QD Video - Week 11 Save

Welcome to QD clinic brought to you by RheumNow live. Today our case is about medication reminders. A 67 year old Hispanic woman has rheumatoid arthritis, fibromyalgia, bronchiolitis, osteopenia, Sjogren's syndrome. She's taking methotrexate and Xeljanz and prednisone, and I got a problem compliance. When I asked the patient about compliance, she's never really quite sure, especially about how she takes methotrexate.

You know, pills once a week, seven pills a day. Again, she seems to not really ever know. So this has become a major problem for her because her disease is really out of control and I don't know what my next move is if she's not compliant. Compound this problem by the fact that she's a victim of polypharmacy. She's on 13 medications for a number of other medical conditions and everybody just seems to be piling on the medicines the more she complains.

So the question is how do you get this patient to be compliant? The first measure of course is to review medications at every visit. What we do is, and found to be really effective, is we print out a copy of the patient's medication list prior to the visit and we hand it out when they check-in and they fill out their survey question. We do survey, questions in our clinic, they look something like this, but we put on that a medication list and ask patients to confirm or change their medicines. That sort of shows an aptitude and an understanding about medicines that they're on.

In a patient like this, we always demand that they bring their medicines, not a medicine list. Everybody must bring either a medicine list or all their medications to the visit. In this patient we've been demanding for the last month or two to bring a medication list to every visit and you know what she sometimes does it but still we have a concern. And then what are going to be your other measures? In this particular case what we did was we decided we were at a crossroads, we have to make a critical decision on therapy.

I need to know she's getting methotrexate. I changed her to parenteral weekly methotrexate and had it done in my office. She had to come in every week. We're gonna do it for eight weeks and decide if that's the missing link on why she still has nine swollen joints. Someone's calling.

The other options for you are a few. I think ours is a bit extreme. Beyond just bringing in the medicines and then having them come back and receiving the medicines in your clinic, that's not appropriate. I think that the rules are a few that you can live by. Number one, ask them how they remember to take their medications.

They'll tell you a story that either works well based on your experience or doesn't work at all. Second, demand that they use a pillbox and introduce them to either the daily pillbox or a pillbox that has twice a day or three times a day dosing that would work with their current medication list. Next is to involve the family. Having a family member, who is concerned, easily will fix the problem as often they're more concerned about the patient taking the medicine correctly than the patient would be. And then you can also build in reminders into your electronic health record if you have a critical issue with a medicine, might need a medicine once a week, once a month, that sort of thing, can use the EHR to prompt calls to either be done by you or an assistant to remind the patient.

And then lastly, are a number of applications. In fact, on Apple Play and the iTunes Store, there's over 500 applications designed solely for the purpose of medication reminders. There's a number of them that I jotted down. One's called MyMeds, Medisafemeds, DoseCast Medication Reminder, another one called tab time vibe meaning that the phone will actually vibrate when there's time for them to take their tablets. Again, the patient can enlist the use of any one of these if you think it's a minor medication issue.

I know the patient last week where they were just forgetting to take their once a week alendronate and we talked about you know link it link that alendronate use to something you do once a week anyway like getting your nails done, getting your hair done, shopping online, whatever it is that you do on the same day every every week, link that to taking a medication like alendronate once a week. So compliance is really really important. Oh, our patient, the one who was doing really poorly, who came in for eight weeks of consecutive subcutaneous methotrexate, no effect, no effect. So we had to jettison her current therapy of Xeljanz and methotrexate and move her on to a whole new plan because she's got horrible arthritis. She has a CDAI score of 42, 25 swollen joints, eight swollen joints.

That was at the last visit. We need to make a change, but at least we did the things to ensure, excuse me, that that compliance was not the issue. I could edit that out, but then again, I want you to know I'm still alive. Lastly, RheumNow live, we just completed it yesterday, in Fort Worth. Fabulous meeting.

Hundreds of people attended online, hundreds in the room. We're gonna make that available to everyone online on demand starting next week, April 1. Look for that announcement. Tune in tomorrow for more QD clinic. Hey there.

QD video, QD clinic brought to you by RheumNow. Live. Today's case, pushing for LDAS versus remission, low disease activity, or do you push forward all the way to remission? Our case is a 42 year old woman who came to see me about three months ago. When she came to me, she had been off of all of her DMARD and biologic therapy.

