QD Video - Week 10 Save

This is QD clinic brought to you by rheumnow. Live. Interactive networking and streaming. That's the tagline for this meeting that starts on Friday. You can register online and watch it online.

Our case today is called When to Stop Methotrexate. A 50 year old gal who's had rheumatoid arthritis for three years has been on methotrexate for nearly three years. She comes in, she's doing well. This is a follow-up visit. She asks the question, How long am I going to be on this drug?

I know we hear that all the time, often at the first visit, often when we first prescribe a medicine like methotrexate, and there the answer is unsatisfyingly easy, meaning I don't know, probably long term. I always tell my patients it's going to be a year. If I'm committing to methotrexate, it's likely to be a year. Talk to me when you've had a year or more of remission and then we can talk about how long you'll be on this drug. And that's what this patient has done.

She's had more than a year of remission. She wants to know how long am I going to be on this drug. So some patients can go off therapy. The chance, with rheumatoid arthritis, the chance of being on a drug free remission is less than ten percent, maybe ten percent in some studies. The odds can go up, in certain people and maybe as much as fifty percent, meaning that when you stop the therapy, only fifty percent will recur or flare up again.

So how do you know what to advise? I think you should number one know the ACR guidelines on this, which I believe are right. And that is if you have remission, you never stop therapy because the odds are so much against long term remission without therapy. The second rule is if you're in low disease activity, can lower therapy but never go off of it. So if you're on a combination, might be able to ratchet down to just one drug or ratchet both of them back to half dose.

The idea is you can reduce but never go off with low disease activity as measured by a formal measure. So my role is, again, show me a year of remission and then we can go off the medicine, then your odds go up, but they don't go up a lot. They go up from ten percent maybe to twenty percent if someone's in remission with, you know, zero across the board if you're looking at the map of their CDAI scores or their DAS scores or their, in my case, the GAS scores. Again, I think that patients would want this to happen as soon as possible. So you need to have some rules that will change the odds, change the odds from ten percent or less to fifty percent or more.

How do you change the odds? As I said, the longer they're in remission, the greater the chance they have of going off the therapy or taking less therapy, let's say. The odds go up if it's early disease. The odds go up if it's a seronegative rheumatoid picture, meaning they're both seronegative for RF and for CCP. The odds go up if they're not a smoker and they're not obese.

And the odds go up if they lead a healthy lifestyle. Each of these will ratchet up the patient's odds of going into true drug free disease free remission once they stop their methotrexate or other DMARDs. We can be talking really about any DMARDs in this situation, but methotrexate is a really good example. I've discussed this with this patient. She's been in remission for three years.

Her C. Dye scores for the last six visits have been 010002310. That's a little bit more than than three years. She's done very good. She started out actually with a C Dice score of 25, went down to six by her two month visit, and then after that she's been skating well.

She's seronegative. She was offered the possibility. She thought about it. She said, I don't want to change right now. There's a lot going on in her life.

You know, so it's got be right for the patient too. You know, do you want to chance that fifty percent risk of maybe having a recurrence? And I think that the idea that if when it comes back, it'll come back angrier and be harder to control and you may not respond. I think that's overstated. I think that's based on old therapies that were largely insufficient compared to what we're currently using in our arsenal today.

So tune in tomorrow for another tale from the clinic on QD clinic. What if Goldilocks had osteoarthritis? This is QD clinic brought to you by rheumnow.live. Our case today is a 75 year old woman who's had osteoarthritis for a number of years. It's affected her back, her neck, her knees, her CMC one joints.

When you look at her medication, she's supposed to be on acetaminophen six fifty, three of those a day altogether in the morning, tramadol once or twice a day PRN, and Xanoflex QHS for her back pain and poor sleep. What is she really taking? She's taking Nose Anaflex. She's on tramadol maybe one or two a week, and she's taking, Tylenol, arthritis strength one a day, maybe two a day. And guess what?

Today's pain is a seven, and she's really, has pain now all over and stiffness all over fingers, wrist, back, knees. Again, the point here is she's got a degenerative arthritis. She has seven out of 10 pain and she takes very little for her pain. She takes less than was prescribed for her pain. And again, she was given not only labels on the medications, but also a handout with instructions on how to take this.

