a meeting. Check it out. Our our case today is called, who gets a vote?

The patient or me? It's a story of a 35 year old Latin female who's had rheumatoid arthritis for about ten plus years. And she's been around the horn. She's taken a lot of different agents. She's had very severe refractory disease.

She's got a lot of deformities that she's left with, including a lot of subluxed joints, swan necks, boutonnieres, a few telescoping digits, and saw, you know, subluxed MTPs. She's been around the block on, three or four different DMARDs, including methotrexate, arava, and sulfasalazine. She's had two TNF inhibitors in the past. Avatacep shots she's received. A lot of this was really without much benefit.

And more recently, she's been on, a combination of methotrexate, leflinamide, and taking, infusions of tocilizumab. And she was doing well for about a year or so. In the last two visits, she shows up. She's taking, the same medicines. Nothing's changed.

She's getting her infusions on time every four weeks. Her milligrams per kilogram dose is almost seven. It's about six point nine. In the last two visits, she's had 11 swollen and then 13 swollen joints, and then obviously many more tender joints. And she's really a bit of a mess.

And when I see her, I say, you know what? It's time to, you know, pull the handle on this dump truck and make a change. And, you know, the question is, who makes that decision? You know, it's my job to be dissatisfied with an unacceptable number of swollen joints or an unacceptable level of a CDAI score or rapid three score or in my case a gas score. All of them were high.

But ultimately you got to convince the patient that's in the right and important move. I laid out the options for the patient, and I wish there are several, and you could list those in your head, both pills and shots and infusions. And instead, I told her that or or we could increase the Actemra dose from six point nine adding another hundred milligrams where she was gonna be eight point three or eight point four milligrams per kilogram. And she said that's what she wanted to do. And I said, really?

I said, I don't think this is a good idea. And she said, yes. And, of course, she came back and I told her, we're making a decision in six weeks. I'm sorry, in eight weeks after your your your two infusions. And she came back and I just saw her the other day.

And what would you guess is her swollen joint count? Drum roll, please. Yes, it was one. And I was wrong and she was right. And the beauty of that is giving patients a voice in their decision makes them motivated to get better, gives them a positive attitude.

I don't think that going from 13 to one joint can at all be a placebo effect, but I don't care if it was. I just like that I'm seeing only one swollen knee and nothing else, and she's very happy with how she's doing. So again, I think it is important to even when, you know, there is a fork in the road and you think you know that the right choice is to go this way and not that way and the patient wants to go that way, you know what, it's okay to let the patient go their way, but set some real limits on it. Meaning, what are we looking to achieve that would say that this is a success? What's the time frame in which we're gonna make a decision?

It's gotta be fast unless the drug itself is an incredibly slow working drug. So I like the idea of giving the patient the choice, setting rules for reassessment, and coming back and finding out that she was right and I was wrong. It was a good day for both of us. That's it for QD Clinic. We got more coming.