She had horrible psoriatic arthritis. Psoriasis diagnosed in 2015. Psoriatic arthritis, I think soon thereafter. She's previously been treated with, where are those drugs, methotrexate, Humira, Enbrel, Remicade, and I put her on Cimzia and Arava. She either couldn't respond or lost response or had intolerance of methotrexate.

So when I saw her a little over three months ago, her C. Diff score was 45. I think she had like 20 something tender joints and I don't know 16 or so swollen joints. Her CRP was 21. She was a red hot mess.

And so we put her on leflunomide and cerdulizumab, which she wanted to go on and unfortunately was the next choice in her tiered system with her insurance. And although I didn't have a lot of hope for it, she came back a month later and or six weeks later and her CDAI score had dropped to 11. She comes back another six weeks later and I see her today and her CDAI score is eight. What that really means is that she has six tender joints, six swollen joints, pain score of one and a, only one check mark on her modified health assessment questionnaire. So she's done much better.

She's delighted in how she's doing. She's doing great according to her, with her only problem being an ankle that's swollen and bothersome. That's another swollen joint not counted in the 28 joint count. So do we stick with the fact that she's real happy that she's cut her, her clinical disease activity score by 75%, she's cut her, CRP by 90%, but all these are still high and abnormal. My answer is no, you don't stop, at LDAS, which she's clearly in or close to being in, she's not in actually yet, not according to this score.

Or do you push forward to get her in remission? Sometimes that's going to be obviously contingent upon how much damage and how much background pain and dysfunction the patient has from mechanical disease or prior antecedent inflammatory disease. Some people you may never get to a remission number with a C. D. I.

Score of three or less. Her, again, still has six swollen joints including the ankle seven swollen joints. She has some tendonitis going on, she still has a high CRP. I think the idea is you still push forward. What are we gonna do?

She's on leflinomide twenty milligrams a day. She's on Cimzia two hundred milligrams every other day. She takes trazodone for pain. She's on five milligrams of prednisone twice a day. So one, we consolidate her prednisone to ten milligrams a day.

We got to get her off prednisone. But what else can we do? Well, it happens again, her diagnosis is psoriasis and she has bad skin psoriasis. That too is significantly improved, but now she's going to get the psoriasis dose, excuse me, of Cimzia which is four hundred milligrams, meaning two shots every two weeks and we're going to do that until she's better. We're going to see her back again in four weeks or six weeks and if she isn't substantially better we're moving on to other and newer therapies.

One of the two, leflunomide or cerdulizumab is gonna be dropped and be replaced by something else that could be IL-seventeen inhibitor, that could be an IL-twenty three inhibitor, that could be a JAK inhibitor. So we'll see, but I think the idea is you push to remission unless remission is impossible based on structural disease and chronic pain from other causes. I think as long as someone has active synovitis, active inflammatory disease, yes, you go as low as you can go and you keep going. That's it for this QD clinic. I want to make a correction to yesterday's QD clinic which had to do with medication reminders.

I still stand by everything I said. I forgot to mention two really important reminders that are very actually effective today and that is the use of either Siri on the iPhone. Siri remind me to take my medicine every Wednesday at five p. M. Or using the Google devices.

It's Google Echo or I'm sorry Amazon Echo or one of the Google devices. Amazon has Echo, Amazon also has Alexa, which you can get reminders recorded in and played back to the patient. So to use those modern devices also are useful adjunctive tools in getting patients to remind themselves to take medication correctly. We'll see you tomorrow. This is QD Clinic.

Hi, I'm Doctor. Jack Cush, the Executive Editor of roomnow.com. Acuity Clinic is brought to you by roomnow.live. Next week you can go to that website and actually register and look at RoomNow Live for free on demand at your leisure. Today's case is smoking and rheumatoid arthritis.

So last week I saw this gentleman, 70 years old, has had rheumatoid arthritis since 2015, so about three and a half years we're talking. His onset was symmetric polyarthritis, no nodules, no tenosynovitis, very high sed rate in CRP, very high rheumatoid factor over 400, very high CCP greater than two fifty, and yes, even very high 14,338. So no, I didn't do CAR P antibodies, I'm but sure they might have been high too. His diagnosis was real clear, real easy, could have made it from across the street. So put him on methotrexate, he did real well, but noted at that visit that strange sort of hint of tobacco as I did an exam.