So this is not an uncommon phenomenon. We have patients who take pain, have pain medicine but don't take it because they don't want to take medicine. And that's a pretty easy solution. You know, if you take no medicine and you have pain, you're going to continue to have pain and that's the story that's going to, there are no other magical solutions. You know, lifestyle, losing weight, immobilizing things, that may all be well and fine.

But you know, generally we have a Goldilocks kind of situation. They take too little, and often too late. So how do you reconcile this? There is this tendency by patients, by patient advocacy groups, by watchdogs to take less medicine, to be wary of medicine, to avoid medicine. Of course, all that's reinforced by when you give a medicine, go to the pharmacy and get a nine page printout of everything they should worry about including blue toenails.

You know, that has to be put into perspective with the patient, that not every side effect listed is something that can realistically happen. And then you have on the other hand, you know, guidelines groups, leaders in the field who are either doing research, developing guidelines, know, providing expert commentary and they want us to be proactive and aggressive. I'm aggressive, I'd like to be labeled as an overtreater. I'm not afraid to do that because I'm also overly concerned about safety at the same time. I think we do need to be proactive if we're to do our job of helping to alleviate pain.

So again, what should you do in patients with osteoporosis and osteoarthritis and lupus and rheumatoid arthritis when they want to take less medicine. I think you should either endorse that as an okay maneuver or you should actually speak out against it and tell patients why it makes more sense to treat because it's either too little, too much or just right, AKA Goldilocks. So take that approach with patients. I'm gonna give you a Goldilocks story. You're my Goldilocks patient.

Guess what? I'm gonna give you a new medicine and we're gonna start low, a really safe dose. Make sure that you tolerate it, and here are the three side effects that you need to know about. And then after we've done that and after some period of time, let's say a week or three days or two days, doesn't really matter, we're going to go to a higher dose. And we're looking to see that you tolerate that well because it is the higher dose that's the right dose.

So maybe that's one jump or two jumps, but the higher dose you're basically looking for too much. And you have to give them the rules for too much because when they get the rules for too much, they can ratchet back to just right. And then they're a happy Goldilocks. So start low, escalate, ratchet back to right dose. This happens all time with trazodone.

Not everybody takes trazodone or amitriptyline or Elavil the same way. I don't know if they need one hundred fifty of trazodone or one hundred twenty five of Elavil or if they need two, three, four, five, six. And the way to do it is to individualize the dosing by telling them to start at one, go up to two, go up to three, go up to four, get to the dose that makes them dopey and hungover, they're not gonna like that, and tell them now you have to cut back to one pill below that and that's the dose made for you. Instead, everybody wants to take half a trazodone or half an of an Alavil thinking that less is better. In fact, less is not enough and not enough leads to more pain.

Again, the Goldilocks approach. Tune in tomorrow. Room now live is but a few hours away. In this QD clinic, I want to review with you why I think this is such a big deal. One, Artie Cavanagh and I have been planning this for almost a year and have spent a lot of time thinking about a meeting that was best for the audience, that the audience had never seen.

The audience would actually come away thinking, wow, that was different. And really it's going to have a big impact. So RheumNow Live has its origins in being audience centric. It's also has its origins in being interactive and plugged in. So we're gonna stream this thing live.

So if you're not planning on being in Fort Worth on Friday, you can actually tune in from home by registering on the website, roomnow.live, and go to register. This meeting was formulated really after a user needs assessments from our RheumNow community, where we asked you what you wanted to hear more and more about. With that, we planned the program. Why is this program going to be different? It's going to be a medical meeting, and the people most are coming thinking it's got great faculty, know, it's got Artie and Jack, you know, running it, it should be fun, it should be good.

It's, know, I'll sit down, I'll listen to sixteen hours of fabulous lectures from fabulous speakers. It'll be a good meeting. Well, if that's the expectation, I hope to surpass it. And why? Well, again, it's supposed to be audience centric.