It turns out that I didn't need to ask him about tobacco, but I did, of course, and he's a two pack a day kind of guy, probably for over fifty years, and said it was hard for him to quit. He was told at that visit, first visit, that smoking has been known to be a risk factor for rheumatoid arthritis and a worsening factor for rheumatoid arthritis. This has been known for over twenty five years in the medical literature and that I strongly advise he make an effort to reduce his risk. And now fast forward three and a half years and he's still smoking and turns out his arthritis is fairly well controlled. He started out with a C.

Dice score of almost 20 and he's been running somewhere between one and six the last few visits. So he's doing fairly well. He's happy with how he's done on just methotrexate and a PRN non steroidal. But I keep bringing up the issue of smoking. So what do you tell someone about smoking?

You know, it's sort of like telling someone to lose weight. No one ever listens to you and it's a bit like badgering a patient. But you should know the research is actually really quite clear of patients who do lose weight. The number one reason why they lost weight was because their doctor convinced them to do it. So the point is, if not you, then who?

So what do you tell them? Guess what? Smoking is associated with increased risk of lung cancer. Yeah, doc, but I'm 70 years old. I've been smoking since I was, you know, 32.

It also increases your risk of lots of cancers, including, oral and head and neck cancers. We know it increases the risk of gingival disease and we know gingival disease is another risk factor for severity and risk of rheumatoid arthritis. We know that smoking increases the risk of getting rheumatoid arthritis. Smokers versus non smokers are likely to get rheumatoid arthritis. We know that smoking worsens, rheumatoid arthritis.

They're more likely to get erosions, nodules, extra articular manifestations, damaging disease and disability. We know that it somewhat hampers drug responsiveness, although inconsistently so, not quite as bad as is seen in obesity. We know that smoking cessation leads to better outcomes in rheumatoid arthritis. That's sort of surprising. It could take several years, but that's been shown.

So what's going on here is the people who are at greatest risk are those who have the shared epitope. The HLA Doctor Beta one alleles previously called HLA Doctor four etc. That if you have that genetic risk factor known to be the strongest risk factor for getting rheumatoid arthritis, it really goes into play in overdrive when smoke. These, aromatic hydrocarbons are in play. It activates osteoclasts, it leads to Th17 cell activation and autoimmunity run amok.

It leads to more autoantibody formation which in the presence of smoking and the HLADR Beta-one allele increases the risk and the severity. It becomes a, you know, a snowball that just won't stop and it grows and hence you get the risk. So this is associated with seropositivity and hence a perspective risk of some even if someone who doesn't have the disease but might well get it if they continue to smoke. So again, need to remind them of the facts and why you're worried about it. Well, I'm very impressed.

While most rheumatologists are not very good at managing comorbidity, you know comorbidity, you worry about comorbidity, you assume someone else is gonna manage comorbidity, most rheumatologists actually do a fair amount of coaching and cajoling and begging their patients to stop smoking. What should you tell them? Number one, it's not easy, they know that. Tell them the success is really based on what is known and what is known that you can't do it on your own, you need to join smoke enders or some kind of group or do it with someone else who's also motivated to quit smoking. You probably need, they probably need medication help, Wellbutrin Chantrix, you know those kind of medicines, whatever it takes to get them over that craving part especially for the first three months if not six months.

And then you need to tell them that again, need to continue to ask for help and they need to surround themselves with non smokers as opposed to smokers. Turns out that people who do quit smoking usually become sort of militant about not smoking and who they hang out with. Of course, smoking and drinking might be a good idea because it's the alcohol that could actually lessen the risk and severity of rheumatoid arthritis, but obviously the smoking negates all that. So going to bars is not going to help your rheumatoid arthritis. It's going to hurt it.

So it's a tough job. If not you, then who? Remind your patients smoking is not just dangerous, it's gonna kill their joints too. See you tomorrow. Hi, this is QD clinic brought to you by RheumNow Live.

I'm Doctor. Jack Cush. Today's case is entitled, give them an inch and well, let's get into the case before we hear the rest of the story. This is a story of a 56 year old woman who's has lupus for good time now, maybe going back almost like eighteen years. I imagine her for a long time.

Great gal, problematic lupus. Now she's doing good. A few years ago she was doing bad. Her story over eighteen years has been mostly good, but a lot of bad. And what do I mean by that?

Her lupus has been complicated by, episodes of nephritis, cerebritis, renal insufficiency, pneumonia, including, PJP pneumonia. Her lupus is based on fatigue, arthritis, leukopenia, anemia, mouth ulcers, nephrotic syndrome, nephritis, polyarthritis, an ANA, a double stranded DNA, a lymphadenopathy, scleritis, a renal biopsy showing class four nephritis, previously treated with prednisone, Plaquenil, methotrexate, CellCept, Cytoxan, azathioprine and nonsteroidals. A few years ago she was in the hospital with both nephritis and PJP pneumonia, really was critically ill, and came back but not without significant impact on renal function. She now has a creatinine of almost two, and some low grade proteinuria but is doing really, really well on her current medicines which are an appropriate dose of hydroxychloroquine, a hundred milligrams of azathioprine, not quite two milligrams per kilogram between one and a half and two. She's also on blood pressure medicine and for kidneys and takes acetaminophen and Fosamax.

So what's big or important about this case? She's doing great. She's doing wonderful, has been doing wonderful for the last five visits since she got out of the hospital two and a half years ago. And that's the problem. When all is looking good, then patients can interpret that as, Hey, I'm great.

Maybe I don't need as much medicine. And that's the problem. What happens in this situation now with this patient is sometimes they go AWOL. They don't come in. They stop taking their medicine or maybe they don't or they take it irregularly.

But when they show up, you know, six months late, and telling you maybe they're taking the medicine, you're not surprised when things are out of control. This particular patient shows up on time, but she has self adjusted her medication. Not in this house, we don't do that. So what did she do? She went off of prednisone.

I think problematic, difficult lupus should always be on a little bit of prednisone. And that's just a personal preference based on something taught to me by Doctor. Ziff and, when I was working at the Parkland Clinic and seeing tons of lupus patients, the ones off of prednisone were always in the hospital. The ones on prednisone were usually not in the hospital. So a little bit of prednisone, two point five, two milligrams, five milligrams, whatever it takes.

She went off it on her own. Not a good idea. She also happened to self adjust, downward adjust her DMARR therapy. She's taking very little azathioprine. She's taking the lowest possible dose of hydroxychloroquine, but again, not in this house.

So we had a little come to Jesus moment and said, can't do that. And the patient needs to understand that and then we had to go reiterate some of the big points here. And that is, who changes medicines? Only one person. And that's the guy who or the gal who writes the prescription.

So I don't mess around with their Cardizem. I don't mess around with Xarelto. You know, if I didn't write the prescription, I may have a strong position about it. But if I think that medicine's got to change, have to go back to the source. Again, I remind the patient that when a doctor treats himself, we usually tell him he has a fool for a patient.

And so when patients treat themselves, it's probably a worse situation. It's worse than being a fool in making medication choices. Again, when they're doing well, they want to think I'm normal. That's the second point. You're never normal.

You're never ever going to be in remission. You got a disease like rheumatoid arthritis and lupus, you got to be teaching the point that this is something we can control. This is something we have to work out. This is something you have to own up to and accept and understand what it's like to be a good patient and so my job to teach you what it's like to be a good patient. Again, my job is to see you and say, hey, you're doing great.

Hey, you're doing wonderful. Hey, taking the medicines really paid off for you. But my, you know, I have to leave the message. You got to stay on this medicine. If you go off of it, bad things are going to happen.

So again, not being vigilant about my instructions, it's not surprising that the patient has come back and self managed herself. Luckily, no problems at this point, but we got to get back on track. You got to do this with every patient, every visit. They listen to everything you say. If you don't say this, then they assume everything's better than it may really be.

That's today's story. Tune in tomorrow for another. Hi, this is our last QD clinic of the week. This one's entitled, Who's the Boss? QD clinic is brought to you by RheumNow Live.