It's going to be grouped as far as the content. So we're gonna have these pods or these sessions that are two hours long. Each session or pod has three half hour lectures and a whole half hour devoted to discussion, Q and A, where we have all the faculty on the stage and in the audience and from home are asking questions. So they're gonna be really great pods and they're gonna be even better q and a sessions because everybody in the audience, whether you're at home or whether you're in the room, is gonna be plugged into an app. And in that app, you can see chat about what's going on at the meeting, what people think about what's being said or what's not being said.

The audience can upload a question, like why isn't he talking about VTE? Isn't that the big issue here? And then you watching others put up questions, you can upvote the questions so that when it comes time for questions, the moderator will ask that question in preference over the others. So this upvoting is kinda cool. All these things that we have, and of course, there's the speaker is gonna be sending you polls and questions to keep you involved and get your opinion about the subject at hand.

All of these features are why we need to devote at least 30% of the whole meeting to q and a and discussion. That's the big thing here that being plugged in and the q and a and discussion really should be something that's important. We want again you and the audience to be teaching everybody else what's going on by tweeting and putting on social media the things that are on there and you can do that right from the app that you'll use to be involved in the meeting. You should take a look at the faculty and the program. It starts on Friday at noon in Dallas.

That's 1PM Eastern Time, with an introduction and then we get right into Rheumatoid Arthritis. Mike Hollers and all his great work on preclinical RA. John O'Shea, the guy who did most of the early JAK inhibitor development work and how important JAK has become, is going to give us his perspective. That's going be a very cool lecture. And then Mike Weinblatt is going give us a thirty year perspective on methotrexate, the drug that he worked on and popularized in the eighties and has now become the staple for all therapy, most therapy in rheumatoid arthritis.

We then go into from these pods or sessions to into what we call TED like Talks or STEP sessions. Science, Technology, Education and Patients. That's supposed to be the context in which they're gonna get these short lectures, twelve to fifteen minutes. Our first one is on the history of rheumatology that features Eric Madison talking on the history of steroids. Fabulous lecture.

Then we get Fred Wolf to do the history of fibromyalgia and Ted Pincus, the history of measurement. Then we have a break and we come back and we do safety. It's going to be Len Calabrese talking about this cool new rising problem that we're seeing with immune related adverse events with the checkpoint inhibitors. Then Lisa Samaritania who headed up the ACR guidelines committee on reproductive health guidelines, a new guideline thing, paper coming out from the ACR. It's gonna be three different publications.

She's gonna put in ACR guidelines on drug management during pregnancy and I get to talk about infection and safety. Then let me come back on Saturday morning at 07:30 with a keynote talk from Matti Feldman is going to talk about basically price of drugs, PBMs and the whole problem of where we stand today with new drugs. We go into another step session where we have great people from the EU, Ron Van Vollenhaven, Gaylord Shet and Philip Conahan are gonna talk about cool things that you've never heard of before. We're gonna do psoriatic arthritis with Arti Kavanaugh doing the new drugs in development. Craig Leonardi, really well known in the dermatology world because he's a dermatologist and does all the education.

We're going get a dermatologist perspective on new drug development and then we're going to hear again from Philip Conahan who's going to tell us the differences between psoriatic disease and osteoarthritis, especially from a radiographic and imaging standpoint. In afternoon we come back with the mavens of lupus, Rich Fury talking about new drugs in lupus, Ken Kolonian talking about new criteria and outcomes in lupus, and Doric Erkan has got a fabulous lecture on catastrophic Antiphospholipid Syndrome and basically Antiphospholipid Syndrome and testing. We go back to another TED session, Len Calvary is talking about empathy, me talking about coaching, and we end up with orthopedics talking about joint replacements in the shoulder exam. On Sunday morning we got another half day, it looks at vasculitis, Carol Langford, Philip Sio, Paul Monarch, fabulous session you're gonna love. Then another step session with Ivan Oransky talking about retraction of scientific papers and Ted Pinka talking about how clinical trials have failed us.

And then we end up with really a blowout on spondylitis with John Rivell, Eric Ruderman and Elaine Husney. Again, I'm really excited about it. It's coming up. You can be a part of it. We'll see you in Fort Worth, or we'll see you online.

You can be a part of it. We'll see you in Fort Worth, or we'll see you online.