A 40 year old patient who has RUPES, bona fide RUPES, because it's clearly got looks like rheumatoid arthritis and associated with seropositivity. It's clearly lupus with having enough criteria. So she has seropositive RA, seropositive lupus, bad lupus, controlled lupus, hard to control actually. She's currently on hydroxychloroquine, trazodone, and Xeljanz and doing really, really well. Her condition is based on the following features: Polyarthralgias, polyarthritis, anemia, leukopenia, lymphopenia, and ANA, a positive RNP, photosensitivity of malar rash, alopecia, real alopecia, lost clumps of hair, Raynaud's, triphasic Raynaud's, dysphasia, dry eyes, dry mouth, miscarriage times two.

She is negative for double stranded DNA, SSA, SSB, and RPR, and lupus anticoagulant. She does has had polyarthritis AM stiffness, CCP is greater than two fifty, rheumatoid factor is 60, even 14,338 is marginally positive. In the past she was difficult to manage, treated initially with prednisone, methotrexate, Plaquenil, leflinamide, rituximab, Atabrine, Enbrel and really not until she got on this combination that she's currently on of hydroxychloroquine and tofacitinib has a really under great control both just skin, inflammatory markers, her arthritis, etc. So what's her story? Her story is that she was doing great until two months ago when she developed a TIA.

TIA manifest as unilateral weakness, little bit of a mouth droop, coming and going, resolved in less than twenty four hours, admitted to the hospital, managed at an outdoor, at an outside far away, Neverland kind of community hospital, for this with a three day hospitalization, and the management of this is aspirin. Really, aspirin. Now, I don't know if that's too little or even necessary and the other part is I don't know what workup ensued. It seemed like it was largely a neurologic workup, But the issue here is who's the boss? And this needs to be made clear, to this patient, but also to all patients in whom you are concerned about and whom you're writing prescriptions for and whom you're following.

And this is not just lupus, this is rheumatoid, dermatomyositis, gout, etc. And I think you have to leave the patient with these important messages. Number one, who owns the medicine? Who's in charge of the medicine? And that's me.

That's the guy that wrote the prescription. That's you, the gal who wrote the prescription, the gal who's refilling that prescription. Again, that means that no one can mess with that medicine but the person who writes the prescription. Not the primary care, not the ER physician, not a neighbor or who seems to say something that seems to resonate with the patient, not a television ad or something that they read in the paper or USA Today. No, no, no, no, no, no.

Again, that's like Internet as far as I'm concerned. I want the patients to look at the Internet. I want them to write things down. I want them to come in and discuss it because the Internet is not a basis for making decisions. Right?

Likewise, those other people don't get a vote in managing this medicine or my patient. And again, you need to know that you're taking strong ownership of that. So call me anytime if you have any questions. What went wrong here? The physicians in the hospital.

What were they doing? They didn't have, they mustn't because they're so far away from where I work in Dallas, they mustn't have telephones up there. Maybe hasn't quite gotten up to that far north in Texas, you know, we're still waiting for the Pony Express to deliver the hospital notes. So the problem here is the patient needs to be instructed that if something goes bad, make sure your doctors call that guy, that gal who's in charge. What are the rules?

If you go in the hospital, even the ER, I got to be called. If you are messing with my medications, even the least of them, the acetaminophen or the magnesium that I prescribe, I got to be called into play because other people are not going to know what to do. If they have seen another specialist, especially if they've seen more than one specialist for something, anything, I gotta be called because, as you know, what often happens is they got a musculoskeletal problem, you're treating them for lupus or Rheumatoid Arthritis, they're going to an orthopedist. What? Seriously?

I'm the person you should call the orthopedist looking to do surgery. Yes, maybe he alleviated you from doing something that could be done by anyone, but really maybe he's not treating or she's treating the right thing. So to go to another specialist is only to allow them to perceive that lupus, RUPES, RA patient as another voodoo problem that they have to deal with. That's not what happens when they call you or I. We know this stuff.

We live and breathe this stuff. We know what we're doing. Everybody else is guessing. Well, the case of these, podunk community hospital doctors, they weren't even guessing. They did nothing.

Aspirin, call me in the morning. Actually, and they referred to another specialist, which was probably inappropriate. So again, has to do like the last case we talked about yesterday. It has to do with the messages and the instructions that we tell our patients that make our patients better patients and make them safer and better managed going forward. Have a good weekend.

QD Clinic.